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Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults' medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily "hold" medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital.
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OBJECTIVES: Our aim was to explore junior doctors' attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. METHOD: An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. RESULTS: Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacist's duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. CONCLUSIONS: Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a 'bottom-up' educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists.
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INTRODUCTION: Dysphagia is a common presentation in older people. Diffuse idiopathic skeletal hyperostosis affecting the cervical spine is an uncommon cause of dysphagia and may be overlooked. CASE PRESENTATION: We present the case of an 88-year-old man with dysphagia and weight loss. Initial investigation with upper gastrointestinal endoscopy was inconclusive. A diagnosis of diffuse idiopathic skeletal hyperostosis as a cause for dysphagia was eventually made using video fluoroscopy. This showed a bony prominence impeding swallow at the level of C3. The patient was unfit for surgical management so a percutaneous endoscopic gastrostomy tube was inserted for feeding. CONCLUSION: The diagnosis of diffuse idiopathic skeletal hyperostosis involving the cervical spine often goes unrecognised as a cause of dysphagia despite its prevalence in the elderly population. Diagnosis is made using cervical radiographs, barium swallow and computed tomography. There is a risk of perforation with endoscopy in patients who have cervical diffuse idiopathic skeletal hyperostosis. Conservative management includes non-steroidal anti-inflammatory medications and a modified diet. Surgery may be considered in certain patients where conservative management fails.
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In summing up, Professor Catto referred to the impossibility of achieving the correct balance in a constantly changing position. Only minor alterations to the curriculum are required, such as improving the ability to prescribe and proper shadow periods. The way PRHO posts are constructed needs changing more than the curriculum. Professor Rawlins summation was brief and to the point: the problem lies in the gap between what the GMC and everybody else would like the job to be and what it actually is: in other words, a reality check is needed. There was no clear winner in this debate. At the start of the debate 18 were against the motion, seven for, with the majority undecided. At the end, 23 were against and 17 for the motion, with only a small proportion still undecided.