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Laurence A Goldberg
HPE Editorial Consultant
Report of a presentation given by Dr Michael Scott at the Guild of Healthcare Pharmacists/ United Kingdom Clinical Pharmacy Association joint conference held on 12–14 May 2006, Radisson Edwardian Hotel, Heathrow Airport, London
The integrated medicines management project in Northern Ireland has resulted in reduced length of stay in hospital, decreased readmission rates, reduced wastage of patient’s own drugs, more accurate drug histories, improved medicines use, better use of doctor and nurse time, more accurate discharge information and improved stock utilisation. All this has been achieved within a three-year time frame, between 2001 and 2004, according to Michael Scott (Chief Pharmacist, United Hospitals Trust, Antrim, Northern Ireland, UK).
Integrated medicines management involves the compilation of an accurate and complete drug history at the time of admission, intensive monitoring and patient education during hospital stay, preparation of discharge medicines and transmission of a written summary of medication changes to both general practitioner (GP) and community pharmacist at the time of discharge. The traditional system lacked this element of communication across the primary/secondary care interface and was associated with inaccurate admission drug histories and medication errors during hospital stay. It was estimated that medicines-related problems cost about £40m per year in Northern Ireland. However, there were no robust data to show that investment in clinical pharmacy services would improve the situation.
Funding of £600,000 was obtained and a randomised controlled study comparing integrated medicines management (IMM) and “usual pharmaceutical care” in 1,000 patients was set up. Teams comprising one clinical pharmacist and one technician were appointed for each of five wards and the IMM process was developed. Part of this involved discharge prescriptions being signed off by the clinical pharmacists and being sent to the GP and community pharmacist on the day of discharge.
When the project was evaluated the length of stay in the intervention group was two days shorter than in the control group and the readmission rate was decreased by 20%. Both of these changes were significant. More accurate drug histories were obtained – 62% of the changes that pharmacists made were classified as “drug name” and involved corrections to the drug name originally recorded. The mean number of queries on drug histories fell by 4.2 per patient. There were also significant improvements in the appropriateness of medicines, as measured by the medication appropriateness index (MAI). Whereas scores in the control group fell from 13.16 to 9.97, score in the intervention group fell from 17.48 to 5.69 (a low score indicates more appropriate treatment).
A significant amount of time was saved as a result of the project. Thirty minutes per patient of junior doctors’ time was saved as a result of pharmacists taking drug histories on admission and preparing the discharge prescriptions. Discharge prescriptions prepared by pharmacists could be processed more quickly as only 1% contained errors compared with 25% written by junior doctors. As a result, the average turnaround time for prescriptions from medical wards fell from 135 minutes to 35 minutes and on the surgical ward, from 100 to 20 minutes.
The ward-based technicians made a major contribution to the overall project. They were trained to undertake routine inhaler counselling and they supervised the ordering and storage of medicines on the wards. As a result a one-off saving of £9,000 was made as the number of items ordered fell by more than 2,000.
Economic analysis of the results suggests that the IMM process yields a return of £4.80–8.00 for every £1.00 invested. The benefit per patient receiving the full service was estimated to be £785–1,351.
Such was the impact of these results that a further £4.6m was allocated to roll the service out across Northern Ireland between 2004 and 2008. A 5,000-patient study is now underway to examine the impact of each stage of the IMM process – admission history taking, inpatient monitoring and discharge.
International links have been forged in connection with this project. Dr Scott explained that a similar project is now running on two wards in Uppsala Hospital in Sweden.
Inevitably, opportunities to improve other aspects of pharmacy work were identified during the project and some of these have been tackled along the way.
One example of this is the development of a new type of individual patient medicine locker. Many of the cupboards designed for this are too small or end up inconveniently positioned for the nurse, the patient or both. Staff at Antrim hospital worked with a manufacturer of bedside lockers and cupboards (Bristol Maid) to develop a new locker that is basically a deep drawer with a pullout tray. The drawer is opened using an electronic key rather than a conventional key. This means that records of the number of times the drawer is opened, and by whom, can be kept and keys are less likely to go missing.
Another example is the development of EPICS (Electronic Pharmacy Intervention Clinical System) – a system that makes use of wireless connectivity and is integrated with the electronic patient administration system (PAS). Through this system, pharmacy interventions, allergy status, medication incidents and drug histories can all be logged. “We have developed a paperless intervention and near-miss recording system and out-pharmacists are now well adapted to this way of working,” said Dr Scott. A community pharmacy-based version of the system is now being developed, he added.
Future developments in Antrim will include a dispensing robot in 2006–7 and electronic prescribing in 2007–8. Better integration with community pharmacy should facilitate rapid transfer of patient information in both directions. Dr Scott is also hoping for funding to appoint a community clinical pharmacist. Another important target is unified use of medicines and wound dressings throughout the province. Finally, independent prescribing by pharmacists will fit neatly with the skills that his staff have developed in the course of the IMM project.