(876-l04) implementing the pharmacist’s patient care

Implementing the Pharmacists’ Patient Care Process: Lessons Learned from Nursing Education

Stephanie Forbes, PharmDThe Medication Management Center, The University of Arizona College of Pharmacy

Stephanie Dawson, MSN, BSN RNThe Martha Mann Smith School of Nursing, Wake Tech Community College

DisclosureIn accordance with the ACPE’s and ACCME’s Standards for Commercial Support, anyone in a position to control the content of an educational activity is required to disclose their relevant financial relationships. In accordance with these Standards, ASHP is required to resolve potential conflicts of interest and disclose relevant financial relationships of presenters.

• In this session:

All planners, presenters, reviewers, and ASHP staff report nofinancial relationships relevant to this activity.

The genesis of our collaboration

2018 National Pharmacy Preceptors ConferenceImplementing the Pharmacists’ Patient Care Process: Lessons Learned from Nursing Education

©2018 American Society of Health-System Pharmacists of 15

Learning Objectives

Describe the need for the implementation of the Pharmacists’ Patient Care Process.

State successes and pitfalls from nursing practice and education on the utilization of the nursing process.

Develop strategies for implementing the Pharmacists’ Patient Care Process into current practice.

Audience Polling Question

How do we teach thinking?

Audience Polling Question

What internal process drives what you do?

2018 National Pharmacy Preceptors Conference



The JCPP 2014 vision

What is the JCPP?

What is the JCPP PPCP?

How did it begin? Why was it developed?

ConsistencyPredictabilityMeasurability with services pharmacists

deliver

The Purpose of PPCP Patient centered approach to use EBM to collect, assess, develop,

implement, monitor, evaluate each patient Application to all areas of pharmacy (education, practice,

management, etc.) Need for standardized process across our profession, as others have

done The Nursing Process ADPIE The Accounting Cycle Aeronautical Decision‐Making




The Pharmacists’ Patient Care Process

Is the PPCP applicable in professional practice for expert pharmacists? Or Do you see the PPCP as more of a tool to be used only the educational setting?

Discussion:

The Whys for Pharmacy Practice

Consistent expectations helps everyone Establishes patient‐pharmacist relationship Improves communication Promotes collaboration Explicit ways to teach learners to think like a pharmacist Aid in targeted development Advance the profession




Embracing the PPCP

TRUST IS BUILT WITH CONSISTENCY – Lincoln Chafee This is what pharmacist do! Need for standardized process across our profession, as

others have done Create a unified representation of what pharmacy has to offer Understood by pharmacists, students, patients, providers,

payers, society...

What barriers do you see in your practice that hinders the adoption of the PPCP?

Think‐Pair‐Share:

What can we learn from

colleagues in other

professions that have

implemented a process?




The nursing process for

clinical decision making.

The Nursing Process

Introduced at the Catholic University of America in 1967 but . . . beginnings of nursing process used by Florence Nightingale in 1860s

Spread throughout 1960s‐1970s but first appeared in literature in 1980s

Now: Widely adopted by nursing in both education and practice Virtually every state has revised its nurse practice acts to

reflect nursing process

The Nursing Process (ADPIE)

Dynamic, not static Method of problem solving Patient‐centered Directed toward patient’s

response to disease process, effects of disease process, interventions, therapies

Cyclical, not linear “Thinking Framework” for

clinical decision making Used in combination with

critical thinking and reflective practice

Widely accepted and practiced . . . this is what we do!




Implementation of the Nursing Process

What did nursing learn from the implementation of their own thinking process?

Benefits of Implementation of ADPIE

Defines our practice and specialty Creates patient‐centered approach to care Unified nursing language Enhanced independent practice Systematized practice EMR integration Applicable to any setting (research, education, and practice) Highlighted on NCLEX

Pitfalls to Implementation of ADPIE Does it really capture all that nurses do? Can create excessive documentation Tends to "label" patients Varying interpretations: static vs. linear or dynamic vs. problem‐based Belief that it is only to be used as "training wheels" to new nurses Nursing diagnosis is the weak link Lack of definitional clarity Contemporary nursing philosophies not integrated Resistance when using a top down approach




Consider…

How does nursing teach their thinking process? Why do seasoned nurses continue ADPIE in

their daily practice?

