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Nearly 200 people gathered in Chester for the UK Clinical Pharmacy Association Residential Symposium in November 2013. Topics included critical care pharmacy, pharmacist prescribing, patient safety with insulin and opioid switching
Christine Clark PhD FRPharmS FCPP(Hon)
Editor, HPE 
A study that assessed the impact of clinical pharmacy in critical care has shown that more than 50% of pharmacists’ activity is directed towards medication optimisation  rather than dealing with errors, according to Cathrine McKenzie (Consultant Pharmacist, Guy’s and St Thomas’ Foundation Trust, London). The Protected ICU-UK study was funded by the UKCPA but also attracted support from the Intensive Care National Audit and Research Centre (ICNARC) and the Scottish Intensive Care Society Audit Group (SICSAG). It involved gathering data from pharmacists in 21 intensive care units in England and Scotland.
Pharmacists’ interventions were categorised as those dealing with prescribing errors, proactive interventions for medication optimisation or reactive interventions (consultations) in response to requests from the critical care multidisciplinary team. For example, a propofol dose greater than 5mg/kilogram/hour was classified as an error, as was the omission of GCSF in a patient with neutropenia. Examples of optimisations were increasing the dose of lipophilic ciprofloxacin in an obese patient and increasing the dose of hydrophilic piperacillin/tazobactam in a patient in hypotensive shock as the volume of distribution increased.
A robust database was constructed for the study and a user-friendly form was designed for data gathering. This made data analysis for the study easy but the database could also be used for reviewing errors on a regular basis, said Dr McKenzie.
During a two-week period in November 2012, 20,740 drug orders were reviewed and pharmacists made 3400 interventions in 870 patients – an intervention rate of 4.1 per patient. Interventions for errors occurred in 6.8% of orders, for optimisation in 8.3% and for consultations in 1%. Five categories of medicine accounted for 80% of the interventions, namely, central nervous system drugs, cardiovascular drugs, anti-infective agents, gastrointestinal drugs and nutrition/blood products. The two main reasons for interventions were therapeutic optimisation and patient safety or risk reduction. The majority of interventions were rated as ‘moderate’ or ‘severe’ and higher-grade interventions tended to be made by more senior pharmacists. In addition, specialist pharmacists often make interventions before prescriptions are written. Junior pharmacists usually underestimated severity, commented Dr McKenzie. Overall, 87.5% of recommendations were accepted.
The study had also shown wide variations in the amount of time spent in critical care areas by specialist pharmacists and variations in the level of activity. “Some relatively senior pharmacists were functioning at a very basic level”, said Dr McKenzie. Moreover, most critical care pharmacy services – with two exceptions – operate only on five days per week, which seems difficult to justify, she added.
Pharmacist prescribers 
Joanne Bateman (Lead Cardiology Pharmacist, Countess of Chester Hospital) now undertakes 75% of the prescribing for patients with heart failure. Heart failure accounts for 2% of the total NHS budget and 70% of these costs are attributable to hospital admissions. In 2011, at the Countess of Chester Hospital, a heart failure specialist nurse (HFSN) and a heart failure specialist pharmacist (HFSP) were appointed as part of an initiative to improve the quality of care for heart failure patients.
It was hoped that this would reduce patients’ length of stay in hospital and reduce the frequency of readmissions. All patients with heart failure are examined by the HFSN and referred to the HFSP if they have an ejection fraction below 40%. This is particularly important for patients with multiple comorbidities, multiple medications, renal complications or other complex problems, explained Ms Bateman. Her task is to review the patient’s record, carry out a full cardio-respiratory examination and then initiate and titrate heart failure medication.
She also monitors patients during their hospital stay and refers them to the community heart failure team on discharge. One result of this initiative is that the numbers of patients discharged on ACE inhibitors and beta-blockers have increased, in line with nationally agreed targets. So far, length of hospital stay has not changed but there are fewer readmissions after 30 days than previously.
Ms Bateman has also made 149 additional pharmaceutical interventions during the past year (such as identifying atrial fibrillation patients who required warfarin) and a number of clinical interventions, such as identifying patients with new atrial fibrillation and patients with acute coronary syndrome.
