A special set of skills (David Gibson)

I have been practising as an independent prescriber in the medical assessment unit at Darlington Memorial Hospital for the past 18 months. A recent restructuring of the ward allowed me the opportunity to collect some information about my prescribing.

Many of the prescribing competences set out by the Royal Pharmaceutical Society involve some element of audit and evaluation of prescribing practice. It is therefore essential for prescribers to review their practice.

During a two-week period I had prescribed 68 different medicines. The exercise also highlighted a number of interesting points, the most notable being the type of prescriptions I had been writing. Most were complex treatments for which a pharmacist’s specialist skills and knowledge are essential. These are situations where, in the past, I would have offered advice about the most appropriate treatments.

Not another “junior doctor”

When I originally qualified as a prescriber I was determined not to become another “junior doctor”. I was equally aware that my prescribing should not “deskill” newly qualified doctors, who learn many of their core skills while working in a busy MAU.

I can use my skills as a pharmacist most effectively by concentrating on complex prescribing decisions, eg, for patients with renal impairment; those with conflicting comorbidities; those taking medicines with narrow therapeutic indices; or pregnant patients. I can take responsibility for the decision to start a medicine. And I can use the opportunity to help educate junior doctors. This has given me renewed job satisfaction.

It also means I have far more contact with patients because it is my duty to explain to them the treatment options, potential complications and how the medicine will be monitored and reviewed in the future.

This month I saw a patient with pneumonia who had a serum creatinine of 174. This translated to a creatinine clearance of 22ml/min. It was an acute problem that improved with rehydration. I reviewed her regular medication and withheld any nephrotoxic drugs or those that would accumulate in renal impairment. I started a subcutaneous sliding-scale insulin infusion to manage her diabetes while her metformin was stopped and because she had a higher insulin demand owing to her infection.

I also adjusted her antibiotic doses to take into account her renal function and put into place a management plan to follow as her condition improved.

Although this is a commonly seen set of circumstances, it shows how the skills of an independent prescribing pharmacist can help to improve the quality of care given to patients.

 

David Gibson is senior clinical pharmacist (medical admissions) at Darlington Memorial Hospital