Transcript Our_MAU2! 3461KB Apr 24 2011 03:46:55 PM

Our medical assessment unit!
Mark Oakley (modern matron) &
David Young (pharmacist)
Southampton University Hospitals NHS Trust
• Introduce ourselves & our professions
• Our plan for the session
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about
 Feel free to shout out with questions or for
clarification at any time!
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Our MAU
Our MAU at SUHT
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The acute medical unit (“AMU”)
48 beds in 3 sections, each with a central nurses station
10 side-rooms for isolation patients
Its own drop-off area, waiting area and 2 interview rooms
Accept admissions 24 hours a day
Average 1,100 admissions a month
– 60% from A&E, 40% from GPs
• Consultant post-take ward rounds twice daily
• MDT 0800-1700 on Mondays to Fridays
• Ambulatory care clinic (largely nurse-led via PGDs)
– Outpatient DVT, cellulitis, blood transfusion, follow-up
– 5 beds set aside for “STATing” of GP referrals
• The future is EAUs (emergency admission units)
– Combined medical and surgical admission units
David Young,
AMU pharmacist
• 4 year degree in pharmacy (MPharm)
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Medicinal and physical chemistry, biology, statistics
Formulation, physiology, pharmacology
Law, ethics & practice of pharmacy
Clinical pharmacy
Research project
• Pre-registration year at Bournemouth Hospital
• Registration exams
– 70% community, 20% hospital, 7% primary care
(industry, academia & other)
• Rotational jobs at Portsmouth & Southampton
• Haslar & Lymington
David Young,
AMU pharmacist
• Postgraduate diploma in clinical pharmacy
• Future for pharmacy
– Ongoing CPD will be compulsory soon
– Expansion of non-medical prescribing
• Supplementary prescribing – formulating a “clinical
management plan” agreed between the NMP, responsible
medic and the patient
• Independent prescribing
– Outpatient clinics
– Splitting of the RPSGB
• GPC responsible for registration and professional standards
• A leadership body that will be responsible for representing
and supporting the profession
– Revalidation expected to start by 2012
Mark Oakley,
Modern Matron for AMU
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Registered General Nurse 1990
Teaching and Assessing in Clinical Practice
UKRC ALS Provider
UKRC PALS Provider
UKRC ALS Instructor
Advanced Physical Assessment and
History Taking
• Cardiac Care Course
• Management Courses
Mark Oakley,
Modern Matron for AMU
• Thromboprophylaxis in Practice
• Change Management
• Studying MSC in Management of Health
and Social Care
• Member of the Society of Acute Medicine
• Member of the Royal College of Nursing
• Member of the UK Resuscitation Council
Our plan
• The pharmacy
department
• Typical day for me as
a MAU pharmacist
• What we add on the
ward
• Other roles
• Thromboprophylaxis
guideline at SUHT
• The patient journey
through the hospital
• Structure of our AMU
• Typical presenting
problems
• Introduction of
Clexane to SUHT
• Thromboprophylaxis
opinions
The pharmacy
department
Dispensary
• Supply medicines
to individual
patients
– Inpatients
– Outpatient
– Patients being
discharged
Stores
• Supply medicines
and fluids kept on
the wards as
“stock”
• Order medicines
Technical services
(“aseptics”)
• Prepare infusions and
other individual items:
– For paediatrics where
the doses used are
small (risk reduction
and cost saving)
– For some adult wards to
reduce the risk of
contamination when
prepared on the ward
– Total parenteral
nutrition (TPN)
– Items not commercially
viable (e.g. due to short
expiry date)
Medicines information
• Answer medicines-related
enquiries:
– Is warfarin safe in pregnancy?
– Does lamotrigine cause
dysphagia?
– What antiepileptics are
available in South Africa?
