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The Guild of Healthcare Pharmacists and United Kingdom Clinical Pharmacy Association held their fourth joint conference in May, with presentations on practice issues and leadership
Laurence A Goldberg
FRPharmS
Editorial Consultant
HPE
Two-hundred-and-eighty delegates participated in a busy programme of cutting-edge professional and academic sessions and workshops at the Guild of Healthcare Pharmacists (GHP) and UK Clinical Pharmacy Association (UKCPA) joint conference
in Warwickshire, UK, in May thus year.
Venous thromboembolism (VTE) accounts for about 60,000 deaths each year in the UK, according to Duncan McRobbie (associate chief pharmacist, Guy’s and St Thomas’ NHS Foundation Trust, London), speaking at a satellite symposium sponsored by Boehringer-Ingelheim. In the UK the annual incidence of VTE is 0.1%, and a proportion of this is preventable. In orthopaedic surgery involving the hips and knees, the incidence of VTE is 55-80%. Although many cases are
asymptomatic, some will develop deep-vein thromboses (DVTs) or pulmonary emboli (PE). Dabigatran, an orally active direct thrombin inhibitor, could provide safe and convenient prophylaxis for this group of patients, he suggested.
There is ample evidence to show that giving low-molecular-
weight heparin (LMWH) or intermittent compression (of the legs) can significantly reduce the risk of VTE in surgical patients, and there is no shortage of clinical guidelines in this field. Thromboprophylaxis increases the risk of bleeding but can reduce the relative risk of VTE by 70%. Mr McRobbie recommended that patients at high risk of VTE should be identified and offered prophylaxis.
Mechanical methods of VTE prophylaxis, such as intermittent pneumatic compression of the legs and graduated compression stockings, and pharmacological methods are recommended in guidelines. Surgeons generally prefer mechanical methods because they avoid the risk of bleeding. Bleeding into the site of
a prosthesis greatly increases the risk of infection and can have disastrous results, Mr McRobbie explained.
Fondaparinux is the most effective agent, followed by danaparoid, LMWHs, unfractionated heparin, warfarin and aspirin. Some guidelines now advise against the use of aspirin. Although it is the most effective, fondaparinux also has the highest risk of bleeding.
VTE prophylaxis should also be given for up to five weeks after discharge from hospital as the risk of VTE remains raised during this period. “We need to be implementing extended prophylaxis wherever possible,” Mr McRobbie emphasised. The current UK
recommendations now call for a mandatory VTE risk assessment, he noted.[1] In his hospital, 94% of eligible medical patients and 85% of general-surgery patients receive thromboprophylaxis.
In England, extended prophylaxis can be provided by the hospital if it is commissioned by the primary care trust and is within the agreed tariff. Patient education in preparation for extended prophylaxis should be started at the preadmission clinic. Staff from Guy’s and St Thomas’ hospital say that about 98% of patients are capable of self-injecting (alone or with help from relatives) once they have been trained correctly.
Many new anticoagulant products are being developed, including oral factor Xa inhibitors, such as idraparinux, rivaroxaban and apixaban. Dabigatran (as the prodrug dabigatran etexilate) is an oral direct thrombin inhibitor that is licensed for primary prevention of VTE in elective total hip or knee replacement surgery. Studies have shown that it is noninferior to enoxiparin treatment and is more convenient to use.
There are numerous medicines management issues concerned with anticoagulant treatment, Emma Richmond (pharmaceutical adviser, Richmond and Twickenham Primary Care NHS Trust, London) told delegates. For example, most people will agree to self-administration of subcutaneous heparin, but compliance is not tested. Safe disposal of sharps in the community is another matter that has to be tackled. Prophylactic treatment with dabigatran after elective total hip or knee replacement surgery would be a useful alternative as it can be taken orally, she commented.
According to England’s National Patient Safety Agency, anticoagulants are most frequently identified as a preventable cause of harm and admission to hospital. For prophylactic treatment, balancing the risk of VTE against the risk of bleeding is a constant challenge. Anticoagulant treatment for VTE presents other challenges – international normalised ratio (INR)
monitoring is a key stumbling block for patients taking warfarin. In Ms Richmond’s locality a specific prescribing protocol has been implemented; she said both prescribing and dispensing software should show the most recent INR. The pharmacist does need to check the “yellow book” (the patient-held anticoagulant record). Clinical medicines management services are also provided in Ms Richmond’s primary care trust. Such management can start at the preadmission stage for patients undergoing elective surgery. It is critical to ensure that the patient receives a consistent message and knows the signs and symptoms of VTE. Discharge
planning for anticoagulated patients is clearly important but often overlooked, she added.
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New professional body
Patient safety must lie at the heart of the work of the new professional body for pharmacy in Great Britain, said Nigel Clarke (chairman, Independent Inquiry into a Professional Body for Pharmacy).[2] The new regulator, the General Pharmaceutical Council (GPhC; see Gill Hawksworth’s article on page 35 of this issue), will become operational in January 2010, and arrangements for the new professional body should also be in place by then, he explained. One of the body’s key roles would be to provide a bridge between members to ensure that daily practice and advice to patients is informed by up-to-date scientific opinion, and the body would also have a central role in education. It would not, however, offer any trade union functions. Overall, the development of a new professional body represents an opportunity for pharmacy, he concluded.
