Pharmacy GRIT – growth, research, innovation, training · FEATURE Shape Shifters: Expanding the role, changing the world Every day we’re bombarded with news that the world is

FEATURE

Shape Shifters: Expanding the role, changing the worldEvery day we’re bombarded with news that the world is falling apart, that the structures are crumbling, that the world is getting more dangerous. But there is so much in the work of SHPA members at the frontline of healthcare delivery to contradict this bleak view. Our members are actually making the world safer: they’re improving structures and making them smarter and more effective; they’re making healthcare more nuanced and patient-centred; and they’re generally spreading light when it comes to using medicines in the best possible ways to make people better.

Pharmacy GRIT’s own roving reporters, Keli Symons, Jane Ermer and John Hand, have physically or virtually crossed the continent to bring you some of these inspiring stories of innovation at the frontline. We found pharmacists working in well-defined roles, with confidence in their knowledge, skills, expertise and value, collaborating with other health professionals to improve patient care.

In Adelaide, we met Joy Gailer on her day off, fresh from a workout at Toddler Gym. She is bringing skills and expertise from the hospital pharmacy to the world of general practice. In Perth, we spent the morning with Deirdre Criddle and her team who provide integrated care to people with the most complex and challenging needs, and later we caught up with Julie Adams, who brings chemotherapy to people in their own home.

All three women have been innovative in finding a way to make a good idea work. If it’s good for the patient they have found a way to work within, around and through the constraints of budgets, legislation, bureaucrats, accountants and convention. They think outside the box, even if they have to work within the box, and they make a difference.

In our search for innovators at the frontline, we were also drawn to a number of other pharmacists who are engaging today’s challenges in their own way, often as part of an allied health team, and often at quite early stages of their career: we spoke to Benita Suckling and Russol Hussain at Redcliffe Hospital, QLD (who have an innovative Director of Pharmacy with a great leadership style in Geoff Grima); as well as Helender Singh, Millicent Ballancin and Paul Firman at Logan Hospital QLD; and to Rose Burgess of Barwon Health, VIC. This is a constellation of motivated people who are expanding

unique pharmacist positions in health care today – sometimes after they helped to create them. Their stories show that the path of an innovative career has many interlinking stages, but there is always one constant: a willingness to put one’s hand up – for a small QUM project or to cover a colleague while they’re away, for example – going beyond their comfort zone, gaining varied exposures to frontline healthcare challenges. No wonder they’re contributing so much to the solutions.

All the pharmacists we spoke to are energised, positive and resilient examples of our profession. They share a love of learning and a passion for the difference that a pharmacist can make and the skills that set us apart. Be prepared to be inspired to go forth and do good.

And there’s more coming… In this issue, we scan the country for innovations at the frontline – which is increasingly difficultbecause the frontline keeps moving! Soon in GRIT, we will be dedicating an entire feature to rural and remote pharmacists and their innovations, and likeminded pharmacists who step beyond the conventional borders of pharmacy practice.

doi: 10.24080/grit.1028

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JULIE ADAMSPharmacist & healthcare service owner | Western Australia

CHEMO IN COMFORTAfter more than 25 years as a hospital pharmacist Julie Adams literally left the building to start her own healthcare service, chemo@home, in her hometown of Perth.

Partnering with her good friend and nurse colleague Lorna Cook, Julie realised that they had complimentary skills: Julie has excellent attention to detail, is protocol driven with extensive oncology experience, while Lorna is the “front of house” extrovert, a nurse with sales and marketing experience.

Julie spent her hospital years working on oncology wards and later established and managed Royal Perth Hospital’s Home Cancer Care Services (HCCS) program. Before starting HCCS, Julie experienced firsthand the effect that chronic illness has on families when her dad developed emphysema and suffered from repeated chest infections. Working with patients with haematological malignancies at the time, Julie engaged her nurse colleagues to teach her how to

administer IV antibiotics so she could take her dad home for Christmas. This experience made her question the notion of the hospital as the patient’s medical home, and to consider, what treatments could be safely given outside the hospital walls?

Several advances occurred over time which made giving chemotherapy at home both feasible and reimbursable. Supportive care continued to improve after the introduction of the colony stimulating factors and the 5HT3 antagonist antiemetics and together with new infusion pump technology and important changes in the regulatory and legislative environment, Julie could see that it was possible to give almost all chemotherapy regimens safely in the home and that there was a framework for reimbursement.

Understanding how the health service could deliver treatment was probably the easiest part of the journey. Much bigger hurdles turned out to be securing funding through the private health insurers, getting doctors to refer patients to the service and letting patients know that they had a choice about where they could receive their treatment. The most important win was securing funding through HBF, WA’s largest health fund. Unbeknown to Julie, one of the people reviewing the agreement for HBF was a past pharmacy student who not only recognised Julie’s expertise in the field and trusted her vision, but who also was pivotal in securing funding for chemotherapy and extending the contract to include immune-modulating drugs. In addition to chemotherapy, chemo@home gives bisphosphonate infusions, iron infusions and a range of immune-modulating drugs for Multiple Sclerosis, Rheumatoid Arthritis and Inflammatory Bowel Disease.

Julie and her business partner, Lorna, put everything on the line to start chemo@home, including their own houses. Julie has had to be brave, thick-skinned and have courage in her convictions to see her vision become reality. She has had to advocate for why her service was not only feasible but a necessary option for patients and their families, and says she became more comfortable managing tense situations and having hard conversations. Julie encountered many barriers from those entrenched in the status quo and she has not been afraid to step on a few toes. “When you innovate you will make some people uncomfortable. Some tension is desirable; being difficult makes you disruptive and a good entrepreneur.”

chemo@home works because it is a service that allows health professionals to work collaboratively, making the most of their differing expertise and skills. Nurses give the infusions in the home and they are supported by specific, tailored protocols developed by specialist pharmacists. Julie ensures that they only deliver what can be safely managed in the home. Nurses are fully equipped to manage infusion reactions and anaphylaxis. The decision to administer at home is made individually for each regimen, and risk minimisation and mitigation strategies are implemented. This may mean that for some treatments – for example, chimeric monoclonal antibodies – an initial number of infusions may need to be given in the hospital setting.