– Tablet identification
• Audit & support other local
NHS medicines information
centres
• Review new medicines for
cost-effectiveness &
applications for adding new
items to the local prescribing
formulary
Clinical pharmacy
Surinder Bassan
Head of Pharmacy
Sharron Millen
Head of clinical pharmacy
Caron Underhill
Directorate pharmacist (MEC)
James Allen
Lead pharmacist for emergency medicine
David Young
Admissions pharmacist
Specialist pharmacists (CF, diabetes,
hepatology/ gastroenterology)
Directorate pharmacists (surgery, cancer care,
women & children, neurosciences, cardiothoracic
& critical care)
Medicine for Older people pharmacists
Principal pharmacist - clinical services
Microbiology consultant pharmacist
Risk pharmacist
Pain services pharmacist
Pharmacy people on our
MAU
• Assistant
– Checks what is needed in the stock cupboards & orders
– Transfers medicines for patients moved to other wards
– Returns medicines to pharmacy or destroys medicines
for patients discharged
– Requests medication history information from the GP
surgeries
• Medicines management technicians
– Piece together information from talking to the patient or
a relative and the medication history, medicines patient
has brought into hospital to provide an accurate drug
history
• Pharmacists (2 and a bit of extra help)
AMU nursing structure
Nicola Lucey
Head of Nursing
(division 2 - unscheduled care division)
Vanessa Arnell-Cullen
Care group manager
(emergency medicine)
Emergency department
AMU/ AMA
Mark Oakley (band 8a)
Modern Matron
Claire Smith (band 7)
Senior sister & education lead
Sisters team (band 6)
Staff nurses (band 5)
Healthcare assistants
Medicine
Medicine for Older People
My role as a pharmacist
on MAU
• Reconciling a patient’s drug & allergy history on admission
– Using an up-to-date drug history (e.g. as too ill or confused, no up-todate information available overnight or recent verbal alternations)
– Identifying medicines that could be responsible for causing admission
(≈ 5-10% of admissions)
– Organising supplies of medicines that aren’t available or changing to a
stocked equivalent as appropriate
My role as a pharmacist
on MAU
• Advice to doctors
– Appropriate drug and dose of new medicines
– Ensuring that medicines that could exacerbate a condition are stopped
or withheld (e.g. NSAIDs in a patient with haematemesis)
– Avoiding duplicated (e.g. tiotropium in a patient on ipratropium
nebules), contra-indicated (e.g. co-amoxiclav in a patient with a
penicillin allergy) or interacting (e.g. trimethoprim in patients on
methotrexate) medicines
– Ensuring that the plans are followed
– Advising on writing legal prescriptions
– Considering historic blood or culture results when selecting an
appropriate treatment (previous MRSA colonisation, usual treatment)
– “What antibiotic can I give this pneumonia patient who is allergic to
penicillins & vomiting with doxycycline?”
My role as a pharmacist
on MAU
• Advice to nursing staff
– Supply of medicines
– Safe administration of medicines
• “Should I give ramipril to this patient with a blood pressure of 95/50?”
• “Is it okay to give this vancomycin stat (as prescribed)?”
– Prompting nurses about new medicines
– When to arrange transport on discharge
– Problems
• Patients with swallowing difficulties
• Storing medicines
• Maintaining confidentiality for a methadone addict
• Other allied healthcare professionals:
– Physiotherapists – what drugs affect muscle strength & movement
(PD, analgesics)
– Occupational therapists – patients getting confused with medicines
My role as a pharmacist
on MAU
• Access to resources:
– Toxbase (for the treatment of overdoses)
– GP records (indication for medicines, previous diagnoses, other
medicines tried in the past)
– Dose adjustments in disease states (reduced renal function, obesity)
– Referring patients to the appropriate specialist nurses and teams (e.g.
microbiology ward-rounds)
– Actioning drug alerts & recalls at the ward level
• Explaining changes to patients & counselling on new and ongoing
medicines
– Risk-benefit of medicines (e.g.warfarin vs. aspirin for AF)
– Best way to take medicines (e.g. use of inhalers (how & which one),
sulphonylureas taken at bedtime)
– Side effects to be aware of (e.g. carbimazole)
A typical day for me
• Shift working to increase hours covered
– 50% of prescriptions are written outside normal working hours
– Able to do discharges from evening PTWR
• Getting drug histories for about 2-3 patients
– Difficult or no available doctor
• Medicines reconciliation for about 20-30 new inpatients
• Reviewing drug charts of about 10 patients who have been
previously seen by a pharmacist
– Are they getting better?
