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Objectives Clinical pharmacy resources are under significant pressures in modern healthcare systems and policy recommends that pharmacy resources are targeted to areas where they will have greatest impact. This research aims to understand how pharmacists are prioritising their clinical workload, their views on the impact of prioritisation on the patient care they deliver, and what are the challenges associated with implementing prioritisation in day-to-day pharmacy practice.
Methods A survey was distributed to nine secondary care and two mental health hospital Trusts’ clinical pharmacy staff in the North East of England to determine their views and perspectives on clinical prioritisation for pharmacy. The survey was undertaken in November 2016 and 207 responses were received from pharmacists and technicians.
Results Results showed that pharmacy staff thought prioritisation was important to their daily work and needed to be flexible dependent upon the clinical situation. High risk and complex patients where viewed as being a priority. An awareness of the individual patients situation and the wider demands on pharmacy services were also considerations when prioritising workload.
Conclusion This research shows that pharmacy teams view prioritisation as being more than highlighting high-risk patients. It also needs to take into account the situation and environment in which the pharmacy teams are working. Further work therefore needs to be done to implement prioritisation tools to empower pharmacy staff to interpret priority within the context of the environment that the clinical pharmacy services are delivered.
The healthcare environment is changing.1 Populations are living longer with complex health issues, and the healthcare resources are not keeping pace with this change. Health services need to break down barriers and introduce new care delivery models while also introducing significant efficiency savings to improve care. It is now the norm that acute and mental health trusts have clinical pharmacy teams, consisting of pharmacists and technicians, that spend the majority of their time on wards. These teams have numerous functions to support patients to optimise their medication.2 Looking at productivity and efficiency within the UK alone,£5 billion of savings could be made by reducing unwarranted variation by focusing 80% of pharmacist resource on direct medicines optimisation, governance and safety.3 Lord Carter’s report states, “In hospital pharmacy we know that the more time pharmacists spend on clinical services rather than infrastructure or back-office services, the more likely medicines use is optimised”.4 Medicines optimisation is about ‘focusing the pharmacy workforce towards clinical activities; working more closely with patients and working alongside doctors and nursing staff in clinical roles to optimise medicines and secure better value and outcomes for patients’.5 Pharmacy needs to consider how it can target its resources to work efficiently and prioritise activities that provide the greatest impact to improve the outcomes for patients. In other words, there is a need to prioritise where pharmacy staff can have the greatest impact and stop any non-value-added activities.
Transformation of services is required to achieve quality, affordable and sustainable clinical pharmacy services seven days a week.6 A transformed seven days a week clinical pharmacy service needs a greater focus on patient-facing medicines optimisation, optimised use of staff skill-mix, flexible workforce to practise as generalist and specialist, implementation of technology, identification of high-risk patients, rationalisation of non-clinical infrastructure, collaboration between healthcare organisations and pharmacy workforce planning.6 A common thread that runs through this is the need for pharmacy teams to prioritise their workloads and focus on activities that have the greatest impact on patient care. To facilitate prioritisation of clinical pharmacy activity, different methodologies and tools have been developed.
Risk assessment forms the foundation of clinical pharmacy resource prioritisation. The principle is that specific patients have higher clinical pharmaceutical need which can be identified by the presence of specific risk factors. The key element to ensure effective prioritisation is accurate information; meaning prioritisation is potentially better suited to focus resources post-medicines reconciliation when an accurate list of a patient’s usual medicines is available. Due to the complexity of collating all the multiple sources of information required to prioritise, many of the more advanced prioritisation tools rely on electronic prescribing technology and other IT-based solutions. One such tool was developed by NHS Ayrshire and Arran following a serious incident on a ward that did not receive routine clinical pharmacy services.7 A screening tool was developed to ensure that patients at the highest clinical risk were targeted by the pharmacy team. Patients were graded as low-, medium- or high-risk using data such as absence of allergy status, no prescribing activity, or the presence of specific high risk medication. During development, the risk scores were then independently validated to refine the tool. Evaluation showed the tool effectively screened both low and high risk patients but was less sensitive to medium risk. The tool has proven to reduce median time to clinical pharmacy activity for high risk patients. The key element to ensure uptake of the tool was automation of the system. Further work is required to improve sensitivity by including laboratory data and to help pharmacy staff to interpret the results within the context of the pharmaceutical service. The tool required significant buy in and time commitment from pharmacy staff to develop.7,8
NHS Greater Glasgow and Clyde developed a ‘Triage and Referral’ model; this included a three-tier risk stratification tool supported by a simultaneous referral system to allow medical and nursing staff to refer back to pharmacy if the patient’s status changed.9 Triage is performed on admission to hospital by an experienced clinical pharmacist using a validated tool and their professional judgement. Each level of risk then corresponds to the frequency of pharmacy review. The ‘Triage and Referral’ tool has been integrated into the patient tracking software, allowing the risk status to be electronically recorded to support efficient workflow and handover. A dashboard has been developed to visually display not only their clinical pharmacy risk status but also other useful factors to aid efficient delivery of pharmaceutical care. This allows pharmacy teams to flexibly deliver services dependent upon where the highest clinical need lies.9–11 The challenge for adoption within the wider NHS is how to integrate into an existing IT infrastructure.
