This case study describes how a pharmacy team introduced an electronic method of ordering controlled drugs to ward areas during COVID-19, thereby reducing the need for controlled drug stationery and providing a safer, more efficient, process
It is widely accepted that heightened infection control measures reduce the rate of transmittable disease. At the outbreak of COVID-19, national steps were put in place to reduce airborne and surface-surface transmission. Within the NHS, this led to new many ways of working and a radical look at how tasks could be made simpler and safer.
For more than 15 years, Ayrshire & Arran Health Board has benefited from hospital electronic prescribing and medicines administration software (HEPMA). This allows users to electronically prescribe and administer medicines to inpatients. Among many of the benefits of this resource, is its paper-lite nature and ability to access the system remotely.
Before COVID-19, staff had progressively embraced this paper-lite working because of HEPMA, particularly in respect to ward ordering of non-stock medicines and immediate discharge letter production. A process that still relies on the movement of paper is controlled drug (CD) request books. In this process, the ward request book is handled by multiple users per order which is then retained for subsequent order and the process repeated. The specific paper-lite/paperless benefit of HEPMA was the inspiration to progress CD ordering to an electronic method, while maintaining the strict governance requirements of CD legislation.
Utilising current systems
NHS Ayrshire & Arran uses pharmacy stock control (PSC) and HEPMA in 99% of inpatient areas, covering 76 hospital wards between eight hospital sites. Staff are familiar with this software and use it frequently throughout the day to prescribe, administer and dispense medicines. A non-stock ordering function (CareFlow Medicines Management, RxSelect) is used to trigger pharmacy order requests if a medicine is not present on the ward stock list. This function allows to automatic orders to be generated when a non-stock medicine is ordered by a prescriber and was adapted to manage ward order requests for CDs.
Order file creation
A HEPMA new patient record was created and named appropriately for each unique ward that introduced the CD ordering system. This record was placed on the ward HEPMA list (manually admitted) which then became the ward ordering record that would hold the details of orders placed and orders completed (Figure 1).
A separate suite of controlled drug files was created within PSC and HEPMA to reflect standard pack sizes, thus aiding ordering and supply. These files were prefixed to allow easy identification by ward and pharmacy staff alike. A HEPMA single selection protocol (ordering bundle) was created and allowed all CD ordering drug files to be nested within this. A process was developed using a standard operating procedure to allow a rapid but standardised method of creating the CD ordering files and protocols.
Permissions and governance
User permissions were created to limit access to the ordering of CDs. An access request template was produced which required completion by the charge nurse of the area. Each nurse was granted access according to this request. A 3-minute training video and nurse quick-guide was developed to provide learning on how to use this new process.
Webpage creation and pharmacy process
A crystal report was written and scheduled to an internal webpage using CRD (crystal reports distributor). This pharmacy-only restricted intranet page allowed staff to be prompted when an order was placed. Notes could be entered on HEPMA records beside each order request to update the status of the order. This was designed to create a task overview for the supply process. The non-stock supply process RxSelect was used to generate issuing paperwork which was included with the supplied medicine (Figure 2).
A phased roll out was commenced and coordinated by pharmacy and charge nurses. Early adaptor wards were chosen based on service need and to ensure the acceptability of the process.
A successfully designed and tested process for ordering CDs was introduced in March 2020. Test of change methodology was used to improve and refine the performance and usability of the tool. Training and education were made available by the same date via a locally available training video and Quick Reference Guide.
Ward uptake progressively increased from March 2020 and allowed all ‘Red’ COVID wards to use the electronic ordering system within one month of implementation. Technical set up and user permissions were managed for each ward by members of the HEPMA team without additional resource.
All wards (regardless of COVID status) were permitted to implement this system as experience and confidence in the process grew (Figure 3).
To date, the electronic CD ordering process is live in 95% of inpatient wards. As wards implemented the process, the overall number of paper order requests fell proportionally so that almost all orders (98%) were placed electronically at 5 months’ post-implementation (Figure 4).
Due to the inherent immediacy of the order request, the pharmacy departed are alerted to electronic orders as soon as they are placed. An analysis of orders placed at ward level reveals that 58% of orders are placed electronically and can now be available for processing first-thing when the pharmacy opens. This compares favourably to previous porter drop offs at 10am and 2pm at one site, or other sites that rely on ward staff to journey to the department (Table 1).
The COVID-19 pandemic has provided opportunities to improve processes and explore novel ways of working. Developing a customised process for CD ordering in the immediate response to this crisis allowed for benefits to be realised in a timely, staged and safe manner. While this new functionality addresses the time delay to pharmacy receiving orders for processing, a change in pharmacy workflow and how these requests are managed must be considered to allow benefits to be maximised. At present, issuing paperwork is still used by the pharmacy department and CD registers do not sit on an electronic platform. Further work and refinement in processes should be considered to make the process of ordering and register keeping fully paperless.
This method of improvement could be considered by other hospital areas who share similar technology. The process is a shared-learning example of enabling team working and innovation during crisis-response.
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