Pharmacist Involvement in a Seizure Clinic Julie A. Hixson-Wallace, Beth Barham, Randell K. Miyahara, and Charles M. Epstein The role of the clinical pharmacist in ambulatory care settings has expanded in the last several years. Various types of clinical pharmacy services in ambulatory clinics have been reported in the literature. This article seeks t o describe the involvement of clinical pharmacists as primary-care givers in an outpatient neurologyseizure clinic of the Veterans Affairs Medical Center in Atlanta, GA. The Neurology-Seizure clinical pharmacy services are provided by faculty, residents, and students from Mercer University Southern School of Pharmacy. The faculty members have been granted clinical privileges t o practice in the ambulatory clinics in order t o function with authority t o perform such duties as giving medication renewals, and writing in the medical chart. In the clinic itself, the pharmacist is
H E ROLE OF T H E pharmacist in ambulatory care settings continues to expand. Examples from the extensive body of literature concerning pharmacists in the ambulatory care setting describe services ranging from patient education' to pharmacotherapeutic and pharmacokinetic con~ultation.*-~ The literature also describes pharmacists as primary-care providers in medication refill,6-10a n t i c ~ a g u l a t i o n , and ~~-~~ other specialty clinics.1J-16This documentation has established ambulatory care as a vital practice area for pharmacists. The treatment of patients with seizures primarily involves the initiation, titration, and follow-up of antiepileptic drugs (AEDs). Monitoring of adverse drug reactions, seizure frequency, documentation of pertinent laboratory studies, and patient education are vital functions that pharmacists are uniquely qualified to provide. This article outlines the clinical involvement of pharmacists in the neurology-seizure clinic at the Department of Veterans Affairs Medical Center-Ambulatory Care Clinics (VAMC-ACC), Atlanta, GA.
From the Depatinietit of Veterans Affairs hledical Cetiter, Atlanta, GA. Address reprint requests to Ratidell K. hl&ahara, PIiannD, CDE, Mercer Univenity Soiitlieni School of Phantiac)., Dcpartnietit of Piramlac). Practice, 3001 hlercer Uniivrsir).Dr, Atlatira, GA 30341. Copyriglit 0 1993 by IKB. Sairtulers Cottipaty 0597-1900/93/0606-000355.00i0 278
responsible for providing a medication profile, an initial interview with the patient, a minor neurological examination, presentation of the patient t o the attending neurologist, writing of a SOAP (subjective, objective, assessment and plan) note, an end-of-appointment consultation, completion of a clinic flow sheet, maintenance of the clinic record, follow-up phone calls relating the results of anti-epileptic drug levels, and monthly quality assurance summaries. Clinical pharmacist-supervised primary care outpatient clinics can b e rewarding endeavors. Through close patient contact and interaction with attending physicians, pharmacists can greatly assist with pharmaceutical care and provide expert drug management of seizure patients. Copyright 0 1993by W.B. Saunders Company
DEVELOPMENT OF AMBULATORY CARE PHARMACY SERVICES
The Ambulatory Care Clinical Pharmacy Service at the Department of Veterans Affairs Medical Center has been in existence since November of 1986. The service provides patient education, patient drug monitoring, and drug information resources for patients and health care providers of the various medical specialty clinics. The service is provided to the VAMCACC by Mercer University Southern School of Pharmacy faculty, pharmacy residents, and students. In order for faculty to practice in the hospital and clinics, clinical privileges had to first be granted. Faculty are given clinical privileges based on their areas of practice and previous clinical experience and training. Privileges such as the ability to write in the medical chart, authorize medication renewals until the patient's next appointment, and others are approved by a physician supervisor, the chief of the pharmacy service, the chief of staff, and the director of the medical center. Pharmacy service in the VAMC-ACC has evolved into two types: a consultant practice and a primary care practice. Initial pharmacy services in the ACC were provided through the role of the pharmacist as a consultant. Through these consultation services, pharmacists and pharmacy students review medication profiles from each clinic specifically looking for potential medication misadventures. If a potential medication misadventure is found on a medication profile (eg, drug-drug interaction, therapeu-
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PHARMACIST INVOLVEMENT IN A SEIZURE CL[NIC
tic duplication, patient non-compliance, drug allergies), then the pharmacist or pharmacy student reviews the patient’s chart. Once the chart is reviewed, the patient is interviewed. During this patient medication interview, the pharmacist o r pharmacy student reviews with the patient the use of medications, compliance, adverse reactions, and signs and symptoms of the disease states the medications are being used to treat. This interview is performed before the physician’s visit, allowing the pharmacist an opportunity to address and correct a detected medication misadventure. Faculty, residents, and Students continue to provide this type of service in the diabetes, hypertension, and endocrinology clinics. With an increased need at the VAMC-ACC to follow up more patients with fewer resources, clinical pharmacists began to get involved in the
Monitoring of adverse drug reactions, seizure frequency, documentation of pertinent laboratory studies, and patient education are vital functions that pharmacists are uniquely qualified to provide.
