Authors (including presenting author) :
Hung A(1), Pang Y(1), So YW(1), Chu L(1)
Affiliation :
(1) Department of Pharmacy, Duchess of Kent Children Hospital
Introduction :
For patients who are eligible for same day admission to surgical joint procedure, prior to confirmation of admission, patients are required to attend to the pre-admission clinic with the anesthetist for final assessment and consent. During this session, patient would receive information about the risk and expectation of the surgery, how they should manage their medications before and after surgery, while nursing staff would further advice patient on the procedure of the surgery day.
Pharmacists at DKCH Pharmacy Department have piloted a Same Day Admission Counseling Clinic to run parallel with the Anesthetist session since 24 July 2020.
Objectives :
Pharmacist perform throughout check to ascertain if patient is taking any other self purchased medications (including over-the-counter medications, supplements and traditional Chinese medicine (TCM)); other than those recorded in CMS; (2) during interview with pharmacist, pharmacist will reinforce their understanding of special arrangement required to their medications prior to surgery; (3) pharmacist enhance patient compliance and understanding of their medications during the counseling session, blood glucose or blood pressure monitoring would be suggested if it is suitable to do so based on their clinical status.
Methodology :
The outpatient medical record officer will generate a list of patients who are attending to the Thursday pre-admission clinic for pharmacy department each Monday. The pharmacist will then review each patient’s clinical information through CMS. Information collected includes patient’s demographic, allergy profile, regular medications and recent blood test results (full blood count, renal and liver function test). Pharmacist will then contact patient over the phone on Wednesday to request patient to bring in their medications and or other supplements at pre-admission clinic for reconciliation.
The flow on the day of pre-admission clinic included: anesthetist assessment -> nursing staff review -> pharmacist counseling. Pharmacist will review each regular medication that patient is taking in order to assess their understanding and compliance, and provide supervision to appropriate home monitoring (eg. blood pressure or blood glucose) for their condition. Furthermore we document all patient’s self purchased supplement, TCM or home made herbal soup in notes.
Pharmacist will further advice patient on the management of the medications in regards to the operation. Self purchased supplements, TCM and herbal soups are suggested to stop one week before surgery. Other medications of concern include antihypertensive, diuretic, antidiabetic agents and anticoagulants are then discussed. As a general rule of thumb to counseling, antihypertensive are to be continued in the morning of surgery in order to prevent rebound hypertensive crisis. In some patient, diuretic may occasionally be omitted to avoid dehydration. The decision is based on the patient’s clinical status as well as the combination of the medication that he/she is taking. Antidiabetic agents should be omitted once fasting has commenced the night before surgery was scheduled. For antiplatelet, aspirin is suggested to continue due to its short half-life, while Clopidogrel is recommended to discontinue 5 days before surgery to avoid bleeding complications1. And lastly, with anticoagulants, warfarin is required to stop 3 days before the scheduled surgery, INR is then monitored and physician will determine if there’s any requirement for bridging anticoagulation such as low molecular weight heparin. With other direct thrombin inhibitors and direct factor Xa inhibitors (DOACs), because of their shorter half-lives, making them easier to discontinue and resume rapidly2. The specific arrangement to these agents will be discussed with anesthetist before counseling patient, and then reinforce during counseling session. Pharmacist’s notes are recorded in CMS to document information discussed during the counseling.
Result & Outcome :
From July 2020 to Dec 2020, a total of 102 patients have attended the pharmacist counseling clinic for same day admission joint surgery.
The pharmacist counseling clinic has provided a platform for screening of self initiated supplements, provide education on medications, assess on compliance and offer reassurance to patients who are required to undergo surgery.
