Medicines optimisation : a pharmacist’s contribution to delivery and education

This thesis describes the author’s publication history from 2001 to 2019, and relates this to their key career milestones from registration as a pharmacist in 1991. From a career output of over 80 items published in a variety of media, eleven key publications form the basis of four publication themes, which the author has related to the concept of medicines optimisation. An exemplar case is used to illustrate these publication themes, arranged into four chapters: a) improving the patient experience and supporting medication adherence b) providing safe care: medication review, polypharmacy and deprescribing c) making medicines optimisation part of routine practice through clinical education, and d) supporting safe practice through professional and personal development of healthcare staff. Following Chapter 1 (introduction), the second chapter discusses the author’s contribution to the medication adherence agenda which closely relates to their outputs encouraging the development of pharmacists’ consultation skills, particularly with patients who have a learning disability. The third chapter discusses the author’s published outputs in the areas of medication review, polypharmacy and deprescribing, the success of which they outline as contingent on the improved communication skills and person-centred approach described in Chapter 2. Chapters four and five discuss the author’s wide-ranging contribution as a clinical educator with a focus on developing others, which the author contends is an essential underpinning of the mission to deliver the benefits of medicines optimisation. The exemplar case from the introduction is briefly revisited to illustrate that the author’s publications directly relate to the challenges of the patient’s medication regime which in turn relate to three of the four Royal Pharmaceutical Society principles of medicines optimisation. The conclusion of this thesis includes a summary of the methodologies used in the key publications, and summarises the author’s belief that their career activity, leading to their publications, broadly align to the concept of medicines optimisation. Moreover, a recommendation can be made that education of all stakeholders should be explicitly mentioned in any future refinements of its definition

Reasoning Ability as a Determinant of Teaching Aptitude: A study on Teachers Trainee Student of Durg-Bhilai Region

This research paper aims to highlight the importance of reasoning ability in selecting the students of teacher training colleges so that they are more likely to develop higher teaching aptitude during their training On examining the reasoning abilty score and teaching aptitude score of selected sample of student from teacher training colleges of Durg-Bhilai reason it was concluded that there was a high significant correlation between teaching aptitude and reasoning ability score of students It was also concluded that reasoning Ability was able to explain about 45 of variation in the teaching aptitude of teacher trainee students This can act as a benchmark to set entrance exam in such a way that at least 45 of the weight age is to be given to the the questions on reasoning abilit

Improving Pharmacists’ Targeting of Patients for Medication Review and Deprescription

Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults’ medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily “hold” medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital

Patient perspectives on the use of ‘My Medication Passport’

My Medication Passport is a written record of a patient's medicines. It is designedto improve communication between patients, carers and healthcare professionalsand maintain a record of changes made to the patient's medication

The Acute Care Assessment Tool:'Pharmacy ACAT’

Background: The Acute Care Assessment Tool (ACAT) was developed as a workplace-based assessment (WPBA) for trainee performance whilst working in acute medicine. Here, we discuss the multi-professional potential of ACAT through a pilot with foundation and senior hospital pharmacists.Context: The pharmacy profession is engaging meaningfully with foundation training for pharmacists akin to doctor foundation training, and has launched a post-foundation Faculty as a route to advanced generalist or specialist practice. Foundation training has included the adoption of familiar WPBA such as mini-clinical evaluation exercise (mini-CEX) and Case-based Discussion (CbD). However, mini-CEX and CbD are ‘snapshot’ assessments, and we identified a need for assessment of practice over a short period of time. A local director of medical education suggested ACAT.Innovation: Permission was gained from the Joint Royal Colleges of Physicians to adapt the ACAT to form the ‘Pharmacy ACAT.’ Adaptations were based on the two current Royal Pharmaceutical Society competency frameworks used for foundation and post-foundation practice. ‘Pharmacy ACAT’ was piloted across three acute hospitals (known as ‘Trusts’) in London for foundation trainees, and was found to be broadly acceptable in terms of time and of value for feedback, particularly for foundation pharmacy trainees. Senior pharmacists at the single pilot site were more sceptical.Implications: We believe that ‘Pharmacy ACAT’ should be considered for routine use in pharmacy foundation training in hospital and community practice as it ‘plugs a gap’ in the current scheme of WPBA, by allowing assessment of a short period of practice as opposed to a snapshot. It also has potential for use at undergraduate level