Ms Bateman acknowledged that it is difficult to isolate the impact of the HFSP because both the nurse and pharmacist specialists started at the same time.  However, the overall impact has been positive and funding for her post has now been increased to 15 hours per week (two days) in heart failure. Her role has been accepted throughout the Trust and she is no longer referred to as a nurse, she commented.
A common question for pharmacist prescribers is, “who checks your prescribing?” Ms Bateman explained that she re-checks herself carefully and documents everything in the electronic patient record. However, if a round has been particularly busy, she asks a colleague to perform a clinical check. The question of de-skilling of junior doctors also arises frequently but Ms Bateman emphasises that it is important for junior doctors to learn to work together as members of a multidisciplinary team. Finally, she said that her autonomy as a prescriber is recognised by medical consultants and, when she does disagree with their decisions, the situation can usually be resolved by discussion of the evidence. Her recipe for success is, “Be brave, work outside your comfort zone and embrace new skills to improve patient care”.
Michelle Cerrato (Lead Pharmacist, Cardiac, Orthopaedic and Neurology, University Hospital of Southampton, UK) described how a project to evaluate the impact of employing a pharmacist prescriber to support clinical staff in the Cardiovascular & Thoracic Care Group (CV&T) had resulted in the establishment of a permanent post.
Previous work at the hospital had shown that 37% of patients required changes to their prescriptions after admission to hospital and 20% of discharge prescriptions required amendment before dispensing. Records also showed that, on average, 148 pharmacy interventions were made in the CV&T.
Audits of the time taken for the discharge process (writing and dispensing of a discharge prescription) before and after the introduction of a pharmacist prescriber showed that there was an average reduction of 62 minutes (from 206 minutes to 144 minutes). In the second audit period the pharmacist wrote 48% of discharge prescriptions during core hours. The total time-saving was estimated to be 121 days over a one-year period. This was in part due to the fact that the pharmacist prescriber made fewer errors than other prescribers, said Ms Cerrato. The time-saving allowed doctors to prioritise sicker patients and permitted a better flow of patients through the CV&T. There is now interest in developing the pharmacist-prescribing into a seven-day service.
Opioid switching
Sometimes there is a perception that morphine is a bad drug and that patients benefit from switching to oxycodone. However, clinical experience shows that switching from oxycodone to morphine can be very effective for some patients, Joy Ross (Consultant in Palliative Medicine Royal Marsden Hospital, London) told the audience at a satellite meeting sponsored by Napp. The National Institute for Health and Care Excellence (NICE) guideline for starting opioids concludes that there is no difference in efficacy between morphine and oxycodone and that morphine is the first line drug of choice, based on cost. In contrast, the European Association of Palliative Care (EAPC) concludes that morphine, oxycodone or hydromorphone may be used as first line opioids, she explained.
A number of studies have examined the outcome of switching opioid in patients who do not respond to the first drug that is prescribed. Although the consensus was that switching was helpful, there were still many unanswered questions; for example, it was not known what proportion of patients would respond to each drug when used as first line treatment. A randomised controlled trial was designed to answer this question. A total of 200 opioid-naïve, cancer patients were randomised to receive either morphine or oxycodone as first line treatment for pain. Doses were titrated to achieve satisfactory analgesia.
Non-responders were switched to the alternative drug. Dr Ross explained that this trial was not blinded because of the complexities of running a trial in the last year of life. The results showed that there were virtually no differences between the proportions of patients who responded to either drug. Overall, the per protocol analysis showed that there was a 95% response. The trialists had concluded that, at the population level, there is no difference between oral morphine and oral oxycodone. There was marked inter-individual variation but proactive switching was shown to be a beneficial manoeuvre.