– Monitoring requirements & interpreting results
– Any drugs withheld or stopped that are indicated
A typical day for me
• Preparing 5-10 discharge summaries and medicines for
discharge
– Documenting all of the current medicines a patient is taking
– Drugs stopped and started and the reason for doing so; review
dates as appropriate
– Communication with appropriate people in primary care
(NOMADs, depot injections, nursing homes)
– Checking what supplies the patient has at home  reduces
drug costs, expediting supply
• 5 trips to the emergency department
– Advise on medicines or to supply medicines
My other roles outside of
MAU
• Guideline review and writing
– Enoxaparin for DVT & PE treatment
– Hyperkalaemia
– Parenteral drug administration
• Teaching to doctors, medical students, nurses etc.
– FY1 teaching session on anticoagulation
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Ordering medicines for outpatient clinics
Intervention & activity monitoring
Training of newly qualified pharmacists
Audit
– NICE guidance on medicines adherence
• Finance
– Justify over-spend, patients from other directorates, high cost
drugs
• Obese patients, indications for unfractionated heparin
infusion, reversal with protamine
My other roles outside of
MAU
• Guideline review and writing
– Enoxaparin for DVT & PE treatment
– Hyperkalaemia
– Parenteral drug administration
• Teaching to doctors, medical students, nurses etc.
– FY1 teaching session on anticoagulation
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Ordering medicines for outpatient clinics
Intervention & activity monitoring
Training of newly qualified pharmacists
Audit
– NICE guidance on medicines adherence
• Finance
– Justify over-spend, patients from other directorates, high cost
drugs
My other roles outside of
MAU
• Guideline review and writing
– Enoxaparin for DVT & PE treatment
– Hyperkalaemia
– Parenteral drug administration
• Teaching to doctors, medical students, nurses etc.
– FY1 teaching session on anticoagulation
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Ordering medicines for outpatient clinics
Intervention & activity monitoring
Training of newly qualified pharmacists
Audit
– NICE guidance on medicines adherence
• Finance
– Justify over-spend, patients from other directorates, high cost
drugs
The SUHT VTE
prophylaxis guideline
• At the time medication errors and VTE prophylaxis was the
top priority on the patient safety arm of the Trust’s patient
improvement framework
• Team set-up to lead
– Pharmacist, clinical director, anticoagulation nurse specialist,
medical consultant
• Thrombosis committee, including a clinician from each care
group, formed
• Agreed points and raised issues for discussion in the
individual care group
– e.g. timing of doses post-operatively discussed at individual
forums leads by specialists from anaesthetics and surgery
The SUHT VTE
prophylaxis guideline
• A band 6 nurse employed (funded by industry)
– Educate nurses in the importance of thromboprophylaxis
– Increase awareness of IPC and it’s role
• Support from sanofi-aventis representative:
– Facilitating networking
• Arranging study days and recruiting participants
• Knowing who had solved a problem already
