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The authors are from the Pharmacy Department, Hammersmith Hospitals NHS Trust
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Following successful pilot studies in various hospitals, one-stop dispensing,
together with the use of patients’ own drugs (PODs), has been strongly
advocated in key policy documents.1–3 The National Service Framework
for Older People states that by 2002 all hospitals should have had one-stop
dispensing schemes in place.3
One-stop dispensing refers to dispensing of inpatient and discharge medicines
as a single supply on admission, already labelled with administration
instructions for the patient. This has also been referred to as “dispensing
for discharge”. Such schemes generally involve the use of PODs,
so that following assessment by pharmacy or nursing staff, these can
be used during the inpatient stay and at discharge. If all medicines
are either available as a POD or dispensed with administration instructions,
patients should not have to wait for a separate supply of medicines to
be dispensed at discharge.
The reports that advocate the use of one-stop dispensing imply that this
is one distinct system, as a clear alternative to the traditional models
of medicines supply involving separate inpatient and discharge supplies.1–3 However, in practice we have found that this is not the case and indeed
have had significant problems in trying to roll out a standard model
of service to all wards.
Instead, we believe that one-stop dispensing consists of five distinct
elements of medicines management, each of which can be valuable in its
own right.
The five elements of one-stop dispensing
Medication history taking On wards operating one-stop dispensing, pharmacy
staff will generally check patients’ drug histories shortly after
admission, together with any PODs they have brought in with them. The
Audit Commission’s report “A spoonful of sugar” stresses
the importance of this, to ensure that a patient’s regular medication
is continued during his or her hospital stay.2
The use of patients’ own drugs Patients are encouraged to bring
supplies of their own medicines into hospital with them, to aid medication
history taking and for use during their stay.
The use of lockable bedside medicines cabinets On wards operating one-stop
dispensing, individually dispensed and patients’ own drugs are
stored in individual lockable bedside medicines cabinets. Master keys
are held by nursing staff.
Dispensing inpatient medication with administration instructions Most
inpatient medication is dispensed as 28-day supplies or patient packs
labelled with administration instructions. Exclusions to this vary, but
typically include analgesia administered “when required”,
antibiotics, antiemetics, laxatives, Controlled Drugs and injectable
medicines.
Counselling patients at discharge The Audit Commission stated that a
quarter of all hospital readmissions are due to non-adherence with medication
and that half of all patients take their medicines incorrectly on discharge.2 By increasing a patient’s understanding of their medicines, what
they are for, how to take them and possible side effects, adherence is
likely to be increased. In particular, patients should understand any
changes made to their medication during their inpatient stay.
Our experience
We initially assumed that the introduction of one-stop dispensing would
involve applying all five of these elements to all of our wards — we
were wrong. We struggled on several wards until we developed the concept
of the five individual elements and assessed each ward for the applicability
of each. We then found that there are many reasons why not all elements
are appropriate for all patient groups.
Medication history taking and discharge counselling are relevant for
all wards. However, the use of PODs is not always appropriate. For example,
private patients may not wish to use their own supplies of medicines
if a flat rate for inpatient medicines is already incorporated into their
fees, resulting in them paying twice.
Lockable bedside medicines cabinets are not suitable for some long stay
care of the elderly wards, where patients are encouraged to be in day
rooms and communal ward areas. Patients on such wards are not at their
bedsides for drugs administered during the day. For wards such as these,
a drug trolley remains the most appropriate option, perhaps with individual
patient compartments to store patients’ own and individually dispensed
drugs.
On other wards, dispensing inpatient medication, labelled with administration
instructions, to individual patients is not practical. An example is
patients admitted for coronary artery bypass grafts, whose post-discharge
medication is likely to be different from that taken preoperatively.
Similarly, many medical patients will undergo numerous changes to their
medication during their hospital stay, as different combinations of drugs
are tried and doses titrated. On other wards, such as those for infectious
diseases, most patients are prescribed only anti-infective drugs, for
which it is rarely appropriate to give a one-month supply. In such cases,
it may be a false economy to dispense inpatient medication much before
discharge, or until medication is likely to be stable. Similarly, for
patients who stay in hospital for more than two weeks, medication is
likely to need redispensing before discharge, resulting in increased
workload for pharmacy staff.
The solution
We have concluded that the most practical way to introduce one-stop dispensing
is to decide which elements are likely to be beneficial and practical
for each ward.
Medication history taking and discharge counselling are carried out wherever
possible, but the other elements are used only where appropriate.
For example, some of our medicine-for-the-elderly wards use drug trolleys
instead of bedside cabinets, and on other wards, only non-stock medicines
are supplied with administration instructions, to reduce workload when
medicines have to be redispensed.
Although operating different systems on different wards is slightly more
complex than operating the same system throughout, we believe that where
one-stop dispensing is concerned, it is a mistake to try to make one
size fit all.
References
1. Department of Health. Pharmacy in
the future — implementing
the NHS plan. London: Department of Health; 2000.
2. The Audit Commission. A spoonful of sugar: medicines management
in UK hospitals. London: The Audit Commission; 2001.
3. Department of Health. Implementing medicines-related aspects of
the NSF for older people. London: Department of Health; 2001. |
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