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7 day working: The Leeds Experience Dr Andy Lowey Lead Clinician – Clinical Pharmacy & Technical Services Leeds Teaching Hospitals NHS Trust
7 day working: The Leeds Experience
Dr Andy Lowey
Lead Clinician – Clinical Pharmacy & Technical Services
Leeds Teaching Hospitals NHS Trust
St James’ Institute of Oncology
Leeds Children’s Hospital
Background – 7 day working
• Pharmacy Services acknowledged as a priority area in “Keogh Report” December 2013
• MMPS Working Group formed January 2014
• Issues identified for MMPS 7 day service – Improving ward presence weekends (inc MDT support)
– Improving Medicines Reconciliation Performance at weekends
– Review of shift leadership & handover
– Patient experience – information on medicines
– Information to GP’s via eDAN
– Improving consistency of access to specialist pharmacist advice
What changes have we made?
• New integrated 7 day (all day) rotas across all 5 clinical pharmacy
“clusters”
– pharmacists, technicians & support staff
– specific focus on acute medicine as a priority
• Introduction of prioritisation system for patient review
• New “huddle” system across all teams, led by SDM
• New pharmaceutical care section embedded in Medicines Chart
• Use of electronic handover tool to highlight outstanding/high risk
issues to follow-up
• Replacement of on-call “resident pharmacist” service with shift
systems across 24hours, 7 days a week
• Extended aseptics opening hours (8am-8pm Mon-Fri & 8am-6pm
Sat/Sun)
• “Whole department” approach to reconfiguring rotas to support 7
day services, led by the MMPS Senior Leadership Team
What does this mean?
• On-site medicines supply & advice available 24/7
• Near-to-patient validation of eDAN’s
– Less errors, better patient contact, less waste, less transport delays
• Access to specialist pharmacists in each major team across 7 days
(e.g. specialist neonatal TPN pharmacist & paediatric pharmacist
present in Leeds Children’s Hospital)
• Access to technical compounding expertise (e.g. urgent cytotoxic
compounding, neonatal parenteral nutrition)
• Better matching of risk/priority with resource
• Improvement in Medicines Reconciliation performance (NB. 30-70% patients have an unintentional medication change during a hospital stay –
NICE PSG001 2007)
Results (NB. changes began 1st Nov 14)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Axi
s Ti
tle
Medicines Reconciliation within 24 hours across 7 days, all areas
2013-14
2014-15
Medicines Reconciliation by day of admission (NB Final changes to ward rotas not completed until March 15)
0%
20%
40%
60%
80%
100%
120%
August September October November December January February March
Axi
s Ti
tle
Significant improvements made for patients admitted on Saturday
Mon
Fri
Sat
Sun
The UK’s first ever double hand transplant, 2016
……and on a Saturday too!
Bed Name Admission eDAN Tech Last L2 Next
L2/Priority Medication
issues Consultation Referral
1 John, Pharmer
MR Med Supp Yes
Awaiting Validation
LLC 17/12/15 16/12/15 17/12/15 Ref from Dr Baker A/D Form
PPM+ Pharmacy Whiteboard – The Vision
Vanc level
x
Warfarin
x
The user could record any medication support issues,
including compliance aid detail which would sit within a
‘form’ in ppm+. The form could replicate the detail from
the adherence assessment and also record detail of
compliance aid supply. This would be accessible each
admission and would only need editing if changes were
required.
This would need to be completed
manually until the ward went live with
eMeds when it would automatically
update with completion of each section of
the eDAN (RFC submitted)
Technicians could note
when the last locker
check has occurred to
ensure the medication
supply was complete
and ready for discharge
(RFC by Gill S)
Populated manually or with
the completion of the meds
rec box on eMeds. The
next L2/priority level would
need to be completed
manually
Medication
consultation requests.
MDT referral in
to pharmacy
services
This could be set up as the current job list is set.
