Band 6 Rotational Training Programme - Pharmacy … · Band 6 Rotational Training Programme Pharmacy Training Pack . ... Outcome Measures Review ... There is a departmental KPI …

Produced by Gareth Nickless, Lead Pharmacist, Education and Training

Version 2

Date Produced: June 2013

1

Trainee’s Name: _________________________

Band 6 Rotational Training

Programme

Pharmacy Training Pack


Version 2


2

Contents Page

Page Number

1. Overview 3

2. Objectives 4-9

3. Links to competency frameworks 10

4. Background preparation 10

5. Experiential learning 10-12

6. Assessment and feedback 12-15

Appendix 1 – Details of individual rotations 16-24

Appendix 2 – Clinical Case Studies 25-31

Appendix 3 – Copies of paperwork for practice based assessments 32-44

Appendix 4 – Feedback on rotation 45


Version 2


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This training pack outlines the following key aspects of the rotational training

programme for band 6 pharmacists working at Wirral University Teaching Hospitals

NHS Foundation Trust (WUTH):

In-house training provided

Details of rotations offered

Competency based assessments used during the rotations

Generic objectives for Band 6 Pharmacists to complete during their time as a

Rotational Pharmacist. Where appropriate there are rotation specific objectives

Band 6 pharmacists at WUTH will undertake a mixture of rotations, each lasting

approximately four months. Due to the time spent as a Band 6 Pharmacist in the

Trust, it is usually not possible to have completed all of the available rotations;

however, by the end of a 2-3 year period a Band 6 Pharmacist will have gained

experience in working in most of the following areas:

Aseptic services

Dispensary (both Arrowe Park and Clatterbridge sites)

Medicines Information

Cardiology

Endocrinology

Gastroenterology

St John’s hospice

Medicine for the elderly (DME)

Rehabilitation wards – e.g. stroke and neurology

Renal

Respiratory

Medical admissions

Surgical admissions

Urology

Orthopaedics

Women’s and children’s

Since this pack is aimed at the Band 6 Pharmacists’ overall development and

performance, they don’t need to have completed this training pack’s objectives

before they are able to work unsupervised on wards. However, if any of the

pharmacists involved in the training or assessment of any band 6 pharmacist have

any concerns over their competence they are to inform the Clinical Services Manager

or the Divisional Lead Pharmacist for Medicine or Surgery as appropriate.

Overview


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4

All band 6 pharmacists will be given a set of generic objectives (which are linked to

the departmental business plan and the Trust’s goals) as part of their individual

review (IR) process (see pages 5-9 for details). In addition, the band 6 pharmacists

are required to identify 3-6 personal objectives for each ward-based area rotation

which they will then agree with the team leader for that rotation. These objectives will

be influenced by the band 6 pharmacists’ previous experience and the common

disease states / management problems that the band 6 pharmacist is likely to

encounter during that rotation (see Appendix 1 for outlines of each ward-based

rotation). The rotations which involve working in medicines information and aseptic

services have their own training packs (which will have their own specific objectives).

Objectives

5

Generic Objectives for Band 6 Pharmacists

Objective Link to

Departmental Goal Actions Timescale

Outcome

Measures

Review Interim

(Comments only)

1. Support the

department in

implementing

systems to

minimise risk

Improve safety &

quality in use of

medicines

Year 1

Complete Trust clinical incident

forms

Undertake quarterly CD checks

on ward attached to each

rotation undertaken

Ensure supplementary paper

charts are completed in a timely

manner

Contribute to intervention

monitoring data collection in

pharmacy

Complete competency

assessment for hand hygiene in

order to help reduce patient risk

of infection

Identify one area of practice

that could be improved to

mitigate risk

Year 2

Attend Quality and Safety

meeting

Attend Pharmacy Clinical

Governance meeting

Completed Trust

clinical incident

forms

Completed forms

for CD checks

All supplementary

charts signed by

Pharmacist

Intervention

monitoring forms

completed on

days required

Completed

competency hand

hygiene

assessment

Reflection on

action taken

I

6

Objective Link to


Outcome

Measures

Review Interim

(Comments only)

2. Take responsibility

for own learning and

development

Support team work

and facilitate staff

development

Year 1

Ensure all workplace

based assessments for

each rotation are

arranged and

subsequently completed

Achieve at least 70%

attendance at

departmental CE Level 2

sessions

Keep validation in

aseptics up-to-date

(when on-call duties

commenced)

Complete training packs

as requested by

Residency Manager

Demonstrate CPD

undertaken

Year 2

As for year 1 plus:

Have enrolled or plan to

enrol in next 12 months

on a Postgraduate

Diploma in Clinical

Pharmacy

Completed

workplace based

assessment

paperwork for

each 4 month

rotation

Database print-

out for CE

sessions attended

Completed CPD

records in line

with GPhC

requirements

Certificates for

completed broth

tests – every 3

months

Enrolment on

postgraduate course

7

Objective Link to


Outcome

Measures

Review Interim

(Comments only)

3. Contribute to

learning and

development of

others

Support team work


development

Present at either a

CE level 1 or 2

session each year

Conduct either

one LJMU 1st year

visit or one

vacational student

ward visit each

year

Deliver either the

medicines

management

induction or

update talk for

clinical staff

Present a

summary of on-

call bleeps at

residency meeting

and discuss key

learning points

Copy of

presentation

delivered and

summary of

feedback for the

session

Timetable

indicating date

visit conducted

Summary of on-

call queries

discussed

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Objective Link to


Outcome

Measures

Review Interim

(Comments only)

4. To support the

Department /

Clinical area

achieving financial

balance and its drug

CIP target

Achieve Pharmacy

CIP and support

Division CIP

Year 1

When verifying orders

for PBR exclusion

drugs ensure that

they are for approved

indications and

endorse the

prescriptions

appropriately

Ensure formulary

adhered to by

prescribers

Review ward stock list

and submit for

approval by Lead

Divisional Pharmacist

(LDP)