– Providing the evidence base for decision making
– Arranging stock (risk assessment stickers, bags)
– Arranging training for clinical staff
• Compliance with thromboprophylaxis: 20%  80%
Acute Medical Unit
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2001 DOH NHS Plan
AMU, MAU, CDU
4 hr targets for A&E
Right place, right time, right person
Ambulatory Care Units
STAT clinic started 2009
Documentation
– Medical and nursing clerking
– VTE risk assessment
Acute Medical Unit
• Assessment, Diagnosis, Treatment,
Discharge, Transfer
• Length of stay
• Acute Physicians
• MDT
• 11 trained nurses, 3 CSW long days
• 10 trained nurses, 2 CSW nights
• Physiotherapist, Occupational Therapist,
Social Services, Speech and language
Therapy, Dietetics, Nurse Specialists
My Day as a Matron
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Check night shift
Handover (twice weekly take case load)
Walk round
Bed meeting
Environmental checks
Various meetings
Peer reviews
Patient stories
Matron’s Role
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Clinical Leader
Visible presence
Patient advocate
Police
Auditor
Role model
Link between “ward and board”
Change agent
What the public want
How AMU Works
• 24 hr admission service
• Rapid assessment of patients
• Rapid access to diagnostics
• MDT
• Rapid treat and transfer/ discharge
• Partnership
Matrons’ charter
Typical presenting
complaints
Headache ± confusion
Diarrhoea
Neurological problems
Short of breath
GI bleeding
Diabetes
Limb pain
Psychiatric
Sepsis
Chest pain
Weakness or falls
Chest pain
Final diagnosis
Tests/ procedures
Drug treatment
Myocardial
infarction
Cardiac monitor, ACS
protocol, 5 day rest
working up to normal,
ECG,?angiography, CABG
Aspirin, clopidogrel, ACEI,
statin, enoxaparin
Arrhythmias
ECG, cardiac monitor,
?electrical cardioversion
Dependant on diagnosis,
often ß-blockers, calciumchannel blockers, digoxin
Angina
ECG, exercise tolerance
test, ?angiography
Antianginals
GTN spray for symptom
relief
Musculoskeletal
CXR,ECG
Analgesics
NSIADs
Short of breath
Final diagnosis
Pneumonia
Tests/ procedures
Drug treatment
CXR, bloods,
physiotherapy
Antibiotics, nebulised
bronchodilators, steroids
Exacerbation of
asthma or COPD
CXR, nebs, peak flows,
Respiratory centre,
physiotherapy, lung
function tests
Heart failure
CXR, daily weight, fluid
balance chart, daily U&E,
heart failure nurse
Diuretics, ß-blockers,
ACEIs, spironolactone
Pulmonary
embolism
D-dimer, ABG, CXR, VQ
scan, CTPA
Heparin (usually LMWH),
warfarin
Sepsis
Final diagnosis
Urinary sepsis
Tests/ procedures
Drug treatment
Urine dipstix, MSU, IV
fluids, daily FBC, U&E
Chest sepsis
CXR, FBC, CRP,
physiotherapy
Abdominal sepsis
AXR, FBC, CRP
Antibiotics according to
likely source or broad
spectrum then rationalised
according to investigations
& culture results
Neurological problems
Final diagnosis
Epilepsy
Tests/ procedures
Drug treatment
neurological observations,
?CT scan, ?LP, epilepsy
nurse, neurological review
Antiepileptics (add, adjust
doses or change),
Headache ± confusion
Final diagnosis
Tests/ procedures
Drug treatment
Subarachnoid
haemorrhage
CT scan, ?LP, neuro
surgical review, ?surgery
Avoid anticoagulants (?