The chemo@home model embraces patient-centred care. Julie tells of a patient with multiple myeloma who works as a truck driver, and who couldn’t afford to give up work for his treatment; his treatment was given by chemo@home at a truck depot.

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Then there’s the young man with glioblastoma, who’s mum can lay on the bed next to him holding his hand and resting while he receives his treatment, something that would be impossible in the hospital day-unit. The mother continues to work around her son’s treatment and gains valuable time with him that would otherwise be spent driving to and from hospital. Students and professionals receive infusions for chronic illnesses at home while they study or in the office while they work. But it’s more than the convenience of time and place, sometimes it can be about sparing someone from a hospital environment which can be intimidating, stressful and frustrating. An elderly lady with mild cognitive impairment received treatment at home for an ocular lymphoma – a treatment she would not have received otherwise because she became very distressed and aggressive in the unfamiliar environment of the hospital.

Julie’s ability to think outside the box has seen her and chemo@home recognised via nine awards in the last 12 months, including Julie being named the 2016 Telstra’s WA Business Woman of the Year. Other awards include the 2016 Highly Commended Winner – Australian Womens’ Weekly Women in Business Award, 2016 Australian Financial Review Aspire Awards – Start-up Disruptor Award, 2017 Westpac’s 200 Businesses of the Future, and she is currently a finalist alongside Andrew “Twiggy” Forrest for the 2017 West Australian of the Year, Business Category. The Pharmacy GRIT team have our fingers crossed! Julie says the awards have given chemo@home credibility and the Women’s Weekly award is spreading the word to its millions of readers.

chemo@home is more than just a business enterprise, it reflects the personal beliefs of its founding owners

– they have strong values and aclear purpose to improve the lives of cancer and chronic disease patients and their families. The chemo@home ethos could well be describing Julie herself: be bold, be flexible, take care, foster relationships, be professional, be innovative, be commercially aware. And above all, leave people better for having known you. l

DEIRDRE CRIDDLEClinical Pharmacist | Western Australia

THE CLINIC WITHOUT WALLS Deirdre Criddle is not afraid of a challenge. When approached for the role of clinical pharmacist on the Complex Needs Coordination Team (CoNeCT) based at Sir Charles Gairdner Hospital in Perth, she knew she wanted the job. Quickly finding out all she could about the Clinic 40.04 funding model and service delivery she not only got the job, but helped ensure that it is a viable service that will continue to be funded into the future.

CoNeCT is a clinic without walls, operating in the space between the hospital and the community. Its clients often don’t have a medical home – they may be ex-IV drug users, have difficult relationships,

live in squalor, some are hoarders and almost all have some mental health problems. The CoNeCT team describe themselves as “Champions of the Vacuum”. They “hold” these individuals until they can find them a medical home in the community. Rather than discharge their clients, they handover to a general practitioner or a community service.

CoNeCT has been innovative from its inception. Team Leader and social worker Carolyne Wood recognised there was a lack of awareness in her interdisciplinary team around pain management and antidepressants. Chatting to pharmacist Bruce Williamson on a ward one day, she asked him to provide an education session for the team; his response was “you don’t need an education session, you need me on your team!” Carolyne managed to secure funding for a full-time pharmacist for her team.

The program aims to keep people out of hospital. The team reduces presentations to the Emergency Department by 82% in the 6 months after exiting CoNeCT compared to the 6 months prior to referral to CoNeCT. But they acknowledge that readmissions don’t tell the whole story – a broader or longer assessment isneeded to show the true value of the program. The program targets the most at-risk patients, the “frequent flyers”, and in helping this group they will sometimes increase presentations to hospital in the short-term. About 10% of CoNeCT patients do not survive, mostly because they are picked up at the end-stages of chronic disease. Carolyne would like to be targeting the “rising-risk” group and feels there is real scope to impact before a patient becomes high-risk. At the moment, the clinic is an investment in high-risk patients. For some patients Deirdre’s role is to help ensure that they link up with their regular GP and pharmacy so they

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can be managed through the existing HMR and MedsCheck processes. Those patients who cannot or will not engage with their usual community medicines management team require more intensive support from CoNeCT.

CoNeCT is more than a hospital outreach service. It employs a case management model that includes home visits, advocacy, education, communication and connection to services that help patients manage their health issues in the community. Recognising that an admission is only a short time in a patient’s health journey, and that utilising all available resources may not be enough to resolve complex chronic issues, the team invests time to develop a working relationship with the patient. The team meet to review each case every two weeks, sharing knowledge, experience and their unique interdisciplinary skills to find solutions. The average amount of time a person spends with CoNeCT is 3 months.

The addition of a pharmacist to the team has been a game-changer. CoNeCT physiotherapist Ben Devine says having a focus on medicines gives the team licence to operate in the medical space. The pharmacist enables conversations with general practitioners, hospital specialists and community pharmacies and bridges the gaps. The pharmacist can escalate a case in a way that is more difficult to do for nurses and social workers, especially with medicines management issues. Some patients are medically complex and may see many specialists and more than one GP. Not surprisingly, community pharmacists are doing a lot of work for some of CoNeCT’s most complex patients and for some they are the primary health care professional. Deirdre will usually phone the GP, if they have one, as soon as a patient is referred to the program. “It’s a courtesy as many will not be aware

of the admission, but it’s also to engage their cooperation. Most are happy for help with their complex patients.” A fierce advocate for the role of pharmacists as medicines management experts, Deirdre is clearly enjoying the chance to dig deeper into her patient’s stories to find a way to help them. “Pharmacists are great investigators,” she explains. Keen to be seen as a link and not a threat, Deirdre is careful to support and utilise existing relationships between GPs and community pharmacists as the ultimate goal is to manage the handover of care.

