Poster Presentations index Page

UKCPA Clinical Research Grant 2013 The following paper successfully secured UKCPA research funding:

Errors in the Preparation of injectable Medicines in the Pharmacy Environment: A Failure Modes and Effects Analysis – K Lynette James* & Richard Bateman†, *Department of Pharmacy & Pharmacology, University of Bath; †Guy’s and St Thomas’ NHS Foundation Trusts

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Poster Number

Poster Presentations

1 Can we stop the meropenem? A review of carbapenem prescribing at a large teaching hospital, with reference to the English Department of Health “Start Smart, Then Focus” guidance - Price A, Vickers M, Hand, K, Wickens H, University Hospital Southampton NHS Foundation Trust (UHS), Southampton

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2 The Feasibility of a Specialist Pharmacist-led Medicines Optimisation Clinic for Patients with Heart Failure - Lawson, A. Plymouth Hospitals NHS Trust. Plymouth, James, DH. And Hodson, K. Cardiff University School of Pharmacy and Pharmaceutical Sciences

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3 Simulation as a tool for teaching clinical screening - Warburton J and Edwards A, University Hospitals Bristol NHS Foundation Trust, Bristol

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4 Improving the quality of medicines-related discharge information - Hathi A1, Pettitt DA1, Barnett N1, Vilasuso M1, 1North West London Hospitals NHS Trust, London

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5 An audit of the medication management of in-patients with Parkinson’s disease - Bharkhada, B. West Suffolk NHS Foundation Trust, Bury St Edmunds

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6 Identification and exploration of factors that influence prescribers decision making in their use and selection of antibiotics in a respiratory unit - Cunnane CM1, Kinnear M1,2, Mullen AB2, Scott J1, Shaw L1. 1NHS Lothian Pharmacy Service, Royal Infirmary of Edinburgh, Edinburgh and 2University of Strathclyde, Glasgow

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7 Pilot of a Pharmacist Independent Prescriber in Orthopaedic Admissions suite (OAS) to support the Enhanced Recovery After Surgery (ERAS) project for patients undergoing Hip and Knee replacement Surgery and to reduce length of stay -O’Brien, N., Hoskins, C, Pharmacy Department, Cheltenham General Hospital (CGH), Gloucestershire Hospitals NHS Foundation Trust.

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8 A study to determine whether the use of a novel triage tool reliably identifies those patients within the Rehabilitation and Assessment Directorate at Glasgow Royal Infirmary with the greatest requirement for pharmaceutical care, and to determine the most appropriate stage of admission to apply this tool - Wheelan C1, Stirton J1, Fenelon C1, McIntosh T2, 1 Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, 2 Robert Gordon University, Aberdeen

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9 Inhaler technique optimisation within Royal Liverpool University Hospital patients - Lucy D, Bullock S, Royal Liverpool and Broadgreen University Hospital Trust

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10 Pharmacy at the bedside: changing the pharmacy service to the wards to improve work flow through the dispensary - Morton D, Liddle J, Adams P, Gloucestershire Hospitals NHS Foundation Trust

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11 Pharmacy at the Bedside, increasing quality of Clinical services - Morton D, Liddle J, Adams P, Gloucestershire Hospitals NHS Foundation Trust

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12 Research into the appropriateness of caspofungin prescribing in a university teaching hospital - Jilka D, Wickens H, Hand K, University Hospital Southampton

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13 A retrospective audit to assess the prevalence of venous thromboembolism in cancer patients undergoing major abdominal surgery at University Hospital Aintree NHS Foundation Trust - Beach D*, Beach T*, University Hospital Aintree NHS Foundation Trust

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14 Description and quantification of Ward Based Pharmacy Activity - Duncan McRobbie, Associate Chief Pharmacist-Clinical Services, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

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15 Selecting The Most Cost-Effective Model Of Care For Delivering Biological Agents As Maintenance Therapy In Patients With Crohn’s Disease - Lougher. E *, Allison. M.C , Hodson. K, Pugh. M, Pharmacy and Gastroenterology departments, Aneurin Bevan University Health Board, Newport. Cardiff School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, United Kingdom

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16 Prospective Audit of IV Vancomycin Prescribing and Monitoring at Aintree University Hospital - Phillips E, Durnin N and Cooke R, Aintree University Hospital NHS Foundation Trust, Liverpool

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17 Introduction of pharmacist-led 24 hour VTE re-assessments using a Quality Improvement Approach - Hardy E, Thakkar K, Zarnegar R, Royal National Orthopaedic Hospital, Stanmore

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18 Encompassing trainees in a culture of compassion during workplace based training -Wright E, Fidler E, Fleming G., Health Education KSS Pharmacy, Haywards Heath, West Sussex

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19 Anticoagulants: improving patient safety and management for patients admitted on oral anticoagulants - Grant F, Aintree University Hospitals, Liverpool

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20 Impact of Pharmacist Independent Prescribers at Imperial College Healthcare NHS Trust - Alaeddine S¥, Khachi M# & Miller G*, ¥ Rafic Harir University Hospital, Beirut, Lebanon, # University College London Hospitals, London, * Imperial College Healthcare NHS Trust, London

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21 Developing and piloting a tool to evaluate pharmacists’ perceptions of their pre-registration pharmacist training programme - Al-Haqan A,#, Portlock J*, Miller G∞, # Faculty of Pharmacy, Kuwait University, Kuwait, * School of Pharmacy, University College London, London ∞ Imperial College Healthcare NHS Trust, London

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22 An audit of the accuracy of drug calculation skills of junior doctors - Gillian Cavell*, Michael Currie**. King’s College Hospital NHS Foundation Trust, *Consultant Pharmacist **Specialist Pharmacist, Prescribing Mentor

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23 An audit of the omission of medication to ‘nil by mouth’ patients pre-and-post ward staff education in emergency surgical admissions - Hall G*, Timmins A*, Johnson J# and Oglesby S*, *NHS Fife. # University of Strathclyde, Glasgow

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24 An Audit of supply of Critical Medicines in West Suffolk Foundation Trust Pharmacy - Musial G, Sapsford D, West Suffolk Hospital Foundation Trust, Bury St Edmunds

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25 Risk to patient of prescribing transcription errors during transfer of care from critical care to general ward level - De Val J, Leal L, Glover G, Mistry J, Wan R, Watson A, McKenzie CA, Institute of Pharmaceutical Sciences and School of Medicine, Kings College London, Pharmacy and Critical Care, Guy’s and St Thomas (GSTT) NHS Foundation Trust, London.

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26 Development of pharmaceutical referral criteria for use by non-pharmacy staff on general surgical wards at Glasgow Royal Infirmary - Clarke J1, Cunningham ITS2. 1 Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, 2 Robert Gordon University, School of Pharmacy & Life Sciences, Aberdeen

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27 How might pharmacists in training best be supported to face emotionally-challenging clinical experiences? - Reygate, K. Foundation Training Programme Director & Prescribing Lead, Health Education, Kent Surrey & Sussex Pharmacy. Hayward’s Heath

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28 Evaluation of Opioid Use in the Management of Acute Postoperative Pain - Allison J, Bowie C, Carthy D, Elliot E, McAndrew C, McCabe C, Platts K, Murray N, Souter C. NHS Lothian Pharmacy Service

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29 To determine whether TCIWorks can accurately predict International Normalised Ratio (INR) response to warfarin dosing for individual patients - Black La, Wright DFBb, Thomson AHc, MacTavish Pa, Tait Ca, McIntosh Td, a. Glasgow Royal Infirmary, National Health Service Greater Glasgow and Clyde (NHSGGC), UK, b. School of Pharmacy, University of Otago, New Zealand, c. University of Strathclyde, Glasgow, UK, d. Robert Gordon University, Aberdeen, UK

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30 Promoting excellence in hospital medicines procurement *Self assessment of regional procurement arrangements in England: a comparison with 2012 outcomes and recommendations - Arkell E, University Hospitals South Manchester NHS Foundation Trust, Tutcher D, OptraPharm Ltd * Commercial Medicines Unit / Pharmaceutical Market Support Group funded project

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31 An Evaluation Of The Error Rate Of An Independent Prescribing Pharmacist Service On The Surgical Day Unit - Graham L, Howarth N, Gordon S, University Hospitals Southampton NHS Foundation Trust.

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32 An audit to determine the quality of prescribing of New Oral Anticoagulants (NOACs) for prevention of stroke and systemic embolism in atrial fibrillation (AF) - Stone, L and Manning, S, Royal Brompton and Harefield NHS Foundation Trust, London

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33 Hospital staff views on their role in providing information to patients on medication side effects - Wilcock M1, Davidson I1 Underwood F2, 1Pharmacy Department, 2Consultant Nurse/Associate Director of Nursing. All of Royal Cornwall Hospitals NHS Trust, Truro

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34 Effective transfer of care – easier said than done? - Wilcock M1, Hill A, 1 Davidson I1, Yelling P2, 1Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, 2Chief Officer, Cornwall Local Pharmaceutical Committee

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35 Pharmacists’ Use and Views of the Electronic Prescribing Web Portal - Mullan N and Jennings A, Aintree University Hospital NHS Foundation Trust, Liverpool.

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36 Introducing a bariatric surgery pharmacy service - Gormley N, Serag M, Stephenson L and Gibson D County Durham and Darlington Foundation Trust, Darlington Memorial Hospital

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37 An audit to assess the quality and accuracy of surgical discharge letters - Dass N1, Makhecha S1, 1Royal Brompton and Harefield NHS Foundation Trust

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38 Reducing cross contamination in preparing injectable medicines: the water effect - Chaplin, J and *Eradiri OL, Colchester Hospital University NHS Foundation Trust (CHUFT), Colchester

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39 An audit of the initiation of oral anticoagulation with warfarin using a Patient Group Direction in the pharmacist-led anticoagulation clinic at Brighton and Sussex University Hospitals NHS Trust – Banwait Pa,b, Conway Aa,b, Warren Ab, aSchool of Pharmacy and Biomolecular Sciences, University of Brighton, UK, bBrighton and Sussex University Hospitals NHS Trust, UK

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40 The Forgotten Victim - Experiences of the person who made the error - Edwards, P, Pharmacy Department, Luton and Dunstable University Hospital. Luton

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41 Use of Ticagrelor in Line with the Royal Brompton & Harefield NHS Foundation Trust Primary Angioplasty Protocol - Pilgrim, R and Manning, S, Royal Brompton and Harefield NHS Foundation Trust

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42 Complementary and Alternative Medication Use Amongst Patients Established on Oral Anticoagulation Therapy - Patel R1, Patel J2, Davies G1 and Byrne R2, 1Institute of Pharmaceutical Science, King’s College London, London, 2King’s College Hospital Foundation NHS Trust, London

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43 A Prospective Audit of the Walton Centre Foundation Trusts’ (WCFT) Venous Thromboembolism (VTE) Prophylaxis Policy in Medical Patients - Lloyd, R. Aintree University Hospital, NHS Foundation Trust, Liverpool

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44 Can Healthcare Professionals Teach Inhaler Technique? - Bullock, S, Royal Liverpool and Broadgreen University Hospital Trust, Liverpool

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45 Improving the quality of hospital outpatient prescribing: an audit approach - Hackney S, Hollister, L and *Eradiri OL, Colchester Hospital University NHS Foundation Trust (CHUFT), Colchester.

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46 Auditing the Impact of Electronic Prescribing on Clinical Pharmacy Services - Gordon,S, Tomlin, T, University Hospital Southampton NHS FT (UHS)

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47 National patient Safety Agency (NPSA) audit: Safer Practice and Use of Epidural Injections and Infusions - Patel S., Al-Hasani M. Central Middlesex Hospital. North West London Hospital NHS Trust (NWLH)

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48 The Introduction of Pharmacist Transcribers on the Surgical Admissions wards at St James’ Hospital, Leeds, to Improve Patient Access to their Regular Medicines - Blow, S. E, Ginday, V, Pharmacy Department, Leeds Teaching Hospitals NHS Trust, Leeds

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49 Reasons why hospital doctors make prescribing errors - Dobrzanski S, Department of Pharmacy, Bradford Teaching Hospitals NHS Foundation Trust

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50 A service improvement project to reduce delayed and omitted doses in an adult critical care setting - Reed, J., Percival, T., Devenish, P., Oxford University Hospitals, Oxford

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51 An Evaluation of the Preparation and Use of Injectable Ephedrine within the Theatre Environment of a NHS Hospital Trust - Percival T, Crowley CY, Pharmacy Department, Oxford University Hospitals NHS Trust, Oxford.

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52 Clinical experience of using new oral anticoagulant agents - Chouhan U and Starling J, Betsi Cadwaladr University Health Board, Departments of Pharmacy & Cardiology, Glan Clwyd Hospital, Rhyl

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53 Implementation of a biologic prescribing pathway by introduction of a Virtual Biologics Clinic in a single rheumatology department - Reid V, Kemp K, Parker B, Division of Specialist Medicine, Central Manchester Hospitals NHS Foundation Trust. Manchester

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54 What is the cost of a modern clinical pharmacy service? Part II – the development of a resource calculator - Simcock V, Blackshaw C, Bednall R, Hanif I, Freeman S. University Hospital of North Staffordshire (UHNS), Stoke on Trent

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55 An audit of the documentation of baseline patient safety data for the commencement of biological therapy within a Rheumatology Department - Baird W, Benson C, Musgrave Park Hospital, Belfast

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56 A service evaluation of the impact of “shortcut” electronic discharge prescribing on the speed and quality of discharge prescribing - Jani, Y1,2; Bijman, L2; Jena-Smol, A1, 1UCLH Foundation Trust, London; 2UCL School of Pharmacy, London

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Poster Presentations

UKCPA Clinical Research Grant 2013 Errors in the Preparation of injectable Medicines in the Pharmacy Environment: A Failure Modes and Effects Analysis

K Lynette James* & Richard Bateman†,

*Department of Pharmacy & Pharmacology, University of Bath; †Guy’s and St Thomas’ NHS Foundation Trusts

Introduction The preparation of injectable medicines is a complex and high risk process. Pharmacy production units prepare cytotoxic medicines, parenteral nutrition and other intravenous injectable medicines. Preparation errors detected and reported after the medication has been released for use, can cause serious patient harm and death. In contrast, near-misses are mistakes detected during the preparation process before the medicine has been released for patient use. Little is known about nature and causes of injectable preparation errors and near-misses occurring within the pharmacy environment.

Objectives This study aimed to determine the incidence, type and causes of near-misses in the preparation of injectable medicines within the pharmacy environment. Method The case study methodology1 (multiple case, embedded design) was adopted for this study. A purposive sample of three pharmacy aseptic production units from across the UK has been selected for participation in the study. A mixed methods approach was used to collect data on the incidence and types of near-missed in the preparation of injectable medicines. Non-participant, structured observation was undertaken at the production units of participating pharmacies to determine the incidence and type of near-misses during the preparation of injectable medicines. Quantitative data on near-misses were entered into SPSS and analysed using frequency tables. Face-to-face ethnographic interviews were also conducted with individuals involved in the near-misses to explore the causes of the preparation errors. Interviews were audio-recorded, transcribed verbatim and analysed in accordance with the principles of framework analysis based on Reason’s Organisational Accident Causation Model.2,3 Results An observation and interview schedule have been developed and are currently being piloted. Study sites have been recruited and include an unlicensed manufacturing unit, one small licensed manufacturing unit (defined as preparing <1000 items per month) and one large licensed manufacturing unit (defined as preparing >1000 items per month). Data collection will commence imminently for a period of four weeks at each study site. Discussion Data from the study will be used to support the development of risk reduction strategies to minimise preparation errors in the pharmacy environment. These strategies will be presented in the risk reduction programme together with a protocol for monitoring the success of the strategies. References 1. Yin, R. K. Case study research: design and methods. London: Sage; 2003 2. Ritchie, J. & Spencer, L. Chapter 12: Qualitative Data Analysis for Applied Policy Research. In: Huberman, A. M. & Miles, M. B. (Eds.) The

Qualitative Researcher's Companion. London: Sage; 2002 3. Reason, J. Human Error. Cambridge: Cambridge University Press; 1990

1. Can we stop the meropenem? A review of carbapenem prescribing at a large teaching hospital, with reference to the English Department of Health “Start Smart, Then Focus” guidance

Price A, Vickers M, Hand, K, Wickens H, University Hospital Southampton NHS Foundation Trust (UHS), Southampton

Introduction There are growing reports of carbapenemase-producing bacteria isolated from clinical specimens across the UK and Europe, posing an increasing threat to public health.1 Data between 2004 and 2006 show a 50% increase in the usage of carbapenems across UK hospitals; this increase correlates with the major rise in cephalosporin and quinolone resistant enterobacteriaceae. The emergence of ESBL (extended spectrum beta-lactamase) producing coliforms, Acinetobacter and P. aeruginosa found resistant to carbapenems has prompted the call for on-going surveillance and emphasis on the formation of antibiotic prescribing policies.2,3 Implementing the antimicrobial stewardship programme, as recommended by the English Department of Health (DH), is a key element in slowing the spread of resistant organisms. The DH 'Start Smart, Then Focus' guidance outlines some key principals of hospital antimicrobial stewardship with regards to empirical therapy:

Start Smart – start antibiotics only where there is suspicion of a bacterial infection; use local prescribing guidelines; document indication, route, dose and duration; send cultures first.

Then Focus – review antibiotic within 48h, and document one of five possible prescribing decisions in the notes (stop/switch IV to oral/change/continue and review at 72 hour/Outpatient Parenteral Antimicrobial Therapy(OPAT)).3

This audit aims to monitor adherence to the “Start Smart, Then Focus” guidance, specifically with relation to documentation of a 48-72 hour review, evidence of an "Antimicrobial prescribing decision" documented in the notes, and de-escalation within an appropriate timescale, along with locally-derived standards for appropriate meropenem prescribing.4 Objectives To assess the adherence to local antibiotic guidelines, by monitoring patients intitiated on meropenem over a six-week data collection period in an NHS teaching hospital. The use of meropenem was audited against the following standards as outlined in local policy:4

1. 100% of patients should have an antimicrobial review documented in the notes at 48 hours. 2. 100% of those with evidence of failure to improve or evidence of deterioration, with no microscopy, culture and susceptibility (MC&S)

results will receive input from an infection specialist within 72 hours (documented in the case notes). 3. All those with MC&S results indicating a pathogen susceptible to a more narrow-spectrum antibiotic, must be switched to a narrow-

spectrum antibiotic within 24 hours of the laboratory report. 4. All those eligible for IV-to-oral switch at 48 hours, must be switched before 72 hours. 5. All those responding to appropriate empirical therapy must have a plan for total course length documented in the case notes before 72

hours. 6. 100% of patients eligible for OPAT (according to local criteria) at 48 hours will be referred to the OPAT service before 72 hours.

Method The audit was undertaken from October to December 2013. Adult patients prescribed meropenem were identified using the electronic prescribing system on a weekly basis and followed up at ward level 48 hours after initiation by review of case notes, laboratory results, and MC&S results. Patients were reviewed for 5 days to record infection and treatment decisions. Results were recorded using a data collection tool in order to measure against the standards above, following a week-long pilot period. As evidence of a 48 hour review, one of the five prescribing decisions outlined above must have been recorded in the notes. The results of the audit will be disseminated to ward doctors and pharmacists for quality improvements. Results 30 patients were included in this audit: a data summary can be seen in Table 1. It was found that 23% of patients (7/30) did not have a documented review of antimicrobial therapy within 48 hours. Of the documented reviews that took place 70% (21/23) of these chose to continue with meropenem treatment and 70% (16/23) failed to record a review or stop date. Table 1: Percentage of standards observed over a six-week period.

Standard Patients eligible

Level expected

Patients actioned

Level observed

Standard met?

1. Review documented 30 100% 23 77% X

2. Specialist input 9 100% 6 66% X

3. De-escalation 6 100% 2 33% X

4. IV switch 6 100% 3 50% X

5. Plan for duration 14 100% 7 50% X

6. OPAT 1 100% 1 100%

Discussion Trust guidelines outline the responsibility of practitioners in the prescribing of empirical antibiotics, stating that antibiotic prescriptions must be reviewed within 48 hours with a clear management plan documented in the medical notes.4 The results of this audit indicate that around 1 in 4 patients initiated on empirical meropenem therapy do not have a documented review within 48 hours. It is important to note that 70% of the documented reviews that took place recorded a decision to continue with empirical therapy. In addition to this, there was a clear shortfall in achieving standards 2 to 5. There appears to be a reluctance to de-escalate or switch patients to more narrow spectrum therapy, supported by the lack of stop/review dates recorded in patient notes. This audit has highlighted the need to re-iterate what is expected of a 48 hour review, and to provide guidance and support for de-escalation and switching of empirical therapy. A limitation encountered during this audit was that verbal discussions held during the review of patients could not be recorded, the results relied heavily on good documentation during ward rounds. Ethics committee approval was not required in order to carry out this audit and Trust R&D approval was granted. References 1. European Centre for Disease Prevention and Control. Annual Epidemiological Report 2013. Reporting on 2011 surveillance data and 2012 epidemic intelligence data. Stockholm: ECDC; 2013. http://ecdc.europa.eu/en/publications/Publications/antimicrobial-resistance-surveillance-europe-2012.pdf (accessed 17 Jan 2014). 2. Cooke J, Alexander K, Charani E et al. Antimicrobial stewardship: an evidence-based, antimicrobial self-assessment toolkit (ASAT) for acute hospitals. Journal of Antimicrobial Chemotherapy 2010; 65;12: 2669-2673. 3. Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI). Antimicrobial Stewardship "Start Smart, Then Focus". Department of Health, Nov 2011. http://www.antimicrobialguide.co.uk/resources/antimicrobial%20stewardship%202011%20DH%20guidance.pdf (accessed 17 Jan 2014). 4. University Hospital Southampton, 2013. Antimicrobial Prescribing Policy. Version 4.0.

2. The Feasibility of a Specialist Pharmacist-led Medicines Optimisation Clinic for Patients with Heart Failure. Lawson, A. Plymouth Hospitals NHS Trust. Plymouth,

James, DH. And Hodson, K. Cardiff University School of Pharmacy and Pharmaceutical Sciences

Introduction Pharmacological therapy has a major part to play in heart failure (HF) with guidelines suggesting that patients treated with appropriate doses of beta

blockers ( blockers), angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (A2RBs) and aldosterone antgonists have a decreased rate of morbidity and mortality. However, many patients are not prescribed appropriate medication and many more are prescribed sub-optimal doses(1, 2). There is also little information relating to the challenges surrounding dose optimisation. On reviewing this situation the local Clinical Commissioning Group acknowledged the need to act in order to improve the service, with current evidence pointing towards optimisation of therapy through utilisation of a prescribing pharmacist. Objectives The aim was to implement and evaluate a community based pharmacist-led clinic for HF patients in order to optimise their treatment. The following objectives were set: o To identify an appropriate GP surgery to pilot the pharmacist-led clinic; o To explore barriers and facilitators encountered when setting up and running a pharmacist-led medicines optimisation clinic in primary care

for patients with HF; o To quantify interventions regarding the initiation and/or up-titration of pharmacological therapy as per guidelines; o To quantify the difference in heart rate of patients with HF prior to and after intervention by the specialist pharmacist; o To describe the nature and frequency of any intervention; o To evaluate patient views regarding the clinic.

Method The study was split into three phases: Phase 1 involved choosing a GP surgery to pilot the clinic and identifying barriers and facilitators regarding establishing and running the clinic; Phase 2 recruited patients with HF due to left ventricular systolic dysfunction through searching the GP coding systems. Suitable patients were then offered an appointment at the surgery. HF related intervention data were collected throughout the consultations. The appointments offered lasted 45 minutes and were on a one-to-one basis. Patients were discharged from the clinic when they were no longer suitable for or required further intervention (ie; they had reached the maximum licensed or tolerated doses of evidence based therapy); Phase 3 involved collecting patient views regarding the service though a semi-structured questionnaire. Results Five of the six surgeries approached agreed to take part. The clinic was set up in the first eligible surgery to respond. The main barriers found were incorrect coding of patients and lack of documented ejection fraction, whilst the key facilitators were the ability of the pharmacist to act as an independent prescriber and ties with the cardiology consultants. A total of 113 interventions were made in eighteen patients including pharmacological

(n = 22), non-pharmacological (n = 79) and referral (n = 12). An increase in the mean total daily doses of blockers, ACEIs/A2RBs and aldosterone antgonists taken by the study population was seen post-intervention and an even greater increase in the sub-group analysis of patients suitable for medication up-titration and/or initiation. The results are represented in the graphs below:

A higher proportion of patients also had a heart rate of between 60-70bpm at the end of the study(3). Patient feedback from twelve participants was positive and revealed an appreciation for the pharmacist’s knowledge of their condition, approachable nature, information given and appointment length. Discussion/Conclusion The aims and objectives of the study were met despite some limitations. It was clear that the surgeries were amenable to a pharmacist-led clinic and aided in the collection of information regarding various barriers and facilitators to setting-up and running the clinic. The major limitation in phase 2 was the time-consuming nature of patient identification, which, together with the narrow time frame involved, contributed to the relatively small number of patients included in the study population. Future work may benefit from a more efficient method of patient identification. The clinic structure allowed a wide range of interventions to be carried out and showed that a prescribing pharmacist can have a modest effect on dose optimisation in HF patients, aiding in the implementation of guidelines. Despite the potential of non-responder bias (due to a <100% response rate), patient views regarding the clinic, collected during phase 3, were all extremely positive and indicated receptiveness to pharmacist-led treatment and the need for greater patient education in HF. Therefore, this small-scale study suggests: - a) that there is a place for this type of clinic in primary care, b) a specialist pharmacist can have a positive impact on HF treatment and c) can result in a modest increase in the doses of evidenced-based medication prescribed in-line with national and international guidelines. The recommendations from the study were:- a) ensure accurate patient coding, b) ensure availability of echocardiogram reports, c) venues considered must be easily accessible to this patient cohort, d) be mindful of lack of equipment (pulse oximeters), e) the specialist pharmacist should be an independent prescriber, f) the pharmacist must have a background in cardiology and HF, g) ensure face-to-face appointments, h) offer extended appointment lengths with a weekly or fortnightly follow-up.

References 1. National Institute for Health and Clinical Excellence. 2010. Chronic Heart Failure. CG108. London: National Institute for Health and Clinical

Excellence. 2. McMurray, J. et al. 2012. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis

and Treatment of Acute and Chronic Heart Failure. European Heart Journal; 33; 1787-1847. 3. SHIFT Investigators. 2010. Ivabradine and Outcomes in Chronic Heart Failure (SHIFT): a Randomised Placebo Controlled Study. The Lancet; 376;

875-885.

3. Simulation as a tool for teaching clinical screening Warburton J and Edwards A, University Hospitals Bristol NHS Foundation Trust, Bristol

Introduction Screening prescriptions before dispensing is a core role of a clinical pharmacy service. The clinical screening process is vital for identifying prescribing errors as well as drug-drug and drug-disease interactions. It is a skill which is taught throughout the preregistration year in hospital by shadowing an experienced pharmacist and practising under their supervision. The transition to technician led dispensaries means that there is potentially a lack of support for newly qualified pharmacists conducting clinical screening alone. Simulation has been used successfully as a teaching tool in many healthcare scenarios. These range from basic role play sessions to the use of high fidelity simulators1. Simulation has been used previously to expose pharmacy students to a ward environment in order to facilitate clinical learning2. Objectives o Determine what aspects of the simulation are valued by clinical pharmacists when learning prescription screening skills o Obtain feedback from participants to improve the simulation sessions Method A 90 minute clinical screening session was developed at a large university hospital incorporating an introduction (including human factors), a 30 minute simulation and a structured debrief. Ethical approval was not required as this project was deemed to be service development focussing on quality improvement3. Thirty prescriptions were designed to give examples of a wide range of clinical specialities covered by the Trust including inpatient, outpatient and discharge prescriptions. Up to 6 participants were selected from those pharmacists new to hospital practice (including community pharmacists due to staff the new outpatient pharmacy), newly qualified or just finishing pre-registration training. During the simulation the participants had access to a variety of standard electronic resources and a phone for contacting a facilitator who took on various healthcare roles to answer prescription related queries. Two participants at a time were given a range of prescriptions to screen which varied in complexity and the extent of action required. The remaining participants and facilitators introduced predesigned interruptions -featuring patient counselling, medicines information enquiries and dealing with conflict- to add realism to the dispensary scenario. These scenarios were designed to test the participant’s ability to prioritise and to delegate jobs which would be better resolved by other members of the pharmacy team. All participants rotated through the “screening desk” which also facilitated practise of handover techniques including the use of the ‘SBAR’ tool.4 The session concluded with a debrief to reflect on the perceived successes, areas for improvement and general experience of the session. The facilitators delivered specific feedback from observations and invited comments on the future application of the learning points. A questionnaire with a 6 point ordinal scale (from strongly disagree to strongly agree) and questions for qualitative feedback was designed to collect anonymous feedback from the participants. The quantitative data from the questionnaire was analysed using the median and interquartile range (IQR) due to the ordinal nature of the data, whilst the qualitative data was subjected to thematic analysis using grounded theory. Results Fourteen pharmacy staff participated in the screening simulation programme over 3 similar sessions from April to November in 2013. The first 2 sessions were for pre-registration pharmacists and hospital pharmacists with little experience of clinical screening. The final session was used to introduce community pharmacists to hospital prescriptions and procedures prior to the opening of a community pharmacy run outpatient service. All 14 participants completed a session feedback form. Participants strongly agreed that the teaching was of a high quality, the debriefing process felt comfortable and that it was useful to everyday practice (median = “strongly agree”, IQR =0). The greatest variation (IQR =3) was seen in response to the comment “the simulation was a scenario that has happened to me” (median =“mildly disagree”). A variety of themes emerged from the open questions from the questionnaire (table 1).

Table 1: Themes and sub-themes identified from written feedback

Positive feedback Suggested improvements

1. The simulation session was realistic a) Realistic scenarios b) Realistic workload volume

2. Session useful for developing skills a) Handing over information b) Communication with other healthcare professionals

i. General communication ii. Dealing with conflict

3. The session highlighted specific individual future learning needs 4. The session was very practical with “hands-on learning” 5. Participants felt comfortable in the simulation scenario

1. The session should be longer 2. There should be follow–up sessions 3. The environment could be improved 4. Include more scenarios from a variety of specialties 5. Abandon the session entirely, time would be better

spent shadowing a senior pharmacist in the dispensary

Discussion/ Conclusion It is difficult to assess whether these results are transferable due to the small numbers involved. Whilst the structure and facilitators of the sessions were consistent the learning points that emerged were different making it difficult to directly compare the nature of the benefit between sessions. The use of simulation for developing clinical screening skills was considered useful, relevant and a comfortable experience for most participants. It is clear from the feedback that one participant was extremely opposed to the use of simulation in this setting. Preferred learning styles and prior exposure to simulation in pharmacy teaching are likely to affect the impact and success of this approach. It would be unwise to adopt simulation as a unilateral approach to clinical screening training but instead explore it further as part of standardised training for the induction of less experienced pharmacists. Furthermore the benefits of simulation for testing systems and procedures, realised as an observation in this study, should be further explored in clinical pharmacy. References 1. Cantillon P and Wood D (eds.). ABC of learning and teaching in medicine (2nd edition). Chichester; Wiley-Blackwell; 2010. 2. Unknown. Liverpool students take part in week-long simulated training exercise [online]. Accessed via www.pjonline.com (Viewed 24/2/2014) 3. National research and ethics service. Defining research [online]. Accessed via www.nres.nhs.uk (Viewed 24/2/2014) 4. NHS Institute for Innovation and Improvement. Quality and service improvement tools: SBAR [online]. 2008. Accessed via www.institute.nhs.uk

(Viewed 16/1/14)

4. Improving the quality of medicines-related discharge information Hathi A1, Pettitt DA1, Barnett N1, Vilasuso M1, 1North West London Hospitals NHS Trust, London

Introduction Medication inconsistencies are increasingly prevalent following discharge from hospital with up to 70% of patients experiencing medication errors or unintentional changes to their medicines1. Medications are often stopped, changed or new medications started in accordance with clinical need. In order to ensure patient safety at the point of discharge, medicines reconciliation is required to ensure the information provided about these changes is correctly relayed to the next sector of care. GPs are often not informed of these changes2 and need to make improvements3 This audit examines the North West London Hospitals NHS Trust (NWLHT) Electronic Discharge Notification (EDN) System, which is the sole formal method of information transfer between primary and secondary care and is subject to a Commissioning for Quality and Innovation (CQUIN) Payment. The audit identifies medicines that have been newly started in hospital, stopped or modified (e.g. route, formulation). It also reviews documentation of the rationale for such changes and the accuracy of information transferred from inpatient medical notes to the EDN. Areas of concern are highlighted and recommendations made to improve the current medicine reconciliation system. Objectives

1. To document number of medications started, stopped or changed in patient notes and on EDN 2. To document number of times the rationale behind medications started, stopped or changed is recorded in the patient’s notes and on

EDN 3. To document the transfer of times the above information is transferred from inpatient notes to EDNs

Methods Data for 65 consecutive patients discharged from a Care of the Elderly ward between 1st and 31st March 2012 were reviewed. 26 patients’ notes were excluded due to commencement of the Liverpool Care Pathway (LCP), incomplete medicines reconciliation on admission or where full notes could not be obtained. For all other patients, inpatient hospital records, including medication charts and corresponding discharge notifications were obtained and retrospectively analysed. Results From 65 patient discharges during the target timeframe, a total of 39 cases were included in the study, for which inpatient medical notes and corresponding EDNs were analysed. 26 patients’ notes were excluded. A summary of results are given in Table 1. 84% of ‘new’ medications started in the notes were categorised as ‘new’ on the EDN. Of medications documented as ‘stopped’ in the medical notes, 94% had been categorised as ‘stopped’ on the EDN. Of amendments made to existing medications, 91% had subsequent documentation on the EDN The indication for a newly started medication was documented 75% of the time in the medical notes and 60% of the time on the EDN. For stopped medication, the reason was documented 63% of the time in the medical notes with a 100% transfer rate to the EDN. Some reasons were only documented on the EDN. Where medication was changed, 45% of EDNs contained information on the reasoning behind such amendments. Table 1. Summary of audit results

Medication started

Medication stopped Medication changed

Categorised in notes n 33 19 12 Categorised on EDN n (%) 28 (84%) 18 (94%) 11 (91%) Reason documented in notes n (%) 25 (75%) 12(63%) 12 (100%) Reason documented on EDN n (%) 17 (60%) *18 (150%) 5 (45%)

*some reasons documented on EDN, not in notes Discussion The results suggest that information transferred to primary care providers is not always complete and these findings are supported by the literature4,5.In particular, it was observed that the reasons for commencing certain medications or changing prescribed doses or preparations during hospitalisation were sporadic and inconsistent. Potential explanations behind the inconsistencies identified include:

the inherent structure of the EDN proformas,

the significance or perceived value placed on the transfer of such information by users of the system

junior doctors working patterns. In addition, increases in patient turnover, increasing complexity of patients seen, frequent medication changes and shorter lengths of stay present challenges to accurate and timely completion of medication related changes on the EDN. Several key recommendations are made including:

Improvement of the current EDN proformas to facilitate key data entry around reasons for medication changes and new medicines started in hospital

Focused education & training on the safety issues around medicines-related discharge for all staff involved in EDN completion

Establishment of electronic medicines reconciliation records linked to EDN, eventually linked to electronic prescribing This audit provides useful information to support achievement of the Trust CQUINs around discharge information.

References

1. Picton C and Wright H. Keeping patients safe when they transfer between care providers - getting the medicines right Final Report. June 2013.

Royal Pharmaceutical Society. http://www.rpharms.com/current-campaigns-pdfs/rps-transfer-of-care-final-report.pdf

2. Roth-Isigkeit, Angela. Harder, Sebastian. Reporting the discharge medication in the discharge letter. An explorative survey of family doctors.

Medizinische Klinik 2005;100(2):87-93

3. Managing patients’ medicines after discharge from hospital. Care Quality Commission (October 2009)

4. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for

Hospitalists. Journal Hospital Medicine 2007;2(5):314-235.

5. Poor medicines information transfer risks patients health. Royal Pharmaceutical Society Press Release (July 2007)

5. An audit of the medication management of in-patients with Parkinson’s disease Bharkhada, B. West Suffolk NHS Foundation Trust, Bury St Edmunds

Introduction Parkinson’s disease (PD) is a progressive, chronic neurological disease which affects 127,000 people in the UK 1. Admission to hospital poses a risk of suboptimal medication management which can result in complications of PD or loss of symptom control, prolonged hospital stay and increased likelihood of re-admission, with poorer patient safety and clinical outcomes. Improved medicines management is a key outcome of NHS reform, and recommendations in the NICE Guideline for PD2 and NSF for Long Term Conditions3 indicate PD medication should not be withdrawn abruptly, and be given at the appropriate times, which in some cases may mean allowing self-medication. There are currently no guidelines for the medication management of PD during hospital admission at WSH. The audit aims to examine the medication management of in-patients with PD during their hospital stay in order to assess if standards are being met according to NICE2 and NSF3.

