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Yorkshire and Humber Pre-registration Advisory Group Clinical Training Workbook Clinical Area: Leeds Teaching hospitals Clinical Training package Trust: Leeds Teaching Hospitals Trust Trust contact: Clare Roberts Email address: [email protected] Last updated: August 2013 Trainee Name: …………………………………………………………….………. PRE-REGISTRATION TRAINEE PHARMACIST CLINICAL TRAINING PROGRAMME These guidelines have been developed to clarify the responsibilities of the pre-registration pharmacist and supervising pharmacist/ward support technician UNIT 1 - ACCOMPANIED WEEKLY WARD VISITS These weekly ward visits cover a variety of specialities and are organised by the advanced clinical pharmacists for the speciality. They form the introduction to clinical pharmacy for the pre-registration trainee - see timetable for allocation of ward visits. UNIT 2 - MEDICINES SUPPLY IN CLINICAL PRACTICE - WARD SUPPORT Full year pre-registration pharmacists work as part of the ward support team for a 6 week rotation under the training and supervision of the ward support technicians Bradford 6 month students and the Leeds Foundation trust pre-reg may spend 1 week observing the ward support team. UNIT 3 - SUPERVISED CLINICAL PRACTICE - CLUSTER WORKING During this unit pre-reg trainees work under the supervision of the cluster pharmacists and are allocated their own selected group of patients (or ward). UNIT 4 - PRESCRIPTION VALIDATION This unit should be worked on throughout the training year. Planning to ensure experience and competence in this area is the responsibility of the trainee and their tutor. UNIT 1 - ACCOMPANIED WEEKLY WARD VISITS AIM & OBJECTIVES Aim: To introduce ward and clinic based pharmacy practice within a wide variety of clinical specialities Objectives: At the end of this unit the student should be able to: Describe the main activities undertaken by a pharmacist on a ward. Demonstrate or provide evidence of a number of clinical skills appropriate to the specialities visited Demonstrate a pro-active approach to ward based learning Reflect on their experiences and develop their own learning objectives. In addition, objectives specific to the clinical speciality may be provided by the supervising pharmacist GENERAL PRINCIPLES Ward visits will be 2 hours each morning from 9am - 11am but will be flexible depending on departmental and pharmacist’s needs. Ward visits should occur on 3 or 4 days of the allocated week Pre-reg should contact the named pharmacist at least 2 weeks prior to the ward visits to arrange the times and dates of the ward visits and to check if any preparatory work is required. If the weeks allocated are not appropriate for the pharmacist or the pre-reg it is the responsibility of the person for whom the date is inconvenient to rearrange. There are some “blank” weeks on the ward visit timetable to facilitate this. The pre-regs’ departmental rotation is highlighted in bold on the timetable. GUIDELINES FOR WEEKLY WARD VISITS The pre-reg should be with the pharmacist for 2 hours but should not just follow them about expecting the pharmacist to do all the teaching. Pre-regs should work alongside the ward pharmacist completing any tasks given to them. They should be pro-active at using their clinical skills checklist to achieve the required competencies. PHARMACEUTICAL CARE PLANS Pre-regs are expected to complete at least 2 pharmaceutical care plans as part of their pre-registration training. Supervising pharmacists should be able to help identify suitable patients with pharmaceutical care needs eg monitoring or counselling. FEEDBACK Pre-regs should ask the supervising pharmacist for feedback on their performance and ask for a feedback form to be completed. UNIT 2 - MEDICINES SUPPLY IN CLINICAL PRACTICE - WARD SUPPORT The following guidance is in 2 parts: Part 1: applicable to Bradford University 6 month placements and Leeds Partnerships Foundation Trust pre-regs (who complete one week shadowing Ward Based Technicians during unit 1), Part 2: applicable to full year pre-regs, who spend 6 weeks completing their medicines supply in clinical practice rotation (unit 2). PART 1: BRADFORD & LEEDS FOUNDATION TRUST 6 MONTH PRE-REGISTRATION STUDENTS AIM: To allow the pre-reg to gain an understanding of ward based pharmacy technical services. OBJECTIVES: At the end of this unit the pre-reg should be able to: Describe the main activities undertaken by a ward based technician Describe common problems in the transcription process, particularly with regard to involvement of different professions Describe systems and procedures that can minimise errors in the ordering and transcription processes See also the Unit 1 objectives that relate to medicines supply experiences 6 month pre-regs do not complete the WS (ward support) training package, so there are a number of restrictions on their activity. If you are working on a ward with a 6 month pre-reg who is