Success of the program is in part due to the innovation of the pharmacy department at SCGH. It was Chief Pharmacist Jenny Benzie who gave Bruce Williamson leave from the ward to join the team, and the program continues to be championed by the current pharmacy team, led by Gillian Babe and Peter Smart. Pharmacy interns are assigned to a rotation with Deirdre, where they get a sometimes shocking insight into how things are in the real world – where insulin sitting on top of the fridge (filled with beer) might not be at the top of the list of priorities. Realising that referrals to the program were mainly coming from social workers and nurses and not pharmacists, Deirdre sought to find out why. Pharmacists agreed that the referral tool to CoNeCT correctly identified eligible patients but it was too long and different weightings for various risk factors meant it wasn’t easy to use on a busy ward. Together they developed the PHARMACIE 4 tool: Polypharmacy, High-risk medicine, lives Alone, Rural or remote, Mental health or cognitive impairment, Age, Comorbidities, Indigenous patient or interpreter required, Extended stay or recurrent admission. Each letter of the acronym gives 1 point, and a total of 4 points is enough for referral if the patient

does not have access to a community medication management service. CoNeCT are currently working together with SCGH Pharmacy on a research project to validate this tool.

Like all our stories of innovation at the frontline, Deirdre saw an opportunity and then found a way to make it work. It’s not a role for the faint-hearted. Some of the patients are the hardest to help, and the team recognises the right of a person not to help themselves, at least not in the way that we want them to. For some patients, the team must be fearless advocates. There aren’t a lot of shiny success stories to celebrate – small wins are important. The team share a rather dark sense of humour and genuine respect for each other’s skills and contribution. Silo smashing at its best. l

ROSE BURGESSRadiopharmacist | Barwon Health, VIC

PHARMACY ACROSS TWO WORLDS Radiopharmaceuticals, being radioactive, start decaying from the moment they’re made. Therefore, they are manufactured on the day they’re to be administered – meaning manufacture must begin at 2:00am. That’s why Rose Burgess, the Radiopharmacist at University


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Hospital Geelong (UHG), who also spends three nights per week learning how to make radiopharmaceuticals at a commercial radiopharmacy north of Melbourne, is ever so slightly weary when we meet her for lunch: she’s been up since midnight.

But Rose perseveres through our questioning because of her clear passion for expanding the role of the radiopharmacist in Australia. When she first considered the role for herself, digging a little deeper into the world of radiopharmacy, Rose was stunned that so much of what she found there was totally new to her despite her years of varied pharmacy work. “I think there was only one sentence in one lecture in my four-year pharmacy course,” she says. “And it’s a shame because I think radiopharmacy is really cool and really changing! The students and interns at the UHG who pass through my area are so interested in it – it’s a growing field in Australia, and I want to learn as much about it as I can to help that growth.”

Indeed, a casual chat with Rose suggests that the realm of nuclear medicine is one full of pretty wondrous stuff, with plenty of opportunities for someone with the unique skills of the pharmacist. She explains that it’s “the coming together of two highly regulated worlds” – the management of medicines and the management of radiation – that demands creative extensions of the traditional pharmacist role. The use of radiolabelled medications is one example: different medications emit radiation of different wavelengths, which correspond to different ‘target’ sizes – a certain wavelength can target certain tumours, for example – but only if they’re manufactured,handled, and administered correctly. And it really is a world of extreme precision: “Auger electrons, for example, can break a single strand

of DNA,” Rose says. With such accuracy avoiding the ‘collateral damage’ of traditional radiotherapy, it’s a perfect example of how radiopharmaceuticals are expanding beyond purely diagnostic uses and increasingly into therapeutics (or, into the new horizon of theranostics, which Rose swears is a real thing), promising even more opportunities for radiopharmacists to expand their role.

A fantastic example of expanded radiopharmacy clinical work is the pharmacist-led Pre-PET Scan Diabetic Clinic at UHG – which seems to be the only such clinic in Australia – established by Rose’s predecessor,Harry Wendt. An overview of its work is on the next page, but essentially, Rose manages the clinic, working very closely with nuclear medicine clinical and technologist staff, nurses and endocrinologists to maximise the effectiveness of patients’ PET scans. Patients admitted to the clinic often bear complex comorbidities at a time of high stress, and so Rose’s work in the clinic is a delicate balancing act of medication management (including the withdrawal of certain diabetic medications such as metformin), radiopharmaceuticals, patient education, the careful customisation of clinical conditions, and even careful sensitivity to and management of patient emotions – all to ensure that the patient’s blood sugar level allows for the most accurate and useful PET scan possible. We’re amazed to hear the layers of care wrapped around the patient in this clinic, all directed by the pharmacist. “It really is all about the patient,” Rose agrees. “You can just see that they feel much more relaxed and better about everything. Even if they’re finding out that they’ve got cancer or a year left to live, they’re still able to feel stable and OK.”

How did Rose get into the position? It helped that in her early years as a pharmacist at UHG, before she

switched to community pharmacy for 10 years, she had volunteered to cover for Harry when he went on leave. It’s one of many examples we’ve found of pharmacists who are pushing boundaries today having put their hand up for varied duties earlier in their career. For Rose, it also helped that she had a natural interest in oncology and sterile techniques, and she also values her time in community pharmacy for how it influences her work today: “Sometimes it’s about understanding something well enough to be able to break it back down into the patient’s language – which is hard, but something, as a pharmacist, you’ve got to keep developing.”

Some of the Nuclear Medicine team have told Rose that each radiopharmacist develops the role in their own way. Harry developed the position at the UHG beyond lab-based work into a more clinical role, following UHG’s acquisition of a PET-scanner; for her time in the position, Rose would like to continue along these lines, but aims to expand the clinical duties further (with increasing therapeutic uses of radioactive medicines) and even bolster the lab-based side again. If UHG acquires a gallium generator, for example, Rose would be able to manufacture some of UHG’s radiopharmaceuticals in-house; further, the radiolabelling of patients’ blood cells (before they are reinjected for diagnostic purposes) is an example of labwork at UHG in which Rose sees scope for greater pharmacist involvement. “The more I learn, the more I can see what else I can do to assist the Nuclear Medicine team,” Rose says.

