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Leadership in action-clinical pharmacy presents the answers


Delegates who attended the GHP/UKCPA 5th Joint National Conference in Leicester in June 2009 heard experts discuss aspects of patient safety, anticoagulation and pharmacogenomics

Christine Clark
Editor HPE

A pharmacist medication safety officer has been in post at the Brigham and Women’s Hospital since the early 1990s, explained Thomas Cooley (assistant director, Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts, USA). At first the role was concerned with  surveying and recording medication errors, but increasingly this has developed into a quality improvement function, searching out solutions to prevent or decrease errors, he continued.

Two projects illustrate clearly the way in which safety initiatives have been embedded into the hospital systems. The first project concerned the prevention of venous thromboembolisms (VTEs) in hospitalised patients and was designed to encourage doctors to prescribe appropriate prophylaxis for high-risk patients. The hospital’s adverse event engine, which is linked to the computerised order entry system, identified patients at risk and offered the doctor the opportunity to prescribe DVT prophylaxis, read a quick reference guide or ignore the alert. This had the effect of reducing VTEs by 41%, but only 34% of atrisk patients actually received prophylaxis. The system was then refined by adding some evidence-based information to the alert screen and asking those who do not prescribe VTE prophylaxis to record the reason. Finally, the prescriber is given one more reminder that mechanical methods of prophylaxis do not increase the risk of bleeding. Alerts that are not acknowledged within 24 hours are referred to senior doctors. Evaluation of this scheme is now in progress, said Mr Cooley.

The second project concerned the administration of unfractionated heparin- one of the hospital’s top five drugs for incident reports. Analyses showed that there was one event per 1,000 patients, and 6% of these led to prolonged hospital stays. A standardised concentration of heparin was introduced, and state-of-the-art “smart pumps” were purchased. Smart pumps are equipped with drug libraries, dose and rate limits and overdose/underdose alerting systems, Mr Cooley pointed out. The pumps also hold an electronic record of all actions in addition to the user’s identity. A retrospective review after 16 months’ use showed that there had been 119 attempts to give under- or overdoses of unfractionated heparin, including 40 attempts to give 100-fold overdoses. Whilst the majority of users corrected their action, almost 30% repeated the incorrect data entry at least once, and on one occasion nine times, noted Mr Cooley. Errors occur frequently with intravenous anticoagulation and often result in prolonged hospitalisation or significant patient harm, he concluded.

The newly formed Haemostatis, Anticoagulation and Thrombosis (HAT) interest group of the UKCPA will provide a forum for pharmacists who work in different specialties but who are involved in the management of haemostasis or anticoagulation, explained Duncan McRobbie (associate chief pharmacist, Guys and St Thomas’ NHS Trust).

Only about a quarter of patients who are at risk of a stroke because of atrial fibrillation (AF) are anticoagulated with warfarin, and the remainder receive aspirin or are not treated, according to Gregory Lip (professor of cardiovascular medicine, University of Birmingham). The presence of AF increases the risk of stroke fivefold, and the risks also increase with age. Warfarin treatment reduces the risk by two-thirds, providing the patient’s INR is in the therapeutic range, he  continued. Logistical problems and underestimation of the risk:benefit ratio by doctors are the main reasons for failure to anticoagulate many patients who are at risk. “This represents a tremendous missed opportunity for improving care,” said Professor Lip. The management of anticoagulated patients is not without problems because keeping the INR within the therapeutic range is not easy. One analysis of 13,000 unselected anticoagulated patients had shown that only 51% were in the therapeutic range. Poor control increases the risks of both haemorrhagic and ischaemic strokes, said Professor Lip. Options to improve control include self-management and individualisation of dosing according to pharmacogenetic status. Another approach is to use newer drugs such as direct thrombin inhibitors and factor Xa inhibitors, neither of which requires routine monitoring.

The most advanced product amongst the new agents is the factor Xa inhibitor rivaroxaban, and there is already a sound literature base to support its use in prophylaxis of venous thromboembolism (VTE) in orthopaedic surgery. The RECORD studies had consistently shown that rivaroxaban was superior to enoxaparin in hip and knee surgery, he said. Now a large study  ROCKET-AF”-is underway to compare rivaroxaban and warfarin in the management of atrial fibrillation. Patients randomised to receive rivaroxaban will take a single daily dose of 20 mg (or 15 mg if they have moderate renal impairment). Some 14,000 patients will be recruited, and the results are
expected in the next two years.

In the discussion that followed, Professor Lip acknowledged that pharmacists are generally better prescribers of warfarin than are doctors. If the new classes of anticoagulant turn out to be effective for atrial fibrillation there will still be a need for “atrial fibrillation management clinics” to monitor patients and ensure that individuals are on the right drugs. Education will also be essential because surveys still show that patients believe warfarin is a safe drug and that atrial fibrillation is a benign condition, he added.

