Is My Prescription Ready Yet? by Laura Graham

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)
laura-g-1 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

laura-g-2Clinical 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
laura-g-3Prescription 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 dg.pharmacydept@nhs.net.

Laura Graham is a Clinical Pharmacist at NHS Dumfries and Galloway

Clinical Care and the Financial Challenge – How do we Respond? by Mike Pratt

MP 1When I was at school I was uncertain of what I wanted to study at university.  Two front runners were Accountancy and Pharmacy.

Obviously I chose Pharmacy, and I have been very pleased with that choice.  This profession has given me opportunity to carry out work that has greatly satisfied me and hopefully has provided some benefit to many patients and I have tried to help other members of staff along the way.

 

However the job is changing and I did reflect to someone recently that I am beginning to feel as much like an Accountant as I do a Pharmacist. 

 

This of course is partly because the NHS, and the country, is in financially difficult times.  We also have an aging population which brings with it increased health challenges.  But it is also because we have seen some very major advances in medicines, some of which come with a huge price tag.  In particular the introduction of highly effective biologic preparations, with very specific and targeted drug action.  This is the result of some very sophisticated science, of which I am struggling to maintain my understanding.  Indeed when I read of a future where big pharmaceutical companies are involved in licensing stem cell products to treat a range of conditions including cancers, cardiovascular diseases, CNS disorders and diabetes, I start to feel well out of my depth.  And I dare not even consider the cost of these treatments. 

MP 2Couple this with emerging work in the area of genomics and stratified medicines where vast amounts of clinical, lifestyle, environmental, genomic and biological data is collected for a patient, allowing us to move to individually tailored treatment and therapeutic strategies.  We move away from standardised medication dosing towards made-to-measure medicines.  It is believed this approach will improve the lives of millions, of chronic disease patients.  If you are struggling to understand any of this, don’t worry my brain is starting to melt at the thought of it!  But again it will not be cheap!

 

The new biologic medicines we currently have, have revolutionised care.  In ophthalmology we can now stop some patients going blind with a regular injection, in rheumatology we have greatly improved the lives of arthritis patients, we have reduced the number of relapses multiple sclerosis patients experience and significantly reduced their MP 3rate of deterioration and we have improved the survival rates in a range of cancers to name but a few of the care benefits.  But whilst as a healthcare provider we rightly celebrate these successes, the down side is they come at a huge cost at a time we have little money.  This Board I have to say, has done extremely well to find funding for these medicines. This should be recognised and applauded.  But if we have a financial challenge now, then a glance to the future is clinically exciting but financially frightening!

 

So how do we deal with a future that comes with seemingly endless opportunities to bring clinical benefit and yet no significant increase in the resource we have to deliver this?

 To a large extent my answer is  – I don’t know!  But I do know we can’t expect our Finance colleagues to continually bail us out.  We are all in this together.

 There are some common sense steps we can take to increase the effective resource we have.  Simple steps that we are doing, but must continue to do with increased vigour:

 Reduce waste at all points of the health system

 There is not much waste nowadays I hear you say.  Well research carried out by the University of York indicates around 10% of medicines prescribed are wasted.  For us that means that with a budget of around £40m, perhaps as much as £4m is wasted.  So there is work to do.

 I also need to highlight that if there is 10% waste in a reasonably controlled process such as prescribing, what waste is there elsewhere? 

 Whatever you use, use it properly

 Research has shown that around 10-20% of hospital admissions are associated with medication related incidents.  By developing models of working across the whole care team including the patient we can improve on this greatly. 

Use the most cost effective products

In prescribing we have made many great improvements in this area, with a high level of adherence to prescribing policies.  We could however still improve, we need to challenge each other on this.  We also need to look at all areas of healthcare and feel free to challenge each other.

All these above are very important and will help us to sustain our position for a little while.  But the scale of the challenges we face in the future will not be dealt with by good housekeeping.  We need to consider some more fundamental changes.  This we cannot do alone.  There are 2 other issues I think we need to deal with as a priority.

 Understand and Work with Our Population

We need to work with our patients and with our population to determine what they want and need.  It might be surprising!

 

Research carried out by respected organisations, such as the Health Foundation and the Picker Institute has shown that the patient and the population can take a very mature and sensible view about healthcare priorities.  Indeed it has been demonstrated that affordability is a factor that citizens recognise as being important, as long as they can also have an opportunity to influence decision making.

 

Research by the Centre for Health Economics & Medicines Evaluation in Bangor also showed that the public had some very clear views on priorities and for example were not prepared to pay more for medicines that prolonged end of life, treated children, rare conditions or disadvantaged populations.

 

Whilst this is very interesting, all it says to me is that we need to understand our population.  We need to ensure that when the real difficult times come, we are all working together with a clear agenda.

Finally we must:

Change the way we do things

MP 4One of the great things about NHS Dumfries & Galloway is that it is full of good people, who are great to work with and are reasonable.  We make reasonable decisions.  However I am reminded of a quote by George Bernard Shaw:

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.

 

As we approach truly difficult times perhaps we need to encourage the unreasonable man (or woman).  We cannot keep on doing what we are doing and expect a different outcome.  We need radical change, and we need to do this in partnership with our population.  So come on stop being so reasonable!!  Lets challenge ourselves to deliver things in a different way to allow us to benefit from an exciting future.

Mike Pratt is Chief Pharmacist at NHS Dumfries and Galloway

Success is not the end by Susan Roberts

Success is not the end, failure is not fatal : It is the courage to continue that counts   (Churchill)

Susans Blog 1

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!)

 Susans Blog 2

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?”