duration)
?Nimodipine
Meningitis/
encephalitis
CT, LP, neurological
observations
Antibiotics ± antiviral
Migraine
FBC, U&E, ?neurological
review
Analgesics
?Triptans
?Prophylaxis
GI bleeding
Final diagnosis
Tests/ procedures
Drug treatment
Upper or lower GI
bleeding
NBM, OGD, IVI, FBC,
?blood transfusion
PPI
?Antibiotics (variceal)
Inflammatory
bowel disease
Isolate, stool culture, IVI,
gastro review, dietician
review
5-ASA compounds
Steroids (iv/ po/ pr)
Diabetes
Final diagnosis
Tests/ procedures
Drug treatment
Oral antidiabetic agents,
insulin (BD/QDS), pens,
meter, hypo advice
New onset
diabetes
BM stix, FBC, U&Es,
glucose, urine dip, HbA1c
Hypo- or
hyperglycaemia
Diabetic
emergency (DKA,
HONK)
Adjustment of diabetic
treatment
IVI, diabetic nurse review,
endocrine review, regular
urine dipstix, BM stix
Sliding scale insulin
Adjustment of diabetic
treatment
Diarrhoea
Final diagnosis
Gastroenteritis
(viral, bacterial)
Clostridium difficile
infection
Tests/ procedures
Isolate, isolation proforma
for audit trail
Stool charts & culture
Drug treatment
Rehydration
Antibiotics as appropriate
Psychiatric
Final diagnosis
Overdose
Schizophrenia
Tests/ procedures
Levels, INR, U&Es
Psychiatric review - ?need
for admission or
community support
Drug treatment
Antidote
Withhold & restart when
appropriate (e.g. lithium)
Limiting supplies
Rapid tranquillisation for
their safety & that of
others
Antipsychotics
Confusion
Final diagnosis
Dementia
Tests/ procedures
High observable bed
Return the wandering
patient, reassurance
Septic screen
Psychogeriatric review
Drug treatment
Symptomatic treatment
Limb pain
Cellulitis
Deep vein
thrombosis
?suitable for AMA
Final diagnosis
Arthritis or gout
Tests/ procedures
Drug treatment
FBC, CRP, x-rays
Proforma
?vascular review
Antibiotics
Analgesics
Proforma
Anticoagulation
Analgesics
CPR
Rheumatology review
Analgesics
NSAIDs
Steroids
Weakness and falls
Final diagnosis
Tests/ procedures
Drug treatment
Stroke/ TIA
CT scan, carotid doppler
FBC
Aspirin ± dipyridamole, BP
control, statin
?VTE prophylaxis
Postural
hypotension
Lying & standing BP
Often over-medicated
Bone protection
Parkinson’s
disease
NG tube is a priority if
NBM
Medication timings is
important
Electrolyte
disturbance
U&Es
As indicated
Introduction of Clexane
to SUHT
• Positive example of how change management
works
• Good communication to the right people at the
right time
• Sanofi-aventis input:
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Information packs & wall displays were useful
Good education and support pre-change
Ensured staff awareness and appropriate training
Ongoing support and teaching
• Didn’t feel as though the change was ‘imposed’
on us
Thromboprophylaxis
opinions
• We asked a variety of AMU staff:
– What they guess the estimated number of deaths
annually from VTE contracted in hospital is
– Do they believe the actual number
– What proportion of these occur in medical patients
– What the incidence of VTE is in the typical MEDENOX
patient
– How effective they think thromboprophylaxis is
– Whether they know the hospital guideline on
thromboprophylaxis in medical patients
– Who’s responsibility is it to risk assess patients
– What is their role in VTE prevention
Thromboprophylaxis
opinions
• Average number of estimated deaths from hospital VTE ≈
4,500
• Typically thought that about one-third of these occurred in
medical patients
• Guessed that incidence of DVT in a MEDENOX patient would
be about one-third
• Thought that RRR with enoxaparin ≈ 85%
• No-one knew what the hospital guideline was for VTE
prophylaxis in medical patients
– but correctly identified many of the VTE risk factors
• Most people thought that all of the doctors, nurses &
pharmacists caring for the patient were responsible for
identifying patients for VTE prophylaxis
– “How often have you challenged a doctor whether a patient
should be prescribed thromboprophylaxis”  mostly never
Visiting a ward
• For medicines not currently used
– Discuss with consultants (via secretaries) &
pharmacy
– Consider non-medical prescribers as these
become available
• Arranged teaching sessions are preferable
– Discuss with the ward manager or educator
– Background to the disease
– Ideally 30 minute sessions between 2-3pm
VTE prophylaxis related
challenges as we see them
• What do other hospitals recommend for VTE prophylaxis in
medical patients?
• Who is the most appropriate person to do the VTE risk
assessment?
• Where should this be documented?
• How can we encourage this to be considered at the PTWR?
• How can we ensure that VTE prophylaxis is considered after
admission (especially when contra-indicated on admission)?
• Sharing of guidelines and risk assessment tools?
• What is the best way to counsel patients on their VTE risk
on admission?
• How can VTE prophylaxis be integrated into electronic
prescribing systems most effectively?