Healthcare trends
We are now living in a period when birth rates are low and the majority of diseases are degenerative or manmade, according to David Taylor (professor of pharmaceutical and public health policy, School of Pharmacy, University of London). The focus of healthcare is changing from treating sick patients to helping
healthy people stay well. At the same time, there is an ongoing change from institutional care, where the normal social role is temporarily suspended, to community care where normal social roles can continue, he said. These trends offer opportunities to community pharmacy, for example, to extend its role to include risk factor management, self-care support and healthcare provision for common conditions.
The next phase of epidemiological transition will be marked by delayed degenerative diseases and emerging infectious diseases. A number of other changes will help to shape the healthcare environment, such as increasingly assertive consumerism in healthcare and greater demand for safety and effectiveness of
medicines. There will be decreased tolerance of health inequalities, and higher expectations of universal care access. This will put pressure on professionalism, Professor Taylor predicted. Other changes will include decreased social distance between health professionals and service users, increased recognition of the role of self-care and a shift of quality management from professional to regulated managerial control.
The continued development of pharmaceutical science is vital for humanity’s future, and research-based pharmaceutical industry plays an important role in this context.
The pharmacy profession can claim a special relationship with pharmaceutical science and its industrial and market applications, and needs to develop a more robust strategic approach to supporting therapeutic innovation, he concluded.
Future pharmacy education
Pharmacy must be patient-focused and medicines-centred. The challenge facing the profession is to stay medicines-centred but to move away from the supply function because pharmacy has the potential to do so much more, explained Anthony Smith (dean, School of Pharmacy, University of London). We need to bring pharmaceutical science into healthcare practice, he said.
The recent UK government white paper[3] makes reference to advanced practice, and, for that, a framework of postregistration professional development will be needed. The first day of registration is a fixed point in pharmacy life, but historically what followed was patchy, Professor Smith said.
Considering the degree to which undergraduate education matches professional needs, Professor Smith said there is currently a dislocation between education and practice. Master of Pharmacy courses are not competency-based, and there is no clear link with practitioner development. Moreover, there is
“frighteningly little dialogue between academics and people in practice about preregistration training”.
A five-year integrated programme – the beginning of a planned educational continuum from student to consultant – run in partnership with the NHS might be the best way forward, he suggested. This would address the discontinuity with the preregistration year, but it would need to incorporate assessments of intellect and performance. Above all, he said, the science of medicines must be our bedrock, otherwise pharmacists cannot claim to be the experts on medicines.
Safer Patient Initiative
The Safer Patient Initiative has enabled staff at Glân Clwyd hospital in Wales to improve several processes, including dispensing and the management of anticoagulant treatment, according to Philippa Roberts (principal pharmacist, risk and medicines management, Conwy and Denbighshire NHS Trust, Wales). The scheme uses “plan, do, study, act” (PDSA) cycles
to test ideas for service improvement on a small scale and then builds on the successful ideas to create widescale improvements. A test might only involve one nurse and one patient. “If it works with one then try three and then five, but do not move on until it is working well,” said Ms Roberts. At Glân Clwyd hospital this approach has been used to redesign the warfarin chart and to implement an education package for doctors. A standardised education package for patients has been
developed to replace the two separate packages used by nurses and pharmacists in the past. In addition, guidelines for perioperative management of anticoagulation have been improved. A related project involved working with local GPs and introducing a scheme to monitor INR values above six.
In a separate scheme, staff mapped the 12 stages of dispensing and scored the likelihood and severity of undetected errors. Clinical checking and picking products manually were found to be the high-risk activities. Once frontline staff were aware of the errors, they had many suggestions for improvement, Ms Roberts said.
The key advantages of this approach are that it involves the staff on the front line, it does not require lengthy planning and it is easy to learn and use.
Patient safety is very much part of routine work now, and pharmacy managers are expected to “have a handle on safety and quality”, said Michael Spencer (general manager, clinical support service group, Cardiff and Vale NHS Trust, Wales). Changes made to improve systems must be embedded into daily practice and not just be “add-ons”, otherwise they are unsustainable. In addition, the effectiveness of changes must be measured, but the process should not be burdensome.
Acetylcysteine prescribing
The introduction of an electronic prescribing scheme for acetylcysteine for the treatment of paracetamol overdoses eliminated prescribing errors with this product, Uttam Chouhan (principal pharmacist, Glân Clwyd hospital) told the audience. Prescriptions for acetylcysteine are weight-based and call for three different doses and infusion volumes, but usually show doses as milligrams per kilogram rather than as infusion rates. Mistakes have led to deaths, and several cases have been reported in the medical literature.
Electronic prescribing software has been developed that requires only the patient’s name, hospital number and weight. It generates a prescription containing all data required, including dose and infusion rate. A paediatric version is also available. This has now become the standard method for prescribing acetylcysteine for paracetamol overdose at Glân Clwyd hospital. But, Mr Chouhan added, problems of safe preparation and
administration were still to be resolved.
References
1. Department of Health. Report of the independent expert working group on the prevention of venous thromboembolism in
hospitalised patients. London: DH; April 2007 [cited 2008 June 11]. Available online at: www.dh.gov.uk/en/Publicationsandstatistics/Publications
2. Clarke N. An independent inquiry into a professional body for
pharmacy. London: Royal Pharmaceutical Society of Great Britain; April 2008 [cited 2008 June 11]. Available online at: www.theclarkeinquiry.com
3. Department of Health. Pharmacy in England: building on strengths – delivering the future. London: DH; April 2008
[cited 2008 June 11]. Available online at: www.dh.gov.uk/en/Publicationsandstatistics/Publications