And she is also keen to note the support the Radiopharmacist position (which sits within Nuclear Medicine) has received from the Pharmacy Department at UHG. Indeed, there is a significant history within Barwon Health of pharmacy


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team members advocating for and supporting the radiopharmacy work at UHG, out of recognition of the need to develop the specialty in order to approach the levels the field has reached in the USA and UK.

Rose tells us that she felt that she was the stereotypical “impersonable” pharmacist – someone who preferred to be active in the background – but her work in this new field has greatly opened her up. She now really loves her close involvement with patients. This, alongside her determination to advocate for women in STEM roles, as well as addressing the gender imbalance in radiopharmacy in Australia more specifically, is what Rose finds especially fulfilling in her current role. Rose gives us an example of the kind of patient interaction that now drives her: “I had a phone consult with the carer of a rural patient, whose condition meant we had to handle her admission to the Pre-Scan clinic in a very different, very customised way. It had been really difficult for both of them, and ultimately it wasn’t able to work out as planned. At the end of our phone catch-up, he said that ‘This was the best conversation I’ve had with someone like you in a situation like this.’ And he really wanted me to know that.”

Pharmacist-led Pre-PET Scan Diabetic Clinic at UHG PET scanners (Positron Emission Tomography) work with radioactive pharmaceuticals (‘tracers’) administered to the patient, whose organs and tissues absorb the material, leading to scans that provide brilliant information on the body’s functions. At UHG,

the goal is usually to image cancer, inflammation or an infection/disease of unknown origin, and the primary tracer used is 18-Flourodeoxyglucose (18F-FDG), a synthetic glucose. If a patient’s blood sugar levels (BSLs) are high, then target cells – e.g. cancer cells – will not take up the 18F-FDG, but the body’s own sugar in preference. Further, certain medications – e.g. circulating insulin, metformin – can also interfere with the18F-FDG and therefore the procedure. Hence fasting and withdrawal of certain medications is a fundamental part of patient preparation for PET scans.

Diabetic patients, then, are obviously at particular risk of sub-optimal scanning, and therefore diagnosis and care. To combat this, diabetic patients scheduled for a PET scan at UHG are booked-in to visit the Pre-PET Scan Diabetic Clinic approximately one week prior to their scan, to review their BSLs and their BSL management (consulting with their doctor and escalating to endocrinologists if necessary), to help them achieve the best preparation for their scan, including helping them manage the restrictions on their medications in the lead-up to the scan.

The clinic is managed by the radiopharmacist who works closely with Nuclear Medicine clinical staff and technologists, as well as endocrinologists. Patients are asked to bring all their medications and their BSL logbook if they have one. Their BSLs are monitored/analysed in

the clinic and the radiopharmacist talks to them about all their medications, as well as their diet, and the PET scan procedure in general (it is sometimes the first chance the patient has had to talk to someone in-depth about the procedure). This means that a lot of the work in optimising the scan boils down to educating patients about their medicines – which often turns up problems in the existing management of their medicines and diet not related to the PET scan. Further, on the day of the scan, patients may have heightened stress levels – these scans often being the “last straw” in a diagnosis of cancer – which further pushes up their BSLs. In these cases, the pharmacist’s connection with the patient plays a role in the effort to ease the patient’s nerves and help them achieve the best scan possible. It is medicines management performed through a very intimate kind of patient care.

While the overriding motivation for achieving the best possible scan is always to facilitate the best possible diagnosis, treatments and outcomes for patients, preventing scan cancellations also avoids wasting highly-customised unit doses of radiopharmaceuticals. Doses of FDG are ordered by patient weight and for administration in a certain half-hour period – that is, in manufacturing the unit dose, the decay that occurs from t = 0 to the time of administration is accounted for – if a scan is cancelled due to elevated BSLs, the highly-customised dose is wasted. l


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JOY GAILERSenior Pharmacist | South Australia

TRULY PATIENT-CENTREDWith a background in hospital pharmacy and as a Senior Pharmacist for South Australia’s Drug and Therapeutic Information Service (DATIS), Joy has forged strong relationships with General Practitioners. What started as a discussion at a medical conference led to the creation of a pharmacist position in a busy general practice in Adelaide. The medical partners supported the creation of the position, with one commenting he “missed his hospital pharmacist”.

When considering different funding models for a practice pharmacist position, Joy was keen to carve out a role as a medicines specialist and careful not to encroach on tasks performed by the practice nurses. Pharmacist, doctors and nurses have different and complimentary skills. The practice made the business decision to fund the position of practice pharmacist themselves. Starting with one 4-hour session per fortnight it quickly increased to two 4-hour sessions per week.

Helping GPs with challenging therapeutic decisions is a major part of Joy’s role. A typical day may involve a couple of consultations with patients who may be considering a new drug therapy or managing a complex condition. Allowing up to 45 minutes per consult gives Joy the time to get to know the person and understand what is important to them and how drug therapy might fit in their lives. For some new therapies, particularly the immune-modulating drugs, the decision to proceed with treatment is huge and there is very limited information available to both patients and GPs. The GP may also enlist Joy’s help in discussions around trial withdrawal of medicines and she will usually see a patient before they commence an anticoagulant, particularly if the decision whether to use warfarin or one of the newer agents is not clear. Having the time to dig a little deeper into the history and find out what is really important to the patient helps enable truly patient-centred decisions. Some patients may also require or may have previously had a Home Medicines Review; however, this is a separate and additional service to that of the practice pharmacist.

The rest of the day is taken up with answering questions that range from investigating a suspected adverse drug reaction (e.g. neutropenia with atorvastatin), providing information around novel therapies like suvorexant, to discussion about what the recent BMJ study on NSAID and MI risk means for the patients of the practice.

