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Published on 9 June 2008

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Quality, safety, improvement and efficiency

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At a recent conference in Northern Ireland, pharmacists heard how re-engineered medicines management services have been successfully rolled out to 12 hospitals across the province

Christine Clark
PhD

Contributing Editor
HPE

Quality, safety and efficiency are part of a “virtuous triangle” in which the one leads to the other and a cycle of continuous improvement is set in motion, according to Andrew McCormick (permanent secretary, Health, Social Services and Public Safety Department, Northern Ireland Executive). Medicines management is a challenge for all healthcare systems and 12-14% of healthcare expenditure the UK is devoted to this “ubiquitous technology”, he continued. During the past four years about £4m has been committed to pharmaceutical staffing in Northern Ireland in response to robust evidence of benefits arising from re-engineered pharmacy services.

Referring to the Northern Ireland integrated medicines management project (see Resources), Dr McCormick highlighted the return on investment of £5-8 for every £1 spent, reduced length of hospital inpatient stay and reduced readmission rates as being particularly persuasive results. The changes that have been made to pharmaceutical services are fundamentally about improved patient care – better quality, better outcomes and improved accessibility. Changing services in this way involves facing up to challenges and taking some risks. Do not be frightened of breaking new ground in this way, he advised.

Integrated medicines management
The integrated medicines management (IMM) project was originally run as a randomised controlled trial comparing the IMM process with “usual” clinical pharmacy services, explained James ­McElnay (School of Pharmacy, Queen’s University Belfast, Northern Ireland). Working in collaboration with Queen’s University, pharmacists at Antrim Hospital set out to re-engineer pharmacists’ activities to provide a standardised pharmaceutical service to all patients. The IMM process involves the compilation of an accurate drug history on admission to hospital and intensive monitoring and patient education during the hospital stay. At the time of discharge, medication is prepared and a written summary of medication changes and intended outcomes is sent to both the GPs and the community pharmacist.

The project produced impressive results: the average length of stay was reduced by two days and medication appropriateness (measured by the medication appropriateness index, or MAI) was increased. Frequency of readmissions during the 12 months after discharge was reduced, and the “time to readmission” was significantly increased. It was calculated that the “number needed to treat” (NNT) to prevent one readmission was 12 patients. Overall, for every £1 invested in the service there was a return of £5-8.

In the course of running the re-engineered service, it became clear that other support initiatives were needed to make the most of the IMM service. A means of recording clinical pharmacy interventions was needed and a system based on handheld personal digital assistants (PDAs) – the electronic pharmacy intervention clinical system (EPICS) – was developed in collaboration with locally based firm Yarra Software Ltd.

Standardisation of medicines across primary and secondary care was needed to minimise the opportunities for confusion at interfaces. For this to happen, a reliable, transparent system for medicines selection that got “buy-in” from doctors was critical and the system of objectified judgement analysis (SOJA; see Resources) was used as the starting point. The IMM team collaborated with pharmacists from the Netherlands who had extensive experience with SOJA and further refined the method to develop the STEPS (safe, therapeutic, economic pharmaceutical selection) process.

Another major challenge was rolling out IMM to other hospitals in such a way as to ensure that the results obtained at the original study site were replicated at other sites. Intensive inpatient education often led to self-medication, and better ways of handling medicines at ward level were needed. Individual patient medication lockers were designed, incorporating several new features. The lockers are deep enough to house all medicines, have a dispensing tray on which nurses prepare doses and are transponder-activated rather than opened using conventional keys. This means a record of openings can be kept, and the lockers can be programmed for use by self-medicating patients.

Another problem that emerged was inconsistent use of wound management products; this prompted the development of a wound management formulary.

Pharmaceutical clinical effectiveness
This can be defined as “the outcome of the application of pharmaceutical skills directed to providing a systematised approach to rational product selection and use, consistently applied across secondary and primary care”. It should take into account clinical need, product clinical performance, product presentation, safety characteristics and economic factors, according to Norman Morrow (chief pharmaceutical officer, Northern Ireland).

Investments in quality and safety, such as protecting patients from adverse drug events, reducing the time in hospital and avoiding additional costs, in turn lead to health gain and efficiency, Dr Morrow said. Enhancing the quality and efficacy of treatment and improving safety required a “more substantive process” than that which operated in the past, he said. One critical element for success is “sowing in the right conditions” – that is, starting projects where attitudes are positive and elements of the appropriate infrastructure already exist. Evidence must be used to develop ideas and must be collected to drive further developments. It is important to challenge the old ways of doing things and to innovate. Moreover, targets must be set and monitored. “People need to know what they are striving to achieve,” he reminded the audience. Leadership and collaboration with other healthcare professionals are both critical to success, and resilience is an essential element. “Nothing happens without effort,” he said. Finally, the new practices and results must be reproduced in other sites. “It’s about mainstreaming new practice, otherwise we have not achieved anything,” he concluded.

SOJA and STEPS
The main benefits of the STEPS process for drug selection are that safety and therapeutic efficacy are the prime determinants for selection and the process is robust, transparent and defensible. This makes it ideal for the selection of standardised products for use across the primary and secondary care sectors – it ensures that there is full ownership (of the final choices) by both general practitioners and hospital consultants, explained Michael Scott (head of pharmacy and medicines management, Northern Health and Social Care Trust, Northern Ireland).

