One Stop Dispensing and discharge prescription time

Delays in hospital discharge have been an issue in the National Health Service (NHS) for many years. Such delays contribute to bed pressures and hamper patient flow. The National Audit Office (NAO) reported that 2.2 million bed days could be attributed to delays in discharge in England in 1998/99, costing the NHS the equivalent of £1 million a day.(1) Discharge delays create frustration for patients and their relatives/carers, and healthcare professionals are frequently confronted with complaints regarding such delays. Releasing hospital beds by speeding up the discharge process is therefore a priority for many hospitals. In this context, some hospitals have implemented strategies, such as a technician discharge prescription transcribing service(2) and a redesigned dispensing system initiated by nurses, in an attempt to shorten the discharge prescription turnaround time.(3)

It is recognised that one of the major contributing factors to delays in discharge is the time taken to prescribe, dispense and deliver discharge medicines to the patient. Traditionally, when the discharge prescription is prepared, it is transported from the ward to the pharmacy dispensary, where the discharge prescription is clinically checked and dispensed. However, it is acknowledged that discharge prescriptions are often incomplete and/or inaccurate and amendments are frequently necessary.(4) If an amendment is necessary, then the prescription may need to be returned to the ward for amendment and a further delay in the discharge process is incurred. This delay may be increased further by the fact that the prescriber may not be readily available on the ward to make the amendment promptly. When the amendment has been made, the discharge prescription is then returned to the pharmacy dispensary again for clinical checking before dispensing. The dispensed medicines are then returned to the ward and delivered to the patient. The ‘traditional’ system is therefore time-consuming and inefficient.

One study reported that the average turnaround time for a prescription to be delivered, that is, from the patient being informed of discharge to being given their medication on the ward, was five hours and 15 minutes, and transportation delays (of prescriptions and dispensed medicines) ranged from one minute to one hour and 15 minutes.(5)

A number of key pharmacy documents have highlighted the need to reform hospital pharmacy services and the concepts of One Stop Dispensing (OSD) and the use of patients’ own drugs (PODs) have been advocated strongly.6–8 OSD refers to the practice of combining inpatient and discharge dispensing into a single supply labelled for discharge.(9) Patients are encouraged to bring their own medicines into hospital on admission and medicines assessed by pharmacy staff as suitable for use are used for the patient during their hospital stay. A 28-day supply is given of any medicines deemed unsuitable for use, when the quantity of a particular medicine is depleted and when new medicines are commenced. All medicines for the patient are then stored in the patient’s bedside medicine locker for the duration of the hospital stay. The National Service Framework for Older People stated that all hospitals should have OSD schemes in place by 2002.(8) Therefore, as a further development of the Integrated Medicines Management service provided in the Trusts, custom-designed patient bedside medicine lockers were installed, to facilitate OSD.(10,11) In theory, OSD should reduce the time taken for the discharge process. Barker and Travers reported that the mean waiting time between the patient being informed of discharge and actual discharge was reduced from five hours 40 minutes to one hour after the implementation of a ‘re-engineered’ process, including OSD and bedside medication lockers.(12) More evidence that OSD reduces the time taken for the discharge process is needed.

The objective of the study was to evaluate the impact of OSD on the discharge prescription turnaround time in the Antrim Area, Craigavon Area and Causeway Hospitals in Northern Ireland.

The study was a multicentre pre- and post-intervention study, conducted in one medical ward in Antrim Area Hospital (AAH), one elective surgical ward and one emergency surgical ward in the Causeway Hospital (CH), and one medical ward in Craigavon Area Hospital (CAH).

The discharge prescription turnaround process comprises a number of phases, which are outlined in Figure 1. A data collection form was designed to reflect the phases of the discharge prescription turnaround process (Fig.2). Responsibilities were assigned to doctors, nurses, ward clerks, porters and pharmacists for completing the form (that is, inserting time) at each stage of the process. The completed forms were placed in a designated location on each ward for collection by pharmacy staff. The observation period was two consecutive one-week blocks, excluding weekends, pre- and post-implementation.

The ten phases of the discharge prescription turnaround process were further sub-categorised into three stages to facilitate data analysis as illustrated in Figure 1. As well as the actual time taken for each stage and phase, the percentage of time spent at each stage was calculated. All results were entered into SPSS® for windows (version 14.0). The non-parametric, Mann–Whitney U-Test, was used to determine if there were significant differences between the pre- and post-OSD data.

Data on a total of 362 prescriptions were collected; 184 pre-OSD and 178 post-OSD. Among the pre-OSD prescriptions, 48 were obtained from the AAH, 50 from the CAH and 86 from the CH. Within post-OSD data, 50 were from the AAH, 42 from the CAH and 86 from the CH.

