In November 2020, Northern Health trialled a 12 week program to have a pharmacist present in the pre-admission clinics.

The trial was led by Jeff Khoshaba, Theatre Pharmacist, who co-leads the team of surgical pharmacists.

“In the pre-admission clinics, there are a large number of high-risk patients that are seen weekly at Northern Health, in preparation for them to come for their elective surgery. If there are no pharmacists at the clinic, it can lead to medication errors at admission,” Jeff explained.

The idea for the trial came after a gap was identified and the team aimed to address that gap. With a number of pre-admission clinics during a week, Jeff attended one of the high risk Anaesthetic Preadmission clinics.

“The aim is for the pharmacist to see the patient before they see the anaesthetist and nurse. Studies have shown that having a pharmacists in the pre-admission clinic space has a positive impact on optimising medication management. That is done by a pharmacist completing an accurate medication history and an accurate medication management plan, and liaising with anaesthetists and nurses as well,” he explained.

A pharmacist in this role reduces the likelihood of surgeries being cancelled due to medications being mismanaged in the perioperative space. It can lead to optimised medication management throughout the admission as well.

“I would contact the patient beforehand to let them know I would see them before the anaesthetists, and to let them know to bring all their regular medications, and ask them for the details of their local pharmacy and GP. We collate an accurate medication history for that patient and when the patient comes into clinic, I confirm exactly what the patient is taking and document the list of medications, talk about the medication management at home and discuss medications before, during and after surgery,” Jeff explained.

He would then look at current guidelines, policies and procedures and advise on medications that might need to be changed before surgery and make those recommendations or interventions to the anaesthetist and nurse.

“We promote stewardship of high-risk medications as well. That includes medications like anti-coagulants, antibiotics and opioids and making sure those medications are being managed accurately before admission, and after. There are some medications that need to be withheld before surgery, and they include blood thinners, some diabetes and blood pressure medications,” Jeff added.

Having an accurate medication history reduces the likelihood of surgeries being cancelled and improves patient outcomes and care. This can also reduce length of stay as medication reconciliation is happening earlier in the patient’s admission.

“If there is no pharmacist, the anaesthetist and the nurse would confirm the medication. We did a survey pre and post the 12 week trial , which showed that having a pharmacist is very beneficial and has optimised medication management within the preadmission clinic space. There was very positive feedback from anaesthetists and nurses,” he added.

“Poor medication history, incomplete documentation and inappropriate perioperative medication management can lead to cancelled or delayed surgeries, inaccurate medication reconciliation, medication related harm and lack of patient education. As pharmacists, we promote safe and appropriate use of medicines  in line with Standard 4,” Jeff said.