Year 2

Identify potential CIP

initiatives

Achieve a personal

CIP target of £10000

Attend wider CIP

meeting

Audit the use of a

drug / treatment area

in line with formulary

Prescriptions for

PBR exclusion

drugs endorsed

with indication to

aid claim for

payment

Use of non-

formulary

medicines

minimised

Stock list

reviewed and

approved by LDP

CIP initiatives

identified and

delivered

Contribution to

others’ CIP

initiatives

Audit report

produced and

action plan

implemented

9

Objective Link to

Departmental Goal Actions Timescale Outcome Measures

Review Interim

(Comments only)

5. Support the

Department in audit

and research work

undertaken, to

support the

department to meet

its publications /

presentations key

performance indicator

(KPI)

Support team work


development

Year 1

Participate in

departmental audits

e.g. ASPIRE,

quarterly ward CD

checks, quarterly

intervention

monitoring

Year 2

As per year 1 plus:

Undertake an audit,

service evaluation or

research project

Publish / present

results via at least

one external (to

pharmacy

department) event –

e.g. Trust audit day,

regional / national

conference, journal

publication

ASPIRE form

completed monthly

CD audit completed

quarterly

Other completed

audit forms

Research / audit

project completed

Completion of all

audit paperwork

using official Trust

paperwork

Results presented

to Pharmacy

department

Results presented

to a wider audience

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The objectives for each of the rotations are linked to the core KSF dimensions and the

competencies listed in the General Level Framework. The competency framework outlined

in this document has been adapted from the General Level Framework (GLF) developed

by the Competency Development and Evaluation Group (CoDeg) in London.

A list of recommended references will be provided for each rotation (see Appendix 1 for

details). The references listed below will be useful throughout the rotational pharmacists’

training.

1. Sexton J, Nickless G, Green C. Pharmaceutical care made easy. Pharmaceutical

Press 2006

2. Royal Pharmaceutical Society of Great Britain. Medicines Optimisation: Helping

patients to make the most of their medicines. May 2013

3. Competency Development and Evaluation Group (CoDEG). General Level Framework

– A Framework for Pharmacist Development in General Pharmacy Practice. 2nd

Edition, October 2007

4. Middleton H, O’Loan L, Varia S. Getting the most from the KSF – how to link it with

CPD. Hospital Pharmacist 2006; 13: 211-214

5. Fenn T. Your KSF development review – how to collect evidence. Hospital

Pharmacist 2007; 14:26-28

A series of case studies (see Appendix 2) have also been written for the rotational

pharmacists to attempt during the first few months of their employment. The case studies

will cover areas such as interpretation of lab tests and screening of prescriptions.

Induction

All rotational pharmacists’ will undertake an intensive induction programme to prepare

them for participation in the residency service. The programme will also include some

training packs and competency assessments to be completed before the band 6

pharmacist is able to perform certain tasks.

Continuing Education Sessions

Continuing education meetings are also held on (at least) a weekly basis during

lunchtimes. Junior pharmacists are required to attend these since they cover a variety of

key topics, including:

CPPE Learning at Lunch modules

Links to Competency Frameworks

Background Preparation

Training / Experiential Learning

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Updates on clinical areas from specialist pharmacists

Case presentations by diploma students

Audit presentations (including those by diploma students)

Service development initiatives

There is a departmental KPI for attendance at these meetings which is reported to

pharmacy board.

In addition to the aforementioned programme, there are the following additional sessions

organised for band 6 pharmacists during the first few months of their employment:

Medication history taking

Basic guide to laboratory tests

Introduction to microbiology

Antibiotic therapeutic drug monitoring

Problem solving exercises in medicine

Problem solving exercises in surgery

Problem solving in critical care

Organisation of Rotations

Rotational pharmacists will also “learn by doing” during their rotations. To facilitate this

experiential learning, each rotation will include:

General overview of the rotation. The team leader for the rotation (or designated

deputy in their absence) will give a general overview of the rotation (ideally on day 1),

including:

o A general introduction to the ward /area including details of personnel (e.g.

consultants, specialist nurses) working in that area

o References including any SOPs that must be read

Workplace-based assessments (WBAs). The WBAs are formative in nature (i.e.

don’t have a mark attached to them) and are used to assess competence and provide

feedback to aid personal development. It is the responsibility of the Band 6 Pharmacist

to arrange dates for the various assessments with the relevant personnel. Further

details of the WBAs listed below can be found on pages 12 - .

o Mini clinical evaluation exercise (mini–CEX). This will be conducted by the

Lead Pharmacist for Education and Training

o General ward visit. This will be conducted by the Lead Pharmacist for

Education and Training

o Case Based Discussion (CBD). This will be conducted by the Team Leader

(or nominated deputy) for the rotation

o Record of In-service Training Assessment (RITA). This will be conducted by

the Team Leader (or nominated deputy) for the rotation

Meetings with team leader for the rotation or Lead Pharmacist Education and

training. Additional ward visits / meetings at other times during the rotation may also

be arranged and this is encouraged. The format of such meetings will depend on both

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the rotation and Activities undertaken during each ward visit should be documented in

the activities diary (see Appendix ).

WBAs are used during the rotations to both assess the band 6 pharmacist’s level of

competence and as a development tool through identifying learning needs. The practice

based assessments used are:

Mini-Clinical Evaluation Exercise (Mini-CEX)

General Ward Visit Summary

Case Based Discussion (CBD)

Record of In-service Training Assessment (RITA)

Copies of the paperwork for these WBAs can be found in Appendix 3. When judging the

complexity of the cases used for the Mini-CEXs and CBDs, consider:

Whether the patient has multiple co-morbidities?