Practical Approaches

Audience Polling: 1. Which step of the nursing

process do you think is most beneficial to patient care?

2. Which step, if left out, would be the most detrimental to patient care?

Assessment Crucial step in making patient specific intervention Carried on through all phases of nursing process Socratic questioning What specific data do I need to collect based on the

medical diagnosis, chief complaint, and chronic conditions?

Subjective vs. objective Assess before implement




Teaching Assessment

You are receiving handoff report for a patient who is 1 day post surgical. The patient has no history of medical problems and has a IV order that states:

D5LR at 125ml/hr; d/c IV when tolerating PO fluids,Ancef 1 g IVPB q 6 h x 3 doses.

You check on him and notice there is only 50 ml of fluid left in his primary IV bag. What should you do? 1. Hang another bag2. Slow the IV down to a 15ml/hr rate3. Saline lock the IV4. Discontinue the IV by removing the IV catheter

Nursing Diagnosis(The single step that does not correlate with the PPCP)

Definition: a clinical judgement about the client’s response to actual or potential health conditions or needs (ANA, 1998)

Not a medical diagnosis! Actual vs. potential problems (preventative) Can be independent, collaborative, or both Interventions then are often centered on nursing diagnosis Great way to teach prioritization What is your patient’s plan of care for the day? Nursing Diagnosis (pocket handbooks or apps)

Commonly Used Nursing Diagnoses Fluid volume deficit At risk for impaired skin integrity Risk for injury Anxiety Acute pain related to . . . Body image disturbance Ineffective airway clearance And so much more . . 235 in total!




Clinical Application Example

Nursing Problem Evidenced ByPROBLEM LIST‐ Based on the data collected; identify the potential and actual nursing problems for this patient and prioritize them (AT LEAST 3).Based on your number 1 priority nursing problem list interventions, and rationale, and evaluation of your short and long goals.

Short Term Goal Long Term Goal

Interventions Rationale

Evaluation of Short Term Goal Evaluation of Long Term Goal

Subjective:

Objective :

NANDA Nursing Diagnosis:

Teaching Preparation and Planning Common Phrase I use: “ADPIE it” What does this patient need? Teach how to write SMART goals How do you incorporate the patient’s readiness

to learn into your plan? Require students to write plan of care with

patient




Teaching Implementation

Independent vs. dependent interventions Care rounding with assigned interdisciplinary

roles Post conferencing to identify creative and

patient‐centered approaches Inter‐professional education

Teaching Evaluation Socratic questioning

• What would it take for your patient to reach the stated goal? Debriefing/post conferencing Self Evaluation

• How did you meet the clinical objectives for the day?Short Term Goal Long Term Goal

Interventions Rationale

Evaluation of Short Term Goal Evaluation of Long Term Goal

Nursing Process Success Create competent nurses Put the patient at the center of care Direct learners to use application, analysis, and

evaluation thinking levels of Bloom’s Taxonomy Streamline care hand off Integrate into EMR Promote nursing cohesive language




Now, how can we take lessons

learned from nursing and

apply them to pharmacy?

Key Takeaways: Lessons Learned from Nursing

Avoid at all costs a top‐down approach Integration into EMR is crucial A standardized thinking process scaffolds learning from

novice to expert Must be reiterated in practice to maintain professionalism Central with interprofessional communication Basis of how nurses communicate with other

professionals (i.e. SBAR)

Implementing the PPCP

Within school's of pharmacy curriculum Within IPPE/APPE In current practice




In what ways can you adopt some of the lessons learned from nursing to apply the PPCP as you mentor students?