Clinical governance and Quality Use of Medicines are at the heart of Joy’s role. The practice was one of the early adopters of ferric carboxymaltose infusions in primary care and they are currently working

on an audit to document the benefits and adverse reactions. The aim is to help determine the best patient selection criteria so that iron can be given safely in primary care while more at-risk patients can be referred to the hospital setting. Similarly, setting up key performance indicators around the novel oral anticoagulants will help ensure that patients receive appropriate renal function monitoring. Providing timely drug information, both for new drugs and where information is changing for existing therapies is an important contribution, in a practice that does not see industry representatives.

Being embedded in the practice is critical. As well as sitting-in on some GP consultations, Joy has full access to patient notes. She writes in the notes, documenting the discussions and “grey” areas around clinical decisions. But the unplanned “corridor conversations” is where a practice pharmacist can really make a difference. All the GPs are busy, most work part-time, and they don’t have an opportunity to discuss really challenging cases. Joy’s sessions always run over lunch breaks to ensure she gets maximum contact with as many GPs as possible. “When I am at the practice, I answer the questions that would otherwise go unanswered.”

Clearly loving her work, Joy reflects on the journey so far. “I really appreciate that I couldn’t be doing what I am doing without the background that I have had... and the GPs having the past experience of really good hospital pharmacy services.” Joy believes that pharmacists have an important role to play in supporting GPs in managing complex patients with multiple medicines. This is our specialist area, this is what we are good at.


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“The most impact I have is not about physical intervention, but more about understanding what the patient wants.”

It’s not just the GPs who are learning in this innovative model. Joy says she has become far more aware that we underestimate how significant it is to put someone on a medicine, to label them with a condition. A decision can be made very quickly, even a correct decision, and it carries forward a range of emotions for the person. You need enough time with a person not just to say be empathic, but to practice empathy. Then you can really help someone. l

RUSSOL HUSSAINPharmacist | Redcliffe Hospital, QLD

PREVENTION IS THE BEST MEDICINES MANAGEMENTThe PREVENT Clinic (Pharmacist Review and EValuation of Existing and New Therapies) at the Redcliffe Hospital was the brainchild of its Director of Pharmacy, Geoffrey Grima – one of his many brainchildren, itseems. The aim of the service is to facilitate medication management in the outpatient setting; identify

and follow-up patients at risk of medication misadventure post-discharge; and provide additional medication management services to patients with chronic diseases or complex medication care needs – all with the view to helping patients avoid medication misadventure and readmission.

PREVENT was established because:

• Redcliffe has a large complexpopulation of patients, anda high readmission rate

• it takes approximately 18-32 days(national average) for a HMRprocess to be completed via a GPpost-discharge from hospital, and

• it is in the first 10 days post-discharge that most medicationerrors and readmissions occur.

Research shows medication discrepancies are responsible for more than half of the medication errors occurring at transitions of care. It is these transitions from the inpatient setting back into the community that involve the highest risk of medication misadventure – this service aims to reduce that risk for the most vulnerable patients.

The clinic aims to review patients who are at high risk of medication misadventure within 15 days of discharge. Medication-related problems include patient confusion, medication non-adherence, poor communication and adverse events post-discharge.

How does it happen?

• Any patient who is identified as atrisk of medication misadventureon discharge from hospital or froman outpatient setting is eligibleto attend the PREVENT Clinic toundergo a Medication Reviewwith a Clinical Pharmacist.

• Patients can be referred to thePREVENT clinic from the inpatientand outpatient setting, by medical,pharmacy, nursing, allied healthstaff or the patient themselves.

• A locally devised referral tool isused to aid in the identificationof patients that are at high-riskof medication misadventurepost discharge. Using this tool,a score is given to the patientthat corresponds to their risk ofpotential medication misadventure.

• Referred patients are contactedby clinic staff to arrange anappointment preferably within 15days of discharge. If there is alinked appointment with anotherhealth professional, the aim isto book the PREVENT clinicappointment around that time.

Referred patients are reviewed by a clinical pharmacist, a Best Possible Medication History is documented, and any medication related issues are addressed. If the referral came from the medical team, the referring doctor is contacted via phone for urgent matters, or issues are communicated on patient’s progress notes. The patient’s GP is contacted either via phone for urgent matters or a letter is generated and sent via fax. If required, a review appointment is organised with the patient to follow-up progress.

This service is relatively new (only six months old), and Russol confirms that the service feels new. “Sometimes it really seems that the whole concept of the review and the service is not understood by the patient – they’re not sure about what the pharmacist can provide. Of course, they trust their doctor and their nurses, and feel that ‘things are going OK’ with their medicines, so they’re hesitant to undertake a review, not understanding what this extra exercise without the doctor is


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going to achieve. But it’s amazing to see how much they embrace it once they’ve done it – they chase you to make monthly appointments instead of the other way around! Patients often say, once they’ve gone through a review, that they’re amazed because prior to that no one had really taken the active interest in all their medications together, going through them one by one.”

“The verbal feedback we have had from patients who attend the clinic has been very positive. It’s also really satisfying to see or speak to a patient during a follow-up appointment and to learn from them how things have improved – there’s improvement in their health and how they feel about their medications since the last interaction.”

Russol has some advice on setting up this type of clinic, which she is happy to share with members, shown in the box below.

Formal patient and GP satisfaction surveys will be conducted in due course. While there’s not enough data yet to confirm outcomes, the data that is available suggests some lowering in the rate of readmissions, which just provides more encouragement to keep going and keep improving.

Russol’s advice for setting up a PREVENT-type clinic: Setting up the PREVENT clinic and achieving hospital-wide buy-in was helped by the fact that there’s a really strong evidence base for the contribution of medicines to readmissions.

