Aim - To improve the quality of pharmaceutical care to inpatients by developing and using pharmacists' skills and making drug therapy a collaborative process.
Design - A prospective study over a 9-week period, preceded by a 4-week induction team brief.
Setting - Two acute wards, one medical and one orthopaedic, at Wansbeck general hospital, Ashington, Northumberland.
Outcome measures - Number of prescriptions written by or amended by the pharmacist. Reason for the pharmacist writing or amending the prescription. Views of pharmacists, nurses, junior medical staff and consultants obtained by structured face-to-face interviews.
Results - Intervention data were collated for 261 patients and involved 317 drugs. Over 70% of the interventions were made for a single reason. Dose/frequency problems accounted for 33% of the interventions, formulary/blacklist problems for 13% and unnecessary therapy for 13% of the interventions. Safety was the prime reason for the intervention in 38% of patients, effectiveness in 17%, value for money in 23%, quality of life in 7% and more than one reason in 15%. 17% of prescriptions were amended with reference to a doctor and 67% without. Pharmacists prescribed drugs after reference to a doctor in 5% of cases, and without reference in 10% of cases.
Conclusion - Pharmacist prescribing is appreciated by nursing and medical staff. It improves patient care and the pharmacist is seen as an educational resource. Pharmacists feel that they have more responsibility for patients' drug therapy and are making better use of their clinical skills.
The process of prescribing encompasses many complex tasks. These may be described as a broad set of activities that include assessment, initiation, monitoring, evaluation and administration of drug therapy. The recent Government review, led by Dr June Crown, examined the roles of various health professionals in all these processes in order to make optimum use of individuals' skills and experience. The first report discussed and made recommendations about group protocols,1 whereas the final report recommended that new groups of professionals be allowed to apply for "prescribing authority" in specific areas.2
The role of the pharmacist in the drug supply and prescribing process is well established: pharmacists recommend initiation of therapy, monitor and suggest modifications. This occurs both at ward level and in the dispensary.
Fourteen states in the United States have had pharmacist prescribing in some form or other for a number of years.3 Systems vary as to which aspects of drug therapy can be addressed, educational requirements of the "prescriber", the drugs to be included and the level of approval required. The various systems include protocols, collaborative agreements, policies and procedures. As may be expected, the degree of success varies among the different systems.
Recognising the changing roles of pharmacists, including their role in pharmaceutical care and overall patient management, is crucial. This study was designed to utilise the pharmacists' skills and promote drug therapy as a collaborative process. The aim of the study was to improve the quality of patient care through multidisciplinary practice within the spirit of the current legislative framework and local medicine and prescribing policies. We expected that this timely pharmaceutical input would reduce the potential risk of the patient experiencing physical or psychological distress. Evidence suggests that collaborative drug therapy management, when characterised by an interdisciplinary approach to patient care, can potentially maximise quality of life and reduce the frequency of drug-related problems and will be discussed later in the paper.
Currently, queries about drug doses and interactions for discharge medication, and medication for casualty patients and outpatients are discussed with the prescriber and the prescription amended accordingly. The patient thus receives the most appropriate drug in the most appropriate formulation for him or her, thereby optimising their drug therapy. The professional skills of the pharmacist are appropriately utilised.
The situation for inpatients is not quite so simple. Potential problems with drug therapy are identified from examination of the drug Kardex, patient's notes and discussion with nursing staff, the patient or a relative. Discussion with the appropriate junior doctor takes place and it is the junior doctor's responsibility to amend the drug Kardex. Unfortunately, this does not always occur and so the patient does not always receive the optimal therapy. The junior doctors are not on site all the time, which has resulted in delays in optimising patients' therapy.
We have developed a model whereby medical staff and pharmacists worked in partnership to improve patient care. The methods used fit well with the current ways of working. Other studies4 have examined models where pharmacists prescribe within protocols. In this study, the emphasis was to encourage the pharmacist to exercise professional judgment. We expected that, as well as improving patient care, there would be a contribution to reducing some demands on the junior medical staff.