Applying the PPCP Collect

• BP is a 59 yo white male with DM, HTN, HLD• Med List: metformin 500 mg BID lisinopril 10 mg qday

simvastatin 10 mg qhs pantoprazole 40 mg qdayCentrum Silver qday Aleve prn (roughly once a month)

• Labs:GFR 95 ml/min A1c 7.1%, BP 128/77 TC 250; HDL 32; LDL 115

• PMH:• Non‐smoker, father died of MI at 64, NKA, prescription claims data available in EMR

which indicate good adherence, no ADRs reported• Vaccines/misc:

• Received all childhood vaccines • Tdap 2014• Zoster May 2018 • Current on flu vaccine• Dilated retinal eye exam 2015 • Comprehensive foot exam May 2018

Practical Use of the PPCP

Assess No clear indication for pantoprazole DM near goal, HTN at goal, HLD not ‘at

goal’ ASCVD 10 year risk ~28% Statin: currently low‐intensity, meets

criteria for high‐intensity Aspirin: meets criteria but not taking Vaccines: due for PPSV23 Screenings: due for retinal exam




Practical Use of the PPCP Plan

Identify pantoprazole indication and recommend discontinuation if appropriate

Lifestyle coaching for A1c improvement (goal <7.0%)

Recommend statin dose optimization Recommend initiation of aspirin

therapy Provide PPSV23 vaccine Refer for retinal eye exam

Practical Use of the PPCP Implement by collaborating with

other health care team members Discontinue pantoprazole Counsel patient on lifestyle changes

for improved A1c Change from simvastatin 10 mg to

atorvastatin 20 mg Initiate ASA 81mg daily Administer PPSV23 vaccine Refer to provider for retinal eye exam

Practical Use of the PPCP

Follow up: Monitor and Evaluate Schedule 3 month follow up to

assess: Improvement in A1c and blood

glucose Recurrence of heartburn symptoms

without pantoprazole Tolerance to new statin therapy Tolerance to aspirin therapy Results of eye examination Changes to adherence Any new diagnosis?




What are two ways you can implement the PPCP into your clinical practice education settings?


Consistent and Habitual

References: Accreditation Council of Pharmacy Education. Accreditation standards and key elements for the professional program

leading to the doctor of pharmacy degree. https://www.acpe‐accredit.org/pdf/Standards2016FINAL.pdf Bennett MS. The Patient Care Process: A Framework for Change. Washington, DC. Joint Commission of Pharmacy

Practitioners. May 2017. Centers for Disease Control and Prevention. Using the Pharmacists’ Patient Care Process to Manage High Blood Pressure: A

Resource Guide for Pharmacists. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2016. https://www.cdc.gov/dhdsp/pubs/docs/pharmacist‐resource‐guide.pdf

Cooley J and Lee J. An Operationalization of the Pharmacists' Patient Care Process at one Public College of Pharmacy. The American Journal of Pharmaceutical Education. 2017

Joint Commission of Pharmacy Practitioners. Pharmacists' Patient Care Process. http://www.pharmacist.com/sites/default/files/files/PatientCareProcess.pdf

Joint Commission of Pharmacy Practitioners: Pharmacists' Patient Care Process Presentation. https://jcpp.net/resourcecat/patient‐care‐process/

Mason. M. C. and Attree M. (1997) The relationship between research and the nursing process in clinical practice. Journal of Advanced Nursing, 26: 1045‐1049.

Murray, M. E. and Atkinson, L. D. (2000). Understanding the Nursing Process In A Changing Care Environment. (6th Ed.). McGraw‐Hill Professional.

NANDA International. (2017). Nursing Diagnoses: Definitions and Classification 2018‐2020. retrieved from: https://health‐conditions.com/nanda‐nursing‐diagnosis‐list‐2015‐2017/

Pearson. (2019). Nursing, a concept based approach to learning. (3rd Edition). Boston, MA: Pearson Education, Inc. Varcoe, C. (1996). Disparagement of the nursing process: the new dogma?. Journal of Advanced Nursing 23:120‐125.




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