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Published on 6 December 2013

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Innovations in transfer of care



The innovative Safely HERE Safely HOME scheme ensure patients’ medicines are correct when they are moved from different care environments and incorporates an electronic tracking method for pharmacists to identify which patients are in need of medicines review  
Alistair Gray BSc (Hons) DipClinPharm MRPharmS
Clinical Services Lead Pharmacist
Fiona Buffey BSc (Hons) MSc MRPharmS
Training and Education Lead Pharmacist 
Joanna Wallett BSc (Hons) DipClinPharm MRPharmS
Senior Clinical Pharmacist (Medicine)
East Lancashire Hospitals NHS Trust, Blackburn, UK
There were over 13 million patient admissions to hospital in England alone in 2011/12.(1) Discounting intra- and inter-hospital transfers, this figure equates to over 26 million transfers of care into and out of hospital. Research has shown that up to 70% of these transfers will have some form of error surrounding the transfer of information regarding patients’ medicines.(2,3)
Around 20 million errors is a worrying statistic but also presents an enormous opportunity for health care professionals to make a difference and improve this situation. The pharmacy team at East Lancashire Hospitals NHS Trust (ELHT) has introduced a number of innovations over the last five years aimed at tackling this issue; this article summarises the solutions that have been employed and that are in development.
Medicines reconciliation
When the National Institute for Health and Care Excellence (NICE) produced patient safety guidance No. 1, the stated aim was that pharmacy staff should reconcile patients’ medication histories within 24 hours of admission to hospital.(4) This presents several challenges, and before consideration is even given to what staff resource might be required to meet this demand another practical consideration needs addressing – how to identify patients in need of medicines reconciliation so they can be targeted. Serendipitously ELHT was piloting an electronic patient tracking system (EPTS) at the same time that the NICE guidance was launched.
The EPTS is essentially a user friendly, bed management tool to identify, right down to bed level, where patients are and to aid flow through the hospital. An approach was made to the developers to allow pharmacy to ‘piggyback’ the application so that a flag can be automatically given to a patient on admission that indicates a patient is in need of medicines reconciliation and for how long since admission that they have had this need.
What has resulted is an integrated medicines reconciliation module that allows the pharmacy team to print or view a ward communications sheet that displays patient demographics in bed ascending order, and translates the medicines reconciliation flag into an overdue message highlighting which patients need this service. The flag actually gives a three-stage message differentiating non-reconciled patients from those whom a pharmacy technician has obtained a drug history from those who then require a clinical check by a pharmacist. Meaningful notes can also be left against each patient listed on the communications sheet aiding pharmaceutical care planning (Figure 1).
Reporting tools allow audit, for any time period, of individual team members’ activity; and also, semi-qualitatively by ward, of how many patients were reconciled within 24 hours, 24–72 hours, >72 hours or not at all. Results from these reports create key performance indicators of pharmacy activity and are used at team performance meetings to drive improvement. At a minimum the system saves around ten minutes/person/day/ward visited, which in ELHT equates to about 23 hours each week and this is invested directly into patient care. In reality the value is much more as the quality of care is improved with the targeting of staff resource (which in itself saves time) and the ease of leaving pharmaceutical care notes.
In 2009, we approached the North West Ambulance Service to ask local ambulance crews to bring patients’ own drugs (PODs) into hospital. Such arrangements exist around the country in pockets and are sometimes known as ‘green bag schemes’. This name aside, we chose an orange bag solution (Figure 2) because it was felt the colour was more easily identifiable and could be distinguished quickly from the green coloured bags used to carry patients’ other possessions. POD bags form part of a medicines optimisation strategy because having access to PODs aids medicines reconciliation, minimises missed doses, identifies adherence issues, may highlight medicines related admissions, prevents accidental recommencement of stopped or changed medicines post-discharge, reduces dispensing activity, and reduces waste. Wouldn’t it be great if there was a national standard and approach for ambulance POD bags?
The ward-based pharmacy teams also ask patients where their medicines are if they have not brought them into hospital and annotate the prescription chart accordingly. This minimises the amount of dispensing required during admission and at discharge if no changes have been made to these medicines.
In October 2013, a medicines reconciliation checklist was introduced into practice to standardise the way information is obtained and captured. This is currently inserted into the patient’s care record once completed; eventually it is hoped it can be printed directly into the care record. The approach lends itself to an e-checklist for organisations with electronic care records.
