Getting it right first time How does pharmacy help? Emma Graham-Clarke Consultant Pharmacist Critical Care AHP/HCS Lead for MCCN

Affiliations/declarations UK Clinical Pharmacy Association – critical care expert group Intensive Care Society – N&AHP committee member Royal Pharmaceutical Society – Faculty Fellow No financial declarations

Outline Drivers The patient pathway - What do we do? Support Gaps

Some of the current drivers The Carter Report Ensure more than 80%… …pharmacist resource… ...medicines optimisation activities More pharmacist prescribers Reduce ‘back office’ expenditure Review drug contracting/costing Hospital pharmacy transformation plan Carter (2016) https://www.gov.uk/government/publications/productivity-in-nhs-hospitals

HoPMOp Hospital pharmacy and medicine optimisation project Model hospital dashboard ‘what good looks like…’

Medicines optimisation ‘Medicines optimisation is about making sure that the right patients, get the right choice of medicine, at the right time.’ NHS England https://www.england.nhs.uk/ourwork/pe/mo-dash/

7 day services …better intergration of clinical pharmacy professionals into the multi-professional team Could lead to: Reduced dose omissions Reduced prescribing and administration errors Systematic on-going review of high risk medications Transformation of seven day clinical pharmacy services in acute hospitals (2016): NHS England

Patient pathway for critical care Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review

Patient pathway for critical care Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review

Medicines reconciliation The process of identifying an accurate list of a person’s current medication, (including prescribed, over-the-counter and complementary medicines) Should occur at every transition of care NICE NG5 2015

Review of levothyroxine prescriptions in a tertiary referral unit 23/133 patients not prescribed it for > 7 days (3/133 not prescribed it at all) 28/133 patients intolerant of enteral feeding i.e. 51/133 received sub-optimal treatment Barrett et al 2012 IJPP 20(5)303-306. Intolerant of ng feeding for >7 days

Patient pathway for critical care Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review

PROTECTED-UK 21 UK units 2/52 audit period Recorded all interventions, contributions and consultations Shulman et al (2015) J Crit Care, 30, 808-13.

PROTECTED-UK 3390 records 1 intervention per 6 medications prescribed 51.4% medicines optimisation 42.3% errors 64.1% of moderate or greater impact

PROTECTED-UK Intervention rate doubled at weekends Rate decreased as case load increased Landa et al 2014 IJPP 22(Sup 2) 44

Patient pathway for critical care Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review

Prescribing 1/3 critical care pharmacists are independent prescribers 70% of remainder intend to become prescribers Mainly utilised for: dose adjustment in multi-organ failure changing route/formulation correcting prescribing errors Bourne et al 2016 IJPP, 24(2), 104-13

Patient pathway for critical care Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review

Standard concentrations for infusions Initial survey published - 2007 39 presentations of noradrenaline 18 different concentrations Borthwick et al 2007 JICS 8(1), 92-96 Recommended standard concentrations published by ICS in 2010

Standard concentrations Repeat survey published - 2017 89.5% of units have adopted recommended concentrations Titiesari et al 2017 18(1), 30-35. New list of standard concentrations published by FICM/ICS

Standard concentrations Reduced variation in practice Encourages drug companies to produce ready-made products

Electronic prescribing With or without decision support Reduces errors associated with hand written prescriptions Caution – can introduce new errors Shulman et al 2005 Crit Care, 9(5), R516-R521. Requires on-going maintenance

Patient pathway for critical care Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review

Med Wreck - My own unit 62 patients audited 1345 medicines prescribed 6.5% admission discrepancies 66.1% discharge discrepancies Many will be deliberate omissions, but documentation variable! Hebron et al 2012 IJPP, 20(Sup 2); 81, Graham-Clarke et al 2010 IJPP ,18(Sup 2); 47-48

And longer term… 21 patients reviewed at a follow-up clinic ¾ had concerns about their medication Cardiovascular most appropriate follow up Issues seen with sedatives/PPI’s/laxatives Some errors of omission identified (antidepressants/diabetic drugs) Variable communication hospital /GP Eijsbroek et al 2013 J Crit Care 28(1),6-50

Patient pathway for critical care Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review

Anything else we do to help? Guidelines Education of MDT Financial review Research collaborations Etc.!

Support Most critical care pharmacists work in isolation No requirement for formal training once registered

Support GPICS/ICS standards ed. 1.1 2016 ‘The most senior pharmacist… ...who routinely works... ...with critically ill patients... ...must be competent to at least Advanced Stage II (Excellence)

RPS Faculty Competency framework Critical care curriculum Six clusters 3 levels (Advanced stage I, Advanced stage II and Fellowship) Critical care curriculum Independently assessed

Education Mainly ad-hoc training Limited opportunities for advanced level practitioners Warin et al 2016 Pharmacy, 4(1), 6. UKCPA ‘Starting out in critical care’, and ‘Advanced level’ masterclasses Band 7 training pack www.mcctn.org.uk Graham-Clarke 2014 JICS 15(2),109-112

Band 7 training pack Fully revised 2017 Based on RPS critical care curriculum Target audience – band 7 pharmacists Aim – support training, and standardisation across network

Band 7 training pack Contributors – network pharmacist group Impact – enquiries from across the world, most recently Singapore

Mcctn.org.uk

Other Support Networks UKCPA Peer review Clinical forums Minimum volumes document Journal club Peer review

D16 GPICS gap analysis Do your units have sufficient pharmacy staff? Majority not dedicated to Crit. Care (70%) Not all units have a pharmacist (21/186) 78/186 don’t meet minimum experience level 80/186 don’t have access to more experienced pharmacist

Overview The drivers Where we can help What supports your pharmacy staff and the problems