good medical/pharmacist practice

[Old Pharmer]

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I have a question or I am asking for your thoughts.

I work at a Veterans Affairs Hospital, teach (very part time) at a local SOP and am an EMT), and some Pharmacists have limited prescriptive authority. In pracice, this means we can extend maintainance medications until the next provider (MD, NP, PA) appointment (often 30 to 90 days). My VA is basically a community hospital, clinics and inpatient beds, so I have back-up).

So if a patient is out of refills on his/her enalapril, and has no appointment, do I:

(1) renew the medication until his next appointment (current practice)

(2) take a blood pressure and depending on response - triage to ER, or renew
(my EMT training kicking in)



(X) There is the future idea of adjusting the dose, but based on what?

What about a oral diabetes med?

Basically you can see the question, and my bias. Should I be practicing some sort of assessment prior to renewing/extending the therapy. This is not the "corner druggist" giving 2 tablets until Monday and calling the office. The provider in that case knows his patient, and his malpractice attorney. My question is not legal, it is clinical.

 

[deleted205891]

Are you a staff or clinical pharmacist? Our VA has 2 tiers of pharmacists, clinical pharmacists and clinical pharmacy specialists. I believe only the clinical pharmacy specialists have scopes of practice and can adjust meds on their own. IMO you should not refill the meds unless these are your patients you either round on or see in your clinic. If you are refilling the meds, you should be assessing the patient (BP, glucometer readings, etc...)

 

[xiphoid2010]

Read your scope of practice. My residency site had limited prescribing authority for both clinical and staff pharmacist. While staff pharmacist can renew existing orders, only the clinical can prescribe (but only if pt has been referred to pharmacy to manage already).

When I was a resident, when I encountered this situation, I would check in CPRS when/what was their renal panel. Read the last pharmacy /md notes for intentions and next scheduled appointment. Ask couple of questions to rule out renal failure /hyperkalemia and make a decision.

If the lab is old, next appointment is a way off, you can order a lab draw and +/- a 10 day fill, add an addendum to last pharmacy clinical note and flag his clinical pharmacist to follow up with a decision. All refills are done by mail now anyway, so 10 day fill will provide enough time for the follow up call or refill to arrive.

 

[Ackj]

I'm no expert on patient assessments, but would you really adjust a med based on one clinic BP reading? White coat will probably make it elevated anyway. If I was going to make any changes in dose, I'd want to see at least a weeks worth of values, assuming they've been on that dose for a while. Same would go for diabetic drugs; and office fingerstick would definitely not cut it, I'd want to see fasting and postprandials for several days before anything was switched.

 

[xiphoid2010]

I'm no expert on patient assessments, but would you really adjust a med based on one clinic BP reading? White coat will probably make it elevated anyway. If I was going to make any changes in dose, I'd want to see at least a weeks worth of values, assuming they've been on that dose for a while. Same would go for diabetic drugs; and office fingerstick would definitely not cut it, I'd want to see fasting and postprandials for several days before anything was switched.

You wouldn't. So unless it was one of your pt, you would only order a lab to verify and have his clinical pharmacist or MD to follow up. You can reasonably defend a 10 day emergency refill and a follow up documentation. Keep in mind that VA only abide by federal law and scope of practice approved by institution. So know what you can or can not do.

 

[Old Pharmer]

I do, the question was do I (1) just renew the med, or do I (2) attempt some sort of assessment. What is better practice. Thanks

 

[Old Pharmer]

If just for a renewal, the question was do I (1) just renew the med, or do I (2) attempt some sort of assessment. What is the better practice?