The medication issue could be added free text
which could then be removed when completed
by clicking on the x. Codes could be identified
for common jobs which could be selected from
a drop down menu. You would be able to see
what issues had been resolved in a list below
(this would be hidden from the board but
available to see)
Move from manual to electronic data (2016)
(~4000 admissions/month)
0
1000
2000
3000
4000
5000
6000
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Nu
mb
er
of
Pat
ien
ts
MedRec Data from PPM+
Number of Patients with a MedRec Started (at any Stage or Time)
At 24hrs Percentage of patients recorded at Stage 2 and 3
Data for “admissions areas” (snapshot Feb 2016)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50
100
150
200
250
Tuesday15/03/2016
Wednesday16/03/2016
Thursday17/03/2016
Friday 18/03/2016 Saturday19/03/2016
Sunday20/03/2016
Monday21/03/2016
Pe
rce
nta
ge
Nu
mb
er
of
Pat
ien
ts
PPM + Data with Length of Stay >= 24hrs for J09, J10, J10H, J12, J26, J27, J28, J29, J46, J47, J96, L19, L34
Total Number of Patients
Percentage of patients seen on PPM+
Percentage of patients with outstanding actions
Electronic data - update
Medicines Review Patient Consultations
0%
10%
20%
30%
40%
50%
60%
70%
April May June
Consultations: L2 - 2016/17
Brief consultations Comprehensive consultations
Winter is definitely coming…
… and it is
EVERYONEs
business
Acute Medicine – Winter
• Confirmation of drug history <24hrs across 7 days –
↑ from 78 to 88% despite winter pressures
• Average turnaround times for eDAN on the acute floor
decreased to <60 mins despite winter pressures
(via use of remote dispensary support room by routine
staff familiar to working in the area 24/7)
– 96% completed within 2hrs
– 84% completed <1hr
Children's’ emergency admissions (0 to 14 years) for Leeds-registered
patients at Leeds Teaching Hospitals NHS Trust with a respiratory primary
diagnosis (exc. Lengths of Stay of 29 days or longer)
Ad
mis
sio
ns
C
han
ge
in
bed
occu
pan
cy
FALSE
Period Daily
Ave.
95%
variation
FALSE
FALSE
TRUE
TRUE
TRUE
FALSE
4.39 ± 5.7
3.53 ± 4.3
3.99 ± 6.2
0
5
10
15
20
25
30
Apr
-09
Aug
-09
De
c-09
Apr
-10
Aug
-10
De
c-10
Apr
-11
Aug
-11
De
c-11
Apr
-12
Aug
-12
De
c-12
Apr
-13
Aug
-13
De
c-13
Apr
-14
Aug
-14
De
c-14
Apr
-15
Aug
-15
De
c-15
Dai
ly a
ctiv
ity
(wit
h s
eve
n d
ay c
en
tre
d m
ovi
ng
ave
rage
)
0.0
5.0
10.0
15.0
20.0
25.0
30.0
1-A
pr
1-M
ay
1-Ju
n
1-Ju
l
1-A
ug
1-Se
p
1-O
ct
1-N
ov
1-D
ec
1-Ja
n
1-Fe
b
1-M
ar
1-A
pr
FALSE
Period Daily
Ave.
