4. Anexos
4.17. Anexo 17: Semana do Saco: Resultados
0 2 4 6 8 10 12 14 49 54 59 64 69 74 79 84 89 Idade
Variação do Nº de Problemas de Saúde e de
Medicamentos de acordo com a Idade dos Participantes
Problemas de Saúde Medicamentos
Figura 16 – Variação do número de problemas de saúde e de medicamentos com a idade dos participantes.
Whittington Hospital
Ana Paula Fernandes Pereira
ii
Faculdade de Farmácia da Universidade do Porto
Mestrado Integrado em Ciências Farmacêuticas
Relatório de Estágio Profissionalizante
Whittington Hospital
Janeiro a Abril de 2018
Ana Paula Fernandes Pereira
Orientador : Dr.ª Caroline Edwards
Co-orientador: Dr.ª Alexandra Cardoso
iii
Declaração de Integridade
Declaro que o presente relatório é de minha autoria e não foi utilizado
previamente noutro curso ou unidade curricular, desta ou de outra instituição. As
referências a outros autores (afirmações, ideias, pensamentos) respeitam
escrupulosamente as regras da atribuição, e encontram-se devidamente
indicadas no texto e nas referências bibliográficas, de acordo com as normas de
referenciação. Tenho consciência de que a prática de plágio e auto-plágio
constitui um ilícito académico.
Faculdade de Farmácia da Universidade do Porto, 07 de setembro de 2018
iv
Acknowledgments
First, I would like to acknowledge the Faculty of Pharmacy of the University of Porto for five years of learning in admirable conditions, from teachers to facilities, for preparing me for my future as a pharmacist and for giving me the opportunity to have this amazing experience.
I must also thank the International Relationships Department of the University of Porto, for promoting the ERASMUS program and for guiding and helping me through the whole process.
To Caroline Edwards, for the opportunity, for the kindness and for all the help throughout the entire internship and even before it started.
To Alexandra Cardoso for your unceasing kindness, guidance and support, for successfully trying to make the most of these three months and for teaching me much more than just science. No words can express my feeling of gratitude towards you.
To Leonor Neves for your words of encouragement, for challenging me to learn and do more every day and for always being available to help me. You truly are a pharmacist I look up to.
To everyone from the pharmacy department, pharmacists, pharmacy technicians and pre-registration pharmacists, I am so grateful for having had the chance of meeting and learning from all of you. You are amazing professionals and even more incredible people. Thank you for making me feel part of the team.
To my family and friends, for the constant support, for the encouragement to embrace this experience and for making me feel at home every day during those three months.
v
Index
Acknowledgments ... iv Abbreviations ... vii 1. Introduction ... 1 2. The Hospital ... 1 3. The Pharmacy Department and My Rota ... 2 4. Inpatients’ Dispensary ... 2 5. Outpatients’ Dispensary ... 5 6. Medicines Information Centre ... 5 7. Anticoagulation Clinic ... 7 8. Production ... 8 9. Wards ... 10 9.1. Care Of Older People (COOP) ... 11 9.2. Women Children & Family Ward ... 12 9.3. Nightingale ... 14 9.4. Victoria Ward ... 15 9.5. Montuschi Ward and Coronary Care Unit (CCU) ... 16 9.6. Surgery Wards ... 16 9.7. Mary Seacole Ward ... 18 10. Learning Sessions ... 1811. Discussion ... 19 12. Conclusion ... 20
13. References ... 21
14. Appendix ... 23 14.1. Appendix 1: Example of a MaPPs leaflet. ... 24 14.2. Appendix 2: Example of an Inpatient prescription. ... 24 14.3. Appendix 3: Example of a One-stop prescription. ... 24 14.4. Appendix 4: Example of a To Take Away prescription. ... 24 14.5. Appendix 5: Query regarding the use of topiramate and levetiracetam in pregnancy and breastfeeding. ... 24
vi 14.6. Appendix 6: Query regarding the possible interaction between bromelain & turmeric tablets and etoposide & carboplatin for a lady with small cell lung cancer. .. 24 14.7. Appendix 7: Medicines Reconciliation Accreditation (SOP 96) ... 24 14.8. Appendix 8: Timetable for my Women Children & Family Ward rotation. ... 24 14.9. Appendix 9: Maternity patient profile presentation. ... 24 14.10. Appendix 10: Mary Seacole North patient profile presentation. ... 24 14.11. Appendix 11: Certificate of attendance to the Level 1 Training in Treating Tobacco Dependence. ... 24
vii
Abbreviations
UK - United Kingdom
NHS - National Health Service A&E - Accident and Emergency MI - Medicines Information Centre COOP - Care of Older People PTS - Prescription Tracking System JAC – JAC Medicines Management PIL - Patient Information Leaflet
MaPPs - Medicines: a Patient Profile summary TTA - To Take Away
CD - Controlled Drug
SOP - Standard Operating Procedure SPS - Specialist Pharmacy Service BNF - British National Formulary
AHFS - American Hospital Formulary Service Q&A - Questions and Answers
UKMi - UK Medicines information DOACs - Direct Oral Anticoagulants GP - General Practitioner
