Monday, November 2, 2009

From Inpatient to Outpatient

Posted by Shannon Hough at Monday, November 02, 2009

I've made the jump from inpatient care at Botsford General Hospital to working in an outpatient clinic area at the Ann Arbor VA. I spent my final weeks at Botsford working on a number of projects that are very representative of what a clinical pharmacist might do, outside of patient care.

One project I tackled was a drug utilization evaluation (DUE) for erythropoiesis-stimulating agents (ESAs). A DUE is a "system of ongoing, systematic, criteria-based drug evaluation that ensures the appropriate use of drugs"1. At Botsford, this entailed printing a daily report of all patients who had been prescribed an ESA, checking the paper medication administration record (MAR) to see if/when it had been administered, and checking a few laboratory parameters (hemoglobin, etc.). Health care institutions frequently conduct a DUE to investigate how a drug is being used to properly make decisions related to formulary considerations, outcomes and economics research, or to ensure that the institution is meeting current standards of care. While searching for numerous paper charts, MARs, and even patients can be tedious, the results are valuable to the institution.
My final project was to give a lecture to patients who had prior cardiac surgery. In the lecture, I gave a brief overview of each of the medication classes that the patients were likely to be using. The overview contained important safety information, expected side effects and specific instructions related to certain agents such as nitrates and warfarin. AND I SURVIVED! As a student and pharmacist intern, I felt very prepared to talk to other healthcare professionals regarding medication topics. However, I was pretty nervous to face a class of patients taking notes and asking questions. And would you believe I actually knew the answers to their questions too? A great way to end rotation 3.

I started my fourth rotation at the Ann Arbor VA last Monday
in ambulatory care. My preceptor and main clinic area is anti-coagulation, however I also attend geriatrics, primary care, and arthritis clinics. Most of the patients I have seen served in World War II. I had the opportunity to see a patient in clinic for a medication reconciliation appointment after he had confused his medication instructions.

Mr. G is 86 and on a fairly complex medication regimen with at least 9 drugs and 3 different medication administration times throughout the day. While reviewing his medications with him (and having to remove and rearrange many medications in his pillbox, and confiscate a number of expired medications), it became clear to me that he was very overwhelmed with his medication list, and was not able to understand the chart that the clinic provided to him. He jokingly told me that I could go ahead, but he wasn't going to understand how to read the chart
to fill his pillbox. At that moment, I was determined to help Mr. G, aside handing him a
chart he couldn't read and filling his pillbox correctly for a single week.
My first step was to put the medication list into his hands. I then asked him to read it to me. When he was having difficulty, I offered him a blank piece of paper, to cover up most of the chart and just read one drug at a time. This was helpful. Then, through a number of open-ended questions, I was able to understand that Mr. G knows when to take his medications by what they look like and what they are for. So it was important to list the indication for each drug on his chart. He also was not able to remember to take his medications at 3 different times, so I was able to change when he took certain medications so that he only had to take his medicines twice a day and not miss any doses. He also told me that it would be easier to read his medication list if the drugs were organized chronologically, with the morning doses listed first. By the end of the appointment, Mr. G was able to tell me when he took each of his drugs by name, reading off of the chart, and match them with the appropriate prescription bottle.
This whole encounter lasted about an hour, and Mr. G was a walk-in patient. Luckily, we had a low patient load that day and were able to spend the time with him. I have no doubt that pharmacists do not always have enough time to spend with their patients. I think that working in an ambulatory care clinic is a place where this can be especially trying. If a patient needs more time than they were scheduled for, what do I do? Spend the extra time with him and fall behind schedule, making later patients wait? Quickly update his medication sheet, throw away the expired medications and give him an encouraging pep-talk to get it together and stay on schedule? Hopefully there is a medium somewhere!

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