carrying out some shadowing of ward support they may ask you for advice & supervision on some clinical issues or tasks. At this stage there should be direct supervision of tasks by a pharmacist (as per unit 1) unless the pharmacist is happy that they are competent in the given task, in which case indirect supervision may be provided. SUMMARY OF ACTIVITIES PRE-REGISTRATION STUDENTS CAN UNDERTAKE DURING UNIT 1 WARD VISITS AND PRIOR TO COMPLETION OF WARD SUPPORT TRAINING Activity Further action required & by whom Activities which Write orders on yellow sheets for The order must be checked & signed by a Pre-regs CAN medication pharmacist not a WS technician Take a medication history The person they are working with must be do . Activities which pre-regs can trained to take medication histories AND must carry out IF check AND countersign the pre-reg’s work. UNDER SUPERVISION Check a patient's own medicines for This must be done under the direct supervision suitability of use on the ward of a pharmacist or WS-trained technician. The pharmacist or WS technician must countersign all documentation. Annotating drug charts eg with generic Pharmacist must provide direct supervision and names, infusion rates and writing in counter-sign any endorsements/entries in medical notes in accordance with local medical notes policy Activities which Validate drug charts in any way pre-regs must This includes: NOT carry out - signing “Pharm” box on inpatient charts - signing the medication review level box on inpatient charts - signing clinical check box on Discharge A pharmacist must do this. If a suitable opportunity arises however, preregs are encouraged to review the whole drug chart and present their findings to the pharmacist who should provide feedback to the pre-reg before the pharmacist signs the chart Advice Notes (DANs) Check one-stop or patients own medication against a validated discharge advice note ie perform an accuracy check on a DAN on the ward An accuracy checker must do this UNIT 2 - MEDICINES SUPPLY IN CLINICAL PRACTICE – WARD SUPPORT PART 2: FULL YEAR PRE-REGISTRATION STUDENTS Unit 2 ward visits should be carried out every day of the week. There is no specific requirement for pre-regs to be back in their department for a particular time, but they are expected to return to their base dispensary once they have finished their ward work. MEDICINES SUPPLY IN CLINICAL PRACTICE: AIM & OBJECTIVES Aim: To allow the pre-reg to gain an understanding of ward based pharmacy technical services and how these integrate with the clinical requirements of patients and clinical pharmacy activity on the ward. Objectives At the end of this unit the pre-reg should be able to: Obtain and document an accurate medication history for a patient. Check Patient’s Own Drugs for accuracy and suitability for use on the ward (but not against a DAN). Review an inpatient drug chart for drugs that need ordering as a non-stock / one stop supply Identify any discrepancies between the drug history, what has been prescribed, and/or what needs to be supplied, and suggest appropriate courses of action. Liaise with the ward pharmacist over medicine supply Accurately and legibly write a non-stock / one stop order (yellow sheet) TRAINING FOR MEDICINES SUPPLY IN CLINICAL PRACTICE Pre-registration students have to complete the same ward support training packages as ward support technicians (POD and chart checking) before they are allowed to provide medicines supply services to a ward on their own. We expect that this training will take no more than 3 weeks, although this time may be reduced if all the background reading is completed during the in-patient dispensary rotation. Pre-reg students should make sure they get their assessments booked in good time. At the beginning of their Unit 2 rotation, pre-regs will initially work with a trained ward support technician to complete the departmental Non-stock/One-Stop Transcription & Ordering Training, which includes: Non-stock/One Stop ordering training pack and observation of WS technicians at ward level Assessment scenarios & questions A 2 part test (total of 18 charts, including many common errors and transcription related problems) Once this is completed, pre-regs will undertake the POD training pack & assessment, which includes: POD training pack (trust procedure) Assessment questions 20-item log Simulation test (15 items) Until the above training packs have been successfully completed, then the pre-reg must work with a trained WS technician on the wards and adhere to the limitations outlined for 6 month pre-regs above. Once the training packs have been passed, they will be allocated to provide medicines supply services to a designated ward for the rest of their Unit 2 rotation. It is the responsibility of the pre-reg to introduce themselves to the ward pharmacist and ward team on the first day. Pre-reg students may then carry out the following activities on the ward: SUMMARY OF ACTIVITIES