The Pharmaceutical Journal Vol 267 No 7173 p673-674
10 November 2001

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How pharmacists help speed up the discharge process to release beds

Discharging patients from hospital can be a time consuming process and often results in patients waiting for their medicines and temporarily blocking beds. Many hospitals are implementing different policies to rectify this problem. Zoë Gross investigates

Pharmacists can help speed up the process of discharging patients from hospital. Waiting for discharge prescriptions to be written and medication to be dispensed takes time. This can delay patients leaving hospital as well as blocking bed spaces so that other patients cannot be admitted.

To help speed up the discharge process, the pharmacy department at University Hospital Lewisham, a 650-bed hospital in south London, is changing the way in which the hospital manages medicines. One-stop dispensing has been implemented, including inpatients being given a 28-day supply of their medicines, to cover a one-week stay in hospital and a supply to take home with them, and labelling inpatient medicines in the same way as medicines for outpatients. Patient packs are also given and patients' own drugs (PODs) are used, where possible, rather than dispensing new supplies.

Chris Cairns, director of pharmacy and dietetics, University Hospital Lewisham, says that, as well as speeding up the discharge process, these initiatives have reduced the workload in the dispensary. Since the scheme was introduced this time last year, the number of discharge prescriptions being dispensed in the pharmacy has decreased from 90 to 50 a day, even though the number of patients admitted to the hospital has increased.

Ward-based discharge dispensing

Ward-based dispensing of discharge medicines is among the initiatives introduced to re-engineer medicines management in the hospital and is in place for surgical patients on the ear, nose and throat (ENT) ward. Mr Cairns explains that 10 per cent of the hospital's discharge prescriptions come from this ward. The majority of patients on this ward are short-term admissions, are generally fit and have minor pharmaceutical care needs. They come into hospital, have their operation the same afternoon, and are discharged the following morning having been prescribed a combination of analgesics, antibiotics and/or topical treatments. A high proportion are on little or no regular medication and those who are on regular medication rarely need to have it changed while in hospital.

The service previously provided was based on pharmacists visiting the ward twice a day. In-patient medicines were supplied for a week at a time and discharge prescriptions were sent to the pharmacy for dispensing. However, Mr Cairns says that it was taking six to seven hours for discharge medicines to reach patients after the prescription had been written. Many patients who said that they would come back to the hospital to collect their medicines did not.

As part of the new model for speeding up the discharge process on the ward, a TTA (to take away) cupboard has been introduced, designed to enable the pharmacist to dispense simple prescriptions on the ward. The cupboard can only be accessed by the ward pharmacist and contains ready-labelled prepacks of routinely prescribed antibiotics, analgesics and topical preparations relevant to an acute ENT ward. PODs are used for regular medication that is written on discharge prescriptions and topical preparations for inpatient use are labelled as discharge medicines.

The pharmacist visits the ward during or immediately after the morning ward round and screens and dispenses any discharge prescriptions that have been written. All patients going home that day are then given their medicines and counselled by the pharmacist.

Mr Cairns says that the nursing staff think the new system is a great idea. Over a six month period, 90 per cent of the 825 items dispensed from the ward were given to patients before 10am. There can be up to eight discharge prescriptions to dispense on this ward a day and it previously took until 4pm or 5pm before medicines reached the patient. In addition, using PODs and not duplicating dispensing saves about £2,500 a year.

The service on the ENT ward is now being extended to other wards such as orthopaedics and gynaecological surgery. Individual patient drug boxes are being introduced on to all wards throughout the hospital and should be in place by April next year.

Electronic prescriptions

Discharge prescriptions are now written electronically on most wards throughout University Hospital Lewisham and amendments to the prescription can be made electronically by the pharmacist. Electronic signatures are used by both doctors and pharmacists to authorise prescriptions.

Electronic discharge prescriptions can be accessed both from computer terminals on the wards and in the dispensary, but copies can only be printed from the terminal the pharmacist is working from.

One drawback is that staff in the dispensary do not get advance warning that prescriptions have been written and are ready for dispensing. They can search information for individual wards using the system to see if discharge prescriptions have been written. However, they do not have enough time to keep checking the system, Mr Cairns said.

Ward pharmacists can, however, telephone the dispensary in advance to let colleagues know that a prescription is ready for dispensing. Alternatively they can send the discharge prescription back to the dispensary using the hospital's vacuum tube system. The vacuum tube was installed last December and is used for sending some medicines from the dispensary to the wards.