Objectives Ascertain the level of adherence of:

recording the patient’s medication reconciliation (MR) within 24 hours of admission (100%)

patients’ medication given and administered on time according to NICE2 and NSF3 (100%) Ascertain the number of patients:

assessed and suitable for self-medication

prescribed inappropriate medication such as centrally acting anti-dopaminergic drugs

Method The audit was registered with governance within the Trust in August 2013 and ethics approval was not required. A data collection form was designed and piloted on five in-patients. Due to the feasibility of acquiring a bigger sample size and a longer time period to collect data the audit was retrospective. The data collection form was codified for ease of data entry. The inclusion criteria were patients who, on admission, were taking one or more medications specifically for PD only. Fifty patients were randomly selected from a list of patients identified as having PD medication dispensed between April and August 2013. A total of 25 drug charts were audited in August 2013 due to the limited availability of case records and patients taking PD medication for other disease states such as restless leg syndrome.

Results The mean age was 80 years and 72% of patients were admitted to general medicine. 12% of patients had a MR completed within 24 hours of admission, and a further 24% had no MR completed during their hospital stay. Figure 1 summarises the results relating to the administration of PD medication. Most common reason for missed doses was unavailability of drug, of which 80% of patients had not brought in their medication from home and 20% brought in a MDS. 100% of patients who had all their medication given brought in their own medication from home. One patient administered their own medication (from a MDS) and had not been assessed to self medicate. Although no patients were prescribed contraindicated medication, two patients were prescribed cyclizine and cinnarizine (both of which should be used with caution in PD). Four patients (16%) had unintentional changes to their PD medication regime in hospital and these were due to incorrect medication timings and doses.

All doses given

One or more doses missed

All given doses on time

9 (36% ((95% Cl) 17.2 to 54.8))

11

One or more given doses delayed

2

3 (12% ((95% Cl) 0 to 24.7%))*

Total patients

11

14

Figure 1: Summary of the results relating to the administration of PD medication *Actual calculated CI is -0.7 to 24.7% (negative value indicates sample size is too small)

Discussion Bias was introduced as the audit was retrospective and used convenience sampling. In addition only patients who had their medication dispensed by pharmacy were identified for the audit. The 95% confidence intervals indicate a bigger sample size will improve the accuracy and quality of results. The identification and prioritisation of PD patients by pharmacy staff can help improve targets of achieving the completion of a MR within 24 hours of admission, and therefore ensure the correct PD regime prescribed and available. This can be achieved by utilising the PD Society ‘Get it on time’ campaign stickers on drug charts and the addition of an icon on ward whiteboards to highlight PD patients to all multidisciplinary staff. Poor documentation of administration times on the MR, possibly because the patient was not commonly used as a source of information, can be addressed by training pharmacy staff to include this information on the drug chart. Poor adherence to the objectives may be due to medical and nursing staff unaware of where to obtain PD medication when pharmacy is closed, lack of awareness by nursing staff that PD medication should not be omitted or delayed and the unavailability of a self administration policy for PD patient. To improve adherence a stock location poster could be designed for use on wards to reiterate where to locate PD medication and the circulation of a Medicines Information memo to all medical and nursing staff highlighting that omission or delayed administration of PD medication are patient safety incidents. Furthermore, patients should be encouraged to bring in their own medication from home, particularly for planned admissions, which ensures continuity of care as financial savings for the Trust. The incidence of missed doses was higher compared to delayed doses due to under-reporting of delayed doses on drug charts. It may be beneficial for nursing staff to use pill timers or alarm clocks which can be set to individual regimes for PD patients. A guideline for the management of PD patients with swallowing difficulties or when nil by mouth is currently in progress. It would be informative to include advice on medications to avoid in PD and greater guidance on utilising the self-administration scheme to promote independence and support self care during admission to hospital. References

1. Parkinson’s Disease Society. www.parkinsons.org.uk (accessed 12/09/13) 2. NICE Guideline (CG35). Parkinson’s Disease: Diagnosis and management in primary and secondary care. June 2006.

http://guidance.nice.org.uk/CG35 (accessed 12/09/13) 3. DoH. NSF: Long term conditions. March 2005. www.gov.uk (accessed 12/09/13)

6. Identification and exploration of factors that influence prescribers decision making in their use and selection of antibiotics in a respiratory unit.

Cunnane CM1, Kinnear M1,2, Mullen AB2, Scott J1, Shaw L1. 1NHS Lothian Pharmacy Service, Royal Infirmary of Edinburgh, Edinburgh and 2University of Strathclyde, Glasgow.

Introduction Unnecessary and inappropriate use of antibiotics over time is known to contribute to resistance and antibiotic associated infections.1 Surveillance systems and education initiatives in conjunction with policies and guidelines that encourage appropriate and rational use of antibiotics are key interventions for the monitoring and containment of resistance. 2,3 Adherence to antimicrobial guidelines for empirical treatment of infections reduce drug related toxicities and limit emergence of resistant strains. 4 Despite antimicrobial management team (AMT) and clinical pharmacist supported implementation of antimicrobial guidelines, local audit suggests variable prescribing practice and non-adherence to guidelines for respiratory tract infections. It is recognised in complex patients that the most appropriate antibiotic may deviate from guideline recommendations. Reasons for variation in uncomplicated patients are less clear. Vignettes are described as ‘simulations of real events which can be used in research studies to elicit subjects’ knowledge, attitudes or opinions according to how they state they would behave in the hypothetical situation depicted’. Short scenarios can be designed to illicit responses to typical situations, allowing the researcher to gain an insight into the influences behind variation in responses and analyse using descriptive analysis. 5 It was decided to use this methodology to provide insight into prescribing decisions to inform quality improvement strategies in the prescribing of antibiotics in a respiratory unit. Objectives To identify factors that influence antibiotic prescribing decisions in the treatment of a range of respiratory tract infections using short case scenarios and identify where there is potential for quality improvement in support for prescribing of antibiotics. Methods Four case scenarios, developed using deviations from guideline recommendations were agreed with a specialist clinical pharmacist, an antimicrobial pharmacist and a respiratory physician to ensure they realistically described typical scenarios. These were infective exacerbation of chronic obstructive airways disease (COPD), community acquired pneumonia (CAP) with variable clinical indices, and lower respiratory tract infection (LRTI). Sufficient information was provided to allow prescribers to diagnose the condition, choose an antibiotic and select 3 most influencing factors from a list based on literature review and multidisciplinary peer review. In addition, respondents were asked to rate the list of factors (and add others) when making initial prescribing decisions for antibiotics in respiratory infections using the scale; not influential, rarely influential, somewhat influential, very influential and extremely influential. The factors were listed under themes; information sources, antibiotic, patient and prescriber. The scenarios and questionnaire were piloted in one junior doctor who was excluded from the survey. An invitation letter detailing the study and allowing non-participation was delivered personally in May 2012 by the investigator to 23 medical prescribers within the respiratory unit of a 900 bedded teaching hospital; 5 Foundation Year (FY 1/2) doctors, 2 specialist trainees, 8 specialist registrars, 8 consultants. The cover letter, scenarios and anonymous questionnaire were distributed in June 2012 supported by specialist pharmacist reminders at local unit meetings and an e-mail reminder. The scientific officer of the Research Ethics Service advised that research ethics approval was not required and Pharmacy Quality Improvement Team approval was granted. Results The response rate was 83% (n=19/23); 1 consultant and 3 specialist registrars did not respond, probably due to leave and rotation out of the speciality. Compliance with local guidelines is illustrated in Table 1. Table 1 Compliance with local antimicrobial guidelines

COPD CAP high severity

CAP low severity

LRTI

FY 1/2 4/5 (80%) 4/5 (80%) 5/5 (100%) 4/5 (80%) Specialist Trainees 2/2 (100%) 2/2 (100%) 2/2 (100%) 2/2 (100%) Specialist Registrars 4/5 (80%) 5/5 (100%) 5/5 (100%) 5/5 (100%) Consultants 6/7 (86%) 7/7 (100%) 7/7 (100%) 5/7 (71%)

Prescribers’ experience, perceived knowledge of resistance patterns and attitudes towards guidelines were influencing factors in decision making. Junior doctors’ decision making was extremely influenced by the local antimicrobial guidelines; whereas more senior doctors reported their knowledge and experience as more influential than guidelines. One doctor reported intentional non-adherence to the local antimicrobial guideline justified by their perceived local knowledge of antimicrobial resistance. Diagnostic factors such as sputum characteristics were reported to be influential in decision making among experienced prescribers. The CURB65 score was reported as influential by junior doctors when prescribing for CAP, confirming its use as a decision aid when included as part of the local antimicrobial guidelines. Experienced prescribers prioritised their clinical judgement over the CURB65 score. For the LRTI scenario where treatment guidelines were less specific variation in choice of antibiotic was based more on clinical signs and symptoms. Financial implications influenced decisions among senior doctors more than junior doctors. Conclusion The scenarios facilitated a standardised approach to explore perceived prescribing influences; although actual prescribing behaviour may differ, the findings tended to reflect current prescribing variation between the different grades of doctors. Subsequent recommendations to the AMT were to educate prescribers about local resistance patterns; and to engage specialist prescribers in guideline development to improve ownership and consistency in prescribing practice. The antimicrobial guidelines have since been updated to include recommendations for LRTI which should reduce the variable prescribing identified. Also, the recent introduction of a mobile phone App should aid accessibility to the guidelines at the point of prescribing. Future work using this methodology could evaluate prescribing behaviour within other specialities to improve the facilitation of local changes. References

1. Levy S. Antibiotic resistance: Consequences of inaction. Clinical Infectious Diseases 2001; 33(Supplement 3):S124-S129. 2. World Health Organisation. The evolving threat of antimicrobial resistance – options for action. 2012.

http://www.who.int/patientsafety/implementation/amr/publication/en/ (accessed 01/01/14). 3. Davey P, Sneddon J, Nathwani D. Overview of strategies for overcoming the challenge of antimicrobial resistance. Expert Review of Clinical

Pharmacology 2010;3(5):667–686. 4. Nathwani D. From evidence-based guideline methodology to quality of care standards. Journal of Antimicrobial Chemotherapy

2003;51(5):1103-1107. 5. Philips T, Spalding N. Exploring the use of Vignettes: From Validity to Trustworthiness. Qualitative Health Research 2007;17:954-962.

7. Pilot of a Pharmacist Independent Prescriber in Orthopaedic Admissions suite (OAS) to support the Enhanced Recovery After Surgery (ERAS) project for patients undergoing Hip and Knee replacement Surgery and to reduce length of stay.

O’Brien, N., Hoskins, C, Pharmacy Department, Cheltenham General Hospital (CGH), Gloucestershire Hospitals NHS Foundation Trust.

Introduction A project team was developed in 2013 within the Trust to look into Enhanced Recovery After Surgery (ERAS) in Trauma and Orthopaedics, with the aim to produce a pathway similar to that already being used with success in many other hospitals 1,2 As part of the ERAS project, practices across the two hospitals within the Trust were compared. It was identified that there was inconsistent and variable prescribing of ERAS analgesia across the Trust. Patients’ regular medication was also incomplete or inaccurately charted in 50% - 96% of cases on admission to the T&O wards and it was felt that both of these factors could be contributing to an increased length of stay for patients undergoing total hip and knee replacement. As a response to these findings, a 3 month pilot of a Pharmacist Independent Prescriber in the Orthopaedic Admissions Suite (OAS), at one of the two hospitals within the Trust, was started on 7th October 2013. Aims and Objectives To reduce missed doses and risk of compromise to patients pre-existing medical conditions through accurate and complete prescribing and medicines reconciliation of patients’ regular medicines by the Pharmacist Independent Prescriber in OAS. For ERAS analgesia to be prescribed consistently by the Pharmacist Independent Prescriber in OAS- It was postulated that this would improve post-operative pain control, allowing early mobilisation and decreasing length of stay. Method The proposal for a 3 month pilot of a Pharmacist Independent Prescriber in OAS was agreed by the ERAS project team. The ERAS analgesic regimen was agreed by the Pharmacist Independent Prescriber, Anaesthetists involved in total hip and knee replacements and the Acute Pain Service. The Pharmacist Independent Prescriber planned to see all total hip and knee replacement patients going through OAS at the one hospital, and had the following remit-

Consultation with patients on the morning of their hip or knee replacement and prescription of their regular medication as appropriate.

Prescription of ERAS analgesia as agreed by the project group.

Prescription of prophylactic antibiotics, VTE prophylaxis and laxatives and anti-emetics as appropriate.

Patient counselling on post-operative analgesia and VTE prophylaxis.

Responding to ambiguities and clinical concerns relating to perioperative management of patient’s medicines as needed. Clinical concerns were referred to the anaesthetist or medical team looking after the patient.

An anonymised log was kept of patients assessed by the Pharmacist Independent Prescriber. Length of stay was followed up for these patients and compared to pre-pilot lengths of stay for patients undergoing total hip and knee replacement. Feedback forms (n=18) assessing the pilot’s impact were distributed and collected from medical (anaesthetists, doctors), nursing and pharmacy staff involved in the care of total hip or knee replacement patients. Results At 6 weeks the pilot demonstrated a decreased length of stay for both total hip and knee replacement patients (Table 1). During the first 6 weeks the only change in practice was the introduction of the Pharmacist Independent Prescriber. A further reduction in length of stay was shown at 12 weeks but may also be attributed to the increased use of a local wound infiltration (Ropivacaine and Adrenaline, RA) within the hospital which the Pharmacist Independent Prescriber helped to implement. Table 1 – Length of stay (days) pre-pilot and at 6 and 12 weeks of pilot.

Average length of stay (days)

Pre-pilot

6 weeks into pilot

12 weeks into pilot

Total Hip Replacement 6.7 5.7 5.27

Total Knee Replacement 7.32 5.47 4.18

From the feedback forms, all responders across all staff grades (18/18) agreed or strongly agreed that prescription of ERAS analgesic medication and patient’s regular medication had improved since the pilot’s initiation. The following comments were received from an F2 Doctor and Consultant Anaesthetist- “ERAS post op analgesia is now prescribed to the same level, whereas anaesthetic prescribing varied greatly previous to this” and the pilot has “greatly improved standards and consistency of post op prescribing”. Discussion As well as seeing a significant decrease in length of stay, feedback forms demonstrated that the pilot was well received by all responders. 100% (n=18) of responders recommended that the pilot continue. Further comments on the feedback forms revealed the pilot saved other healthcare professionals’ time in their routine workload associated with elective hip and knee replacement patients. This included nursing, anaesthetic and medical staff time as well as pharmacy staff time spent on the wards. Notably, junior doctors reported an estimated time saving of at least forty five minutes to one hour per day as a result of them not being required to attend OAS. Consequently, they were able to spend more time on the T&O wards looking after patients post-operatively and preparing for their discharge. As a result of increased time available for the doctors, the percentage of T&O discharge summaries being sent to GPs from the hospital within one working day increased from 69.48% in August 2013 to 78.12% in November 2013.

The Acute Pain service at the hospital also reported that since the pilot’s initiation, with the new simplified analgesic regimen being prescribed consistently by the Pharmacist, there have been virtually no referrals for patients in pain who have undergone hip and knee replacement surgery. References

1. Scott NB, McDonald D, Campbell J, et al.; The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units--an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland.

2. White, Jonathan J E; Houghton-Clemmey, Robert; Marval, Paul ; Enhanced recovery after surgery (ERAS): an orthopaedic perspective

;Journal of Perioperative Practice; October 2013; Volume 23, Number 10, , pp. 228-232(5)

8. A study to determine whether the use of a novel triage tool reliably identifies those patients within the Rehabilitation and Assessment Directorate at Glasgow Royal Infirmary with the greatest requirement for pharmaceutical care, and to determine the most

appropriate stage of admission to apply this tool. Wheelan C1, Stirton J1, Fenelon C1, McIntosh T2, 1 Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow

2 Robert Gordon University, Aberdeen

Background The population in Scotland is aging. By 2033, an 80% increase in those aged over 75 years1 is projected. Prescribing for elderly patients represents a significant proportion of NHS prescribing activity2, with adverse drug reactions occurring commonly3. Resources are increasingly limited throughout the NHS and clinical pharmacists must consider novel ways to ensure services are targeted towards those patients with the greatest requirement for pharmaceutical care4. Within NHS Greater Glasgow and Clyde, elderly patients are cared for within the Rehabilitation and Assessment Directorate (RAD). Clinical pharmacy service to RAD wards is dependent on staffing levels, and reliant on informal systems of ward staff referring patients or individual pharmacists triaging their workload. Objectives 1. To adapt, validate, pilot and implement a novel triage tool, to be used within RAD, GRI. 2. To use the triage tool to group patients based on their requirement for further pharmaceutical care as: red (high risk); amber (moderate risk);

and green (low risk). 3. To quantify and compare the number, type and clinical significance of pharmaceutical care issues identified between the triage groups. 4. To determine if the tool reliably identifies those patients with the greatest requirement for pharmaceutical care, and to determine whether the

tool is best applied on Day 1 or 2 of admission. Method A pre-existing referral tool was adapted for use in patients within RAD, GRI using a combination of literature review and specialist clinical pharmacist input. The tool was validated by senior pharmacist investigators, CW and JS, working independently to confirm inter-rater validity. The tool was piloted before being implemented over two weeks in March 2013 within the RAD area of the Medical Admissions Unit at GRI. Patients were triaged by application of the tool on Days 1 and 2 of admission, by CW and JS respectively, and a pharmaceutical care plan (PCP) was initiated. Thereafter patients received standard ward based pharmaceutical care from a member of the RAD clinical pharmacist team, and PCPs were updated accordingly, for a maximum duration of ten working days. PCPs were collated and comparison was made between the triage groups for three outcome measures: the number; type; and clinical significance of the pharmaceutical care issues (PCIs) per bed monitoring day. Type of PCI was sub-divided into those which resulted in a check or a change, whilst clinical significance of PCIs was sub-divided into those of minor, moderate and major clinical significance. This rating was adapted from a rating scale used previously at University of Strathclyde. Unpaired t-tests and Fishers exact test were used to determine any statistically significant difference between the three triage groups for each outcome measure. Ethical approval was obtained from Robert Gordon University, and the project proposal was submitted to the West of Scotland Research Ethics Service (WoSRES) who determined that local ethical approval was not required, as patient care was not altered. Results A total of 57 patients were included in the study and were distributed across the red, amber and green triage groups, with 33% to 49% triaged as green on Day 1 and Day 2 respectively. Patients in the three triage groups had a similar number of pharmaceutical care issues per bed monitoring day. The number of pharmaceutical care issues resulting in a change was greater in the red triage group than in both the amber and green triage groups, with the difference between the red and green triage groups considered statistically significant (p<0.05). Similarly, the number of pharmaceutical care issues of moderate significance were greater in the red group compared to the amber and green groups, with the difference between the red and green groups considered statistically significant (p<0.05). Results based on triage on Days 1 and 2 of admission are summarised in Table 1. Application of the tool on Days 1 and 2 yielded similar results, with a potential to reduce the number of bed monitoring days by 29-32% by withdrawing the clinical pharmacist service post triage for patients triaged as green. Table 1: Summary of pharmaceutical care issues per bed monitoring day across red, amber and green triage groups based on triage on Day 1 and Day 2 of admission

Red Amber Green

Day 1 Day 2 Day 1 Day 2 Day 1 Day 2

Care issues per bed monitoring day 1.54 0.79 1.57 1.0 1.25 0.71 Care issues resulting in check per bed monitoring day 1.00 0.43 1.15 0.59 0.89 0.46 Care issues resulting in change per bed monitoring day 0.43 0.33 0.3 0.29 0.16 0.15 Care issues of minor significance per bed monitoring day

0.91 0.39 1.13 0.59 0.85 0.46

Care issues of moderate significance per bed monitoring day

0.51 0.36 0.31 0.29 0.20 0.15

Care issues of major significance per bed monitoring day

0.01 0.01 0 0 0 0

Conclusion Application of the tool on Day 1 and Day 2 of admission reliably identified those patients with the greatest number of pharmaceutical care issues which resulted in a change to therapy, and those with the greatest number of pharmaceutical care issues of moderate clinical significance. It was concluded that the tool could reliably identify those patients with the greatest requirement for pharmaceutical care. Introducing the tool, and withdrawing the clinical pharmacist service to those patients triaged as green, has the potential to reduce the number of bed monitoring days, allowing redistribution of limited clinical pharmacist resources to those patients triaged red and amber. It is suggested that patients triaged as red and amber should receive clinical pharmacist review daily or on alternate days respectively, until such time that they are re-triaged as green. All patients would continue to receive pharmaceutical care at the point of discharge. It is recognised that the tool is unable to predict the course of a patient’s admission, and therefore it is proposed that it can only be introduced safely when used in conjunction with robust referral criteria. This would aim to ensure that patients triaged as green on admission would be referred back for review and re-triage by a clinical pharmacist if their clinical condition changed. Further work is required to develop appropriate referral criteria. References 1. The Scottish Government. Demographic change in Scotland. 2010. 2. Oborne CA, Batty GM, Maskrey V, et al. Development of prescribing indicators for elderly medical inpatients. British Journal of Clinical Pharmacology 1997; 43(1): 91-97. 3. Lindley CM, Tully MP, Paramsothy V, et al. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age and Aging 1992; 21(4): 294-300. 4. Cook G, Thomson G, and Lowdon K. Targeting clinical pharmacy services to high risk hospital patients. Pharmacy Management 2012; 28(1): 13-16.

9. Inhaler technique optimisation within Royal Liverpool University Hospital patients Lucy D, Bullock S, Royal Liverpool and Broadgreen University Hospital Trust

Introduction Inefficient inhaler technique is a common problem amongst asthma and chronic obstructive pulmonary disease (COPD) patients, resulting in poor drug delivery, decreased disease control and increased use of short-acting b2-agonists1. Research in The Isle of Wight found that 92% of patients have poor inhaler technique2. Additionally, the Asthma United Kingdom (UK) report ‘Compare Your Care’ found that 1 in 5 patients said nobody had ensured that they knew how to use their inhalers3. It is important that patients are counselled on their inhalers initially and at regular intervals to ensure they have not developed bad habits. Liverpool has one of the highest prevalence’s of both asthma and COPD. Emergency admissions for asthma patients in Liverpool are amongst the highest in the UK and around 43% of people here are more likely to be admitted to hospital with COPD than the UK average4. The Vitalograph Aerosol Inhalation Monitor© (AIM) is designed to assess the patient’s inhalation rate, coordination (ability to inhale and press the canister simultaneously) and breath holding. Visual observation is unable to assess these factors accurately therefore this machine helps to determine correct use of inhalers. Hence, this audit aims to ensure patients can use their inhalers, with a view to improving patient outcomes, reducing respiratory related hospital admissions and reducing the respiratory drug budget. Aims To assess inhaler technique and provide accurate inhaler technique counselling to all patients using inhalers within the Trust. To compare the AIM© and visual assessments and to determine if the received counselling improves inhaler technique. Objectives

• Assess inhaler technique using visual observation and the AIM© where clinically appropriate. • Provide appropriate inhaler technique counselling and assess impact upon inhaler technique. • Determine if ward staff assess the inhaler technique of inpatients.

Methodology

51 patients using inhalers admitted to RLUBHT were identified.

Inhaler technique was assessed using both the AIM© and visual observation in 27 patients.

Relevant data was collected using an approved data collection form.

Patients were then counselled and technique was reassessed.

Interventions were made where appropriate. Inclusion criteria: All patients admitted to the Royal Liverpool hospital prescribed inhalers. Exclusion criteria: All patients that are deemed too unwell to participate, did not wish to be involved or are unable to agree to be involved. Standards 1. 100% of patients should be counselled on appropriate inhaler technique. 2. 100% of patients should understand and perform good inhaler technique after appropriate counselling. As this was an audit, ethics approval was not required. All patients gave verbal consent to participate. Data was collected over a two week period in September 2013. Results 51 patients who had a total of 129 inhalers prescribed had inhaler technique assessed (Table 1). Of these patients, 71% had COPD, 25% had asthma and 4% had no formal respiratory diagnosis. Within this cohort of patients, 49% had been admitted due to an exacerbation of their respiratory condition. Table 1: Inhaler technique observation using AIM© and visual assessment; all figures refer to number of patients.

Assessment Vitalograph AIM© 27 patients participated

Visual 51 patients participated

Good technique 7% 79% Demonstrated good technique after counselling 37% 96%

Needed pharmacy intervention N/A – need further assessment when patients are medically fit

4% required a change in device

Use of reliever therapy varied, 27.5% of patients overused this inhaler and 43% of these had poor technique. Of the 51 patients, 45% did not know what their inhalers were for or their prescribed dose. Due to the self-medication policy, 59% of patients did not have their technique checked by ward staff on medication rounds; of these patients 35% had poor technique that was not identified by ward staff. Upon completion of assessment and counselling, 80% of patients felt their understanding had improved and 63% felt that their technique had improved also. Discussion A large proportion of patients with poorly controlled Respiratory conditions have poor technique. The patient's diagnosis affects the usage of their reliever inhaler, as patients with severe COPD will commonly overuse due to the nature of the condition. A limitation to the study is that patients may have poor control of their respiratory condition as a result of several factors besides poor technique, including non-compliance or inadequate therapy. Although all patients identified were counselled in accordance with standard 1, it would be beneficial to assess patients with AIM© when medically fit for optimum results, as many had been hospitalised due to an exacerbation and were unable to perform sufficient inspiratory flow. However the data obtained did find that patients who did not achieve good technique with AIM© did have good visual technique. The common misconception with metered dose inhaler use was ‘double-spraying’ the canister to achieve the one to two puffs prescribed dose, consequently this issue should be highlighted during counselling to all patients. Correspondingly 45% of patients did not know what their inhalers were for, yet following counselling 96% of patients did. This result suggests that building initial concordance with the patient in early diagnosis would be beneficial and may improve overall compliance with inhalers. The conclusion of this audit finds that although visual observation may demonstrate good inhaler technique, this may be misleading with regards to inspiratory rate. Furthermore patients should receive repeated counselling to ensure that they gain the most benefit from their inhalers. On the recommendations of this audit, a pharmacist now attends morning medication rounds on the respiratory wards to assess inhaler technique. Pharmacists now refer suitable candidates to community pharmacies for New Medicines Service and Medicines Use Reviews to improve inhaler technique. Education is now provided to nursing staff to ensure they have good inhaler technique themselves. All of these implementations will help to improve patient outcomes. References 1. Evaluation of Inhaler Technique Improvement Project, The Cambridge Consortium. August 2012.

Available from: https://wessexhiecpartnership.org.uk/wires/files/2013/07/120904-CIREM_ITIP_HIEC_Evaluation.pdf (accessed: 7/12/13). 2. Isle of Wight Respiratory Inhaler Project, National Institute for Health and Care Excellence. February 2011.

Available from: http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=461 (accessed: 7/12/13).

3. An Outcomes Strategy for COPD and Asthma: NHS companion document. May 2012. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216531/dh_134001.pdf (accessed 7/12/13).

4. Invisible lives: Chronic Obstructive Pulmonary Disease (COPD) – finding the missing millions, British Lung Foundation. Available from: www.blf.org.uk/Files/94ff4ae1-1858.../Invisible-Lives-report.pdf (accessed 7/12/13).

10. Pharmacy at the bedside: changing the pharmacy service to the wards to improve work flow through the dispensary Morton D, Liddle J, Adams P, Gloucestershire Hospitals NHS Foundation Trust

Background Within the Trust, pharmacy provides a clinical service to the wards, including a daily visit by a Pharmacist and a Medicines Management Technician. The team undertake drug histories; medicines reconciliation; assessment of patient’s own drugs (PODSs), and medication supply. They also provide pharmaceutical advice, assess prescriptions for clinical appropriateness and check discharge prescriptions. When the pharmacy team is not on the ward, prescription charts come to the dispensary for a clinical check and supply of medication for in-patient use or discharge prescriptions. This clinical check is a fundamental part of the pharmacist’s role and considers: patient factors (e.g. ethnic background, intolerances and preferences) and indication for and changes in regular medication1. From the dispensary it is not possible to easily access the patient and their notes for information about their medical condition and treatment, so a complete clinical check is not possible. Without knowledge of ward conditions such as bed pressures, it can be difficult to appropriately prioritise discharge prescriptions. This can mean they are expected to regard most or all of them as “urgent”. The flow of work is affected and pressure on dispensary staff increases the risk of errors. Objectives The project aimed to review whether providing a second visit to the wards increased the proportion of medication supplied as dispensed from discharge (OSD) above 70% by July 2013, facilitating quicker discharge and improving throughput and work flow in the dispensary. Method Ethics approval was not required for this service improvement project. A reconfigured service provided an additional afternoon visit (Monday-Friday) to clinically check any inpatient or discharge prescriptions written after the usual pharmacy visit, preventing items being sent to dispensary. With support from the Director of Pharmacy, Matrons and Ward Managers the reconfigured service was rolled out to wards in three phases according to need: Phase 1: Respiratory, orthogeriatrics, care of the elderly and general surgery Phase 2: Cardiology, gastroenterology, trauma & orthopaedics and vascular surgery Phase 3: Elective orthopaedics The three phases included a total of five medical and four surgical wards. During the additional afternoon visits data was collected between October 2012 and July 2013 about the work done (number of prescriptions clinically checked and supplies of medication undertaken) and time spent. Feedback forms were sent to dispensary staff in March 2013. Results Between October 2012-July 2013 the following work was undertaken on afternoon visits: 912 discharge prescriptions clinically checked and 1,383 items clinically checked and supplied. Table 1 compares the dispensary workload for January–April; 2013 versus 2012. Items dispensed for discharge (OSD) increased by 14% as supplies were identified earlier in the in-patient stay reducing the number of items supplied at time of discharge. The number of ad hoc in-patient supplies has also decreased by 20% as items are increasingly supplied in a planned way. Acute admissions to the trust increased by 6.5% in 2013, whilst total dispensary workload has only increased by 2% with a 13% reduction in the number of discharge prescriptions received in pharmacy. Returns have also fallen by 3% compared with the same period in 2012. Table 1: Dispensary workload January – April; 2012 versus 2013

2012 (items) 2013 (items) Percentage change

In-patients 3,270 2,635 20%

OSD 22,561 25,689 14%

Discharge 14,838 13,105 13%

Total returns 16% 13% ↓ 3%

Percentage of medication available as OSD at discharge

70% (48-81%)

76% (61-93%)

↑ 6%

Dispensary staff were asked to return a feedback form (nine received back):

57% agreed that discharge prescriptions were dispensed and checked more quickly (14% neutral)

63% felt that team working between the dispensary and clinical teams improved

50% stated there was more organisation to the work (less urgent prescriptions) Discussion Work coming to the dispensary from wards arrives in three ways: items dispensed for discharge (OSD) transcribed by pharmacy staff on the wards; in-patient charts containing new prescriptions; and discharge prescriptions for dispensing. Within the dispensary, dispensing and checking OSD items is the quickest way of processing items as it has the fewest number of steps in the process. Discharge prescriptions require a more complete clinical check and greater interpretation. Increasing the proportion of OSD and reducing discharge items enables medication to be processed more quickly, improves work flow in the dispensary and improves the skill mix of staff required. An increased presence on the wards allows better communication with ward staff regarding discharge planning. This allows pharmacy staff to supply OSD in advance of the discharge prescription being written, improving the efficiency of the discharge process and smoothing the flow of work. Undertaking the clinical check on the wards, allows greater ability to prioritise urgent discharges, through more knowledge of the wards, patients, transport situations and pressures in the Emergency Department. This reduces the number of discharge prescriptions requested as urgent, allowing the dispensary greater ability to prioritise and manage its workload. Clinical checking at ward level rather than in the dispensary has led to a reduction in medication wastage, through utilisation of PODs, locating “missing” medications to prevent re-dispensing and identifying patient transfers to other hospitals which do not require a discharge prescription. Decreasing this waste is also a cost saving in staff time and potentially reduces length of stay. Clinical checking on the ward rather than in the dispensary is also more efficient as there is easy access to patients, notes, and the staff caring for them, rather than using pagers and the telephone system to resolve queries. The reconfigured service has been provided within existing staffing resources. It has been staff neutral because the time required to undertake afternoon visits has come from a reorganisation of the morning visits and a reduction in dispensary staffing. References 1. Royal Pharmaceutical Society. Clinical check: A quick reference guide [internet] 2011. http://www.nicpld.org/courses/hospVoc/assets/RPS_ClinicalCheckQuickReferenceGuide.pdf

11. Pharmacy at the Bedside, increasing quality of Clinical services Morton D, Liddle J, Adams P, Gloucestershire Hospitals NHS Foundation Trust

Background Within the Trust, pharmacy provides a clinical service to the wards, including a daily visit by a Pharmacist and a Medicines Management Technician. When the pharmacy team is not on the ward, prescription charts come to the dispensary for a clinical check and supply of medication for in-patient use or discharge prescriptions. This clinical check is a fundamental part of the pharmacist’s role and considers: patient factors (e.g. ethnic background, intolerances and preferences) and indication for and changes in regular medication1. From the dispensary it is not possible to easily access the patient and their notes for information about their medical condition and treatment, so a complete clinical check is not possible. The medication chart is not available on the ward when it comes to Pharmacy for a clinical check and supply of medication. This can lead to missed doses if the medication chart is not on the ward at the drug round or when required by the doctors. Moving the clinical check to the bedside from the dispensary will increase the quality of the clinical check and reduce missed doses. Objectives To focus the clinical checking process at ward level to increase the quality of the clinical check. To improve the quality of the clinical service provided by increasing pharmacy presence at the patient care interface (bedside) and increasing the proportion of medication dispensed for discharge to 70% thus facilitating timely discharge. Method Ethics approval was not required for this service improvement project. A reconfigured service provided an additional afternoon visit (Monday-Friday) to clinically check any inpatient or discharge prescriptions written after the usual pharmacy visit, preventing items being sent to dispensary. With support from the Director of Pharmacy, Matrons and Ward Managers the reconfigured service was rolled out to wards in three phases according to need: Phase 1: Respiratory, orthogeriatrics, care of the elderly and general surgery Phase 2: Cardiology, gastroenterology, trauma & orthopaedics and vascular surgery Phase 3: Elective orthopaedics The three phases included a total of five medical and four surgical wards. During the additional afternoon visits data was collected between October 2012 and July 2013 about the work done (number of prescriptions clinically checked and supplies of medication undertaken) and time spent. Feedback forms were sent to staff involved in March 2013. Results The work completed during the afternoon visits between October 2012 and July 2013 included:

912 discharge prescriptions clinically checked

1,383 items clinically checked and supplied

All wards involved exceeded the Key Performance Indicator of 70% of medication dispensed for discharge, prior to the discharge prescription being written

An extra 31 hours devoted to patient education (277 patients) particularly those on complex regimens or taking high risk medication such as anticoagulants.

720 pieces of advice given to staff including: stopping of inappropriate supply of a high risk injectable, confirmation of immunosuppression regime with the tertiary centre and appropriate choice of antibiotics in a patient with multiple allergies.

Acute admission increased by 6.5%, whilst there was a 13% reduction in discharge prescriptions dispensed, January-April; 2013 versus 2012. The number of compliance aids dispensed each month was reviewed over a two year period and fell from 78 in November 2011 to 57 in November 2013. All staff involved in the reconfigured service were asked to complete a feedback form.

Nurses (87) clearly indicated that missed doses were reduced as charts are remaining on the ward (99%), patient safety was improved (98%). They also felt the reconfigured pharmacy service aided timely discharge (89%), increased early initiation of discharge prescriptions (80%) and aided weekend discharges (77%).

All doctors (14) agreed that having a pharmacist on the ward in the afternoon improves patient safety, allows efficient discharges and ensures queries are dealt with more quickly.

All pharmacy staff (8) agreed that the new system was beneficial to patients and improved patient safety. The majority (78%) agreed they were able to provide a better service to the wards and it helped with timely discharge (75%).