Insulin safety 
An incident involving a tenfold overdose of insulin alerted pharmacists at Kings College Hospital to the continuing danger of this type of error and led to the introduction of safer systems. Gillian Cavell (Consultant Pharmacist, Medication Safety, Kings College Hospital, London) described how the introduction of electronic prescribing had largely eliminated insulin-dosing errors arising from handwritten prescriptions. In the past, the word ‘units’ was sometimes abbreviated to ‘u’ and this was occasionally misread as a zero, resulting in a tenfold overdose. On this occasion a prescription for six units of soluble insulin was written on a paper chart. Although the word ‘units’ was written in full, the nurses misinterpreted the prescription and administered a dose of 60 units.
Further investigation of the incident showed that the system to prevent this type of error relied heavily on individuals recognising that the dose was unusually large, said Mrs Cavell. Work in Australia has shown that a scheme that requires prescribers to validate high doses of insulin – the so-called 25/50 rule – can be effective in reducing accidental overdoses. High doses are defined as more than 25 units of short-acting insulin or more than 50 units of intermediate or mixed insulins. The administration of high doses that are not validated and documented as such is delayed until validated by the prescriber (or, if necessary, by a pharmacist). A spot survey using electronic prescribing data determined the likely workload of such a scheme and discussion with the diabetes team confirmed that the 25/50 rule could be implemented at Kings College Hospital. This has now been incorporated into the electronic prescribing system.
Medication safety staff also identified that the widespread use of 100-unit insulin syringes could contribute to the failure to recognise an accidental overdose. In practice, doses of more than 50 units are rarely needed and the 100-unit syringes have now been replaced by 50-unit syringes.
When involved in the investigation of adverse incidents, pharmacists should look more deeply and widely, and not just at the event itself, and consider all the contributory factors, concluded Mrs Cavell.
Only 48% of nurses correctly identified a blood glucose level of less than 4mmol/l as being indicative of hypoglycaemia before the launch of hypoglycaemia guidelines, according to an audit by Fiona McFarlane and Lucy Devany (Wirral University Teaching Hospital NHS Trust). Other questions concerned the correct treatment and procedure for managing hypoglycaemic episodes. Nurses’ knowledge and awareness of the guidelines improved significantly six and 18 months after the launch of the guidelines and the introduction of hypoglycaemia boxes in all clinical areas. The authors noted that one in four patients with diabetes will experience a ‘hypo’ during their hospital stay and so inadequate management could have serious consequences.
Post-partum VTE 
An episode in which a woman suffered a fatal pulmonary embolism two weeks after giving birth prompted pharmacists at Hull and East Yorkshire Hospital NHS Trust to audit the level of compliance with the Royal College of Obstetricians and Gynaecologists guidelines for prevention of venous thromboembolism (VTE). Simon Gaines (Senior Principal Pharmacist, Clinical Services) and Huey Chong audited 100 records for post-natal women. The results showed that only 62% were risk-assessed using the Trust risk assessment document and that the correct treatment was prescribed for 86% of those who experienced a VTE. As a result of the study, pharmacists are now working with midwifery and medical colleagues to improve documentation, training and practice.
Pharmacy Faculty 
The Royal Pharmaceutical Society (RPS) Faculty was launched in June 2013 and exists to provide a common framework for professional development for pharmacists in all areas of practice. Peter Kopelman (Chairman of the RPS Faculty and Principal of St George’s, University of London) explained how the Faculty will work and the challenges that it faces in its first year. “The Faculty is supporting pharmacists to be the best they can be”, said Professor Kopelman.
The Faculty journey starts at the completion of foundation training. There are three stages of membership – stage 1, stage 2 and Faculty Fellowship – with advancement through an assessment process. The primary purpose of the Faculty is professional development and therefore there is no commitment to submit for assessment, emphasised Professor Kopelman. Fellowship status would normally be associated with leadership in an area of expertise at national or international level alongside a demonstrable breadth of experience and expertise. The UK Government wants to see the introduction of revalidation for all healthcare practitioners and, following the establishment of the Faculty, the RPS is now in a strong position to address this, he explained.
A number of challenges exist for the Faculty. Within the profession, pharmacists do not want to ‘punch above their weight’ and are sometimes reluctant to embark on the Faculty journey. The older generation of pharmacists needs to be reassured about the processes of accreditation and advancement. On the other hand, the younger generation is optimistic and the major challenge will be to meet its aspirations.

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