The concept of a “top-up service” was introduced into Danish hospital pharmacy in the mid-1990s. The hospital pharmacy in Frederiksborg County was one of the first to carry out a three-month pilot project into the top-up service, on a medical ward at Hilleroed Hospital.
The evaluation report for the project period concluded that the ward’s medicines use had been reduced by 13% (excluding cytotoxics). An actual saving in the medicines budget had been realised through tighter controls on the ordering of medicine and on ward stocks. The nursing staff were very pleased with the improved working relationship between the ward and the pharmacy, and in addition the service freed up nursing time that could be better used on patient care.
The service was made permanent on 1 May 1996, and today it encompasses 40 wards, primarily at Hilleroed Hospital, and also at the Esboenderup Hospital Rehabilitation Centre. The types of wards currently covered include: surgery, medicine, ENT, renal, gynaecology, ITU, neurology, orthopaedics, rehabilitation and psychiatry.
The most recent addition to the top-up service has been the start of a project on the medical and gynaecology wards at Helsingoer Hospital. The service to these wards was expected to become permanent before the end of 2002.
What is a top-up service and how does it work?
The object of a top-up service is that, in conjunction with the individual ward, the pharmacy technician ensures the necessary medicines are available and assists the ward in optimal use of medicines. In addition, the service plays an active part in the quality assurance of medicines management on the ward and also acts as a readily available source of evidencebased drug information. The top-up service is just one part of Frederiksborg County’s overall aim to provide optimal patient care.
The top-up service is carried out by a pharmacy technician, in collaboration with a pharmacist. The wards receiving the service have a nominated pharmacy technician, who has the day-to-day responsibility for the ordering, delivering and topping up of medicines on the ward. The pharmacy technician ensures that the requisitions are in accordance with the ward’s actual medicine usage and also handles requisitions for medicines that are outside of the ward’s normal stock. When these medicines are no longer required on the ward, the pharmacy technician is responsible for removing and returning them to the pharmacy and crediting the ward where applicable.
A large part of the top-up service involves the substitution of prescribed medicines that do not feature in the hospital’s drug formulary. Drugs are accepted onto the formulary only after a medicines committee, which is made up of doctors and pharmacists, considers whether they are pharmacologically and/or economically acceptable. The pharmacy department in 2002 influenced prescribing such that 87% of prescriptions were within the drugs formulary. The hospital pharmacy has shown that implementation of a top-up service leads to smaller ward stocks, and more prescriptions within the drugs formulary, which in turn leads to savings in the ward’s drugs budget.
The pharmacy technician deals with drug information queries from the ward, alone or with the help of the pharmacist, and also plays a key role in the delivery of information from the pharmacy to the ward. In 2001 the pharmacy department dealt with 1,126 queries, originating both via the top-up service and directly from the ward.
In addition to the routine tasks, the pharmacy technician is involved in the following:
- Informing the ward of changes in medicine usage, whether the usage is within budget, and of any new treatment regimens.
- Continuous updating/monitoring of the ward stock, in collaboration with the medical/nursing staff.
- Advising on the organisation of the ward’s medicine room.
- Removing medicines before their expiry date.
- Informing the ward of changes to the drugs formulary.
Implementing a top-up service on a new ward
When it is decided that a ward will receive a top-up service, a service-level agreement is drawn up between the ward and the pharmacy. This agreement is approved and signed by the ward management and the pharmacy. It describes:
- The responsibilities of the staff.
- The competencies of the staff involved in the top-up service.
- Any special arrangements agreed.
- The communications options available (IT, telephone) and the best times that the staff can be contacted.
- How many staff will visit the ward, the time spent on the ward, and the cost of the service.
- Arrangements for cover during periods of holiday/sickness.
- Conditions for changes in the agreement.
- The project period: time registering, etc.
The ward receives written information about the top-up service, in which the pharmacy technician/pharmacist describes the routine and responsibilities agreed between the ward and the pharmacy.
A communications sheet is posted in the medicine room and is used to communicate simple questions from the nursing staff. Any questions involving the ordering of medicine are discussed with the nursing staff, and in the case of an acute need the top-up service is contacted by telephone.
A pharmacy information file can be found in the medicine room. This file contains a copy of the ward stock list, communications sheets, information regarding any changes, reports of meetings and other information from the pharmacy.
When the top-up service is started on a new ward, an introduction day is arranged. The pharmacy technician and pharmacist follow a nurse on his/her daily routine (paying particular attention to medicines handling) so that the service can be individualised to the ward. The amount of medicine on the ward is calculated both before and after the start of the service, so that the impact of top-up service can be assessed at a later date. Medicines-related queries are registered and monitored, as are the numbers of drug substitutions made.
The top-up service contract is evaluated every second year at a meeting between the pharmacy technician, the pharmacist and the ward management. The pharmacy also presents an activity report at the meeting. The nurse nominated as “pharmacy contact person” meets with the pharmacy technician and pharmacist once a year to assess/amend the ward stock list, and to discuss other aspects of the service, including whether the ward personnel are satisfied with the service.
Developing and standardising the service
In 2002 there was an increased focus on the competencies required of the individual pharmacy technician to provide an optimal service. It has been agreed that the pharmacy technician should have a sound knowledge of IV preparation, anatomy and physiology, therapeutics, pharmacology and the range of products available. Courses in teamwork, problemsolving, IT and the provision of information are also available to the staff.
Since the implementation of top-up services in wards in Denmark, it has become apparent to hospital pharmacy departments that the procedure requires standardisation. The Danish Society of Hospital Pharmacy Managers established a working group of pharmacy technicians and pharmacists, who developed a quality standard for the service, including the aims and visions for the service in Denmark.
The standard covered the following points:
- The objectives of the top-up service.
- The competencies and responsibilities of the pharmacy technician.
- A description of the pharmacy technician’s routine functions and other tasks.
- Guidelines for communication between the pharmacy and the ward.
- Guidelines for the drawing up of contracts of collaboration.
- Guidelines for the education of pharmacy technicians.
This standard will hopefully provide a more focused approach to contact between the hospital pharmacy and the ward, which in turn will optimise the patients’ medicines management and lead to optimal patient care in Denmark.
Looking to the future
The future task of hospital pharmacy will be to incorporate all wards in hospitals. The vision is for the standard to be implemented in all Danish hospitals, to ensure the quality of the top-up service and so that pharmacy technicians’ and pharmacists’ broad knowledge is further expanded. Hope for the future is that top-up services can open the way for patient specific clinical pharmacy, carried out by pharmacists, so that both services can be provided as a single concept. This will provide savings in the ward’s drugs budget, while at the same time optimising medicines management on the ward, which ultimately will give an increased level of patient care.
Contribution to optimal patient care
- The best economic use of medicines.
- Prescriptions reviewed to optimise the ordering of medicine.
- Focus on medicines management.
- The supply of evidence-based drug information.
- Rationalisation of ward stocks.