PRE-REGISTRATION STUDENTS CAN UNDERTAKE FOLLOWING COMPLETION OF THEIR WARD SUPPORT TRAINING Activity Activities which Pre- Check the transcription of an item regs can do without ordered by a pharmacist supervision Check the transcription of an item Further action required None None ordered by a WS tech or nurse as long as the entire chart has been validated by a pharmacist Annotate drug charts according to local SUPPLY policy Write orders on yellow sheets for medication None Must be checked and signed by a pharmacist, or if the chart has been validated by a pharmacist, a qualified WS tech can check and sign. Activities that pre- Any clinical activity including any Pharmacist must provide direct or indirect regs must carry out clinical annotation of drug charts, eg supervision according to guidance, and under supervision generic names, infusion rates or countersign any written work (see detailed of a pharmacist* writing in medical notes guidance on unit 3) Activities that pre- Check the transcription of another Must be done by a pharmacist or WBT regs must never pre-registration student carry out Check PODs or OSDs against a Must be done by an accuracy checker validated DAN Validate a drug chart Must be done by a pharmacist *For Unit 2, there is no requirement for the pharmacist to be on the ward at the same time as the pre-reg student. If clinical issues are identified by the pre-reg then these should be highlighted to the ward pharmacist (either verbally or on the handover sheet) and, where possible, the pre-reg should suggest an appropriate course of action. Examples of clinical issues include; A discrepancy between the drug history and what is prescribed A strange looking dose or frequency on the prescription order form Any interactions or therapeutic duplications A missing brand name (if required) A medicine we do not keep, that there is a manufacturing problem with, or that is non-formulary Orders for restricted antimicrobials Solid dosage forms ordered for a patient who is NBM An important medication has been omitted for a period of time PRE-REGISTRATION PHARMACISTS AND CLUSTER WORKING AIM & OBJECTIVES Aim: At the end of the supervised clinical practice rotation pre-registration pharmacists should be able to demonstrate the necessary competencies required of a newly qualified pharmacist at ward level. Objectives At the end of this unit the pre-reg should be able to: Identify, document and resolve pharmaceutical care problems Know their limitations and the sources of help/advice available Follow all the ward and pharmacy based clinical policies and procedures. Communicate appropriately with patients, medical staff and other healthcare professionals Reflect on their experiences and/or feedback and develop a learning plan GENERAL PRINCIPLES The pre-registration pharmacist will be on the wards 8.45am-1pm Monday to Friday unless agreed otherwise. SUPERVISING PHARMACIST RESPONSIBILITIES (BAND 7 OR ABOVE) Ensure pre-reg is aware of who is the supervising pharmacist, their contact details and what time they will be present on the ward Ensure the pre-reg and supervising pharmacist spend at least 20-30minutes overlapping at ward level for a complete handover of work. Handover should be carried out in person, before the pre-reg leaves the ward, to minimise the risk of error and to ensure problems are sorted without delay. Liaise with the pre-registration trainee about following up Pharmaceutical Care issues and any monitoring associated with specific drugs or the patient’s condition. Discuss medicine information enquiries with the pre-registration trainee and check that the answer is correct and that they are prepared for extra associated questions before they feedback the answer at ward level. Ensure formal (department approved, where available) or informal (observation by the supervising pharmacist) assessment has taken place to establish that the pre-registration trainee is competent to carry out tasks such as discussing medicines with the patient, ensure that they have the correct information to counsel patients eg on warfarin, inhalers, amiodarone, any other new medication etc, and to provide direct supervision where competence is not established. Provide the pre-registration pharmacist with a communication or handover sheet to enable them to document any activities they have undertaken ie drug histories, counselling etc so that you can verify their work where appropriate. This document should be used during the face to face handover before the pre-reg leaves the ward. Give regular feedback to the trainee (positive and/or negative) and communicate in writing with the pre-registration tutor regarding the trainee’s performance at least once a month (email is sufficient). Feedback should always be given at the earliest opportunity and in a constructive manner. Inform the trainee of any AL/LT or late nights and which pharmacist will be covering and countersigning their work. PRE-REGISTRATION