Surgical Pre Admission

Review Clinics (SPARC)

Truc NguyenPharmacy Surgical Team Leader

CMH Pharmacy

Surgical Preadmission Clinics• Aim to improve patient safety and experience

– Identify/minimise peri-operative risks– Improve patient education– Enables patients to present to surgery fully prepared

and as fit as possible

Nurse Doctor Pharmacist

• Primary objectives:• To assess the effectiveness of clinical pharmacy service to

pre-admission clinics

– Evaluation of the number and type of discrepancies/contributions recorded by pharmacist

• Secondary objectives:– To assess the value of having a pharmacist in a

preadmission clinic

– Patient satisfaction survey

– Doctor satisfaction survey

Objectives

Methodology

Phase One: Control phase

• How accurate patients medication lists were• How accurate doctors medication histories are• Errors charted by the doctor• What the patient thinks about seeing a pharmacist• Time(s) taken

Nurse

Initial patient flow

Dr Pharmacist

Methodology

Phase One: Control phase (110 patients)

Nurse

Initial patient flow

Dr Pharmacist

Nurse Dr

PharmacistNurse Dr

Pharmacist

Phase 2: Intervention phase (140 patients)

Results - Safety

• Phase 1 = 110 patients

Phase 1 Regular meds and PRN meds

Patient and Pharmacist

2.22 discrepancies per patient

Pharmacist and Doctor

9% more regular medications

38% more PRN medications

17% more Allergies/ADR

Nurse

Phase 1

Dr Pharmacist

• 0.8 discrepancies per patient

– Wrong medication - Wrong strength

– Wrong frequency - Wrong route– Inappropriate pre/post-operative prescribing

Dis: 89/110

Discrepancies(Drug charting errors)

Phase 1 = 110 patients

• Easy done when retrospectively

• Davies et al state a moderate adverse event in hospital can increase length of stay 7-9 days.

• Average length of stay for a general surgical patient is ~3 days

• 1 day? – 50 bed days saved…

• ½ days- 594 bed days saved (1307 pts)

Calculating cost of interventions

• Medication history + review

• Pre-chart medications (including analgesics, anti-emetics) for the doctors

• Printed out electronic history form with any potential recommendation in Dr alert section

• Educated patient on start/stopping of medications, compliance etc

What did the pharmacist do??(2nd phase)

Times taken at Pre-admission clinics

Time taken with Pharmacist at Pre-Admission clinics

40

30

10

35

20

14

0

5

10

15

20

25

30

35

40

45

Total Time Doctor Pharmacist

Tim

e ta

ken

(m

inu

tes)

Phase One

Phase Two

P<0.05

=110 pts

=140 pts

Nurse

Phase 2

DrPharmacistNurse

Phase 1

Dr Pharmacist

• Saved 5 minutes per patient (waiting time)– 5min X 140 patients = 11.6 hours clinic time

• Doctors time saved 10 minutes per patient– 10 X 140 patients = 23.3 hours of doctors time

…..Then extrapolated over 1307 patients…..

Time

Doctors feedback• Adds value• Reduces workload• Improves peri-operative

plan for the patient– High risk medications

• Accurate medication history

• Allergy recording• Patient counseling

• “Reduces time spent on each patient in regards to medications allowing doctors to focus more on the medical problems of the patient in the short period of time available in pre-admission clinics”

Patients feedback•Useful person to see•Discussed regular medication•Clear directions about what medication to stop prior to surgery•Discussed any concerns about medications associated with surgery (e.g. pain relief)•Discussed what medication would be started after surgery (potentially)

Feedback

Conclusions

- Accurate medication histories

- Significant amount of errors picked up

- Improved clinic times

- Valuable service to both patient and MDT

- Future plans - Expansion of clinics to Orthopaedics??

THANK YOU!

• 0 FTE allocation to initiate surgical pharmacy pre-admission clinics

HOW??• Restructured MMH pharmacy surgical team from a

ward based service to team based.• We now have become a proactive service to that

of a reactive one• Structure creates sustainability with more than one

pharmacist doing clinics

What was the cost?

Example of Grade 4• 58Y Maori female• Staging laproscopy (Gastric cancer)• Salbutamol 15 puffs inh BD• Not known to our Respiratory service• Recently moved up from Taumaranui• Alerted doctor as patient high risk of peri-

operative chest infection and intra-operative respiratory problems

• Referred to anaesthetic -> Respiratory review• End result -> family discussion