Discussion The additional afternoon visits have increased the profile of Pharmacy on the wards, to both staff and patients. One comment received from a nurse was “It also gives confidence to the relatives in that they see the “face” of pharmacy so they are reassured that the pharmacy team know that the patient’s medications are important.” Patient safety has been increased through enhanced clinical checking of prescriptions on the ward with access to notes, patients, medical and nursing staff. There is also improved access to pharmacy expertise for doctors and nurses and increased information and education available to patients. The new approach also reduced the number of missed doses through more efficient supply of medication and retaining medication charts on the ward. Patient experience at discharge has also improved. Earlier identification of planned discharges by liaising with the staff involved in discharge planning has improved the overall process. Increasing the percentage of medication dispensed for discharge and as pre-packs, enables nurses to assemble the discharge prescription on the ward, reducing delays in discharge. There has been a greater ability to prioritise urgent discharges, through more knowledge of the ward, patient and transport situation. There has also been a reduction in medication wasted through location of “missing” medication and increased use of PODs. Ward-based pharmacy staff can identify patients being transferred to other hospitals avoiding unnecessary requests for discharge prescriptions and preventing inappropriate requests for compliance aids. From the ward setting there is greater ability to utilise the community supply of existing compliance aids, preventing waste, duplication of work and unnecessary delays in discharge. The reconfigured service has been provided within existing staffing resources. It has been staff neutral because the time required to undertake afternoon visits has come from reorganisation of the morning visits and a reduction in dispensary staffing. References 1. Royal Pharmaceutical Society. Clinical check: A quick reference guide [internet] 2011. http://www.nicpld.org/courses/hospVoc/assets/RPS_ClinicalCheckQuickReferenceGuide.pdf

12. Research into the appropriateness of caspofungin prescribing in a university teaching hospital Jilka D, Wickens H, Hand K, University Hospital Southampton

Introduction Broad spectrum antifungal agents such as caspofungin have high acquisition costs, and as their use can drive resistance also, it is imperative that these agents are initiated and prescribed rationally. We conducted a retrospective review of dispensing records and clinical case notes for all patients initiated on caspofungin at a 1,110-bed UK teaching hospital between 1st July and 31st December 2012. Aim To determine if caspofungin treatment or prophylaxis was advocated according to current guidelines for fungal infection (national and international) and to establish whether caspofungin was prescribed for the appropriate duration. Objectives

Determine what indication caspofungin had been initiated for. Categorised into: 1. invasive fungal infection (IFI) in haematology/oncology patients 2. febrile neutropenia 3. yeast positive blood culture in non-haematology/oncology patients 4. severe sepsis/septic shock in non-haematology/oncology patients 5. prophylaxis of invasive fungal infection 6. other indications

Determine if the initiation of caspofungin during the research period had been appropriate according to current antimicrobial standards (national and where no national guidelines existed international)1,2

Establish the number of days of appropriate vs. inappropriate caspofungin prescribing

Method A retrospective review of dispensing records was undertaken for all patients initiated on caspofungin between 1st July and 31st December 2012. The study was registered with the hospital R&D department and ethics approval was not required. A data collection template was designed using guidelines from the British Committee for Standards in Haematology, European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group, the National Institute of Allergy and Infectious Diseases Mycoses Study Group and the Infectious Diseases Society of America (IDSA). For each patient, the medical notes were examined retrospectively to determine: • Documented Indication • Any isolated fungi and related drug susceptibilities • Patient factors such as immune status, presence/duration of pyrexia, presence of SIRS/sepsis criteria, and whether criteria for diagnosis of

proven/probable/possible invasive fungal infection (IFI)1 and/or febrile neutropenia2 were met according to international standards • Antimicrobial (anti-bacterial and anti-fungal) treatment received and duration (before and after caspofungin initiation) • Evidence of clinical response (using among other measures improvement in CRP, clinical signs/symptoms, imaging) • Course length Results 48 inpatients were initiated on caspofungin in the 6 month period. These 48 patients received a total of 677 days of caspofungin, with an average of 14 days per treatment course (range 1-91 days). 33/48 patients were at high risk of IFI due to significant immunosuppression. 29/48 patients received at least one other systemic antifungal for at least one day prior to caspofungin initiation; 47/48 had received antibacterials immediately prior to initiation of caspofungin (47/47 for ≥48 hours). 28/48 patients were initiated on caspofungin on microbiology recommendation. 25/48 patients had shown evidence of a clinical response to caspofungin, 3/48 had no response and in 20/48 it could not be determined whether or not the patient had responded. Using national and international standards, we evaluated whether caspofungin was indicated. Of 48 evaluable cases, 35/48 (73%) were appropriately initiated on caspofungin, meaning 13/48 (27%) did not meet accepted criteria for initiation of an echinocandin antifungal (see table 1). A review of course length found that of the 677 total days of caspofungin prescribed, 132 were potentially inappropriate (19%) at a cost of approximately £50,000 representing 15% of total expenditure on caspofungin for a 6-month period. Table 1: Indications for caspofungin and appropriateness of prescription in days

Discussion & Conclusion This small case series suggests that caspofungin had been initiated appropriately in the majority of cases; clinicians should be guided to switch to azoles where culture and sensitivity data support this. Where caspofungin was not indicated, this was most commonly because the isolated organism was azole-susceptible. This study was limited to a single centre and the findings require validation in other centres. Determining appropriateness of antifungal prescribing is a largely subjective process with limited evidence to guide decision-making. There is an unmet need for NICE guidance on the treatment, prophylaxis and duration of therapy for invasive fungal infection in hospitals. References

1. Ascioglu, S. et al. Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoeic stem cell transplants: an international consensus. Clin Inf Dis 2002; 34:7-14

2. Pappas P, Kaufmann C, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Inf Dis 2009; 48: 503-535

13. A retrospective audit to assess the prevalence of venous thromboembolism in cancer patients undergoing major abdominal surgery at University Hospital Aintree NHS Foundation Trust

Beach D*, Beach T*, University Hospital Aintree NHS Foundation Trust

Introduction The development of venous thromboembolism (VTE) is a well known complication of major abdominal surgery1. It is estimated that one in five cancer patients will have a diagnosis of a VTE event at some point during their treatment2. NICE guidance published in January 2010 (CG92) recommends extension of pharmacological VTE prophylaxis to 28 days postoperatively in those patients who have undergone major surgery in the abdomen or pelvis related to cancer3. At present, the current hospital formulary guidelines for VTE prophylaxis in cancer patients undergoing major abdominal surgery at University Hospital Aintree does not recommend extending VTE prophylaxis to 28 days post-surgery, and so does not follow current NICE guidelines. Aim To assess the prevalence of VTE in cancer patients undergoing major surgery of the abdomen and pelvis due to non-compliance with NICE CG92 January 2010 on extended VTE prophylaxis within the surgical directorate. Objectives To determine the number of inpatients who had a DVT or PE confirmed during their hospital stay. To determine the number of confirmed DVT’s or PE’s at 28 days and three months postoperatively. To identify any additional individual patient risk factors for developing a deep vein thrombosis (DVT) or pulmonary embolism (PE) within the selected group (as defined by NICE).

Method Data collection was carried out by the lead author. The hospital coding system was used to obtain retrospective colorectal, upper GI and hepatobiliary oncological surgical patients between January and March of 2011. Individual case notes and electronic care records were used to collate all relevant information (date of operation, number of days treatment with VTE prophylaxis, patient risk factors for VTE) and this was recorded on a specially designed audit data collection sheet. Telephone contact was made with GP surgeries to complete the 3 month follow-up process. Ethical approval was not required for the purpose of this audit. Results A total of 87 colorectal, hepatobiliary and upper GI oncological surgery patients were reviewed. From these patients, three patients were identified as having had a radiologically confirmed VTE event as an inpatient. Of these, two patients had confirmed PE’s. Both were male. One female patient, with a central venous catheter (CVC), had a diagnosis of a right internal jugular thrombus. The mean time between the above diagnoses and the index operation was 7.3 days. The mean age at diagnosis was 66.7 years. Their average BMI was calculated as 27.7kg/m2. All three patients had an ITU admission post-operatively and had a CVC inserted. Of the total study population 82 (94.3%) of patients received the recommended 5,000 units of dalteparin subcutaneously once daily as an inpatient. Of those not receiving the recommended dose, one patient was admitted on treatment dose Tinzaparin after developing a PE whilst on chemotherapy, one patient was prescribed 2,500 units of dalteparin s/c once daily, and three patients had no VTE prophylaxis prescribed. However, only 38 (43.7%) of patients had mechanical VTE prophylaxis (TED stockings) prescribed on their inpatient chart. Also of note, only one patient received the recommended 28 day post- operative VTE prophylaxis, as they were an inpatient due to a prolonged hospital stay. With the exception of the one patient who was an inpatient at day 28, the remaining 78 patients of the audit group had a 28 day and three month follow-up. No patients were found to have had a DVT or PE within these timeframes. Table 1 Audit Results

Total number of inpatient DVT’s 1

Total number of inpatient PE’s 2 Total number of DVT’s at 28 days and 3 months post-surgery 0 Total number of PE’s at 28 days and 3 months post-surgery 0

Discussion Results from this audit have shown the incidence of VTE to be 3.4% at University Hospital Aintree post major abdominal surgery, with all of these occurring within the inpatient setting. Of those with confirmed VTE, 100% had an ITU admission with complications including hospital acquired pneumonias, new onset AF, hypertension, acute kidney injury and line infections – demonstrating that complications beget complications. CVC’s were present in all patients positively identified with VTE. The presence of a CVC is a well-established risk factor for VTE. Regular review of CVC’s is, therefore, vital and the earliest possible removal should be a priority. The average length of stay patients with VTE in this audit was 11 days in comparison to 9.9 days for those who did not develop VTE; suggesting that increased length of stay may also contribute to the increased risk of VTE. A number of shortcomings can be identified with this audit. Firstly, reliance was placed on receiving accurate coding data to identify all relevant patients within the audit population. Secondly, both 28 day and three month follow-up involved contact with GP receptionists and dependence on them for accurate information which means that some outpatient VTE’s may have been missed. A more reliable method of getting this information may have been to directly contact the patient at the 28 day and 3 month follow-ups. In conclusion, information gathered from this audit would suggest that extended VTE prophylaxis is currently not justified. Cumulative available evidence, as well as results from this audit, show those at greatest risk of VTE are inpatients, especially those with an increased number of risk factors. This should be our target population. Perhaps then the emphasis should be on adequately protecting the inpatient population by focusing on improving our inpatient prescribing of VTE prophylaxis (both mechanical and pharmacological) until more sound evidence is available to justify extended VTE prophylaxis. The American Society of clinical Oncology guidelines recommend VTE prophylaxis for 7 to 10 days post-surgery with extended prophylaxis for up to four weeks in ‘high risk’ patients4. Should this be the approach our trust takes? References 1 .Rasmussen MS, Jorgensen LN, Wille-Jorgensen P et al. Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicentre randomised open- label study. J Thromb Haemostat 2006; 4: 2384-2390 2. Lyman G, Khorana AA, Falanga A et al. Preventing Venous Thrombolism in Cancer Patients: Can we do Better? American Society of Clinical oncology 2009; 5: 165-166 3. NICE clinical guidelines. Venous Thromboembolism: Reducing the Risk 2010; 92 : 2 4. Lyman G. American Society of Clinical Oncology Guideline: Recommendations for Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer. J Clin Oncol. 2007;25: 5490- 5505

14. Description and quantification of Ward Based Pharmacy Activity. Duncan McRobbie, Associate Chief Pharmacist-Clinical Services, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Introduction: While dispensing activity and drug costs are easily measured ward based pharmacy activity is difficult to quantify. At this hospital, pharmacy staff visit wards to facilitate supply and to ensure the safe and effective use of medicines in line with recognised NHS initiatives.1, 2 Objectives: To quantify the activity under taken at ward level by pharmacy staff at this hospital. Method: A data collection form had been in use for 4 previous years. Proformas were used for the data collection to ensure consistency and guidance notes were made available to participants. Data collection was divided into activity that occurred on admission, during the patient stay and on discharge. The time taken on the ward was recorded in minutes. Intervention data was separately recorded. Data was collected for one week (Monday – Sunday) in November 2013. Ward based activity data was recorded in Excel®. Results

In total 10,330 activities were logged in 1151 hours of ward based pharmacy activity over one week.

36 different ward based pharmacy activities were described.

979 medicine reconciliations were undertaken, of which 40% required input from the pharmacy to ensure accuracy. In total 802 individual changes were made to medicines at the MR stage.

1290 clinical screens were undertaken at the admission process of which 38% of which required pharmacist input to ensure the medicines were optimised.

1910 patients own drugs (PODs) were evaluated for suitability of which 1632 were used. This equates to 42% of all medicines prescribed on admission.

2485 clinical screens were undertaken of inpatients charts and 552 clinical screens of TTOs were undertaken, resulting in 2740 contributions to clinical care.

859 electronic discharge prescriptions were screened of which 38% of which required pharmacist input to ensure the medicines were optimised. In total 916 individual changes were made to medicines at the discharge stage.

Patient education was provided on 1419 occasions and staff information on 1198 occasions.

2836 individual changes were made to improve medicines optimisation. (see table 1) Table 1. Activities which result in an action

Discussion This project describes and quantifies the activity taken by pharmacy staff on the wards. While others have described parts of the process we are unaware of any work which described all the activities undertaken3. Extrapolating these data over a year indicates that 32.4 WTE pharmacy staff undertake over half a million activities. These activities result in 150 000 individual contributions to medicines optimisation. Activity is collected by individual and hence can be.used to determine if tasks are being undertaken by the appropriate level of staff. Equally activities can be broken down by service (directorate) and data can be used to determine the appropriate staffing levels for each service. Others have identified the time taken for ward pharmacy activity4. The way these data were collected did not allow us to measure the times of individual activities. We believe this data collection is important in demonstrating the value of pharmacy services in ensuring the medicines optimisation. Acknowledgments This work demonstrates the commitment to patient care of the ward based pharmacy staff without whom the data collection would not have been possible. Special thanks to Lisa Salemi, Clinical Pharmacy Administrator for entering the data. References:

1. Audit Commission, A Spoonful of Sugar– Medicines Management in NHS Hospitals. London 2001. 2. Pharmacy in England: Building on strengths – delivering the future, Department of Health, April 2008. 3. Scullin C, Scott M, Hogg A, McElnay JC. An innovative approach to integrated medicines management. Journal of Evaluation in Clinical

Practice; 13 (2007) 781–788 4. Stuchberya P, Kongb DCM, DeSantisc GN and Kai Lod S, Clinical pharmacy workload in medical and surgical patients: effect of patient

partition, disease complexity and Major Disease Category. IJPP 2010, 18: 159–166

Pharmacists weekday 681 622 420 879 58053 3664 27.4 2602 94.9

Pharmacists weekend 72 66 10 37 1495 0.7 185 278.4

Tech weekday 49 0 9521 260 4.3 49 11.3

Total 2013 802 688 430 916 69069 3924 32.4 2836 87.4

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15. Selecting The Most Cost-Effective Model Of Care For Delivering Biological Agents As Maintenance Therapy In Patients With Crohn’s Disease

Lougher. E *, Allison. M.C , Hodson. K , Pugh. M, Pharmacy and Gastroenterology departments, Aneurin Bevan University Health Board, Newport. Cardiff School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, United Kingdom

Introduction The introduction of anti-TNF alpha monoclonal antibodies in 1999 has revolutionised the management of inflammatory bowel disease (IBD). A significant increase in gross spend on biological agents in the management of Crohn’s disease has occurred since the implementation of NICE guidance in 2002 1, 2. The unplanned nature of the service expansion and evolution has led to a wide variation in service delivery 3. Within the Aneurin Bevan University Health Board (ABUHB) the approximate doubling in the gastroenterology spend on biologics (between 2010 and 2011) prompted a review of current services and an investigation of other potential models of care for delivering the service. Methods A service evaluation for both adalimumab and infliximab (IFX) including: an assessment of the current services from a patient’s perspective (study 1), identifying and exploring models of care for delivering the service (study 2) and evaluating the costs associated with each model of care (study 3) was undertaken. Study 1 comprised face-to-face semi-structured, tape recorded patient-interviews, which were transcribed verbatim and then thematically analysed. Study 2 utilised a number of methods to identify key-informants at various secondary care sites to participate in telephone semi-structured interviews, models identified were compared and contrasted. Study 3 identified and compared the costs of current models within ABUHB with viable models identified in study 2. Full ethical approval was not deemed necessary as the project was classed as a service evaluation by the Research and Development committee within the Health Board. Results Study 1 revealed overall satisfaction with the IBD services and with the service provided by Healthcare at Home. Patients were complementary of the IBD team and the telephone help line. Nonetheless improvements to the infusion facilities were suggested by the IFX group. Study 2 identified five models of care for IFX and two for adalimumab. Those identified via the literature search (n=3) were excluded from cost analysis (study 3) due to limited available information. The remaining four identified models were taken forward to study 3 where one was further excluded due to lack of cost/patient benefit. Study 3 analysed the cost associated with the three models identified in study 2, and the existing two models in place within the Health Board at the time of the study: (1) IFX drug cost alone (ABUHB model) (2) IFX prepared in pharmacy inclusive of nursing administration cost, (3) IFX prepared and administered by a specialist nurse at ward level, (4) IFX at home via a home care company and (5) Adalimumab at home via Healthcare at Home (ABUHB model). For standard dosing (79kg: mean IFX patient weight at ABUHB) annual costs were £11614, £12,237, £12,314, £10,254 and £9,156 respectively. All costs were inclusive of drug cost and exclusive of those associated with the use of hospital facilities. Adalimumbad via the Healthcare at Home service was identified as the most cost effective model. Discussion Although study 3 identified adalimumab via Healthcare at Home as the most cost-effective model, vial sharing would further reduce the cost of models (1) and (2) with a predicted annual saving of £25000. Maximum vial sharing will require complex re-organisation of current facilities which itself has a cost implication. Specialist unit models were identified in study two and the evidence demonstrates patient satisfaction & cost-effectiveness in both gastroenterology and other specialties 4,5. However a fully staffed purpose built specialist unit requires further investigation. Conclusion Where clinically appropriate adalimumab via Healthcare at Home is recommended as first line, with IFX via a home care company as second line. Work should be done to improve the current infusion facilities. Future work should include reviewing the potential of setting up a biologics unit shared between specialities. References 1. National Institute of Health and Clinical Excellence. 2002. NICE technology appraisal 40- Guidance on the use of infliximab for Crohn's disease [Online]. Available at: http://www.nice.org.uk/nicemedia/pdf/NiceCROHNS40GUIDANCE.pdf [Accessed: 23rd March 2012]. 2. Bodger, K. 2011. Cost effectiveness of treatments for inflammatory bowel disease. PharmacoEconomics 29(5), pp. 387-401. 3. Carter, M. J. et al. 2004. Guidelines for the management of inflammatory bowel disease in adults. Gut 53 Suppl 5, pp. V1-16. 4. Doran, J. P. et al. 2009. An audit of hospital based outpatient infusions and a pilot program of community-based monoclonal antibody infusions. Ir J Med Sci 178(4), pp. 497-501. 5. Phan, V. et al. 2010. Introduction of a dedicated IBD service quantitatively and qualitatively improves outcomes in less than 18 months: a prospective cohort study in a large metrapolitan centre. Gastroenterology 138((Supl. 1): s318). Ethics Approval The protocol for the study was submitted to the Cardiff University School of Pharmacy and Pharmaceutical Sciences Research Ethics Committee. Approval was granted on the 30th May 2012. The protocol was then submitted to the ABUHB Research Scrutiny Committee and the ABUHB Risk Review Committee, who also gave their approval on the 6th June 2012. The study was approved as a service evaluation and therefore full ethics approval was not required.

16. Prospective Audit of IV Vancomycin Prescribing and Monitoring at Aintree University Hospital Phillips E, Durnin N and Cooke R, Aintree University Hospital NHS Foundation Trust, Liverpool

Background At Aintree University Hospital (AUH) NHS Foundation Trust, IV vancomycin treatment is indicated for serious infections in patients allergic to alternative antibiotics and methicillin-resistant staphylococcus aureus (MRSA) infections. However, glycopeptide use in hospitals has been associated with inpatient acquisition of glycopeptide resistant enterococci (GRE); enterococcal species resistant to vancomycin and teicoplanin. GRE are highly resistant bacteria that are problematic to treat, necessitating the use of combination antimicrobial therapy, or newer antimicrobials with unfavourable side effects. It is critical to control the spread of GRE as they serve as a reservoir of resistance genes, with the ability to confer plasmid-borne resistance to more pathogenic organisms, including Staphylococcus aureus.1

Monitoring of trough vancomycin serum concentrations is essential to ensure the infecting pathogen’s minimum inhibitory concentration (MIC) is met, and that vancomycin is clinically efficacious. Equally, effective serum concentration monitoring can reduce the incidence of vancomycin toxicity. At AUH, the antimicrobial guidelines stipulate that the initial vancomycin dose should be calculated by a pharmacist, or, dosing commenced empirically (with a 1g loading dose), and pharmacy contacted for further dosing advice.2 However, a 2012 audit of AUH’s pharmacy-led out-of-hours vancomycin dosing and assay monitoring service identified poor compliance with Trust guidance: only 66% of vancomycin starting doses were to standard.3

To date, AUH’s compliance with Trust indications for IV vancomycin has not been audited. The extent to which AUH currently complies with the principles of good antimicrobial stewardship (i.e. optimal antimicrobial drug regimen, dose, duration of therapy and route of administration) is therefore unknown. This audit sought to establish this information, and to determine what impact the 2012 audit and its recommendations for action had on practice. Objectives The aim of this audit was to assess the compliance of IV vancomycin prescribing and monitoring, on all AUH electronic prescribing (EP) wards, with Trust guidelines. The objectives were to collect the relevant clinical, microbiological and prescribing data to determine whether the antibiotic’s indication, initial dosing, and trough serum concentration monitoring followed established antimicrobial guidance. The documentation of patients’ penicillin allergy status and reaction type on EP was also evaluated. Method Following a one-week pilot, prospective data was collected over an 8-week period (18th June 2013 – 12th August 2013). All patients prescribed IV vancomycin on the EP system were identified by a daily report. Information on the appropriateness of each patient’s prescription indication and route were collated using a data collection form. The appropriateness of the IV vancomycin starting doses, serum concentration monitoring, and subsequent dose adjustment were assessed. EP documentation of allergy status and reaction was monitored. As this study was an audit, ethical approval was not required. Results During the 8-week audit, data was collected on 94 IV vancomycin prescriptions. Table 1 below shows percentage compliance by audit standard. Table 1: Prescription Compliance by Audit Standard

Audit Standard Percentage Compliance

Standard Actual

Vancomycin therapy indicated (as per Trust guidelines) 100% 96%

Vancomycin prescribed by the appropriate route 100% 100%

Appropriate initial dose of vancomycin prescribed (1g loading dose, or starting dose calculated by a pharmacist)

100% 83%

Trough vancomycin serum concentrations requested pre-forth dose 100% 86%

IV vancomycin dose adjusted (prior to next scheduled dose) on receipt of vancomycin serum concentrations.

100% 67%

Therapy reviewed as necessary according to culture and sensitivity results 100% 100%

Penicillin allergy and reaction recorded on EP 100% 54%

98% of penicillin allergic patients had their allergy status documented on EP. However, the allergic reaction or adverse drug effect was not reported in 46% of the audited population. Discussion and Conclusion This audit has identified good adherence to AUH IV vancomycin prescribing guidelines. The deviations from Trust protocol highlight the continuing

need for education around the use of the Trust antibiotic formulary, and the prescribing of -lactam antibiotics in patients with mild penicillin allergies, or adverse drug reaction to penicillin. Despite improvement in initial vancomycin dosing since the 2012 audit, 17% of patients still received an inappropriate vancomycin starting dose, reducing the likelihood of achieving therapeutic steady-state levels. The failure to measure pre-4th dose trough concentrations in 12% of patients complicates the interpretation of vancomycin levels, and makes the process of appropriately adjusting dosing regimes more challenging (2% lost to follow up). This, along with delayed and omitted vancomycin doses, explained why a clinical decision was taken not to adjust 22% of doses – despite sub-/supra-therapeutic levels (11% lost to follow up). Poor compliance with allergy documentation

guidelines was identified, potentially denying patients effective -lactam antibiotic therapy. As a result of these findings it is recommended that vancomycin consumption data be tracked to monitor hospital-wide vancomycin usage. The weaknesses identified with allergy documentation on the EP system adds weight to the urgency for completion of ongoing work reviewing the allergy bar layout. The audit results and associated recommendations will also be communicated to the medical teams, pharmacy department and antibiotic awareness group in the Trust bi-monthly antibiotic bulletin. This will highlight the success of current antimicrobial stewardship efforts, and educate practitioners about key learning points drawn from the audit’s findings. Limitation of this audit included the exclusion of non-EP wards from the sample population, and loss of patients to follow up on transfer to non-EP wards. The prospective audit design means staff aware of the audit may have amended their practicing behaviours for the duration of the data collection period. References 1. Cookson BD, Macrae MB, Barrett SP, Brown DFJ, Chadwick C, French GL et al. Guidelines for the control of glycopeptide-resistant enterococci in

hospitals. Journal of Hospital Infection 2006;62(1):6-21 2. Aintree University Hospitals NHS Foundation Trust & The Walton Centre NHS Foundation Trust. Guidelines for Antimicrobial Therapy 12th edition.

Liverpool: Antibiotic Action Group Aintree University Hospitals NHS Foundation Trust; November 2012 3. Willis Z. A prospective audit of the pharmacy led out of hours dosing and assay monitoring service for vancomycin and gentamicin. LJMU

Postgraduate Diploma; 2012

17. Introduction of pharmacist-led 24 hour VTE re-assessments using a Quality Improvement Approach Hardy E, Thakkar K, Zarnegar R, Royal National Orthopaedic Hospital, Stanmore

Background In 2005, it was estimated that 25,000 people in the UK die from preventable hospital-acquired venous thromboembolism (VTE) every year1. A UK survey found that 71% of patients assessed to be at medium or high risk of VTE did not receive any form of mechanical or pharmacological prophylaxis1. VTE risk assessments were implemented to aid recognition of the need for prophylactic measures1. In accordance with NICE guidance1, all inpatients should be re-assessed for VTE risk and bleeding risk within 24 hours of admission to identify whether changes should be made to the initial VTE prevention plan. At the Royal National Orthopaedic Hospital (RNOH) the majority of patients are admitted for elective surgery and therefore the re-assessments takes place post-operatively. Introduction A multidisciplinary VTE Group leads quality improvement in relation to VTE prevention and management at RNOH. In 2012, audits of VTE risk assessment demonstrated that although initial assessments were done in over 95% of admissions, documented reassessment at 24 hours / postoperatively was rare. The VTE Group designed a template for 24 hour (24h) re-assessment and ward pharmacists took on the responsibility for carrying this out during the working week, a novel idea both in the Trust and nationwide. Implementation of this plan was led by the Specialist Pharmacist in Haemostasis and Thrombosis. It involved a three month process of piloting of the initial template with subsequent improvement in design and clarity (using small-scale Plan-Do-Study-Act cycles), one-to-one training of ward pharmacists and ward visits. The new initiative was launched in May 2013. The responsibility for 24h reassessments outside the working week continues to be with the surgical teams. Patients requiring 24 hour re-assessment are identified daily by the ward pharmacist and the assessments carried out as part of ward duties for the day. The pharmacist reviews the patient’s clinical status in relation to clotting and bleeding. The template designed by the VTE Group facilitates identification of new risks. A new action plan for prophylaxis is then formalised which may involve initiating or stopping TEDs/pharmacoprophylaxis, or making amendments to prescriptions, working closely with surgical teams at all times. The effectiveness of this approach was evaluated by clinical audit. Aims and objectives This audit aimed to determine the efficiency of 24h VTE re-assessments. The expected standard is that patients should have this done by a trained ward pharmacist or a doctor within 24 hours of admission. The expected adherence level is 100%. Method Data was collected by pharmacists at the point of discharge. Information on whether 24h VTE re-assessment had been done was gathered from the medical notes, by looking at the VTE risk assessment chart. Pharmacists captured this data on hand-held tablets using commercially available software (AuditrTM). The pharmacists also collected data on other aspects of VTE prevention including correct prescribing and administration of prophylaxis. Data was collected every week Monday through to Friday in a large random sample of all discharges. The monthly samples were therefore representative of the adult surgery patient population at RNOH. Ethics approval was not required. Results

The results in Graph 1 display a month on month increase in percentage of patients who had documented 24h VTE risk re-assessments. Over the same period, there was also improvement in prescribing and administration of VTE prophylaxis in line with national guidance. Discussion The quality improvement strategy for VTE prophylaxis and management at RNOH has been led by a multidisciplinary group that has always included a pharmacist. The process developed for 24h risk re-assessment put pharmacists in the forefront of this improvement process and our audit demonstrates its success as an initiative that utilises pharmacists' knowledge and skills in a novel way. Through its implementation, pharmacists' role in patient care has expanded considerably. The process of VTE risk re-assessment relies on comprehensive and accurate initial assessment, planning of prophylactic measures and their administration as well as review of risks and logical change of plan. We have found that the involvement of pharmacists has prompted discussion with surgical teams on all aspects of prophylaxis, raising the quality of documentation and decision making. In addition, through their direct involvement in VTE prophylaxis, pharmacists have had to collaborate with surgical and nursing teams further than they would in their traditional role, raising their profile in the hospital. Although the task of VTE risk assessment could have been allocated entirely to doctors or senior nurses, who are also represented in the multidisciplinary VTE Group, pharmacists were chosen because they had the knowledge base and enthusiasm to take on this task. They are able to understand the principles of assessment and perform the role effectively with relative ease. Their background knowledge in pharmacology and prescribing puts them in an ideal position to discuss the pros and cons of prophylaxis with surgeons. Ward pharmacists are busy and already have multiple tasks that cannot be delegated to other health professionals. In the early stages of implementation, we were unsure about the sustainability of pharmacists taking on additional responsibilities. In practice we have found they rapidly adjusted to the task which became easier and quicker to complete. At RNOH, pharmacists are now also actively engaged in teaching ward nurses and trainee doctors on VTE prevention. Future work may involve independent prescriber pharmacists completing initial VTE risk assessments and prescribing prophylaxis in collaboration with the surgical and also medical teams. The main limitation of this process in our institution is that pharmacists are not able to complete this work during weekends with current levels of staffing. References 1. National Institute for Health and Care Excellence (2010) Venous Thromboembolism: reducing the risk. Clinical Guideline 92. London: NICE.

0%

20%

40%

60%

80%

100%

% of 24 hour VTEre-assessmentscompleted

Graph 1. Percentage of completed 24 hour re-assessments and percentage of overall VTE prevention in line with national guidance from patients audited on discharge, 2013 (n = total number of patients entered in the audit)

18. Encompassing trainees in a culture of compassion during workplace based training. Wright E, Fidler E, Fleming G., Health Education KSS Pharmacy, Haywards Heath, West Sussex.

Context The necessity of an underpinning culture of compassion and patient safety is a must in the current NHS. This was highlighted in the recent Francis report1 and is reflected in the NHS Constitution values2. This culture needs to be evident through every facet of the NHS workforce, including trainees. The balance of compassion and safety should be as evident for the struggling trainee or ‘trainee in difficulty’ (TiD) as it is for patients. December 2013 saw pre-registration pharmacists classified as ‘professionals in training’ by the General Pharmaceutical Council. The focus on the accountability of all pharmacy trainees was also highlighted by the concurrent introduction of a procedure to deal with serious concerns3. Research shows us TiDs will often have struggles throughout their career4 which can have serious implications for patient care. Within NHS trusts covered by this study, all 200 pre-registration pharmacy, pharmacy technician and foundation pharmacy trainees are supported through their programme of study by a named educational supervisor (ES). This ES is also responsible for identifying whether a trainee is in difficulty and requires additional support. ESs are supported within their organisation by an Education Programme Director (EPD) who will oversee the respective training programme. EPDs are supported by the Local Education and Training Board (LETB) Pharmacy Team who will provide external support, advice and expertise when required. Over the past 4 years the LETB Pharmacy team has participated in a multi-disciplinary Trainee Support Group (TSG)4 which has supported over 40 recorded cases of pharmacy TiDs since 2012. This experience has highlighted the necessity to develop robust ‘systems and processes’4 to identify and support the struggling trainee, particularly where there are issues regarding professionalism and NHS values and behaviours. Objective(s) To create robust internal and external processes that will facilitate early identification and support of potential TiDs. To empower and educate ESs in the management of these trainees. Method Ethics approval for this work was not required as it is a service evaluation. In September 2012 an external facilitator led a one day workshop to review the internal and external TiD reporting and recording processes within the LETB Pharmacy Team. The classifications of TiDs were reviewed and aligned to the wider TSG:

Health

Personal

Skills Development

Professionalism

Educational

Visa The outputs of the review meeting are outlined in Table 1. Table 1 Outputs of TiD system review

Internal External

Process algorithms – reporting, documentation, communication processes

Reporting algorithms - electronic reporting to Health Education KSS, indicators outlining when to report, Red Amber Green (RAG) classification

Meeting outlines/agendas – internal and external (i.e. Trust visits)

Reviewed TiD guide using defined classifications of ‘difficulty’

Anonymised recording of individual trainees Templates - action plan, progress report, online reporting form

Designated leads for each trainee group a point of direct contact for trainees and supervisors

RAG matrix

An early warning system and triggers

The outputs of this meeting were further discussed with various ES and EPD groups in 2012. As a result further minor modifications were included and an implementation plan produced to introduce the changes outlined below. Results As an outcome of the review, changes were made to internal LETB pharmacy processes as well as guidance and tools put in place for Trusts to use. In addition to existing training, the early detection of TiDs and their management is now embedded in regional Practice Supervisor and Educational Supervisor courses respectively. Bespoke training on Professional Conversations to support the one to one interaction between ES and trainee have also been well received. Local reporting and support of trainees has been promoted as these processes were implemented throughout 2013. Professional appraisals for Pharmacy Technicians have been developed and put into practice throughout the South East Coast region. These tools and processes support the creation of an infrastructure that ‘proactively identifies’4 issues and seeks to address them. The hallmarks of such a culture can be identified through struggling trainees being detected and reported earlier. It is also reflected by trainee progress and TiD discussion now being an inherent part and standing agenda item of all local pharmacy educational governance meetings. Discussion Limitations of this work are that improved systems should lead to improved reporting which may suggest that we have more TiDs rather than less. We believe future quantification demonstrating TiDs with professional behaviour concerns identified early in their training programme and supported to overcome their challenges will be a measure of success. Qualitative research of the impact of supportive processes with identified trainees on culture and behaviour changes could be a further area to explore. There also needs to be further research to complete the loop, with a focus on values based recruitment – to ensure future trainees are fit for purpose. References 1. R Francis (chair). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive summary. London, The Stationery Office Limited, 2013. 2. Department of Health. The NHS Constitution. London 2013. 3. General Pharmaceutical Council. Procedures for the initial education and training of pharmacists and pharmacy technicians in Great Britain and Northern Ireland. London 2013. 4. D Black, J Welch. The under-performing trainee – concerns and challenges for medical educators. The Clinical Teacher 2009; 6: 79–82.

19. Anticoagulants: improving patient safety and management for patients admitted on oral anticoagulants. Grant F, Aintree University Hospitals, Liverpool

Background In March 2007, the National Patient Safety Agency (NPSA)1 released an alert highlighting the potential harm that can result in patients taking anticoagulants. The research carried out to date predominately investigates compliance with initiation guidelines and loading protocols. There is less information regarding the continued safe use and management for patients that are admitted into hospital on anticoagulants. The British Society for Haematology guidelines2 updated in 2005, have also identified inpatient management of anticoagulants as an area for improvement and audit. Aim To determine whether or not medical inpatients at Aintree hospital admitted on oral anticoagulants are managed in compliance with the trust guidelines for safe prescribing and monitoring throughout their admission. Main Objectives:

To ensure that every patient admitted on oral anticoagulants has a documented indication, INR (International normalised ratio) target and current maintenance dose recorded on the paper prescription chart (compliance standard set at 100%).

To determine if every patient admitted on oral anticoagulants has a completed medicine reconciliation note detailing drug, indication, INR target and usual maintenance dose (compliance standard set at 100%).

To record the time of the administration of anticoagulants for all patients admitted on oral anticoagulants.

To record any sub-therapeutic or high INR’s during admission and to establish if there is an identifiable cause for the variation in INR above target range. (‘INR out of range’ defined as greater than 0.3 above or below the target range).

To establish through use of audit, if any changes need to be made to the current clinical procedures. Methods The audit data collection period ran from 11th February to 8th March 2013 at Aintree University Hospitals Liverpool. Patients were identified for 3 weeks and then followed up for a further 1 week period, giving a total audit data collection period of 4 weeks. 77 patient’s met the inclusion criteria and were eligible for review in this study. All patients prescribed oral anticoagulants were identified through a daily JAC report. Only patients admitted on oral anticoagulants from medical wards were included in the study. Two separate data collection forms were completed to record compliance with documentation of patient’s information, anticoagulant administration times and the frequency and reason for out of range INR’s. Ethical approval was not required since this project was carried out as an audit which did not involve direct patient contact. Results Of the 77 paper prescriptions reviewed, pre-admission details such as the patients usual dose, target INR and indication were completed in 53%, 67.5% and 67.5% of the prescriptions respectively. Pharmacists and technicians documented patient’s drug and usual dose in the medicine reconciliation note in over 91% of patients. However, only 27% of patients had their target INR and 49% had the indication for the anticoagulant documented electronically in the medicine reconciliation note. Administration times of 738 anticoagulant prescriptions were reviewed from the 77 patients in this study. 53% met the required standard to be administered between 5-7pm daily. Results reported that on average, 1 out of every 2 days in hospital patients had their INR checked. The most common reason for out of range INR’s was due to patients being admitted with a high or low INR (35.4%). However, antibiotics and new medications also had a large impact on INR control during admission, accounting for 16% of out of range INR’s. 17% of the 87 high INR’s recorded (see table 1) were greater than 5. 30% of the patients in this study had all INR’s in range during their admission. Table 1: Number of INR’s greater than 0.3 above or below individual target INR range A total of 379 INR’s were checked from 77 patients during the audit:

Total out of range INR’s Percentage high INR’s (from those out of range)

Percentage of sub-therapeutic INR’s (from those out of range)

147/ 379 87 of 147 = 59.2% 60 of 147 = 40.8%

The auditor randomly checked 25 paper prescription charts for any evidence of pharmacist review or input and found that of the 25 prescriptions reviewed, only 2 had any evidence of pharmacist review. Discussion and conclusion Management of patients admitted on oral anticoagulants is often sub-standard, and can be a contributing factor to reported INR’s outside the target range. Poor documentation of patients preadmission details, late administration of medicines and daily INR recording, as well as a lack of awareness of the effects other medications can have on INR level can affect patient care and INR control during their hospital admission Further education to medical staff on how to prescribe oral anticoagulants as well as an improved knowledge of the potential for drug interactions would be beneficial to improve patient management. In all cases, the dose of oral anticoagulant should be prescribed by the medical day team who are familiar with the patient to improve continuity of care and reduce late prescribing and administration times. Administration time of oral anticoagulants at Aintree hospital has now changed to 2pm. A re-audit is required following implementation of this new clinical procedure. Unless indicated or necessary to guide management of patient care, a reduction in the number of INR checked each admission will reduce the risk of daily dose changes and therefore should stablise INR control further. In addition, the importance of pharmacists to take a more pro-active approach to review anticoagulant prescriptions should be encouraged to improve the standards expected in this group of patients. A review of pharmacy clinical procedures to incorporate a system for checking the paper prescription chart should be carried out. A box is available on the current prescription chart allowing space for pharmacy input however this is rarely filled in. An additional box could be added which pharmacists have to sign to show they have clinically checked the prescription. Pharmacists should also encourage the medical staff to fill in any non-complete prescription charts or to document the information themselves as they see competent to do so. References 1. National Patient Safety Agency Alert number 18. Actions that can make anticoagulant therapy safer. March 2007. www.npsa.nhs.uk (accessed

18/08/12). 2. Baglin TP, Keeling DM, Watson HG et al. Guidelines on oral anticoagulants (warfarin): third edition- 2005 update. British Society for Haematology

2005; 132. 277-285.

