Adherence to UK national guidance for discharge information: an audit in primary care.

AIMS: Poor communication of clinical information between healthcare settings is associated with patient harm. In 2008, the UK National Prescribing Centre (NPC) issued guidance regarding the minimum information to be communicated upon hospital discharge. This study evaluates the extent of adherence to this guidance and identifies predictors of adherence. METHODS: This was an audit of discharge summaries received by medical practices in one UK primary care trust of patients hospitalized for 24 h or longer. Each discharge summary was scored against the applicable NPC criteria which were organized into: 'patient, admission and discharge', 'medicine' and 'therapy change' information. RESULTS: Of 3444 discharge summaries audited, 2421 (70.3%) were from two teaching hospitals and 906 (26.3%) from three district hospitals. Unplanned admissions accounted for 2168 (63.0%) of the audit sample and 74.6% (2570) of discharge summaries were electronic. Mean (95% CI) adherence to the total NPC minimum dataset was 71.7% [70.2, 73.2]. Adherence to patient, admission and discharge information was 77.3% (95% CI 77.0, 77.7), 67.2% (95% CI 66.3, 68.2) for medicine information and 48.9% (95% CI 47.5, 50.3) for therapy change information. Allergy status, co-morbidities, medication history and rationale for therapy change were the most frequent omissions. Predictors of adherence included quality of the discharge template, electronic discharge summaries and smaller numbers of prescribed medicines. CONCLUSIONS: Despite clear guidance regarding the content of discharge information, omissions are frequent. Adherence to the NPC minimum dataset might be improved by using comprehensive electronic discharge templates and implementation of effective medicines reconciliation at both sides of the health interface.

Medication administration in patients with dysphagia.

The results of a small-scale observational study and a root cause analysis were used to describe the types of errors that occur in medication administration to patients with dysphagia and identify possible solutions. Patients with dysphagia in four UK hospitals were shown to be three times more likely to experience medication administration errors than patients without dysphagia and, as a consequence, were at increased risk of harm. Regular observation of nurses administering medicines to patients with dysphagia is a simple intervention that would enable individual practice to be reviewed. It would also allow system, practitioner and patient factors that underpin any 'near misses' to be addressed to enhance the quality of patient care.

Understanding pharmacogenomic testing and its role in medicine prescribing.

When making prescribing decisions, it is important for healthcare professionals to remember that individual patients may respond differently to medicines. For example, some patients may experience a therapeutic benefit while others may experience an adverse drug reaction. The aim of personalised medicine is to tailor treatment based not only on a patient's clinical factors, but also on their genetic profile. Pharmacogenomics is a branch of personalised medicine that is concerned with how differences in people's genomes affect their response to medicines. Pharmacogenomic testing, which recently has become less expensive and increasingly available, can inform nurses' prescribing decisions and improve patient outcomes. This article discusses personalised medicine and pharmacogenomics, including how pharmacogenomic testing can optimise medicine prescribing, and explains the role of nurses in the process.

Learning from community pharmacists' initial experiences of a workplace-based training program.

INTRODUCTION: To prepare community pharmacists for the provision of clinical and patient-focused services, a novel postgraduate course for community pharmacists in the United Kingdom was developed. The program incorporated personal development planning against a personal development framework, workplace mentoring, employment of work-based assessment tools, activities that encouraged increased inter-professional working, reflection, and opportunities for peer support. Objectives were to identify course components that support development, describe the effect on practice, and explore the perceived advantages and disadvantages of this model of postgraduate education. METHODS: Interviews were conducted with a purposive sample of 15 community pharmacists after they had completed approximately one year of the three-year course. A topic guide covering approaches to learning, rationale for course selection, course experiences to date, and impact on practice was used. Interview recordings were thematically analyzed. RESULTS: Two themes were identified. 'Support for learning' describes the components of the course that provided support for learning, including opportunities to learn with and from others, workplace mentoring, and facilitated access to general practitioners. 'Outcomes of learning' encompasses how the course was a way of effecting change within existing roles and the increase in confidence and motivation to change practice. CONCLUSIONS: The model has merit in supporting community pharmacists to develop the confidence and competence required for extended clinical and patient-focused roles. While this model of learning seems to provide educational value, further research is required to determine whether the additional resources required to provide workplace mentoring, use work-based assessment tools, and encourage inter-professional working are justified.