Whether the patient subject to polypharmacy?

Whether the patient has altered drug handling?

Whether the patient is prescribed unusual (e.g. unlicensed) medicines?

Videos demonstrating these assessment tools, which have been produced by the Joint

Programmes Board, are available at: http://www.jpbsoutheast.org/assessment-tools/jpb-

assessment-tools-dvd/

Mini-Clinical Evaluation Exercise (Mini-CEX)

The Mini-CEX involves observation and assessment of the band 6 pharmacist in their day-

to-day practice. It will be used to assess their performance against the GLF competencies

of delivery of patient care and problem solving. The Mini-CEX is intended as a 15-20

minute snapshot of a pharmacist / patient or pharmacist / doctor or even pharmacist /

patient / doctor interaction. Whilst the mini-CEX is designed to be used in the ward

environment assessing the band 6 pharmacist prospectively providing pharmaceutical care

for new patients on their wards, it may also be conducted in the dispensary or during a

rotation in medicines information (by observing them dealing with a telephone query).

Each mini-CEX should represent a different clinical problem which will depend on the

rotation being undertaken. The suggested process for conducting a Mini-CEX is:

The band 6 pharmacist and assessor will agree the time and date of the assessment

The band 6 pharmacist will identify up to THREE patients that are new to them in

advance of the ward visit and tell assessor the name and location of these patients

The assessor will then select ONE of these patients for the Mini-CEX

The assessor will be looking at the band 6 pharmacist’s ability to prospectively deliver

pharmaceutical care for the patient selected (from the initial consultation with the

Assessment

http://www.jpbsoutheast.org/assessment-tools/jpb-assessment-tools-dvd/

http://www.jpbsoutheast.org/assessment-tools/jpb-assessment-tools-dvd/

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patient and information retrieval from the case notes, to problem identification and

resolution if feasible)

The assessor should position themselves carefully (to avoid being intrusive)

During the Mini-CEX, the assessor should question the junior pharmacist at appropriate

times to ascertain how they are prioritising problems identified. However, interjections

and interruptions should be kept to a minimum. Whilst clinical knowledge is assessed

to some degree during a Mini-CEX, the band 6 pharmacist should not be subjected to

intensive questioning by the assessor

Once the assessment is over, the assessor should complete the feedback form in the

absence of the band 6 pharmacist. The assessor and the band 6 pharmacist should

meet to discuss the results (ideally within an hour of the observation) and identify

agreed strengths, areas for development and an action plan following each encounter.

The action plan should include objectives for the next accompanied ward visit or

assessment.

General Ward Visit Summary The principle behind this ward visit is to gain a better overview of how a band 6 pharmacist

is coping with their workload at ward level and assess some of the competencies that are

not included in the Mini-CEX and CBD proformas. The assessor’s role will be mainly

observational with questioning of the band 6 pharmacist tailored to evaluating their

approach on the ward rather than assessing clinical knowledge.

The activities will be observed for a number of patients seen during the ward visit and the

tutor will form an overall impression of how the student performed for each activity. No

mark is attached to this visit, but the following rating scale will be used to assess overall

performance:

Rarely: 0-24%

Sometimes: 25-50%

Usually: 51-84%

Consistently: 85-100%

Not applicable / unable to observe on this occasion

It is envisaged that a visit will last approximately an hour to allow observations for several

patients. Practicalities of the visit:

The assessor will select patients for review at random

For each patient seen the assessor will ask the band 6 pharmacist to provide a brief

overview of the patient’s priority problems and any input they have had

For each patient seen the assessor will review the prescription chart (or electronic

equivalent) to determine:

o The number of items verified

o Whether the items verified are clear, legal and safe

o Appropriate endorsements to the prescription order have been made in line with

departmental policy / standards

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For items prescribed > 24hours ago that have not been verified, the band 6 pharmacist

will be questioned to ascertain the possible reason(s) for this

The band 6 pharmacist will be asked whether there are any issues for follow up to

determine how they prioritise tasks / manage workload

Where the band 6 pharmacist has had input (including medicines reconciliation and

counseling) or offered advice, the assessor will review the patient’s case notes to

determine whether the documentation of their actions complies with departmental

policy

Case Based Discussions (CBD)

Case based discussions are designed to assess clinical decision-making and the

application or use of pharmaceutical knowledge in the care of the band 6 pharmacist’s own

patients. In essence, it involves a senior pharmacist questioning the band 6 pharmacist

about the care they have provided for a patient, allowing the senior pharmacist to explore

the band 6 pharmacist’s understanding of specific issues (from pharmacology and

pathophysiology to monitoring and counselling). It also enables the discussion of the

ethical and legal framework of practice (when appropriate), and in all instances, it allows

the band 6 pharmacist to discuss why they acted as they did.

Each CBD should represent a different clinical problem which will depend on the rotation

being undertaken. The suggested process for conducting a CBD is:

The band 6 pharmacist will select three case records from patients they have recently

been caring for (week to be penciled in diary at start of rotation, exact date/time to be

confirmed at least 1 week prior to assessment).

The designated senior pharmacist will select one of these for the case-based

discussion session. The assessment will preferably be undertaken at ward level, with

follow-up discussion in pharmacy if required.

The discussion should focus around the 5 question areas listed on the form in

Appendix 3.

The whole assessment should take no longer than 30 minutes including feedback

and completion of the assessment form.

Immediate feedback will be provided after each encounter by the designated senior

pharmacist.

In order to maximise the educational impact of using CBD the band 6 pharmacist and

designated senior pharmacist will need to identify agreed strengths, areas for

development and an action plan for each encounter. The band 6 pharmacist is

expected to follow-up on any action plan agreed.