20. Impact of Pharmacist Independent Prescribers at Imperial College Healthcare NHS Trust Alaeddine S¥, Khachi M# & Miller G*, ¥ Rafic Harir University Hospital, Beirut, Lebanon, # University College London Hospitals, London

* Imperial College Healthcare NHS Trust, London

Introduction Imperial College Healthcare NHS Trust (ICHT) is a large, acute teaching hospital, where there is increasing pressure to facilitate better patient flow, alleviate ongoing bed pressures and ensure that patient safety remains central to providing high quality care for inpatients and outpatients. A trust-wide strategy for prescribing by Pharmacist Independent Prescribers (PIPs) was developed with the aim of improving patient access to medicines, reducing doctor workload and facilitating medicines optimisation. The strategy targeted prescribing in specific areas including high risk medication such as anticoagulants, vancomycin and aminoglycosides; medicines reconciliation; acute pain management; on consultant-led ward rounds; discharge medication; and other specialist practice areas. Senior experienced clinical pharmacists undertook training to become PIPs and the first PIPs started prescribing in the trust in 2008. There are currently PIPs in a range of specialties including surgery, general medicine, infectious diseases, neonatology, HIV, haematology and critical care. Aim To identify how PIPs use their prescribing skills in ICHT. Objectives

To identify the frequency of prescribing, the type of medicines prescribed by BNF category by PIPs and the areas in which PIPs prescribe in ICHT.

To identify any barriers to prescribing in ICHT. Method An electronic questionnaire was developed and piloted on three pharmacists. The questionnaire was developed to assess prescribing against the trust-wide PIPs strategy, the frequency of prescribing, the type of medicines prescribed, the rationale behind prescribing and the barriers to prescribing. The questionnaire comprised 18 questions: 14 closed and four open questions. The questionnaire was sent by email to all 19 PIPs at ICHT. All responses were anonymised. Quantitative data were analysed using descriptive statistics and qualitative data were analysed for common themes. The trust approved this study as a service evaluation project and therefore ethical approval was not required. Results The response rate was 68% (13 out of 19 PIPs). The key results were:

77% of PIPs report prescribing only for inpatients, 15% solely in outpatient clinics and 8% in both.

Most PIPs report prescribing at least one medication daily (54%), some prescribe weekly (31%) and the remainder monthly (15%).

The majority of PIPs report that they prescribe 1-5 medicines per day (30%). Figure 1 details the frequency of prescribing by PIPs.

The main BNF categories from which PIPs prescribe were infections (77% of PIPs), cardiovascular system (54% of PIPs), gastro-intestinal system (54% of PIPs), respiratory system (46% of PIPs) and eye (46% of PIPs).

The percentage of PIPs who prescribe within the areas stated in the PIPs strategy were: o Prescribing of high risk drugs: anticoagulants 23%, vancomycin 77% and aminoglycosides 69% o Medicines reconciliation: 85% o Acute pain management: 38% o Prescribing on consultant-led ward rounds: 46% o Discharge medication: 62% o Specialist practice: 54%

Although some pharmacists use their diagnostic skills most PIPs (85%) do not utilise their diagnostic skills, as most of the diagnostics have already been undertaken by doctors.

Figure 1: Frequency of prescribing medication by Pharmacist Independent Prescribers

A number of barriers were noted by respondents which make them prescribe less frequently. The main reasons why PIPs do not prescribe more frequently were: “do not wish to de-skill medical staff”, “time constraints due to other duties”, “high workload/coverage of multiple rounds”, “asking doctors is faster”, “not seeing patients independently”, “difficulty assessing patients”, “covering a mixture of specialities”, “need to expand the scope of practice” and “not having the opportunity to attend ward rounds.” Discussion A trust strategy has aided a targeted approach for PIPs, allowing the focus of PIPs to be on key areas for the trust. Although this project has highlighted certain barriers that PIPs face when prescribing, PIPs at ICHT are regularly prescribing a range of medication for patients within the trust with a significant proportion facilitating better patient flow through prescribing medication during the medicines reconciliation process and prescribing discharge medication. Lessons learnt include ensuring pharmacists had sufficient time to act as a PIP and making sure that junior doctors were not deskilled by the prescribing of a PIP. The main limitation of this study was that the questionnaire was only sent to pharmacists within ICHT, therefore the results may not be generalisable elsewhere.

21. Developing and piloting a tool to evaluate pharmacists’ perceptions of their pre-registration pharmacist training programme Al-Haqan A,#, Portlock J*, Miller G∞, # Faculty of Pharmacy, Kuwait University, Kuwait, * School of Pharmacy, University College London, London

∞ Imperial College Healthcare NHS Trust, London

Introduction Pre-registration pharmacist training is a one year supervised training programme which allows pharmacy graduates to develop the knowledge, skills and attitudes to become a competent pharmacist1. Evaluation of pre-registration training programmes are essential to identify the strengths and weaknesses of the programme and allow for improvements to be made, by continually ensuring that the training provided, results in appropriately educated and clinically skilled pharmacists. We were interested in developing a tool to evaluate our pre-registration pharmacist training programme, by asking for the views on the training programme once the pre-registration pharmacists had qualified and been working as a pharmacist for six months, rather than asking for their views immediately at the end of the programme. Through evaluating the programme this way, we believe that the pharmacists would be better placed at assessing the programme based on their experiences of working as a pharmacist. Objectives

To develop a tool to determine the perceptions of the pharmacists who had completed their pre-registration training regarding how it prepared them to be a pharmacist.

To identify the strengths and weaknesses of the pre-registration training programme.

To make recommendations to further improve the pre-registration training programme. Method Following a literature review and interviews with a pre-registration pharmacist and three pharmacists, a self-administered, web-based questionnaire was designed using Qualtrics Survey Software. The questionnaire was designed to elicit participants’ feedback regarding their pre-registration training experience and acquirement of core skills in an NHS Hospital Trust. The questionnaire comprised 17 questions: seven closed and ten open questions. Following a successful pilot, a link to the web-based questionnaire was sent by e-mail to all 13 pharmacists who had been qualified for at least six months and had undertaken their pre-registration pharmacist training within the last three years in the same organisation. Two reminders were sent after the first e-mail. A paper questionnaire was available upon request. All responses were anonymised. Quantitative data were analysed using descriptive statistics and qualitative data were analysed for common themes. This study was undertaken in June 2013. The Trust approved this study as a service evaluation project and therefore ethical approval was not required. Results The response rate was 84.6% (11 out of 13 pharmacists). From a four-point scale question about the quality of the training experience, the majority (72%) of respondents rated their experience as good and the remainder (27%) rated their experience as excellent. Rotations in ward services, medicines information and dispensary were identified by respondents as the rotations that contributed the most in preparing them to be pharmacists. Figure 1 details the level of preparedness the pharmacists felt for a range of key skills after completing the pre-registration training programme.

Figure 1: Responses about the level of preparedness for a range of key skills after completing the pre-registration training programme Responses helped identify strengths and weaknesses of the pre-registration training programme. Key strengths include the wide variety of rotations, teaching sessions, supportive training staff and a degree of autonomy in learning. On the other hand, respondents felt that they would benefit from having “a ward visit with a pharmacists [sic] every day”, “[clinically] screen inpatient items in the dispensary” and “look after bays [of patients] earlier on in the year”. Discussion Overall, pharmacists generally had a positive view of their training experience. This may be attributed to the fact that their training had prepared them to acquire the key skills required to be a pharmacist. Previous literature showed similar results where high satisfaction with a training programme was linked to the acquirement of core competencies.2,3 Following this evaluation, a number of suggestions to improve the pre-registration training programme have been implemented including undertaking supervised ward work on most days and having the opportunity to screen items when in the dispensary. The main limitation of this study was that the survey was only sent to pharmacists who completed their pre-registration training and are currently working in the same organisation, therefore the results may not be generalisable elsewhere. Evaluating the pre-registration training programme by asking the views of recently qualified pharmacists has provided insightful feedback, as they are more able to reflect on the adequacy of the training programme based on the practical experience that they have gained in the first few months of their career. This tool will be now be used to ask all pharmacists who completed their pre-registration training in the organisation for their views on the training programme irrespective of where they work. References 1. General Pharmaceutical Council. The GPhC Pre-Registration Manual 2011 [cited 2013 11 April]; Available from:

http://www.pharmacyregulation.org/ 2. Komperda KE, Padiyara RS. Pharmacists' perspectives on postgraduate training. Am J Hosp Pharm. 2011;68(18):1681-2 3. Smith KM, Romanelli F. Use of an electronic survey to assess the training and practice experiences of pharmacy residency graduates. Am J Health-

Sys Pharm. 2005;62(21):2283-8

22. An audit of the accuracy of drug calculation skills of junior doctors Gillian Cavell*, Michael Currie**. King’s College Hospital NHS Foundation Trust,

*Consultant Pharmacist **Specialist Pharmacist, Prescribing Mentor

Introduction Medicines use is complex, particularly when it involves injectable medicines. Calculations may be needed before doses are prescribed, prepared and administered. The National Patient Safety Agency NPSA) described drug dose calculation as a key factor contributing to potentially harmful medication errors including 10-fold errors.1 Some healthcare professionals have difficulty calculating doses.2 Errors resulting from miscalculation of drug doses have been reported locally. Since 2011 all pharmacists joining the trust are required to achieve 100% on a drug dose calculation assessment. However competence of other healthcare professionals involved in the medicines process is assumed and there has been no formal assessment of the calculation skills of nursing or medical staff. Following an adverse incident which identified an incorrect drug calculation as a contributory factor we were asked to extend the pharmacist’s calculation skills assessment to Foundation Trainees (FT1s) joining the trust in August 2013. This audit has been designed to assess whether FT1s are competent in drug calculation skills in a range of clinical scenarios. Objectives 1. To measure foundation trainees’ accuracy in drug dose calculations. 2. To identify situations where 100% accuracy is not achieved and where support is needed 3. To propose a system to support FT1s to achieve competence in drug calculation skills Standards 100% of Foundation Trainees achieve 100% accuracy in a drug calculation assessment Method The pharmacy questionnaire which tests 20 calculation competencies was modified to focus on those skills most relevant to prescribing and patient assessment. Five questions testing skills relating to drug administration were removed. The final questionnaire contained 15 questions testing skills deemed to be essential for prescribers. Two questions were presented in 2 parts. The maximum score was therefore 17. As the questionnaire had previously been validated for pharmacist assessments it was not piloted for further validation. All FT1s joining the trust across 2 sites were required to complete the assessment during an hour long scheduled teaching session. Completed questionnaires were returned to the investigators for marking. Results were analysed and feedback was disseminated to participants individually in writing. Results Sixty seven FT1s completed the questionnaire: Eight FT1s did not consent for their results to be included in the analysis. Results of 59 FT1s B are presented. The average score on the assessment was 15/17 (88.2%, median 16, range 11-17). Thirteen (13/59, 22%) of FT1s achieved the required standard of 100%. Seventeen FT1s (17/59, 29%) answered 16 questions correctly and 10/59 (17%) answered 15 questions correctly. One question was answered correctly by all FT1s. Thirteen questions were answered correctly by more than 52/59 FT1s. Four questions were answered incorrectly by more than 10 FT1s. The skills these questions assessed are described in Table 1. Table 1. Questions most frequently answered incorrectly

Skill being assessed Number of FT1s

Practitioners should be able to: Correct Incorrect

a calculate the volume of a solution containing a dose of a drug where the concentration of the solution is expressed as a percentage.

38 21

b calculate the dose of a drug in mcg/kg/min being delivered as a solution of known concentration (mg/ml) infusing at a rate of Xml/hr, taking into account the weight of the patient

39 20

c calculate the dose of a drug in mcg/kg/min being delivered as a solution of known concentration (mg/ml) infusing at a rate of Xml/hr, taking into account the weight of the patient

44 15

d round a calculated dose up or down so that the dose can be accurately measured but ensuring that the dose remains within 10% of the required dose

48 11

Discussion and Conclusion Not all FT1s achieved the standard of 100%. The complexity of the calculations varied throughout the paper. The question that was answered correctly by fewest prescribers was an example of a calculation involving magnesium sulphate where the concentration of the solution was expressed as a percentage. Interestingly it was an investigation involving magnesium sulphate solutions which recommended the assessment of calculation skills. Calculations b) and c) in Table 1 require doses to be checked from infusions in progress. This may be a calculation which has not been required by junior doctors but it is important for assessing patients on infusion therapies. These calculations are ‘complex’3 requiring 5 and 4 calculation steps respectively. The results of the questionnaire have been reported back to individual practitioners and training needs will be addressed by the Specialist Pharmacist, Prescribing Mentor working within the Post-graduate Medical Education Department. FT1s identified as needing support will be recalled in small groups for additional teaching. Educational supervisors will be notified if there are particular concerns about competence. There may be debate about whether 100% is a realistic target for drug dose calculation skills. The risks of harm from error and the potential for inadvertent 10-fold dosing errors is so high we feel that staff should be confident to accurately calculate across the whole range of skills. Our results included 10-fold errors in answers to more than one question. 100% competence is expected of and demonstrated by pharmacists within our organisation. It is difficult to argue that the same standard should not apply to other professional colleagues involved in safe medicines use. Whilst the standard of 100% is desirable there is currently no system to enforce this within the current Foundation School structure. The need to incorporate drug dose calculation teaching into the FT1 prescribing skills programme has been confirmed. Further discussion across the organisation about how to ensure more senior grades of medical staff, and nursing staff, are competent in drug dose calculation skills is needed. References:

1. National Patient Safety Agency. Review of patient safety for children and young people. London. June 2009 2. Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child 1998;79:56–8 3. National Patient Safety Agency. 2007. Patient Safety Alert 20. Promoting safer use of injectable medicines.

23. An audit of the omission of medication to ‘nil by mouth’ patients pre-and-post ward staff education in emergency surgical admissions. Hall G*, Timmins A*, Johnson J# and Oglesby S*, *NHS Fife. # University of Strathclyde, Glasgow

Introduction Medication incidents were the third largest type of incident reported to the National Patient Safety Agency’s (NPSA) Reporting and Learning System (RLS) in 2007 1 . Subsequently the NPSA published a report stating that omission / delay in medication administration is the second largest cause of reported medication incidents and has the potential to cause patient harm1. Emergency surgical procedures complicate the prescribing environment. If procedures can be anticipated food should be discontinued six hours and fluids two hours prior to procedure 2. When the patient is awaiting a planned event that requires an empty stomach, they are often termed ‘nil by mouth’ (NBM). The Royal College of Nursing (RCN) states that “Regular medication taken orally should be continued preoperatively unless there is advice to the contrary.”3 Up to 30ml of water orally can be given to aid the administration of oral medication which does not constitute a break in fasting conditions3. Medication should therefore be administered to NBM patients unless specific instructions are documented to the contrary. Aim To determine current practice of medication administration, or omission, to patients termed ‘nil by mouth’ admitted to the acute surgical admissions unit. An educational intervention will be made to ward staff, by a pharmacist, and the effect on practice evaluated. Objectives

Determine current practice: frequency of prescribed medications where at least one dose is inappropriately omitted in patients that are termed NBM. Audit against RCN standards.

Develop educational tool incorporating the findings from initial data collection and present to ward medical and nursing staff.

Measure any effect of educational intervention on the inappropriate omission of prescribed medication to patients termed NBM.

Method A study specific data collection form was designed and used to collect prospective data from all patients on the surgical admissions unit, at time of audit, over a 12 day consecutive period in August 2012. Specific information about prescribed medication and doses omitted was collected for all medication prescribed on the hand written drug chart. A missed dose was recorded if no signature or alternative reason was entered in administration box on the drug chart. The appropriateness of the omission was decided by the project team (e.g. omission of anti-diabetic medication in the fasting patient was considered appropriate whereas failure to sign drug chart/ document omission code was deemed inappropriate). This data was used to produce an educational intervention in the form of a Power Point presentation. The presentation included examples of inappropriate medication omissions from the study ward and recommendations for appropriate medication omission in the NBM patient. This was delivered to nursing staff on four occasions and presented at the surgical team meeting. The data collection process was repeated post-educational intervention in January 2013. Ethics committee approval was not required for this study as this service already existed for surgical admissions patients, and when the new service was implemented it was indiscriminately offered to all patients. Results Omission of a medication dose is common in the surgical admissions ward. However not all of these omissions are inappropriate. Of the 281 medicines prescribed pre-intervention where at least one dose was omitted, 66.9% of these were considered to have been inappropriately missed. Post-educational intervention the percentage of inappropriately missed medicines was reduced to 55.9% of the 533 medicines omitted. There was also a reduction in the proportion of medications where at least one dose was inappropriately omitted in the targeted population of ‘nil by mouth’ patients. Before the educational intervention 29.7% of oral medications prescribed to NBM patients were considered to have had at least one inappropriately omitted and post intervention this was reduced to 19.2%. Table 1: Audit and re-audit results. n= Number of medications due to be given where at least one missed dose occurred.

Feeding instruction At least one inappropriately

missed dose

Pre-education

(%) n= 222 Post-education

(%) n= 421

NBM 66 (29.7) 81 (19.2)

Non-NBM 75 (33.8) 139 (33.0)

Unknown 0 (0) 10 (2.4)

Total inappropriately missed medicines 141 (63.5) 230 (54.6)

Discussion/Conclusion A reduction of 10.5% in inappropriately missed medicines to NBM patients post-education suggests that pharmacist education reduces the number of inappropriately omitted doses on a surgical admissions ward. Sample size was a limitation of this study. A total of 1330 patients is required to statistically prove the post-educational reduction found by this study. Post- educational reduction of 10.5% would seem clinically significant: 44 less medications would have had a dose inappropriately omitted than before the education. Largely omissions of at least one dose of medication were higher than other published medicines omission studies4. This is a concern; however the clinical significance of the omissions in these studies was not always determined. Significance of omissions was not evaluated by this study. Irrespective of clinical significance, there is a concern that an environment where dose omission is generally acceptable (67.9% omission rate indicates more medications have a dose omitted than do not) could lead to potentially dangerous omissions being tolerated rather than questioned. Potentially the data collected in the present study could be used to allow follow up of the patients in the audits to evaluate the impact of missed doses, as this study did not assess this factor. Furthermore, the implementation of electronic prescribing including would allow easier and consistent data collection. References

1. National Patient Safety Agency, National Reporting and Learning Service. Safety in doses. Improving the use of medicines in the NHS. 2007. 2. Brady MC, Kinn S, Stuart P et al. Perioperative fasting for adults to prevent perioperative complications (Review). The Cochrane

Collaboration.2010. Published by John Wiley& Sons Ltd. 3. Royal College of Nursing. Perioperative fasting in adults and children. An RCN guideline for the multidisciplinary team. 2005. Available at:

http://www.rcn.org.uk/__data/assets/pdf_file/0009/78678/002800.pdf. Accessed 12/02/12. 4. Kester L, Stoller JK. Prevalence and Causes of Medication Errors: A Review. Clinical Pulmonary Medicine. 2003;10: 322-326.

24. An Audit of supply of Critical Medicines in West Suffolk Foundation Trust Pharmacy Musial G, Sapsford D, West Suffolk Hospital Foundation Trust, Bury St Edmunds

Introduction In the hospital setting, doses of medicines are often delayed or omitted for a variety of reasons. While the majority of these events are not known to have serious negative impact on the patients’ clinical condition, there are situations where timing of the dose is crucial (e.g. Parkinson’s disease). Following reports of deaths and severe harm relating to omitted or delayed medicines the National Patient Safety Agency (NPSA) issued an alert advising all organizations to compile a list of critical medicines where the timeliness of administration is crucial and review and change systems of supply of those medicines1. At the West Suffolk Hospital (WSH) during July 2013 an audit of omitted doses revealed that there were 107 omissions of medicines that were marked on the drug chart as unavailable on the ward, this included 10 critical medicines2. Aim and objectives To investigate the timeliness of supply of critical medicines requisitioned from in-patient pharmacy and ascertain the following:

The percentage of critical medicines unavailable on the ward at the time of ordering (CMU) marked as urgent (Urgent CMU),

The timeliness of dispensing process,

Potential delay in the supply of CMU (identified as Delayed CMU - i.e. items that were ready in pharmacy only after their administration time). It is expected that 100% of CMU will be prioritised during the dispensing process. Method The audit was registered with WSH Governance support. A ward order sheet was designed to enable data collection at the time of ordering of all medicines on the wards by pharmacy staff. For requisitions completed by nurses on the ward a label was designed to enable recording of times and pharmacists screening these requisitions were asked to annotate whether the medicine is thought to be available on the ward and when the next dose is due. A pilot was undertaken on two wards and all requisitions that were sent to pharmacy on the morning of pilot were included. Minor amendments were introduced to the ward ordering sheet and to the annotations on requisitions as a result of the pilot. Data were collected from all wards on one working day. The data from the pilot were included in the analysis. All ward order and requisitions with requests for medicines for named patients that were sent to pharmacy on the audit day were included. Items that had incomplete essential data or were unavailable in pharmacy were excluded. Appropriate descriptive statistical analysis was undertaken. Results There were 213 items that met inclusion criteria, 14 were excluded due to incomplete data and 2 items were not available in pharmacy. A total of 197 dispensed items were analysed and included 18 CMU ordered on ward order sheets and 10 CMU ordered on requisitions. Data collected are summarised in Table 1. Only 44% (8 items, 95%CI 21.5 to 67.4%) of CMU ordered on ward order sheets and only 10% (1 item, 95%CI 0 to 28.6%) of CMU ordered on requisitions were marked as urgent. The average delay (i.e. time between the due dose and the time they were ready in pharmacy for collection) was 123 minutes (95%CI 34 to 212) for Delayed CMU ordered on ward order sheets and 300 minutes (95%CI 204 to 396) for Delayed CMU ordered on requisitions.

Table 1: Data collected from Ward Order Sheets and Requisitions

Ward Order Sheets

Total Marked as

urgent CMU

CMU marked as urgent

Delayed CMU Delayed CMU

marked as urgent

Nr. of items 149 34 18 8 5 2

% of total (± 95%CI) 100 22.8 (±6.7) 12.1 (±5.2) 5.4 (±3.6) 3.4 (±2.9) 1.3 (±1.8)

Average total dispensing time [min] (± 95%CI)

116 (±11) 49 (±11) 91 (±24) 42 (±21) 95 (±48) 45 (±28)

Requisitions

Nr. of items 48 4 10 1 7 0

% of total (± 95%CI) 100 8.3 (±7.8) 20.8 (±11.5) 2.1 (±4.1) 14.6 (±10) 0

Average total dispensing time [min] (± 95%CI)

147 (±31) 25 (±11) 133 (±33) 33 177 (±57) N/A

Discussion The average dispensing time for items identified as urgent are significantly shorter than the average for all items. This shows that there are effective processes within the Pharmacy to prioritise dispensing of items that are highlighted as urgent. However only a small proportion of the CMU are being identified as urgent and this might suggest that pharmacy staff do not routinely identify those items that should be prioritised. No formal procedures exist relating to the timeliness of dispensing of CMU, and the decision to prioritise those items is left to the practitioners’ professional judgement. This audit confirms that a lack of prioritising may be contributing in some cases to the delayed or omitted doses of critical medicines. It is therefore recommended that a formal process of identifying and prioritising CMU by pharmacy staff is developed and implemented into the relevant standard operating procedures. This will ensure CMU are delivered to in-patients in a timely manner, preventing delayed doses and enhancing patient care. The main limitation of this audit was one of convenience sampling. Due to limited time and the feasibility data collection was conducted on one day only and therefore the results may not be generalizable. Additionally the screening pharmacists in the dispensary were expected to annotate ward requisitions as to whether the medicine ordered is thought to be available on the ward, based on the limited information available (e.g. the pharmacy and nursing staff annotations on the drug chart, medicines reconciliation and ward stock list), this data may not always be accurate. Finally, it is essential that any improvements in dispensing process are accompanied by interventions aimed at increasing awareness of the risks of omitted or delayed doses of critical medicines amongst nursing staff. References: 1. Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital – Supporting Information,

National Patient Safety Agency, February 2010, available from: http://www.nrls.npsa.nhs.uk/ (accessed on 28/7/13) 2. Omitted medicines due to drug not available on ward Audit, West Suffolk Hospital, July 2013.

25. Risk to patient of prescribing transcription errors during transfer of care from critical care to general ward level De Val J, Leal L, Glover G, Mistry J, Wan R, Watson A, McKenzie CA, Institute of Pharmaceutical Sciences and School of Medicine, Kings College

London, Pharmacy and Critical Care, Guy’s and St Thomas (GSTT) NHS Foundation Trust, London.

Introduction It was identified within GSTT that the transfer of care from critical care to general ward level posed significant risk of harm to patients from prescribing errors. The process involves transcribing from an electronic prescribing system, (Intellivue Clinical Information Portfolio, ICIP) in critical care to a paper based drug chart at general ward level. In 2011 a preliminary evaluation of the process was undertaken, which demonstrated that 30% of patients stepped down from critical care were exposed to risk from a transcription error. A series of changes were then implemented in an aim to reduce this risk with annual re-evaluation of the service. Objectives The aim of the project was to assess the effect of an integrated prescribing and medication review approach for each critical care discharge prior to transfer of care, evaluating changes implemented over a three year period. Method The project was considered by both the medicines safety forum (MSF) and critical care pharmacy committee (CCPC) and was registered as a service evaluation which did not require ethical approval. Patients were identified prospectively on 4 separate occasions between 2010 and 2013. After each occasion prescribing error detail was presented to MSF and CCPC and changes were agreed to reduce the risk of error to the patient. It was after the 2012 evaluation of transfer of care that both CCPC and MSF agreed process improvement would be for the critical care clinicians to prescribe the ward drug chart and an extra step be put in place: clinical pharmacist review. This was intended to assure best protection for the patient from prescribing error risk on care transfer. For each evaluation, patients were identified through daily review of the patient handover. Prescribing details were collected at the point of transfer or within 24 hours after discharge. The ward (paper) drug chart was located for the discharged patient and analysed and each item compared against the ICIP e-chart. All transcription errors were identified, and each chart was then independently reviewed by a senior critical care pharmacist to ensure accuracy and reliability of results. Errors were recorded in the categories of drug name, dose, route, frequency and omissions. A percentage transcription error rate was then calculated per patient and per prescription item, and the results analysed using the chi-squared test for significance. Comparisons were made between results over the three year evaluation. Errors were graded using a recognised severity scoring system. The drug charts were also analysed for supplementary information pertaining to GSTT agreed antimicrobial stewardship criteria. Results The 2013 evaluation was conducted over four weeks, and a total of 120 charts were analysed which comprised a total of 1646 prescription items. 18% of charts (patients) contained a transcription error with an absolute frequency of 24 prescription items out of 1646 items (1.5% error rate) reviewed containing an error. In previous years the transcription error rate per chart (patient) had been: 2012 - 40% (20/51), 2011- 30% (16/54) and 2010 - 33% (17/52). The reduction in 2013 was statistically significant using the chi-squared test. Historical comparison of the type of errors made was carried out for 2012 and 2013 and is shown in table 1 below. Table 1: Breakdown of transcription error types

Year Error Type frequency (as percentage of all errors)

Drug Name Dose Frequency Route Omissions

2012 38% 29% 14% 0% 19%

2013 0% 29% 29% 0 42%

In 2013 of the 24 errors that occurred 21 (88%) were classified as ‘simple’ as they had little potential to cause harm to the patient. The remaining 3 were considered ‘serious’ with the potential to cause harm. 97 antibiotic prescriptions were evaluated during the 2013 data collection period. In order to meet antimicrobial stewardship standards supplementary information is required on these prescriptions, namely antibiotic indication and duration. Of those 97 items, 60% (58/97) contained the full and relevant information associated with each antibiotic prescribed on the chart. Partial supplementary information was included on 34% (33/97) of prescriptions in the form of either an antibiotic indication or duration and 6% (6/97) of charts contained no additional information regarding the indication and duration of the antibiotics prescribed. A total of 94% (60/64) of charts transcribed containing antibiotics documented additional supplementary information (full and partial information combined). In 2012, 78% of drug charts documented additional supplementary information whilst 22% contained no information. Discussion The results of this study show that that a fully integrated step down review process is better embedded throughout the Trust. The risk of transcription errors is now highlighted in prescribing inductions of junior doctors and critical care pharmacists play a role in prompting them to early chart transcription to allow timely review and provide transcription checks where possible. Patients due to step down to general wards are highlighted in the critical care morning safety brief which is consultant led. The effect of these implementations is reflected in the markedly improved transcription error rate obtained in this study. An error grading system used by Perren et al1 was used to evaluate the severity of the transcription errors. The errors classified as ‘serious’ were: Omission of a corticosteroid (prednisolone), an increased dosage of an immunosuppressive drug (tacrolimus) and a doubled dose of an antidepressant (venlafaxine). The limitations of this study included not being able to evaluate the full effect of every annual change, some of the data collection varied annually so it was difficult to perform additional analysis, and that the full impact of pharmacist intervention on each prescription in 2013 was not assessed. The changes considered to be most significant was for the critical care clinician to transcribe to the paper drug chart rather than the receiving ward level clinicians, and for critical care pharmacists to support the prescribing and review the charts prior to discharge from critical care. Conclusion Transfer of care from critical care to general ward care poses significant risk to patient in form of prescribing error. At GSTT a fully integrated clinician prescribing and pharmacist clinical check resulted in a significant reduction in the risk. References 1. Perren et al. From the ICU to the ward: cross-checking of the physician’s transfer report by intensive care nurses. Intensive Care Medicine 2008; 34: 2054-2061

26. Development of pharmaceutical referral criteria for use by non-pharmacy staff on general surgical wards at Glasgow Royal Infirmary Clarke J1, Cunningham ITS2. 1 Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow,

2 Robert Gordon University, School of Pharmacy & Life Sciences, Aberdeen

Introduction In 2002 the Scottish Executive published “The Right Medicine – a strategy for pharmaceutical care in Scotland” calling for all hospital patients to receive pharmaceutical care from a clinical pharmacist1. Acknowledgement was made, at the time, that there were restrictions to this, particularly in terms of staffing2. Ten years later, in 2012, the economic and political climate has changed considerably, the pressures on staff time and resources have grown and so it is necessary to develop more efficient ways of working to better target pharmaceutical care. There are no formal procedures, set standards or guidelines for prioritising patients who require pharmaceutical care; it can be a subjective process. Screening and prioritisation methods are not commonly taught; instead it is a skill developed over time as pharmacists gain experience working at ward level. In many ways pharmacists generate their own work with many medication related problems identified if the patients’ medication chart is seen in conjunction with the pharmacist having some knowledge of the patients’ history and current condition. Presently the main way that this is achieved is for every patient’s medication chart, and notes, to be seen every day however this rarely happens in practice and is not thought to be the most effective use of pharmacists’ time3, 4. Many allied healthcare professionals obtain referrals from ward staff to identify patients that require their specialist input. It would be helpful to determine if pharmacy could work in a similar way, with non-pharmacy ward staff identifying patients who require review by pharmacists, in order to develop more efficient methods of providing pharmaceutical cover to general surgical wards. Using this method may enable pharmacists to focus their time and attention on patients with the greatest requirement for pharmaceutical care. Aim To determine whether or not referral criteria can be developed for use by non-pharmacy staff on general surgical wards to identify patients that require pharmaceutical care. Objectives

1. Develop referral criteria that can be used by a wide range of healthcare professionals to identify and refer patients requiring pharmaceutical care on a general surgical ward

2. Assess appropriateness of criteria for use in practice Methodology Ethical approval for this project was sought, and granted by The School of Pharmacy and Life Sciences Ethics Review Panel at Robert Gordon University. It was also confirmed that ethical approval was not required at a local level. The project was carried out in accordance with good research governance principles. A two round consensus Delphi method was carried out in June 2013. A range of staff working in general surgical wards in Glasgow Royal Infirmary were invited to participate and try to gain consensus about potential referral criteria. For the first round, fifty proposed referral criteria were developed following literature searches and discussion with experienced clinical pharmacists. These were presented, via questionnaires, as a series of statements about patients or medicines and participants were asked whether they would always; most times; occasionally; never refer the patient to pharmacist at ward level for review or advice. Once questionnaires were completed the results of this initial survey were collated and percentage of participants giving each answer was calculated. For the second round, participants were asked to compare their initial answers to the results of all participants from round 1 and change their initial result if they wanted to. The results of this round were collected and analysed. No further Delphi rounds were carried out. Following completion of the Delphi study, vignettes were written describing patients typically encountered on general surgical wards. These vignettes were written to describe patients or situations that matched a selection of referral criteria suggested in the Delphi forum. Participants, who had not been involved in the Delphi forum, were presented with paper questionnaires containing twelve vignettes and asked to decide whether or not the patient should be referred to the pharmacist for pharmaceutical care. Space was provided for comments to explain decisions. Results Out of the 50 statements initially presented to the participants in the Delphi study only 6 achieved consensus as times when patients would always be referred for pharmaceutical care. Another 12 statements gained consensus when ‘always’ and ‘most times’ categories were combined. There were no criteria for which patients would ‘never’ be referred. There were a number of differences between the results of the Delphi forum when compared to the results from the vignette study (Table 1). Table 1 – Comparing anticipated referrals based on Delphi results with actual results from vignette study

Patient Details Anticipated results from Delphi forum Vignette results

% patients referred to pharmacist % patients referred to pharmacist

Child 50 40

Renal impairment 25 44

Taking NPSA alert medicine

92 0

Ex IVDU 25 89

Discussion Stability between Delphi rounds led to the decision to conduct only two rounds of the Delphi study. Vignettes were to be used to validate the appropriateness of the developed referral criteria but instead showed differences between referrals expected from Delphi results when compared to referrals made from vignettes. This highlighted some of the difficulties with developing clear, user-friendly referral criteria. It is difficult to quantify the work that pharmacists do; a number of things may be checked by a pharmacist but may result in no changes to a patients’ medication. Therefore it may be difficult for ward staff to clearly identify the circumstances in which pharmaceutical care and input from a pharmacist is required. There can a wide variety of reasons for referral to pharmacy and pharmacists often identify medication related problems not recognised by other healthcare professionals. It is important that further work determines the validity of any referral criteria or risk assessment tools developed for use to prioritise patients requiring pharmaceutical care are validated and appropriate education is provided to users to ensure optimal use and outcomes. References 1. Scottish Executive. The Right Medicine: A Strategy for Pharmaceutical Care in Scotland. Edinburgh: Scottish Executive; 2002. 2. The Audit Commission. A Spoonful of Sugar: Medication Management in NHS Hospitals. Wetherby: Audit Commission Publications; 2001. 3. Cook G, Thomson G, Lowden K. Targeting Clinical Pharmacy Services To High Risk Hospital Patients. Pharmacy Management. 2012; 28(1):13--16. 4. Franklin BD, Rosa MB, Miller G, Jacklin A. The evaluation of a novel model of providing ward pharmacy services. International Journal of Clinical Pharmacy. 2012; 34(4):518-23.

27. How might pharmacists in training best be supported to face emotionally-challenging clinical experiences? Reygate, K. Foundation Training Programme Director & Prescribing Lead, Health Education, Kent Surrey & Sussex Pharmacy. Hayward’s Heath.

Introduction Pharmacists who teach pharmacy trainees at ward level primarily focus on the knowledge and practical skills required to perform the fundamental roles of a hospital pharmacist. Self-reflection after a critical incident teaching on the ward highlighted the lack of preparation of trainees to deal with emotionally-challenging clinical experiences (ECCE). There are services available for trainees to access if required, however in referring trainees to these services clinical trainers shift the responsibility of dealing with psychological needs of the trainee to someone else, whilst they deal with the easier physiological issues within the hierarchy of needs as described by Maslow1. In not showing empathy with the trainee’s emotional needs, trainers are not reinforcing the positive unconditional regard that Rogers2 explains is essential to educational effectiveness. Objectives

To investigate the effect of dealing with an ECCE on trainees performance.

To discover the different avenues for preparing trainees to face ECCE.

