Optimising care rather than medicines

Dear Editor,

I read with great interest the recent article on ‘closing the loop on medicines optimisation’,¹ in which the authors raise a number of interesting points and present some quite shocking figures as they present the argument against original pack or ‘one-stop dispensing’ (OSD).

They accurately describe the thinking behind the introduction of OSD and then assert that in their experience, and in the experience of others, this process has ‘failed to deliver’ and indeed is counter-productive.

This is clearly not a universal finding. A study of OSD conducted in two hospitals in Northern Ireland identified a reduction, both in medication administration errors and in the time taken to administer medicines (by over 50% in one site).² In a more recent article, the same team suggest that OSD, coupled with a number of other initiatives such as pharmacist generation of discharge prescriptions, has led to medication rounds being 25 minutes quicker and discharges 90 minutes faster.³

These findings suggest that the negative experience of OSD may be more closely related to the implementation process than to the strategy adopted. It seems that the fundamental problem is in ensuring that the medicines remain with the patient throughout their time in hospital and that this is often not achieved, leading to re-dispensing of the same medicines. This, together with the need to re-supply medicines if doses or medication selection changes due to changing patient needs, leads to a waste of manpower in checking large numbers of returned packs and significant medicines wastage.

The issue of ‘changing treatment’ was fully investigated when OSD was first introduced, although the majority of prescribed medicines remained unaltered, there were certainly a number (perhaps 20–30%) that underwent some change. In such circumstances, some waste is inevitable and this caused consternation amongst pharmacy staff at the time. A brief analysis of returned medicines identified that the average value of a returned pack was £0.60 but the staff cost of recycling this was £2.60.

Naturally there are some high value medicines that should be recycled but for the vast majority, this was not financially viable.

Ensuring medicines are transferred with the patient, in the same way that the patient’s property (clothing, money, mobile phone, etc.), is should help alleviate the demand for re-dispensing and an eclectic approach to the recycling of ‘part-packs’, should reduce the burden on pharmacy staff, without having significant impact on the cost of waste.

I must say that for me, the most significant issue in this article was the description that a patient can expect to be transferred four or five times between admission via the Emergency Department and their eventual transfer to the ‘Discharge Lounge’. This is presumably to alleviate pressure in ‘acute’ areas and ensure that targets are met; but four or five transfers in a three day length of stay must have a detrimental impact on the delivery of care (as an increase in problems at ‘handover’ areas is well documented) and perhaps this article has exposed a much bigger issue that the failure to ensure that ‘medicines follow patient’?

The article goes on to describe an automated process for the provision for unit dose, which I must say I was impressed by when I first heard of it some years ago. However, independent of the ‘process’ adopted, the requirement for timely supply of medication remains the same. It is inevitable that the ‘medication needs’ of the patient will at some point include the need to supply at least one item that is not readily available at ward level (non-stock item) and that cannot be met by medicines brought in with the patient; and that must therefore be ‘supplied’ in an ad hoc manner. Ensuring the timely supply of such an item is a challenge that applies equally whether the supply is unit dose or original pack.

While it is evident that any potential ‘waste’ (should medicines fail to follow the patient) is certainly minimised if the supplied quantity is reduced, the real cost lies in the cost of the supply process and this is less impacted by the quantity supplied than it is by the frequency of re-supply. The challenges of transfer of medicines will remain even with a unit dose solution, as a number of medicines such as inhalers, creams, and a number of liquid preparations, will not be available in a unit dose format and will still need to move with the patient.

The basic concept behind the process developed and delivered by IBSL is that electronic prescriptions create orders that are checked by pharmacists, processed by robots and delivered to the ward, where the medicines trolley is automatically loaded before each medicines round and the drug administration process is controlled by scanning the barcode on the patient’s wristband and on the medicine presented for administration.

There are studies to indicate that the use of electronic systems to support prescribing and medicines administration, with the use of barcodes or other machine-readable identifiers to confirm appropriate selection of both patient and medication improves the management of medicines.⁴ Other studies have shown that the use of automation to support the dispensing and distribution of medicines also reduces the opportunity for error.⁵ So a drive to ‘close the loop’ on medicines management with integration between electronic prescription, supply and administration that minimises the ‘human element’ as much as possible is a positive initiative.

Whether this can be only be delivered by the introduction of a productionised process for re-packaging a proportion of these medicines (the solid oral medicines) into unit doses or achieved by better use of existing processes is still in question?

The ‘benefit’ of the unit dose approach outlined in this paper seems to hinge on the reduction in waste and in the manpower costs of reprocessing that ‘waste’ (in the form of part-packs). Even with a unit dose system, the challenge of moving medicines (such as inhalers, etc.) with the patient will remain. Whereas for an OSD process the balance between cost of waste and cost (and risks) of any reprocessing will need to be carefully assessed.

In either case, appropriate change management processes will need to be introduced and perhaps the insight and support from colleagues in Northern Ireland could obviate the need for such a radical change to current practice?