Proving the patient safety benefits of a multi-skilled Pharmacy Team to the Emergency Department

Heald, Victoria, Kaba, Suhail, Kwok, Jon and Sinopoulou, Vassiliki orcid iconORCID: 0000-0002-2831-9406 (2018) Proving the patient safety benefits of a multi-skilled Pharmacy Team to the Emergency Department. In: Pharmacy Together: UKCPA 2018, 2 November 2018, Novotel London West.

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The project was implemented in a large, busy emergency department (ED) in the North West of England. The pilot was carried out during the winter months at ED’s busiest time. Pressure on EDs is well-documented and prescribing errors on admission has been studied (1). Use of prescribing Pharmacists has been explored in ED (2) and acute medicine (3) with a variety of roles considered including prescribing on admission and discharge. Prescribing clinical pharmacists are recommended in the Carter Report (4) which considered inefficiencies in NHS acute hospitals and recommends that 80% of Trusts’ Pharmacist resource is utilised for direct medicines optimisation activities, governance and safety remits. The pilot embraced the ethos of the report optimising the use of clinical pharmacists to improve patient safety. Ethics approval was not required for the project.
1/ Prove the impact of a prescribing Pharmacist alongside a Pharmacy Team in ED and establish the most effective skill mix for Pharmacy teams in ED. 2/ Understand impact on key patient safety markers including missed doses, unintentionally omitted medication, prescribing errors and transfer of patients own medication (POMs). 3/ Understand the impact of a service on medicines reconciliation targets in the trust.
Baseline data was gathered prior to implementation of the service using identical data collection forms to the main pilot.
Between 8th January and 20th April 18, pharmacy services were provided to ED between 5pm-7.30pm on weekdays. The teams were made up of a combination of Pharmacist Independent Prescribers (IP), Clinical Pharmacists (CP) and Pharmacy Technicians (PT). The shifts were filled using 5 different skill mixes; [IP], [CP], [IP+PT], [CP+PT] or [IP+CP+PT].
Teams performed medication histories, reconciliation and prescribing for patients who were to be admitted. A data collection form capturing any prescribing errors and pharmacy interventions was completed for each patient. A separate form documenting tasks undertaken and time taken to perform “clinical interventions” was completed by each pharmacy staff member. Patients who became inpatients were reviewed by ward pharmacists the following day who recorded their interventions, any prescribing discrepancies and whether POMs were transferred. Data from the forms was inputted onto Excel and analysed in comparison to the baseline data.
Compared to baseline, there was a reduction of: 80% of incorrect doses, 66% of unintentionally omitted medicines, 50% of missed doses for prescribed medications and 71% of discrepancies found on clinical review. There was a 50% increase in POMs transferred to the ward. On the admission wards, medicines reconciliation rates within 24 hours improved on weekdays from 77.9% to 96.43%.
Graph 1 and the results above highlight the significant reduction in error rates. If a patient was seen by PT, IP and then CP a 100% error reduction was observed. Error reduction at this stage may directly impact on length of stay in hospital (5); further research would be of interest. Results demonstrate the largest error reduction when an IP is involved. The presence of an IP to prescribe inpatient medications significantly reduces error rates. The IP’s ability to resolve and prevent prescribing errors in comparison to a CP means they are integral to an ED pharmacy service.
Graph 2 highlights prescribing activity was at its peak when a team of IP/CP and PT worked together.
Improvement of weekday medicines reconciliation targets was clear; acute medical areas showed an increase from 77.9% to 96.43%, exceeding national targets.
Results showed that the time taken at ward level for clinical check of an inpatient chart reduced by 5.7 minutes if the patient had been seen in ED; subsequently freeing up ward pharmacists to focus on medicines optimisation and discharge planning. The 50% increase of POMs being transferred meant a pharmacy presence was enough to promote a culture change within ED and could provide a financial saving of £3,556 per year for the Trust due to redispensing avoidance; increasing to £17,069 if a 12 hour/day shift was implemented. We conclude that an IP should be included in an ED Pharmacy team. These results suggest the ideal ED pharmacy team skill-mix should include an IP, CP and PT to ensure the greatest reduction in medication errors on admission to hospital.
1/ Dornan, T., Ashcroft, D., Heathfield, H., Lewis, P., Miles, J., Taylor, D. & Wass, V. (2009). An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. London: General Medical Council, 1-215. 2/ Health Education England. Pharmacists in Emergency Departments a commissioned study by Health Education England. Executive Summary. 30th June 2015 3/ Physick A, Smolski K, Mann, S, Price G. Pharmacy innovation at discharge – impact of pharmacist non-medical prescribing on quality and streamlining processes. Journal of Medicines Optimisation Vol 2; Issue 1. March 2016 4/ Department of Health. Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. 11 June 2015. Updated 5 February 2016 5/ Cadman B, Wright D, Bale A, Barton G, Desborough J, Hammad E et al. Pharmacist provided medicines reconciliation within 24 hours of admission and on discharge: a randomized controlled pilot study. BMJ Open 2017.

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