To implement a tool or resource into training programmes that would highlight the issue of pharmacy trainees dealing with ECCE. Method Ethics approval for this work was granted. Consent was obtained from all participants to use anonymised information. Action research (AR) is described as “finding ways to improve your practice” 3, specifically how to improve educational practice. Undertaking AR takes a completely different process to that of research carried out in the pharmaceutical world, most importantly AR is centred on the practitioner who undertakes it. The first strategy was to conduct structured interviews with a variety of pharmacist trainees; two pre-registration (PRP), two newly-qualified (NQP) and two one-year qualified foundation pharmacists (FP). Prior to this a literature review focusing on the effects of experiences on staff within the NHS was undertaken. From this, questions were generated for the interviews, which were carried out via telephone and recorded in writing. The interview answers and the literature review aided generation of a resource. An information leaflet was decided to be most appropriate. The leaflet was sent to original trainee interviewees via email with accompanying questions. Emails were also sent to educational programme directors (EPDs) to get their thoughts on their experiences on ECCE and the usability of the leaflet within the various programmes within the region. Data was gathered in November to December 2013. Results Six trainees were interviewed initially. In response to the leaflet three EPDs, one PRP, one NQP and two FPs responded. The variety of attitudes between the trainees in their anxiety of dealing with ECCE was dependant on their experience within the NHS setting. The anxiety felt by the PRPs concerned their fear of feeling useless. The NQPs were more concerned about their own reactions to seeing patients that cause emotional unease. There were a variety of scenarios mentioned within the calls that trainees found difficult, such as dealing with death and seeing patients with altered physical states, the latter of which provoked emotions such as embarrassment or shock. Inclusion of different examples within the resource would better prepare trainees for potential ECCE and reduce stress when faced with them. When asked if death was a taboo subject in pharmacy, 5/6 trainees gave a negative comment within the answer, even if they decided it was not taboo. The PRP’s would refer to their peers, direct educational supervisors or pastoral care if an ECCE were to occur. The NQP would talk to pharmacy staff or supervisors despite giving concerns that it is not dealt with well within pharmacy. The FPs would not discuss it within pharmacy or at all. These discussions highlighted that when preparing trainees to face ECCE one size will not fit all. A leaflet was produced with an aim to provoke thought on the subject and provide different choices of support for the trainees dependent on their personal preferences. Not “a lot of thought “and “no real preparation” the EPD thoughts on the preparedness of pharmacy trainees to deal with ECCE. The EPDs felt that pharmacy undergraduate’s lacked exposure to some of the experiences they may find difficult and ultimately “affect their career path”. All EPDs include pastoral care in induction for trainees. They shared additional ideas for preparing trainee’s however they aired concerns about implementing them due to the perception of death being a taboo subject. Dealing with ECCE leaflet “it brings to light the realities that you might face on the ward, enabling you to prepare”. Product testing: Trainee and EPD opinions. All the respondents felt that they would find the leaflet useful and would refer to it. Most commented on the additional support of colleagues which should be highlighted as a primary resource. Conclusion AR in its nature means that bias can easily affect the results, as the participants knew and had worked with the researcher. Although the small numbers of participants may appear to affect the validity of results, the qualitative responses gave insights and greater understanding into the effects of ECCE on trainees. This work has had two significant outcomes, firstly on the participants of this AR, who have had revelations regarding ECCE. From the PRP who felt the “leaflet brings up situations that as a student I never thought about, even though I looked forward to working in the hospital” to the EPD for which the leaflet got them thinking about the subject more and how to approach it. Secondly the generation of a resource available for Trusts within the region to use for all pharmacy trainees and existing staff that who work at ward level that may face ECCE, which in turn can affect staff performance and ultimately affect patient care. References:

1. Maslow AH. Motivation and personality, ed2, New York 1970 Harper Collins 2. Rogers, C. Freedom to learn for the 80s, New York 1983 Merrill. 3. McNiff, J. and Whitehead, J. You and your action research project. 3rd ed. 2010 London: Routledge

28. Evaluation of Opioid Use in the Management of Acute Postoperative Pain Allison J, Bowie C, Carthy D, Elliot E, McAndrew C, McCabe C, Platts K, Murray N, Souter C. NHS Lothian Pharmacy Service

Introduction Effective pain management can prevent postoperative complications, reduce hospital stay and promote recovery and rehabilitation.1 Opioids are routinely prescribed in acute postoperative pain yet a recent study reported 27.2% of opioid prescriptions contained an error, of which four were life threatening.2 The Scottish Patient Safety Programme (SPSP) aims to reduce avoidable harm to patients by improving the safety of high risk medicines such as opioids. The local Acute Pain Service (APS) released guidelines for managing acute pain in August 2013 and this audit aims to evaluate the prescribing of opioids in acute postoperative pain. Objectives To quantify adherence to the acute pain guidelines, identify areas for improving the use of opioids and produce a series of recommendations. Method The audit tool was informed by the acute pain guidelines and validated by the Lead Pharmacist for Theatres/Anaesthetics. The tool was piloted in seven patients and after inter-rater reliability testing and subsequent modification, applied to a convenience sample of 100 adult patients in the 72 hour postoperative period. Data was collected from 18 surgical wards across three hospitals during 07/11/2013-06/01/14, using the prescription and administration chart, the electronic patient management system, patients’ notes and the Standardised Early Warning Signs (SEWS) chart. A Microsoft Access® database was designed for data analysis. Ethics approval was not required for this audit. Results The mean (standard deviation (SD)) age of the study sample was 60.9 (17.82) years, 45% were male, 81% had chronic kidney disease stage 1-2, and no patients had altered liver function. Of the 17 criteria applied to 100 patients, 978 (57.5%) were applicable. Overall adherence was observed on 626/978 (64.0%, 95% CI 61.0-67.0) occasions. The lowest adherence concerned the ‘golden rules of prescribing’ (local policy) and the mean (SD) number of opioid prescribing errors per patient was 1.7 (1.1). Overall adherence was higher in the 14 patients reviewed by the APS (81.1% v 61.1%). The APS had reviewed 2/50 (4.0%) of patients on a combination of potent and weak/intermediate opioid and 11/42 (26.2%) of those who were not on a combination. Adverse effects were documented for 28 patients of which 15 (53.6%) were prescribed a combination of opioids and 2 (7.1%) were prescribed a dose considered too high for their renal function. On five occasions, there was a choice of route prescribed for a single potent opioid where formulations are not bioequivalent. Table 1: Adherence to audit criteria

Criteria Applicable, n Adherence, n (%)

Patient receiving potent opioid that is not morphine, has been tried on morphine first 53 32 (60.4)

Immediate release potent opioid is prescribed for breakthrough pain at no less than 1/6th of total daily regular potent opioid dose

41 29(70.7)

Dose of current potent opioid is safe for age, renal function and hepatic function 92 78 (84.8)

Patient is not receiving potent and weak/intermediate opioid concurrently 92 42 (45.7)

Patient on potent opioid is prescribed paracetamol and NSAID/COX2 92 66 (71.7)

Morphine/ Oxycodone modified release is prescribed generically 40 26 (65.0)

The exact dose of potent opioid is prescribed 92 80 (87.0)

Patient on potent opioid is prescribed an anti-emetic 92 78 (84.8)

Patient on potent opioid is prescribed a laxative 92 56 (60.9)

Patient with two consecutive pain scores ≥4 (scale of 0-10) or self reported “moderate pain”, had analgesia reviewed

31 21 (67.8)

Patient experiencing side effects with potent opioids is managed according to “side effects of opioid analgesia(adults)” guidelines

28 17 (60.7)

Patient prescribed fentanyl patch has fentanyl monitoring chart 3 3 (100.0)

Fentanyl patch monitoring chart completed in full 3 3 (100.0)

New fentanyl patch prescribed on advice from pain team 3 3 (100.0)

PCA is prescribed on ‘Opioid infusion and PCA chart’ and reference made on kardex and official PCA chart

24 13 (54.2)

Opioids prescribed by single route 100 69 (69.0)

Opioids prescribed in line with ‘golden rules for prescribing’ 100 10 (10.0)

Total adherence 978 626 (64.0)

Discussion/Conclusion This audit has provided baseline data for adherence to the new acute pain guidelines. Despite being restricted to second choice opioid, oxycodone was often prescribed first line irrespective of contraindications/cautions to morphine. Different surgical procedures are associated with their own pain characteristics and clinical consequences which should influence analgesic choice.3 The dose of potent opioid prescribed in elderly patients or those with renal impairment was largely within the recommendations possibly reflecting a higher likelihood of junior prescribers to refer to guidelines or experienced staff in these patient groups. The findings suggest a lack of awareness of general aspects of opioid use including avoiding combinations, bioequivalence of different routes of administration, and the prevention and management of adverse effects. Although adherence to the prescribing guidelines was higher in patients reviewed by the APS, the proportion of patients reviewed was small suggesting few underwent procedures associated with complex pain management. The audit had a number of limitations: deviation from guidelines was not discussed with prescribers and may have been appropriate; the type of procedure and complexity of pain were not considered; pharmacists’ interventions were not recorded so their contribution to adherence is not clear; and although the sample included data from most of the surgical wards in the Health Board, the numbers in some wards was insufficient for statistical analysis. The findings were presented to the APS and recommendations made to raise awareness of the guidelines, develop an education programme for undergraduate and foundation level prescribers, and consider a prescribing support tool. Further work should include qualitative exploration of deviation from guidelines and more detailed evaluation of the prevalence and management of adverse effects of opioid and non-opioid analgesics used in multimodal regimens. References 1. White PF, Kehlet H, Neal JM, et al. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to peri-operative medical care.

Anesthesia & Analgesia 2007;104(6):1380–1396. 2. Denison Davies E, Schneider F, Childs S, et al. A prevalence study of errors in opioid prescribing in a large teaching hospital. The International Journal of

Clinical Practice. 2011; 65(9):923-929. 3. Whyte PF, Kehlet H. Improving postoperative pain management. Anesthesiology 2010; 112: 220-225.

29. To determine whether TCIWorks can accurately predict International Normalised Ratio (INR) response to warfarin dosing for individual patients

Black La, Wright DFBb, Thomson AHc, MacTavish Pa, Tait Ca, McIntosh Td, a. Glasgow Royal Infirmary, National Health Service Greater Glasgow and Clyde (NHSGGC), UK, b. School of Pharmacy, University of Otago, New Zealand,

c. University of Strathclyde, Glasgow, UK, d. Robert Gordon University, Aberdeen, UK

Introduction Warfarin is used to prevent coagulation of blood in serious conditions, such as atrial fibrillation (AF) and pulmonary thromboembolism (PTE). It exerts its anticoagulant action by inhibiting the hepatic recycling of vitamin K which is essential for the activation of clotting factors1. There is a wide variation in the individual dose response to warfarin due to several factors such as: age, genetic differences, concomitant medication and diet1. The effectiveness and safety of warfarin is monitored by determining the INR. Although there are newer anticoagulants available that may not require routine monitoring of clotting, a major disadvantage of these treatments is the lack of a specific antidote to reverse the anticoagulant effects in the event of bleeding. There are several prediction tools to aid warfarin dosing; however in NHSGGC there is no reliable warfarin induction tool for inpatients beyond day 4 of initiation. Currently dosing beyond day 4 relies on the expertise of the clinician, who is usually a junior doctor and may have no specialist knowledge. An experienced haematologist in NHSGGC has reported that patients presenting to their first anticoagulant appointment frequently have INRs outside the therapeutic range. Bayesian methodologies involve the use of computerised programs which combine a pharmacokinetic and pharmacodynamic (PKPD) model for warfarin response, prior PKPD parameter estimates and response data from the individual to predict drug response for that patient. When used in relation to warfarin, response data will come in the form of feedback INRs. Previous studies have shown that Bayesian programs are accurate at predicting INR response to warfarin dosing, however none have aimed to predict the steady state (SS) INR2-4. Aim/Objectives To determine whether TCIWorks, a Bayesian forecasting tool, can accurately and precisely predict INR response to warfarin dosing for individual patients. To assess bias and precision of TCIWorks and to determine if there are any differences in the predictive performance of TCIWorks using no feedback INRs and up to six feedback INRs. Finally to make recommendations regarding the potential role of TCIWorks, in routine clinical practice in NHSGGC.

Method An existing dataset was used to identify patients who were previously initiated on warfarin. In January 2013, 377 of these patients were assessed for suitability for inclusion. Patients were included if the following information was available: age, gender, warfarin dosing history and INRs from initiation to SS INR. INR and dosing data was collected retrospectively from the DAWN AC® database, the computerised program used to manage patients on warfarin at anticoagulant clinics in NHSGGC. Patients age, gender and dosing data were entered into TCIWorks and the SS INR was predicted using no feedback INRs and then with the progressive addition of up to 6 feedback INRs. The prediction error (PE) was used to assess the performance of TCIWorks; this is the observed SS INR value subtracted from the predicted SS INR value. Mean prediction errors (MEs) with 95% confidence intervals and a t test comparing ME to 0 were used to assess bias. Squared prediction errors (SPEs) and the root mean squared error (RMSE) were used to assess precision. Analysis of variance, using a Wilcoxon Signed Rank Test, assessed differences in precision between each feedback INR. A p value <0.05 was considered statistically significant. Ethical approval for this study was granted from the West of Scotland Research Ethics Service and from the Research Ethics Committee at the School of Pharmacy and Life Sciences Robert Gordon University. Results Ninety eight patients were suitable for inclusion however, 2 were later excluded due to a technical error within TCIWorks. Of the 96 subjects included: 48 were male and 48 were female; the median age was 70 (range 19-89). The dose required to obtain a SS INR ranged from 1.5mg to 10mg. Table 1 shows a statistically significant overestimation of the SS INR with the population model, however, bias was lost and precision improved with the addition of feedback INRs. Analysis of variance showed that the average SPEs for feedback INRs 0-4 were all significantly different from the average SPEs for feedback INRs 5-6. There was no significant difference between the average SPEs of feedback INRs 5 and 6. Table 1. Bias and Precision of TCIWorks

INR 0 INR 1 INR 2 INR 3 INR 4 INR 5 INR 6 ME 0.23 0.08 0.06 0.09 0.04 -0.02 -0.06 SD 0.67 0.63 0.61 0.64 0.58 0.45 0.42 95% CI 0.09 to 0.36 -0.04 to 0.21 -0.06 to 0.18 -0.03 to 0.22 -0.07 to 0.16 -0.11 to 0.06 -0.16 to 0.02 P Value (t test ME v 0)

0.00 0.18 0.34 0.15 0.44 0.62 0.16

MSE 0.51 0.40 0.37 0.42 0.33 0.21 0.18 RMSE 0.71 0.63 0.61 0.65 0.57 0.45 0.42

Discussion/Conclusion

The population model overestimated the predicted SS INR however only one feedback INR was required to remove bias. This corresponded with previous studies which used a Bayesian forecasting methodology2-4. Although TCIWorks can predict INR response to warfarin dosing without bias, the inclusion of five feedback INRs improves the predictive precision. Since TCIWorks can predict INR values in the future for individual patients, it could be used to determine a suitable maintenance dose of warfarin at the point of hospital discharge. Anecdotally most patients initiated on warfarin in hospital in NHSGGC remain inpatients for at least 4 days. This means that in practice, there would be enough feedback INRs to ensure maximum precision of TCIWorks. It is envisaged that TCIWorks could be used by clinical pharmacists to assist in the prescribing of warfarin for patients being discharged form hospital. A limitation of this study is that it relies on the accuracy of the INR and dosing data collected from DAWN AC®.

References

1. The International Warfarin Pharmacogenetics Consortium. Estimation of the Warfarin Dose with Clinical and Pharmacogenetic Data. New England Journal of Medicine. 2009; 360(8):753-64 2. Svec JM, Coleman RW, Mungall DR, Ludden TM. Bayesian pharmacokinetic/pharmacodynamic forecasting of prothrombin response to warfarin therapy: preliminary evaluation. Therapeutic Drug Monitoring. 1985; 7(2):174–180 3. Lee C, Coleman RW, Mungall DR. Effect of using warfarin plasma concentrations in Bayesian forecasting of prothrombin- time response. Clinical Pharmacy. 1987; 6:406–412 4. Boyle D, Ludden TM, Carter BL, Becker AJ, Taylor JW. Evaluation of a Bayesian Regression Program for Predicting Warfarin Response. Therapeutic Drug Monitoring. 1989; 11(3):276-284

30. Promoting excellence in hospital medicines procurement * Self assessment of regional procurement arrangements in England: a comparison with 2012 outcomes and recommendations

Arkell E, University Hospitals South Manchester NHS Foundation Trust, Tutcher D, OptraPharm Ltd * Commercial Medicines Unit / Pharmaceutical Market Support Group funded project

Ethics Statement: Research & Ethics Committee approval not required since an audit project Background This project was commissioned in 2012 by the Department of Health to review regional procurement arrangements for medicines across England with the broad remit of reviewing:

Delivery and sharing of best procurement practice.

Rolling out successfully delivered procurement opportunities.

Driving up standards and consistency of purchasing across the country. Phase 1 of the research identified 43 “success factors” that the Regional Procurement leads felt contributed to successful procurement. Each Regional Procurement lead then manually scored practice against these “success factors” to obtain an overall “applicability score” to their region. Communication of Phase 1 results to stimulate regional internal review and national benchmarking has been via several channels:

Chief Pharmacists Newsletters

Presentations at Chief Pharmacists Group meetings, Pharmaceutical Market Support Group and National Pharmaceutical Supply Group (NPSG)

Presentation at GHP Procurement & Distribution Interest Group June 2013 symposium

Objectives In September 2013, NPSG decided an extension to this work would support further improvement in practice and requested:

A re-audit of procurement “success factor” applicability scores in all regions in England to compare against the results of 2012.

An assessment of progress against ten key NPSG endorsed recommendations from Phase 1 of the project.

Method

In 2013, an electronic survey tool using Adobe FormsCentral was designed to facilitate the re-audit of regional procurement “success factors” to obtain an overall “applicability score” to their region. It was also used to assess status against the ten Phase 1 recommendations. Assessment by both the NPSG regional representative and the procurement lead was encouraged. Results 1.“Success factor” applicability Average applicability score per region rose from 69% in 2012 to 76% in 2013. Two regions have shown significant increase in score:

South East Coast – 28%)

East Midlands – 24%)

All other regions are within +/- 7% of last year’s score. Six out of ten regions now score over 80% compared with four from the last survey. The overall outcomes are depicted in the graph. Work is on-going to determine whether there is a correlation between procurement “success factor” applicability in a region and return on investment.

2. National progress against Phase 1 recommendations The following Phase 1 recommendations scored less than 80% in terms of regions declaring that they are compliant: No1. There is a strategic steer on procurement priorities from the Regional Chief Pharmacists Group (67%). No2. Commissioners are integrated into regional procurement decision making (20%). No3. There is access to a common pool of procurement expertise to provide support for data analysis, tendering programmes and contract management (60%). No5. There is capacity to work collaboratively on projects with other regions (40%). No6. There is an established process for sharing experiences (good or bad) on procurement initiatives with colleagues in other regions (60%). No7. There is a preparatory process to obtain the views of clinical staff before defining the tender specification documents (30%). No9. An annual procurement work plan is agreed with regional Chief Pharmacists (70%). No10.There is a process to effectively monitor progress against the work plan (70%). Discussion and conclusions Regional procurement teams support the work of purchasing staff in hospital pharmacy departments. Regional teams should be strategically led by, and work to an annual agenda set by, Chief Pharmacists in the Trusts in the region served. This study has shown that there is wide variation between regions in terms of the operational environment currently provided for their regional procurement team. The results list the circumstances and working arrangements that should be in place for regional procurement teams to operate at maximum efficiency, and go on to identify where each region’s deficiencies lie. This information has been fed back to all regions, and has already been used by some Chief Pharmacists groups to reappraise regional procurement arrangements and to come to decisions on how deficiencies should be addressed. If replicated and progressed, this process will see steady improvement in regional procurement performance in all regions across England, which in turn will create the capability and capacity for regional teams to work collaboratively in pursuit of even greater cost-effectiveness in procurement practice and outcomes. In conclusion, the December 2013 meeting of the NPSG were able to put forward the following recommendations for national prioritisation: 1. Chief Pharmacists must provide strategic direction for regional procurement priorities and assurance

Annual work plans must be signed off, against which outcomes will be monitored e.g. savings trackers and reported at regular review meetings. This will support avoidance of lost opportunities through failure to implement initiatives.

2. Commissioning involvement Working with commissioners to put in place gain share and other commissioning agreements will be essential to ensure value for money for medicines procurement.

3. Collaboration and sharing of initiatives There is a need to explore options to share resources in terms of procurement process, quality assurance and engaging the opinions of clinical staff.

Su

cc

ess

fa

cto

r s

co

re Regions

EM = East Midlands EoE = East of England Lon = London NE = North East NW = North West SC = South Central SEC = South East Central SW = South West WM = West Midlands Y&H = Yorkshire & Humber

31. An Evaluation Of The Error Rate Of An Independent Prescribing Pharmacist Service On The Surgical Day Unit. Graham L, Howarth N, Gordon S, University Hospitals Southampton NHS Foundation Trust.

Introduction There are several studies looking at medication error rates amongst doctors but less is known about the error rates of independent prescribing pharmacists. The EQUIP study, highlighted that nearly 9% of prescriptions in a selection of UK hospitals contained an error when written1. Almost all of these errors were intercepted by pharmacists before they could affect patients. The EQUIP study included independent pharmacist prescribers but the total amount of prescriptions was very small compared to doctors (179 items prescribed by pharmacists v 109,203 items prescribed by doctors). The development of a new pharmacist prescribing role within a new combined Surgical and Orthopaedic Day Unit (SDU) at University Hospitals Southampton NHS Foundation Trust (UHS) provided an opportunity to review error rates. This new service was developed to save junior doctors time but primarily to improve the patient journey by preventing delays in their regular medication being prescribed, a problem that had been highlighted on an inspection by the care quality commission 2. Aim To assess the accuracy of pharmacist prescribing within SDU and determine the time associated with prescribing to assist with future workforce planning. Objectives

• To determine how many patients are currently seen by the pharmacist in SDU. • To establish if any prescribing errors are made and the severity and rate of occurrence.

Method In order to ensure consistency, a standard operating procedure was written for pharmacists covering SDU detailing the service, explaining which patients should be prioritised for review, medications to be prescribed and the required documentation. A data collection form was developed to collect information on the number of patients seen, how long this took and how many medications were prescribed. A note was added to the electronic prescribing system for the screening pharmacist on the downstream ward to document whether or not any prescribing or drug history errors were identified. Patient records were then searched retrospectively to see if the patient had been seen by a pharmacist post-operatively and if any errors had been identified. Data collection took place for a 7 month period from 28/5/13 until 4/1/14. Data was entered into an Excel spreadsheet. The errors identified were classified using the grading system3 used within the trust for the annual intervention audit. Ethics approval was not required for this service evaluation. Results A total of 699 patients were seen on the unit over 171 days and 2865 medicines were prescribed. On average 4 patients were seen each day (range = 0 to 9 patients) who were each prescribed an average of 4 medicines (range = 0 to 25 medicines). The average time spent with each patient was 13 minutes (range = 1 to 80 minutes) 467 patients were seen by ward pharmacists after their surgery this was a total of 2057 items screened. 21 errors were identified, this represents an error rate of 1.02 %. Of the 21 errors 20 were classified as minor (score 1 to 3) and 1 scored as moderate (score 4). Discussion The service evaluation has shown that patient’s regular medication can safely be prescribed by a pharmacist within SDU. On average the pharmacist can see 4 patients per hour. The evaluation showed a low rate of minor medication prescribing errors (1.02%). This rate is in line with the EQUIP report which also highlighted pharmacists as the safest prescribers. Anecdotally pharmacist prescribing of patient’s regular medication pre-operatively has reduced the number of missed doses of regular medication post-operatively and reduced patient anxiety about missing vital medications post-operatively. This is something that could be formally audited in the future. An unanticipated advantage of taking a medication history on SDU, compared to the ward is the reduced level of distractions to the patient e.g. televisions, visitors, post-operative pain, drowsiness and post-operative nausea and vomiting. This means the information given by the patient is more accurate and can be gained more quickly. The low rate of errors made by the prescribing pharmacist has raised questions over whether having a second check by another pharmacist within a ward setting is an efficient use of resources. Currently the prescribing pharmacist in SDU does not prescribe post-operative analgesia or thromboprophylaxis. This is done by the surgical team whilst the patient is in theatre. The ward pharmacist therefore still plays a valuable role in post-operative care but the time spent on the medicines reconciliation process is reduced. Additional prescribing data would need to be reviewed to justify the removal of the second check at this stage. There are some challenges. There is currently only 1 pharmacist on SDU each day but multiple surgical lists for different consultants. This means that there is a lot of competing priorities for the pharmacist’s time and it is not always possible to see all those patients who would benefit most from the pharmacists time before they are taken to theatre. This problem may be overcome by extending the service to utilise medicines management technicians to allow more drug histories to be confirmed prior to the patient being taken to theatre. We believe that this service has been a real success for patients and the data is being used to develop further business cases for an increased service to SDU. References

An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education.2009. http://www.gmcuk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf. Accessed January 2014.

Care Quality Commission Inspection Report: Southampton General Hospital. 2012. http://www.cqc.org.uk/sites/default/files/media/reports/RHM_University_Hospital_Southampton_NHS_Foundation_Trust_RHM01_Southampton_General_Hospital_20121212.pdf. Accessed January 2014

Hatoum HT, Hutchinson RA, Witte KW, et al. Evaluation of the contribution of clinical pharmacists: inpatient care and cost reduction; Drug Intelligence and Clinical Pharmacy; 1988; 22:252-9.

32. An audit to determine the quality of prescribing of New Oral Anticoagulants (NOACs) for prevention of stroke and systemic embolism in atrial fibrillation (AF)

Stone, L and Manning, S, Royal Brompton and Harefield NHS Foundation Trust, London

Introduction Atrial fibrillation (AF) is a common cardiac arrhythmia affecting approximately 1 in 100 people in the UK1. AF patients have an increased risk of stroke and anticoagulation is recommended for those with a CHA2DS2VASc score of ≥ 12. New oral anticoagulants (NOACs) were first approved by NICE in May 2012 as an alternative to warfarin for preventing stroke in patients with AF2. Apixaban and rivaroxaban are factor Xa inhibitors, whilst dabigatran is a direct thrombin inhibitor. Objectives To audit the quality of NOAC prescribing in line with current NICE and Trust guidelines for the prevention of stroke and systemic embolism in patients with AF with the following standards:

1. 100% of patients are prescribed a NOAC in line with NICE guidelines for the prevention of stroke and systemic embolism in AF. 2. 100% of patients are prescribed the correct NOAC at the correct dose according to Trust guidelines. 3. 100% of patients prescribed a NOAC had their baseline renal function calculated. 4. 100% of patients prescribed a NOAC do not fulfil any exclusion criteria, which would contraindicate the prescribing of a NOAC as outlined in

the Trust guidelines (prosthetic valves, severe renal impairment, non-compliance with warfarin or as an alternative to heparin as a bridging agent pre or post surgery).

Method A retrospective audit was conducted. The pharmacy JAC dispensing system was used to identify patients dispensed apixaban, dabigatran or rivaroxaban between April 1st 2012 and November 11th 2013. A data collection form was designed and piloted on 10 patients. Minor amendments were made to the final audit form. The electronic patient record system and patient medical notes were used to collect data. Renal functions recorded up to 3 months before the date of prescribing were defined as a baseline reading. A total of 44 patients, including the pilot, were audited. Patients not newly prescribed a NOAC or prescribed a NOAC for an indication of anything other than stroke prevention in AF were excluded from the audit. As per hospital protocol, ethics approval was not required for this audit. Results See figure 1. 10 patients were excluded from the audit. 9 patients had insufficient data because the NOAC was prescribed by another Trust and 1 patient was being treated for a pulmonary embolism. 17 patients were prescribed dabigatran, 14 prescribed rivaroxaban and 3 prescribed apixaban. Discussion 91% of NOACs (n=31) were prescribed in line with NICE guidance. Further evaluation of this data showed that of the remaining patients, 2 had a CHA2DS2VASc score of 0, guidance recommends prescribing for a score of more than 1 and another was awaiting a cardioversion. Only 29% of patients were prescribed the correct NOAC at the correct dose. 14 patients did not have their renal function documented. This may not reflect actual prescribing in practice, as it unlikely all patients without a renal function documented had a decreased CrCl, but shows the importance of assessing renal function for dosing.

Figure 1 A comparison of prescribing adherence to standards. Other prescriptions for the wrong dose included 3 patients given rivaroxaban 20mg OD when they had a CrCl of between 15ml/min and 50ml/min so needed a reduced dose of 15mg OD. Some patients prescribed dabigatran 150mg BD were also taking concomitant aspirin (n=3) or were over 80 (n=1) so required a reduction to 110mg BD. In one case dabigatran was an inappropriate anticoagulant because the patient was taking concomitant aspirin and amiodarone. 41% of patients had a baseline renal function documented. An arbitrary figure of 3 months was chosen to represent baseline, although we are aware renal function could change significantly within this time frame. 100% of patients prescribed a NOAC as an inpatient had a baseline renal function calculated (n=6), compared to only 25% of outpatients (n=28). 44% of patients were found to have no exclusion criteria for NOACs. Renal failure is an exclusion criterion so it was assumed patients with unknown renal function should be not have been prescribed a NOAC. However, 100% of patients did not have a prosthetic valve or valvular disease. Conclusion Compliance with NICE guidelines was found to be good. Only 29% of patients were definitely prescribed the correct doses, because it had to be assumed the dose was inappropriate for the patients without a renal function documented. This lack of documentation of baseline renal function was a significant problem and can cause inaccurate prescribing, which can lead to safety issues especially in the elderly population, due to bleeding risk. Recommendations to improve future practice include educating doctors by producing quick reference guides on guidelines, increasing information availability in clinics where the majority of NOAC prescribing occurs and implementing clear and specific documentation of baseline renal function. CPD on guidelines would be useful for thorough screening by pharmacists for outpatient prescriptions. Pharmacists can check inpatient dosing by assessing renal function and concomitant medicines. An annual re-audit is recommended. References 1. British Heart Foundation. Atrial Fibrillation [Internet]. London: British Heart Foundation; 2013. Available from: http://www.bhf.org.uk/heart-health/conditions/atrial-

fibrillation.aspx (accessed 20.11.2013) 2. National Institute for Health and Care Excellence (2012) Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (TA249). 3. National Institute for Health and Care Excellence (2012) Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation (TA256).

4. National Institute for Health and Care Excellence (2013) Apixaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (TA275).

33. Hospital staff views on their role in providing information to patients on medication side effects Wilcock M1, Davidson I1 Underwood F2,

1Pharmacy Department, 2Consultant Nurse/Associate Director of Nursing. All of Royal Cornwall Hospitals NHS Trust, Truro

Introduction Discharge from hospital is a vulnerable time for patients, who often go home without understanding critical information about their hospital stay, such as their discharge diagnosis or medication changes.1 Studies have shown that on discharge from hospital, patients lack knowledge about the medicines they have been prescribed, the purpose and duration of treatment, the dose to take, and potential side effects.2,3 The provision of medicines’ information to patients is a national imperative with four medication questions featuring in the Care Quality Commission inpatient survey. In their latest survey, where inpatients were asked if they were told about medication side-effects to watch out for, our trust received only a score of 4 out of 10.4 Although this score means that our trust is about the same as most other trusts, we wish to explore how this could be improved. Objective The aim of this study was to elicit views of the clinical staff specifically on the provision of information on medication side-effects to inpatients, by asking when, how, and by whom such information should be given. Method A questionnaire, based on a review of the relevant literature, was developed to survey staff attitudes and beliefs about this topic. This was piloted on a small number of staff resulting in minor modifications. The questionnaire consisted of 10 multi-response questions with 4 of these inviting free text comments. The only personal information collected was the respondent’s profession. The electronic questionnaire (SurveyMonkey) was emailed to clinical staff once a week over six weeks in autumn 2013. The covering email explained the reason for the questionnaire, invited staff to complete it and guaranteed anonymity. The electronic reach of the survey to the Trust’s approximately 1,700 clinical staff would always be uncertain. Ethics committee approval was not required because the study was defined as service evaluation. Results The electronic survey was completed by 275 clinical staff (126 registered nurses, 84 senior doctors, 36 FY1/FY2 doctors, 20 pharmacists, 9 pharmacy technicians) though not all respondents answered all questions. When asked if they give patients verbal information about their medicines, 91.9% (248/270) responded yes, with 83.3% (194/233) reporting that they include information on side-effects as part of this verbal information. Although different staff groups have differing views on when it is best to provide information, overall more staff would prefer to give information when medicines are prescribed (58.8% think this is the best time whereas 40.4% usually give information at this time). Approximately one-third usually give information whenever it is convenient, though only 14.6% think that staff convenience is necessarily best for patients. When asked how confident they feel in explaining about the side-effects of commonly used medicines, FY1/FY2 doctors and pharmacy technicians expressed the least degree of confidence (Table 1). Table 1. How confident do you feel in explaining to patients about the side effects of commonly used medicines such as analgesia, commonly prescribed cardiac drugs, gastrointestinal drugs or respiratory drugs? Where 1 is not confident and 10 is very confident

Score of 1 - 3 Score of 8 - 10 Average score

Registered Nurses n = 110 6 (5.4%) 49 (44.5%) 6.77 FY1 or FY2 doctors n = 24 3 (12.5%) 1 (4.2%) 5.63 Senior doctor n = 69 2 (2.9%) 46 (66.7%) 7.96 Pharmacists n= 18 0 (0%) 13 (72.2%) 7.89 Pharmacy technicians n= 6 1 (16.7%) 1 (16.7%) 5.33 Total n = 227 12 (5.3%) 110 (48.4%) 7.06

When asked about perceived barriers preventing staff from communicating well enough about medication side-effects close to discharge (two reasons could be chosen), there was an overwhelming response by 91.4% (181/209) staff that time to talk to the patient was the main barrier. Overall just under one third of all staff identified insufficient knowledge of side-effects as a barrier – notably 38.8% (38/98) nurses, 54.2% (13/24) FY1/FY2 doctors, and 66.7% (4/6) pharmacy technicians. Pharmacists and senior doctors did not see this as a barrier - 5.6% (1/18) and 7.9% (5/59) respectively. A smaller proportion of the overall staff – 15.3% (32/209) - feared the provision of side-effects information might put the patient off from taking their medicines. Few staff either did not see the giving of information as their role (4.8% (10/209), or were unsure how to communicate side-effects to patients (3.3% (7/209). Overall, pharmacists were seen as having the primary responsibility for providing verbal information about side-effect to patients by 59.9% (118/197) of staff. The two most popular resources that staff would turn to if they had to give information about a side-effect for a medicine with which they were unfamiliar were the BNF (93.1%) and a pharmacist colleague (61.5%). Conclusion We have shown that there is some degree of consensus amongst different health professions in the way they perceive the provision of information on side-effects to patients. There are also differences around confidence and knowledge of side-effects, possibly reflecting issues of staff training or beliefs and attitudes about perceived hierarchical structures or professional recognition amongst hospital staff. This survey allows us to focus further exploration with staff on the perceived time challenge they face when discharging patients and ways to improve information giving. We also plan to seek patient views on the nature of side-effect information they would wish to receive. References 1. Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc 2005; 80: 991–4. 2. Kerzman H, Baron-Epel O, Toren O. What do discharged patients know about their medication? Patient Educ Couns 2005; 56: 276–282. 3. Bagge M, Norris P, Heydon S, et al. Older people’s experiences of medicine changes on leaving hospital. Res Social Adm Pharm 2013, doi:10.1016/j.sapharm.2013.10.005. (accessed 27 November 2013) 4. Care Quality Commission. Survey of adult inpatients. Royal Cornwall Hospitals NHS Trust April 2013 http://www.cqc.org.uk/survey/inpatient/REF (accessed 20 November 2013)

34. Effective transfer of care – easier said than done? Wilcock M1, Hill A, 1 Davidson I1, Yelling P2

1Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, 2Chief Officer, Cornwall Local Pharmaceutical Committee

Introduction When patients move between care providers the risk of miscommunication and medication errors is a significant problem. Targeted Medicines Use Review (tMUR) and New Medicines Service (NMS) offer an opportunity to encourage patients to attend community pharmacy for a post discharge medicines check up. Although community pharmacists are reported as wanting to play a more active part in improving the management of patients’ medicines after discharge1 and patients appear willing to have their medication details communicated to their community pharmacy,2 actually achieving measurable outcomes from these services appears problematic.3 RCHT Pharmacy is attempting to support the take up of these services through signposting of patients to their community pharmacy after discharge. Objective To describe the challenges for a district general hospital in trying to achieve evidence of worthwhile patient outcomes from a transfer of care sevice. Method The service, encouraging patients to take up the tMUR/NMS after discharge from hospital, was initially introduced in autumn 2012 after discussions with relevant stakeholders. The initial passive service involved a leaflet describing the potential benefits of tMUR/NMS which was routinely given to patients with their take home medicines. In a redesigned more proactive service, the leaflet was given to the patient by pharmacy staff during face-to-face contact, generally at the point of reconciling medicines at admission. From April 2013 this transfer of care service became a component of the Commissioning for Quality and Innovation payment framework, which links NHS funding to the achievement of local quality improvement goals. Targets for referring patients to community pharmacy after discharge were set at 15 for June’13 quarter, 30, 45 and 60 for the consecutive quarters. The service was refined further in early 2013. This revised process, ‘triggered’ by the paper TTO prescription arriving in the dispensary, resulted in the community pharmacies being faxed a sheet notifying them that their patient had been in hospital and was being discharged, and had consented to the pharmacy being advised of the patient’s medication details. At the same time, a list of the patient’s discharge medication was faxed to the community pharmacy. However the implementation across medical wards of an electronic prescribing and medicines management (EPMA) system meant that the service had to be altered again as the paper TTO ‘trigger’ arriving in the dispensary was no longer in existence. Hence there was no obvious, immediate ‘trigger’ to prompt us that a consented patient was going home. The new process (from August 2013) required patients to be consented at the point of admission when medicines reconciliation was being undertaken. About once a week pharmacies were notified by fax that their patient was in hospital and was expected to be discharged shortly. The fax explained that the patient was willing for the community pharmacy to phone them over the next few days to support them as appropriate on their return home. The fax also noted that a medication list for the patient could be obtained on request to the hospital pharmacy, and that we wanted to receive feedback on what action was taken by the community pharmacy. The Local Pharmaceutical Committee (LPC) has endeavoured to support this service by actively promoting it to community pharmacies. The LPC also receives a list of which pharmacies have been notified about a discharge patient (no patient details are provided to the LPC) and subsequently the LPC attempt to phone each pharmacy and encourage them to make contact with the patient and complete the feedback form. Results During the period September-December 2013 (with the EPMA system in place), 133 patients were referred to their nominated community pharmacy (across 54 pharmacies). There had been only five requests received by the hospital for a copy of the patient’s medication list. Fourteen feedback forms have been returned describing the actions undertaken within the community pharmacy comprising of one NMS, six tMURs, two instances of advice given, two patients were deemed not suitable for tMUR/NMS, one patient did not want to engage with the tMUR/NMS, one community pharmacy was not undertaking tMUR/NMS at that time, and in one instance the information was sent to a community pharmacy which was not the patient’s regular pharmacy. Conclusion Despite the enthusiasm and commitment from the hospital pharmacy and the LPC to make the transfer of care an embedded routine service that delivers evidence of benefit, various challenges have yet to be overcome. The current paper based process needs to become an electronic process as others are planning.4 More importantly there needs to be a clearer understanding of why there is a low rate of service take up by patients, as described here and by others.5 It is recognised that when patients have been in hospital as a result of illness, managing their medicines is just one of a number of issues they face when at home and it may be a low priority for them. In addition, further work with community pharmacy may be required to ensure that there is sufficient motivation and engagement to act on the discharge information they receive. References 1. Bhatti N, Devlin L, Farooq H, et al. Community pharmacists’ experiences of managing patients’ medicines after discharge from hospital: a preliminary study of discharge medicines use reviews (DMURs). Int J Pharm Prac 2013; 21 (Suppl. 2); 86-87. 2. Dobrzanski S, Hemmings L. Transfer of care in acute trauma hospital patients – can their community pharmacy be identified? Int J Pharm Prac 2012; 20 (Suppl. 2); 84-5. 3. Baqir W, Desai, N, Harker N, et al. Can targeted Medicine Use Reviews support safe transfer of care from hospital to community? Int J Pharm Prac 2012; 20 (Suppl. 2); 82-3. 4. East Lancs Hospitals NHS Trust refertophamacy service http://www.elht.nhs.uk/refer (Accessed 7 January 2014). 5. Kayyali R, Otukpe M, McKee C, et al. Post discharge referral and perceptions of community pharmacists within South West London about the New Medicine Service. Int J Pharm Prac 2013; 21 (Suppl. 2); 105.