Record of In-service Training Assessment (RITA)

The RITA will be undertaken by the designated senior pharmacist towards the end of each

four month rotation and should take approximately 30-45 minutes to complete. It is a

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formal meeting between the band 6 pharmacist and the designated senior pharmacist and

allows for a review of the band 6 pharmacist’s progress, highlighting:

Achievements during the rotation (including progress with objectives)

Areas to concentrate on during future rotations

Problems or difficulties the band 6 pharmacist may be experiencing

Portfolios

Each new member of staff is issued with a portfolio on behalf of the Trust’s Learning and

Development directorate. The evidence contained in this portfolio should be used during

the individual review process, to demonstrate achievement of the GLF competencies and

included in the portfolios for the Liverpool John Moores University Postgraduate Diploma

in Clinical Pharmacy.

Minimum Portfolio Evidence Requirements

Completed clinical checking test

Completed accuracy checking test

Completed kinetics competency log

Certificate of completed broth test every 3 months since date of commencing on-call

duties

Mini-CEXs – minimum of two at Foundation gateway, three for subsequent annual IRs

General ward visit summary - minimum of two at Foundation gateway, three for

subsequent annual IRs

Case based discussions – minimum of two at Foundation gateway, three for

subsequent annual IRs

RITAs - 2 at Foundation gateway, 3 for subsequent annual IRs

Quarterly CDs check forms – one for each rotation (containing ward commitments)

completed

Interventions log

Incident forms x 10

E&T database printout of CE sessions attended and delivered

CPD records using GPhC format x 9

Certificates of completion for:

1. E-BMJ Packs

1. Starting patients on anticoagulants – how to do it

2. Maintaining patients on anticoagulants – how to do it

3. Injectable medicines

2. NHS diabetes e-learning – The safe use of insulin

3. Information governance training (completed every 12 months)

4. Safeguarding children (completed every 3 years)

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Respiratory Rotation

Overview

This rotation will involve provision of a ward pharmacy service to ward 38. Ward 38 has

38 beds organised as follows:

12 Lung Support Unit (LSU) beds

1 sleep study room – often empty. When patients undertake a sleep study they arrive

in the evening and leave the next morning. No TTH is produced for these patients

7 side rooms

18 “general” beds divided between 4 bays

Therapeutic Problems

By the end of this rotation you should have encountered patients with the following

conditions:

o Asthma

o COPD

o Community acquired pneumonia

o Hospital acquired pneumonia

o Bronchiectasis

o Pleural effusions

o Pulmonary emboli

o Type 2 respiratory failure

Depending on the patients admitted to the ward, you may also gain experience in the

management of:

Tuberculosis

Environmental mycobacterium infections

Pulmonary fibrosis

Directed Reading

BTS asthma guidelines (current edition)

NICE COPD guidelines

BTS CAP guidelines

Respiratory section of medicines guide

Respiratory section of antimicrobial formulary

Appendix 1 – Details of Individual Rotations


Version 2

Date Produced: July 2012

17

Medicine for the Elderly (DME) rotation

Overview

This rotation will involve provision of a ward pharmacy service to a selection of DME wards

which are organised as follows:

Ward 20 – 20 rehab and 10 acute medical beds

Ward 21 – 31 bed acute male ward

Ward 22 – 12 bed OPSS unit (older persons short-stay ward), 2 side rooms used

for OPRA clinic (outpatients) 16 mixed male and female acute beds.

Ward 23 – 12 acute stroke beds and 17 step down beds.

Ward 24 – 30 bed acute female ward

Ward 26 – 12 acute DME beds (rest of ward is endocrine)

Ward 36 – Rehabilitation ward


DME patients are likely to have multiple comorbidities and multiple pharmaceutical

problems. By the end of this rotation you are likely to have encountered patients with the

following conditions:

Community acquired pneumonia

Hospital acquired pneumonia

Dementia

Falls

Stroke

Parkinson’s disease

Renal impairment

Heart failure

Acute coronary syndrome

Atrial fibrillation

GI bleeds

Diabetes

Leg ulcers and other skin conditions

COPD

Nil by mouth patients

Polypharmacy

Compliance issues

Directed Reading

The reading used will depend on the patients seen; there are a variety of conditions that

will be covered in DME. All rotational pharmacists should read:

Respiratory section of antimicrobial formulary

WUTH Dementia Care guideline


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18

NICE Clinical Guideline – Falls

WUTH Falls Pharmaceutical Care standard

Parkinson’s Disease – Clinical Features and Diagnosis. Clinical Pharmacist. December

2011

Parkinson’s Disease – Management. Clinical Pharmacist. December 2011

WUTH Parkinson’s guideline

WUTH ACS and AF pathways

NICE bites – Heart failure

WUTH Compliance aid guidelines

“Time is Brain” – WUTH stroke pathway

Formulary / NICE guidance for other conditions.

If covering ward 23, must read:

Stroke classification and diagnosis. Clinical Pharmacist. 2011; 3: 200-202.

Stroke acute management. Clinical Pharmacist. 2011; 3: 205-208.

Stroke long-term management. Clinical Pharmacist. 2011; 3: 209-212.

NICE TA 122. Alteplase for the treatment of acute ischaemic stroke.

NICE TA 210 – Clopidogrel and modified release dipyridamole for the prevention of

occlusive vascular events.


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19

Renal rotation

Overview

This rotation will involve provision of a ward pharmacy service to the renal directorate.

The renal directorate is set out as follows:

10 acute inpatient renal beds APH

Haemodialysis unit APH (3 bays of 6 beds and 1 side room)

Haemodialysis unit CGH

There are approximately 80 patients having haemodialysis on the haemodialysis unit at

APH. These consist of outpatients who regularly dialyse at APH, and inpatients who have

been admitted acutely unwell. These inpatients usually:

Have established ESRF and are dialysis dependent and may normally dialyse at

another dialysis unit but are currently admitted at APH with an acute illness.