PHARMACIST RESPONSIBILITIES Inform supervising pharmacist well in advance of any AL, LT or late nights. Before leaving the ward ensure any work that requires a pharmacist counter-signature is counter-signed. Discuss with the supervising pharmacist any specific training/learning needs. Read relevant policies/evidence etc. WORKING ON THE WARD WITH YOUR PRE-REG: Days 1 & 2: Introductory period of shadowing the pharmacist to gain familiarity with the speciality (and read any relevant references). Introduce pre-reg to ward staff and location of drug lockers/medicine cupboards etc Day 3 onwards: 1 bay of patients (increasing to 2 or more bays when appropriate) to be allocated to the pre-reg to look after for 1-2 months. Pre-regs should carry out the daily pharmaceutical care tasks for these patients, and then discuss their recommended interventions during the handover or as they go along (depending on the supervising pharmacist’s preferred way of working). Supervising pharmacists should also “spot check” some of the charts that the pre-reg says do not require interventions, to check they have not inadvertently missed any issues. Other useful learning tasks: The pre-reg should complete detailed 1 or 2 pharmaceutical care profiles for typical patients in your speciality (you may need to help them identify suitable ones), in a similar way that junior pharmacists would complete care profiles for a diploma or other learning exercise. We have provided a care profile template for pre-regs to use along with guidelines for use, but they may need directing to suitable references for your speciality (eg PJ articles or Oxford Clinical Handbook etc). This is intended as a learning exercise to help them become familiar with the types of interventions and thought processes required in pharmaceutical care of patients in your speciality. Please set aside time so that the pre-reg can talk you through their profiles and you can provide feedback. Set the pre-reg tasks that you (or the pre-reg) have identified, observe them and, if you consider them competent, allow them to carry out these tasks under indirect supervision in the future. CLUSTER WORKING SUPERVISION: Supervision for different activities in cluster working are summarised as follows: Direct Supervision - Supervising pharmacist MUST be present Indirect Supervision - Once competency established supervising pharmacist does not have to be present but must be aware of activity and countersign work where appropriate. Activities ALWAYS under DIRECT supervision Activity Action required by pharmacist Sign the “pharm” box by each medication Supervising pharmacist to countersign immediately Sign that a medication level review has been undertaken Supervising pharmacist to countersign immediately Writing in patients medical notes (except when annotating medication histories see below) Ensure entry is carried out to CPS SOP standard. Supervising pharmacist to countersign Activities INITIALLY under DIRECT supervision (and can change to indirect supervision when considered competent) Verbal advice or counselling Discuss prior to pre-reg providing advice/counselling to ensure competence. Supervise if appropriate Take a medication history and annotate medical notes according to policy Check & countersign (unless DHx taking package taken & passed, in which case can do independently and no countersignature is necessary. Activities under INDIRECT supervision Writing care plans Check & discuss Therapeutic monitoring Check, provide feedback Endorsing drug charts (eg with generic name or infusion rate etc) Check, provide feedback & sign pharmacy box Write orders for medication (yellow sheets) Check & countersign (WS tech may do this but only if pre-reg has passed WS training & test) Check patients own medicines against a validated TTO WS tech or pharmacist must do this Activities that the prereg must NEVER do UNIT 4 - PRESCRIPTION VALIDATION AIM To provide the pre-registration pharmacist experience of validating and annotating prescriptions OBJECTIVES All of the objectives MUST be carried out under the direct supervision of a pharmacist who must countersign all work At the end of this unit the student should be able to; Follow the clinical SOP for Validating and Annotating Prescriptions From a variety of prescription formats identify problems that require immediate action and note all the potential problems. Demonstrate the ability to deal with problems requiring immediate action and any other problems identified. TRAINING PROVIDED Theory and examples covered in regional study day in October Two Tuesday workshops to provide prescription examples in December and May/June In-house experience working alongside pharmacists GENERAL GUIDANCE Full year students and 2nd placement sandwich students (August-Jan); In addition to validating prescriptions at ward level, validation should form part of the inpatient and outpatient dispensary rotations. As a guide approximately 12 hours (4 afternoons) should be spent working alongside the dispensary based pharmacist in each dispensary rotation. Pre-registration pharmacists (with support from their tutor) should liaise with the lead technician to agree the most appropriate time for this to happen and ensure the agreement of the supervising dispensary pharmacist 1st Placement sandwich students (Feb-July) As part of final dispensary based rotation students should spend approximately 3hours (1 afternoon) validating prescriptions (in addition to ward level validation) Evidence of competence Use validation workshops as evidence of prescription validation Supervising pharmacist to provide a testimonial of the pre-reg’s ability to identify and deal with problems identified whilst validating prescriptions CONTACT DETAILS FOR ACCOMPANIED WARD VISITS Ward visits for the following specialities will be co-ordinated by the following pharmacists. The named pharmacist should be your initial point of contact. It is recommended that the pharmacists are contacted at least 2 weeks before the timetabled ward visits to discuss a timetable and establish if any pre-reading or preparatory work is to be completed. Pre-reading may be found on the pre-reg folder; I drive; Pre-reg; clinical references 2013 Pharmacists COMPULSORY SPECIALITIES PHARMACIST CONTACT DETAILS (BLEEP) PHARMACIST CONTACT DETAILS (BLEEP) Respiratory Cardiology Elderly & Stroke Rehab Surgery Paediatrics Renal Acute Medicine SPECIALIST AREAS Rheumatology Gastroenterology Infectious Diseases Liver Neurology Cystic Fibrosis (CF) A&E/CDU Vascular Endocrinology PRE-REG TIMETABLE FOR ACCOMPANIED WARD VISITS – AUGUST 13-JAN 14 Date 29/709/08 INDUCTION, THEN BASED IN SERVICE ROTATIONS 12/08 LGIP Elderly 19/8 Cardiology 26/8 A&E/CDU LGOP Cardiology Elderly 02/09 Bexley Cardiology SJIP A&E/CDU SJOP Surgery Bexley Surgery LGIP Paediatrics -1 Surgery Cardiology Renal Renal Surgery Liver Liver A&E/CDU Respiratory Paediatrics -2 Gastro Cystic Fibrosis Liver Neurology Infectious Dis Neurology Cardiology Cardiology Aseptics Aseptics SJOP Respiratory Aseptics Aseptics Elderly Aseptics Aseptics Psychiatry Aseptics Aseptics Psychiatry REGIONAL STUDY DAYS (TUE-THURS) 09/09 Liver CAH Paediatrics 1 Elderly 16/09 Surgery Paediatrics 2 Respiratory 23/09 Infectious Dis Rheum 30/9 Community Psychiatry Aseptics 07/10 Community Psychiatry Aseptics 14/10 SJOP CF Ward support; Unit 2 LGI Aseptics 21/10 AS BELOW Renal 28/10 Respiratory Elderly Ward support; Unit 2 SJ Aseptics REGIONAL STUDY DAYS (MON-WED) MI Infectious Dis Vascular Vascular Ward support; Unit 2 MI Respiratory MI Paediatrics 1 Community Psychiatry Vascular Paediatrics 2 Community Renal Psychiatry Elderly A&E/CDU SJOP Gastro Bexley Surgery Community CAH Rheumatology LGIP Cardiology Renal Community Paediatrics 1 Paediatrics 1 Vascular 09/12 Respiratory Acute Medicine Paediatrics 2 Paediatrics 2 Elderly 16/12 CF Acute Medicine Neurology 23/12 - LGIP - - - - - - - - - 06/01 Aseptics Paediatrics 1 Aseptics Psychiatry Acute Medicine 13/01 Aseptics Paediatrics 2 Aseptics Psychiatry Acute Medicine 20/01 Aseptics A&E/CDU Aseptics Community Community 04/11 Respiratory 11/11 Acute Medicine 18/11 Acute Medicine 25/11 Psychiatry 02/12 Psychiatry 30/12 Ward Support; Unit 2 LGI Ward support; Unit 2 SJIP Endocrinology Acute Medicine Acute Medicine Ward support; Unit 2 LGI PRE-REG TIMETABLE FOR ACCOMPANIED WARD VISITS – AUGUST 13– JAN 14 Date 29/709/08 INDUCTION, THEN BASED IN SERVICE ROTATIONS 12/08 CAH Rheum SJIP Paediatrics -1 Aseptics Aseptics 19/8 Neurology Endocrinology Aseptics Aseptics 26/8 Respiratory Paediatrics 2 Aseptics Aseptics 02/09 09/09 AS BELOW Aseptics Aseptics Aseptics REGIONAL STUDY DAYS (TUE-THURS) LGIOP A&E/CDU MI Elderly MI A&E/CDU MI Acute Med 16/09 Surgery Cystic Fibrosis Acute Med Renal Renal 23/09 Renal Renal Surgery Elderly Surgery Community LGIP Rheumatology SJIP Respiratory Bexley Cardiology Community A&E/CDU Paediatrics 1 Paediatrics 1 Cardiology Paediatrics 2 Paediatrics 2 Respiratory Surgery Respiratory 30/9 07/10 14/10 21/10 Acute Medicine Acute Medicine Ward Support Unit 2 LGI Acute Medicine Acute Medicine 28/10 LPFT LPFT LPFT REGIONAL STUDY DAYS (MON-WED) 04/11 11/11 LPFT Ward Support Unit 2 18/11 LGOP Neurology Paediatrics 1 Acute Medicine Elderly Cardiology Paediatrics 2 Cardiology Gastro Respiratory Renal CF Liver 25/11 Bexley Endocrinology SJIP Cardiology LGIP Neurology 02/12 Cardiology A&E/CDU Cardiology 09/12 Gastro 16/12 Liver 23/12 - 30/12 Inf Diseases Ward Support Unit 2 SJ Liver CLUSTER; Unit 3. SJOP CLUSTER; Unit 3 LGOP CLUSTER; Unit 3 LGIP - - - - - 06/01 Aseptics MI Paediatrics 1 MI CF 13/01 Aseptics Paediatrics 2 Elderly 20/01 Aseptics Psychiatry Gastro PRE-REG TIMETABLE FOR ACCOMPANIED WARD VISITS – JAN 14-JULY 14 Date 27/01 Ward support LGI 03/02 Aseptics MI Renal Psychiatry MI Renal 10/02 Aseptics Neurology Psychiatry Gastro 17/02 Aseptics Endocrinology 24/02 Aseptics 03/03 MI Paediatrics 1 Community 10/03 