Systematic review and narrative synthesis of pharmacist provided medicines optimisation services in care homes for older people to inform the development of a generic training or accreditation process.

OBJECTIVES: To develop a training programme to enable pharmacists with prescribing rights to assume responsibility for the provision of pharmaceutical care within care homes, a systematic review and narrative synthesis was undertaken to identify reported approaches to training pharmacists and use this literature to identify potential knowledge requirements. METHODS: A PROSPERO-registered systematic review was performed using key search terms for care homes, pharmacist, education, training and pharmaceutical care. Papers reporting primary research focussed on care of the older person within the care home setting were included. No restrictions were placed on methodology. Two researchers independently reviewed titles, abstracts and papers. Agreement on inclusion was reached through consensus. Data on titles, training and activities undertaken were extracted and knowledge requirements identified. Findings were synthesised and reported narratively. KEY FINDINGS: Fifty-nine papers were included, most of which were uncontrolled service evaluations. Four papers reported an accreditation process for the pharmacist. Thirteen papers reported providing tools or specific training on a single topic to pharmacists. The main clinical and therapeutic areas of activity (requiring codified knowledge) were dementia, pain, antipsychotic and cardiovascular medication. Provision of pharmaceutical care, effective multidisciplinary working and care home staff training represented the main areas of practical knowledge. CONCLUSIONS: Information regarding training and accreditation processes for care home pharmacists is limited. This study provides insight into potential codified and practical knowledge requirements for pharmacists assuming responsibility for the provision of pharmaceutical care within care homes. Further work involving stakeholders is required to identify the cultural knowledge requirements and to develop a training and accreditation process.

Role of nurses in supporting proactive deprescribing.

Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.

Administration of aspirin tablets using a novel gel-based swallowing aid: an open-label randomised controlled cross-over trial.

INTRODUCTION: To ease administration of medicines to people with dysphagia we developed and patented a gel formulation within which whole tablets could be inserted. The aim was to determine whether the gel would affect bioequivalence of uncoated aspirin tablet. METHOD: A gel containing gelatin, hydroxypropylmethylcellulose, citric acid, potassium sorbate and water was developed to maintain structure on tablet insertion and increase saliva production to lubricate the swallow.In an open-label cross-over trial 12 healthy male volunteers were administered a 300 mg uncoated aspirin tablet with and without gel with a 7-day washout period. Blood salicylate levels, platelet activity and patient satisfaction were measured over 2 hours. Analysis was based on a random effects cross-over model. RESULTS: The estimated mean ratio (90% CI) of effect on salicylate levels when comparing administration with and without gel was 0.77 (90% CI 0.40 to 1.47) for amount absorbed and 0.76 (90% CI 0.44 to 1.31) and on total ASP-arachidonic acid platelet activity 1.16 (90% CI 0.88 to 1.53) and maximum ASP-arachidonic platelet activity 0.98 (90% CI 0.79 to 1.22). These results are outside of the range allowable for the assumption of bioequivalence. Participants rated the taste of aspirin tablets significantly better when encapsulated in the gel (p<0.05). DISCUSSION: We cannot assume that uncoated aspirin administration with and without gel is bioequivalent. Administration with gel resulted in reduced salicylate levels and therefore increased platelet function. Further research is required to determine the exact reason for this result. The results bring into question current processes for providing marketing authorisation for medical devices which are designed to aid swallowing.

Deprescribing admission medication at a UK teaching hospital; a report on quantity and nature of activity.