A third approach was described by a large UK teaching hospital.12 Again a three-tier clinical risk stratification tool, the ‘pharmaceutical assessment screening tool’ (PAST), was implemented to help clinical pharmacists prioritise frequency and seniority of clinical pharmacy reviews. Evaluation of the tool to confirm validity of scores demonstrated 57% (20/35) of patients were given an acuity level that matched the PAST guidance. This meant that in 43% of patients, the pharmacist risk stratification did not match the expected level as per the guidelines. The author concluded that the tool was not validated in consistently assessing a patient acuity level. This is thought to be because individual pharmacists assigned an acuity level based on their own interpretation of complexity, that the risk score was not updated as a patient’s condition changed through the hospital stay, and that the tool was used to remind pharmacists of tasks to perform out width the scope of PAST. The author concluded that pharmacists’ clinical experience and judgement might be as important when assessing patient clinical acuity. Additionally, it was noted that pharmacists on wards with less-complex patients tended to assign patients a higher acuity level; conversely wards with a higher average patient complexity tended to undervalue patients’ acuity level. The author explained this discrepancy because the tool was not sensitive enough to separate large numbers of patients who were assessed as being in the highest risk category.12
Further work on the PAST tool concentrated on pharmacists’ attitudes towards its use in prioritisation.13 All 32 pharmacists working at the study hospital were questioned about their attitudes towards the use of PAST, with a response rate of 87.5% (28/32). The study found that pharmacists felt confident about using PAST but that clinical experience and judgement over-rode any score generated by the tool. Pharmacists were using the tool as a guide to prioritise their own work but were not using it to prioritise the wider pharmacy team’s work schedule.13 To effectively implement clinical pharmacy prioritisation into practice, a validated tool is needed with enough precision to accurately predict a patient’s acuity level, while also being easy to use, and preferably automated.
Work has been undertaken to understand what prognostic factors make patients a priority for pharmaceutical care. Using a review of published literature and an internet survey of 247 pharmacists, 23 important or very important prognostic factors were identified. These included renal function, patient age, number of medications prescribed and comorbidities. The author states that identification of these prognostic factors will allow the development of tools to enable prioritisation based on clinical credible prognostic factors for risk.14
Despite the drive to introduce prioritisation and triage tools, to facilitate efficient and targeted clinical pharmacy services, there has been no research into how clinical pharmacists currently view prioritisation in their day to day practice. This research aims to understand how pharmacists are using prioritisation, how they view the impact of prioritisation on the patient care they deliver and what are the challenges associated with implementing prioritisation into day-to-day pharmacy practice.
Participants in the study were pharmacists and technicians working in clinical roles in NHS secondary care acute and mental hospital organisations in the North East of England and North Cumbria. This covers nine acute Trusts and two mental health Trusts.
An electronic questionnaire was developed by a panel of nine clinical pharmacy leaders representing all acute and mental health hospital organisations in the North East of England and North Cumbria. The questionnaire was emailed to all pharmacists and technicians working in clinical, patient-facing and clinical leadership roles within the surveyed organisations. The questionnaire explored how pharmacy teams were prioritising in their practice, what methods for prioritisation were in use, their view on both the benefits and challenges associated with prioritisation (see appendix for copy of the questionnaire).
The study commenced in November 2016 and concluded once 200 responses had been received. Quantitative data were transferred into an Excel document for analysis. Data were analysed by simple statistical methods and qualitative data were analysed using a thematic approach. Information was coded and analysed for themes using inductive methodology.
