teaser
James Goddard
MRPharmS BPharm
Cardiac/Clinical Trials Pharmacist
Morriston Hospital
Swansea
UK
E:james.goddard@swansea-tr. wales.nhs.uk
Hospital pharmacists are responsible for pharmaceutical care, which has been defined as “the provision of drug therapy for the purpose of achieving definite outcomes which improve a patient’s quality of life”.(1) Pharmacist activity has a major impact on the patient care process, particularly in reducing the risks of drug therapy. It is beneficial to document pharmacist intervention activity for a number of reasons, as such data may:
- Provide a record of advice offered and evaluate acceptance rates of interventions.
- Demonstrate patient benefit and promote clinical pharmacy services.
- Identify problem drugs or drug groups.
- Allow managers to identify areas for education and training.
- Allow pharmacists to monitor their performance against their peers.
- Be used for audit and aid risk management. Intervention data may be widely disseminated so that it forms part of the healthcare trust’s approach to improve quality in a clinical governance framework.
However, it is difficult to maintain an accurate log of the diverse activities of a clinical pharmacist. The majority of pharmacist intervention monitoring schemes rely on manual data capture using a paper recording process, which can be tedious, and processing the data is time-consuming. Due to the laborious nature of intervention recording, the consistency of data recording declines with time. As a consequence, many of the interventions made by pharmacists go unrecognised and their impact on patient care is not evaluated.
Personal digital assistants (PDAs) are pocket-sized, handheld electronic computers that use touch-screen technology to record and retrieve data. Information can be easily exchanged between a PDA and a PC or laptop. Due to the number of customised medical and pharmacy applications written for PDAs, their use is becoming more popular with clinical pharmacists undertaking their duties.
Within the pharmacy department of the Morriston Hospital, we are developing a program to record pharmacist interventions by PDA. This article discusses the background to this project and progress to date.
Why use a PDA for intervention monitoring?
The need to collect, collate and present data as effectively and accurately as possible is essential to the audit process. With these demands in mind, we examined how we collected our audit data and whether this collection was accurate. Whether the tool used is a questionnaire, data collection form, audio/visual media analysis or any other form, it needs to provide data that are as accurate, reflective and unbiased as possible. The collection method must be relatively simple to use, uncomplicated, nontime-consuming, and effectively answer the questions and/or provide the data required by the initial audit criteria. Paper-based audit is time-consuming and difficult to undertake in busy departments. This often means that a shorter timespan is allowed for data collection, and results may be inappropriately extrapolated.
Pharmacists at Salford Royal Hospitals NHS Trust devised a clinical pharmacy activity monitoring system using a handheld organiser.(2) They highlighted the need for paperless recording and time-saving data management; however, their method still requires the user to negotiate a keyboard.
We decided to develop an intervention monitoring program that, when running on a handheld computer, would guide the user easily through the monitoring process with a touch-sensitive screen. The data collection program would offer a series of answers that could be selected by tapping the appropriate button – “point-and-select”. Data would be stored on the PDA and transferred to a PC database for collation and generation of reports.
It was hoped that the availability of an easily accessible method of recording pharmacist activity and its implications for patient care might serve to increase the profile of the profession and provide useful data when making business cases for new staff. By making the audit process less time-consuming and easier with regards to collation of data, it was anticipated that we would improve the uptake of intervention monitoring and therefore produce more accurate data.
Aims and objectives of the audit
Our aim was to make efficient and cost-effective use of the technology available. We identified an area in which we could apply a workable system that would improve current practice. The program was developed with the hope that it might encourage further utilisation and development of PDAs at ward level. Therefore we have also examined potential developments beyond the intervention program.
We wanted to make the intervention recording program attractive to pharmacists who might not usually use technology in this way. It therefore had to be easy-to-use with minimal or no training required before uptake.
There are several objectives that we hope to attain from accurate intervention monitoring, which have been highlighted by a previous paper.(3) These include:
- Compilation, analysis and dissemination of data with minimal effort.
- Utilisation of touch-screen technology to enable easy software-directed data collection.
- Provision of good-quality data and invaluable information regarding the role of a pharmacist.
- Evaluation of acceptance rates of interventions.