Mr Cairns says that to overcome the drawbacks of the current technology — that on occasions pharmacy staff are unaware that discharge prescriptions have been written and are ready for dispensing — a system may be set up whereby every hour someone checks the screen in the dispensary for discharge prescriptions.

Mr Cairns says that by using electronic discharge prescriptions the information is clear and legible, with no written changes. "GPs love it," he says. A copy of the discharge prescription is electronically transferred to patients' general practitioners via NHSnet.

There are plans for also sending hard copies of discharge prescriptions to community pharmacists. However, electronically transferring the information is difficult because community pharmacists are not connected to NHSnet.

Sending discharge information to community pharmacists

However, at the Glenfield Hospital, Leicester, a dedicated discharge liaison pharmacist has started faxing through discharge prescription information to community pharmacists of the patients' choice. This is being done for patients on cardiology wards who have specific pharmaceutical care needs, for example, elderly patients requiring medication aids to help manage their medicines.

Bhavisha Pattani, senior clinical pharmacist, Glenfield Hospital, has been involved in developing a discharge prescription sheet for day case patients undergoing cardiological procedures on one of the hospital's cardiology wards. The prescription sheet, to be filled in by a doctor, highlights any new medication that the patient has been started on, any dose changes made and any medication that has been stopped while in hospital. Copies are sent to the patient's GP and to the hospital pharmacy. A copy is kept in the patient's notes. Mrs Pattani says that on another cardiology ward, for patients staying in hospital for a couple of days, discharge prescriptions are being written by the discharge liaison pharmacist.

Pharmacists writing discharge prescriptions

At the University Hospital Lewisham, a pilot project involving pharmacists writing discharge prescriptions was carried out at the end of last year. A senior pharmacist was employed for six months to write discharge prescriptions for all medical wards. Instead of a junior doctor writing the prescription when the medical team decided to send a patient home, the pharmacist would be bleeped to let him or her know that the discharge prescription needed writing.

A request form was filled in by a doctor on the team and attached to the inpatient chart. The pharmacist then checked the patient's chart, electronically wrote a discharge prescription and took a copy to the pharmacy to be dispensed. Patients were not given their medicines until a doctor had authorised the discharge prescription. This was done at the point of discharge. Mr Cairns comments that the pilot was "quite successful".

Mr Cairns adds that more pharmacists will be writing discharge prescriptions in the future. The intention is to incorporate this into the duties of most pharmacists. "It will be the norm eventually," he says.

Anne Tyrrell, deputy chief pharmacist, St George's Hospital, London, has been involved in developing a training programme to ensure that pharmacists are competent in writing discharge prescriptions safely and accurately. In-house data at St George's have shown that pharmacists make fewer errors than junior medical staff when transcribing discharge prescriptions (PJ, 2 June, p760). Miss Tyrrell says that the biggest drawback in the discharge process is getting doctors to write discharge prescriptions.

At St George's, a 900-bed hospital, pharmacists are starting to write discharge prescriptions, but there is still a legal need for such prescriptions to be signed by a doctor. However, she says that she looks forward to trying to change this so that there is no need for the prescription to be authorised by a doctor.

In terms of pharmacists dispensing discharge medicines on the ward, she says that pharmacists are doing so if the discharge prescription needs to be dispensed urgently. Rather than using preprinted labels, pharmacy staff can print labels using label printers that have been installed on each floor of the hospital.

Technicians dispensing discharge prescriptions on wards

Miss Tyrrell says that pharmacy technicians are needed to help dispense discharge medicines on wards and a pilot study involving technicians has been started at St George's. Technicians are going to the orthopaedic and trauma wards for one hour in the morning and one hour in the afternoon to see if any discharge prescriptions have been written. These are then either dispensed by them on the ward or brought back to the pharmacy to be dispensed. If a discharge prescription for a surgical patient is ready, technicians can dispense items such as analgesics and laxatives on the ward. Discharge prescriptions for medical patients are screened and dispensed by pharmacists on the ward, she says.

A pilot study for preparing discharge prescriptions electronically is being carried out on one of the general medical wards. However, St George's Hospital still sends paper copies to GPs. Miss Tyrrell comments that discharge prescriptions are not being sent to community pharmacists but can be photocopied and given to patients to give to community pharmacists.

At Ealing Hospital, Middlesex, a "dispensing for discharge" pilot study has been carried out on two medical and two surgical wards. The study includes, among other initiatives, pharmacists dispensing discharge medicines on the wards to help reduce patient waiting times. Individual medicine cupboards have been fixed to patients' bedside lockers.

As a result, improvements in the management of medicines on the wards were seen and most discharge medicines were ready on time during the study.