Paediatrics 2 Community 17/03 Gastro 24/03 Aseptics Acute Medicine Acute Medicine Neurology Aseptics Surgery Ward Support; Unit 2 LGI Acute Medicine Acute Medicine Community Acute Medicine Acute Medicine Community Psychiatry 28/04 05/05 CLUSTER; Unit 3 (Regional study days; 14th-16th April and 6th-8th May) 26/05 02/06 09/06 16/06 23/06 30/06 07/07 14/07 21/07 Aseptics Vascular Psychiatry 21/04 Aseptics MI Renal Community 14/04 19/05 Aseptics Ward Support; Unit 2 LGI 07/4 Ward support LGI Aseptics Ward Support; Unit 2 SJ 31/3 12/05 Community Cystic Fibrosis PRE-REG TIMETABLE FOR ACCOMPANIED WARD VISITS – JAN 14-JULY 14 Date Bexley - LGIP - SJIP - MI Vascular LGOP Vascular - - - Community Paediatrics 1 Wards with Natasha Wards with Elaine Elderly Community Paediatrics 2 Renal Respiratory Respiratory Surgery Gastro Liver Surgery MI Paediatrics 1 Aseptics SJIP Surgery Aseptics Aseptics 10/03 Paediatrics 2 Aseptics Liver Aseptics Aseptics Respiratory 17/03 Elderly Aseptics Endocrinology Aseptics Aseptics Elderly Aseptics Elderly Aseptics Aseptics Community 31/3 MI Respiratory MI Renal MI Renal Bexley Endocrinology CF Community 07/4 Paediatrics 1 Paediatrics 1 Infectious Dis Surgery Acute Medicine 29/01 Aseptics 03/02 Community 10/02 Community 17/02 Psychiatry 24/02 Psychiatry 03/03 24/03 Psychiatry MI Elderly Infectious Diseases 14/04 21/04 28/04 Acute Medicine Acute Medicine SJOP Renal Rheumatology Surgery Bexley Renal Respiratory REGIONAL STUDY DAY (MON-WED) CLUSTER; Unit 3 (Regional study days; 14th-16th April and 6th-8th May) Paediatrics 2 Paediatrics 2 Vascular Aseptics LGIP Cardiology Bexley Acute Medicine 05/05 Acute Medicine Aseptics Aseptics REGIONAL STUDY DAY (TUE-THURS) 12/05 Aseptics Elderly Endocrinology Aseptics Aseptics 19/05 Aseptics Ward support LGI Psychiatry MonWed Aseptics Aseptics 26/05 Aseptics Neurology Ward supp SJ Aseptics Aseptics 02/06 LGOP Cardiology Ward support LGI SJOP CF Acute Medicine Psychiatry Mon-Wed Cardiology LPFT LPFT 09/06 16/06 23/06 30/06 07/07 14/07 21/07 CLUSTER; Unit 3 (Regional study days; 14th-16th April and 6th-8th May) Rheumatology Psychiatry Mon-Wed Wards with Natasha Wards with Natasha Wards with Natasha Surgery Wards with Elaine Wards with Elaine Wards with Elaine Paediatrics 1 Paediatrics 2 SJIP Elderly Wards with Clare Wards with Clare Wards with Clare COMMON CLINICAL QUESTIONS PRE-REGISTRATION PHARMACY STUDENTS NAME………………………………………………. These should be completed within 4 weeks of commencing pre-registration training. Some answers will be found on the Trust intranet site, others will require discussing the questions with pharmacists. 1) What is the appropriate antibiotic choice and course length for an elderly male, 82years old, Cr-150, weight 65kg with a lower urinary tract infection (not catheterised)? 2) What is the antibiotic of first choice for a moderately severe community acquired pneumonia in a 50year old patient allergic to penicillin? 3) How would you deal with a patient on Uniphyllin 300mg bd newly prescribed clarithromycin? 4) What do the following abbreviations stand for and why might they be important to you whilst talking to patients? a. MMSE b. AMTS c. MEWS score 5) How does the Trust deal with patients on statins newly prescribed a macrolide antibiotic 6) Looking at the injectable medicines guide how should nursing staff administer the following; (include in your answer a suitable diluent, volume and rate for administration) a) Flucloxacillin 2g iv? In which patients are you likely to see the above prescribed? b) clarithromycin 500mg iv? In which patients are you likely to see the above prescribed? c) Pabrinex I and II iv? In which patients are you likely to see the above prescribed? 7) What is VTE? For the following patients what is the most suitable drug choice (drug and dosage) for VTE prophylaxis? a) 36 year old rugby player (weight 80kg), admitted for elective urological surgery, considered to be a standard risk of VTE? Nil other medical history. b) 85 year old female, Cr-200, Weight 55kg. PMH; Angina, admitted with community acquired chest infection c) 55 year old male, Cr-60, Weight 75kg. Exacerbation of COPD. 8) The ward pharmacist informs you that one of his/her patients has an NG tube for medication and feeding. They are prescribed amlodipine 5mg daily and ramipril 5mg daily. How can these be safely administered? 