Case studies for Hospital Pharmacy standards

Standard 1.3 Support with effective medicines use

Systems are in place to identify patients who may need support, or to allow patients to request support with medicines choice and use

Luton and Dunstable University Hospital Foundation Trust Luton and Dunstable University Hospital Foundation Trust

As part of the Trust’s commitment to support on-going adherence and medicines optimisation, the Interface Pharmacist attends meetings with Domiciliary Care Providers and is the link person with primary care. They also refer patients to the Community Based Pharmacy Technicians and liaise with any other external agencies involved in the patients care to ensure that the patient is supported in their care. Within the division of medicine pharmacists attend daily board rounds gaining insight into any adherence support patients might require. Monitored Dosage Systems (MDS) have been a particular issue. If a patient is to be considered for initiation of an MDS upon discharge an 'Equality Act' assessment is undertaken by a member of the pharmacy team, to determine if the criteria are met. However for patients admitted on an MDS, if there have been no changes in care provision then they will automatically be discharged on an MDS.  The Trust also has an SLA with a local community pharmacy to provide an MDS, for patients whose regular local community pharmacy cannot provide a timely service at discharge or for patients newly started on an MDS.

An adherence counselling service for GUM patients, encouraging them to discuss any issues with the GUM clinic pharmacist.

If it is felt by the nursing, medical or pharmacy team that the patient requires extra support a Medicines Administration Record (MAR) chart can be requested from the pharmacy dispensary. This will illustrate in an easy to read format the name of the medicine, the dosage, frequency and formulation as well as the indication it used for. This can be particularly useful for patients being discharged home with a number of new medicines or used as ‘aide memoir’.

They are currently working with the trust IT department to introduce either the Refer to Pharmacy or PharmOutcomes scheme. This will enable clinical pharmacists to directly refer discharged patients to their designated chemist for a follow up service. This could focus on any medication related issue ranging from adherence concerns to targeted MURs or the new medicine service. When established it is hoped this will help reduce medicines related problems in primary care and potentially reduce hospital readmissions.

Standard 2.1 At pre-admission, on admission or at first contact

Patients’ medicines are reviewed to ensure an accurate medication history , for clinical appropriateness and to identify patients in need of further pharmacy support.

East Lancashire Hospitals NHS Trust East Lancashire Hospitals NHS Trust

The Trust have developed a Medicines Reconciliation checklist that is used for all non- elective adult hospital admissions. It is designed to be used by a pharmacist, technician or pre-registration student who has an underpinning knowledge of the medicines reconciliation process (any new member of the team is competency assessed on completing the activity by senior pharmacist or technician).

Each statement in the checklist is designed to act as a prompt so that the right information is elicited in a logical manner such that the best possible drug history is established. The final prompt is to ensure the patients prescription chart (or ePMA list) reflects reality and any anomalies are resolved, so the drug history can be considered as clinically checked.

In terms of success related to it, the checklist is designed to provide the Trust with the assurance that an effective process has been followed in order to achieve medicines reconciliation. They carry out occasional audits of it; sometimes we have incidents reported where the process has not been followed. If the checklist is used and the SOP followed, invariably the drug history is correct.

Standard 2: Episode of Care

Patients’ medicines requirements are regularly assessed and responded to in order to keep them safe and to optimise outcomes from medicines.

NHS Greater Glasgow and Clyde - Clinical pharmacy triage and handover service NHS Greater Glasgow and Clyde - Clinical pharmacy triage and handover service

Acute hospitals in Scotland, including across NHS Greater Glasgow & Clyde (NHS GG&C) as well as some hospitals in England have invested in electronic systems, which enable triage, prioritisation and handover of patients across multiple wards and hospital sites (see p.31 of NHS England: Transformation of seven day clinical pharmacy services in acute hospital for full case study).

Nottingham University Hospitals - Integrated clinical pharmacy services on the acute medical unit (AMU) Nottingham University Hospitals - Integrated clinical pharmacy services on the acute medical unit (AMU)

The pharmacy and the acute medicine teams worked together to create an enhanced clinical pharmacy role which integrated closely with the medical team (The full case study can be viewed on p.29 of NHS England: Transformation of seven day clinical pharmacy services in acute hospital).

Standard 3: Integrated Transfer of Care

The toolkit Hospital referral to community pharmacy: An innovators’ toolkit to support the NHS in England produced by the RPS Innovators’ Forum contains useful case studies (see appendix 1) from the following organisations showing referral systems they use in practice:

    • Case Study 1: East Lancashire Hospitals Trust, Refer-to-Pharmacy
    • Case Study 2: Newcastle-upon-Tyne Hospitals with North of Tyne LPC, PharmOutcomes electronic referral
    • Case Study 3: Derby Hospitals NHS Foundation Trust

Standard 4.3: Digital technology and informatics to support medicines use

A multidisciplinary team including senior pharmacy team members lead the development of digital systems that support medicines use across the organisation and the wider health system.

Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne Hospitals NHS Foundation Trust

This trust is one of several hospitals nationally who have developed and implemented a model to prioritise patients, as an enabler in providing targeted seven day clinical pharmacy services. Electronic prescribing systems have the added value of providing intelligence of prescribing activity that occurs during the patient pathway in hospitals . (The full case study can be viewed on p.20 of NHS England: Transformation of seven day clinical pharmacy services in acute hospital ).

The clinical informatics team at Newcastle Hospitals was created when the trust introduced an electronic patient record (EPR.) The electronic prescribing (ePx) component of the system was implemented by the pharmacy department with the assistance of a multi-disciplinary project team. Over the last decade the system has been continually developed and is now digitally mature. 

Key to their ongoing informatics development is the Trust’s investment in a permanent pharmacy informatics team. The pharmacist-managed team of pharmacy technicians, led the initial implementation being involved in process mapping, process design, system build and user engagement. They also designed the testing, training and governance processes to ensure safe successful implementation and compliance with information standards for clinical systems. 

The team have subsequently developed the system in close collaboration with the Trusts IT services. They have provided leadership on several system upgrades e.g. JAC upgrades and creation of a network version of the Trust’s chemotherapy ePx system. The team have also led on the uptake of new EPR functions. An example of this being the development of clinical pharmacy prioritisation tools, which provide a supplement to traditional decision support models. The skills gained during this have benefitted medicines optimisation and wider applications of the EPR such as laboratory services.

Experience, through continuity of the team, has been an important factor in ongoing improvement. This has been developed through the Trust supporting the pharmacy informatics team to undertake informatics qualification e.g. Informatics degrees, system architecture courses. With a wider understanding of the technical and operational aspects of developing and maintaining an EPR the team has improved in troubleshooting , rule creation, report writing, interface development an example utilising all of these being the development of an EPR-generated and automated community pharmacy referral process (Clinical Handover).

Another key to success is ensuring the pharmacy informatics team are represented on key Trust groups and committees. Representation at these has been essential to ensure that informatics is developed according to Trust priorities and to ensure that informatics and its opportunities are embedded into new Trust developments with the engagement of key stakeholders.

Finally the team are heavily involved in national collaborative forums for informatics. This has greatly enhanced their own knowledge but also allowed them to share their own experiences as informatics centres drive to share good practice.

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We are keen to hear about examples of how your organisation are using the standards and implementing them in your organisation.

To support users of the standards, we are planning to develop the examples you share with us into case studies for the website. You can share your examples with us by emailing us at [email protected] .

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