Transfer of care
In 2011, ELHT became an early adopter site of the Royal Pharmaceutical Society’s (RPS) transfer of care guidance.5 The four key principles of this guidance are:
1. Medication information is accurately recorded and transferred
2. This information is acted upon
3. The patient (or advocate) is involved
4. Communication is timely and clear – ideally generated and/or transferred electronically.
The early adopter programme allowed ideas and concepts that improve transfer of care to be trialled and shared so that successes (and less successful blind alleys) could form part of the final report published in June 2012.(5)
Developments from ELHT include a transfer-of-care-friendly prescription chart that overtly shows which medicines a patient has come into hospital on, and which have been started, stopped, and changed, and crucially why those changes had taken place (Figure 3). Providing a means of capturing the indication on the prescription chart also supports the standards stated by the Academy of Medical Royal Colleges.(6)
The electronic discharge letter was also enhanced to make it transfer-of-care-friendly. A section was created allowing easy transcription from the prescription chart and prompting the capture of which medicines had been started, stopped and changed, together with the rationale for these changes (Figure 4). In this section, extra information was provided for community pharmacists should a patient be suitable for a new medicine service (NMS) or a targeted medicines use review (MUR); and each medicine line in the prescription section of the letter indicates what action the patient’s general practitioner (GP) may or may not need to take (Figure 5).
Care homes residents present particular challenges with regards to transfer of care issues. To address this the local medicines interface forum developed what we now call The Care Home Golden Rules – these form an informal agreement between care homes and the hospital pharmacy team to aid better transfer of information and medicines in and out of hospital. These have been shared with the care homes in the locality by written letter, although subjective feedback suggests a stronger communications campaign might be required to fully gain the cooperation of care home staff at the admission stage. The current version of the Golden Rules can be viewed on the RPS transfer of care virtual network.(7)
The latest iteration of this scheme is a care home admissions checklist, which will be launched in the Pennine Lancashire health economy in early 2014.
The Safely HERE Safely HOME scheme
Safely HERE Safely HOME is a bundle of measures aimed at creating high quality discharge letters the day before the patient’s actual discharge from hospital. This is achieved through doctors and nurses using a locally developed checklist during ward rounds to ensure patient interactions, observations and plans are systematically carried out in standardised manner to keep patients safe while they are in hospital (Safely HERE) and ensure safety when their care is transferred back to their GP (Safely HOME). The checklist was developed following consultation with a wide variety of people in the Trust including clinical directors, consultants, junior doctors, matrons and nurses and is currently in its sixth iteration (Figure 6). This has subsequently been adapted by some ward teams to meet the specific needs of their specialty. We now have several versions of a ward round checklist in operation. The use of a checklist approach was inspired by Gawande’s, The Checklist Manifesto.(8)
Systematically capturing information in the patient notes and on the prescription chart has a number benefits:
  • Improved communication and team working
  • Improved forward planning
  • Improved transfer of care
  • Improved patient flow
  • Improved patient experience
  • Reduced pressure on staff
  • Reduced length of stay
  • Improved clinical coding
  • Facilitates the cost improvement programme (CIP).
Another element of the Safely HERE Safely HOME scheme has been to give junior doctors guidance on how to structure their working day to facilitate the creation of tomorrow’s discharge letters today. Ward managers have created a model day for their junior doctors which shows fixed activities such as the times of ward rounds, when there are teaching sessions, and allows the identification of the optimum time on their ward to write discharge letters in advance (Figure 7). Some wards have identified this as protected time for their junior doctors and allowed them to write the discharge letters in the relative seclusion of a ward office. Any non-urgent queries for a doctor during this time are left in a communications book, which also acts as an audit trail to indicate completed jobs as well as outstanding ones.
For the system to function at maximum efficiency, it is essential that all hospital prescribers are fully conversant with transfer of care issues. Traditionally undergraduate medical training has paid little attention to the technical aspects of prescribing; however, this is being rectified in the wake of the Equip study.(9) This study demonstrated that most prescribing errors in the secondary care setting occur at the point of admission and the point of discharge.
Pharmacists are involved in delivering prescribing training for medical undergraduates, foundation year 1 (FY1) trainees and beyond in many UK Trusts. At ELHT, opportunities for learning about transfer of care issues are incorporated into undergraduate doctor and FY1 trainee Safe Prescribing sessions. The knowledge gained is reinforced by mandatory assessment of the application of the principles via case studies and also by ward-based practice under the guidance of both pharmacy technicians and pharmacists.
