1. To Call Or Not To Call... That Is The Question Communicating With Physicians About Medications Daniel L. DePietropaolo, MD National Medical Director Compassionate Care Hospice Wilmington, DE Delaware Association for Home and Community Care 3 November 2010

2. Why Is This Important? There are 34.9 million discharges per year in the United States from inpatient hospitalizations The average American gets 12 prescriptions per year, which has increased from 7 per year in 1992 Home Health Care in the United States currently serves 1.4 million patients per year, and growing! (www.cdc.gov)

3. Communication is KEY!  Years ago, patients would have one family practitioner that would care for all of their needs  Now, patients have doctors, nurse practitioners, nurses, PT, OT, and specialists all taking care of them  We have to work together to best serve our patients

4. What do Physicians/Practitioners assess from the medication list? Are the new and/or current medications appropriate for the patient? Are they effective for the patient's conditions? Are they safe for the patient given other medications and co-morbidities? Are there duplicate medications?

5. What should Home Health Nurses being looking at? When pt comes into your care, review the medications and treatments: Still indicated, or a remnant of medical care past?? Do they really take them? Can they afford them? Is it money well-spent or a waste of their resources? Have they been effective? Serious interactions likely?

6. Example of a bad nurse to physician telephone encounter “Hi Doctor Smith, I’m here visiting my pt Mrs. Jones……but it’s really her neighbor up the street who I’m calling about. She’s not doing well at all tonight. Can I increase her medicine??”

7. What this doesn't tell the Doctor: Who is the lady up the street? Is she our patient? What’s wrong with her tonight? What medicine are we talking about? Why do you want to increase it?

8. What should have been included in that call to the Doctor: Patient’s full name and age Attending physician Diagnosis Major additional diagnoses Symptom or situation you’re calling about Location of the patient – Home/ LTC/ Hospital/ IPU Medication list, including allergies CURRENT TREATMENT PLAN And what the Doctor can do for you

9. Another Example... Good or Bad? “Hi there Dr._____, I have our patient Mrs. Puffer here in the ER. Her diagnosis is COPD. It looks like she’s had an MI.”

10. What this does tell us...  Mrs. Puffer is our patient  She is being treated for COPD  She went to the ER and was diagnosed with an MI  This will call for a change in how we take care of Mrs. Puffer!

11. What this does not tell us... Why did she go to ER?  Dyspnea? Or was it chest pain? How was an MI diagnosed?  EKG? Abnormal enzymes? What are her wishes re: extent of aggressive treatment? What is it that you would like OUR doctor to help you with?  Would you like him or her to talk with ER doctor?  Would you like him or her to speak with the family?

12. Effective Communication Tools S.B.A.R. Tool: Situation Background Assessment Recommendation

13. Elements of the SBAR Situation/Subjective: Patient’s name, age, room #, Diagnosis/es, Attending Physician, medication list, allergies Background: Current treatment plan, symptoms Assessment: Symptoms that have changed or worsened, new onset symptoms Recommendations: Clearly state your question or request for a treatment plan/medication

14. Example of a good nurse to physician telephone encounter Good evening Dr.______. I was calling about my pt Mrs. Clarrett. She is a 57 year old female, hospice dx Pancreatic Cancer, lives with her daughter at home. She called tonight because her pain is now 8/10- it was 4/10 yesterday. Her quality of pain is same- no N/V or SOB. Is it OK if I increase her Roxanol from 20 to 40 mg every 4 hrs? And if we do, she will run out of Roxanol. Can you call a prescription to the Pharmacy? Their number is: (302)xxx-xxxx. Thank you!

15. This is great... but WHEN do I call???

16. During Day-Time Hours: Criteria for calling doctors about medications:  Adverse reactions  Patient not responding to the treatment  Patient/family does not want the treatment or is requesting a different treatment

17. During off-hours “On-Call” hours are for talking about things that cannot wait With an off-hours admission, sometimes these issues DO need to be discussed with on-call doctor. Not usually. Given a choice, best to wait for the doctor who will have a relationship with the pt Present copy of list State your concerns and propose a solution

18. What if you don't get what you're asking for?  Ask yourself if it's you or the patient/family who wants it  Decide if you have stated your request clearly- Maybe they didn't understand your question  Tell them!  Ex: “Dr. I understand what you're saying but I was expecting ____ because____, can you explain why that would not work?”

19. Summary Patients will often present with a long list of medications, some of which are useless holdovers from previous treatment plans. The list as a whole may have “just grown” and never been evaluated as a whole. Some medications may be harmful or a waste of the patient's money, which is a form of harm.

20. Summary Review list, taking a serious look at overall goals for the patient Respectfully discuss with the Doctor, who has a relationship with the patient, and propose a solution Communication is KEY and EFFECTIVE communication can make all the difference!

21. Thank You!!!....and a special 'Thank-You'...and a big one...to Ms. Annie Ingrahm, NP student from Wilmington University, who helped me understand this issue from a nursing point of view...