’primary care of patients in selected clinics. It was rationalized that pharmacists could easily monitor the drug therapy of medically stable patients while allowing a physician to attend to diagnostically challenging patients. If the pharmacist detected a problem in the patient, a physician would then be consulted. One of the first clinics to use a pharmacist in this setting was the neurology-seizure clinic. Since that time other primary care pharmacy services have been developed including medication renewal, anticoagulation, and gastroente‘rology refill clinics. THE NEUROLOGY-SEIZURE CLINIC
The goal of establishing a separate neurologyseizure clinic (NSC) was to ensure the efficient evaluation and follow-up of seizure patients who attend the VAMC-ACC neurology clinic. More immediate follow-up of medication levels
and other laboratory results, side effects, abnormal electroencephalograms (EEGs), and complex management problems are also possible. Additionally, the NSC may be used to provide data for various research efforts in the areas of epilepsy and pharmaceutical care. Patient referrals to the NSC are made from the general neurology clinic, the neurology miniclinics, the emergency room, the evaluation clinic, other specialty clinics, and inpatient services. The medical records of all referral patients are initially evaluated by an attending neurologist. If deemed appropriate, the patient is enrolled in the NSC. Patients are enrolled in the NSC for a variety of reasons including the following: (1) known seizure activity, (2) new onset seizures, (3) difficult to control seizures, and (4)questionable history of seizure activity. The NSC is supervised by an attending neurologist who is assisted by the clinical pharmacist. During each visit the patient is initially interviewed by the pharmacist. After the interview, the pharmacist presents the patient to the attending neurologist, who may o r may not want to further evaluate the patient depending on the patient’s status. Once the patient’s disposition is decided and a plan of action is arrived at, the patient’s follow-up appointment and any laboratory tests or referrals to other clinics are arranged, if necessary. Patients who are stable are seen at 4- to 6-month intervals, and patients who are relatively unstable are seen as frequently as monthly or bimonthly. THE PHARMACIST’S RESPONSIBILITIES
The interaction between the clinical pharmacist and the patient makes up the majority of the patient’s visit. Before the patient arrives, a current medication profile is generated from the hospital computer system and reviewed by the clinical pharmacist who is then prepared to see the patient. An initial interview with the patient is performed during which a medication history is obtained along with information pertaining to adverse effects and recent seizure frequency. The clinical pharmacist then proceeds with a minor neurological examination to assess for signs of antiepilepsy drug (AED) toxicity. This information is documented in the patient’s chart using a SOAP note (subjective, objective, assessmentplan). The clinical pharma-
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cist also updates the neurology clinic flow sheet. All of the results of these pursuits are then presented to the attending neurologist along with any therapeutic suggestions the clinical pharmacist feels are needed. Any changes in therapy are decided on jointly by the attending neurologist in consultation with the clinical pharmacist. These decisions are then discussed with the patient by the clinical pharmacist who documents and maintains the clinic record. Laboratory tests are scheduled as needed, the results of which are followed up with patients through pharmacist-initiated telephone consultations. Finilly, the clinical pharmacist performs monthly quality assurance summaries. The patient interview is a crucial part of the overall clinical assessment. If a patient is visiting the clinic for the first time, an attempt is made to obtain a thorough history of seizure activity
Antiepileptic serum drug levels and other laboratory studies used in the monitoring of a seizure patient's therapy are ordered on a regular basis.
including when the seizures began, a known 'medical cause for the seizures (eg, head trauma, brain surgery, drug-induced, neurological infection), a description of pre- and postictal behavior, a description of the seizures, previously used AEDs, current AEDs, and medication allergies. At all subsequent visits, the pharmacist reviews the date of the most recent seizure, frequency of seizures since last visit, compliance with current antiepileptic regimen, and any complaints of adverse effects from the medications. If seizure frequency has increased, the pharmacist reemphasizis compliance, questions the patient regarding any recent 'febrile illnesses, reviews any recent changes in sleep patterns, or any other changes in lifestyle such as alcohol consumption that may indicate increased stressors in the patient's life. The minor neurological examination by the
clinical pharmacist is performed in order to screen for possible A E D toxicity. Standard tests include the following: (1) far lateral gaze to detect nystagmus, (2) Romberg sign to detect postural instability, and (3) tandem walking to detect gait ataxia. Other tests that are sometimes used include tremor evaluation, cerebellar tests, and checking deep tendon reflexes. All findings of the interview and neurological examination are documented in a SOAP note. The original is kept in the medical record while a carbon copy is kept in a clinic record for easy access. If a patient calls asking for clarification of instructions or is having trouble, their clinic record is then available for the clinician to review quickly. With this clinic record is a seizure clinic flow sheet that is used to record the seizure classification, seizure frequency, present and past anticpileptic medication and the dates of administration, any medication side effects, drug levels, and EEG or CT results for each patient. The primary physician evaluating the patient is responsible for completing the form, but the clinical