Four possible areas of pharmacist activity were proposed:
An examination was made of the current and potential future pharmacist clinical activity on the wards and each type of activity was matched with one of the four different means outlined above (see Panel 1).
Panel 1: Examples of interventions, and the categories of the proposal into which they fit
Key: 1.1 = amendments without reference to the medical staff; 1.2 = amendments with reference to medical staff; 2.1 = prescribing with reference to the medical staff; 2.2 = prescribing without reference to the medical staff (see "Method" for definitions) |
A paper outlining these processes was presented to the trust's drug and therapeutics committee and it was proposed that pharmacist prescribing should be deemed appropriate in the following circumstances:
This proposal gained approval. The trust's operational management board, the medical director, the clinical directors and the director of patient services also ratified it, thus ensuring issues of indemnity and liability were addressed.
Wards at Wansbeck general hospital are visited once a day, Monday to Friday. This did not change during the pilot study. It was not the intention of the investigators that pharmacists should be seen as a "short-cut" when doctors were not available. Ideally a full-time ward presence is desirable, but is not currently resourced. Prescribing, therefore, took place during the "regular" ward visit. Two pharmacists were involved in this pilot study. The pharmacists annotated the drug Kardex appropriately, and, where necessary, made an entry in the clinical notes. Initial discussions with clinicians suggested that entries in the notes for every intervention were not necessary, providing the drug Kardex was clear. More complex issues were documented in the notes. For the purposes of this study Controlled Drugs and cytotoxics were excluded from proposal 2.2.
All prescribing interventions were documented on a standard form, which had been previously piloted. A "communication book" was left on the ward for all staff (nurses, doctors and pharmacists) to use, if necessary. The pharmacist also kept a logbook throughout the study period. One-to-one structured interviews with key staff took place at the end of the study.
The two wards were visited each weekday during the nine-week study period. Intervention data were collated for 261 patients, involving 317 drugs. Gender was recorded in 259 (151 female, 108 male) patients (99.2 per cent). Age was recorded for 256 patients (98 per cent) and ranged from 7 to 95 years (average 69 years). The orthopaedic ward had a six-bedded unit for children.
Over 70 per cent of the interventions were made for a single reason and the remainder were for more than one reason. The main problems were due to dose/frequency, which accounted for 33 per cent of the interventions, formulary/blacklist for 13 per cent, and unnecessary therapy for 13 per cent of the interventions.
Interventions, classified according to BNF category, are shown in Table 1. Most interventions were made for cardiovascular drugs. Most prescriptions initiated, or amendments made, by the pharmacist were for safety reasons (Table 2) (P<0.001, chi-squared test).
Forty-five prescriptions (17 per cent) were amended with reference to a doctor, and 174 (67 per cent) were amended without referring to a doctor. In 14 cases (5 per cent pharmacists prescribed drugs after reference to a doctor, and without reference in 10 per cent.
In three cases (1 per cent) there was no change in the prescription but the pharmacist-initiated discussion with the junior doctor resulted in that doctor referring the issue to a senior colleague. The pharmacists probably discussed more issues with the junior medical staff than was actually necessary, because it was a pilot study.
There was also felt to be an improvement in the doctors' prescribing as the study went on, as they increasingly learnt various prescribing practices from the pharmacists. This was not formally evaluated as it was an unexpected benefit observed as the study progressed. Pharmacist prescribing or amending was not dependent on eventual (rather than immediate) review by the medical staff. The emphasis was on exercising professional judgment and making the pharmacists accountable for their actions or advice.
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Face-to-face interviews Consultants The consultants were positive. They all appreciated the benefits of the study and felt that it had gone well. They were supportive and were not aware of any problems (which, they said, proved the study's worth). The educational benefits for the junior staff were also highly valued by consultants. One said: "Get on with it everywhere. Don't stop now!"
Junior medical staff Interviews were particularly valuable as all the junior doctors had worked on other wards as well as the study wards, and were ideally placed to comment on the difference. This entire group felt that there was more discussion and interaction between the pharmacist and the doctor on the study wards. Panel 2 describes how junior doctors viewed the study both from their own view and from the patients' perspective. They felt that things were being "done properly". All this group felt that their working practices had been affected as they used pharmacists more. They all felt that their time had been saved but were unable to quantify it. The study was felt to have been excellent and useful, and made for teamwork, communication and education.
