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Published on 2 March 2009

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Supplementary prescribing on an emergency admissions unit

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A UK study found supplementary prescribing by pharmacists on an emergency admissions unit (EAU) ensured that the required medicines were identified and prescribed on admission and that treatment delays were avoided

Beverley Chambers
MRPharmS MSc
Senior Clinical
Pharmacist
Emergency Care

Nicola Wake
Lead Clinical Pharmacist,
Medicine

Joanne Arasaradnam
Senior Clinical
Pharmacist,
Emergency Care
Pharmacy Department
North Tyneside General
Hospital
North Shields
UK

The emergency care pharmacist’s role has been described previously.[1],[2] Pharmacists working on emergency admissions units (EAUs), make many interventions – typically identifying regular medicines omitted by clerking doctors, optimising therapy and recommending new treatments.[3–5] In this hospital, senior pharmacists providing a regular service to the EAU, had gained supplementary prescribing qualifications and wanted to take responsibility for therapeutic recommendations, made as multidisciplinary team members.

It was originally envisaged that supplementary prescribing (by nonmedical prescribers), would be most useful in dealing with  long-term medical conditions such as asthma, diabetes or coronary heart disease, or with long-term health needs, such as anticoagulation.[6] This is partly because the framework for supplementary prescribing requires an agreed individual clinical management plan to be in place for each patient. However, our experience suggested that if pharmacist supplementary prescribers were able to prescribe for patients in the EAU, many common situations, such as medication unintentionally omitted on admission, rationalisation and review of medicines for chronic conditions and medicines initiated during post-take ward rounds,
could be resolved by the pharmacist. Delays in treatment
could be avoided and everyone’s time used more efficiently.

Medical supervision on the EAU is provided by three acute-care physicians (ACPs), all of whom had mentored pharmacists undertaking the supplementary prescribing course and supported nonmedical prescribing.

We set out to implement pharmacist supplementary prescribing on the EAU and to evaluate the impact.

Methods

The senior pharmacists working on the EAU recorded their interventions for one week. Common situations in which interventions were made included:

  • Patient’s regular medication incorrectly prescribed.
  • Incomplete drug history causing medication to be unintentionally omitted from patient’s drug chart.
  • Recommendations for amendments to prescribed drugs due to changing clinical condition of patient.
  • Recommendations relating to chronic disease management unrelated to the current admission.
  • Provision of prescribing advice.

The intervention records were reviewed by two senior pharmacists and common events or situations were identified. From these a generic clinical management plan (CMP) was devised, then approved and agreed by the three ACPs. Supplementary prescribing was introduced to the EAU; two senior pharmacists were involved, who collected information about their own prescribing for one month.

[[HPE41.57]]

Table 1 lists the medicines and corresponding indications that were covered by the CMP.

It was important to ensure that all staff members on the EAU and on base wards were aware of the introduction of supplementary prescribing. An information leaflet was given to each of the nurses, doctors and other staff members who were likely to come into contact with the service. The leaflet explained what supplementary prescribing is, how it differs from independent prescribing, how the supplementary prescribing scheme would work, and the types of problems that it would solve. A copy of the CMP was also provided.

Supplementary prescribing is based on a partnership between the independent prescriber, supplementary prescriber and patient, therefore patient consent was required before the pharmacist prescribed.

For each patient a generic CMP was completed with an attached addressograph (containing patient name and date of birth or trust number), the allergy status of the patient and the date of agreement. The completed CMP was filed in the patient’s  medical notes and an entry was made stating that medication had been prescribed by the pharmacist in accordance with a
CMP.

Results

During the evaluation period, 326 patients were seen by the supplementary prescribing pharmacists. One or more medications were prescribed for 162 patients (50%) by the supplementary prescribing pharmacist. The prescribing could be divided into three intervention categories and most patients needed more than one type of intervention. Forty-two patients (26%) were prescribed one or more new medications after
diagnosis by the ACP. When pharmacists prescribed new drugs they chose appropriate drugs, doses, formulations and frequencies. Ninety patients (56%) were prescribed medication after review by a pharmacist, and 127 patients (78%) were prescribed one or more of their regular medicines unintentionally omitted on admission. Of these, 72 patients (57%) were prescribed medication specifically covered by the CMP. Of the other 55 patients, (43%) medication was not covered by the CMP, but discussed with the ACP before being prescribed by the pharmacist. This was possible because, under the CMP, any medication could be prescribed by the pharmacist after discussion with the ACP.

Discussion and conclusions
This evaluation shows that a range of medication was prescribed by the pharmacists. These could be divided into three intervention types with the majority of patients requiring more than one type of intervention. Some medicines are not individually named in the CMP, but the plan states that “any medication as indicated by the independent prescriber” can be prescribed by the pharmacists. Pharmacists and ACPs work in close partnership, which enables discussion between the ACP and the pharmacist before prescribing occurs.

Traditionally, drugs omitted on admission were identified by the pharmacist and prescribed by the doctor. In this situation the doctor takes responsibility for the medication prescribed, based on information provided by the pharmacist. When pharmacists prescribe they take responsibility for their own clinical decisions and judgements. Medication review is an existing role of the EAU pharmacist, as the EAU doctors focus on the acute medical problem(s) and do not routinely review management of chronic conditions. Further studies are needed to determine whether supplementary prescribing by pharmacists reduces the number of missed doses of medication and improves patient care, and whether the introduction of independent prescribing by pharmacists on a medical admissions unit will further increase their input.

Using a CMP has empowered pharmacists to make changes to patients’ medication without having refer to the independent prescriber each time. The ACPs feel pharmacists are an integral part of their team, are confident that they work within their competence and so support the move towards independent prescribing.

References
1. RPSGB Hospital Pharmacists’ Group. Hosp Pharm 2004;11:72-7.
2. Hill H. Hosp Pharm 2005;12:445-6.
3. Bednall R, et al. Pharm J 2003;271:22-3.
4. Brady D, et al. J Pharm Prac 2004;12:1-6.
5. Slee A, Farrar K, et al. Pharm J 2006;277:737-9.
6. Bellingham C. Pharm J 2002;268:262–3.



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