Award presentations
The introduction of automated dispensing reduced picking errors but was associated with an increase in labelling errors, according to Richard Boldero (Princess of Wales Hospital, Abertawe Bro Morgannwg University Trust, South Wales), the recipient of the 2009 Pfizer patient safety award. Analysis of dispensing error near misses before and after the introduction of automated dispensing showed that the error rates increased for in patients but decreased for outpatients. The most common error type after the introduction of automation was “wrong directions”, which increased by about a third. Part-packs also gave rise to some problems. Mr Boldero noted that one-stop dispensing was introduced at the same time as dispensary automation and this could have accentuated the labelling problems. “One-stop dispensing” describes the supply of medicines to an inpatient labelled with full patient instructions so that the patient can use the remaining supply at home after discharge from hospital. The incorporation of barcode reading and a mechanism to handle part-packs would improve the automated dispensing system, he suggested.

The application of LEAN principles led to dramatic reductions in the time taken to dispense prescriptions, Gail Richardson (head of pharmacy services, Wishaw General Hospital, Lanarkshire), recipient of the Teva Leadership Award, told the audience. After six weeks the proportion of prescriptions processed within one hour had risen from 42% to 69%. There has also been an 86% decrease in the number of phone calls asking whether prescriptions are ready.

A multidisciplinary group of staff of all grades had participated
in a “value-stream mapping” exercise, which identified all the steps involved from the decision to discharge a patient to the time when the patient left the hospital. All the processes were timed, and the waiting times between processes were also noted, she said.

The key changes were the introduction of an online prescription tracking system that is accessible to all ward staff and “single-flow dispensing” where one technician both dispenses and labels items on a prescription. Portering services were enhanced, and the weekly results (prescription turnround times) are displayed in the dispensary. Other important results of this project have been a fall in dispensing error rate, and
an increase in staff morale. “Previous studies involved endless form-filling, but in this study we were able to test and implement modifications and demonstrate improvements quickly,” said Ms Richardson.

Alia Gilani (health inequalities pharmacist, Glasgow) received the Sanofi Aventis Diabetes Award for her work in establishing the minority ethnic long-term medication service (MELTS). MELTS is an open-access service, but patients are also referred by healthcare professionals. Two of the driving factors for this initial medication review project were the high level of diabetes
in the South Asian population in the UK and the fact that South Asians are often described as being a “hard to reach” group, explained Ms Gilani. Key elements of the project were making contact with diabetic patients using an Urdu-speaking pharmacist and holding clinics in community venues (such as a mosque or voluntary centre) and in a community pharmacy.

Over a six-year period, 1,128 patients have received medication reviews. The results show that more medicines have been prescribed and more blood monitoring has been undertaken. Other conditions such as hypertension have been detected, and patients have been referred to other services for further investigations such as retinal screening or bone scans for osteoporosis. Review of a sample of 90 patients’ records showed that the pharmacy outreach service had made a total
of 90 medication changes and diagnosed 17 new longterm

In future, Ms Gilani would like to develop a service for asylum-seekers and become more involved in the management of insulin-dependent diabetes.

“For most of us the genomic revolution seems remote- but it is not,” said Bill Dawson (Science Committee, Royal Pharmaceutical Society of Great Britain; Academy of Pharmaceutical Sciences, London). Patient counselling has always been an important element of the pharmacist’s work, but in the genomic age pharmacists should become the “translators (of genomic information) for the general public”, suggested Professor Dawson.

Patient-specific prescribing will change steadily, he predicted. In the short term there will be increased activity in diagnostic and typing arenas, and immediate advances will involve existing medicines. In the medium term there will be more medicines such as Herceptin and Gleevec, and in the long term new medicines will be derived from genomic science and will be
introduced with patient genetic profiling advice.

The National Institute for Health and Clinical Excellence (NICE) provides guidance in three main areas- public health, health technologies and clinical practice, said Sarah Garner (associate director, Research and Development, NICE, London).

Guidance on health technologies encompasses the use of new and existing medicines, treatments and procedures within the NHS. In order to answer the question “Should the NHS invest in this technology?”
NICE considers the following points:

  • What are the issues?
  • What are we doing at the moment?
  • What is the difference in cost?
  • What is the difference in effect?
  • What are the comparative advantages?
  • What are the comparative disadvantages?
  • What is the consequence of adopting the technology for all patients?
  • Health gain expressed as quality-adjusted life years
  • (QALYs)- cost per QALY gained.

NICE does not seek merely to get the largest possible number of QALYs but also takes into account other factors such as uncertainty, equity, practicalities of implementation and social value judgements, emphasised Dr Garner.

There are a number of ways that pharmacists can get involved in the work of NICE. They can contribute to NICE consultation when guidance is at a draft stage, they can suggest topics for guidance or apply to join a NICE committee or working group. Other options are to participate in the NICE “patient and public involvement” programme or to help implement NICE

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