OBES SURG (2011) 21:1477–1481 DOI 10.1007/s11695-011-0455-5
SHORT COMMUNICATION
Bariatric Surgery Pharmacy Consultation Service Jon B. Silverman & Jennifer G. Catella & Ali Tavakkolizadeh & Malcolm K. Robinson & William W. Churchill
Published online: 10 June 2011 # Springer Science+Business Media, LLC 2011
Abstract Bariatric surgical patients often need changes in formulation and dosages of their medications. The literature contains minimal information regarding pharmaceutical care and consultation services for the bariatric surgery patient. Complex medication regimens and safety concerns initiated a collaborative effort between surgeons and pharmacists to manage more effectively bariatric patients perioperatively. The consultation service included patient identification, pharmacy referral, pharmacist consultation with the patient, communication of recommendations with surgeons, follow-up, and documentation. There were 124 consultations performed from February 2, 2009 to December 1, 2010 with an average of 7.7 medications optimized per patient. Every patient required a minimum of one adjustment to their regimen. The surgeons approved 98% of these recommendations. Of recommendations provided, the majority focused on changing the formulation of the medication in some J. B. Silverman (*) : J. G. Catella L2 Pharmacy Department, Investigational Drug Services Pharmacy, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA e-mail:
[email protected] A. Tavakkolizadeh : M. K. Robinson Bariatric Surgery Service, General and GI Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA W. W. Churchill L2 Pharmacy Department, Pharmacy Administration, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
manner. The collaborative effort between surgeons and pharmacists effected changes in medication transitioning perioperatively and resulted in improved pharmaceutical care for this patient population. Keywords Consultation . Pharmacy . Medication . Bariatric surgery
Introduction The literature lacks specific pharmaceutical protocols and guidance around medication transitioning and pharmacydriven medication management consultation services for the bariatric surgery patient population. Medication transitioning is the adjustment of a patient's medication regimen perioperatively to formulations that are more efficacious and safe as a result of the changes that occur during surgery. Bariatric surgical procedures often lead to anatomical changes that affect the pharmacokinetic and pharmacodynamic profiles of multiple medications [1–3]. The bariatric surgeons at our institution perform over 500 Roux-en-Y gastric bypasses, laparoscopic adjustable gastric bands, sleeve gastrectomies, and revisional bariatric procedures annually. Previously, the surgeons were solely responsible for the pharmaceutical management of patient medications with no direct clinical pharmacy support. An increased number of complicated medication regimens and safety concerns prompted the surgeons and the department of pharmacy to initiate a collaborative effort to manage more effectively the pharmacotherapy needs of these patients. An internal retrospective analysis of 149 consecutive surgical patients looking at medication transitioning determined the need for a partnership between bariatric surgery and pharmacy to optimize care. An initiative was undertaken
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to implement a pharmacy consultation service for patients in the bariatric surgery perioperative period.
Procedures The basic model of the consultation service included identification of patients by surgeons, referral to pharmacy, assignment of a pharmacist to perform the consultation, pharmacist preparation for the consult, clinic visit with the patient, communication of recommendations with surgeons, follow-up, faxing of prescriptions, and documentation (Fig. 1). Surgeons referred patients for a pharmacy consultation based on complexity of a patient's medications or issues surrounding polypharmacy. The surgeon referred the patient for a consult indicating the purpose for the consult and type of surgery and if the patient is presurgery, inpatient, or postsurgery. Pharmacists performed consults as part of their usual daily patient care assignments as there was no other personnel or monetary support for the service. The pharmacy committee team leader determined these assignments in advance of the consult, coordinating with the general staffing Fig. 1 Flow chart of the bariatric surgery pharmacy consultation service process
schedule. Patients were scheduled a minimum of 1 to 3 weeks prior to the visit by the Bariatric Surgery Service administrative staff. This time period was required to adjust assigned pharmacist scheduled assignments and allow time for pharmacist preparation prior to the visit. The Bariatric Surgery Service did not have a permanent location available for pharmacy consults. The Department of Pharmacy had a patient consultation room being used as office space which would need to accommodate obese patients. Consults could now occur in either the pharmacy consultation room, the Bariatric Surgery Service suite, or the patient's room while admitted postsurgery. Location of the consult was assigned on a per patient basis. Traditionally, pharmacists do not have background experience with this patient population, and there is little available published information to guide pharmacists in this area. Therefore, all pharmacists performing consults required training and approval to perform consults. The pharmacists were required to review any available literature and research varying formulations of medications. This research was used to create a database of information that contained general recommendations that could be used for patients. The database became a resource and guideline that
Surgeon refers patient and indicates reason for consult
Referral is booked for pharmacy consult
Pharmacist assigned to consult in coordination with the general staffing schedule
Pharmacist evaluates patient history and medication list prior to consult
Pharmacist meets with patient utilizing standardized checklist
Recommendations are communicated to the surgeon and a care plan is determined Care plan and approval or disapproval of recommendations are documented in the medical record Information regarding consults and recommendations is maintained in a database for guidance for future consults and reporting
