HPE LIVE 2014: part II

Sunderland has been using electronic prescribing (EP) since 2001 and has had robotic dispensing (RD) directly linked to the EP system since 2009. The presentation outlined, as a case study, what the benefits were and what features Sunderland found to deliver benefits. The impact of EP-RD systems was also considered on ward-based pharmacy services and the findings were linked to academic models of sustainability of organisations.

Background: Sunderland is a 1000-bed hospital employing approximately 5000 staff that has had a fully integrated EP system since 2001. Integrations refers to the ability of the system to pass information seamlessly across different modules without re-keying of the information (for example, pathology results, nursing notes, medication etc).

The talk explored how the Drug Error Analysis Study (quoted in the document, A Spoonful of Sugar) identified the frequency of dispensing errors. The talk showed how, by skilfully linking the EP-RD system, every one of the errors mentioned was designed out of the EP-RD system. Also, by linking automatic labellers to the system, there was no potential to introduce errors in the dispensing process, and as a by-product of doing this, dispensing became almost instantaneous. The impact on efficiency is significant. Some parameters around operational efficiency were discussed, which are published in the literature.

The operational impact of this method of working freed staff from mundane dispensary work to being available to deliver clinical services. The talk looked at published work about pharmacists’ views on these systems on their practice. The survey found overwhelming support, particularly in the areas of amount of information, policy enforcement, job satisfaction and ward working relationships. The fact that EP enforced the formulary meant pharmacists did not have to do the task of policy enforcement. The talk identified that pharmacists received three months’ training on the systems at Sunderland, significantly more than junior medical staff. This in turn created an environment conducive to good team working. This contributed to a positive view of working at Sunderland, and this fed through to corporate recognition of the value of pharmacy services.

The talk linked this to the taxonomies of Bloom and Ackoff, and showed how there were similarities to the ‘higher’ valued-added clinical services pharmacy could offer (warfarin clinics, independent prescribers, Emergency Department pharmacy teams, re-admission pharmacy teams etc).

This presentation covered the diagnosis of osteoporosis and risk factor assessment for the clinical outcome of interest when reviewing a patient with osteoporosis. These are fragility or low trauma fractures, with morbidity and mortality projections indicating an increase in the incidence due to longevity and an aging population. A-related loss of bone mineral density generally starts at age 40 years and occurs asymptomatically until a fragility fracture occurs. Fractures result in disability, pain and vulnerability; with high personal, NHS and social care costs and burden.

The evidence base for risk factors has been reviewed by National Institute of Health and Care Excellence (NICE) Clinical Guidance CG46 and include age, sex, genetic risk for loss of bone mineral density and secondary risks associated with co-morbidities or co-prescriptions. The intervention threshold for bone sparing therapy for steroid-induced osteoporosis is a T Score of –1.5 as opposed to the generally applied higher threshold of  –2.5. For a patient on planned oral steroid treatment for three months or more, RCP guidance recommends simultaneous co-prescribing of a bisphosphonate or alternative bone sparing therapy without needing T score results from a DEXA scan.

What the lifetime management plan for a textbook case of an osteoporosis patient could look like, to include lifestyle interventions and choice of bone sparing therapy, was also discussed. How the NICE guidance fits in when considering the initiation of prescription for primary or secondary prevention of osteoporosis fractures was an important part of the presentation. Lastly, the various bone sparing therapies and specific risks and benefits for each option were covered, including discussion of patient compliance/concordance issues. Current evidence base suggests that compliance to bisphophonate drugs drops to around 50-70 % within the first year. There is also the question of whether hormone replacement therapy has a place in osteoporosis risk management, particularly for premature ovarian insufficiency and women with recent menopause and a diagnosis of osteopenia (DEXA T Score between –1.0 to –2.5)

Before 2011, the Heart Failure (HF) Service comprised of a non-prescribing specialist nurse who counselled patients and collected Advancing Quality audit data to meet Trust targets. In 2011, funding was provided for eight hours per week of a specialist cardiology Pharmacist to join the HF team. The nurse and pharmacist both completed the prescribing course and in addition the pharmacist undertook a Clinical Examination Course. Their role was to independently assess, clinically examine and prescribe for HF patients referred in the Trust with left ventricular systolic dysfunction (LVSD, ejection fraction <40%). The pharmacist prioritised the complex patients with multiple co-morbidities and medications to individualise treatment and minimise interactions, adverse reactions and contraindications. Last year, 170 additional pharmaceutical interventions (excluding prescribing) were recorded by the pharmacist (wards had existing pharmacist cover). Interventions included providing specialist advice on the safest medications in cardiac patients, renal impairment and therapeutic drug monitoring.

The pharmacist accounted for 75% of HF prescriptions within the team. This has resulted in a reduction in the number of patients inappropriately discharged without an ACE inhibitor or beta-blocker. In addition, overall readmissions were reduced. During routine examinations, acutely unwell patients were identified and referred to a Cardiologist or transferred to CCU.

The HF service has continued to evolve. There is a day-case intravenous diuretic service to reduce re-admissions and symptomatically manage end-stage patients. Daily visits are made to MAU to ensure AQ standards are met, facilitate early discharge and ensure transfer of care to the Community HF team. Recently, Urgent Review Clinics For patients who need to be seen within one week of discharge have begun to facilitate discharge from hospital and reduce early re-admission.

The prescribing role has continued to develop in areas other than HF. Prescribing during the CCU ward round has resulted in fewer prescribing errors, increased time for teaching and provided a more efficient service. The Pharmacist is undertaking a ‘Clinical Diploma in Cardiology’ at Bradford University to complete an MSc. This opens further possibilities for prescribing in other areas such as AF, in the future.

Developing the new role was scary at first. Clinical examination and presenting cases to consultants is intimidating. Evaluating chest X-rays, ECGs and complex patients can be challenging and may require advice from senior colleagues. However, over the years the role has been hugely rewarding and had a positive impact on improving patient care.

Prescribing for cardiology patients in hospital

Medicines provided through a homecare service allow treatment to be delivered to, and if necessary, administered to patients in their own home. There are currently over 260,000 patients receiving medicines through homecare and the market is worth over £1.5bn per annum. There are a number of benefits to delivering medicines through homecare including:

However, there are challenges such as lead times, maintenance of cold chain, and particularly capacity issues with providers. The later has resulted in NHS England issuing a safety alert in April 2014 relating to missed doses with homecare services.

In 2011, the Department of Health published the first review of homecare services, Homecare Medicines: Towards a Vision of the Future.  This made a number of recommendations, including recommending the Chief Pharmacist is at the centre of managing homecare services, and the need for national standards.  In 2013, the Royal Pharmaceutical Society (RPS) published the first national standards for managing homecare services.  This was followed in 2014 with the publication of a handbook to support homecare teams working to the standards.  Both documents are accessible on the RPS website (www.rpharms.com/support-resources/professional-standards.asp) and are organised around three key domains;

There is much that can be done locally to maximise the benefits and minimise the risks with homecare services. First, Chief pharmacists need to develop a homecare strategy which should be based on a gap analysis between how they currently manage homecare services and the RPS standards. Central to good governance arrangements when managing homecare services is having the appropriate staffing resource which could be funded out of the VAT savings. As most medicines provided via homecare are excluded from tariff, it is the commissioners who benefit from these savings. Therefore they need to be engaged at an early stage and should be prepared to share any savings with hospitals.