Time must be spent on very practical matters in setting up the skeleton and making initial improvements to existing processes. Some of the first steps should be:

• streamlining referral processes• improving/streamlining how

the patient is contactedto book the review

• anecdotally, it seems that a greaterpercentage of patients agree tothe review when contacted directlyby a pharmacist (as opposed tonon-pharmacist admin staff)

• it’s also important to try andbook-in suitable patients beforethey have left the hospital(“Occasionally I’m taking myappointment book and runningdown the hall and to the ward tosee them face to face,” Russolsays, “talking to them about theservice. Booking them in then andthere seems to get a better result.”)Russol says “there was hospital-wide excitement about theservice and its potential benefits,but still the hardest thing isgetting people to actually thinkof referring the patients to theclinic – that is, making sure thatat the right moment, hospitalstaff, when dealing with a patient,the switch comes on in theirminds and they remember thatthe service is available andactually refer the patient.”

One way to flag patients forreferral is to review the 28-day readmission report whichis run daily. This report ischecked every day by the clinicpharmacist or clinic adminofficer and appropriate wardpharmacists are contacted toinform them that the patient hasbeen readmitted within 28 days ofa previous discharge. This allowsthe pharmacist to have PREVENTin the back of their mind whenreviewing the patient. l

BENITA SUCKLINGClinical Pharmacist Redcliffe Hospital, QLD

MORE GAINS, LESS PAINBenita has 4 years of hospital pharmacy experience under her belt and has been working at Redcliffe for virtually all of those 4 years.

The idea for an Opioid Stewardship Service (OSS) was another brainchild of Geoff Grima’s – when Benita asked Geoff for a project, this was the assignment he tasked her with.

Opioids/narcotics are acknowledged to be a high-risk group of medications. “In our hospital,” Benita says, “it was identified that admissions and incidents which were coded as being ‘opioid-related’ were higher than at some other peer groups’ hospitals within the ‘Health Round Table’”. Redcliffe’s pharmacists had also seen an article about a pharmacy-led opioid stewardship service in the USA which had reported good effects; they believed that they could improve the safety of opioid medications in this way, too. With a large proportion of new opioid prescriptions coming from their Orthopaedic and Surgical wards,


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they made these areas (the acute pain setting), the targets of the service, in an effort to maximise its impact.

With the idea growing rapidly, they prepared an application for local innovation funding, which after rounds of business pitches and project plans they were successful in obtaining. Funding and the project officially started in February this year, with Redcliffe’s outpatient clinic reviewing its first patient by Telehealth in early May. Benita’s advice here is to absolutely put as many applications in as you can, for any random, external funding that you can find!

The OSS team consists of a Clinical Nurse who specialises in pain and works in the Acute Pain Service (part-time), and a Senior Clinical Pharmacist (full-time) as well as a part time administration officer. This team works closely with the Acute Pain Service, and the Anaesthetist who leads that service.

In planning the OSS, Benita identified themes in incident reports and pharmacy interventions, and discussed common problems encountered by the pain team, such as:

• Incorrect drug administrations – eg.tramadol/tapentadol (sound-alike),patch application and monitoring.

• Prescribing issues includingduplicate orders and under-managing pain of opioid tolerantpatients after surgery.

• Management of patientsexperiencing excess sedation– selection of appropriateagents to withhold.

• Patient counselling aroundmanagement if pain relief isineffective, titration plans, anddisposal of excess medications.

Redcliffe’s GP Liaison Officer was also consulted, being shown draft examples of handovers to ensure a practical format; and patients were consulted to obtain their views of pain management and interventions they thought would be helpful to them after discharge.

The OSS interventionFOR STAFF“So far,” Benita says, “we have collaborated with Education staff to provide 7 medication safety vignettes for nursing education that address the themes of errors identified from incident reports and pharmacy interventions at Redcliffe Hospital”. The plan moving forward is to also provide education to medical staff (particularly juniors) and pharmacists. The education for pharmacists will focus around some additional areas, including reviewing Acute Pain Charts such as Patient-Controlled Analgesia forms.

Benita has gained a wealth of knowledge and experience attending the APS rounds with the team on the orthopaedic and surgical wards. These rounds are all about pain medications and are very educational. Benita says this made the Redcliffe pharmacists aware that so much more thinking goes into pain medications, the rationale behind their use and strategies for particular patients, than anyone realised. This would all be very useful background information for the ward pharmacists, patients’ GP’s, allied health professionals and patients’ community pharmacists

– the team are working towardsways to comprehensively communicate this.

FOR PATIENTSThe Opioid Stewardship Pharmacist assists in clinical review and makes interventions on the daily Acute Pain Rounds, hands over plans to ward pharmacists to ensure appropriate discharge scripts, and depending on the complexity of the discharge pain medications, provides an extended GP handover by fax and offers follow-up to the patient in their outpatient clinic. In the outpatient clinic, they review the patient’s medications, address any adverse reactions, liaise with their consultant anaesthetist as needed for ongoing plans and communicate these goals with the GP by fax. They also provide information to the patient about appropriate disposal of their medications if they have excess supply. Benita says, “We are aiming to utilise our Telehealth facilities for our outpatient clinic to improve the convenience and attendance rates for our patients who often find getting to hospital difficult due to their recent surgery.” Importantly, Telehealth services seem to work well with younger patients.

THE RESEARCHBenita says: “We are presently refining the protocol and ethics submission to complete research into the effect of this service on readmissions, patient satisfaction and GP satisfaction so that we can share quality results with the pharmacy community.”


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A consumer engagement survey that Benita completed in April of this year revealed that patients on either the Surgical or Orthopaedic wards who were taking pain medications generally didn’t see the benefits of pharmacist involvement in their pain management, and very few were concerned about any side effects of pain medications. Benita believes this shows that what health professionals think about pain medications and what patients think about them are very different and just how much work there is to do in this arena! l

MILLICENT BALLANCINSenior Pharmacist Logan Hospital, QLD

AT THE FRONTLINE OF THE HEP C TREATMENT REVOLUTIONWith the advent of the new Direct Acting Antivirals (DAAs) in March 2016, Millicent Ballancin, senior pharmacist at Logan Hospital in Queensland, and Jo Sexton, Logan Hospital Hepatology Clinical Nurse Consultant (CNC), developed a multidisciplinary pathway for safe and effective access to these curative new medications.