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pharmacists could utilize as part of their preparation for consults. A limited number of pharmacists performed the initial consults to develop a more standardized approach for subsequent consults and assess needs for determining future competence of pharmacists. These limited pharmacists became responsible for training and authorizing other pharmacists to perform consults. Once assigned to a consult, the pharmacist evaluated the patient's ambulatory medical record and medication list to develop a preliminary plan prior to the consult. Communication occurred with the surgeon as needed in advance of the consult. The standard list of recommendations was utilized to ensure that all pharmacists provided consults and communicated accurate, consistent, and standard recommendations. A patient visit checklist was developed and utilized to guide the pharmacist prior to and during the consult. The checklist described pertinent information to discuss including basic demographic and contact information, the purpose for the consult, general principles regarding surgery, potential effects of medications, review of the current medication list, and potential plan for the perioperative period. Consults were scheduled for an hour time period. The average time for preparation, consultation, and follow-up was documented. Following the pharmacist's checklist, the pharmacist reviewed the patient's history, medication and allergy list, patient's general knowledge of their medications, and over the counter medications or herbal supplements. The pharmacist provided education as required and developed final recommendations from the standard medication list. For example, if a patient was receiving verapamil sustained release 240 mg by mouth daily, the recommendation would read for the patient to change to verapamil immediate release 80 mg by mouth three times a day, may crush tablet prior to administration. A standard template was also designed for documentation of recommendations in the medical record. This template contained two columns indicating the current medication regimen and the new recommendations for each medication. The pharmacist advised the patient that they would receive final recommendations after discussion with and approval from their surgeon. Following consult with the patient, the pharmacist drafted a patient chart note with their recommendations for the ambulatory or inpatient medical record. At our institution, there are multiple methods to document within the medical record; thus, a consistent method for documentation and communication was important. The groups agreed that before posting the patient note, the pharmacist would contact the surgeon for discussion and approval. The pharmacist would then fax prescriptions to the patient's local pharmacy following approval from the surgeon when applicable. Surgeon approval was documented in the
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medical record, and primary care physicians were alerted to the recommendations. A separate database was developed to determine the effect on medication utilization from pharmacy consults and included patient demographic information including age, body mass index, gender, overall number of consults prior to procedure versus postprocedure, average number of medications prior to consult, average number of medications following consult, average number and type of medication recommendations, average surgeon approval rate for recommendations, average number of new prescriptions recommended, and average amount of pharmacist time spent per consult.
Results There were 155 referred and 124 (80%) consulted surgical patients from February 2, 2009 to December 1, 2010. Data only include the 124 consulted patients. The other 31 patients did not accept the service. The majority of referred patients were scheduled prior to surgery. There were 23 patients seen postsurgery due to laparoscopic gastric banding adjustment complaints of heart burn, reflux, or constipation. Three of these patients had undergone revisional repair. The average age of patients was 53 years with a body mass index of 45 kg/m2. There were 96 (77.4%) female patients. There were 61 (49%) Roux-en-Y gastric bypass procedures, 57 (46%) laparoscopic gastric banding procedures, and 6 (4.8%) sleeve gastrectomies performed. Baseline demographics can be found in Table 1. Consulted patients received an average of 11.5 medications prior to their consult and 10.8 medications following the consult. Pharmacists had an average of 7.7 medication recommendations per patient, of which 7.6 were approved by the surgeon. The remainder of medications not approved, 0.1 per patient, were decided to be discontinued by the surgeon or by other healthcare providers. The number of recommendations requiring new prescriptions was 2.2 per patient including either a change in formulation or a new drug. As clinically indicated, the recommendations were communicated to other healthcare providers, an average of 1.6 per patient. There were 12 different types of recommendations not including standard actions such as the recommendation to crush the medication (1.3 per patient) and for the medication to be continued as previously prescribed (1.2 per patient). Standard actions are those recommendations that surgeons were providing to patients prior to pharmacy involvement. The 12 recommendations to optimize the medication regimen included changing from a pill formulation to an available liquid formulation (1.7 per patient), adding specific administration instructions (1.5 per patient),
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Table 1 Summary of patient characteristics and perioperative medication adjustments Patient characteristics Total patients Patients referred prior to surgery, n (%) Patients referred following surgery, n (%) Revisional patients Female, n (%) Average age, years Average BMI, kg/m2 Type of surgery, n (%) Roux-en-Y gastric bypass Laparoscopic gastric banding Sleeve gastrectomy
124 101 (81.5) 23 (18.5) 3 96 (77) 53 45 61 (50) 57 (45) 6 (5)
Pharmacist time spent (average minutes per patient) Preparation prior to consult Duration of consult Follow-up research, documentation, and communication
11.4 30.5 42.7
Perioperative medication adjustments (average medications per patient) Medications prior to consult Medications following consult Medication recommendations Approved Not approved/surgeon discontinued medication Requiring prescription Sent to other healthcare providers Types of recommendations Pill formulation to liquid formulation Should not be crushed Specific instructions Discontinued medications Pill to chewable Change to alternative formulation Extended release to immediate release Enteric coated to non-enteric coated Calcium carbonate to calcium citrate Change to divided doses Add a medication Special compounding
11.5 10.8 7.7 7.6 0.1 2.2 1.6 1.7 1.5 1.5 0.8 0.8 0.4 0.4 0.3 0.2 0.2 0.1