35. Pharmacists’ Use and Views of the Electronic Prescribing Web Portal Mullan N and Jennings A, Aintree University Hospital NHS Foundation Trust, Liverpool.

Introduction NHS Connecting for Health state that electronic prescribing systems “have the potential to support the whole medicines use process, enabling medications (and other prescribed therapies) to be managed electronically at every stage, from prescribing through to supply and administration.”[1] Implementation of electronic prescribing was completed at Aintree University Hospital NHS Foundation Trust (AUH) in 2011. The use of electronic prescribing (EP) systems makes large amounts of data accessible for interpretation and if used intelligently can transform clinical pharmacy services. The pharmacy department at AUH uses a web portal system: a system designed in-house which collates live data from multiple electronic systems and allows pharmacists view data for all patients on a ward on a single screen. It then assists pharmacists in prioritisation, a form of clinical decision support[2], through categorisation. . In general, EP systems are very focused on the individual patient; this can make it difficult for pharmacists with limited time to see the right patients. Prior to the introduction of the web portal system, pharmacists could prioritise new patients and respond to requests from nursing or medical staff regarding complex or high risk patients, but with limited information this prioritisation was difficult. The web portal applies scores or warnings to all patients based on time since admission, RED-AMBER-GREEN medicines risk category, pharmaceutical problems including interactions and pharmaceutical-biochemistry alerts such as heparin induced thrombocytopenia. Order sheets for wards can be printed, which integrate with the AUH dispensary computer system. Many other reports can be generated which allow pharmacists to work efficiently and assist in achieving the standards required by the AUH clinical pharmacy procedures policy[3]. The ability to view this live data for multiple patients from a single screen allows the clinical pharmacist to provide a directed pharmacy service. Objectives

1. Examine web portal access and report generation 2. Understand how pharmacists use the web portal to prioritise patients 3. Understand how the features and alerts of the web portal are used by pharmacists 4. Gain feedback on possible improvements to the web portal

Method This research projects ascertained the way in which pharmacists use the EPMA web portal system was ascertained through a user survey, with questions covering access, the use of individual features, prioritisation, report generation and pharmacist views on the system. Questionnaires were provided to all pharmacists who deliver clinical services to wards using electronic prescribing. Data were also collected from the web portal itself, which electronically records pharmacist log-ins and report printing. This activity was recorded by the system between 28/02/13 and 21/03/13. The results were collated and analysed to establish how the department as a whole uses the system. Ethics approval was not required as no patient information was used. Results Questionnaires were sent to all 29 pharmacists who cover EP wards at AUH between 01/04/2013 and 12/04/13. Of those, 28 (97%) responded. From the survey responses, most pharmacists access the system between two and three times a day (per ward). Of those pharmacists that responded, 93% of pharmacists (n=26) use the web portal to prioritise patients. The methods of prioritisation used by pharmacists demonstrate a great deal of variation, as shown in Table 1. Table 1: Pharmacist prioritisation by web portal feature

Web portal feature Ranked importance for patient prioritisation

1st 2nd 3rd

New patient/admission length 19 (66%) 5 (17%) 1 (3%) RAG risk assessment 10 (35%) 4 (14%) 2 (7%) Unverified medicines - 12 (41%) 5 (17%)

Web portal access peaks between 08:00 and 09:00, with a second smaller peak between 15:00 and 16:00; however users access the system continuously through the day. Qualitatively, pharmacists greatly value the web portal system. All pharmacists (28) stated that they felt the introduction of the web portal has had a positive impact on the practice of their colleagues as a cohort. Pharmacists were asked to assign a score of between “1: Isn’t relevant” and “6: Couldn’t work without it.” The mean of these scores was 4.9. The feedback from pharmacists regarding possible improvements and changes to the web portal shows that staff members appreciate the flexible nature of the system. Discussion The majority of pharmacists (90%, n=25) access the web portal before visiting their ward to start traditionally ward based tasks. The web portal gives a view of the ward that is not available elsewhere without viewing each patient on multiple systems - pharmacists can view new patients and patients with unverified or high risk medicines all from a single screen. This enables activities such as medicines reconciliation, drug interventions, and biochemistry review from any networked location and on a single screen. As a result the web portal is a key method of prioritisation for pharmacists at AUH. The RAG medicines risk levels, unverified medicines and patient colours (i.e. no medicines reconciliation, new patient <24/48/72 hours) account for the bulk of pharmacists 1st, 2nd and 3rd choice methods of prioritisation. The newly prescribed report appears to be underused; ten pharmacists (36%) stated that they use this function; however orders may be generated on an individual patient basis. This will need to be assessed by a follow up study as it represents a potential problem and may lead to missed doses. Feedback from pharmacists regarding how they value the system was positive. Pharmacists provided many varied suggestions for improvement. Many of which have been implemented or are in progress, demonstrating the system’s dynamic nature. It is anticipated that a further assessment planned for this year will demonstrate a higher reliance on the web portal. This project has demonstrated the value of the web portal system to pharmacy and a similar portal is currently being piloted for nursing staff. Both systems highlight the potential ways in which patient safety may be improved by the using existing electronic data in a way that supports efficient and safe working practices. Further work to understand the impact of the web portal on patient safety would provide valuable information but may be difficult to assess without a before and after study. References 1. NHS Connecting for Health. ePrescribing Functional Specification of NHS Trusts 2007. www.connectingforhealth.nhs.uk (accessed 14th January 2014) 2. NHS Connecting for Health, Electronic Prescribing: Briefing for Pharmacists, 2009 www.connectingforhealth.nhs.uk (accessed 14th January 2014) 3. Clinical pharmacy procedures, MEDICINES POLICY. Aintree Hospitals NHS Foundation Trust, April 2011

36. Introducing a bariatric surgery pharmacy service Gormley N, Serag M, Stephenson L and Gibson D County Durham and Darlington Foundation Trust, Darlington Memorial Hospital

Introduction Bariatric surgery is an option in severely obese patients where lifestyle and medication have not been effective. There are various surgical options dependent upon patient specific factors and degree of obesity. The procedures themselves have risks associated with them, including venous thromboembolism, malabsorption, and altered bioavailability of medication. In addition, as the patients’ weight falls, any obesity related conditions (e.g. hypertension, diabetes mellitus) can alter dramatically1. At the study hospital, a bariatric surgery service was introduced with minimal pharmacy input. Prior to the pilot service, patients were seen at pre-assessment by a Band 5 pharmacy technician where medicines reconciliation was completed. As there was no further pharmacy input throughout the patient’s journey, a number of errors occurred with patient’s medication following the bariatric procedures. In light of this, the surgical pharmacy team undertook a project to determine the potential impact of a pharmacy bariatric service. Objectives

Define the pharmacist role at bariatric pre-assessment clinic, at ward level post-operatively and on discharge from hospital

Record any medication changes and interventions made in order to improve patient safety

Introduce a review process to ensure that patients receive appropriate treatment and monitoring and observe the effect of this on other pharmacy functions

Determine the need to develop a medication formulary with preparations suitable for use post bariatric surgery Method The pilot service was introduced for a 4 month period between October 2013 and January 2014. Ethics approval was not required as it was a service improvement pilot. A pharmacist (band 6) completed a full drug history at pre-assessment followed by a review of the patients’ regular medication, detailing alternative formulations available and ensuring a supply was available for admission. The patient was counselled on the potential changes to their medication and the problems associated with their specific procedure. On admission to hospital, the pharmacist reviewed medication ensuring that it was prescribed appropriately following surgery. Particular importance was placed on ensuring the most appropriate formulations were prescribed and the patient was receiving the correct supportive treatments, such as vitamin supplements and gastro-protection. On discharge the patient was counselled regarding the on-going changes to their medication and the discharge prescription checked to ensure that appropriate information was communicated to the GP. The service was evaluated after four months. The impact of the pharmacy service was recorded including how the pharmacist ensured the patient received the most appropriate medication/ formulation and what impact the service had on other pharmacy functions e.g. dispensary and procurement. Results In total 57 patients were reviewed by the pharmacy team in pre-assessment, 465 medications were reconciled. The pharmacist was particularly useful in recommending formulation changes such as switching tablets to suitable sugar free liquid alternatives. In addition, recommendations were made for medication changes in advance of the planned procedure, ensuring the patient was stabilised before surgery, e.g. switching from Morphine Sulphate Modified Release (MR) to Fentanyl patch (MR preparations are unsuitable following bariatric procedures). In total 189 medication recommendations were made; common recommendations include:

Ensuring appropriate licensed liquid formulations were used where possible

Obtaining unlicensed ‘specials’ medication, sourced in a timely manner

Providing up to date medicines information for crushing tablets and opening capsules

MR preparations reviewed and alternatives recommended e.g. Lithium carbonate MR switched to lithium citrate liquid

Patients with compliance or concordance problems were supported to ensure they understood the complex changes to their medication

The pharmacist was also involved in the discharge process of 32 patients, ensuring that discharge planning, follow up and compliance issues were considered. The input and interventions not only improved the flow of prescriptions through the dispensary but also improved medication safety and reduced the potential for prescribing error. A spread sheet was also initiated to record advice and recommendations obtained from various resources regarding use of medications following bariatric procedures; this is on-going. The pilot results have now been presented to the surgery directorate for consideration to obtain funding for on-going support of the project. Discussion Without pharmacist input, significant problems were occurring with medications for bariatric surgery patients. By introducing a bariatric pharmacy service we have been able provide advice and support to doctors and the bariatric team about medication. The service has improved patient safety by ensuring patients receive the most appropriate dosage and formulation of medications. Bariatric patients are complex and time consuming. The alteration of the stomach size can lead to unpredictable absorption profile of medication. The patients are therefore very resource intensive and will require a specialist prescribing pharmacist to ensure they have the most appropriate care. A pharmacy service will ensure patients are given the correct advice and are on appropriate medications and formulations during the peri-operative period, including the supportive and preventative medication required for managing the complications of the surgery. Finally, a pharmacist needs to be involved in the on-going care of the patient post discharge. It is essential that the patient receives accurate information on complex drug regimens for discharge and advice on how their obesity related conditions may change. Further work to consider would be providing GP support in the management of these patients, and pharmacist led clinics to manage the patients post discharge. This project was only a four month pilot and did not involve any cost saving, patient satisfaction or significant end point analysis such as reducing length of stay. It did, however, demonstrate the value of a pharmacy service in managing complex bariatric patients. References

1. Miller AD, Smith KM. Medication and nutrient administration considerations after bariatric surgery. American Journal of Health System Pharmacy 2006; 63:1852.

37. An audit to assess the quality and accuracy of surgical discharge letters. Dass N1, Makhecha S1, 1Royal Brompton and Harefield NHS Foundation Trust

Introduction Hospital discharge letters aim to provide accurate information during a patient’s transition between secondary and primary care. Poor communication at transition points within the healthcare system account for approximately 50% of medication errors.1 Insufficient information on discharge letters make it difficult for General Practitioners (GP’s) to understand the changes that have occurred during an inpatient stay.2 It is a national requirement for discharge letters to be sent to GP’s within 24 hours.3The need to audit the current quality of surgical discharge letters within the trust arose as a result of a patient’s informal complaint. Aim To assess the accuracy and quality of information on surgical discharge letters at the Royal Brompton and Harefield NHS Foundation Trust (RBHT). Objectives This audit was conduct from 11th-22nd November. Objectives of this audit were:

To document if patients receive a discharge letter on the day of discharge To determine the proportion of discharge letters with accurate information To assess if there is a difference in quality of discharge letters for cardiac and thoracic surgical patients

Standards 100% of discharge letters include the correct information on the surgical procedure 100% of discharge letters incorporated the correct:

o Past medical history (PMH) o Patient allergy status o Planned follow up o Discharge medications including reasons for changing any medication

100% of discharge letters were received by the patients GP surgery within 24 hours 50% of letters have no spelling mistakes of discharge

Method A prospective study was conducted in patients being discharged at both sites on four surgical wards; one week was spent at each site. Ethical approval was not required, but the audit was registered with the RBHT clinical audit department. A target was set to obtain data from a minimum of 50 discharge letters. Currently, no guidelines are available within the trust, thus standards for the audit criteria were set using categories installed on the electronic discharge system, infoflex. Junior medical staff wrote the discharge letters, and training is carried out by the information technology department. To date, only prescription details are checked by pharmacists in surgery. Letters were compared to the patient’s medical notes to determine whether the information was correct. Follow up calls were made to the GP to determine whether the letter was received within 24 hours. A pilot study was conducted on five patients; the data collection form was amended to include a comments section under each question. A different discharge format exists for inter-hospital discharges and private patients; therefore they were excluded from this study. Results Fifty-eight patients met the inclusion criteria, 30 cardiac and 28 thoracic surgical patients. Table 1: Audit results

Criteria Cardiac Thoracic Overall result Target

Discharge letter received 100% 92% 97% 100% Correct and appropriate surgical procedure 63% 38% 69% 100% Correct PMH 43% 57% 48% 100% Correct allergy status 90% 86% 84% 100% Correct planned follow up 13% 22% 12% 100% Correct discharge medications 90% 86% 88% 100% GP received letter within 24 hours of discharge 7% 14% 10% 100%

No spelling mistakes 57% 45% 48% 50%

Discussion This audit illustrated that none of the targets were met. Details and outcome of the procedure often lacked sufficient information. For example, various letters simply stated “thoracic surgery”. Patients PMH’s were often documented but incomplete, in some cases, they were incorrect. In one case, a patient was documented to have had surgery in 1798. Infoflex requires prescribers to choose a category based on the drug class to document the patient’s allergy. A Simvastatin allergy was documented as an allergy to Somatostatin analogues. Discharge medicines were reported correctly in a high number of cases but did not meet the target; drugs that were charted were often missed out on the discharge letter. The results illustrated that discharge letters currently lack accuracy and are often poorly written. Consequently important information about the inpatient stay is not communicated to the GP, which could negatively impact patient care. 7070 incidences were reported nationally relating to medication errors during admission and discharge.1 The incidences of spelling mistakes were high, suggesting a requirement for a spell check mechanism. Assessment of receipt of the discharge letter by the GP within 24 hours of discharge was a major limitation. GP surgeries scan letters electronically which may take a number of days. As a result, if the letter is not on their database, they claim the letter is not received. Additionally the date received is not documented and an accurate assessment of the time frame stated cannot be made. Another limitation was that some notes were not accessible so these patients were excluded from the study. Conclusion More effective training for junior medical staff with pharmacy involvement should be implemented. Additionally, basic guidelines need to be developed and standards set to advise junior staff on how to write discharge letters. Safeguards should be introduced on infoflex as well as a spell check mechanism. Once these measures have been implemented, the audit should be repeated. References 1 National Patient Safety Agency. NICE/NPSA issues its first patient safety solution guidance to improve medicines reconciliation at hospital admission. Dec 2007. www.npsa.nhs.uk (accessed 28th November 2013). 2 Department of Health. Discharge from hospital: pathway, process and practice. Jan 2003. www.dh.gov.uk (accessed 28th November 2013). 3 Helen Goodman. Policy for discharge of adult and paediatric patients from hospital. Jan 2012. http://www.intranet.rbht.nhs.uk/current-projects/discharge/discharge-policy (accessed 28th November 2013).

38. Reducing cross contamination in preparing injectable medicines: the water effect Chaplin, J and *Eradiri OL, Colchester Hospital University NHS Foundation Trust (CHUFT), Colchester.

Introduction Injectable medicines are best prepared in closed systems, to minimise the risk of contamination by micro-organisms or cross contamination with residues of previously prepared products(1). The National Patient Safety Agency’s (NPSA) alert 20 (2007) recommended the preparation of injectable medicines under controlled conditions in pharmacy, such as with the use of pharmaceutical isolators, and the presentation of ready-to-administer injections in near-patient areas(2). However, some injectable medicines are still being prepared in clinical areas, with the risk of spills and contamination. Cross contamination can be reduced by effective cleaning methods. Our routine pharmaceutical isolator cleaning method employing 70% denatured ethanol (industrial methylated spirit, IMS) left traces of the antibiotic cefuroxime, as detected by a sensitive thin layer chromatography (TLC) method(3). An investigation of this non-compliance suggested that the root cause was the poor solubility of cefuroxime sodium in the IMS cleaning agent. One of the corrective actions was to develop and validate a high performance liquid chromatography (HPLC) method with greatly improved sensitivity to allow the study of the effectiveness of different cleaning regimes. Aim To develop and implement a cleaning method that reduces the risk of cross contamination with residues that show poor solubility in ethanolic solutions. Method Defined segments (coupons) of a stainless steel surface were contaminated with an aqueous solution containing 50 mg of cefuroxime sodium and allowed to dry. These coupons were cleaned using various quantities of water, followed by IMS sanitisation. The coupons were then swabbed using a double-layer polyester sampling swab, and any cefuroxime sodium residue was extracted from the swab. Extracts were analysed using a validated HPLC method with a sensitivity of 2.5 ng/ml. Fresh coupons were then contaminated with the same solution of cefuroxime sodium and allowed to dry for various periods of time. Any residue was then recovered and analysed as before. A final study determined the amount of residue remaining following a gross spill of 1500mg cleaned immediately, and an aerosol contamination of approximately 10mg which was allowed to dry for 45 minutes. Both of these were cleaned using a just visible film of water which is mopped up using absorbent swabs, followed by a ‘just visible’ film of IMS mopped up using IMS wipes. Results The data showed that IMS alone was the least effective at removing cefuroxime sodium residues, with 2670 ng/cm2 detected. Water followed by IMS was found to be increasingly effective as more water was applied (see Table 1). When a spill was cleaned immediately using 0.01 ml/cm2 of water followed by IMS, 15 ng/cm2 of residue was detected. This deteriorated to 20 ng/cm2 after 15 minutes, 56 ng/cm2 after 30 minutes, 67 ng/cm2 after 45 minutes, and 172 ng/cm2 after 60 minutes. The gross spill of 1500mg cleaned immediately, and the aerosol contamination of approximately 10mg which was allowed to dry for 45 minutes showed similar results of 8 ng/cm2 and 7 ng/cm2 of residue detected respectively. Table 1: The effect of a water step on reducing cefuroxime residues

Quantity of water (ml/cm2) Remaining residue (ng/cm2) 0.00 (IMS only) 2670

0.01 163 0.02 78 0.05 17

Discussion The addition of a water step prior to the IMS step in the traditional IMS-only aseptic cleaning regime can significantly improve cleaning efficiency by up to 160-fold, for drugs that are poorly soluble in IMS. The results also show that cleaning gross spills immediately increases the effectiveness of cleaning. As aerosol contamination is less obvious, procedures should ensure that cleaning is done between batches of prepared medicines. Consideration should be given to the duration of batch manufacture to ensure that excessively long periods are avoided - longer than 45 minutes gives significantly lower cleaning efficiencies. We have reviewed our operational guidelines and adopted these principles within Pharmacy services. Plans are underway to introduce the same to other clinical areas. Conclusion Taking all results together, the findings demonstrate that cleaning effectiveness improves as more water is applied, and deteriorates with increased time lapse between spills and clean. Cleaning up spills immediately and no later than 45 minutes after, using a water/ethanol regime, gives greater cleaning effectiveness than an ethanol-only regime. By applying these simple measures to the cleaning of pharmaceutical isolators or ward clinical areas, pharmacists and clinicians can greatly minimise the risk of cross contamination when preparing injectable medicines. References:

1. Ogden, S., Eradiri, O.L. and Needle, R.; Rational and safe transfer and mixture of Medication; Hospital Pharmacy Europe; 2008; 38: 51-52.

2. National Patient Safety Agency; Patient Safety alert 20; London; 2007 3. Chaplin, J., Eradiri, O.L. and Douch, M; Validation of cleaning methods using MHRA criteria; NHS National Pharmaceutical Quality Assurance

Symposium; 2010.

39. An audit of the initiation of oral anticoagulation with warfarin using a Patient Group Direction in the pharmacist-led anticoagulation clinic at Brighton and Sussex University Hospitals NHS Trust

Banwait Pa,b, Conway Aa,b, Warren Ab, aSchool of Pharmacy and Biomolecular Sciences, University of Brighton, UK bBrighton and Sussex University Hospitals NHS Trust, UK

Introduction Management of warfarin is complex and requires good systems to be in place for the initiation and subsequent monitoring and dosing for each patient1. At the Royal Sussex County Hospital all patients commenced on warfarin in the outpatient clinic are seen by a pharmacist at their first appointment. In addition to a comprehensive counselling episode the pharmacist will initiate the supply of warfarin for any previously untreated patients. The pharmacist will check for contra-indications and providing none are present will select a starting dosage regime based on the indication for warfarin, any patient co-morbidities and concomitant drug therapy. The loading doses used are in line with the British Society for Haematology recommendations for warfarin2. If the patient is currently prescribed anti-platelet therapy they will review whether this is to continue once warfarin is established, and where necessary contacting the referring clinical for clarification. Arrangements will be then made for the subsequent INR monitoring and on-going dosing. In order to facilitate the initiation of warfarin for previously untreated patients, a patient group direction (PGD) has been developed and approved by the Trust3. This allows the pharmacist to supply warfarin in the clinic setting in line with the indications, exclusions and dosing regimens set out in the PGD. Audit of the use of the PGD and its appropriateness for patient care are an essential part of the governance surrounding the use of PGDs in practice setting. Objectives This audit was undertaken to assess the pharmacists’ adherence to the PGD and to ensure that the initial dosing regimens in the PGD deliver safe patient care. An audit target of 100% was set for each of the following objectives: 1. Percentage of patients for whom there is documentation that the exclusion criteria have been checked by the pharmacist and where exclusions

apply warfarin has not been supplied. 2. Percentage of patients that received the correct loading regime (intensive versus slow loading) and dose for that regime as defined in the PGD. 3. The INR after the first 3 doses (intensive loading) or after 1 week (slow loading) is not supra-therapeutic (INR > 5.0). 4. For patients prescribed antiplatelet agents prior to the initiation of warfarin a documented plan as regarding stopping or continuing with warfarin

was in place. 5. All records of supply of warfarin had been completed in the clinic PGD register. Method This audit was carried out retrospectively by obtaining a list from the anticoagulation clinic database of all patients commenced on warfarin by the pharmacist in the anticoagulation clinic over 7 month period (July 2012-January 2013). A data collection form was designed for this project, and piloted for the first 5 patients. The documentation by the pharmacist on the database, the pharmacist’s clinic records and the PGD register were used to collect the data required. This gave details of exclusions, co-morbidities, concomitant therapy and the dose regime employed. The database was also used to obtain the INR at the first test after loading. All the data was collected by the project lead (PB) who was not involved in service delivery. The data collected was evaluated against the PGD standards and analysed using Microsoft Excel® to calculate the number and the percentage of patients for each criterion. Ethical approval was not required as this was an audit project. Results 103 patients were included in the audit (54 male, 49 female). The mean age was 69 years (range 43-93). The results of the audit are summarised in table 1. Table 1: Results for the warfarin PGD audit

Objective Outcome Comment

Exclusion criteria fully documented as checked 100% In 6 cases concern over potential exclusions were discussed with the consultant in clinic prior to initiation of warfarin

Loading dose regime complied with the PGD 97% 2 patients were loaded at a lower dose than the regime in the PGD 1 patient was loaded on the higher dose regime despite potential drug interactions

INR on the second visit not > 5.0 ∞ 100% 4% patients had a supra-therapeutic INR (2.8-4.7) but no patients had an INR >5.0

Documented plan regarding pre-existing antiplatelet regimes

97% 75 patients were taking antiplatelet therapy when referred to commence warfarin. In 2 cases no plan was documented in the clinic records From the records it was seen that the pharmacist often needed to contact the referrer for clarification

Record of supply in the clinic PGD register 96% For 4 patients (2 clinics) the supply had not been documented in the register ∞ Results for 2 patients not available Discussion This audit has demonstrated that use of a PGD as an integral part of the pharmacist-led anticoagulation clinic is a safe method for the initiation of warfarin. By checking against pre-defined inclusion and exclusion criteria the pharmacist is able to highlight any potential safety issues to the consultant haematologist prior to initiation. The dose regimes used are safe (no patients had an INR >5.0) and felt to be suitable for the majority of patients. The results of the audit were fed back to the pharmacy team. Compliance with the PGD was high. Discussion of the results within the team led to the following recommendations:

Clarification of loading regimes including clearer distinction for which patient groups can have “slow loading” and for reloading previously warfarinised patients.

Highlighting to referrers the need to specify whether antiplatelet treatment can be stopped or need to be continued at point of referral.

Future audit should be undertaken to explore subsequent INRs and the time to achieve therapeutic. These recommendations will help to further define the most appropriate regimes for the varying clinical indications and inform the development of the PGD. References 1. National Patient Safety Agency: Patient Safety Alert – Actions that can make anticoagulant therapy safer. March 2007.

www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59814&p=3 (accessed 5th December 2012). 2. Keeling D, Baglin T, Tait C et al. Guidelines for oral anticoagulants 4th edition. British Journal of Haematology 2011; 154(3) 311-324

3. The Medicines and Healthcare products Regulatory Agency (MHRA): guidance on the development, implementation and review of Patient Group

Directions in the NHS. www.mhra.gov.uk (accessed 5th December 2012).

40. The Forgotten Victim - Experiences of the person who made the error Edwards, P, Pharmacy Department, Luton and Dunstable University Hospital. Luton

Background Error occurrences within the NHS are well documented. A culture of openness on mistakes and learning from errors has been recommended.1 Datix is used at the Trust for reporting medication errors. There is an important link between staff well-being and patient’s well-being.2 Objective To evaluate to what extent Doctors, Nurses and Pharmacy staff are supported in their learning from medication errors. Method Ethical approval was obtained from University of Bedfordshire Ethics Committee. Study was undertaken from January – August 2013. This study was carried out at an Acute University Hospital Foundation Trust. The objective was explored using modified focus groups as a qualitative research method. Five sub-questions were set as follows: What emotional responses to error have staff experienced and how might this affect their learning? What are the barriers to learning from errors? How have staff experienced senior staff responses to error in terms of support in coping with errors, feedback and promoting learning? In what ways are staff engaged in learning activities post errors? Suggest strategies to overcome key issues identified. Participants recorded key points on flip charts, and encouraged to use drawings. Written narratives of discussions were recorded by the researcher. The data was analysed for each professional group, and key themes that emerged were noted. Limitations of the study included time, which prevented the use of peer review of raw data, which could further verify consistency in findings. Those working unsocial hours did not have an opportunity to participate. The results from this study cannot be generalised to other Trusts. Results: A total of 108 staff participated in the study. Participants included 20 medical students, 12 Foundation Year 2 (FY2) doctors, 22 nursing students, 25 nurses, 4 Pre-registration Pharmacists, 16 Pharmacists, 9 Pharmacy technicians. 16 focus groups were held. Emotions: A wide range of emotional responses to errors was reported, with worry, fear and shame common across all professional groups. Statements such as “I could have killed myself” and “till today I have not got over it” raised concern over the psychological wellbeing of the participants concerned. Nurses reported that they felt “unable to do the same task again” and “did not want to come back to work”. Nurses and doctors reported loss of sleep and feeling sick (nausea) as a reaction to errors. Nurses stated that emotions post errors led to “unhappy, worried and scared staff who as a result cannot be 100% effective in patient care” which they believed will lead to further errors. Barriers: The major barrier to learning was the lack of feedback. However, hierarchy; lack of awareness that an error has been made; perception of a blame culture; the environment in terms of location, attitudes and communication used to share errors; work/time pressures; shift patterns and traceability, and emotions were key themes reported as barriers. Nurses felt discouraged from ‘self reporting’ errors for fear of being penalised and reprimanded. Support: A few participants reported good support by senior staff. However, a large proportion of participants reported lack of support and feedback. The key themes included: how errors were communicated, and attitudes; error procedure variance across and within professional groups; inability to seek help as a result of past experiences that made them “feel stupid”; ways in which errors were shared that resulted in “embarrassment and humiliation”; blame culture; “anger” and refusal to accept responsibility for errors when previous expression of concerns about unsafe practice had been ignored; and “knocked” confidence. Juniors discussed the “awkwardness” they felt when pointing out senior staff errors. The view across all professional groups and grades is that the Datix reporting system is a “tick box” exercise and any action plans from Datix reports are “not shared”. FY2 doctors mentioned they did not feel their consultants were aware of their errors. Doctors felt they got more support from Nurses and Pharmacists. Pharmacists and doctors both felt that nurses are generally given a “raw deal” when it comes to errors. Nursing staff concluded that “it did not matter if wards were well staffed with a good skill mix; they felt if they did not have the confidence to ask questions, seek help and support, then errors will continue to occur”. Learning activities: All professional groups mentioned reflective practice and CPD as the main learning activity. It was acknowledged that learning was dependent on the type of error, and that learning was an individual responsibility. Participants questioned whether staff knew how and when to reflect. Peer learning was reported by students and juniors. Strategies: Strategies to improve support and promote learning post errors included a review of the error procedure to ensure equality across all professional groups and grades; sharing of errors in a blame free way; introducing a session on errors at all new staff induction; training sessions for managers on communication and feedback skills on errors; and debrief post errors with the suggestion to introduce the term ‘staff safety’ and an error support line. Discussion / Conclusion The study has revealed that there is an ‘unseen’ problem in terms of promoting individual learning and support post errors. This study highlights the psychological impact of errors, and the need to improve support to staff post error. To provide support, the Trust has now added a support link to the Datix reporting system. This link directs staff to Confidential Care (CiC) helpline that offers free and confidential information, support and counselling. Taking on board this research, CiC is producing a ‘coping with errors’ leaflet which will be made available to other NHS Trusts. The Trust has supported the development and introduction of a Trust training day on ‘Coping with Errors and Understanding Human Factors. References

1. Francis, R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London 2013. www.official-documents.gov.uk Accessed

31st August 2013

2. Schwartz, KB. A patient’s story. The Boston Globe Magazine, 16 July 1995.

www.theschwartzcenter.org Accessed 31st January 2014

41. Use of Ticagrelor in Line with the Royal Brompton & Harefield NHS Foundation Trust Primary Angioplasty Protocol Pilgrim, R and Manning, S, Royal Brompton and Harefield NHS Foundation Trust

Introduction Ticagrelor (Brilique®), the first direct-acting P2Y12-receptor antagonist for use as an antiplatelet, is licensed in combination with aspirin to prevent atherothrombotic events in adults with acute coronary syndrome (ACS)1. Guidance issued by the National Institute of Health and Clinical Excellence (NICE) cites ticagrelor as a treatment option in the following conditions: ST elevated myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI); non-ST elevated myocardial infarction (NSTEMI); and in those admitted to hospital with unstable angina2. The older agent, clopidogrel, also remains an option in those who have had an NSTEMI or a STEMI treated with a stent3. The PPCI protocol produced by the Royal Brompton and Harefield NHS Foundation Trust (RBHT) states that ticagrelor is to be used first line in all patients treated with PPCI, aside from those suffering from NSTEMI, where clopidogrel remains the anti-platelet of choice4. The Trust has however agreed to begin using ticagrelor first line for NSTEMIs too, as of 2014. Aim To assess the extent to which the use of ticagrelor complies with the guidelines set out in the Trust’s primary angioplasty protocol4. Objectives From the 11th to 22nd November 2013 the objectives of this audit were:

To determine the percentage of patients undergoing PPCI who had ticagrelor prescribed.

To determine the percentage of patients who were prescribed ticagrelor for a minimum of 12 months, and who had this correctly documented on their discharge summary.

To determine the percentage of patients given a loading dose of 180mg ticagrelor.

To determine the percentage of patients given a 180mg ticagrelor loading dose (despite any clopidogrel loading doses given pre-admission).

To determine the percentage of patients who were prescribed a maintenance dose of 90mg BD of ticagrelor. Standards 1. 100% of patients who have undergone PPCI are prescribed ticagrelor in combination with aspirin. Exceptions include: those undergoing PPCI

for an NSTEMI; those with a contraindication to ticagrelor; those taking warfarin; those who are intolerant; any other documented clinically valid reason.

2. 100% of patients prescribed ticagrelor have been specified a duration of one year of treatment, which has been documented in their discharge summary.

3. 100% of patients requiring PPCI have been given a loading dose of 180mg ticagrelor. 4. 100% of patients prescribed ticagrelor were given a loading dose of 180mg despite receiving a loading dose of clopidogrel pre-admission. 5. 100% of patients requiring PPCI have been prescribed a maintenance dose of 90mg BD ticagrelor. Method Ethics approval was not required for this audit. A list of patients who underwent PPCI at Harefield Hospital between the period of 1st October 2013 and 31st October 2013 was obtained from hospital admission records. A data collection form was designed and piloted on a sample of 10 patients and amendments made. Data from all 52 patients admitted during this period was collected. All data was collected over a period of 9 working days between 12th November 2013 and 22nd November 2013 solely by the auditor. Relevant information was obtained from electronic patient discharge summaries and patient medical notes. Results Of the 52 patients who underwent a PPCI during the month of October 2013, 3 patients were excluded from the study: 1 due to the indication being an NSTEMI, and 2 due to notes not being available. All remaining patients (n=49) were correctly prescribed ticagrelor, and at the correct maintenance dose. 6.1% (n=3) did not receive a loading dose, and 30.6% (n =15) did not have a duration of treatment documented on their discharge summary. 34.7% (n=17) received a loading dose of clopidogrel prior to admission. Of these, 88.2% (n=15) still received the appropriate ticagrelor loading dose. Of those who did not receive a ticagrelor loading dose, 66.6% (n=2) had been given a loading dose of clopidogrel prior to admission. Adherence to standards is summarized in table 1. Table 1: Adherence to audit standards

Discussion The use of ticagrelor as a first-line antiplatelet has been well adopted within the Trust, and all prescribers have an understanding of the correct dosing regimen. A lack of loading dose (or lack of documentation of a loading dose) has occasionally occurred; prescribers must be made aware of the importance of this as it allows a rapid onset of antiplatelet action1. Prescribers should also be made aware that this is safe to do regardless of any clopidogrel loading dose given pre-admission. Ticagrelor has been approved for use in ACS for a duration of 12 months by NICE; there is no supporting trial data for use any longer than this. Staff involved with writing discharge summaries need to ensure the duration for use of ticagrelor is documented to allow for a seamless transition of care to primary healthcare teams. In some areas within the Trust, the ability to automatically add in a duration to discharge summaries is being piloted; this may help improve adherence to this particular standard. Conclusion The use of ticagrelor as a first-line agent in PPCI has been well adopted within the Trust. There is some room for improvement to ensure full adherence to guidelines, particularly surrounding documentation of duration of treatment. Further audit to evaluate how many patients prescribed ticagrelor are correctly stopped after 12 months of use, as well as linkage of this data to patient outcomes, is also required. References 1. Electronic Medicines Compendium. SPC: Brilique 90mg Film-coated Tablets. November 2013.

http://www.medicines.org.uk/emc/medicine/23935/SPC/Brilique+90+mg+film+coated+tablets (accessed 07 January 2014). 2. National Institute of Health and Clinical Excellence. Ticagrelor for the Treatment of Acute Coronary Syndromes. Manchester; NICE; 2011. 3. National Institute of Health and Clinical Excellence. MI- Secondary Prevention. Manchester; NICE; 2013. 4. Pottle A, Hayes C, Lane R, Mitchell C. Protocol for the Management of Patients undergoing Primary Angioplasty. London; Harefield Hospital; 2012.