Background Deprescribing medication may be in response to an adverse clinical trigger (reactive) or if future gains are unlikely to outweigh future harms (proactive). A hospital admission may present an opportunity for deprescribing, however current practice is poorly understood. Objective To quantify and describe the nature of deprescribing in a UK teaching hospital. Method Prescribing and discontinuation data for admission medication from a hospital's electronic prescribing system were extracted over 4 weeks. The rationale for discontinuation of a random sample of 200 was determined using medical records. This informed categorisation of deprescribing activity by clinicians into 'proactive' or 'reactive'. Data were extrapolated to estimate the proportion of admission medications deprescribed and the proportion which were reactive and proactive. Results From 24,552 admission medicines, 977 discontinuations were recorded. Of the 200 discontinuations sampled for review, only 44 (22.0%) were confirmed deprescribing activities; categorised into 7 (15.9%) proactive and 37 (84.1%) reactive. Extrapolation yielded 0.6% (95% CI 0.5-0.7%) of all admission medications deprescribed. Conclusion Limited deprescribing activity, dominated by reactive behaviour was identified, suggesting prescribers require a clinical trigger to prompt deprescribing. There may be scope for increasing proactive deprescribing in hospital, however the extent to which this is feasible is unknown.

Identification of the benefits, enablers and barriers to integrating junior pharmacists into the ward team within one UK-based hospital.

INTRODUCTION: A high nurse-vacancy rate combined with high numbers of applications for junior pharmacist roles resulted in Colchester Hospital University National Health System Foundation Trust trial employing junior pharmacists into traditional nursing posts with the aim of integrating pharmacists into the ward team and enhancing local medicines optimization. The aim of the evaluation was to describe the implementation process and practice of the integrated care pharmacists (ICPs) in order to inform future innovations of a similar nature. METHODS: Four band 6 ward-based ICPs were employed on two wards funded within current ward staffing expenditure. With ethical committee approval, interviews were undertaken with the ICPs and focus groups with ward nurses, senior ward nurses and members of the medical team. Data were analyzed thematically to identify service benefits, barriers and enablers. Routine ward performance data were obtained from the two ICP wards and two wards selected as comparators. Appropriate statistical tests were performed to identify differences in performance. RESULTS: Four ICPs were interviewed, and focus groups were undertaken with three junior nurses, four senior nurses and three medical practitioners. Service enablers were continuous ward time, undertaking drug administration, positive feedback and use of effective communication methods. Barriers were planning, funding model, career development, and interprofessional working and social isolation. ICPs were believed to save nurse time and improve medicines safety. The proportion of patients receiving medicine reconciliation within 24 hours increased significantly in the ICP wards. All ICPs had resigned from their role within 12 months. DISCUSSION: It was believed that by locating pharmacists on the ward full time and allowing them to undertake medicines administration and medicines reconciliation, the nursing time would be saved and medicines safety improved. There was however significant learning to be derived from the implementation process, which may enable similar future models to be introduced more successfully.

Community pharmacy: an untapped patient data resource.

As community pharmacy services become more patient centered, they will be increasingly reliant on access to good quality patient information. This review describes how the information that is currently available in community pharmacies can be used to enhance service delivery and patient care. With integration of community pharmacy and medical practice records on the horizon, the opportunities this will provide are also considered. The community pharmacy held patient medication record, which is the central information repository and has been used to identify non-adherence, prompts the pharmacist to clinically review prescriptions, identify patients for additional services, and identify those patients at greater risk of adverse drug events. While active recording of patient consultations for treatment over the counter may improve the quality of consultations and information held, the lost benefits of anonymity afforded by community pharmacies need to be considered. Recording of pharmacy staff activities enables the workload to be monitored, remuneration to be justified, critical incidents to be learned from, but is not routine practice. Centralization of records between community pharmacies enables practices to be compared and consistent problems to be identified. By integrating pharmacy and medical practice records, patient behavior with respect to medicines can be more closely monitored and should prevent duplication of effort. When using patient information stored in a community pharmacy, it is, however, important to consider the reason why the information was recorded in the first instance and whether it is appropriate to use it for a different purpose without additional patient consent. Currently, community pharmacies have access to large amounts of information, which, if stored and used appropriately, can significantly enhance the quality of provided services and patient care. Integrating the records increases opportunities to enhance patient care yet further. While community pharmacies have significant amounts of information available to them, this is frequently untapped.