A total of 207 responses were received (39 technicians and 162 pharmacists) working in 11 different acute physical and mental health Trusts based across the study region. This is a response rate of 58%. Respondents ranged across a broad spectrum of pay grade suggesting a diverse level of experience and seniority. The respondents were senior technicians (n=39), junior pharmacists (n=79) and specialist pharmacist (n=89) who are those most often working in ward based or direct patient care roles. Responses were received from a wide range of specialties including acute admissions, general surgery, specialist surgery, general medicine, medical specialities, mental health, orthopaedics, critical care, and paediatrics. Respondents’ workload varied between 5 to over 50 patients on an average day. This variation was explained by non-clinical workload demands and patient or ward complexity.
Views on the importance of prioritising for various different ward-based clinical activities are shown in Table 1. The majority of respondents (62%, n=207) felt that prioritising was essential for medicines reconciliation but fewer rated it as essential for clinical review and discharge activity (37% and 44%, respectively).
Methods of prioritisation varied dependent upon the pharmacy activity undertaken. Methods used to prioritise patients for medicines reconciliation differed from those used to prioritise clinical review. Discharge was also prioritised by differing methods. Date and time of admission was the most important factor that drove prioritisation for medicines reconciliation (Table 2). Communication with the multidisciplinary team and referrals from nursing and medical staff were also important mechanisms to aid prioritisation in all clinical activities. Another important factor that determined the priority of the pharmacy clinical workload was the complexity of a patient’s drug regimen reflected by polypharmacy and long hospital stay. Prioritisation tools were widely available across the study hospitals but pharmacy staff did not rate them highly as a method used for prioritising clinical workload (See Table 2 for responses on methods pharmacy staff used for prioritisation their clinical workload).
Influences on pharmacy staff prioritisation include high risk medicines, pharmaceutical complexity, referrals from other health professionals and patients’ individual clinical factors were the most important factors that were considered. Electronic resources such as dashboards and electronic prescribing systems were shown to not have as much influence when prioritising workload for medicines reconciliation. Workload pressures were also shown to have less influence on how activities were prioritised. Similar results were seen when it came to pharmacy staff prioritising clinical activities (see Table 3 for responses on factors that influence pharmacy staff prioritising). Response about discharge priority however did show that pharmacy teams were influenced by non-clinical factors such as pressure to discharge patients quickly and maintain flow of patients through the hospital. This was in addition to the factors around the patient’s clinical condition and complexity.
The most common barrier to effective clinical prioritisation was a lack of time and information. Pharmacy staff felt that due to a lack of readily available information effective prioritisation was a time consuming process. Communication was highlighted as a key facilitator to enable effective prioritisation practice. It was felt that pharmacy staff needed to work flexibly to prioritise patients dependent upon the individual patient factors and overall workload. Common ideas that were highlighted to improve clinical pharmacy prioritisation included developing an evidence-based prioritisation tool that would consistently flag up high-risk patients. To support this, pharmacy staff felt that effective IT solutions would help, as well as a robust definition to define a clinical pharmacy priority. Other improvements included better training for pharmacy and non-pharmacy staff about clinical pharmacy priorities and standardised methods of prioritisation. In particular respondents felt the need to empower junior staff to feel confident to make decisions. There were 80 (39%) of respondents who felt that they were happy with how they prioritise.
Common themes identified through thematic analysis were that prioritisation was an essential skill that all pharmacy professionals required. It is described as a ‘skill that needs to be learnt’ and that ‘professional judgement needs to be applied’. Respondents views were prioritisation changes dependent upon the context of the patient, ward environment and pharmacy team circumstances. Prioritisation is a skill that is viewed as ‘continually developing’ throughout an individual’s career. The process of prioritisation ‘involves the analysis and interpretation of situations’. Individuals described ‘using multiple methods to prioritise’ and changing their prioritisation practice dependent upon workload or complexity of patients.
One respondent stated that ‘insulin is a high-risk medicine but the risk associated depends upon the context. A patient prescribed insulin on a diabetes ward is likely to have a different level of risk profile than if they were prescribed insulin on a ward without speciality diabetes input’. Individuals described needing to understand the context of the clinical service they were working within. Key competencies that were described were communication with the wider healthcare team and confidence to make decisions. Training was a main theme that was identified by respondents. They described ‘junior staff members being taught prioritisation skills’ involving understanding and interpreting the complexity of patients’ pharmaceutical care.