Standard Percentage Adherence To Standard

1 100.00%

2 69.39%

3 93.88%

4 82.35%

5 100.00%

42. Complementary and Alternative Medication Use Amongst Patients Established on Oral Anticoagulation Therapy Patel R1, Patel J2, Davies G1 and Byrne R2

1Institute of Pharmaceutical Science, King’s College London, London, 2King’s College Hospital Foundation NHS Trust, London

Introduction Whilst most CAM therapies are considered innocuous, there is the potential for CAM-drug interactions to occur with anticoagulant therapy, both from a pharmacokinetic (St.John’s Wort) and pharmacodynamic (garlic) point of view; potentially placing patients at an increased risk of bleeding or rendering the warfarin less effective. Though a number of studies have been published over the last 8 years describing CAM use in the anticoagulant clinic population, none have explored the specific influence ethnicity may have on the use of CAM amongst patients prescribed warfarin. This could be important, as certain parts of the UK have become increasingly ethnically diverse and different types of CAM may be being consumed by different ethnic groups. [1] The aim of this study was to quantify the prevalence of complementary and alternative medicine use amongst patients established on warfarin therapy. Objectives

• To quantify the usage of CAM by a sample of patients established on warfarin anticoagulation therapy in the anticoagulation clinic at a London teaching hospital

• To explore the usage of CAM amongst different ethnic groups • To determine the percentage of patients using CAM which are known to interact with warfarin • To explore any correlation between CAM use and the individual time in therapeutic range results

Methods A prospective, cross sectional study involving 303 patients established on warfarin therapy was conducted at the anticoagulation clinic of a London teaching hospital. Patients were recruited whilst attending for their routine warfarin INR test. Their use of CAM and awareness for the potential for some of these preparations to interact with warfarin were determined during consultations, along with their ethnicity. Additional information regarding the patient’s warfarin therapy, including the patient’s time in therapeutic range (TTR) and the specific indication for warfarin, was collected from the anticoagulant clinics computerised patient records. Ethics committee approval was not required, as the consultation was part of routine clinical care. Results Of the 84 patients (27.7%) who reported use of CAM, 66 (78.6%) were using herbal medicines, vitamins or mineral supplements documented to interact with warfarin. Commonly reported CAMs that were being consumed by the cohort questioned (Table 1) included cod liver/fish oil, chondroitin and glucosamine supplements and garlic capsules, similar to what has been reported by other groups. A significant proportion of patients (51.7%) were unaware of the potential for these interactions to exist. Ethnicity did not impact on whether a patient used a CAM or not or the type of CAM used. Furthermore, no significant relationship between the use of CAM and the TTR with warfarin were found, when comparisons were made between CAM and non-CAM users, suggesting that any interactions that do occur may not be clinically significant (Mean TTR CAM users- 64.91%, mean TTR non-CAM users- 64.64%, p=0.568). Table 1: The top ten most commonly reported CAM (complementary and alternative medicine) by the study population

Number of patients using CAM (% of total participants n=303)

CAM known to interact with warfarin Cod liver oil/Fish oils 47 (15.5) Multivitamin preparations (containing vitamin K) 15 (5.0) Garlic supplements 9 (3.0) Chondroitin and glucosamine 8 (2.6) Co-enzyme Q10 2 (0.7) Ginger supplements 2 (0.7) Vitamin E 2 (0.7) CAM not known to interact with warfarin Vitamin C 8 (2.6) Vitamin B 5 (1.7) Vitamin D 2 (0.7)

Discussion This study describes the prevalence of CAM use in a subset of patients established on anticoagulant therapy and provides valuable information regarding the use of potentially interacting CAM in patients prescribed warfarin. No significant differences were found between the use of CAM amongst different ethnic groups or the effects of CAM use on TTR results. Overall, of those found to be using CAM, a significant number (78.6% of total CAM users) were using CAM known to interact with warfarin with limited awareness for the potential for CAM-warfarin interactions. The majority of CAMs used in the studied population could be classed as minor interactions with warfarin, though it must be remembered that use of other types of CAMs not seen in this population could be problematic. Furthermore, of CAMs which interact through a pharmacokinetic mechanism, occasional CAM use is likely to be more problematic compared to regular consumption. Healthcare practitioners should regularly enquire about the use of such therapies and improve patient awareness of these potential interactions, particularly with new oral anticoagulants now available. References 1. Office for National Statistics. 2011 Census: Key Statistics for England and Wales. Newport: Office for National Statistics, 2011. www.ons.gov.uk (accessed 20.12.2012).

43. A Prospective Audit of the Walton Centre Foundation Trusts’ (WCFT) Venous Thromboembolism (VTE) Prophylaxis Policy in Medical Patients.

Lloyd, R. Aintree University Hospital, NHS Foundation Trust, Liverpool

Background The House of Commons health committee report in 2005 stated an estimated 25,000 people die each year from preventable hospital-acquired VTE1. This is a staggering number of preventable deaths and leaves much scope for improvement. It is therefore extremely important patients are assessed on admission to hospital and throughout their stay for the risk of developing a VTE and decisions about VTE prophylaxis made. WCFT has recently switched to a nurse led VTE risk assessment system to ensure all patient VTE risk assessments are completed on admission and during in patient stay at ward level. Aim The aim of this audit is to assess compliance to the WCFT VTE prophylaxis policy in medical patients. Objectives

To identify all medical patients admitted to Chavesse ward during the audit period and collect data using a data collection form.

To determine if all medical patients are assessed for VTE and bleeding risk on admission using the online nurse VTE risk assessment form.

To determine if all medical patients are reassessed for VTE and bleeding risk using the online nurse VTE risk assessment form 24 hours after admission.

To assess if all completed risk assessment forms are inserted into medical and nursing notes.

To determine if in situations when pharmacological prophylaxis is not prescribed and not indicated the treatment plan is documented in the medical notes and on the prescription.

To assess if appropriate pharmacological prophylaxis is prescribed and administered if indicated for patients.

Methods All medical patients admitted to Chavesse ward were identified and audited during a one month audit period (July to August 2013) via a daily ward visit. A data collection form was completed for each patient identified and to be included in the audit. On the ward visit the following day, the auditor would check the patients identified the previous day to see if the VTE risk assessment was reviewed after 24 hours. The medical notes and nursing notes would be checked for a printed copy of the VTE risk assessment form completed by the nurses. VTE risk status for the patients included in the audit was determined from data supplied by IT from the completed VTE risk assessment forms. Ethics approval was not required due to the nature of the audit. Approval from WCFT audit committee was obtained. Results

Results Total Patients %

Patients included in audit 76

Patients with documented reasons for not prescribing VTE prophylaxis 4

Patients in which VTE prophylaxis was not needed due to other treatment e.g warfarin 3

Patients eligible for VTE prophylaxis 69

Patients with VTE risk assessment completed on day of admission 49 64%

Patients with no VTE assessment completed during admission 6 8%

Patients with no VTE prophylaxis prescribed 34 49%

Patients with VTE risk reassessed 24 hours after admission 3 4%

Patients with risk assessment form placed in nursing notes 2 3%

Patients with risk assessment form placed in medical notes 0 0%

High risk patients as identified on VTE risk assessment form 23 30%

High risk patients not prescribed any VTE prophylaxis, with no documented reason for omission 8 35%

Discussion The results demonstrate a failure to comply with all of the standards set by the trust, NICE, DoH and SIGN for VTE prophylaxis in medical patients. 64% of patients received a VTE risk assessment on the day of their admission but this needs great improvement as the standards state all patients should be risk assessed on their admission to WCFT. This figure highlights a problem with nurses assessing patients on admission. 8 patients within the audit period who were identified as high risk for the development of VTE did not have any VTE prophylaxis prescribed and there were no documented reasons for these omissions. This highlights a proportion of high risk patients being put at increased risk for VTE development as their VTE risk status is not being reviewed or acknowledged. The audit demonstrated the VTE risk assessment forms completed by the nursing staff were not being printed out or filed in the medical or nursing notes so were not available for review or reference. The details of completed forms could not be viewed on the trust system via the ward Ipad. This highlights a great flaw in the system of operating as it appears not only are the nursing staff struggling to complete VTE risk assessments at ward level for all patients admitted; but also that nobody is able to view and utilise this information if it is completed because it is not being printed. Consideration needs to be given as to why the nurses are struggling to complete the assessment at ward level; has the change in practice not been communicated or are the nursing staff too busy. The possibly of increasing pharmacy input at ward level to ease this pressure could be considered. Conclusion Results demonstrate the current procedure is not effective in ensuring all medical patients receive a VTE risk assessment on admission and are prescribed VTE prophylaxis as appropriate during clerking. The auditor recommends training and education of nursing and medical staff regarding the WCFT VTE policy and the results of this audit; alteration of IT access to allow ward access to forms once completed; implementation of reports to highlight patients not prescribed VTE prophylaxis once electronic prescribing is implemented and a total review of the WCFT VTE policy including consideration to change nurse led system to assessment by the medical team at the point of prescribing. References

1. House of Commons Health Committee (2005) The prevention of venous thromboembolism in hospitalised patients. London: The Stationery Office.

44. Can Healthcare Professionals Teach Inhaler Technique? Bullock, S, Royal Liverpool and Broadgreen University Hospital Trust, Liverpool

Introduction Inefficient inhaler technique is a common problem amongst Respiratory patients, resulting in poor drug delivery, decreased disease control and increased inhaler use1. One study in the Isle of Wight found that 92% of patients had poor inhaler technique, furthermore 94% of healthcare professionals involved were unable to demonstrate the ability to use the inhaler device correctly themselves2. If patients are to have good inhaler technique, they need to be taught how to use their inhalers correctly. Several studies have been carried out looking at improving patient's inhaler technique by using the 'training the trainer' concept, i.e teaching healthcare professionals to use inhaler devices and ensuring that they then train patients correctly1. These studies demonstrated significant improvements in patient outcomes and reduced burden on the NHS1,2. Liverpool has one of the highest prevalences of both asthma and COPD in the UK. If the results from the Isle of Wight study were reproduced in this city, there could be a significant reduction in emergency admissions with Respiratory disease, length of hospital stay, asthma related deaths and the Respiratory drug budget. The aim of this audit was to determine if healthcare professionals who are expected to counsel patients on inhaler technique as part of their job role, were confident and competent to do so. Objectives

Determine if healthcare professionals are confident to counsel a patient on inhaler technique

Determine when the healthcare professionals last received training on inhaler technique

Assess if the healthcare professionals can identify 3 different commonly used devices

Assess if the healthcare professionals know whether each of the 3 devices contain either a dry powder or an aerosol

Assess whether the healthcare professionals would recommend the correct inhaler technique for each of the 3 devices to patients Method Questionnaires were completed by a range of healthcare professionals from the pharmacy department and the Respiratory directorate. The multiple choice questionnaire contained clearly worded questions based on three commonly used inhaler devices, an Accuhaler, a Handihaler and a metered dose inhaler (MDI). The audit data was collected in March 2013. No ethics approval was required for the project as it was deemed an audit by the Trust audit committee. Audit Standards

1. 100% of healthcare professionals should be able to identify commonly used inhaler devices 2. 100% of healthcare professionals should be aware of the correct inhaler technique to administer commonly used inhaler devices 3. 100% of healthcare professionals should be competent to counsel patients on inhaler technique if it is part of their job role

Results 32 healthcare professionals took part in the audit; 5 Respiratory consultants, 2 Respiratory registrars, 3 junior doctors, 5 nurses, 15 pharmacists and 2 pre-registration pharmacists. Table 1 details the number of healthcare professionals that could identify the inhaler devices and the inhaler technique required to use each of them (as per audit standards 1 & 2). 50% (16/32) of the healthcare professionals asked, stated that they would be confident to counsel a patient on inhaler technique. 2 of the 32 healthcare professionals had never received any inhaler technique training, 2 people had received training within the past year, 9 people stated that it was between 1-5 years previously, 12 people stated that it was between 5-10 years previously. The remaining 7 healthcare professionals stated that it had been at least 10 years since they had received any training.

Table 1. Inhaler Device Identification and Inhaler Technique

Accuhaler Handihaler MDI

% able to correctly identify inhaler device 90.6% (29/32) 90.6% (29/32) 93.7% (30/32)

% able to identify if device contains a dry powder or an aerosol 87.5% (28/32) 87.5% (28/32) 75% (24/32)

% able to state the correct inhaler technique to use for device 25% (8/32) 40.6% (13/32) 40.6% (13/32)

Only 6.2% of healthcare professionals asked could identify all 3 devices and would teach the correct inhaler technique to patients, i.e. audit standard 3 was not met. Discussion Of the healthcare professionals who participated, there was a range of different professions and abilities. This demonstrates a fair overview of the level of knowledge within the Respiratory directorate and of the pharmacists who regularly see patients prescribed inhalers across the Trust. One limitation is that these results cannot be generalised across the Trust, as other directorates will be less familiar with inhaler devices and results may be worse for staff in specialities other than Respiratory. Results showed that although most healthcare professionals are counselling patients on how to use their inhalers, they may be teaching them a bad technique which inevitably leads to poor disease control. However, this strengthens the existing evidence that 'training the trainer' is an important aspect of improving patient's inhaler technique. Regular training is required to refresh and keep knowledge up to date with any new devices available. As a result of this audit, a rolling staff training programme has been introduced for inhaler technique across the Trust. This includes practical sessions involving the use of placebo inhaler devices for third year medical students, junior doctors, nursing staff, pharmacists and pharmacy technicians. Formal feedback from each session has been positive so far. References 1) Evaluation of Inhaler Technique Improvement Project, The Cambridge Consortium. August 2012. Available from: https://wessexhiecpartnership.org.uk/ wires/files/2013/07/120904-CIREM_ITIP_HIEC_Evaluation.pdf Accessed online 23/3/13 2) Isle of Wight Respiratory Inhaler Project, National Institute for Health and Care Excellence. February 2011. Available from: http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=461 Accessed online 23/3/13

45. Improving the quality of hospital outpatient prescribing: an audit approach. Hackney S, Hollister, L and *Eradiri OL, Colchester Hospital University NHS Foundation Trust (CHUFT), Colchester.

Introduction At present, prescribing on inpatient medication charts is audited for quality on an annual basis in the trust. The four most common errors are wrong dose, wrong dose frequency, items omitted, and brand name or abbreviation used for drug name(1).The 2013 annual prescribing audit showed an error rate of 19% occurring for inpatient prescribing across CHUFT (up from 15% in 2012). Fortunately many of these errors are categorised as minor. All prescriptions are handwritten in the trust, introducing errors caused by illegible handwriting and omission of important clinical details. Electronic prescribing is currently being developed, with oncology prescriptions planned to benefit first. The trust considers improved patient safety, reduced medication spend and improved income recovery to be the benefits of e-prescribing, resulting from supposed guaranteed “compliance with appropriate standards and guidance”(2). The ‘Spoonful of Sugar’ report also advocates e-prescribing by suggesting that rules to prevent incorrect or inappropriate prescribing could be incorporated, thereby reducing incidence of errors and increasing appropriateness of medical treatment(3). Aim To assess the quality of prescribing practice in a hospital outpatient setting. Objectives

To establish an audit that demonstrates the types and quantities of prescribing errors occurring in outpatient prescriptions.

To validate the introduction of e-prescribing in an outpatient setting. Standards Standards were derived from prescribing guidance in the British National Formulary (BNF) and various trust policy documents (see Table 1). All standards were set to 100%. Method The audit included all outpatient prescriptions screened and filed in Clacton pharmacy during August 2013. Prescriptions where the screening pharmacist had to speak to the prescriber or patient to clarify or correct the script, resulted in an audit form being completed. The audit was piloted in Colchester hospital pharmacy for 2 weeks in August using a prospective data collection technique that required all screening pharmacists to complete an audit form for each prescription where they encountered problems. Reviewing the pilot data resulted in a redesign of the audit. It was decided that it would be more effective for the authors to collect retrospective data by using the same audit forms and only audit prescriptions filed in Clacton hospital pharmacy. The reasons are as follows:

1) Prescriptions can originate from both Colchester or Clacton outpatient clinics, and many of the prescribers work in both. 2) One pharmacist screens all prescriptions in Clacton pharmacy therefore endorsements are consistent. 3) Access to filed prescriptions and data collection at Clacton was less time-consuming. Data collection was completed on Friday 31st August

2013.

Results A total of 284 outpatient prescriptions were audited; 134 (47%) of these prescriptions required intervention. Table 1: Compliance with the audit standards

Standard % Compliance 95% CI Patient name correct 99.7 98.7-100 Patient date of birth correct 97.9 96.2-99.6 Appropriate drug name prescribed 60.9 55.2-66.6 Appropriate dose prescribed 81.3 76.8-85.8 Appropriate frequency prescribed 95 92.6-97.6 Appropriate strength prescribed 97.2 95.3-99.1 Quantity/duration of treatment specified 88.7 85.1-92.4 Prescription is signed 99.3 98.3-100 Non-formulary prescribing is appropriate 98.9 97.8-100 Supplementary information is correctly annotated 100 N/A

Discussion and Conclusion The trust met one standard - supplementary information is correctly annotated. When 95% confidence intervals are considered, the trust may be meeting the standards for prescriptions signed, appropriate non-formulary prescribing and patient name correctly transcribed. The most common errors identified were, in order, inappropriate or absent drug name (particularly proprietary prescribing), dose, quantity/duration of treatment and dose frequency. Proprietary prescribing may not be a particular problem in hospital dispensaries as generics can be dispensed. However when FP10s are issued out-of-hours, the hospital picks up the costs as community pharmacists cannot substitute with generics. Interestingly, this error is also the most common in inpatient prescribing. Inappropriate/absent dose, frequency and quantity/duration of treatment are more significant errors in a hospital dispensary, as they frequently require clarification from the prescriber. E-prescribing may play a role in improving these areas by creating rules that ensure these fields are completed accurately. Convenience sampling was a limitation, as Colchester hospital prescriptions were not included in the audit. The timing of the audit was also a potential limitation as it was conducted during the school holidays, when fewer clinics were running. Recommendations include repeating and expanding the audit to include Colchester to gain a wider picture of typical prescribing practice. Greater awareness of prescribing standards needs to be created. Annual audits would monitor effectiveness of the proposed interventions in improving practice. Longer term, the introduction of e-prescribing in outpatients will help to reduce these types of errors, while introducing other types. References

1. Hollister L. Summary findings: prescribing quality audit July 13. Internal trust audit, available at request. 2. Colchester Hospital University Foundation Trust. ICT implementation plan. April 2010.

http://www.colchesterhospital.nhs.uk/meetings_minutes/supporting_docs/april_2010/April%2010%20-%20Board%20-%20Item%205.pdf (accessed 5 October 2013)

3. Audit Commission. A spoonful of sugar – medicines management in NHS hospitals. 2001.

4. British National Formulary. BNF 66. September 2013. p. 1-6

46. Auditing the Impact of Electronic Prescribing on Clinical Pharmacy Services. Gordon,S, Tomlin, T, University Hospital Southampton NHS FT (UHS)

Introduction Mistakes with the prescribing of medicines are well known. The EQUIP study, highlighted that nearly 9% of prescriptions in a selection of UK hospitals contained an error when written1. The authors examined 124,260 prescriptions across 19 UK hospitals for any error. They found mistakes in 11,077 (8.9%). Only about 2%, however, had the potential to cause significant harm to the patient e.g. prescribing a drug the patient was reported to be allergic to. Over half the errors involved transcription or medicines reconciliation errors, where prescriptions were not correctly transferred during admission or discharge. UHS had an error rate of 7% at the last review in 2012. In 2012 Electronic Prescribing & Medicines Administration (EPMA) was introduced within UHS and the trust perceived that this would result in safer prescribing and create staff savings for clinical pharmacy. The following audit compares ward pharmacy activity and intervention data from last year (without EPMA) with this year’s data, with EPMA. Objectives To look at the impact of EPMA on ward pharmacy activity by reviewing, on the ward, pharmacy activity and interventions and comparing the data with last year’s results. . Method All pharmacy staff working on the wards across UHS collected activity (quantitative) data for one week starting on Monday 13th May 2013 06.00 and finishing at 05.59 on Monday 20th May, describing 36 activities undertaken on the ward. In the subsequent week (Monday 20th May 06.00 – Monday 27th May 05.59) pharmacy staff were asked to collect data on the interventions (qualitative) undertaken on the ward. The intervention results were recorded in MS Access. Ward based activity data was recorded in excel. UHS admission data and staff numbers have been incorporated into the data set to assist in the interpretation of the activity being provided. As this was part of an audit of a service, ethics approval was not required. Results

2012 2580 Admissions

2013 Admissions 2634 (2%)↑

ADMISSION ACTIVITY Numbers per week Numbers per week

Medicine reconciliation (MR) = Drug History (no. of pts) 1080 971 (10%) ↓

Level 1 MR requiring change (no. of pts) 360 (33%) 359 (37%) ↑

Number of individual changes to MR (no. of items) Level 1 & 2 896 1077↑

IN PATIENT PERIOD ACTIVITY

Clinical screen / review undertaken inc. blood monitoring (no. of pts) 2696 3022↑

Clinical reviews requiring change (no. of pts) 465 (17%) 583 (20%) ↑

DISCHARGE ACTIVITY

No. of TTO's (total no. of pts) 548 565 ↑

No. of changes made to TTO prescribing (no. of items) 368 (15%) 602 (20%) ↑

INTERVENTION TYPE

Save a Life (Grade 4) 4 (0.6%) 8 (0.6%)

Save and Organ (Grade 5) 8.4% 125 (9.9%)

Major (Grade 6) 42.3% 566 (44.6%)

Total time spent on wards 921 hours 1057.25 hours

Employed wte 59.16 68.74

Discussion In total 36 activities were measured in the first week of data collection. Only 4 measures showed a reduction in activity. In all other areas activity increased. Results related to safety are presented in the table above. These results suggest that EPMA has not reduced the number of errors being made with medicines. More errors were found at admission (33% to 37%), during in-patient stay (17% to 20%) and at discharge (15% to 20%). It is possible that the increase in discharge errors is related to the different electronic systems used and theoretical errors in how the data is pulled between systems. In the second week the qualitative data highlighted that the total number of interventions had increased by 30% overall with an increase from 51.2% to 55.1% of interventions graded 4-6 (the most serious) and 10% of errors being attributed solely to prescribing on the new EPMA system e.g. incorrect drug selection from auto select boxes. It was expected that EPMA would save time on the wards but the increase in time spent on the wards 921 hours to 1057 hours (15%) is in line with investment in staff 59.16 wte to 68.74 (16%). However the results suggest that there does appear to be efficiency savings as an increase in activity is seen (admissions, increased by 2% and interventions increased by 30%) within the same staffing resource. Unpicking these changes is complicated. As an example in 2013 the average time to complete medicines reconciliation has increased from 10 minutes with the previous system to 17 minutes per patient with EPMA, partly due to the lack of any intrinsic drug history template within the EPMA system used. Increasing the total time spent on MR in 2012 from 180 hrs (for 1080 patients) to 275hrs in 2013 (971 patients) and possibly part of the cause of a 10% reduction in MR activity. This is the first year of EPMA and any problems highlighted are continually resolved. We hope that next year we may see a reduction in some errors as familiarity is gained and more decision support is built and incorporated. Despite these challenges EPMA offers the benefit of improved audit trails, better reporting and remote access. References 1 An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. 2009. http://www.gmcuk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf. Accessed January 2014

47. National patient Safety Agency (NPSA) audit: Safer Practice and Use of Epidural Injections and Infusions. Patel S., Al-Hasani M. Central Middlesex Hospital. North West London Hospital NHS Trust (NWLH)

Introduction: A National Patient Safety Agency alert published on 28 March 2007 made recommendations on how to make the administration of epidural injections and infusions safer. This alert came about after 3 patient deaths were reported, which led to the revelation that there were actually 346 incidents involving epidural injections and infusions. A recurrent problem was that epidural drugs were administered via the intravenous route. Although the majority of incidents were of low harm, the potential for fatal harm was apparent1. Objectives:

To determine whether epidural infusions and other epidural devices stocked on the wards at Northwick Park Hospital (NPH) and Central Middlesex Hospital (CMH) comply with the 6 recommendations of the NPSA alert 2007. (See recommendations as standards below)

To suggest any improvements that can be made across the trust for the safer practice and use of epidural infusions. Standards: 1. 100% of all epidural infusion bags and syringes must be labelled with ‘For Epidural Use Only’ in large font, with judicious use of colour. 2. 100% of epidural infusions must be ready-to-administer epidural infusions. 3. 100% of epidural infusions must be stored in separate cupboards or refrigerators. 4. 100% of epidural administration sets & catheters must be labelled with ‘Epidural’ when in use. 5. 100% of infusion pumps and syringe drivers for epidural infusions are easily distinguishable and used exclusively for epidural therapy or, if not,

devices should be labelled ‘For Epidural Use Only’ when used for epidural therapy. 6. 100% of all staff involved in using epidural therapy should have received adequate training. Method: Wards that stock epidural injections and infusions were identified using the pharmacy dispensing software program JAC. The nurses on the pain team also confirmed the wards which stock epidural injections and infusions, as they provide epidural training to the staff on these wards. A data collection form was made and piloted on 2 wards at NPH. The aim of the form was to tally the number of epidural infusions and epidural devices that comply with the standards across the trust. The data collection form was successful and was used for the actual audit across the NWLH trust for one week from 18th November until 23rd November 2013. Ward managers were able to provide information on the total number of staff on each ward and the total number trained by the pain team to use epidurals. Ethics approval was not required for this audit. Results: There were 102 epidural infusion bags across the trust, all of which were labelled with ‘For Epidural Use Only’ in large font, with judicious use of colour, were ready-to-administer epidural infusions and were stored in separate cupboards or refrigerators. 1 epidural infusion pump was currently being used by a patient and this was labelled with 'For Epidural Use Only' as required by standard 5. Standards 4 and 6 were not met across the trust. In total there were 7 patients on an epidural catheter. 3 of which were labelled 'epidural' therefore only 42.86% complied with standard 4. 396 out of the 426 staff who should be trained to be involved in epidural therapy were trained by the pain team (92.96%). A comparison of the results from the initial audit undertaken in 2011 and this year's audit can be seen in table 12. Table 1: Results of adherence to each standard from the initial audit and this year's audit.

Standards % Adherence to standards % Adherence to standards (initial audit results) (This year’s audit results)

1 100% 100%

2 100% 100%

3 100% 100%

4 100% 42.86%

5 100% 100%

6 91% 92.96%

Discussion: Standard 1, 2 and 3 were fully met by the trust in this year’s audit and in the audit conducted in 2011. Therefore there are no concerns that 100% adherence to these standards will be maintained. Standard 4 was not fully met across the trust in this year’s audit. The percentage adherence across both hospitals is 42.86% this year (3 out of 7 epidural catheters). Incompliance to standard 4 was only observed in the maternity ward at NPH. The maternity ward manager was therefore e-mailed to ensure staff are aware of the incompliance. In the previous audit there was 100% adherence to standard 4. Standard 5 was fully met across the trust on both this year’s audit and 2011 audit. However, in this year’s audit only 1 patient was on an epidural infusion pump across the trust. A limitation for standards 4 and 5 is that there were only a small number of patients on epidural catheter therapy or on an epidural infusion pump and so this may not be a true representation of the results. The final recommendation by the NPSA was that all staff involved in epidural therapy should be adequately trained (standard 6). This year’s audit has shown that 92.96% of staff who would be involved in epidural therapy have been trained. The pain team stated that those who have not been trained are new starters and are due for training in the near future. In the 2011 audit, 91% of staff had been trained. The same reason as to why some staff had not been trained, applied last time as well as this time- the untrained staff were new starters. Conclusion: The correct route of administration of drugs used for epidural purposes is important to ensure patient safety. The trust should continue to re-audit the safe use of epidurals annually, especially as there are some areas of improvement needed. References: 1) NPSA alert. Epidural injections and infusions- patient briefing. Patient alert 21. Issue 0396. 28/03/2007. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59807. Accessed online 25/11/2013 2) Sherreard, N., Al-Hasani M. An Audit on the Safe Use of Epidural Infusions at North West London Hospitals (NWLH) NHS Trust 2011.

48. The Introduction of Pharmacist Transcribers on the Surgical Admissions wards at St James’ Hospital, Leeds, to Improve Patient Access to their Regular Medicines

Blow, S. E, Ginday, V, Pharmacy Department, Leeds Teaching Hospitals NHS Trust, Leeds

Introduction On admission to hospital it is vital to ascertain an accurate and complete medication history for each patient1. To ensure patient’s co-morbidities are managed throughout their stay these medicines need to be prescribed on the administration record, thereby allowing safe and accurate administration of patient’s regular medicines2. Following a local review of patient access to their regular medicines it was ascertained that upwards of 60% of patients admitted for elective surgery were not prescribed (nor received) their regular medicines during their stay, with a further 20% prescribed an incorrect dose of their regular medication. The picture was similar regarding acute surgical admissions, with only 11% being prescribed their regular medicines (at 24hours post admission). This highlighted the need to improve patient access to their regular medicines. Owing to the increased likelihood of a period of acute illness, or post-operative phase affecting patient ability to safely comply with their medicine regimen, all medicines need to be available for nursing teams to support the safe administration of medicines. We wanted to investigate whether transcribing pharmacists assist and improve the management of patient’s co-morbidities by ensuring patients have access to their regular medicines. Objective(s) To demonstrate the benefit of pharmacist transcribers working on surgical admissions wards to improve patient access to regular medicines. To consider how or if the process of medicines transcription can safely and effectively support prescribing or access to appropriate medicines for patients in an acute surgical environment. Method Support for this project was obtained from the Medical Director, the Clinical Directors for the clinical service units who provide care to surgical admissions and the nursing staff. Pharmacists who were not independent prescribers were trained as pharmacist transcribers. Transcribing differs from the act of prescribing as transcribing is the process of duplicating details of a patient’s confirmed current regular medication regimen on to the administration record to facilitate administration of regular medicines. Whereas prescribing is undertaken by a registered practitioner, who is responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required. To work as a pharmacist transcriber, pharmacists must be a member of the surgical pharmacist team, undergo training with a trust registered pharmacist transcriber and be assessed as competent. The pharmacist takes full responsibility for the safe and accurate transcribing of medication; any errors resulting from the use of this procedure are recorded and reviewed by medicines management and clinical staff. An initial pilot of pharmacist transcribers was initiated on the same day admissions unit (elective admissions) and later rolled out onto the acute surgical admissions wards. The process of transcription is as follows; 1) Introduce yourself to the patient and explain your role 2) Generate, confirm and document a drug history, from more than one source, following the trust procedure. Includes confirmation and documentation of patient’s allergy status. 3) All medicines currently prescribed and taken by the patient should be transcribed on to the administration record. 4) After transcribing each individual medicine, sign, print name and bleep and annotate ‘Pharmacist Transcriber’ and GPhC (General Pharmaceutical Council) number 5) A medication review to check the prescription is required, by a different pharmacist within 24 hours as per clinical pharmacy standards. Where a medicine is judged to be contra-indicated by the patient’s medical condition or not suitable for administration, the medication is transcribed by the pharmacist and annotated to omit or review. The decision to do this was made in conjunction with our medical/surgical colleagues. To ascertain the impact of pharmacist transcribers, the number of patients who had access to their regular medication (prescribed and available on the ward), within 24hours of their admission was compared to that prior to the introduction of pharmacist transcribers. Results Table 1: The number of patients (%) whose regular medicines are correctly prescribed (according to the N.E.W. Yorkshire prescribing standards3) and available within 24hours of their admission, before and after the introduction of pharmacist transcribers

Same day admissions unit (elective admissions) Acute surgical admissions wards

Before After Before After

13% 75% 12% 88%*

*Increased to 91% at 48hours To assess the severity, and impact to patient outcomes, a review of the medicines not prescribed was performed. The most commonly omitted medicines included; anti-hypertensive medication (19%), analgesia (15%) and inhaled therapies and proton pump inhibitors (10%). To date, no errors by pharmacist transcribers have been reported. Discussion The introduction of pharmacist transcribers significantly increased patient access to their regular medicines during their hospital stay. Although feedback from the introduction of this service was not formally sought, a number of nursing and surgical colleagues provided comment on its impact. Positive comments included; “Good, speeds up discharges”, “Regular meds prescribed, no delays waiting for FY1s”, “Fantastic changes…regular medicines are written up and given within 24hours”. Less positive comments related to our medical colleagues, and not the pharmacy service. Additional benefits to patient care included;

Improved management of co-existing conditions through the peri-operative period, resulting in shorter recovery times and reduced length of stay

Nurses are spending less time contacting prescribers to prescribe patients regular medicines - releasing time to care

Medical teams can focus on specific patient issues and are no longer being chased to write drug chart - releasing time to care. The improved access to patient’s regular medicines demonstrates there is a need to continue working in this way. The introduction of pharmacist transcribers is an interim measure whilst additional Independent Pharmacist Prescribers are trained. References 1. National Patient Safety Agency. Guidance to Improve Medicines Reconciliation. December 2007.

http://www.npsa.nhs.uk/corporate/news/guidance-to-improve-medicines-reconciliation/ (accessed 19th December 2013) 2. National Institute for Health and Clinical Excellence/National Patient Safety Agency. Technical patient safety solutions for medicines

reconciliation on admission of adults to hospital. December 2007. http://www.nice.org.uk/nicemedia/live/11897/38560/38560.pdf (accessed 20th December 2013)

3. N.E.W. Yorkshire Prescribing Standards. June 2007. http://www.aomrc.org.uk/publications/statements/doc_view/9364-4-n-e-w-yorkshire-prescribing-standards.html (accessed 11th February 2014)

49. Reasons why hospital doctors make prescribing errors Dobrzanski S, Department of Pharmacy, Bradford Teaching Hospitals NHS Foundation Trust

Introduction While hospitals may record prescribing errors made by doctors, the precise individual reasons why a given doctor has made a given prescribing mistake may often remain unclear. This study is a record of interviews carried out with medical staff to identify the factors that they felt made them particularly vulnerable to making prescribing errors. Methods The study was carried out in a Teaching Hospital where the pharmacy department had been asked by the Trust to meet with doctors whose prescribing rights had been suspended as a result of serious prescribing errors. The meetings took the form of semi-structured interviews that looked at prescribing risks at hospital admission, during the patient’s ward stay and at discharge. The doctors were asked to reflect on common prescribing errors previously seen in the hospital and to identify working practices, lack of support structures and unsatisfactory professional relationships that might make them vulnerable to making further errors. All the doctors were happy that the information they provided could be shared in order to prevent future doctors repeating the same prescribing mistakes. Ethics Committee approval was not sought as this study emerged from a Trust initiated pharmacy service development related to the reduction of prescribing errors. Results Between November 2011 and December 2013 a total of 22 interviews were held. The themes that were identified by the doctors as being linked to greatest prescribing risk are shown in Table 1. Table 1. Important causes of prescribing errors

Prescribing at admission 1. Difficulties in obtaining a medication history at admission. The doctors felt that access to the primary care electronic health record

would help to prevent the most common prescribing error seen in the hospital, namely failure to identify essential medicines prescribed for patients by their GP.

Prescribing on the ward 1. Not knowing the patient. Doctors often found themselves prescribing for patients that they did not know. This occurred when they

were new to a ward, where they were covering for another doctor, when at weekends they inherited patients belonging to other consultant teams or where they were required to cover several consultant ward rounds at the same time.

2. Poor handovers and documentation. Doctor handovers are not a systematic as nursing handovers. Doctors working on downstream wards complained that they often had no idea why prescribing changes had been made on acute admission units.

Ward situations leading to errors 1. Delegated prescribing. Some consultants do not prescribe on ward rounds but expect their minions to carry out this task for them. The

risk is that the junior doctor will hurriedly scribble down whatever the consultant dictates – without questioning if it is right. 2. Being task focused instead of patient focused. Doctors who are caught in chaos become task focused, robotically ticking off their list

of duties at the nurses station. This means that the patient is not informed about hurried prescribing decisions by a doctor who is unable to cope and who is not thinking about the needs of the patient.