The STEPS methodology was developed from the SOJA process. This process involves the construction of a matrix in which criteria for drug selection, such as clinical efficacy, tolerability and interactions, are listed and assigned weighting points in a single stage. However, the STEPS process sequentially evaluates clinical effectiveness, safety and finally budgetary impact. At each stage unsatisfactory products are eliminated from the list. Thus, a cheap product with a low clinical effectiveness score could be eliminated at an early stage. The safety evaluation is concerned with risks and safety in use and includes issues such as packaging and labelling, Dr Scott explained.

So far the STEPS approach has been applied to statins, proton pump inhibitors, ACE inhibitors, angiotensin receptor blockers (ARBs) and selective serotonin reuptake inhibitors (SSRIs). Erythropoietin stimulating agents (ESAs) for patients with renal failure and biologicals for rheumatoid arthritis are next on the list. Prescribing guidance – currently paper-based but shortly to become electronic – has also been produced for all of these groups. The STEPS process has recently been applied to other products including wound dressings, point-of-care testing devices and dietary products, Dr Scott added.

Until recently, a mixture of generic products and parallel-imported products was used in primary care and different agents within the same therapeutic class were often used in hospital and primary care, Dr Scott said. Most patients were over the age of 65 years and changes in the appearance of medicines when they were admitted or discharged from hospital caused confusion, he commented. The use of standardised products in primary and secondary care should eliminate many of these problems.

“Saving our skin”: wound management
The introduction of a wound management formulary in July 2007 has improved the continuity of patient care and put one hospital trust on track to meet its efficiency savings target, according to Anne ­Witherow (assistant director of nursing, governance and performance, Western Health and Social Care Trust) and Dianne Gill (assistant chief pharmacist, Northern Health and Social Care Trust).

In 2005 total (primary and secondary care) expenditure on wound management products amounted to £7.1m in Northern Ireland, Ms ­Witherow said. A review of wound care provision had shown that practices varied widely between primary and secondary care. In 2005, 773 different products were prescribed in the community compared with 136 in hospital. The absence of a clear rationale for ­decision-making and inadequate knowledge and skills in relation to wound care products both contributed to serious governance and safety concerns. Furthermore, sales representatives sometimes appeared to have a significant influence on product selection, Ms Witherow noted.

A multiprofessional project group was set up to steer the development of a formulary. Members of the group included tissue viability nurses, a podiatrist, a pharmacist and a representative of the Surgical Dressing Manufacturers’ Association. The STEPS process was used and a list of clinical evaluation parameters compiled. In order to avoid being swamped with irrelevant information, manufacturers were invited to mark the parameters relevant to their products and to provide the single best published paper or supporting evidence for each one. After evaluation, 97 products were listed for inclusion in the formulary, Ms Gill said. In addition to the formulary itself, a pocket-sized ready-reckoner (quick reference guide) and a patient information leaflet were produced.

Much of the evidence received from manufacturers was of poor quality – often in-house data or ­promotional material, Ms Gill commented. On occasion, illegible, poor-quality documents were provided, and some had not been translated from the original language. There was a noticeable lack of randomised controlled trial data, she added. This problem is well recognised in the wound management field and one author has already called for an international working group to be set up to determine the best way to provide evidence for the effectiveness of wound management products, she added.

EPICS
The EPICS system enables pharmacists to record interventions and “near-miss” events in real time using a PDA, Peter Beagon (pharmacist, Antrim Area Hospital) told a workshop group. The wireless-enabled HP iPAQ pocket PCs can be used throughout the hospital. Details of interventions are recorded using a stylus to pick menu options. The data entry process was designed for bedside use, although Mr Beagon admitted that some pharmacists prefer to record interventions after ward visits. No data are held on the PDAs – all data are recorded directly on to a central server. This means performance reports can easily be generated, he noted.

Integrated medicines management in Uppsala
When Claes Mörlin (director of medicine, Uppsala University Hospital, Sweden) was appointed  to his present post he sought to introduce clinical pharmacy services as a way of reducing the frequency of medication errors, he told the audience. After a visit to Antrim Hospital the team from Uppsala decided to try to replicate the integrated medicines management project in Sweden.

A survey of emergency hospital admissions showed that 9-14% were drug-related and the most common factors were adverse drug reactions, poor compliance and suboptimal dosing. The annual cost of drug-related admissions was estimated to be just under €4m, and approximately 50% of these admissions were potentially preventable, Dr Mörlin said.

A randomised, controlled study of 400 patients of 80 years and older was set up to compare the impact of systematic medicines management with standard care (with no pharmacy input). The preliminary results suggest that there has been a reduction in drug-related admissions and overall visits to the ER, Dr Mörlin said.

“Working in this way, we feel a change in the wind – less competition, more cooperation. We should take advantage of each other’s knowledge,’ said Ulrika Gillespie (senior pharmacist, Uppsala University Hospital).

As a result of the success of this project the clinical pharmacy team grew from two pharmacists in January 2007 to 14 by January 2008. â–

Resources
IMM:
Scullin C, Scott M, Hogg A, McElnay J. An innovative approach to integrated medicines management. J Eval Clin Pract 2007;13:781-8.

SOJA:
Janknegt R. Rational drug selection using SOJA. Clinical Pharmacy Europe 2006:(5);27-9.



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