Prioritisation is a developing part of clinical pharmacy practice in secondary care. It can be thought of as complex multifactoral process that requires interpretation and understanding of the system. The core act of prioritisation for pharmacy staff is to perform a risk assessment considering the importance and urgency of a patients’ clinical condition. The risk level will be determined by the clinical situation and the individual patients’ circumstances. To undertake this risk assessment, information is key and pharmacy staff use a wide range of resources to prioritise. They need to communicate with other healthcare professionals as well as gather information about a patient’s specific circumstances. Prioritisation needs to be a rapid process that assimilates and analyses the pertinent patient specific issues to assign a degree of pharmaceutical risk to a patient. Electronic prioritisation tools have been developed to aid pharmacy staff to collate the complex information involved with prioritising a patient. The experience, knowledge and skill of pharmacy staff is however essential to be able to put context into the situation when prioritising. Pharmacy staff need to use their experience and knowledge to interpret the risk and complexity of the individual and consider this within the wider context of the current clinical picture. Patients’ pharmaceutical risks and clinical needs evolve as they journey through hospital. Systems need to enable pharmacy staff to focus on activities when a patient is most at risk or has greatest pharmaceutical need. It is important to highlight that pharmacy staff appear to place individual patient factors above targets and system pressures as the most important factors when prioritising workload.
For pharmacy to make the most of its workforce, it should aim to move from a basic prioritisation process that solely highlights patients with defined high-risk characteristics to a more nuanced approach. Pharmacy staff have described the need for a flexible approach to prioritisation that enables them to identify patients with greatest risk or pharmaceutical need. Pharmacy services can then focus the appropriate level of pharmaceutical care to address the patient’s individual requirements. The process needs to go beyond simple prioritisation to a system-wide approach that would be better described as triaging patients for pharmaceutical clinical intervention. A triaging process would empower pharmacy staff to use different prioritisation methods. This process would include collection of all the relevant information about patients, analysis of the data, identifying the activities where pharmacy could have the greatest impact and then act to implement the plan. The challenge is for pharmacy to perform ‘pharmaceutical triaging’ rapidly and accurately to enable appropriate deployment of the pharmacy workforce. A pictorial representation of the ideas developed (Figure 1) describes how pharmacy staff should work flexibly and be influenced by different factors when prioritising patients for different clinical activities.
The model of prioritisation of clinical pharmacy services described by this study can best be explained by situational awareness. Situational awareness is our mental picture of what is happening around us and of what is about to happen.15 This can be broken down into three steps that involve the perception of the current situation, comprehension of the situation and anticipation of future changes.16 The key element that differentiates this from a simple clinical prioritisation method is that it involves the pharmacy professional interpreting the information using their experience and knowledge to assign value to relevant risk factors. The advantage of this approach is that it will allow the pharmacy staff to interpret the complexity of situations, decide upon relevancy of different variables and then allow focussed action to resolve the problems which pharmacy are best suited to deal with. Systems need to be set up so that pharmacy teams can rapidly review the patients they are caring for and identify those with greatest risk. They need to be able to consider the complexity of individual patients, understand the context of the current pharmacy service provision and communicate effectively with other healthcare professionals. The pharmacy team then needs to be empowered to make decisions and have the appropriate level of skills and knowledge to anticipate what might happen in the future. The key to pharmacy teams being able to prioritise workload is to use these prioritise tools, apply their judgement to the information and respond flexibly dependent upon the specific circumstances.
This research describes that pharmacy staff perceive pharmacy clinical prioritisation in hospital as a complex process that involves risk assessment and also situational awareness. This is a process that requires the clinical knowledge and experience of trained pharmacy staff interpreting risk in the context of the pharmacy service they deliver. Further work needs to be done to understand the development needs of pharmacy staff to enable implementation of situational awareness and judgement into their practice to aid prioritisation. Links between clinical pharmacy prioritisation and efficiency could also be explored in further studies. To enable the efficiency goals that modern healthcare demands whilst ensuring that pharmacy provides optimal care for those with greatest pharmaceutical need an increased understand of how best to focus pharmaceutical resources are needed. This research highlights that situational awareness and risk management are tools that may aid in balancing the conflict demands made of clinical pharmacy teams to ensure they provide the best care for the patients with the greatest need. It is worth noting this study focused on the views of pharmacy staff in the North East of England. It would be beneficial to understand the views of pharmacy staff working in other areas and countries to explore how prioritisation is viewed elsewhere.