Careers in pharmacy: What is it like to be a hospital pharmacist working in oncology?

Katie Waghorn

 

As I have progressed through my university career, I have become interested in the idea of working as a hospital pharmacist. Although my university provided me with some mornings in Aberdeen Royal Infirmary, I still felt I did not have enough experience to make a true decision with regards to my future career path, with my pre-registration year coming near. Due to this, I decided to interview for the NHS Scotland Hospital Pharmacy Placement Scheme. I was successful and was placed at Aberdeen Royal Infirmary (ARI) for a week this summer.

 

Prior to my placement, I was contacted by ARI who asked me if I had a specification with regards to where I spent my week in the hospital. The options were as follows: surgical, general medical, maternity, paediatrics or oncology. I had an interest in oncology, although I was aware it was highly specialised, as I knew I would come across unfamiliar treatments I had not heard of so far at university. As a result of this, my week with the oncology team was confirmed and I was excited to begin my placement.

 

On arrival at ARI on my first day, I was met by a pre-registration pharmacist who took me to get a hospital ID badge and discussed my timetable for the week. I was then taken on a tour of the hospital, which showed me just how large the hospital was, with each zone being colour coded. Just before lunch, I was taken to a pharmacist who was responsible for calculating and checking doses in chemotherapy regimens for patients. To do this, the pharmacist used data such as the patient’s weight to work out their creatinine clearance. It was important that these values were accurately calculated and approved by the pharmacist, as well as the consultant, to ensure that the patient was receiving both a safe and effective therapeutic dose of chemotherapy. After lunch, I was given a small talk in the clinical trials department of the hospital, where two pharmacists discussed how they manage and run clinical trials not just in ARI, but throughout the country. I found this interesting as I realised that ARI was the main hub for new clinical trials, which also tied into my oncology placement as a substantial number of trials were being used to treat different cancers. At the end of my first day, I was shown how medicines reconciliation is carried out when a new patient arrives at the hospital. I was shown the different resources that can be used for a record of their medication and that a minimum of two is needed to have an accurate representation of this.

 

On my second day at the hospital, in the morning I shadowed one of the rotational pharmacists on the oncology ward. During this time, the pharmacist discussed what happens after pre-registration in the hospital and the subsequent courses that a pharmacist goes through. She explained the two-year diploma programme and independent prescribing course that follows. Before my lunch break, the quality assurance pharmacist showed me how they keep track of particle counts in an aseptic suite. He showed a scenario from last year where although the particle counts were within limits in the Grade A/B cleanroom, they were slowly increasing and became out of control. He explained that this was fixed through further training of staff and the addition of a rule to ensure staff were changing out of outdoor clothes prior to reaching the Grade C cleanroom. In the afternoon, I was timetabled to visit the radiopharmacy department, where the pharmacist went through some prescriptions for radiopharmaceutical treatments. This activity tied in well with my placement, as many of the treatments were being used for patients prior to chemotherapy. An example of this was the MUGA scan, which checks the ventricles of the heart are pumping properly if they are not then chemotherapy cannot be commenced.

 

On the Wednesday of my placement, I and the pre-registration pharmacist undertook the task of a mini-audit of chemotherapy prescriptions. The outpatient chemotherapy clinic did not have a regular pharmacist working there at the time, and so the department was interested to see if a pharmacist would be needed. To do this, we looked through prescriptions which went to the dispensary to see how many prescribing or legal issues arose which needed to be changed by another pharmacist, thus keeping the patient in hospital for longer than needed. Once we had sorted through all the prescriptions with issues, we then made a spreadsheet with the data and sent it to the lead pharmacist of oncology for analysis. In the afternoon, I was shown some doses of pain relief for patients in end-of-life care on the oncology ward. The pharmacist with me allowed me to check the doses were appropriate by calculating breakthrough doses needed for the patients and ensuring conversions of quantities between administration routes were correct.