In her poster presentation that was displayed at the 2016 Australasian Hepatitis Conference, Millicent explains that the advent of the new Direct Acting Antivirals (DAAs), as well as the development of new hepatology services at Logan Hospital, and the Australian consensus statement in 2016 for the management of hepatitis C, together determined that a multidisciplinary approach was necessary to enhance patient’s medication management and prevent drug–drug interactions involving DAAs. And indeed, at Logan Hospital the introduction of a pharmacist to conduct medication reviews with patients prior to commencement of Hepatitis C therapy has helped to proactively identify potential drug interactions that could affect the ability of patients to achieve a Sustained Virological Response (SVR).

Early efforts and the setting up of this particularly innovative hepatology pharmacist role have included:

• Initial discussions with gastroenterology-hepatology, infectious diseases and pharmacy services to review existing gaps in service provision and discuss ways to address this need.

• The investigation of funding arrangements via utilisation of Activity Based Funding (ABF) to ensure ongoing service delivery.

• The establishment of a referral pathway to enable a pharmacist-led medication review inclusive of the patient’s community pharmacy and general practitioner.

• The provision of a medication review report to treating clinicians to enable patient initiation on direct acting antivirals outlining ongoing supply arrangements (Section 85 vs Section 100).

• The implementation of in-house pharmacy script management and ordering system for DAAs to ensure patient involvement and minimisation of purchasing costs.

• Working alongside the hepatology CNC, provision of an in-service education program to participating local community pharmacies to ensure continuity of care for duration of therapy utilising the Section 85 authority.

And, as with all the ground-breaking work we’ve admired across the country, the patient is always front and centre. “Patients are extensively counselled by the pharmacist to enhance understanding and compliance with these medications,” Millicent explains. “Patients have reported feeling more involved in their therapy with an improved understanding of their medications, compliance and side effect monitoring.”

In the preliminary phase of this role the hepatology pharmacist completed 24 medication reviews, identified 39 drug interactions, and conducted 3 successful community pharmacy in-services.

And as the position has progressed, Millicent has collected data, revealing that each patient reviewed was taking on average 6 medications and had 2 significant drug interactions identified by the pharmacist. And therefore she has been able to show the importance of medication reviews prior to commencement of therapy to ensure that drug interactions do not reduce cure rates (SVRs), do not reduce patient and prescriber confidence, and do not increase the burden on taxpayer-funded therapy.

Further testament to the importance of the pharmacists’ role in the multidisciplinary team at the advent


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of this revolutionary therapy, is the fact that currently the physicians involved with prescribing DAAs will not commence a patient on therapy until a medication review has been taken by the pharmacist and their recommendations have been actioned. Indeed, Millicent writes “The successful implementation of a pharmacist within the multidisciplinary hepatology team at Logan Hospital has resulted in improved relationships between hepatology, pharmacy and community providers, and the smooth and timely initiation of treatments for patients with hepatitis C.” l

HELENDER SINGHDistrict Medication Management Pharmacist Metro South HHS, QLD

GETTING MEDS MANAGEMENT ON THE EXEC AGENDAThe title of District Medication Management Pharmacist (DMMP) was bestowed on Helender Singh of Logan Hospital, within the Metro South Hospital and Health Service in Queensland, in November 2016. This position evolved from a temporary, 6-month Project Officer role, which had been created by the Health Service in February to convene

and manage a district-wide Drugs and Therapeutics Committee. This committee was designed to bring clinicians from across the health district together 4 times per year to discuss overall strategic use of medications and gain consensus on procedures and medication management (MM) issues affecting the district. To her surprise, the position became so much more than developing processes and managing meetings: Helender was quickly pulled into discussions about district-wide initiatives including e-medicines management, incident reporting, cold-chain management, formulary management and high-risk medications. The culture within the organisation was also just right to produce change; there was the enticing “prospect of doing something together, and doing it well once rather than four or five times in a rush”, as Helender says, which helped achieve buy-in – and so the DMMP position was born.

One of the immediate things to be figured out when Helender started in the Project Officer role was whether the committee would provide input to medicines management on a micro or a macro scale. Ultimately, the answer to this question was “both”: a micro-scale focus for services that operate in gaps/grey areas across the district, helping them gain consistency in work instructions and procedures; and a macro-scale, encompassing all the systems and how everything is operating together, in developing an overall strategy for the district.

Helender also quickly identified that there was a lack of overarching governance for MM systems – that is, individual hospitals all had well-functioning governance systems for their own site, but there were many differences between sites which made it challenging for services operating across the district such as hospital

in the home, palliative care, oral health and chronic disease services. Helender had to help develop and integrate a district-wide medication governance framework into all levels of the organisation, giving particular focus to the support of the district-wide services that function outside of the typical hospital setting; for example, conducting a review of hospital-in-the-home admission data and advocacy to district executive to provide a pharmacy outreach model of care for this service; and trying to find other sources of funding (e.g. ABF funding), so that financially self-sustaining pharmacy support services can be created.

Another focus of Helender’s role is the standardisation of drug-use guidelines. Helender’s work identified that there were over 1000 medication-related documents on the intranet for her district. Standardising such guidelines is inevitably tricky in many ways. Helender worked with the Committee to prioritise which guidelines were tackled first: those for drugs with a high risk of harm from prescribing or administration error or for emergency treatments were prioritised and included publications on idarucizumab, hypertonic saline and high-strength insulins. “Some of the guidelines have been really hard to bring together because they are fundamentally different,” Helender says. “This then involves a lot of negotiation. It’s interesting that the same topic is approached so differently from one location to the next, and it can be challenging trying to tease out why they may have developed that way”, she says.