Lack of support 1. Lack of training or insight into the pitfalls of hospital prescribing. The doctors claimed that prescribing errors and their prevention were

not studied at medical school. 2. Lack of prescribing guidelines. Where guidelines do exist then they may be difficult to find on poorly designed hospital intranet sites.

One doctor said, ‘Lot of good things on the Intranet – pity you find out about them just as you are leaving.’ 3. Hierarchical obstacles to communication. The doctors conceded that ‘It is just not done to admit that you don’t know something on a

ward round’. They were tempted to take a chance and prescribe on a ‘that looks about right somehow’ basis rather than risk shame and humiliation on the ward round by admitting ignorance to their consultant. The doctors saw hierarchy as the enemy of safe prescribing – especially when faced with consultants who were unapproachable and ‘did not tolerate fools gladly’.

4. Unhappy doctors make more errors. Doctors admitted to feeling especially vulnerable to making errors when left alone, without support from their seniors, while being asked to deal with prescribing issues outside their areas of competence.

Prescribing at discharge 1. Being pressurised by nurses to write ‘urgent’ discharge letters while not knowing the patient or referring to their medication history.

Doctors made the following quotes: ‘Sometimes the first time I see a patient is when I write their discharge letter.’ ‘Half the discharge letters I write are for patients that I have never seen.’

2. Writing discharge letters while being unable to track or explain drug changes made during the patient’s hospital stay. Such discharge letters contain insufficient information for the patient to be counselled or for the GP to understand medication changes made in hospital when the patient first visits them after discharge.

3. Simply copying the drugs on an in-patient treatment chart onto the discharge letter. 4. Seeing a discharge letter purely as a prescribing document and not as something that is intended to provide information to the GP and

to be discussed with the patient.

Despite being distressed by having made serious prescribing errors, the doctors were frank and open in their interviews, hoping that their insights might help their medical colleagues. Conclusions The hospital pharmacy now routinely explores the reasons for serious prescribing errors in one to one interviews with doctors before reinstatement of their prescribing rights. Making doctors aware of where they are vulnerable to making prescribing errors may promote safer prescribing and the outcomes of these interviews have been incorporated into hospital prescribing training. Pharmacy awareness of medical prescribing vulnerabilities may help in providing targeted support for doctors finding themselves in situations linked with high prescribing risks. Reference Dobrzanski S, Khan G, Holdsworth H, et al. The nature of hospital prescribing errors. British Journal of Clinical Governance 2002; 7: 187-193.

50. A service improvement project to reduce delayed and omitted doses in an adult critical care setting Reed, J., Percival, T., Devenish, P., Oxford University Hospitals, Oxford

Introduction Missed and delayed doses can have a significant and detrimental effect on patient care. Between September 2006 and June 2009 in the United Kingdom, 27 patients died as a result of missed or delayed doses and 68 patients suffered severe harm.1 Since the critical care unit often hosts the most unwell and vulnerable patients, it could be assumed that giving all prescribed doses promptly is especially important in this area. The critical care units in the Oxford University Hospitals also use electronic prescribing (Carevue®) which has been shown to facilitate data collection of omitted doses.2 The NHS Institute for Innovation and Improvement has been encouraging and supporting NHS staff to implement change through service improvement projects which identify a problem, trial small changes on a small scale, analyse the benefits and then make further changes before implementing the successful change on a large scale.3

Objectives To reduce the number of unintentional omitted and delayed doses by 50% in the Adult Critical Care units by November 2013 using service improvement methodology by:

establishing current practice

reviewing delayed and omitted doses and identifying improvement strategies

implementing service improvement strategies

evaluating the effect of service improvement strategies

Method Baseline levels of omitted and delayed doses in the critical care units were audited over a week using the electronic prescribing system, Carevue®. The results were analysed and reasons for omitted and delayed doses were brainstormed. Service improvement ideas were selected and implemented for ease of implementation, impact and cost. These included updating stock lists and educating nurses on the importance of giving first dose IV antibiotics within one hour of prescribing. The levels of omitted and delayed doses were re-audited over a week and compared to the baseline results. The next set of service improvement measures implemented included creating posters telling nurses how to contact pharmacy at different times of day on weekdays and weekends and collaboration with doctors and resident pharmacists to ensure all appropriate prescribed medicines are given promptly. Ethical approval was not needed, as the data collection did not influence patient care and the service improvement processes are hoped to lead to an improvement in patient care. Results Table 1 – Difference between levels of delayed and omitted doses after initial service improvement strategies compared with baseline levels

Parameter Percentage reduction

Percentage reduction in delayed doses 69

Percentage reduction in omitted doses 70

Discussion The author was concerned when analysing the baseline data about the number of medicines delayed or omitted because they were “unavailable” (4% and 18% respectively). The trust offers a 24hour pharmacy service where time critical medicines can be supplied outside standard pharmacy opening hours. Education of nurses about the pharmacy service may have led to the decrease in omitted and delayed doses seen in the second set of data collection (only one dose omitted and no delayed doses due to medicines not being available). Posters have now been displayed to ensure nursing staff knew how to contact pharmacy at any time of the day or night. When analysing the types of time critical medicines that were delayed, it was immediately seen that first dose antibiotics were the group of medicines most commonly given late. This was surprising since most of these medicines were available as stock on the critical care units with no reason documented for their delay; because of this, it was thought that perhaps nurses were not aware that first dose antibiotics needed to be given within an hour of prescribing. The deputy matron responded by sending out an email highlighting the issue to all ITU nursing staff. The second data collection saw a decrease in delayed doses (69%), but the majority were still first dose antibiotics (67%). Since the nurses had recently been educated on the importance of administering first dose antibiotics promptly, other reasons for the delay were considered. The project was presented to a group of ITU doctors with a clear emphasis that when prescribing first dose antibiotics, it is their responsibility to tell the appropriate nurse immediately and to stress that the medicine needs to be administered within an hour. Resident pharmacists were informed that microbiology approval is not needed for restricted antibiotics out of hours and time should not be wasted insisting upon this. The second data collection showed 14% doses were omitted as they were “awaiting pharmacy.” The pharmacy department are now reviewing their protocol on how urgent medicines are ordered and prioritised in the dispensary. Limitations of the project include that it relied on nurse documentation, the author undertook all data collection and analysis which may have led to interpretational bias and that the short timescale of the project allowed for only two short periods of data collection. Ideally data collection would have occurred after each individual service improvement measure. Conclusion The project aim “to reduce the number of unintentional omitted and delayed doses by 50% in the Adult Critical Care units by November 2013 using service improvement methods” has been met. Further reduction of delayed and omitted doses may be achieved through liaison with the antimicrobial steering group, the pharmacy department and the doctors and nurses working in the critical care wards. References 1. National Patient Safety Agency, 2010. Rapid Response Report. Reducing harm from omitted and delayed critical medicines in hospital. London NPSA. 2. Coleman J J, Hodson J, Brooks H L. and Rosser, D. Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis. Int J Qual Health Care 2013, 25 (5): 564-572. 3. NHS Institute for Innovation and Improvement. [Online] Available from: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/quality_and_service_improvement_tools_for_the_nhs.html [Accessed 4th July 2013]

51. An Evaluation of the Preparation and Use of Injectable Ephedrine within the Theatre Environment of a NHS Hospital Trust Percival T, Crowley CY, Pharmacy Department, Oxford University Hospitals NHS Trust, Oxford.

Introduction Medication errors are well described in anaesthesia and may arise from latent or active errors. They are the second most common category of anaesthetic specialty incident reported to the National Patient Safety Agency (NPSA)1. The use of injectable medicines is widespread within theatre anaesthetic practice, and frequently involves high-risk medicines where inappropriate management can result in significant harm to the patient. In a survey of 856 UK anaesthetists 51% identified that they had made a syringe swap error (selection and sometimes administration of unintended prepared syringe) at some time during their career2. Such errors have been reported locally. Nationally and internationally, numerous risk reduction measures have been proposed including up to date protocols and procedures for preparation and administration, standard concentrations, colour differentiated labels, purchasing ready to administer injectables and training1,3. This evaluation was undertaken within one large acute NHS teaching hospital to develop an understanding of the current preparation and use of the injectable vasopressor agent ephedrine by anaesthetic staff within the theatre environment. Ephedrine was considered appropriate for this study as the 30mg in 1ml vial supplied requires dilution to administer the 3-6mg adult dose, it may be prepared in advance of clinical need (“just in case”)4 or as required (“just in time”) and is commercially available in a ready to administer pre-filled graduated syringe at a concentration of 3mg/ml. Objectives 1. To ascertain the processes undertaken by anaesthetic staff in the preparation and administration of injectable ephedrine. Then compare these

with generic Trust standards, which are based on NPSA recommendations3. 2. To identify potential safety improvements regarding alternative pharmaceutical presentations of ephedrine from anaesthetic staff perspective. Methods Governance approval for the project was obtained from the anaesthetics directorate; ethics approval was not required as this was classed as service improvement. A mixed method approach was employed with initial qualitative interviews based on the project objectives yielding information for the later quantitative stage. Ten semi-structured interviews with anaesthetists and anaesthetic support staff, selected by purposive and convenience sampling to cover a range of specialities were undertaken. A quantitative survey tool was developed from key themes identified during the interviews. A pre-piloted electronic self-administered questionnaire was dispatched to the 140 anaesthetists employed by the Trust. One electronic follow up reminder was sent to increase response rate. Aspects of the results were compared to generic Trust standards for preparation and administration of injectable medicines. Results A total of 71 survey responses were received, of which 66 (47% of 140) fully completed the survey and identified having prepared ephedrine within the previous 12 months. Partial responses were excluded from analysis. The majority of respondents (39% of 66) had been Consultant Anaesthetists for more than 10 years with general anaesthesia the most frequent cited speciality (76% of 66 respondents). Ninety one percent of respondents prepared a 3mg/ml concentration, the same as commercial pre-filled syringes. Details of who prepares the syringe, when and discard details are shown in table One. Table 1. Practices associated with preparation and use of ephedrine (n=66 respondents) Question Never Sometimes Mostly Always Who prepares:

The doctor themselves 0 4 51 11 Another anaesthetist when available 12 49 3 2 Anaesthetic support staff 20 42 4 0

When a syringe is prepared: In advance so available to administer (‘just in case’) 3 37 19 7 At the time it is needed to be administered 5 39 19 3 Some/all components assembled to enable quick 17 32 11 6 preparation if needed (‘just in time’)

Discarding of UNUSED syringe: At the end of each patient’s surgery 26 28 4 8 At the end of the theatre session 4 6 13 43 Not discarded 47 17 1 1

Table one shows that the practice of ‘just in case’ and ‘just in time’ preparation of injectable ephedrine are almost equally common. Respondents reported always only attaching an ephedrine anaesthetic label to ‘just in case’ syringes in 59 of 66 replies. This is a deviation from current Trust generic injectable medicine labelling standards. A range of storage locations were identified for ‘just in case’ syringes, with 45% using the anaesthetic room most or all of the time. The majority of anaesthetists identified selection errors, either of the wrong medicine from the stock cupboard or the wrong syringe from a tray containing multiple prepared syringes (syringe swap) as potential safety issues so would use pre-filled syringes in preference to the currently supplies ampoules. Many felt they would save time (89%) and the main disadvantage would be cost (72%). Conclusions The results of this evaluation suggest that generic Trust standards for injectable medicine preparation and administration may not always be appropriate for anaesthetic practice, where the set up differs from the ward environment. Work needs to be undertaken to develop workable injectable medicine standards and procedures specific for the theatre environment. Implementation of pre-filled syringes could enhance safety and anaesthetic practice regarding ephedrine and other ‘just in case’ medicines and should be considered if financially possible. The majority of anaesthetists would use ephedrine and other pre-filled syringes if available. It is intended to confirm the results of this evaluation by direct observation. Re-evaluation and/or error monitoring, particularly concerning syringe swap errors, would be required post introduction of pre-filled syringes and theatre specific injectable medicine procedures to establish any safety or practice improvements. References 1. Safe Anaesthesia Liaison Group (SALG). Patient Safety Update, March 2013. Available at http://www.rcoa.ac.uk/system/files/CSQ-PSU-

MARCH2013.pdf. Accessed 16.01.14 2. Lewis J, Hill M, Gale T. A national survey of syringe swap anaesthetic drug errors. Anaesthesia 2010; 65: 1248. 3. NPSA. Patient Safety Alert 20: Promoting Safer Use of Injectable Medicines, 2007. 4. Stone JP, Fenner LB, Christmas TR. The preparation and storage of anaesthetic drugs for obstetric emergencies: a survey of UK practice.

International Journal of Obstetric Anesthesia 2009; 18: 242-248.

52. Clinical experience of using new oral anticoagulant agents Chouhan U and Starling J, Betsi Cadwaladr University Health Board, Departments of Pharmacy & Cardiology, Glan Clwyd Hospital, Rhyl

Introduction Warfarin has been the predominant oral anticoagulant in use in the UK and lately new oral agents have been introduced, namely dabigatran, rivaroxaban and apixaban. The main advantages of the newer agents over warfarin are short half-life, rapid onset of effect, lack of anticoagulant monitoring and significantly reduced incidence of intracranial bleeding.1

Clinical experience of using these new agents is described. In addition, the use of dabigatran in patients planned for direct current cardioversion (DCCV) will be discussed.2 Objective To analyse the clinical reasons and side-effects of all patients commencing one of the new oral anticoagulants indicated for stroke prevention in atrial fibrillation or treatment of thromboembolic disease. Method Patients meeting the Drug and Therapeutics Group (DTG) guidance and subsequently the national guidance3 on the eligibility criteria for dabigatran and rivaroxaban were referred to the first author. Agent selection and dose were based on indication for use, renal function (assessed by the Cockcroft and Gault equation) and other patient related co-morbidity factors. Discussion with patient (and their partner if present) included education on the new product, importance of compliance, likely side-effects including bleeding risk and repeat dispensing. Records of the patients’ demographics and clinical reasons for initiating the agent were recorded on a database. Results In the period July 2011 to 31st August 2013, 124 patients were commenced on one of the new oral anticoagulant agents. The demographic details of the patients are described in table 1. The mean age of the population was 65.5 years with a range of 20 to 90 years of age. Apixaban was prescribed to more elderly patients with a mean age of 81.2 years compared to the other two agents. The major clinical indication for selecting one of the new oral anticoagulant agents in 86 patients (69%) was for stroke prevention in patients with atrial fibrillation, the second most common indication was for the treatment of venous thrombo-embolism. The primary reasons for initiating one of the agents were poor INR control in 60%, transferring patients from low molecular weight heparins (LMWH) in 11%, warfarin related side-effects in 6.5% and in a further 5.6% of patients who refused warfarin treatment. 5 patients with significant history of major bleeds, for example idiopathic intracerebral bleeds, and epistaxis were initiated or transferred to either dabigatran or apixaban. 73 out of 124 (59%) patients have been transferred to the care of their GP for long term continuation of the prescribed agent and to-date, without any problems. With respect to DCCV and prior to the introduction of dabigatran use, 33% of the procedures were cancelled in patients on warfarin due to the INR being less than 2 on the day of procedure. With the approval of DTG, dabigatran use was allowed in this specific group of patients. With its introduction between 14th June 2012 and 1st March 2013, DCCV was cancelled in 22% of patients, a reduction of 33% in cancellation rate. Side-effects Six patients have had to change from one agent to an alternative agent due to tolerability, predominately indigestion and itchiness. One patient with a history of thromboembolic disease, renal impairment and with extremely erratic INR control had to stop treatment as she was unable to tolerate either rivaroxaban or apixaban due to severe symptoms of itch and dizziness. All side-effects have been reported to MHRA.

Table 1: patient demographic details and reasons for using one of the agents

Apixaban Dabigatran Rivaroxaban Total

Patient demographics

Number of patients 18 72 34 124

Age range, years 59 to 90 31 to 88 20 to 79 20 to 90

Mean age, years 81.2 69 49.7 65.5

No of patients ≥ 80 years 12 12 0 24

Male, female 8,10 46,26 17,17 71,53

Clinical indications

Atrial fibrillation (AF) 15 37 3 55

Cardioversion (for AF) 1 30 0 31

DVT/PE 2 4 31 37

other indication 1 1

Why agent selected

Poor INR control 8 51 15 74

Parenteral anticoagulant 0 2 12 14

Refusing warfarin 3 4 0 7

Warfarin side-effects 0 6 2 8

Needle phobia 1 1 1 3

Work related 0 0 3 3

History of serious bleed 2 3 0 5

other uses 4 5 1 10

Duration of treatment

Total, months 60 379 85 524

Bleeding side-effect In the whole cohort of 124 patients one patient stopped treatment due to presumed gastrointestinal bleed but subsequently found to have an haematological disorder. One patient was swapped from dabigatran to apixaban due to haematuria. He is currently tolerating apixaban at full therapeutic dose without any further episodes of bleeding.

Discussion Introduction of new oral anticoagulant agents has provided further treatment options for patients who previously either had poor INR control or side-effects with warfarin. Although experience is limited, especially in those over 80 years of age, analysis of the data to date indicates that these agents are well tolerated and their non-bleeding side-effects are manageable. Apixaban has been selectively used in more elderly patients because of its pharmacokinetic parameters, namely less reliance on renal function for its excretion. Furthermore, the use of dabigatran in DCCV has reduced cancellation rate by 33% and probably should be considered as first line agent in DCCV primarily due to efficient use of staff resources and patient benefit. References 1 Camm AJ, Lip GYH, Caterina R D et al; 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal

2012;33:2719-2747 2 Nagarakanti R, Ezekowitz MD, Oldgren J et al; Dabigatran versus warfarin in patients with atrial fibrillation - an analysis of patients undergoing cardioversion.

Circulation 2011;123:131-136 3 All Wales Medicines Strategy Group. All Wales advice on the role of oral anticoagulants for the prevention of systemic embolism in people with atrial

fibrillation. October 2012

53. Implementation of a biologic prescribing pathway by introduction of a Virtual Biologics Clinic in a single rheumatology department Reid V, Kemp K, Parker B, Division of Specialist Medicine, Central Manchester Hospitals NHS Foundation Trust. Manchester

Introduction In 2007-8, expenditure on biologic drugs for the treatment of rheumatoid arthritis alone ranged between £0.8 and £3.5 million per acute trust. Expenditure on biologic drugs accounts for the highest pharmaceutical spend within some trusts1. On average biologic drugs cost around £9500 per patients. Inappropriate prescribing of these drugs could place a large financial burden on the NHS. A harmonised pathway for biologic prescribing in rheumatoid arthritis (RA) was implemented through MAHSC (Manchester Academic Health Science Centre) for use in the Greater Manchester region. The pathway builds upon existing national NICE guidelines, and aims to standardise pre-treatment assessment , minimise variation in prescribing and maximise cost savings, where appropriate. This represented an opportunity to improve the experience of patients prescribed high-cost biologic therapies, standardise safety screening, enhance recruitment to research studies, and achieve cost savings. A Quality Improvement (QI) Project was therefore initiated with the aim of improving patient experience, reducing treatment delays, increasing the reliability of pre-biologic safety screening, increasing research recruitment and to realise cost savings in the biologics budget. A Virtual Biologics Clinic (VBC) was therefore established, with the aim of ‘virtually’ reviewing all patients starting a biologic at Central Manchester University Hospitals NHS Foundation Trust (CMFT). Aims and objectives To implement a virtual biologics clinic using QI methodology to maximise recruitment into relevant clinical trials, to have consistent pre-biologic assessment to minimise potential harm, make sure patients are receiving the most appropriate 1st line agent and where appropriate and in the absence of contra-indications, the cheapest available 1st line agent. Method The RA biologics pathway was devised to build upon existing national NICE guidelines using up to date evidence based medicine to preserve prescriber independence whilst allowing deviation from NICE guidelines. At CMFT the pathway was used as a basis for the prescribing of patient’s treatment through the virtual biologics clinic. A standardised safety checklist was also included in the pathway which provided a basis for pre-treatment assessment of patients in the VBC. The QI team formed part of a scaled-down Breakthrough Series (BTS) to better understand processes and identify barriers in the current system. Plan-do-study-act (PDSA) cycles of rapid change were used in clinical settings to implement the changes. The main changes were the introduction of a weekly VBC in August 2013 and the implementation of the RA biologics pathway. Novel documentation was produced that included an enhanced safety checklist and prescribing advice. All patients starting a new biologic were assessed ‘virtually’ by a RA Consultant, RA Specialist Nurse, Specialist Pharmacist and Research Nurse. Pathway adherence, safety screening, research study eligibility and follow-up were reviewed in the VBC, and prescriptions issued. Cyclic PDSA’s were conducted to refine the changes, outcome measures were assessed weekly after implementation of VBC. Results In the 4 months following the implementation of the regional biologics pathway 40 patients were prescribed a biologic therapy (23 with RA), 100% of whom were reviewed in the VBC. Mean treatment delay in all patients fell from 40.6 days (range 4-92) to 19 days (range 4-38) by week 14 and remains stable. Use of the enhanced safety checklist increased from 50% to 100% within 7 weeks, and remained universal at week 14. The recruitment of RA patients into research studies increased by 61% over the first 14 weeks, compared to the pre-VBC period, and all patients initiating a biologic are now actively considered for research (see table 1). Adherence to the biologic pathway in RA improved over the course of the QI project, and reached 90-100% by week 7. Annual cost savings to date, attributed to pathway adherence and enhanced research recruitment, is estimated at £51,000. Table 1 Number of patients recruited into clinicals trials in 2012-2013 and 2013-2014

Apr Mar Jun Jul Aug Sep Oct Nov Dec Jan

2013-2014

1 1 5 14 15 13 7 8 17 5

2012-2013

6 5 2 0 12 1 9 9 1 5

Discussion Introduction of a VBC in rheumatology has shown to be an effective method to streamline the initiation of high-cost drugs, increase recruitment to interventional and observational research studies and improve the reliability of pre-biologic safety screening. From implementation, significant cost savings have be achieved within 3 months. From audit data an estimated annual savings of £150,000 has been projected which can be put back into the trust. Through the success of this QI project the model is being implemented for other specialities at CMFT such as gastroenterology. References

1. National Audit Office (2009) Services for people with rheumatoid arthritis. London: The Stationery Office

54. What is the cost of a modern clinical pharmacy service? Part II – the development of a resource calculator. Simcock V, Blackshaw C, Bednall R, Hanif I, Freeman S. University Hospital of North Staffordshire (UHNS), Stoke on Trent

Background Pharmacy resource requirements have often been overlooked when business cases for service development are written. We are seen as an expensive staff group and whilst we may justify our costs in both direct and indirect savings, it remains challenging to secure adequate resources when other services expand, particularly when bed numbers are unchanged. However, pharmaceutical care is provided to patients and not beds and increasing patient throughput increases the need for pharmacy resource. Previous studies identified the resources required to staff dispensary services but there is little published evidence on clinical pharmacy requirements1-3. We recognised the need to develop a robust calculator tool to describe the pharmacy workforce required to provide basic pharmaceutical care to additional patients identified in Trust business cases. This paper describes the process to date, its application and identifies further development. Objectives

1. To develop a robust calculator tool enabling simple, objective identification of pharmacy resource requirements in response to Trust business cases for service expansion

2. To apply this to business cases at UHNS and gain agreement for its future application

Method This service development (requiring no ethics approval) was based on time and motion studies conducted at UHNS in 2009/10. The ward based study has been previously reported4; the dispensary based work was generated by a service review by a management consultancy firm. In both cases tasks required for patient care e.g. medicines reconciliation, in-patient supply, TTO supply (dispensary and clinical processes) were timed over a range of wards and individuals of differing grades. Data was utilised to form the basis of a Microsoft Excel® Pivot table. This allowed population of new bed and/or additional patient numbers in the relevant fields, along with predicted length of stay. The spread-sheet calculated the required resource needed to provide basic pharmaceutical care to the patients, identified by staff grade. The results were then compared with staffing requirements identified through traditional techniques of benchmarking and used to inform negotiations at Trust level. Results The calculator works for both the opening of new beds, specific additional patient case numbers or simple increase in throughput due to reduced length of stay. This tool has been successfully utilised on several occasions over recent months to generate additional pharmacy workforce during times of austerity. In one example the tool was used to verify requirements for staffing within Acute Medicine at UHNS. Over a period of several months a benchmarking exercise had been undertaken, requiring visits to several Trusts to establish process and staffing resource. This generated a staffing profile for the unit significantly greater than the existing model. This was a time consuming process and the output remained subjective and open to challenge. Application of the calculator to the patient population, resulted in objective confirmation of the resource required as it was based on specific measurable activity necessary for patient care (see Table 1.) This data therefore enabled a more informed and sound discussion with Divisional finance and management staff, resulting in successful negotiation and inclusion into the business case of additional 1.0 whole time equivalent (wte) band 7 pharmacist and 1.0 wte band 5 technician for the reconfigured service to Acute Medicine. Table1. Staffing requirements Acute Medical Unit: benchmarking v resource calculator tool.

Ward Area Benchmark* Resource tool calculation Current Staffing Shortfall

CDU 1 x Band8a

1 x Band 6/7 1 x Band 5

1 x Band 8a 1 x Band 6

1.5 x Band 5 1 x Band 8a

1 x Band 6 1 x Band 5

AMU

1 x Band 8a 1 x Band 7 2 x Band 6 2 x Band 5

1 x Band 8a 2 x Band 7

0.5 x Band 6 2.5 x Band 5

1 x Band 8a 1 x Band 7

0.5 x Band 6 2 x Band 5

1 x Band 7 0.5 x Band 5

SSU (122) Not compared 1 x Band 7 1 x Band 5

0.5xBand 7 0.5 x Band 5

0.5 x Band 7 0.5 x Band 5

210 (new ward) Not compared 0.25 x Band 7 0.25 x Band 5

Ad hoc cover 0.25 Band 7 0.25 Band 5

*Benchmark – UHNS service compared with other equivalent Trusts –regional and national Discussion The resource calculator provides a simple, objective and robust method of identifying staffing requirements for service development. Whilst the grades of staff are suggested by the tool, these have been negotiated at local level for recruitment purposes e.g. a recent ward opening required 0.5wte band 7 pharmacist and 0.5 wte band 5 medcines management technician – we recruited 1.0 wte band 6 pharmacist – the cost of the service is equivalent and unchallenged. Further development is needed to identify resource implications for other aspects of the pharmacy service i.e. clinical information and technical services. Review of the timings on which the tool is based will be required as we move into a more technological era and tasks are undertaken in a different way – but the premise of calculating staffing requirements has now been established and accepted at UHNS. The transferability of the tool to other Trusts is currently being established and the outcomes of this process will be reported separately. NB. The tool does not correlate when applied to certain specialities e.g. Critical Care, Renal - nationally recognised pharmacy staffing levels can be applied to business case calculations. References

1. Acres S. How many staff members are needed to run a busy hospital dispensary? Pharmaceutical Journal (vol 273) 7th August 2004; 184. 2. Low J, Macintyre J, McIver L et al. The development of a capacity planning model for pharmaceutical services to cancer patients. The

Pharmaceutical journal (vol 270) 15th Feb 2003; 239. 3. Purkiss R. How to get the Staff you need, calculation of pharmacy manpower requirements. Pharmacy in Practice, September 1997; 393-

6. 4. Blackshaw C, Simcock V. What is the cost of a modern clinical pharmacy service? Part 1: First stage of developing a model. UKCPA poster

presentation Leeds May 2010

55. An audit of the documentation of baseline patient safety data for the commencement of biological therapy within a Rheumatology Department.

Baird W, Benson C, Musgrave Park Hospital, Belfast

Introduction Biological drugs are increasingly being prescribed in the management of inflammatory arthritis. Due to the immunosuppressant nature of these drugs there is potential for serious adverse effects such as severe infection and reactivation of latent Tuberculosis (TB).1,2 Recommendations have been made that all patients should have baseline screening prior to commencement of biological therapy.3 All patients should have a baseline risk assessment for previous exposure to TB (including Chest X-ray - CXR), a risk assessment for hepatitis and assessment of varicella immunity.2,3 Our Rheumatology Department (which has approximately 1600 patients on biological therapy) has therefore introduced local guidelines for baseline safety checks that should be performed on all patients commencing biological therapy. This includes the completion of a baseline patient data sheet, documentation of TB exposure, baseline CXR, Hepatitis and Varicella screening. With the aim of improving patient safety, we audited the screening of all patients starting biological therapy. Objectives Audit to assess whether the Rheumatology Department was adhering to current guidelines on baseline patient safety screening prior to the commencement of biological therapy, with view to intervention to improve standards if required. Standards used were that all patients commencing biological therapy should have a completed baseline data sheet with documentation of TB exposure, respiratory history, baseline CXR, Hepatitis and Varicella screening. Method An audit pro forma was designed based on current best practice recommendations and local rheumatology biologics guidelines. This was used to assess the case notes of patients funded for biological therapy between March and May 2012. A total of 45 patients were included in the audit, randomly selected from a population of 98 during the month of January 2013. Ethical approval was not required. Results See table 1. There was poor documentation of respiratory history and TB exposure. 15 of the 45 patients had no documentation of TB exposure. 16 patients had no documentation of previous respiratory history. 43 patients had recent CXR performed, however only 12 had the result documented in the notes. Of the patients with no documentation of TB or respiratory history all but 1 patient had a CXR performed with results documented for 3 of the patients. 1 patient had a granuloma on CXR, which was discovered post commencement of treatment, resulting in treatment being discontinued and referral for Quantiferon testing. Varicella screening was performed in 43 patients, with 12 patients having more than one test performed. Previous exposure to Varicella was not documented in the patient baseline pro forma for 16 of 45 patients. 44 patients had hepatitis screening tests performed prior to commencement of biological therapy with 14 patients having hepatitis screening performed more than once. Table 1 Results of documentation findings (n=45)

Criteria Yes (%) No (%)

TB Exposure Documented 30 (67%) 15 (33%) Respiratory History Documented CXR Performed CXR Result Documented

29 (64%) 43 (96%) 12 (27%)

16 (36%) 2 (4%) 33 (73%)

Varicella Exposure Documented Varicella Screening Performed Varicella Screening Duplicated

29 (64%) 43 (96%) 12 (27%)

16 (36%) 2 (4%) 33 (73%)

Hepatitis Screening Performed Hepatitis Screening Duplicated

44 (98%) 14 (31%)

1 (2%) 31 (69%)

Conclusion The audit confirmed that documentation of baseline patient safety data was poor, especially with regards to respiratory history and TB exposure. Although most patients did get a CXR performed, there was poor documentation of the result. One potentially serious adverse event was identified, where the findings of a CXR was not followed up until after commencement of therapy, resulting in one patient being given biological therapy despite positive findings of granuloma on CXR. Although current guidelines advise that screening for hepatitis risk factors should be performed prior to the commencement of biologics with hepatitis testing performed in those with risk factors2,3, it is local practice to perform hepatitis testing in all patients commencing biologics. This was therefore used as the standard for the audit, which demonstrated that although hepatitis screening tests were carried out in all but one patient, there was high repetition of tests. This resulted in unnecessary cost for the department and led us to question whether or not original test results were being followed up appropriately. Due to patient safety issues identified, repetition of tests and poor compliance with guidelines we recommended that changes be implemented as a result of this audit. The first of which was to make staff aware of audit findings and educate them on current guidelines. The existing patient baseline data sheet was deemed not very user-friendly by clinical staff and may have contributed to poor documentation. A more comprehensive, user-friendly patient summary sheet was therefore designed to replace the existing patient baseline data summary sheet. We recommended that this patient summary sheet be included at the front of the notes of all biologic patients and regularly updated by clinical staff. We identified that ideally in the future this would be replaced by one standard computer database for biologics patients, accessible by all clinical staff, however the patient summary sheet should be used in the interim, with a plan for re-audit one year following implementation of patient summary sheet. References 1.JB Galloway, KL Hyrich, LK Mercer et al; Anti-TNF therapgy is associated with an increased risk of serious infections in patients with rheumatoid arthritis especially in the first 6 months of treatment: updated results from the British Society for Rheumatology Biologics Register with special emphasis on risks in the elderly. Rheumatology 2011:50;124-31. 2.LC Coates, W Tillett, D Chandler et al; The 2012 BSR and BHPR guideline for the treatment of psoriatic arthritis with biologics. Rheumatology 2013;52(10):1754-1757. 3.T Ding, J Ledingham, R Luqmani et al; BSR and BHPR rheumatoid arthritis guidelines on safety of anti-TNF therapies. Rheumatology 2010;49:2217-2219.

56. A service evaluation of the impact of “shortcut” electronic discharge prescribing on the speed and quality of discharge prescribing Jani, Y1,2; Bijman, L2; Jena-Smol, A1, 1UCLH Foundation Trust, London; 2UCL School of Pharmacy, London

Introduction Electronic prescribing systems have been shown to reduce prescribing errors, overcome illegibility and transcription errors, and improving the clarity of medical records. The use of clinical decision support and protocol prescribing using order sets is additionally beneficial and can improve the quality of prescribing and reduce the time taken to prescribe 1-3. At the tertiary academic hospital, an in house electronic prescribing system has been in use for discharge prescriptions for nearly a decade. In 2011 the system was enhanced to enable the use of protocol based prescribing using pre-populated order sets of a group of medicines – referred to as “shortcut prescribing”. This functionality was available on five of the forty wards within the organization in March 2012 and increased to eight wards by March 2013. The aim of this study was to investigate the effects that shortcut prescribing on the speed and quality of discharge prescribing. Objectives The primary objectives were to assess the impact of shortcut prescribing on the total time taken to generate a discharge prescription, and the rate of clinical pharmacists’ interventions. Secondary objectives were to assess the impact on time taken to prescribe and pharmacist screening time. Method A comparative study discharge prescriptions generated using shortcut or standard prescribing over two one-month periods March 2012 and March 2013. Data was extracted from the electronic prescribing system using a custom report to provide 1) the full audit trail of generating a discharge prescription through three main stages: a) initiation of a discharge prescription to final sign off by

prescriber b) initiation of the pharmacist review process through to sign off by the clinical pharmacist c) printing the discharge summary for dispensing.

2) details of prescriptions that were changed (or intervened on) by a pharmacist as part of the clinical review process. For changes to the prescription by a pharmacist, the system prompts selection of PC-prescriber contacted or PNC-prescriber not contacted.

Data analysis: Time taken to prescribe was calculated as the difference between the time at which the prescriber logged on (T1) and signed off the prescription as complete (T2); the ‘pharmacist screening time’ was derived time difference between the pharmacist logging on to begin screening (T3) and signing off the prescription as complete (T4). The difference between T1 and T4 was to be considered the total time to generate the prescription. Prescribing and screening time was expressed as the median time taken per prescribed item. Statistical Package for the Social Sciences (SPSS) version 21 for Windows® was used for data analysis. Non-parametric tests were applied as data were not normally distributed. The rate of pharmacist intervention was calculated as the number items with changes made by a pharmacist divided by the number of items prescribed expressed as a proportion. The project was deemed a service evaluation and therefore did not require ethical approval. Results A total of 6277 discharge prescriptions, containing a total of 35588 items, were included in the analysis. 48.7% (n=17322 items) of these were written in March of 2012 and the other 51.3% (n=18266 items) in March 2013. As expected, the number of items prescribed using shortcut prescribing was higher in 2013 (1499/17322; 8.7% in 2012 compared to 2216/18266; 12.1% in 2013 p <0.001, Chi-squared test). There was wide variation (20 seconds per prescribed items to several weeks) in the total time taken to generate the prescription from initial log-on by prescriber to pharmacist signing off the prescription as screening completed, with no change as a result of shortcut prescribing. The time taken to prescribe reduced from 37 seconds per prescribed item to 13 seconds per prescribed item (p<0.001 Mann-Whitney U Test) and pharmacist screening time decreased from 28 seconds per prescribed item to 19 seconds per prescribed item (p<0.001 Mann-Whitney U Test) The overall rate of pharmacist interventions decreased with shortcut prescribed items (670/3715; 18% compared to 11722/31873; 36.8%; p <0.001, Chi-squared test). Discussion/ Conclusion The introduction of shortcut prescribing led to a reduction in the time take to prescribe and the pharmacist screening time but did not alter the overall time taken to generate a discharge prescription. The latter requires further exploration; possible reasons include other factors between end of prescribing and the start of pharmacist screening that are not affected by system functionality e.g. from situations where discharge prescriptions were commenced and then their completion delayed because of a delay in the patient’s discharge, or otherwise being started too early and not completed until a later date. A reduction in the rate at which pharmacists are required to make clinical interventions was also seen, mainly due to fewer errors in the order-set prescribed items, suggesting an improvement in the quality of prescribing. Further work is required to assess whether new types of errors, such as over-prescribing or selecting medicines that may not be needed, are generated as a result of pre-populated order sets. References 1. Donyai, P., O'Grady, K., Jacklin, A., et al. The effects of electronic prescribing on the quality of prescribing. British Journal of Clinical

Pharmacology, 2008, 65, 230-7. 2. Kaushal, R., Kern, L. M., Barron, Y., et al. Electronic prescribing improves medication safety in community-based office practices. Journal of

General Internal Medicine, 2010, 25, 530-6. 3. Redwood S., Rajakumar, A., Hodson, J. et al. Does the implementation of an electronic prescribing system create unintended medication

errors? A study of the sociotechnical context through the analysis of reported medication incidents. BMC Medical Informatics & Decision Making, 2011, 11, 29-40.