95%
variation
FALSE
FALSE
TRUE
TRUE
TRUE
FALSE
5.19 ± 13.5
3.22 ± 8.8
4.25 ± 13.7
-10
-5
0
5
10
15
20
25
30
35
40
Apr
-09
Aug
-09
De
c-09
Apr
-10
Aug
-10
De
c-10
Apr
-11
Aug
-11
De
c-11
Apr
-12
Aug
-12
De
c-12
Apr
-13
Aug
-13
De
c-13
Apr
-14
Aug
-14
De
c-14
Apr
-15
Aug
-15
De
c-15
Dai
ly a
ctiv
ity
(wit
h s
eve
n d
ay c
en
tre
d m
ovi
ng
ave
rage
)
-10.0
-5.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
1-A
pr
1-M
ay
1-Ju
n
1-Ju
l
1-A
ug
1-Se
p
1-O
ct
1-N
ov
1-D
ec
1-Ja
n
1-Fe
b
1-M
ar
1-A
pr 19
User Feedback
• Medical/nursing staff very positive on access to more
“normal” MMPS on weekends – esp. acute medicine
• “It made such an enormous difference - patients
received their non-stock medication promptly, and
discharge medications were delivered without delay,
helping patient flow, and reducing patients’ waiting. The
service ran smoothly and efficiently and we had no
complaints. The difference was massive”
• Romy Smith, Senior Sister – Acute Medicine
MMPS Staff Feedback
“I’m working in my normal area instead of fire-
fighting in the dispensary or on a random ward”
“The better service on the acute floor at the
weekends means Monday is less chaotic – less
‘catch up’ and fewer delayed/missed doses”
Lisa McCreadie, Pharmacy Technician, Higher Level
Case study – Ward Service
• May 4th 2015, Acute Medicine
• Patient AB admitted to J29 on bank holiday Monday
• Specialist pharmacist reviews Drug History
• Reconciles Drug History with medicines chart
• “New” nitrazepam & pregabalin challenged by
pharmacist
• Investigated – appears patient had forged prescription
• Outcome - medics informed, prescriptions discontinued
Case study - Aseptics
• Kai, 26 week premature neonate
• Reviewed by neonatal TPN pharmacist in am – TPN
prescribed & validated
• Blood gases reviewed ~2pm – drop in K+
• Amendments made to TPN formulation in conjunction
with registrar
• Prevented need for any (high risk) ward-based IV
manipulations
• Outcome – K+ level normalised overnight
Case study – Dispensary
• LTH at SILVER command due to bed pressures, notably
SJUH
• MMPS responds by prioritising eDAN’s
• New staffing & skill mix until 10pm in SJ inpatient
pharmacy to process high workload
– 27% of workload was received 5pm-10pm during winter 14/15
– 85% completed within 2hr target
• Co-ordinator moves staff from LGI to SJUH
• Overnight shift pharmacist reviews Bluespier eDAN
system
– processes appropriate eDAN’s for early next day and/or
highlights priorities to follow up specialist pharmacist
Discharge Prescription Turnaround Times 14/15 &
15/16
25
Data updated to Sept 2016
Future plans
• Review of service specification & models in each area
• Use technology to improve efficiency and follow-up
– Specify date of next pharmacist review according to risk on
MedChart system
• Skills escalator +++ - non-registrants in ward areas,
maximise use of highly skilled technicians to release
p’cist resource
• Expand use of NMP’s to help patient flow
– “Contributions” not “interventions”
• Assess other areas of our CSU for 7 day working –
medicines warehouse, IT support, production unit etc
Limitations & barriers
• Tension between generalist and specialist roles
• What is a high priority/risk patient?
• Workforce issues:
– pipeline for technicians & scientific non-registrants to fulfil
“supervisor” roles
e.g. AfC band 4 clean room supervisor
– “brain drain” to other sectors with M-F working
• Resilience of outsourced services e.g. home PN
• Discharge pathways complex
• Transfer & handover to primary care
• Pressure on patient flow – pts going home without eDAN
Outliers
Summary
• Significant changes in MMPS service delivery over 7 days in last 2+ years
• Significant improvement in responsiveness in all key areas of MMPS across 7 days including evenings & overnight
• Skill mix & IT changes releasing registrant resource to improve patient care
• Multiple discussions with CSU’s over “enhanced roles” for MMPS staff
• ……all being delivered within our current budget
• Nominated for “LTH Time to Shine” Award for Quality & Patient Safety – Highly Commended (October 2015)
“Breakthrough 7 days” Vision
“We are committed to being recognised as
the leading Pharmacy department in
England for 7 day services”
MMPS Project Team
https://www.youtube.com/watch?v=lvLH2m4
ZGUw
(3rd video at around 1min 50secs)