Clinical Judgement Analysis: An innovative approach to explore the individual decision-making processes of pharmacists

Background: Pharmacy stands increasingly on the frontline of patient care, yet current studies of clinical decision-making by pharmacists only capture deliberative processes that can be stated explicitly. Decision-making incorporates both deliberative and intuitive processes. Clinical Judgement Analysis (CJA) is a method novel to pharmacy that uncovers intuitive decision-making and may provide a more comprehensive understanding of the decision-making processes of pharmacists. / Objectives: This paper describes how CJA potentially uncovers the intuitive clinical decision-making processes of pharmacists. Using an illustrative decision-making example, the application of CJA will be described, including: Scenario and associated task development around a defined judgement / Capture of pharmacists' decision-making processes and analysis using appropriate statistical methods / Method: An illustrative study was used, applying an established method for CJA. The decision to initiate anticoagulation, alongside appropriate risk judgements, was chosen as the context. Expert anticoagulation pharmacists were interviewed to define and then refine variables (cues) involved in this decision. Decision tasks with sixty scenarios were developed to explore the effect of these cues on pharmacists’ decision-making processes and distributed to participants for completion. Descriptive statistical and regression analyses were conducted for each participant. / Results: The method produced individual judgement models for each participant, for example, demonstrating that when judging stroke risk each participant’s judgements could be accurately predicted using only 3 or 4 out of the possible 11 cues given. The method also demonstrated that participants appeared to consider multiple cues when making risk judgements but used an algorithmic approach based on one or two cues when making the clinical decision. / Conclusion: CJA generates insights into the clinical decision-making processes of pharmacists not uncovered by the current literature. This provides a springboard for more in-depth explorations; explorations that are vital to the understanding and ongoing development of the role of pharmacists

Deprescribing medicines in the acute setting to reduce the risk of falls

ABSTRACTBackground:Falls are a common cause of morbidity and hospitalisation in older people. Inappropriate prescribing and polypharmacy contribute to falls risk in elderly patients. This study’s aim was to quantify the problem and find out if medication review in the hospital setting led to deprescribing of medicines associated with falls risk.Methods:Admissions records for elderly patients were examined to identify those whose presenting complaint included a fall. Inpatient medication charts, pharmaceutical care notes, medical notes and discharge summaries were examined to identify any falls-risk medicines from admission histories and to determine if any medication review took place, and whether or not changes were made as a result. In particular deprescribing and dose reduction details were analysed. Results:100 patients over 70 years old were admitted following a fall during the two months study period. The mean number of medicines on admission was 6.8 per patient with polypharmacy found in 62/100 (62%). One or more falls-risk medicine was found in 65/100 (65%) patients. Medicines review was carried out in 86/100 (86%) of patients, and 59/697 (8.5%) medicines were deprescribed. Pharmacist involvement in medication review led to a significant reduction in the number of falls-risk medicines per patient (p=0.002).Conclusion:Inappropriate prescribing and polypharmacy are found frequently in elderly patients at admission following a fall. Comprehensive medicines reviews should be carried out in all such patients with the objective of deprescribing or reducing doses to minimise risk of harm. Involvement of a pharmacist improves the rate of reduction of falls-risk medicines.<br/

Stopping Inappropriate Medicines in the Outpatient Setting

Medicines are prescribed for patients, usually appropriately, in response to illness and symptoms. Many are continued for life, especially when prescribed for chronic conditions. With increasing age, some medicines, particularly those requiring adequate organ function for drug clearance, can produce more harm than benefit. Research shows that high risk prescribing increases with the number of medicines, and that patients prescribed five or fewer medicines are less likely to present to hospital with adverse events.1,2 Polypharmacy can be appropriate with increasing morbidities in older age, but regular review is needed to ensure that each medicine is still appropriate, based on clear outcomes. We have recently described our experience of reviewing, holding and stopping medicines in the rehabilitation setting using the North West London STOPIT tool.3 Here, we describe our early experience of adapting the Screening Tool for Older People’s Inappropriate Treatments (STOPIT), including specific consideration of anticholinergic burden, for use in the outpatient setting. This was a service improvement pilot to explore the practicalities and challenges of deprescribing for elderly outpatients at the Chelsea and Westminster Hospital NHS Foundation Trust (CWFT)