Have had deterioration in renal function and have been newly initiated on

haemodialysis as an inpatient.



conditions:

AKI of various causality

CKD3-5

ESRF requiring haemodialysis

Secondary hyperparathyroidism

Anaemia associated with CKD

Depending on the patients admitted at time of admission, you may also gain experience in

the management of:

Renal transplant

ESRF requiring peritoneal dialysis

Vasculitis and SLE

Activities

Ward Round

Patient reviews with lead pharmacist

Ward based assessments

Shadow renal MDT colleagues – To be arranged by rotating pharmacist if rota

allows


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20

Directed Reading

Shaw S, Coleman A, Selby N. Acute kidney injury: diagnosis, staging and

prevention. Clinical Pharmacist 2012; 4:98.

Shaw S, Morlidge C, Ashley A. Acute kidney injury: management. Clinical

Pharmacist 2012; 4:103.

CPPE Renal Focal Point. Access at: http://www.cppe.ac.uk

Brown C, Prescribing principles for patients with chronic kidney disease. Pharmacy

in Practice 2008; 18(1):23-27. Available at: http://www.pharmacyinpractice.com

Wood S, Calculating GFR is crucial when determining drug dosage requirements in

reduced renal function. Pharmacy in Practice 2008; 18(1):19-22. Available at:

http://www.pharmacyinpractice.com

Brown C, Pharmacological management of chronic kidney disease and its

complications. Pharmacy in Practice 2009; 19(1):22-30. Available at:

http://www.pharmacyinpractice.com

Levy J, Pusey C, Singh, A. Fast Facts: Renal Disorders Health Press Ltd; 2006.

http://lib.myilibrary.com/ProductDetail.aspx?id=81430 [accessed 09/04/13]

O'Callaghan, C. The Renal System at a Glance 3rd Edition

Wiley-Blackwell; 2009. http://lib.myilibrary.com/ProductDetail.aspx?id=237096

[accessed 09/04/13]

http://www.cppe.ac.uk/

http://www.pharmacyinpractice.com/



http://www.myilibrary.com/?ID=81430&Ref=Athens

http://lib.myilibrary.com/ProductDetail.aspx?id=81430

http://www.myilibrary.com/?ID=237096&Ref=Athens

http://lib.myilibrary.com/ProductDetail.aspx?id=237096


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21

Cardiology Rotation

Overview

This rotation will involve provision of a ward pharmacy service to a selection of cardiology

wards which are organised as follows:

Ward 32 – General cardiology ward

Ward 33 – Beds 1-10 and 23-29 Heart failure unit

HAC – Heart Assessment Centre – located beds 11-22 on ward 33.

CCU – Coronary Care Unit

Cardiology Day Suite – Located next to the catheter lab on the 3rd floor


Cardiology patients are likely to have multiple comorbidities and multiple pharmaceutical

problems. By the end of this rotation you are likely to have encountered patients with the

following cardiac conditions:

o Acute Coronary Syndrome

o Heart failure

o Atrial fibrillation (acute and chronic)

o Complex arrhythmias

o Bradycardia

o Ischaemic heart disease

o Endocarditis

o Resistant hypertension

Directed Reading

The reading used will depend on the patients seen; there are a variety of conditions that

will be covered in cardiology. All rotational pharmacists should read:

General

Cardiology section of the medicines Guide which will cover local Wirral guidelines:

Chest Pain Pathway (including ticagrelor and fondaparinux prescribing guidelines)

Atrial Fibrillation Pathway

Heart Failure Guidelines

Hypertension

Hypercholesterolemia

New Oral Anticoagulant Prescribing guideline for stroke prevention in AF

Additional Reading

Hypertension

o Hypertension: Clinical management of primary hypertension in adults CG127

Published August 2011


Version 2


22

Heart Failure

o Sani M. Heart failure – Clinical Features and Diagnosis. Clinical Pharmacist

2009; 1: 113-119

o Williams H. Heart failure – Management. Clinical Pharmacist 2009; 1: 120-125

o Management of chronic heart failure in adults in primary and secondary care.

Nice Clinical Guideline 108 Aug 2010.

o ESC Guidelines for the diagnosis and treatment of acute and chronic heart

failure 2012

o NICE Technical Appraisal for Ivabradine for treating chronic heart failure

Myocardial Infarction

o Worrall A. Acute Coronary Syndromes – Assessment and Interventions. Hospital

Pharmacist 2007; 14: 285-292

o Fletcher G, Worrall A. Acute Coronary Syndromes – Pharmacological

Treatment. Hospital Pharmacist 2007; 14: 295-299

o MI: Secondary prevention. Nice Clinical Guideline No48 2007

o Hyperglycaemia in acute coronary syndromes: Management of hyperglycaemia

in acute coronary syndromes Nice Clinical Guideline 130 October 2011.

o NICE Technical Appraisal for ticagrelor in acute coronary syndrome

Atrial Fibrillation

o The Management of Atrial Fibrillation. NICE Clinical Guideline No 36 2006

o NICE Technical Appraisals for dabigatran, apixaban and rivaroxaban for stroke

prevention in atrial fibrillation.