Helender finds the potential for advocacy really valuable in the DMMP role. “Is everyone across the country solving this problem by themselves?” and “How far do you take things?” are questions that often arise for Helender and the committee – they


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have developed connections with the district and state executives, along with statewide and national bodies to advocate for change. For example, the committee has advocated for review of the Closing The Gap program (specifically around CTG prescribing for hospital doctors).

But it’s still too soon to prove whether patients have benefited from Helender’s DMMP role, as there’s not yet enough statistical data available to form evidence. Helender says so far the primary focus has been setting up things which indirectly help patients such as standardised guidelines and procedures. However, there are some examples of committee work that has more directly helped patients, including an early win with optimising smoking cessation, where an approval granted by the committee to introduce smoking cessation medicines within mental health wards may have reduced aggression towards staff and the amount of time patients require seclusion or isolation from other patients on the ward.

The uniqueness of the role means that for Helender every day is different, each week is different; the business of the committee is remarkably varied. “It keeps things fresh and interesting” she says, “there’s never a shortage of work, and there’s always something new to learn.”

When asked what she thinks has enabled her to successfully establish the DMMP role, Helender suggests that it was the result of being exposed to, and putting her hand up to do, varied project work such as QUM and DUEs as a junior pharmacist. Having an interest and taking opportunities, even when it seems to be just a small thing, is also important. “I just expected to go in and set up a committee and go back to my job – but it’s turned out to be

something so much bigger than that, so I’ve taken the concept and run with it. It’s helped place medicines management on the executive agenda. Executive know who we are, have a lot confidence in what we do, and now ask us for our advice. It’s been really good for the profession, the pharmacists here, in general.” l

PAUL FIRMANMedication Safety & Quality Improvement Pharmacist Logan Hospital, QLD

A PHARMACIST-INITIATED KEEPING-THE-EYES-OPEN PROCEDUREIn a time of multiple rapid changes (e.g. going digital, developing/expanding services), immediately post-accreditation, the pharmacy at Logan Hospital was working at capacity, and therefore management needed to reassess to make sure medication management was in good shape. They needed to take time to look at the big picture and make sure nothing was falling through the gaps, and out of this emerged the Medication Safety and Quality Improvement (MSQI) Pharmacist

position, created in 2016 as a 12-month proof of concept position.

The business case for the position was fundamentally simple: the position was to be funded by the savings it created – 1 year was given to achieve this, but, ultimately, only 5 months were needed. (With the cost savings since then a great bonus!) Consequently, it became a permanent position at the hospital, first held by Jane Dunsdon, who engaged all stakeholders and laid the foundations for the success of this position. When Jane embarked on maternity leave, Paul, who was previously working as a clinical pharmacist, stepped up.

It’s quite sobering to learn that the position has shown total cost savings to the hospital of $385,408.00 through Quality Improvement Projects. Paul walked us through a fantastic example of a project which directly improves patient-care, involves an allied health team, and leads to significant time and cost saving: the introduction of a “nurse-initiated keep-the-vein-open procedure” (see breakout box on the next page).

The impressive impact of the position, though, is not just in its savings or innovations, but also in the breadth of its work. Jane and Paul have also been involved in changes to medicine procurement (including significant cost savings for changes to parenteral iron procedures to ensure PBS reimbursement can be claimed – and working with Helender Singh to make these changes district-wide!); development of a state-wide iPharmacy custom report; development of MQSI network and becoming involved in other key interdisciplinary initiatives, including the Queensland Health Safe and Quality Use of Medicines Advisory Group, and the Queensland Health Medication Advisory Committee.


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Improving fluid use – Keeping the vein open

ACHIEVED IN FIRST SIX MONTHS OF POSITION

Essentially, too many 100mL bags were being used to flush lines to make sure that the patient was getting the full amount of medication, because these bags are easy to access.

Some nurses had approached the pharmacy to find out what the correct standards were for flushing lines. Pharmacy investigated and found that there’s no evidence base to support one correct way to flush lines i.e. no evidence-based guidelines. So Jane, Paul and the team “did a little digging around the hospital” and discovered that just about every nurse was doing it differently. Sometimes nurses, as a time-saving measure, when administering intermittent medications (e.g. antibiotics) were using a 100mL bag at the end as a flush. This, of course, generated a lot of waste and expense, and this fluid, “taken” by the patient, was not being documented, resulting in no record of what

could be an extra 400-600mL of fluid a day per patient. A new “nurse-initiated keep-the-vein-open procedure” was trialled over a couple of months, using a 1 L bag of fluid and a burette. In this procedure, medications are administered via the burette, with specific instructions for how much fluid follows specific medications. When medications are not being administered the bag runs fluids at 5 mL per hour to keep the vein open. Suitable patients are identified by nurses with a decision support tool. All such fluid is now documented.

To introduce this new procedure, some sessions were first conducted in the Nursing Education Simulation Lab. They labelled these sessions “time in motion studies”. Firstly, they asked nurses how they would normally flush lines, then they showed them the new procedure, so the nurses could see for themselves how it saved time and how much easier it was. The 2-month trial in a couple of medical units proved the benefits of switching to this now hospital-wide procedure,

which has streamlined medication administration, reduced waste (consumables), reduced fluids (and associated costs) and reduced nursing time.

Following the 2-month trial, this new procedure was entirely handed over to the nursing education unit, in the form of an education package (NUM Information Guide, exercises – including exercises in simulation lab – PowerPoint education sessions, decision support tool).

Needless to say, the nurses at Logan are very happy with these improvements.

So, what was it about Paul’s past that led him to this position? Paul says that he has always been one for putting his hand up for projects, big or small and importantly, he has had experience rolling out new services for pharmacists, e.g. starting a pharmacy service where the previously wasn’t one, or expanding very minimal pharmacy services. These were particularly good experiences to take into this role, especially as this role involves a lot of allied health angles. “But,” Paul says, “who knew that that work would lead to this work?!” l


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Pharmacy GRIT – growth, research, innovation, training · FEATURE Shape Shifters: Expanding the role, changing the world Every day we’re bombarded with news that the world is