Success is not the end, failure is not fatal : It is the courage to continue that counts (Churchill)
There is something stirring in the lower ground floor of DGRI. Over the last few weeks the hospital clinical pharmacy team have been busy polishing and admiring their award for Scottish hospital pharmacy team of the year. We are equally proud of our senior pharmacy technician, Melanie Bryan, who was runner up as Employee of the year – leadership, against tough competition, at the Celebrating Excellence awards. The icing on the cake is our recently refurbished department which has improved work flow, the safety of our working environment and had a positive impact on morale. I will share the highs and lows and why the shape of clinical pharmacy had to change.
As a keen, enthusiastic clinical pharmacist, tasked with setting up a clinical pharmacy service to the surgical unit, far too long ago in Stirling Royal Infirmary, I used to whizz round at least 4 wards daily checking every in-patient chart and reviewing patient’s medical notes. Even though this was a Monday – Friday service I was up to date with all medicine changes. Many patients stayed a week or longer. I had time to discuss medicines with the patients as well as providing advice to the clinical team.
I don’t need to explain that healthcare has changed since those golden days for clinical pharmacy. Like other services we needed to review ours to meet the needs of todays patients. We can’t see every patient every day, even Monday to Friday, due to shorter admissions and increased demand. How can we target our medicine expertise to the patient’s that need our in-put most and the activities that add greatest value? We knew we had to work out how to do more with the same staff resource. Where to start?
With the help of Joan Pollard we set about process mapping. We suspected it was chaotic but once mapped we could see clear areas where our service was duplicated and confused particularly at admission. We also identified, in our opinion, two points which provided the greatest patient value. The pharmacy contact with the patient on admission and discharge. We knew we had to focus on providing the best service we could at these points for as many patients as possible.
We developed an admission process in medicine and surgery that utilised the skills of the team more efficiently. The role of the pharmacy technician was extended to include checking patients own drugs, against medicines reconciliation sheets and in-patient charts. To release this resource we had to disinvest in pharmacy technicians providing a kardex top-up service to the wards. This was not adding value and unless we could provide this service 24/7 to every patient, doing it once or twice a week was inefficient and could be argued was a risk. We agreed this plan with senior nursing staff.
Targeting our clinical pharmacy service to those who needed it most was our next goal. As part of an MSc project, Lizzie Cook developed a triage service on admission. In the past pharmacists covering non admission units had to resort to identifying patients who needed to be seen by starting at one end of the ward and working their way round . The risk was that the patient who most needed your in-put was the last to be seen or worst still was not reviewed at all. A very labour intensive process.
Pharmacists in ward 7, whilst providing input to the clinical team, screen patients to identify any pharmaceutical issues, categorise the patient according to the required review frequency and communicate this to the pharmacy team. Those at lowest risk are not seen until discharge. High risk medicines are added or the patients ability to handle medicines may alter during their stay and we still rely on referral by clinical teams to highlight patients who need seen more quickly than planned. Electronic prescribing will help us identify these patients in the future. The triaging system is allowing pharmacists to spend more time utilising their skills following up high risk patients, ensuring patients go home with the right medicines in close liaison with the patient/carer and ensuring cost effective use of resource for individual patient’s as well as the organisation.
At the same time we have developed the discharge service. From a baseline of 0, now 75 % of patient’s Monday to Friday have their discharge prescription reviewed at their bedside by a pharmacist (excluding paediatrics, obstetrics and palliative care). IT development of the Immediate Discharge Letter system which includes a colour coded progress tracking system allows better management of workload. These changes have reduced our discharge prescription turnover within pharmacy from an average of 4 hours to 54 minutes.
Failure is not fatal (usually)
Although it sometimes feels like it. What went wrong?
There were days or sometimes weeks when it seemed like the easiest thing was to return to our old ways. It has been hard for staff to accept that we don’t aim to review every patient every day. It’s a struggle to maintain momentum. There was a temptation to try and change too much too quickly, probably by me, which we had to curtail.
There are no prizes for identifying our glaring error. We haven’t sought the views of patients or carers.
It is the courage to continue that counts (As our rowing teams know only too well!)
So what next? Our vision of a super slick service must take into account views of patients in conjunction with the pharmacists knowledge of a patient’s pharmaceutical need. As we continue to review the service and ask “What matters to you about your medicines? We may be surprised by the answer.
We have an excellent team, we need to continue to optimise the use of our skills. We must consider ways of providing a service where all patients receive the same in-put regardless of admission time. Pharmacy assistants will play a greater role in medicines management and help to reduce waste. Supporting nursing staff to ensure medicines are in the right place at the right time. Whilst pharmacists and technicians ensure it’s the right medicine.
So there is no rest for the pharmacy team, despite our success so far, and we wouldn’t want it any other way.
Susan Roberts is a Clinical Pharmacist at Dumfries and Galloway Royal Infirmary
Next weeks blog will be by myself, Ken Donaldson, and will be entitled “Whose experience is it anyway?”