pharmacist reviews these sheets at the end of each clinic session to ensure completion. The physician also makes any pertinent notations on the pharmacist's SOAP note. The clinic records contain medication profiles from each visit that are generated by the pharmacist, as well as current laboratory values. The clinical pharmacist is responsible for filing and updating these records. Once the interview and minor neurological examination are complete and documented, the pharmacist presents the findings to the attending neurologist. If the patient is stable and is having minimal or no seizure activity, the neurologist approves the pharmacist's plan and signs for any refills of medication. If, however, the patient is unstable and continuing to have poorly controlled seizures, the neurologist will intervene, examine the patient, and complete the SOAP note. At the end of the appointment, the pharmacist counsels the patient. This counseling session can include explanation of any changes in therapy, possible adverse reactions to expect and how to avoid them, how to record seizure frequency, and what laboratory tests the patient will need to have done that day o r at the next
PHARMACIST INVOLVEMENT IN A SEIZURE CLINIC Table 1. Diagnostic Mix of PatientsAttending Seizure Clinic
(N = 114) No. Patients (%I
CPS secondarily generalized CPS Nocturnal No diagnosis GeneralizedTC Alcohol-related Simple tonic Pseudoseizures Mvoclonic
39 (34) 26 (23) 14 (12) 14 (12) 14 (12) 2 (2)
appointment, along with an explanation of plans for telephone follow-up in the event of a critical serum drug level. Antiepileptic serum drug levels and other laboratory studies used in the monitoring of a seizure patient's therapy are ordered on a regular basis. The pharmacist is responsible for reviewing these laboratory results and discussing possible therapy changes with the neurologist. Once a new plan is devised, the pharmacist is then responsible for contacting the patient via a telephone call. The patient is then counseled regarding the change in drug therapy, and the pharmacist documents this interchange both in the medical record as well as in the clinic record. At the end of every month, the pharmacist is responsible for summarizing the activity of the NSC and providing this documentation to the 'chief of the neurology service. Laboratory follow-up and reduction of seizure activity serve as the basis for the report, which is used to satisfy the quality assurance documentation needed by the neurology service. EXPERIENCE WITH THE CLINIC
Our clinic is currently treating 114 adult veterans with a mean age of 47.0 12.8 years.
Table 2. Distributionof Causes of Seizures (N = 114) .
Unknown Head trauma Cerebrovascularaccident Tumor Alcohol withdrawal Subarachnoidcvst
Table 3. Distributionof Anticonvulsant Use (N = 114) Anficonvulsant
Phenytoin Phenobarbital Carbamazepine Valproate
Primidone Clonazepam Mephobarbital
36 (32) 13 (11) 8 (7) 2 (2)
Abbreviations: CPS, complex partial seizures; TC, tonicclonic.
Cause of Seizures
No. Patients 1%)
63 (55) 39 (34) 6 15) 3 (3) 2 (2)
Of these patients, 95% are men and 5% are women. The diagnostic mix of our patients is presented in Table 1, and the causes of their seizure disorders are summarized in Table 2. Many patients seen in the clinic do not return regularly to the NSC, but are seen in other medical clinics. This makes a thorough history and follow-up difficult to obtain. Also, many of these patients do not have a clear recollection concerning their seizure history. The mean duration of seizure disorders in this group of patients is 19.1 f 11years (n = 89; 25 patients had no record of duration of seizure disorder). It is unclear how long these patients have been taking antiepileptic medications because that information is not recorded. However, all patients in the group are currently taking one or more antiepileptic medication. Seven AEDs are being prescribed (Table 3), although two of these medications are being given to less than 2% of the patients. A larger than expected percentage (44%) of patients are on phenobarbital in our clinic primarily because these patients were referred to the NSC already on this medication, maintained on this drug for years, and do not desire to change their therapy. The percentage of patients on valproate (11%) is less than in the general population of seizure patients. This corresponds to our veteran population having a higher incidence of partial seizures and a lower incidence of primary generalized epilepsy. Many of our patients are receiving more than one medication (Table 4). The majority of patients are stable on their current regiTable 4. Distributionof Multiple Drug Therapy (N = 114) No. of Medications
One Two Three Four
No. Patients 1%)
52 (46) 53 (47) 8 (7)
men. It is expected that much of the information obtained will eventually be entered into a computerized data base program. The ability to rapidly accumulate date should stimulate research efforts in the area of epilepsy. Besides enhancing both patient care and teaching endeavors, the seizure clinic aids other VAMCACC areas, in particular the evaluation clinic and inpatient services. Reliable telephone contact, more frequent follow-up appointments, patient education, and continuity of care with the same provider may improve patient outcomes in this population. We are currently in the procesi of identifying objective outcome criteria such as decreased number of emergency room and evaluation clinic visits as well as
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seizure-rclated admissions, and decreased seizure frequency in order to measure the impact of this pharmaceutical care service. CONCLUSION
Clinical pharmacist-supervised primary care outpatient clinics can be rewarding endeavors. The seizure clinic at the VAMC-ACC is a prime example. Through close patient contact and interaction with attending physicians, pharmacists can greatly assist with pharmaceutical care and provide expert drug management of seizure patients, while at the same time receiving job satisfaction from being an integral part of the health care team.
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