9) What is the LCP? What drugs are likely to be prescribed for patients on the LCP? 10) Reviewing the NetFormulary what is the equivalent morphine dose for a patient prescribed Butrans® 20microgram/hour? b) What breakthrough oromorph dose should be prescribed for this patient? PRE-REGISTRATION PHARMACIST CLINICAL SKILLS CHECKLIST It is not expected that you will be competent in all the activities but you should have attempted each activity at least on one occasion It is not expected that you demonstrate each task 3 times in order to be competent. It is the judgment of the assessing pharmacist who may believe following one observation competency has been achieved. Similarly, it may be that following 3 observations more practice is needed in order to be consistently competent. NAME PRE-REGISTRATION TUTOR Clinical Pharmacist Activity Complete a pharmaceutical care plan with appropriate actions and monitoring Calculate renal function for a patient and review drug therapy Calculate body surface area for a patient and review drug therapy Check doses correctly on a paediatric prescription Identify a drug interaction and deal with it appropriately Assess a patients ability to manage medication at home Deal with a patient unable to manage medication at home Deal with a patient discharged with a compliance aid Advise on the appropriate use of anti-microbials Deal with a patient admitted on weekly methotrexate (follow SOP) Understand vancomycin prescribing and monitoring Understand digoxin prescribing and monitoring Understand gentamicin prescribing and monitoring Understand aminophylline prescribing and monitoring Deal with a medicines information enquiry at ward level Check and endorse a DAN correctly (countersigned by pharmacist) Contact doctor to discuss a pharmaceutical intervention Date observed (Witness to sign and date) Considered competent Date Clinical Pharmacist Activity Calculate an intravenous drug infusion rate Advise on administration of an intravenous drug (fluid volume and diluent) Warfarin Attend pre-reg workshop on warfarin counselling Attend warfarin clinic (2x4hour counseling sessions) Attend warfarin clinic and provide counselling under supervision of clinic pharmacist/technician (final sign off) Inhaler Counselling Attend pre-reg workshop on inhaler counselling Only 1 observation required of the following; Assess patients respiratory flow rate Undertake counselling under supervision for; MDI Turbohaler Accuhaler Spiriva Handihaler Psychiatry Understand clozapine prescribing and monitoring Undertake lithium counselling under supervision Understand aspects of the Mental Health Act relevant to medication / treatment Date observed (Witness to sign and date) Considered competent Date PHARMACEUTICAL CARE PROFILE During your pre-registration year you will be expected to complete a Pharmaceutical Care profile for at least 2 patients. It is likely that one of these will be the basis for your case presentation. The example below illustrates the type of information that goes in each section of the profile, and the sorts of information to record Main points to bear in mind: Remember confidentiality - use initials or keep document secure. Presenting complaint - can contain brief history of presenting complaint also if you feel it’s appropriate Drug History section - see the relevant department SOPs on how to carry this out. This is for all medication being taken prior to admission. You should always record the source(s) you have used to confirm this history as well as allergies, type of reaction and any compliance aids needed (if none write “none”) Currently prescribed medication - all medication currently on the in-patient medication chart. Always include an aim or indication - if you don’t know what it is, find out, and if you can’t find one, query whether the patient needs that medication! Stop dates can be put in the comments section. Blood levels and other monitoring - space for you to record monitoring relevant to your patient’s condition. You might not need to record all parameters on every day. Record what is relevant and look at the trend. Pharmaceutical Care Issues - space for you to record any problems you have noted. Keep these relevant to pharmaceutical care - don’t get sidetracked with finding out about things that would not affect pharmaceutical treatment, management or counselling, eg - “needs home care every day nurse to ring social services”. State what your plan is (you can revise this through that patient’s stay if needed by using a new entry), and what the outcome measure is, but be specific, eg instead of “monitor BP” put “aim for BP below 140/85”, or whatever range is relevant for your patient. Using the profile should help you think about planning and monitoring of patients with the relevant conditions. It can be used for any ongoing pharmaceutical care interventions you make. Pre-registration Trainee Pharmacist Clinical Training Programme Leeds Teaching Hospitals Pre-registration Trainee Pharmaceutical Care Profile Example Patient name Jenny Bloggs DOB 14th Oct 1920 Date of admission Unit no 10th November 123456 Ward/speciality 33 / Care of the Elderly Age 87 Weight 74kg Presenting complaint Fall. Felt dizzy, grabbed chair for support, missed and banged head. Found on floor by neighbour. Bruise and pain to cheek. Past Medical History Osteoarthritis Falls x 2 # NOF 2 years ago Osteoporosis Depression Hysterectomy age 45 hypertension GP: North Leeds Medical Centre Social History Lives alone. Husband died 4 years ago Meals on wheels three times weekly Son does