Consultant pharmacist for critical care at Sandwell and West Birmingham Hospitals NHS Trust
Here's something new: talking to the patient (Emma Graham-Clarke)
Prescribing in critical care is different to that in most other areas. The most obvious variation is that patients do not have much input into the process — it is difficult when they are tubed, ventilated and sedated. Moreover, if you do have a patient you can talk to, the chances are that he or she will disappear to a ward quickly, before the outcome of your prescribing can be seen.
But it is not always like that.
We recently had a patient who had been with us for several days, having had respiratory problems. She was finally at a stage where we could send her safely to a ward but, because no bed was available, she stayed. By then she was not only off the ventilator, but also had her tracheostomy tube removed so she was talking — and making up for lost time!
On the day in question, I was playing catch up after the ward round and reviewing her drug chart. Could I recommend something for itch, asked the nurse? At this point the patient showed me scratch marks she had from itching — they were everywhere.
I knew that we had also been treating her for oral thrush for the past few days and I wanted to know if that had resolved. A lively three-way discussion ensued. No, the thrush was still there (this was confirmed when she stuck out her tongue).
What about the cause of the itch? The nurse and patient both believed that it was caused by the body wash she was using — was there an alternative? In the meantime was there something soothing we could use to calm the itch?
Finally, after a little debate, we decided to try a different preparation for the thrush (miconazole instead of nystatin). The body wash was changed to an alternative and menthol in aqueous cream was added to soothe her pruritus (antihistamines were out since the patient did not tolerate them). Phew! I put pen to paper and prescribed it all.
The following day I fully expected to find that the patient had moved to a ward and, therefore, that I would have no idea if my suggestions had worked. Instead I found her sitting up in her critical care bed, beaming, and giving me the thumbs up. She obviously felt a lot better!
I was delighted to have a positive outcome and pleased that we had achieved it through discussion with the patient, so that she was confident we had addressed her problems and concerns. I know that it is what normal prescribing is like — but, like I said, my set-up is not normal.
Citation: Clinical Pharmacist URI: 11096106
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