 

On my fourth day at ARI, I spent the morning in the radiopharmacy suite with two pharmacists where we dispensed radioactive medicines for similar treatments to the ones we looked at on Tuesday. The radiopharmacy preparation room was a Grade C suite and we had to wear specialised clothing which was provided prior to entering. One medicine that we prepared was a radioactive iodine capsule, which we had to ensure had the correct activity level for the patient. The capsule was used to treat thyroid cancer as the thyroid cells absorb the iodine when it is swallowed.   Another medicine that was prepared was for a gastric emptying study. A radioactive isotope was prepared in the suite which was then to be incorporated into scrambled eggs for the patient to consume. This would allow the consultant to see how their stomach emptied the food, and if there were any issues. In the afternoon, I travelled to Roxburgh House to meet with the pharmacist who was involved in end-of-life care. Together, we looked through Kardex sheets of the patients currently staying at the house and discussed dosages of pain relief and other drugs. The pharmacist described to me the idea of a ‘just-in-case’ box which included diamorphine for pain, midazolam for agitation, levomepromazine for nausea or vomiting, and hyoscine hydrobromide for respiratory secretions. He explained that these medicines can be used to improve both out-of-hours care and make the patient comfortable when they are at the end of life in hospital.

 

On the final day of my oncology placement, I was first taken on a ward round with one of the senior pharmacists and the consultant, alongside two junior doctors. The ward round was fast paced and consisted of the consultant reviewing a patient whilst the pharmacist kept them up to date with current drugs the patient was taking alongside her recommendations. After the ward round, I was given a talk by one of the aseptic pharmacists with regards to the aseptic suite at ARI and how this operates. She then went through a prescription for medication for a neonate and explained how many steps must be undertaken to ensure the dose is correct and safe and won’t cause adverse effects. Before lunch, I visited the medicines information department at ARI, where the pharmacists working there discussed some interesting queries they receive throughout the day from healthcare professionals. This once again tied in well with my placement as they explained that many queries involve possible interactions between homeopathic remedies and chemotherapy. In the afternoon, one of the senior pharmacists showed me some common chemotherapy regimens that patients are given for cancer treatments, this was highly specialised as the treatments were constantly changing and new trials were being established.

 

Overall, I highly recommend trying to spend some time in a hospital setting if you are interested in pursuing hospital pharmacy as a career. I feel that my experience at ARI was valuable to me and has helped me understand the career further, aiding me in my decision with regards to where I would like to work in the future.

 

Katie Waghorn is a stage 4 MPharm student at the Robert Gordon University Aberdeen.

Vision for pharmacy education will fail without funding

Gail Fleming

 

The Royal Pharmaceutical Society (RPS) has said that the vision for pharmacy education will fail without funding.

 

This response comes as part of the response by the RPS to the General Pharmaceutical Council’s consultation on initial education and training standards for pharmacists.

 

The consultation makes a number of proposals, including revising learning outcomes focused on developing clinical skills and communication skills; strengthening experiential learning and inter-professional learning and a more structured approach to learning in practice.

 

Gail Fleming, Director of Education, said:

 

“We welcome the GPhC’s ambition to see closer integration of academic study and learning in practice. However, meeting this ambition will require considerable investment and infrastructure. If these proposals are implemented prior to additional funding being secured, the potential disruption could pose a risk to the future supply of the pharmacy workforce. This comes just when pharmacists are playing an increasing role across the NHS to support better outcomes for patients.

 

“Changes to education and training must have patient safety at their core.  This is essential to ensure future pharmacists provide the best possible patient care. Pharmacists must also have the opportunity to develop throughout their careers, building on their initial education and training through to foundation level practice and beyond to create a safe, capable and adaptable workforce.

 

“This should be supported by a national approach to coordinating learning in practice placements so that employers can attract students from around the country. With a current 20% failure rate at registration, more transparency is needed so that students are able to see what outcomes are likely from a course, and can make an informed choice about where they choose to study.”

Three further batches losartan recalled from pharmacies

 

The MHRA has recalled three batches of Losartan tablets due to contamination with the nitrosamine N-nitroso-N-methylamino butyric acid.