A big selling point for FY1 doctors is the simple fact that recording dose changes, the reasons for starting and stopping medication during the hospital admission on the inpatient chart and compliance with the ward round checklist serve to greatly reduce the time needed to populate the required fields on the electronic discharge letter.
Exposure of more senior prescribers is via poster presentations and the opportunity for discussion during induction. It is more difficult to convince FY2 trainees and higher grades of the need to assist in the provision of protected time for FY1 doctors to complete discharge prescriptions in a timely manner due to conflicting priorities. As undergraduates and FY1 doctors, who have been persuaded of the importance of these issues, progress in their careers it is anticipated that the processes will become embedded within the service and that a greater degree of consistency and engagement will be facilitated.
The success of the Safely HERE Safely HOME scheme is measured in two ways. The timeliness element is monitored by running a report on the e-discharge letter system, which compares the time difference between the pharmacist authorising the letter and the time of discharge. A graph is produced for each ward showing the monthly trend in the percentage number of letters authorised >18 hours before discharge (that is, the previous day), on the day of discharge, or after the patient has been discharged (Figure 8). The latter is the worst-case scenario and occurs when the patient states they will come back later for their medicines and letter. This is an unsafe discharge and the principle is not supported. Nevertheless, it does occur and there are many risks associated with such a strategy: the patient may not come back, the urgency for a doctor to expedite a discharge letter can disappear with the patient, leading to delays in information transfer to the GP that can further put the patient at risk.
A report of median length of stay is also extracted from this report as this is an indicator of success because a secondary aim is to reduce the median length of stay by half a day per ward through facilitating discharge in the early morning rather than in the late afternoon. The quality element of the scheme is achieved by regularly auditing the patient notes and discharge letter.
In September 2013, a reinvigoration of the scheme commenced with small cohorts of wards working as breakthrough series collaboratives to find out ways to further improve the processes. This has included refining the way improvements are tracked with a series of online reporting tools which allow live analysis, and for wards to drill down from a summary report through to individual patients’ data
Pharmacy ward visit checklist
The pharmacist and technician teams adopted the Safely HERE Safely HOME checklist concept and developed a ward visit checklist, which is designed to help prioritise clinical activities to maximise their benefit to patients and the organisation. The current iteration, which comprises three elements, is shown in Figure 9. The first element of the checklist prompts a daily discussion within a pharmacist/technician pairing (who typically cover about 60 beds, or two wards, between them) before leaving the department. This is to develop a plan for the day based on various reports that can be accessed from the EPTS and a re-admissions report.
The second element triages activity when the team reach the ward; and the third element relates to pharmacists only and provides prompts on how to assess a prescription chart for clinical appropriateness. There is a reference to the STOPP START toolkit here – this is an evidence-based method for reviewing medications to reduce the likelihood of falls in elderly patients. The toolkit was developed by a team from Belfast University(10) and has been tuned for local use and is available on the East Lancashire Medicines Management Board website.(11)
By coincidence, in October 2012, the Royal College of Physicians and the Royal College of Nursing issued guidance on best practices around ward rounds in medicine.(12) They, too, recommended the use of a locally developed checklist; they also recommended including a pharmacist on ward rounds.
Pharmacist ward round participation
It was felt that pharmacy needed to become a visibly integral part of the ward round, in order to maximise the buy-in to the Safely HERE Safely HOME principles by all members of the multidisciplinary team. The timely best practice guidance served to support the theory, and pharmacist attendance on consultant-led ward rounds was trialled across two fast-flow medical wards and two gastroenterology wards. Although many hospitals have involved pharmacists on ward rounds for a number of years, sometimes in just one or two specialised areas, ELHT had never had the capacity to support such an initiative until recently.
Rollout has continued across a number of medical and surgical specialties, and although the development is still very much in its infancy, a number of benefits are becoming clear. Obvious benefits, such as being present at the point of review to advise on choice of therapy, monitoring requirements, interactions and medicines reconciliation anomalies, were somewhat predictable.