Endocarditis

o Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a

report of the Working Party of the British Society for Antimicrobial Chemotherapy

2012 – available at britishinfection.org


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23

Haematology Rotation

Overview

This rotation will involve provision of a ward pharmacy service to ward 30 and the

Haematology Day Ward. Ward 30 has 22 single rooms used for the following specialities:

Haematology

Endocrinology

General Medicine

Rheumatology

The number of patients admitted for each speciality is not fixed and may change week-by-

week.



conditions:

Lymphoma

Myeloma

Leukaemia

Depending on the patients admitted to the ward, you may also gain experience in the

management of:

Complications of Chemotherapy / Oncological Emergencies

o Neutropenic Sepsis

o Chemotherapy induced Nausea and Vomiting

o Chemotherapy induced diarrhoea

o Superior Vena Cava Obstruction

o Spinal Cord Compression

o Tumour Lysis Syndrome

Idiopathic Thrombocytopenic Purpura

Activities

Ward Round

Patient reviews with lead pharmacist

Ward based assessments

Complete competency assessment to clinically verify SACT prescriptions

Shadow haematology MDT colleagues – to be arranged by rotating pharmacist if rota

allows

Directed Reading

ABC of Clinical Haematology (book available in Pharmacy)

BOPA E-Learning Website


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Surgical Rotation

Overview

This rotation will involve provision of pharmaceutical care to patients admitted to the

surgical wards, namely:

SAU – surgical admissions

Ward 10, 11 (+ Trauma) and 12 – orthopaedics

Ward 14 - urology

Ward 16 – special surgery

Ward 17 – colorectal

Ward 18 - vascular



management problems:

Thromboprophylaxis

Prevention of surgical site infection

Medicines requiring discontinuation in the peri-operative period

Post-operative pain

Post-operative nausea and vomiting

Post-operative constipation

Recommended Reading

1. NICE-venous thromboembolism, reducing the risk.

2. WUTH Antimicrobial Formulary – surgery section

3. WUTH Clinical Guidance - Pain management


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These case studies aim to develop some of the core skills and knowledge required for the provision of pharmaceutical care to patients and provides on-going education as a bridge to starting a clinical diploma. It consists of some small case studies and prescription reviews to be completed by the rotational pharmacist and discussed with their line manager. 1. Laboratory tests For each patient described in this section:

Comment briefly on the blood results (high, low, normal)

Give a possible explanation for the changes observed

Patient 1 Male, aged 52 years old PC Lethargy and weight gain PMH Bipolar Disorder IHD DH Priadel 600mg ON Atenolol 50mg OD Aspirin 75mg OD Simvastatin 40mg ON Blds U&Es (NAD)

TSH 22.3 (0.5-5.5)

Patient 2 Female, aged 72 years PMH Heart failure DH Bumetanide 3mg om, 2mg at lunchtime

Metolazone 5mg om Spironolactone 50mg om UE K+ 6.4mmol/L

Na + 121mmol/L Creatinine 214 micromoles/L Urea 38.3mmol/L

Patient 3 Male 59 years old PC Jaundice and abdominal swelling SH Drinks 3 litres of strong cider per day U&Es Na = 129 mmol/L

Bili 45 µmol/L Gamma GT 200 IU/L ALP 178 IU/L ALT 34 IU/L

Appendix 2 – Clinical Case Studies


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Alb 27g/dL Patient 4 Male, aged 69 years PMH COPD DH Salbutamol nebs 5mg QDS Ipratropium nebs 500mcg QDS Prednisolone 40mg OD Oxygen 40% O/E Patient drowsy and confused Investigations PaO2 11kPa PaCO2 9.3kPa pH 7.27 HCO3 29mmol/L Patient 5 Male, aged 63 years PMH AF DH Digoxin 125mcg OD Warfarin 2mg OD Miconazole oral gel 5ml QDS started 4 days ago for oral thrush Blood tests Hb = 12.3g/dL INR = 6.2 (target 2.5) 2. Calculations (NB: Calculators should not be used for these questions)

1) Nimodipine is infused at a dose of 1mg/hour for 2 hours, then 2mg/hour for at least 5 days. 50ml vials are available containing 200mcg/ml. How many vials would you need to supply for the first 24hours of treatment?

2) Phenytoin is given as a loading dose to treat status epilepticus at a dose of 20mg/kg infused at a rate of 50mg/minute. For a 70kg patient, what dose would you recommend and how long should this dose be infused over?

3) A patient is being discharged home on the following chlordiazepoxide reducing regime for alcohol withdrawal. How many 10mg and 5mg capsules would you need to supply to complete the course?

Day 1: 10mg TDS and 20mg nocte Day 2: 10mg QDS Day 3: 10mg TDS Day 4: 10mg morning and night, 5mg at lunchtime Day 5: 5mg morning and lunchtime, 10mg nocte Day 6: 5mg TDS Day 7: 5mg BD Day 8: 5mg nocte then stop.


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4) A patient usually takes phenytoin sodium capsules 300mg at night. She is no longer able to swallow solid dose forms and needs to be changed to liquid.

a) What dose would you recommend? b) What volume of liquid would need to be given each day? c) What volume of liquid is needed for 2 weeks supply?

5) A patient on your ward has a provisional diagnosis of Guillan Barre syndrome and is

to receive Vigam® (5% human normal immunoglobulin, available in 200ml vials) at a dose of 0.4g/kg/day for 5 days. This should be rounded up or down to the nearest 10g dose. His weight is 80kg, and his height is 5ft 9inches. Vigam® needs to be infused at an initial rate of 0.01ml/kg/min for the first 30 minutes.

a) Would you consider this an appropriate request? b) What would you need to do before you supply this? c) What dose would you recommend? d) How many vials would you need to supply for the whole course? e) What initial rate of infusion would you recommend in mls per hour?

6) What would be the appropriate initial infusion rate of dopamine for a patient? (BNF

says dilute to 1.6mg/mL and give at 2-5microgram/kg/min). Dopamine is available in your Trust in 40mg/mL x 5mL ampoules, but not as pre-mixed infusion bags. Assume the patient is a typical 60kg elderly man.

7) The BNF loading dose of aminophylline is 250-500mg IV over at least 20minutes (5mg/kg) (if not previously treated with methylxanthines) followed by 500micrograms/kg/hour. Mrs. B is a 60kg lady and heavy smoker of 35 who has been admitted to your ward and the house officer asks for advice on how to give these infusions/injections. Tip: Aminophylline comes in 250mg/10mL ampoules

3. Short answer case studies Full care plans are not expected for each case, but for each patient:

Identify any actual and potential problems that the patient may have?