DVT - Deep Vein Thrombosis PE - Pulmonary Embolism AF - Atrial Fibrillation
INR - International Normalised Ratio TPN - Total Parenteral Nutrition MIG - Medical Interoperative Gateway OTC - Over-The-Counter
BP - Blood Pressure
MAR - Medication Administration Record IV - Intravenous
MDT - Multidisciplinary Team NICU - Neonatal Intensive Care Unit SCBU - Special Care Baby Unit VTE - Venous Thromboembolism
COPD - Chronic Obstructive Pulmonary Disease NRT - Nicotine Replacement Therapy
viii
T2RF - Type II Respiratory Failure PSP - Patient Specific Protocol CCU - Coronary Care Unit
NSTEMI - Non-ST-segment Elevation Myocardial Infarction STEMI - ST-segment Elevation Myocardial Infarction ACS - Acute Coronary Syndrome
ITU - Intensive Care Unit GI - Gastrointestinal LAGB - Gastric Banding
LRYGB - Roux-en-Y Gastric Bypass LSG - Sleeve Gastrectomy
SAGB - Single Anastomosis Gastric Bypass PCA - Patient-controlled Analgesia
CQUIN - Commissioning for Quality and Innovation MAU - Medical Admissions Unit
HHS - Hyperglycaemic Hyperosmolar State MBTI - Myers-Briggs Type Indicator
1
1. Introduction
The end of degree internship is the first step into the work environment and it is very important not only to develop your scientific, clinical and practical knowledge, but also to shape you as a professional. Taking this perspective into account, I wanted to make the best choice when considering where to begin my working experience.
When I heard about the chance of doing an Erasmus placement at the Whittington Hospital and got positive feedback from other students who had done it previously, I thought it was an incredible opportunity. Firstly, because I knew I would learn a lot from working in a hospital in one of the busiest cities in the world, London, characterized by its diversity. Furthermore, I would be living by myself in a foreign country, what would contribute to my personal growth and to improve my fluency in english.
There I was able to see the different roles of a hospital pharmacist in the United Kingdom (UK) and their importance to the healthcare service. I was welcomed and made part of a team composed by amazing professionals. Every day I was challenged to learn and to do more. Honestly, I could not be more grateful for my experience at the Whittington Hospital.
2. The Hospital
The National Health Service (NHS) is the public health service in the UK, responsible for providing a curative and preventive care service to the whole population. The fundamental principles behind the creation of the NHS were, and still are, that services should be comprehensive, universal and free. The system integrates hospitals, a national network of general practitioners and community and domiciliary health services [1].
A NHS trust is a health care organisation that provides hospital services, community services and/or other aspects of patient care, such as patient transport facilities [2]. Whittington Health NHS Trust includes a general hospital, the Whittington Hospital, and several community care services, providing health to 500,000 people living in Islington and Haringey as well as other London boroughs [3].
The hospital dates from 1948, resulting from the junction of 3 pre-existing hospitals, and provides a large range of services, including accident and emergency (A&E), maternity, diagnostic, therapy, elderly care and outpatients’ clinics. It is named after Sir Richard Whittington, an English merchant and a politician of the late medieval period, four times Lord Mayor of London [4].
The Whittington Health’s mission is to “help local people live longer, healthier lives” and in order to achieve it the important values that are promoted are the ones that form up the acronym “I- CARE”: Innovation, Compassionate, Accountable, Respectful and Excellent [5].
2
3. The Pharmacy Department and My Rota
The inpatients’ pharmacy is a department in the Whittington Hospital with about 70 professionals, including pharmacists, pharmacy technicians, storekeepers, among others. It is divided in sections, such as the inpatients’ dispensary, the distribution room, the medicines information centre (MI) and several offices. Throughout this report I am going to describe the role of the pharmacists in each section and rotation.
On my first day, I was introduced the department and given a timetable (Table 1) for my time there. This comprised most of the rotations in which the department pharmacists work.
4.
Inpatients’ Dispensary
The first three weeks of my internship were spent in the inpatients’ dispensary, which is responsible for supplying medication to patients within the hospital or attending Day Surgery, Ambulatory Care, Chemotherapy Suite, Thalassaemia and Sickle Cell Unit. In the dispensary, the prescriptions are screened, dispensed and, finally, the items dispensed are checked and are ready to be collected by the pharmacy porter who takes the medication to each ward.