A more pleasing development has been the increasing recognition of the much-underused role of the pharmacist within the multidisciplinary team. The clinicians and nursing staff now actively consult with the ward-based pharmacy team much more than in the past regarding many aspects of the patient’s pharmaceutical care, allowing pharmacists to provide a more proactive service. Following ward round attendance, the EPTS pharmacy communications sheet is updated with an evolving mini care-plan for each patient, enabling seamless transfer of pharmaceutical care from day to day. Being present at the point of prescribing allows real time ordering of medications, thereby reducing, or even eliminating, the delay from prescription to administration to the patient.
It has been challenging to facilitate the changes to long-established ward round practices, but feedback from the consultants has been positive. It is hoped that as the rollout continues, and as the culture of ward round continues to evolve, the principles of planning a safe, timely and appropriate discharge from the point of admission will become recognised standard practice.
Patients receiving post-discharge pharmaceutical care follow up has been shown to reduce the likelihood of being re-admitted to hospital within 30 days of discharge.(13,14) Commissioned services in NHS England such as the NMS and post-discharge MUR have been shown to improve health outcomes,(15,16) but getting a patient to engage with their community pharmacist within a few days of leaving hospital can be difficult. There are several models for persuading patients to engage with their community pharmacist; we have been using a self-refer approach with the patient counselled, given a leaflet and encouraged to take their discharge letter to their community pharmacist.(17) Feedback from colleagues and reports from elsewhere suggests that this approach does not work.(18)
Alternative approaches include ‘phone-a-pharmacy’ where a member of the ward team contacts the patient’s community pharmacist to make an appointment. The flaws in this approach include: the necessity to transcribe information, low quality information transfer, a discharge summary is not guaranteed to be received, and the time consumed. ‘Fax-a-pharmacy’ is an alternative, but flaws include the time required to capture the referral information, the logistics of safely faxing a referral, failure of the fax machines and loss of faxes.
Electronic referral addresses all these issues and should be speedier. ELHT are in the process of developing such a solution called ‘Refer-to-Pharmacy’ aimed at creating an integrated pharmaceutical care model from hospital to community pharmacy by massively increasing the numbers of referrals to community pharmacies for post-discharge pharmaceutical follow up (NMS, targeted MUR, and some information only transfers for patients using blister packs, care home residents, or those on complex regimens).
Consenting patients’ demographics will be drawn into the system by scanning their wristbands. The pharmacist or technician will then select the reason for the referral and then use the ‘find-a-pharmacy’ function to identify which community pharmacy to send the referral to. When a patient is discharged, their referral will be sent with a copy of their discharge letter, and the community pharmacist will receive a prompt to log into the system to acknowledge the referral and contact the patient to come into the pharmacy for the intervention. The patient may also receive a text or e-mail reminder on the day the referral is sent. There will be various audit and research tools built in to check if these processes really do decrease admissions or re-admissions to hospital.
The key to success of Refer-to-Pharmacy will be ensuring that patients, hospital and community pharmacists, fully understand what and why we are doing this. A communications campaign has been developed to deliver key messages. There are posters, bookmarks, but the most important part is the patient-facing film that has been made. This can be viewed at but will also be available on the patients’ bedside televisions making it easy for the hospital team to present it to patients. The film explains the problems associated with medicines adherence, how community and hospital hospitals working together can benefit patients, and finishes with patient stories to provide examples of successful community pharmacy interventions. Refer-to-Pharmacy’s Facebook and Twitter accounts can be accessed via the website for anyone interested in following developments up to go-live and beyond. It is hoped that referred patients will also share some of their stories via these media.
Refer-to-Pharmacy is due to go live in December 2013 and the scheme also features as one of the models of care in the RPS’s recent publication Now of Never: Shaping pharmacy for the future.(19) Once it has launched the next phase will be to work with the software developers (Webstar-Health) to see how Refer-to-Pharmacy can be shared with other health economies around the country.
Domiciliary medicines optimisation
The Refer-to-Pharmacy application will also allow the pharmacy team to refer appropriate patients to the local domiciliary medicines care services who deliver medicines optimisation in the front room. There are two teams in East Lancashire, one of which only recently acquired a pharmacist after a two-year hiatus. At that time, the RPS created a virtual network for pharmacy staff providing these services and this has been helpful to the pharmacist who has just commenced this rotational post.(20)
The future?
The future can be summed up with the current word de jour – optimisation:
  • Optimise the Safely HERE Safely HOME scheme through on-going audit cycles and introducing mobile technology to allow doctors to create some, or all, of the discharge letter during ward rounds
  • Optimise the amount of information going into a discharge letter. Standards exist for this already in terms of the fields of information required;(21) but sometimes prescribers will write an extended piece of prose rather than giving the GPs what they desire which is usually ‘just the facts’.