shopping, private cleaner once a week Community pharmacist: Co-op Main St Alwoodley Drug History (include strength, frequency, form, etc) Paracetamol 1g qds prn (usually only takes once or twice daily) Alendronate 70mg weekly (weds) Citalopram 10mg od (? Still taking) Bendroflumethiazide 2.5mg om Source(s) used? GP print out PODs Allergies/sensitivities: Type of reaction? Penicillin - rash Currently prescribed medication OA OA OA Nov 10 Nov 10 Alendronate tabs Citalopram tabs Paracetamol tabs Codeine PO4 tabs Lactulose liq Dose (strength,freq) 70mg weekly 10mg om 1g qds 30mg prn 10ml bd Nov 12 Calceos tabs i bd Date started Name & form Compliance aids? Large print labels please Indication / intended therapeutic outcome Fracture prevention Depression Pain control Pain control Prevention of constipation while on opiates & poor mobility Fracture prevention in conjunction with bisphosphonate comments Stopped Nov 14 New Counselled Pre-registration Trainee Pharmacist Clinical Training Programme Leeds Teaching Hospitals Blood Levels and Other Monitoring Parameter Parameter Date Na+ K+ Ur Creatinine BP (lying) BP (standing) Pain score Nov 10 Nov 12 Nov 15 128 3.8 8.8 182 150/84 120/80 3/5 130 3.9 6.3 149 120/80 116/82 1/5 134 4.1 5.5 130 122/86 118/84 Pharmaceutical Care Issues Date What is the problem? Nov 11 No day for alendronate prescribed Ask patient which day normally taken and amend chart Nov 11 Postural drop Nov 11 Na is low; pt may not be compliant with citalopram Nov 11 Urea & Creatinine are high - ? dehydration Monitor BP and recommend treatment if needed. Ensure GP informed of any change Bendro is already stopped - consider stopping citalopram if non-compliant or mood satisfactory. Counsel pt on taking SSRI if decide to continue. Monitor Na+ to ensure comes back into range. Review treatment as necessary. Ensure pt drinking plenty. Monitor Ur & Cr. Calculate CrCl and ensure no medication being given that is renotoxic, or adjust dose as needed Nov 12 Pt has osteoporosis and is on bisphosphonate but no calcium/vit D3 Pt due for discharge Nov 15 How do you plan to address it? D/W Drs re starting Calceos. Counsel patient Ensure TTO written & changes documented for GP. Provide clinical check and arrange for POD accuracy check & additional medications to be dispensed. Ensure in-pt & community pharmacy aware pt requires large print labels. Counsel patient on any changes to medications and answer any questions. What is your intended outcome? Alendronate to be prescribed on the correct day BP to be below 140/85 with no postural drop Na to be between 135145. Pt to either take citalopram as directed or stop if no benefit. Ur to be between 3.55.0; Cr to be between 70-100 or relevant medication doses to be adjusted as needed Ensure efficacy of bisphosphonates in preventing fractures Safe & timely discharge to the community with all appropriate medication. That patient understands when & how to use meds safely Completed? Nov 11 Nov 15 Nov 12 Pre-registration Trainee Pharmacist Clinical Training Programme Leeds Teaching Hospitals Pre-registration Trainee Pharmaceutical Care Profile Date of admission Patient name DOB Age Unit No Weight Ward/speciality Presenting complaint Past Medical History GP: Social History Community pharmacist: Drug History (include strength, frequency, form, etc) Source(s) used? Allergies/sensitivities: Type of reaction? Compliance aids? Currently prescribed medication Date started Name & form Dose (strength,freq) Indication / intended therapeutic outcome comments Pre-registration Trainee Pharmacist Clinical Training Programme Leeds Teaching Hospitals Blood Levels and Other Monitoring Parameter Parameter Date Pharmaceutical Care Issues Date What is the problem? How do you plan to address it? What is your intended outcome? Completed? Pre-registration Trainee Pharmacist Clinical Training Programme Leeds Teaching Hospitals PRE-REGISTRATION TRAINEE WARD VISIT FEEDBACK FORM Trainee: Speciality: Pre-Reg. Tutor: Ward Pharmacist/Supervisor: No of ward visits with trainee Excellent Very Good Good Average Poor Punctuality/Time-Keeping. Professional appearance/Manner. Application, Effort. Standard of work, Reliability. Ability to demonstrate Clinical Knowledge. Communication/Attitude to Patients. Communication/Attitude to Colleagues. Response to Advice, Criticism. General Performance. Pharmacist/Supervisor’s Comments: ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... Trainee’s Comments: ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... Pre-Reg. Tutor’s Comments: ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... Signed: ..................................... Pharmacist/Supervisor Tutor ...................................... Trainee ..................................... Pre-Reg. Date: ....................................... Please return by e-mail as an attached word document to the trainee’s pre-registration tutor or hand to the trainee to return to the tutor Not assessed