Pharmacist-Managed Toxicology Consult Service at the Ottawa Hospital
INTRODUCTION
The role of clinical pharmacy services in acute care settings such as the emergency department and the intensive care unit (ICU) has been documented since the 1970s. These studies have demonstrated that the participation by pharmacists in direct patient care exerts a positive influence on patient outcomes, cost containment, and prevention of adverse drug reactions. In comparison, pharmacy-managed consult services in acute care settings are less common, and the few that have been described in published reports appear to have been limited to the monitoring of specific therapeutic drugs, medication history-taking, and the provision of drug information.
SERVICE DESCRIPTION
The Toxicology Consultation Service (TCS) at the General Campus of the Ottawa Hospital, a 482-bed university-affiliated teaching institution, has been operated by the Department of Pharmacy since 1978 and is a major component of the general practice Pharmacy Residency Program. The primary objective of the TCS is to provide verbal and written recommendations regarding toxicologic management and monitoring for referred patients who have presented with drug overdose or any other toxic chemical exposure. The service is available to all medical disciplines and operates 24 h/day every day of the year. The TCS is staffed by a program coordinator (who is a pharmacist), the residency coordinator (also a pharmacist), a critical care intensivist, a board-certified toxicologist (who is an emergency department physician), 5 pharmacy residents, and 6 to 8 senior clinical pharmacists.
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The 5 pharmacy residents who participate in the service each year undergo 12 h of intense training, consisting of didactic and practical sessions and self- directed readings, over the course of 4 weeks at the beginning of the residency program. The topics covered during these training sessions include clinical assessment of a patient who has had an overdose, the process of writing a consultation report, and the epidemiology, clinical presentation, and management of overdoses and toxic exposures involving a variety of agents, including acetylsalicylic acid, acetaminophen, toxic alcohols, sedatives and hypnotics, tricyclic antidepressants and selective serotonin reuptake inhibitors, lithium, theophylline, antihypertensive agents and digoxin, benzodiazepines, barbiturates, recreational and illicit drugs, carbon monoxide, cyanide, and organophos- phates. All didactic and practical training sessions are conducted by the senior staff of the TCS.
New pharmacy residents are required to “shadow” outgoing residents for a minimum of 2 consults before taking call alone. Coverage for call duty is ensured through self-scheduling, and the residents are typically on call for 24 h at a time during the week and 48 h on weekends. Outside of regular work hours, the residents are on call from home. The residents are required to confer with a senior clinical pharmacist on every call, before providing final recommendations to medical staff. Senior pharmacists undergo the same training as pharmacy residents before joining the service. External resources available to TCS participants include a regional drug information service and a provincial poison control centre. kamagra soft tablets
When a patient is referred to the TCS, a pharmacy resident responds, assessing the patient’s clinical status, reviewing the patient’s medical record, and interacting with the clinical staff and the patient’s family to evaluate the cause, severity, and most appropriate management care plan for the exposure, including a determination of the roles of decontamination, antidote therapy if possible, and monitoring parameters. After consulting with a senior pharmacist by telephone, the resident prepares written consultation notes using a standardized toxicology consult form. If the patient is admitted to hospital, the pharmacy resident is not required to monitor the patient throughout the hospital stay, but is required to follow up with the clinical pharmacist responsible for the medical service that has admitted the patient, to facilitate seamless care. Quality assurance and educational initiatives include a review of each written consult by the senior TCS staff person and the program coordinator, with the resident receiving feedback within 24 h. In addition, monthly toxicology rounds focusing on a review of cases and new topics are attended by both residents and senior staff.