- Demonstration of patient benefit and promotion of clinical pharmacy services.
- Identification of problem drugs or drug groups.
- Allow managers to identify areas for education and training.
- Allow pharmacists to monitor their performance against their peers.
- Audit and aid risk management. Intervention data may be widely disseminated so that they forms part of the trust’s approach to improving quality in a clinical governance framework.
By designing a tool capable of providing good and universal data, we aim to make more accurate active comparisons between hospitals, wards, pharmacists, etc, inviting the opportunity of providing good quality control and possibly “benchmarking”.
Putting the project into place
By obtaining PDAs for the department we had already taken one step before the commencement of this project. We were already encouraging the use of PDAs for storage and retrieval of medical references and resources at ward level.
We had to move a paper-based system onto handheld computer. We decided that the program would follow a tree structure, with each selection taking you down a route of further relevant questions. The user requires knowledge about what selection to make; however, this would still be the case with the paper-based audit. The only difference with the program is that we can incorporate guidance into it that will automatically refer the user to the next relevant choice or give them further information. It was decided that the program should try to incorporate the UK National Patient Safety Agency (NPSA) guidelines and definitions.
Research into various PDA programming languages highlighted one that was relatively easy to pick up with a little computing experience. The NS Basic development environment enabled us to design and develop a suitable program (see Figure 1). Each screen would contain a series of buttons for the different options. The user selects an option by pointing at it; this then guides them to the next option. After learning the programming language to a basic level we produced a workable version, which at this first stage would record each intervention record as a unique key. Each key would describe the intervention and/or intervention route: for example, an intervention on a cardiac ward, which was clinical and involved adjustment of a dose that was too high, might be key “24”, which would then describe that intervention appropriately against a predefined table of keys. We initially used this method due to lack of programming experience, but decided that we would develop a sequential system that recorded each stage of the intervention under a separate field. The sequential system gives us a more accurate record that can be read and manipulated using a Microsoft Access database. This required further development with the help of a software company.
[[HPE09_fig1_16]]
By using a sequential record it is possible to create highly specific reports. For example, you can request the total number of interventions that involved a particular ward, drug, etc, over a specified date range, or evaluate how many near misses have been associated with a certain drug. This enables us to create a detailed analysis that can be used in providing support and evidence for audit, and in demonstrating the importance of the role of the ward pharmacist.
Results so far …
The PDA audit program development has worked well, resulting in the production of a usable program that records results accurately, labelling them with a time, date and identity stamp.
Uptake of the program has been good. Pharmacists at the Morriston Hospital were given a copy of the program for their handheld devices and shown how to use it. Results are stored on the handheld until they are removed after a certain number of days. The information is not readable once recorded on the PDA and contains no patient-identifying factors, so is therefore secure.
Although at the moment we have no statistical comparison between paper and PDA audits, it is clear that the program has been an improvement on current working practice. With the use of the PDA program the audit is far easier to undertake and can be performed more frequently. Data have been collated with far more ease and speed than before, as no one is needed to input the data (it can just be uploaded). The recording system has produced successful data that can now be analysed.
With the paper-based system we only undertook intervention recording over a period of three sets of two weeks per year, with the exception of an underlying baseline of more catastrophic incidents being recorded continually. Since using the PDA-based system we have began recording interventions more frequently, on a daily basis.
For future releases we will include useful guidance and definitions within the program. These can then be selected at any stage of the program, should the user be unsure of how to commence. The software company is further developing the system to make it more efficient and is adding the “professional touch”. We will then launch the new system with the aim of incorporating it into the All Wales Hospital circuit.
[[HPE09_kp_18]]
References
- Hepler CD, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533-43.
- Clark CM, McGlynn S, Goldberg LA. Clinical pharmacy activity monitoring using Psion Series 3 palm-top organisers. Pharm J 1995;255:247-50.
- Price RN, Rogers A. Intervention monitoring on admissions wards. Hosp Pharmacist 2000;7(3):81-4.
Useful websites
Palm, Inc
Handheld computers
W:www.palm.com
UK National Patient Safety Agency
W:www.npsa.org.uk
NS BASIC Corporation
Development tools for handheld computers
W:www.nsbasic.com