Assess each problem (e.g. what may be causing / contributing to the problem - is any action required?)

Discuss how you would approach each problem – what changes would you suggest?

Prioritise the problems you find as “low” “medium” or “high” and suggest how quickly you would have to resolve each problem

1) Mr AA, Age 55 years PC Shortness of breath and ankle swelling, generally unwell PMH CKD 3, IHD, Type 2 diabetes DH Furosemide 80mg OD Calcichew 1.25g TDS Sodium bicarbonate 500mg TDS


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Atenolol 50mg OD Aspirin 75mg OD Simvastatin 40mg OD Metformin 1g TDS Pioglitazone 30mg mane Ramipril 10mg OD Quinine 300mg ON GTN spray 2 puffs prn

NKDA Bloods Na+ 137mmol/L

K+ 6.3mmol/L Ur 20.1mmol/L (was 11.6mmol/L 3 months ago) Cr 370micromol/L (was 205micromol/L 3 months ago) Bicarb 15mmol/L

2) Mrs BB, Age 45 PC Fatigue PMH Back pain, depression DH Diclofenac 50mg TDS Citalopram 20mg mane NKDA

Bloods Hb 6.4 g/dL (11.5-16.5)

Platelets 242 x 109 (150-400)

WCC 6.4 x 109/ L (4-11 x 109) Urea 10.4mmol/L (2.5-7.5)

H. pylori positive 4. Mr CC, age 64 Mr CC is a patient with Parkinson’s disease who is admitted to your ward with swallowing difficulties. His drug history is confirmed as; Stalevo 100mg/25mg/200mg – 1 tablet qds (at 8am, 12pm, 4pm and 8pm) Ropinirole 1mg TDS Lactulose 15ml BD Senna 15mg nocte He is to have an NG tube placed to allow administration of his medicines. How would you advise them to be given? If he could not have an NG what other options are there for control of his Parkinson’s symptoms. 4) Mrs DD, age 42 PC Seizure, recently unwell with chesty cough PMH Alcoholic, multiple admissions with alcohol withdrawal, COPD SH She usually drinks a bottle of vodka per day but hasn’t drunk any alcohol for the

past 3 days Smokes 20-25 cigarettes per day


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DH Nil reg – says she took some vitamin tablets a few months back, after her last hospital admission but has not taken since that supply ran out. Has salbutamol and beclometasone inhalers on repeat prescription but has not taken for several weeks.

GP issued a prescription for levofloxacin 500mg daily yesterday, but she has not yet taken any. Allergic to penicillin

Bloods: Na = 136mmol/L

K = 2.7mmol/L Ur = 4.5mmol/L Cr = 65micromol/L Hb = 9.8g/dL MCV = 105.4 WCC = 14.4 x 109/L Bili = 16micromol/L ALP = 145IU/L ALT = 39IU/L GGT = 234IU/L

Impression: Alcohol withdrawal + chest infection What medication would you expect her to be started on? What counselling would you give her about her medication? 5) Mr EE PC Abdominal pain, jaundice, confusion PMH Known alcoholic liver disease, no longer drinking DH Thiamine 100mg BD Multivitamins 1 daily Spironolactone 50mg daily Nitrazepam 10mg nocte Co-codamol 8/500 2 qds – regularly for the past 4 days

Allergic to Trimethoprim Bloods: Na = 137mmol/L

K = 3.7mmol/L Ur = 6.1mmol/L Cr = 85micromol/L Hb = 11.2g/dL Bili = 73micromol/L ALP = 225IU/L ALT = 193IU/L GGT = 682IU/L Albumin = 30g/L INR = 2.0

Impression: Worsening liver disease with ascites 6) Mr FF


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PC Newly diagnosed heart failure PMH 2 previous MI’s, AF, hypertension DH Furosemide 40mg mane Ramipril 2.5mg mane Amitriptyline 25mg nocte Verapamil MR 240mg daily NKDA

7) Mrs GG PC CVA PMH previous stroke, post-stroke epilepsy DH Aspirin 75mg daily Dipyridamole MR 200mg BD Bendroflumethiazide 2.5mg mane Pravastatin 20mg nocte Ramipril 5mg mane Sodium valproate EC 200mg TDS NKDA On admission she is thrombolysed with alteplase for an ischaemic stroke. She is nil by mouth awaiting SALT review. Advise what changes you would expect to her prescription and what alternative routes you would use for her medication temporarily. For the following 3 scenarios: Identify medicines that may cause falls Any questions you would want to ask the patient? Identify an action plan 8) Mr HH, age 67 PC fall at home PMH T2DM, angina, anxiety DH Aspirin 75mg mane

Metformin 500mg TDS with meals Simvastatin 40mg nocte GTN spray 400mcg 1-2 sprays prn Nitrazepam 5mg nocte Amitriptyline 20mg nocte Diazepam 2mg TDS prn

9) Mr JJ, age 75 PC reduced mobility and unsteadiness PMH Parkinson’s disease, heart failure. DH Co-beneldopa 125mg TDS (8am, 2pm and 6pm)

Sinemet CR 50/200 nocte Quetiapine 25mg BD Furosemide 40mg mane Ramipril 5mg mane Bisoprolol 5mg mane

10) Mrs KK, age 70


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PC confusion, fall and knee pain PMH OA knees, hypertension, urinary incontinence, hay fever. DH Tramadol 50mg TDS

Ibuprofen 400mg TDS (OTC) Oxybutinin 5mg TDS Bendroflumethiazide 2.5mg mane Doxazosin 4mg mane Chlorpheniramine 4mg QDS (OTC)

Prescription chart reviews Screen the drug charts provided as if you were clinically checking the prescription. Full care plans are not expected for each case, but for each patient:

Identify any actual and potential problems that the patient may have?