  • Like many Trusts, ELHT is shortly to commence using an electronic prescribing and medicines administration (ePMA) solution. It will be important for us and anyone considering purchasing such a solution to ensure that transfer of care issues are optimised. ePMA presents a virtuous opportunity to capture and track changes to medication together with the rationale for those changes by making the capture of this information mandatory at the point of prescribing
  • Optimising the pharmacists’ input into ward rounds will ensure we make the best use of clinical skills on the wards and which produce the best return on the pharmacists’ availability on any given day
  • Optimise the delivery of Refer-to-Pharmacy to every eligible patient going through the organisation
  • Working together with colleagues from other hospitals to optimise transfer of care between organisations is an unresolved challenge. In tomorrow’s world it must surely be possible to have a standardised pharmaceutical care record that individual Trust’s pharmacy systems can share so that information can pass seamlessly from one hospital to the next with the patient. A pilot has already commenced within the North West critical care network with the moniker Safely HERE Safely THERE.
Key points
  • Up to 70% of transfers of care contain an error. This is a huge opportunity for pharmacy teams to improve patient safety.
  • Checklists build quality into processes. Many ward and pharmacy functions can be enhanced with their use.
  • Working collaboratively with ward teams and doctors to improve patient safety improves relationships, leads to the pharmacy team becoming an integral constituent of ward multidisciplinary team
  • Refer-to-Pharmacy allows bedside e-referrals of consenting patients to their community pharmacists for post-discharge pharmaceutical care. It helps patients get the best from their medicines and to stay health at home.
  • Communication strategies are crucial for getting patient and professional buy in to transfer of care schemes.
  1. Health and Social Care Information Centre) Hospital Episode Statistics, Admitted Patient Care England, 2011–12. (accessed 7 November 2013).
  2. Cornish PL et al. Unintended medication discrepancies at the time of hospital admission. Arch Int Med 2005;165:424–9.
  3. Gleason KM et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health-System Pharm 2004;61:1689–95.
  4. National Patient Safety Agency and National Institute for Health and Clinical Excellence. Technical safety solutions, medicines reconciliation. (accessed 7 November 2013).
  5. Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers: Getting the medicines right. (accessed 7 November 2013).
  6. Academy of Medical Royal Colleges. Standards for the design of hospital in-patient prescription charts.  (accessed 7 November 2013).
  7. Royal Pharmaceutical Society. Transfer of Care virtual network discussions. (accessed 7 November 2013).
  8. Gawande A. The Checklist Manifesto: How to get Things Right. London: Profile Books Ltd;2011.
  9. Dornan T et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. (accessed 7 November 2013).
  10. Gallagher P et al. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): Consensus Validation. Int J Clin Pharmacol Ther 2008;46(2):72–83.
  11. East Lancashire Medicines Management Board. STOPP START toolkit. (accessed 7 November 2013).
  12. Royal College of Physicians and the Royal College of Nursing. Ward rounds in medicine: principles for best practice. (accessed 7 November 2013).
  13. Wilkinson ST et al. Impacting readmission rates and patient satisfaction: Results of a discharge pharmacist pilot program. Hosp Pharm 2011; 46(11):876–83.
  14. Voss R et al. The Care Transitions Intervention. Arch Intern Med 2011;171(14):1232–7.
  15. Barber N et al Patients’ problems with new medication for chronic conditions. Qual Saf Health 2004;13(3):172–5.
  16. Elliot R et al. The cost-effectiveness of a telephone based pharmacy advisory service to improve adherence to newly prescribed medicines. Pharm World Sci 2008;30(1):17–23.
  17. East Lancashire Medicines Management Board New Medicine Service. (accessed 7 November 2013).
  18. Barnett N, Parmar P, Ward C. Supporting continuity of care: referral to the NMS after discharge from hospital. Pharm J 2013;290:178.
  19. Royal Pharmaceutical Society (2013). Now or Never: Shaping Pharmacy for the Future. (accessed 9 November 2013).
  20. Royal Pharmaceutical Society. Domiciliary Medicines Management Group virtual network. (accessed 7 November 2013).
  21. Royal College of Physicians. A clinician’s guide to record standards – part 2: standards for the structure and content of medical records and communications when patients are admitted to hospital. (accessed 7 November 2013).

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