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Piece of the jigsaw

In the past few months I have been spending more time in the ambulatory acute medicine clinic. My aim is to try to divert some of the less ill patients from the admissions wards and thus reduce the burden on the A&E department.

This is especially important considering the increasing pressures on hospital admissions and the potential impact on patient safety of departments operating over capacity. The different work environment of an acute medical clinic has uncovered some new challenges and made me re-evaluate how I have perceived my prescribing to date.

This is best illustrated by an example: a patient who had attended A&E on a Saturday with a rash over his trunk and arms. He had recently started on one of the new oral anticoagulants for both atrial fibrillation (AF) and recurrent pulmonary embolism (PE). He had completed the initial loading dose and had just switched to the maintenance dose. The A&E doctor diagnosed a drug-related rash and consulted the haematologist, who recommended a low molecular weight heparin plus a review in the ambulatory acute medicine clinic on Monday.

This is where I come into the picture. I reviewed the patient and the rash had resolved. I therefore had to rely on the colleague in A&E having made the appropriate diagnosis. I discussed treatment options with the patient. He had previously been taking warfarin and wished to go back onto it. Here was that dilemma again: I had not made the diagnosis of AF or PE and was relying on colleagues for these diagnoses, too.

I examined the patient and reviewed his previous notes to ensure I was satisfied that I was treating AF and PE. I then prescribed him warfarin with low molecular weight heparin to cover until the INR was therapeutic. Again, I realised that I was building on the advice given by the haematologist. I ensured the patient had appropriate follow-up for his INR monitoring in the warfarin clinic. Finally, I wrote to the GP informing her of the rash attributed to the new oral anticoagulant and ensured the ongoing management plan was clear.

This scenario reinforces the fact that I am one piece of the jigsaw within the whole of the NHS. Healthcare provision, including pharmacist prescribing, needs to be customised according to the needs of the patient. Co-operation between clinicians is essential — moreover, we cannot forget that the patient is the common cause guiding this care.

Citation: Clinical Pharmacist DOI: 10.1211/CP.2014.11133541

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