our medical assessment unit! mark oakley (modern matron) & david young (pharmacist) southampton...

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• Ideas of what you would like us to talk

about

Feel free to shout out with questions or for clarification at any time!

In fact, please do!!

Our MAU

Our MAU at SUHT

• 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)– 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

• 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

D a vid Yo u ngA d m iss io n s p h a rm a c ist

Ja m es A llenL e a d p h arm ac is t fo r e m e rge n cy m e d ic ine

S p e c ia lis t p ha rm a cis ts (C F , d iab e te s,h e p a to log y/ ga s tro e nte ro lo g y)

M e d ic in e fo r O ld e r p e o p le p ha rm a c is ts

C a ro n U n d e rh illD ire c to ra te p h a rm ac is t (M E C )

D ire c to ra te p ha rm a cis ts (su rg e ry, ca n cer ca re ,w o m en & ch ild re n , n e u rosc ien ce s, ca rd io th ora c ic

& c rit ica l ca re)

P rin c ip a l p h a rm a c is t - c lin ica l se rv icesM ic ro b io lo g y co n su lta n t p h a rm a c ist

R isk p h arm a c istP a in se rv ices p h a rm a c ist

S h a rron M illenH e a d o f c lin ica l p h arm a cy

S u rind e r B a ssanH e a d o f P h a rm a cy

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

E m erg en cy d e pa rtm e nt

H e a lth ca re a ss is ta n ts

S ta ff n u rse s (b a nd 5 )

S is te rs tea m (b a nd 6 )

C la ire S m ith (b an d 7 )S e n io r sis te r & ed u ca tio n le ad

A M U / A M AM a rk O a k ley (b a nd 8 a)

M o d ern M a tron

M e d ic ine M e d icin e fo r O ld e r P e o p le

V a n e ssa A rn e ll-C u llenC a re g rou p m a na g er

(e m e rg e n cy m e d ic in e)

N ico la L u ceyH e a d o f Nu rs ing

(d iv is io n 2 - u n sch e d u le d care d ivis io n )

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-to-

date 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


• 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?”


• 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


• 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

• 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

• 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

• 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

• Check night shift • Handover (twice weekly take case load)• Walk round• Bed meeting• Environmental checks• Various meetings• Peer reviews• Patient stories

Matron’s Role

• 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

Chest pain

Psychiatric

Short of breath

Limb painSepsis

GI bleeding

Diabetes

Headache ± confusion

Neurological problems

Diarrhoea

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, calcium-channel blockers, digoxin

Angina ECG, exercise tolerance test, ?angiography

AntianginalsGTN spray for symptom relief

Musculoskeletal CXR,ECGAnalgesicsNSIADs

Short of breath


Pneumonia CXR, bloods, physiotherapy

Antibiotics, nebulised bronchodilators, steroids

Exacerbation of asthma or COPD

CXR, nebs, peak flows, Respiratory centre, physiotherapy, lung function tests

Heart failureCXR, 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


Urinary sepsis Urine dipstix, MSU, IV fluids, daily FBC, U&E

Antibiotics according to likely source or broad spectrum then rationalised according to investigations & culture results

Chest sepsis CXR, FBC, CRP, physiotherapy

Abdominal sepsis AXR, FBC, CRP

Neurological problems


Epilepsyneurological observations, ?CT scan, ?LP, epilepsy nurse, neurological review

Antiepileptics (add, adjust doses or change),

Headache ± confusion


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


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 compoundsSteroids (iv/ po/ pr)

Diabetes


New onset diabetes

BM stix, FBC, U&Es, glucose, urine dip, HbA1c

Oral antidiabetic agents, insulin (BD/QDS), pens, meter, hypo advice

Hypo- or hyperglycaemia

Adjustment of diabetic treatment

Diabetic emergency (DKA, HONK)

IVI, diabetic nurse review, endocrine review, regular urine dipstix, BM stix

Sliding scale insulinAdjustment of diabetic treatment

Diarrhoea


Gastroenteritis (viral, bacterial)

Isolate, isolation proforma for audit trailStool charts & culture

RehydrationAntibiotics as appropriate

Clostridium difficile infection

Psychiatric


Overdose

Levels, INR, U&EsPsychiatric review - ?need for admission or community support

AntidoteWithhold & restart when appropriate (e.g. lithium)Limiting supplies

Schizophrenia

Rapid tranquillisation for their safety & that of othersAntipsychotics

Confusion


Dementia

High observable bedReturn the wandering patient, reassuranceSeptic screenPsychogeriatric review

Symptomatic treatment

Limb pain


CellulitisFBC, CRP, x-raysProforma?vascular review

AntibioticsAnalgesics

Deep vein thrombosis

ProformaAnticoagulationAnalgesics

Arthritis or goutCPRRheumatology review

AnalgesicsNSAIDsSteroids

?suit

able

for

AM

A

Weakness and falls


Stroke/ TIACT scan, carotid dopplerFBC

Aspirin ± dipyridamole, BP control, statin?VTE prophylaxis

Postural hypotension

Lying & standing BPOften over-medicatedBone protection

Parkinson’s disease

NG tube is a priority if NBMMedication 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:– 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?

our medical assessment unit! mark oakley (modern matron) & david young (pharmacist) southampton...

Documents

mau slide

pharmacy department

amu thromboprophylaxis

clinical pharmacy future

uk resuscitation council

clinical management

acute medical unit amu

mau pharmacist