Assess each problem (e.g. what may be causing / contributing to the problem - is any action required?)

Discuss how you would approach each problem – what changes would you suggest?

Prioiritise the problems you find as “low” “medium” or “high” and suggest how quickly you would have to resolve each problem


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Appendix 3 – Copies of Paperwork for Practice

Based Assessments


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Mini-Clinical Evaluation Exercise (CEX) Name of Junior Pharmacist: Name of Designated Senior Pharmacist Name of Current Rotation: Date assessment performed: Clinical Problem(s): Complexity of case: (please circle) Low Average High

Please grade the following

areas using the scale

below:

Below Border-line Meets

expectation

Above Unable to

comment

Patient consultation

Consent

Appropriate questioning

Documentation

Need for drug

Relevant patient background

Medication history

Selection of the drug

Drug-drug interactions

Drug-patient interactions

Drug specific issues

Appropriate dose, dosing regimen and formulation

Provision of drug product

Prescription clear and legal

Medicines information

and patient education

Identifies need and considers patient’s circumstances

Provides accurate info in appropriate format

Professionalism


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Confidentiality

Recognises own limitations

Gathering information

Accesses and summarises info

Knowledge

Pathophysiology, pharmacology, side effects and interactions

Analysing information

Identifies problems

Decision making

Overall Clinical care

Anything especially good?

Suggestions for development

Agreed action:

Rotational Pharmacist satisfaction with mini-CEX (please circle) 1 2 3 4 5 6 7 8 9 10 Not at all Highly Designated Senior Pharmacist satisfaction with mini-CEX (please circle) 1 2 3 4 5 6 7 8 9 10 Not at all Highly Signature of designated senior pharmacist: Signature of junior pharmacist:


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General Ward Visit Summary

Student Name: Date:

Ward:

Summary of patients: Total number of patients on ward =

Total number of new admissions =

Number of patients seen during the visit =

Duration of visit =

Prescription Verification / Validation

Activity Assessment of

Performance

Comments

Prescription orders verified are

clear / legible


legal


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Prescriptions orders have been

verified in an appropriate

timescale

Prescription orders verified have

appropriate additional information

(e.g. additional administration

instructions, specific instructions

for IV administration, brand

names where appropriate) or

endorsements in line with

departmental policy


clinically appropriate, i.e.

Drug choice appropriate

Dose appropriate

Dosing regimen is appropriate

Formulation prescribed is

appropriate

Route of administration

prescribed is appropriate


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Managing Workload


Performance

Comments

Demonstrates method for

highlighting patients

requiring follow up

Patients followed up in a

timely manner

Knowledge of patients

demonstrated


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Demonstrates method for

prioritising workload

appropriately

Enlists the help of

colleagues where

appropriate (e.g.

delegation of tasks to the

ward based technician)


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Communication


Performance

Comments

Documentation of actions

complies with departmental

policy

Uses appropriate language

when communicating with

nursing staff



medical staff



patients and their carers


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Overall Comments Relating to the Visit:

Actions Required:

Tutor Signature:

Student Signature:


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Case-based Discussion (CbD) Junior Pharmacist name: Name of Designated Senior Pharmacist: Name of Rotation / Therapeutic Area Covered: Date of Assessment: Complexity of case: (please circle) Low Average High

Please grade the following Areas:

Below Border-line Meets expectation

Above Unable to comment

Pharmaceutical needs Assessment

Identifies the patient’s problems

Prioritises the patient’s problems

Treatment recommendations:

Refers to EBM, local & national guidelines

Knowledge of pathophysiology, pharmacology and therapeutics

Follow up/ Monitoring

Discusses rationale for monitoring

Demonstrates practical on-going and appropriate monitoring

Discusses how patient was managed in conjunction with the wider healthcare team

Professionalism

Timely and succinct

Ethical approach

Recognises own limitations

Considers interface issues

Overall Clinical judgement

Discuss own judgement, synthesis, caring and effectiveness for patient


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Anything especially good?

Suggestions for development

Agreed action:

Rotational Pharmacist’s satisfaction with CBD (please circle) 1 2 3 4 5 6 7 8 9 10 Not at all Highly Assessor’s satisfaction with CBD (please circle) 1 2 3 4 5 6 7 8 9 10 Not at all Highly Signature of designated senior pharmacist: Signature of junior pharmacist:


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Record of In-service Training Assessment (RITA) Name of Junior Pharmacist: Name of Designated Senior Pharmacist: Name of Current Rotation: Date of Review: Period covered: from …………………….to…………………. Please provide a brief description of experience / activities undertaken, since the last review (if applicable): Documentation taken into account during the review: 1. 2. 3. 4. 5. Please describe progress made with the departmental objectives and highlight particular strengths of the band 6 pharmacist


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Please identify any areas of particular weaknesses/difficulties/perceived problems or areas that need further work and give details of the proposed action plan Overall Tutor comments:

Signature Band 6 Pharmacist comments:

Signature


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Name of Rotation: _______________________________________ 1. The objectives were made clear to me at the start of the rotation (1 = strongly

disagree, 5 = strongly agree) 1 2 3 4 5 2. A list of relevant references was provided (1 = strongly disagree, 5 = strongly

agree): 1 2 3 4 5 3. Please indicate how many meetings (including ward visits) you had during the

rotation:

_____________________________________ 4. Please provide any other information relating to the organisation of the rotation

that you think would be useful for future rotations

Appendix 4 – Feedback on Rotation

Documents

Band 6 Rotational Training Programme - Pharmacy … · Band 6 Rotational Training Programme Pharmacy Training Pack . ... Outcome Measures Review ... There is a departmental KPI …