Panel 2: Junior doctors' views of the study in terms of benefits for themselves and patients |
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Benefits for junior doctors
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Benefits for patients
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Nurses Nurses felt that the main issues were related to patient safety and quality of care. The study made them question doctors' prescribing more, rather than assuming it was correct. The pharmacist was seen as a useful resource. Prescriptions were amended quickly without the nurses having to chase doctors. Nurses also saw that the patients were reassured by the drug therapy being reviewed by "an expert" and felt that the pharmacists' expertise was being appropriately used. The ward managers felt that it had been good for the junior doctors and the nurses to use the "excellent pharmacist resource".
Both medical and nursing staff felt that the group of patients who had particularly benefited were "medical boarders", ie, medical patients on surgical wards. Neither doctors nor nurses thought that there were any disadvantages to either themselves or the patients in the study. Indeed, they all strongly supported the proposal that this should be extended to all hospital wards.
This project explored how pharmacists can use their professional skills and knowledge to contribute to the process of collaborative drug therapy. This proactive use of their skills improved the quality of patient care and led to greater team working. It was particularly valuable in the light of the recommendations of the recent Crown review.1,2 Drug therapy became truly collaborative, and the skills and expertise of all the professionals involved were used appropriately. As can be seen from the examples given in Panel 1, a number of issues might potentially have been discussed with the prescriber.
Benefits for patients Patients benefited from the most appropriate therapy and care from a multidisciplinary team. If patients are kept waiting for interventions involving medication, they may be caused discomfort or anxiety (eg, if pain relief is needed and analgesics have not been prescribed), and potentially physical or psychological harm. Patients also benefited from a quicker discontinuation of drugs no longer considered clinically appropriate (eg, laxatives) or which the patient chose to refuse (eg, analgesics, food supplements, night sedation).
Benefits for pharmacists Professional resources were used appropriately to improve the quality of care. There was also increased patient contact. Pharmacists were seen as an educational resource for patients, and medical and nursing staff. Pharmacists felt that they had a greater responsibility for drug therapy. Their role in the multidisciplinary team was recognised and valued.
Benefits for doctors Doctors have a large workload and various other commitments outside the ward environment. The amount of medical time spent responding to calls is not always cost-effective and may reduce time available for other duties. Interventions from pharmacists are a learning tool for future prescribing. Junior doctors valued the time-saving and educational aspects. Consultants remarked on the improvement in the team as each professional's skills were being appropriately used.
Benefits for nurses Nurses spent less time contacting doctors for routine prescriptions and medication amendments. They had another resource to help with anxious patients and saw the patients benefit.
This pilot study was well received by pharmacy, medical and nursing staff and the intention is to extend this practice across the hospital. This would have implications for the ways in which pharmacists practise and how others perceive their role. This practice could also have an impact on patient care in the community hospitals which are part of this trust. We intend to evaluate this in future studies.
Sheila Woolfrey is principal pharmacist (clinical services), Catherine Dean is a pharmacist and Helen Hall is nursing research/practice development co-ordinator at Northumbria Healthcare NHS trust. Dt Woolfrey is also an honorary lecturer in the institute of pharmacy, chemistry and biomedical sciences at the University of Sunderland. Correspondence to Dr Woolfrey at Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ
| 1. Crown J. Review of prescribing, supply and administration of medicines. A report on the supply and administration of medicines under group protocols. London: Department of Health, 1998. |
| 2. Crown J. Review of the prescribing, supply and administration of medicines. Final report. London: Department of Health, 1999. |
| 3. Carmichael JM, O'Connell MB, Devine B, Kelly W, Ereshevsky L, Linn WD et al. ACCP position statement: Collaborative drug therapy management by pharmacists. Pharmacotherapy 1997;17:1050- 61. |
| 4. Hughes DS, Kinnear AE, Macintyre JL, Pacitti L. Collaborative medicines management: pharmacist prescribing. Pharm J 1999;263:170-2. |