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

15

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

16

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

17

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

18

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

19

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

20

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

21

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.

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

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

33

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

34

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

35

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

36

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

37

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

38

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

39

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.

40

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

41

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

42

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

43

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

44

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

45

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.

46

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

47

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

48

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

49

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

50

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

51

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

52

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

53

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

54

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

55

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

56

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

57

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

58

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

59

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.

60

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

61

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)

62

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

63

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

64

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

65

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.

66

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

67

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

68

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

69

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

70

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

71

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). 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

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)

http://www.pjonline.com/http://www.nres.nhs.uk/http://www.institute.nhs.uk/

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)

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

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.

http://www.who.int/patientsafety/implementation/amr/publication/en/

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)

http://www.ncbi.nlm.nih.gov/pubmed?term=Scott%20NB%5BAuthor%5D&cauthor=true&cauthor_uid=23070220http://www.ncbi.nlm.nih.gov/pubmed?term=McDonald%20D%5BAuthor%5D&cauthor=true&cauthor_uid=23070220http://www.ncbi.nlm.nih.gov/pubmed?term=Campbell%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23070220

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

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).

https://wessexhiecpartnership.org.uk/wires/files/2013/07/120904-CIREM_ITIP_HIEC_Evaluation.pdfhttp://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=461https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216531/dh_134001.pdf

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

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

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 hi