The screening is done by pharmacists who ensure that the information regarding the patient, the ward and the consultant is correct and make sure that the medication prescribed is adequate considering the diagnostic, the current clinical guidelines and other medication, allergies or
Week 1:
15/01/18 – 19/01/18
Introduction to the department Inpatients’ dispensary
Distribution (one morning)
Weeks 2 and 3:
22/01/18 – 02/02/18 Inpatients’ dispensary Weeks 4 and 5:
05/02/18 – 16/02/18
Medicines Information
Anticoagulation (one morning)
Weeks 6 and 7:
19/02/18 – 02/03/18 Care of Older People (COOP) Wards Week 8:
05/03/18 – 09/03/18 Production
Week 9:
12/03/18 – 16/03/18 Women Children & Family Wards Week 10:
19/03/18 – 23/03/18
Nightingale Ward (two days) Victoria Ward (one day) Montuschi Ward (one day) Production (one day)
Week 11 and 12:
26/03/18 – 06/04/18 Surgery Wards
Week 13 and 14:
09/04/18 – 19/04/18 Mary Seacole Wards
3 morbidities the patient might have. The pharmacist should also confirm that appropriate quantities are to be dispensed and that the administration instructions are clear for both the pharmacy staff and the patients. When the pharmacist is certain that all the above-mentioned points have been satisfied, the prescription has been rectified if necessary and is deemed as being correct and safe to dispense, the screening is complete and the prescription can be booked in the Prescription Tracking System (PTS).
When a prescription is booked in, the PTS prints a unique barcode that allows the dispensary staff to know the stage every prescription is at, for example, they can check if it has already been dispensed. The system also records the average waiting times which is useful to monitor the work rates in the dispensary.
The next step in the process is to dispense and label the items prescribed on the JAC Medicines Management (JAC). JAC is a platform used in more than 50% of the trusts in the UK, including the Whittington Hospital, in the process of prescribing, dispensing and administrating medication, as well as stock control [6]. The items dispensed and their respective labels must match the ones prescribed in terms of being the appropriate product and quantity, formulation and strength. Furthermore, the dispenser must check the expiry date, make sure that the label contains clear directions and/or warnings (supplementary labels - e.g. “Contains Penicillin”) and provide the appropriate dosage systems, warning cards (e.g. Steroid Card) and information leaflets (PILs: “Patient Information Leaflets” or MaPPs: “Medicines: a Patient Profile summary”) when required. MaPPs (Appendix 1) is a condensed summary of important information about a drug, like its indication and how to take it, in a way that is easy for the patient to understand. When every product has been properly dispensed, the prescription is signed by the dispenser who places everything in a tray, ready to be checked.
Finally, either pharmacists or accredited checking technicians perform the final accuracy checking. As soon as the checking is complete, the checker signs the prescription and bags up the medication which is then ready to be taken to the respective wards by the porter or collected by someone from the ward when it’s urgent.
There are different types of prescriptions: Inpatient (to a patient on one of the hospital wards, no label directions needed in the labels) (Appendix 2); One-stop (to a patient on one of the hospital wards who may take the medication home, label directions needed in the labels) (Appendix 3); Outpatients (to a patient who had an appointment with a doctor in the hospital); TTA (“To Take Away” - medication given to a patient on discharge from hospital, label directions and additional information leaflets (PILs or MaPPs) required, particularly for antibiotics, oseltamivir and when the patient is taking some medication for the first time) (Appendix 4); and Controlled Drugs (CDs).
Some of the medication dispensed was ‘Named Patient’ medication or non-formulary. ‘Named patient’ medicines are unlicensed medication which have no product license in the UK and have been imported from abroad. These drugs are prescribed for patients with specific indications for
4 which there are no licensed medicines available and should be dispensed normally, but batch number and expiry date should also appear on the label.
Non-formulary drugs are medicines not included in the Whittington Health formulary, which means that the pharmacy normally doesn’t keep stock of these items as they are considered to be less appropriate for prescribing than formulary options. Non-formulary drugs are an option when the patient is admitted on them and there is no clinically suitable alternative available on the formulary, so it would be inappropriate to change therapy, or they can be initiated in hospital. In this case, a ‘request to order a non-formulary medicine’ form needs to be filled in and the request has to be approved by the lead pharmacist so the medicine can be ordered. The medication should be entered into the ‘to-follow’ book to ensure that it is dispensed once it arrives.