 

As a precautionary measure to protect public health, the Medicines and Healthcare products Regulatory Agency (MHRA) today recalled three batches of Losartan tablets due to contamination with the nitrosamine N-nitroso-N-methylamino butyric acid (NMBA). The affected batches can be viewed here.

 

The recall is taking place as part of the continued investigation into potential nitrosamine contamination of sartan containing medicines, a class of medicine to treat blood pressure and heart attacks and heart failures.

 

Currently, there is no evidence that nitrosamine impurities can cause harm and patients are being advised to continue taking their medication.

 

The investigation into possible contamination of sartan medicines began in 2018, after the nitrosamine N-nitrosodimethylamine (NDMA), was identified in valsartan manufactured at a facility based in China.

 

Last year, the MHRA recalled batches of valsartan containing tablets to pharmacy level in July and November due to possible NDMA and N-nitrosodiethylamine (NDEA) contamination.

 

In January and February 2019 the MHRA recalled batches of irbesartan containing tablets after testing revealed possible contamination with NDEA.

 

The MHRA continues to monitor the situation in the UK and are comprehensively investigating the issue alongside the European Medicines Agency (EMA) and the European Directorate for the Quality of Medicines (EDQM).

 

Bernadette Sinclair-Jenkins, MHRA’s Manager, Regulatory Assessment Unit of the Inspection, Enforcement and Standards Division, commented:

 

“Our priority as regulator is to make sure the medicines you and your family take are effective and acceptably safe. This recall shows we are continuing to investigate potential contamination of sartan containing medicines. There is no evidence at present that medicines containing NDMA, NDEA or NMBA have caused any harm to patients and this recall is a precautionary measure. Because of the risk associated with suddenly stopping high blood pressure medication, continue to take your medicines as prescribed by your doctor.”

 

Meet the author: Cathy Geeson describes the relevance of the newly developed MOAT tool in modern pharmacy practice

Cathy Geeson was the first pharmacist to receive a Clinical Doctoral Research Fellowship from the National Institute for Health Research (NIHR). Her research involved the development of a prediction tool to help hospital pharmacists identify patients at highest risk of preventable medication-related problems.

 

The newly developed Medicines Optimisation Assessment (MOAT) tool has potential to predict those patients most at risk of moderate or severe preventable ‘medication-related problems’ a recently published study has found.

 

The findings of this research were recently published and Cathy was kind enough to join us on the podcast to explain the results and the implication in practice.

 

 

If you prefer to never miss an episode you can subscribe on your preferred podcast platform. Just click on the links below to get going.

 

Personalised asthma action plans – what are they and what’s the point?

asthma plan

IN life it’s always good to have a plan. Asthma is no different.

The good thing about asthma is that if managed correctly, symptoms can often be completely reversed. Unfortunately, if not managed well, symptoms can deteriorate quickly leading to hospital admissions or worse.

Self-care is key to managing a chronic disease like asthma. Coaching people on how to self assess the progression or regression of their symptoms through a written plan is very helpful, and allows the person to take some control over their own care. Concordance is defined as the agreement of both patient and practitioner in how to proceed with care. A personalised written asthma action plan can help achieve concordance.

A typical written asthma plan will include the following components:

  • A brief description of the inhalers to be used. A note is made here about the difference between the reliever and preventer inhalers.
  • Some detail around the number of puffs of each inhaler to be used and when.
  • Information on how to assess symptoms (such as peak flow variations).
  • What to do if symptoms suddenly get worse: how long to maintain increases in inhaler use, and when to return to maintenance levels.
  • Information on when to seek urgent help in an emergency.
  • How often to attend review at the local respiratory clinic.

The guidance for the management of asthma (SIGN 141) recommends that every asthmatic patient should have a written personal asthma action plan (PAAP). Indeed more than this, the evidence for the use of PAAPs with asthmatics according to SIGN 141 is grade A.

Asthma UK have produced a good example of an asthma action plan as you can see above.

