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Getting it right first time How does pharmacy help?
Emma Graham-Clarke Consultant Pharmacist Critical Care AHP/HCS Lead for MCCN
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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
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Outline Drivers The patient pathway - What do we do? Support Gaps
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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)
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HoPMOp Hospital pharmacy and medicine optimisation project
Model hospital dashboard ‘what good looks like…’
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Medicines optimisation
‘Medicines optimisation is about making sure that the right patients, get the right choice of medicine, at the right time.’ NHS England
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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
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Patient pathway for critical care
Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review
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Patient pathway for critical care
Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review
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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
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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) Intolerant of ng feeding for >7 days
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Patient pathway for critical care
Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review
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PROTECTED-UK 21 UK units 2/52 audit period
Recorded all interventions, contributions and consultations Shulman et al (2015) J Crit Care, 30,
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PROTECTED-UK 3390 records 1 intervention per 6 medications prescribed
51.4% medicines optimisation 42.3% errors 64.1% of moderate or greater impact
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PROTECTED-UK Intervention rate doubled at weekends
Rate decreased as case load increased Landa et al 2014 IJPP 22(Sup 2) 44
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Patient pathway for critical care
Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review
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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),
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Patient pathway for critical care
Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review
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Standard concentrations for infusions
Initial survey published 39 presentations of noradrenaline 18 different concentrations Borthwick et al 2007 JICS 8(1), 92-96 Recommended standard concentrations published by ICS in 2010
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Standard concentrations
Repeat survey published 89.5% of units have adopted recommended concentrations Titiesari et al (1), New list of standard concentrations published by FICM/ICS
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Standard concentrations
Reduced variation in practice Encourages drug companies to produce ready-made products
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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
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Patient pathway for critical care
Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review
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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
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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
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Patient pathway for critical care
Admission Medicines reconciliation Stay Medicines optimisation Prescribing Safety Discharge Medicines review
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Anything else we do to help?
Guidelines Education of MDT Financial review Research collaborations Etc.!
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Support Most critical care pharmacists work in isolation
No requirement for formal training once registered
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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)
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RPS Faculty Competency framework Critical care curriculum
Six clusters 3 levels (Advanced stage I, Advanced stage II and Fellowship) Critical care curriculum Independently assessed
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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 Graham-Clarke 2014 JICS 15(2),
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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
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Band 7 training pack Contributors – network pharmacist group
Impact – enquiries from across the world, most recently Singapore
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Mcctn.org.uk
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Other Support Networks UKCPA Peer review Clinical forums
Minimum volumes document Journal club Peer review
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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
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Overview The drivers Where we can help
What supports your pharmacy staff and the problems
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