Patient Discharge & counseling

[Omar Green]

To maximize the benefits for our patients upon discharge and to provide them with necessary information to assure safe and effective medication use in order to reach desired therapeutic outcomes.
And to make benefit from others experience if applicable to us, I would like your kindness to share the procedure for discharging and counselling patients.
And those the points that i am looking to find an answer.
1- whom will do the counseling?
2- whom will be eligible to be counseled? Any criteria?
3- when the physician write a discharge medications, do the clinical pharmacist review those medications before being dispensed by pharmacist.

[Rachel Phillips]

1- whom will do the counseling?

all medication counselling at the adult and children hospital are done by a pharmacist, pharmacy interns and students can also do this under the supervision of a pharmacist.

2- whom will be eligible to be counseled? Any criteria?

Due to the chronic shortage of pharmacists in our hospitals, we tend to prioritize who gets counselling, by that i mean ideally the ward pharmacist is responsible for carrying out all discharge counselling, he or she will at their discretion determine who needs this service, if they are on leave or absent and their ward is covered by someone else (rarely happens as we don’t have the staff to do this), then the replacement pharmacist will do the counselling based on handover discussion.

Otherwise if pharmacist is absent or a ward is not covered, we tend to rely on the medical team or the nursing staff to flag those patients that require counselling. Having said that we do ensure that wards like renal, cardiology etc always have pharmacy cover. Again this also depends on the patient and their medical complexity, e.g. post renal transplant patient versus surgical post appendectomy patient. For renal and cardiac and to some degree respiratory and some infectious disease wards have a standard discharge template whereby a pharmacist needs to sign off that they have done medication counselling for some patients. In the pediatric setting, the process is more or less the same but with a less structured format (currently being reviewed).

3- when the physician write a discharge medications, do the clinical pharmacist review those medications before being dispensed by pharmacist.

Since we do not have the distinction between pharmacist and clinical pharmacist in Australia, yes all discharge medication scripts are screened and reviewed by a pharmacist to ensure they are correct (med rec wise, labs checked, supply etc). Scripts are subsequently entered/typed by a pharmacy technician and further checked by pharmacist (double check system), but the pharmacist checker does rely on the ward pharmacist to ensure all that the discharge script is clinically sound. Again this process is less defined in our paediatric hospital and is being reviewed.

[Naveed Rivas]

1- who will do the counseling?

Pharmacists and pharmacy interns under supervision of pharmacist even your manager, assistant manager and supervisor can also go for counseling. usually we have one pharmacist on clinical rotation from every area so he or she is doing discharge counseling but he is not 24/7 and patients are getting discharge 24/7 to cope up with this situation we have separate discharge pharmacy (take home pharmacy) their staff is going for counseling. we have designed education material for patient education in form of booklets and pamphlets in case pharmacist or intern is not available for discharge counseling that is a rare scenario.

2- whom will be eligible to be counseled? Any criteria?

When we started discharge counseling ( five years back) at that time our target group was cardiac patients especially patients on warfarin and other anticoagulants as we have started anticoagulation clinics also, transplant patients, pediatric patients, oncology patients and patients getting discharge on pharmacy compounding but now it is extended to all discharge patients.

3- when the physician write a discharge medications, do the clinical pharmacist review those medications before being dispensed by pharmacist.

In akuh (Pakistan) we don’t have two terms in practice i.e. pharmacist and clinical pharmacist as we have six years Pharm-D graduates (5 years of Pharm D and one year internship) so our pharmacists are clinical pharmacists. our process flow is physician enter discharge order in CPOE then one pharmacist process the order after that technician fill the order as we don’t have automated prescription filling system, if you have automated prescription filling then it will add another feather in your cap, then second pharmacist review that order. our goal is to dispense the discharge medication within 45 mins.

[Christian Lancaster]

We started our program ” Bed side discharge” 9 months ago and to answer your questions :

· We are now a team of two discharge pharmacist and 3 unit based pharmacists looking for around 250 beds with a barrage of 20 discharges per day for now.

· Our turn around time targeted to be less than one hour

· We started with selected poly pharmacy patients and now we are covering all discharges around the hospital weekdays from 8 am to 5 pm.

· We have a team of pharmacotherapy specialists who took care of any discharge consultation if required.

· The discharge pharmacist assess all discharge cases clinically before preparing the medications while now we are looking into introducing a “Transition of care team” to do the medication reconciliation on admission and discharge.

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