PAAPs
The national review of asthma deaths (NRAD) says the following statement about personal asthma plans: “There is strong research evidence of the effectiveness of PAAPs. In only 44 (23%) of the 195 patients who died was there a record of them having been provided with a PAAP in either primary or secondary care.

“For 65 of the 195 patients who died (33%), there was no record of them seeking medical assistance during the final attack; 11 (17%) of these had been provided with a PAAP. A further 22 patients sought medical assistance but died before treatment could be administered, of whom eight (36%) had been provided with a PAAP. This suggests a need for improved advice for patients on the recognition and emergency self-management of asthma attacks. Wider use of PAAPs has the potential to prevent death from asthma by increasing the number of people who take appropriate action and seek help.”

The lessons from NRAD are far reaching for all those involved in the care of asthmatics. It occurs to me that PAAPs are a very straight forward way to instruct the patient how to self manage. At no time is this more important than as their condition deteriorates.

A patient that knows what to do as their condition deteriorates is less likely to have the most severe of outcomes.

In community pharmacy we often check steroid, lithium or warfarin books to check that appropriate monitoring is taking place. Perhaps adding the personalised asthma plan to this list as we dispense might just save a life.

Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in based in Aberdeen.

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Preventer inhalers in asthma – what’s the point, and how can pharmacists help?

 

Johnathan Laird

Johnathan Laird


WELL
the simple answer is that preventer inhalers should be the mainstay of treatment, and relievers should only be used if the patient is suffering symptoms.

At the moment, this simple point is the basic principle health professionals use to treat many patients with asthma. The evidence based guidelines support this principle: inhaled steroids are used in all steps of asthma treatment in the UK except step 1 [SIGN 141].

Beta 2 agonists like salbutamol are relievers inhalers. Salbutamol is useful, because it causes rapid bronchdilation and so eases the symptoms of asthma. For example, a Ventolin Evohaler will cause rapid bronchodilation (onset within 5 minutes) in reversible airways disease like asthma and the effect will last for 4-6 hours [EMC, 2015]. This is, of course, useful in acute situations or pre-exercise, but it is rarely the answer if we have an interest in managing asthma long term.

The diagram below shows the effect of inflammation on an asthmatic airway. The preventer inhaler (usually an inhaled steroid alone or in combination with long acting beta-2 agonist) has been shown to be effective in reducing, and often reversing this inflammatory response, hence allowing the patient become symptom free.

The National review of asthma deaths [NRAD, 2104] had the following to say about how preventer inhalers were being used by those patients who sadly died:

“There was evidence of widespread underuse of preventer medication. Overall compliance with preventer inhaled corticosteroid (ICS) was poor, with low repeat prescription fill rates both for patients treated with ICS alone and for those treated with ICS in combination with a long-acting beta agonist (LABA).

“Non-adherence to preventer inhaled corticosteroids is associated with increased risk of poor asthma control and should be continually monitored.”

The management of asthma of course is multi-factorial and successful treatment depends on many factors beyond the compliant use of preventative medicine. It is, however, something we as pharmacists can have an impact on, and I would argue that in this case community pharmacists should be monitoring compliance.

If we can educate and support patients to use more preventer inhaler, and hopefully as a result use much less reliever inhaler, then we can have a positive impact on their care.

I have blogged previously about checking how frequently reliever inhalers like beta-2 agonists are dispensed, but monitoring the frequency of dispensing of preventer inhalers like inhaled steroids is equally important. In my experience, if a patient is overusing their beta-2 agonist, then it is likely that they are underusing their inhaled steroid preparation.

Spotting this at the point of dispensing, and then engaging with the patient in England through a medication use review or in Scotland through the chronic medication service could help prescribers to manage patients better and lower their risk of exacerbation.

For pharmacists there is no better time to have this chat than when dispensing the inhaler.

I always find it interesting to note that this type of intervention requires no access to the patient record, it does not depend on the pharmacist being a prescriber and also can be completed in a busy community pharmacy.

Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in based in Aberdeen.

Follow Johnathan @JohnathanLaird

 

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