Have you ever pondered why this question is asked so frequently? The lifecycle of a hospital discharge prescription is rather complex, hopefully I am going to highlight the current process, and why it matters for everyone to be mindful of it in order to help improve it.
• Patient identified as being suitable for discharge within 48 hours, via a daily dynamic discharge meeting or ward huddle (planned) or during a ward round (often unplanned)
• Doctor finalises typing the prescription which also includes a summary letter of the admission using the inpatient notes, electronic prescribing system (HEPMA) and any other relevant info e.g. lab findings/scan results/social work info/referrals for follow clinics etc. Most prescriptions are started prior to discharge, but only submitted to the pharmacy team once finalised (doctors have the option not to submit to the pharmacy team where possible, for example a nurse could dispense simple prelabelled medicines from the ward). Average time 20 minutes
• Clinical pharmacist performs an initial prescription check–
which means that they are happy that the prescription is accurate, cost-effective and safe for that patient. On surgical, medical and care of the elderly wards this happens at ward level using the initial medicine reconciliation (list of medicines that a patient was actually on admission), inpatient notes, any relevant investigations, and by speaking to the patient which helps detect any discrepancies or further issues. The medicines are sorted into either ward stock, pharmacy stock, medicines to be labelled on discharge or the patient’s own medicines to be returned (note we try to only supply any new or changed medicines to improve efficiency & reduce confusion for the patient) Average time 30 minutes
• Amendments are required in 75% of DGRI prescriptions by the prescriber for various reasons e.g. Wrong inhaler device selected, interacting medicine, out of stock medicine prescribed, incorrect legal requirements documented, non-formulary medicine started with no documented rationale, patient requests an alternative medicine, medicine missing from the discharge prescription that the patient was previously on. This percentage just highlights the complexity of the process and does not reflect lazy doctors. Average time 15 minutes.
• Prescription and medicines are taken to the pharmacy department on the lower ground floor by a porter or auxiliary nurse (no designated service). Average time 10 minutes
Prescription is dispenesed then accuracy checked, relevant medicines are supplied, labelled and any pharmacy stock returned by a pharmacy technician. It is then accuracy checked by a different staff member, usually a checking pharmacy technician, before the patient copies of the discharge prescription are printed and an electronic copy is emailed to their GP. Note the dispensary also produces prescriptions for other areas such as out patient clinics, peripheral hospitals, prelabelled ward medicine packs, controlled drug orders, therefore there is often an invisible workload already there. Average time 60 minutes.
• Prescription identified as ready & collected from pharmacy by a nurse checking the ward Cortix board for the live status of when a prescription is ready (green pill icon) or pharmacy will call the ward if it requested urgently. The prescription must then be collected from pharmacy by a porter or nurse. Average time 10 minutes
• Registered nurse goes through the prescription with the patient on the ward. Average time 10 minutes
Are you still awake? Me neither! So on an average day it takes around 2-3 hours from when a patient has been told that they are going to home, to their prescription being ready, and that is only if we get each of the 8 steps correct. In practice, there is usually a delay in one or more of the steps which can be very frustrating for the whole team and the patient. The exact point of the delay varies each time due to external factors such as staffing levels, the POD system not working, no designated prescription porter service, a high number of patients admitted, complex polypharmacy, high risk medicines, poor documentation or planning. We do have quicker variations of the above cycle,but only for patients deemed to be at a lower risk of medication errors, such as arranged admissions where prelabelled medicine packs are available for nurses to dispense straight from the ward for simple medicine regimes, such as painkillers.
The most crucial part of the whole process, I would argue, is talking to the patient. It is well documented that 50% of patients do not take their medicines as prescribed, for various reasons, perhaps lack of understanding, their regime is too complex or they get unbearable side effects. Up to 10% of hospital admissions are due to medicines, again perhaps due to side effects or treatment failure by not taking the correct regime. The most common medical intervention in hospital is to prescribe or alter a medicine. We also know that 25% of medicine reconciliation lists are incorrect on admission and 75% of discharge prescriptions require amendments. Our current I.T systems are very useful in isolation, but information often must be copied from one system to another making mistakes easy and slowing us down significantly. Here in lies the problem; the communication of what a patient was taking when they came into hospital, verses any changes made during their hospital stay is not always fully documented, especially for patients already on several medicines (polypharmacy). Medicines are poisons when not used correctly or with extreme care. Why does it matter if we get a few medicines wrong or miss off their bisoprolol 2.5mg daily, who cares?
I want my prescription now and I want to get home!
Currently the pharmacy team are spending too much resource focusing on rectifying problems at the point of discharge, resulting in avoidable delays. We have completely revamped the way we work by:
• Becoming paperless for our pharmacy team communication (via notes on HEPMA) and documenting any relevant information within the inpatient notes
• Constantly developing a semi electronic discharge prescription & workflow system (eIDD & eIDL)
• Developing a triaging process for emergency admissions; so that only relevant patients are followed up during their inpatient stay, as we need to focus on where we have the most impact which is admission & discharge
• From this week, investment has enabled the triaging service for emergency admissions to be extended to 7 days a week, this will improve the number of patients seen on admission by the pharmacy team (currently only 10% with a weekday service) to allow any medicine related issues to be identified earlier.
• This investment also includes a hospital pharmacist now working with primary care to follow up any complex issues or referrals from the hospital team on discharge
Discharge times matter to us all. So what can you do the improve this?
• Follow the national medicine reconciliation process when clerking in, if you do not carefully check what medicines a patient is actually taking on admission, this will cause delays in their discharge when the junior doctor is trying compare the admission and discharge medicine list for any changes.
• If you are reviewing a patient, look at the medicine reconciliation list, if there is not a clear plan documented for each medicine, challenge it and ensure someone reviews it. It will soon become common practice not to ignore any lists which do not include a dose or a plan.
• If you prescribe a medicine, document an indication, plan and review date. Never assume that it is obvious, telepathy is not a skill! Everyone has different knowledge.
• Also think about ‘realistic medicine’, could you manage to take the regime that you have just prescribed?
• Listen to patients during a medicine administration round, if they think something is wrong, please check as we are all human and errors happen.
• Encourage patients to bring their medicines into hospital, it reduces missed doses, unnecessary ordering of medicines and highlights any compliance issues (our pharmacy technicians check them against the HEPMA system)
• If you are a patient, please ask at every opportunity, what medicines you are being given and why. It matters to all of us that there is a clear rationale and plan for everything.
• If you want to check if a prescription is ready, view the colour of the pill symbol on your ward’s cortix board before calling the pharmacy team, as this delays us
I apologise that the blog today was not an easy read, but if you have any further ideas for improvement then please contact us at firstname.lastname@example.org.
Laura Graham is a Clinical Pharmacist at NHS Dumfries and Galloway