The total discharge prescription turnaround time (mean±standard deviation) was significantly decreased from 225.14±106.82 minutes pre-OSD to 107.24±58.65 minutes post-OSD (p<0.001) in the medical ward at the AAH site; from 210.85±120.34 minutes to 114.22±58.12 minutes (p=0.031) in the medical ward at the CAH site; from 233.00±132.20 minutes to 97.30±74.35 minutes in the elective surgical ward at the CH; and from 233.00±132.20 minutes to 116.00±82.13 minutes in the emergency surgical ward at the CH (Table 1). The change in time required for each stage is also presented (Table 1). The percentage reduction in total discharge turnaround time before and after OSD was 52.4% in the medical ward of AAH site; 45.8% in the medical ward at the CAH site; 58.2% in the elective surgical ward of the CH site and 50.2% in the emergency surgical ward at the CH site (Table 2).

The introduction of OSD significantly reduced the time taken at each stage of the discharge prescription turnaround process in all wards involved in the audit. These results reflect similar findings of ward-based pharmacy dispensing services in other hospitals. In Bristol Royal Infirmary, a near-patient dispensing service reduced the discharge turnaround time by 58%.13 In Wishaw General Hospital, the introduction of a similar PODs scheme resulted in a ‘significantly reduced’ discharge turnaround time once the discharge had been written.(14) In another UK hospital, the decrease in discharge turnaround time was 50%.15 Dawes and Buckley, in a study carried out in medical wards at Leighton Hospital, estimated that the introduction of a ward-based pharmacy dispensing team reduced the discharge turnaround time by 1.4 hours per patient.(16)

The main delay in stage one of the discharge process can be attributed to difficulties in the preparation of the discharge prescription. Wall highlighted this problem in Wishaw General Hospital, indicating that the rate-limiting step was the time delay after the consultant had advised the patient of discharge until the junior doctor was available to write the discharge prescription.(14)

Following the introduction of OSD, the nursing staff and pharmacy team have developed a system to highlight discharges to junior doctors to facilitate the prompt writing of discharge prescriptions.

In the second stage, the time taken saw a mean decrease of 57.6%, 65.4%, 64.3% and 51.8% in the AAH medical ward, CAH medical ward, CH elective surgical ward and CH emergency ward, respectively. The use of both bedside lockers and PODs play an important role in the reduction of the time taken selecting medication because the medicines are readily available, in one location in the bedside locker. In addition, most PODs are already labelled for the patient on admission, which accounts for a further reduction in dispensing time. The removal of the need for transportation of prescriptions and dispensed medicines between the ward and the pharmacy dispensary contributes most significantly to the reduction in time taken for this stage.

The reduction in time taken for stage three across all four wards can be attributed to the availability of the pharmacist on the OSD ward to deliver the dispensed medicines to the patient prior to discharge. Traditionally this was a nursing role and delays often occurred due to the nursing workload. Furthermore, OSD has facilitated discharge patient counselling by the pharmacist.

OSD could be further developed by pharmacists undertaking the preparation of discharge prescriptions instead of junior doctors, and it is anticipated that this will further reduce the discharge prescription turnaround time. It has been reported that the introduction of a ward-based pharmacist preparing discharge prescriptions on a medical ward resulted in a reduction in the time spent by patients awaiting discharge from 4.5 hours to 40 minutes;(17) however, further research is needed. The advent of independent pharmacist prescribing will further improve this process because it will eliminate the need to obtain a doctor’s signature on the discharge prescription.

In economic terms, the average reduction in the discharge prescription turnaround time (roughly 120 minutes/patient) has the potential to create a substantial saving to the Trusts, in terms of opportunity costs. The cost of a medical bed in the Northern Trust is currently £350 per day (including over- heads, routine drug costs and routine laboratory costs); therefore the savings per patient equates to £29.17. When extrapolated across the Trust using the medical discharge figures (roughly 21,000 per annum), the potential annual opportunity cost saving is £612,570.

Given the similar pattern of results across the medical and surgical wards at the three hospital sites, the reliability of the effect of OSD on the discharge turnaround time has been reinforced.

One of the major limitations of this study is that it relied on the accurate recording of the times at each stage of the discharge process.  Also, in some of the data recording forms not all times for each stage were completed. The percentage completion rate was 85.73% at the AAH site, 78.58% at the CAH site 86.00% at CH site, and as a result not all collected data could be utilised in the analysis. However, the sample size was deemed acceptable. Ideally one dedicated observer should collect the data at all stages; however, this was not possible owing to staffing and resourcing issues.

The introduction of OSD significantly reduces the discharge prescription turnaround time on both medical and surgical wards.

• Quickening the discharge process is a priority for many hospitals as delays contribute to bed pressures and hamper patient flows.
• New pharmacy concepts of One Stop Dispensing (OSD) and the use of patients’ own drugs (PODs) have been advocated.
• OSD refers to the practice of combining inpatient and discharge dispensing into a single supply.
• With OSD implemented, the total discharge prescription turnaround time significantly decreased during each stage of the discharge process.
• Potential exists for substantial savings, in terms of opportunity costs, by reducing pressure on beds.