‘To-Follow’ is a term used to describe medicines that are owed to a patient because there was insufficient stock available in the pharmacy at the time. These medicines must be ordered and given to the patient as soon as possible. There is a person from staff allocated to check if the medication has arrived and dispense ‘To-Follow’ drugs every day.
In the inpatients’ dispensary I spent most of the time dispensing, so I had to start my period there by learning how to do so correctly through reading the SOPs (Standard Operating Procedures) and the dispensary guidelines and by observing other pre-registration pharmacists and technicians while they were dispensing. This allowed me to understand how the JAC dispensing programme worked and the particularities of dispensing the various types of prescriptions and medicines, including the adequate label directions, dosage systems, warning cards, supplementary labels and information leaflets, when required, to be given in each case. I also learned where the different items are stored within the department, since some of them weren’t kept in the robot but in specific shelves in the dispensary room, for example “Named Patient” or non-formulary medicines, or even outside the room like feeds, internal and external liquids, injections and dressings.
While dispensing, certain situations came up such as an item not being available for dispensing or not being able to clearly understand the dose and frequency directions written in the prescription. In those situations, I had to talk to the pharmacist who screened the prescription in order to solve the query. During my third and last week in the dispensary, as I felt more confident with the process, I had to complete a dispensing log of a total of one hundred items.
Apart from dispensing, it was also part of my duties to keep the inpatients’ dispensary clean and tidy; replenish the patient information leaflets and the bottles and boxes stock, used when dispensing tablets or liquids as a part pack instead of giving the patient the original package; return items to the robot in cases in which these were incorrectly ordered; check the fridge and the non- formulary, named patient, part packs and antibiotic shelves for expiring drugs; ensure that the ‘To- Follow’ items were dispensed as soon as received; book prescriptions in the PTS; and answer calls and people presenting at the hatch of the dispensary.
5 Additionally, I had to monitor and record the temperature of specific areas in the pharmacy department (dispensary room, Controlled Drugs room, frigdes, robot area and feeds room) every day to make sure that the products were kept in optimum storage conditions.
4.1. Controlled Drugs
In the three weeks of my rota allocated to the inpatients’ dispensary I also had the opportunity to spend some time in the Controlled Drugs room, where all the controlled drugs are kept in locked cabinets and are dispensed either to a specific patient or as wards’ stock.
I was able to observe the process of dispensing the requests for controlled drugs for the wards’ stock, which are written down in the CD order books and are brought to the pharmacy at the latest by 10am each day. These requests are, once again, booked in the PTS, screened, dispensed on JAC and checked. For CDs, however, the legal requirements applied are stricter and everything needs to be documented on registers that are specific for each drug, including the requester details, the amount supplied and the signature of the receiver.
5.
Outpatients’ Dispensary
The outpatients’ dispensary is an independent company located in the Whittington Hospital which dispenses medication to patients who were seen in the hospital outpatients’ clinics, sells over the counter products and provides vaccinations, including Seasonal Flu, among other services.
I spent one morning there and realised that the process of dispensing medication is very similar to the one described for inpatients’ dispensary, even though the software used is not the JAC platform. First, in the reception area, the pharmacy staff is handed out the prescription by either the patient or their representative and the charge is paid, unless the patient is exempt. The prescription is then logged in the PTS and the patients are told the estimated waiting time and receive a ticket so they are able to collect it after it has been screened, dispensed and checked.
The main difference between both dispensaries is that the pharmacy staff in the outpatients’ one contacts directly with the patients who are waiting for their medication. This context reflects on the work pace which is much faster in the outpatient’s dispensary.
6. Medicines Information Centre
The Whittington Health medicines information centre (MI) is responsible for answering enquiries either from healthcare professionals or patients, after they have been discharged (patient helpline), receiving ten to fifteen enquiries per month in average. The MI staff is formed by the MI manager, one rotational pharmacist and pre-registration pharmacists that spend between 2 to 4 weeks there. I was allocated to the MI for two weeks.
6 In the UK, usually, each trust has its own medicines information centre. The MI pharmacist’s job is to gather data, evaluate it and present it in a way that will be useful to the enquirer, which requires clinical knowledge, experience, evaluation skills and judgement. This role becomes very important nowadays due to the increasing number of new medicines on the UK market, ageing population, complexity of patient morbidities and changes in medical practice [7].
Common enquiries’ matters are related to administration and dosage, adverse effects, availability and supply, choice of therapy, drugs in pregnancy, drugs in breast milk, identification, pharmacology/pharmacokinetics, toxicity, general information about some medicine, complementary medicine, substance misuse, among others [7].
Most of my time in MI was spent using MiCAL, which is an online learning tool aiming to provide healthcare professionals the core skills to answer enquiries related to medication use and be