The Pharmaceutical Journal
Vol 272 No 7290 p329-330
13 March 2004

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Northern Ireland integrated medicines management

Length of stay and readmissions down in NI medicines management project

Reductions in the length of stay and readmission rates are two key results of the Northern Ireland integrated medicines management (IMM) project, according to researchers at United Hospitals Trust, Antrim, and Queens University, Belfast. Other benefits include increased appropriateness of medicines use, improved use of time for nurses and doctors and elimination of waste. The project has been so successful that additional funding has now been allocated to roll the project out to all wards at the United hospitals group and to start a similar project at Craigavon Hospital.

The Northern Ireland IMM project is the first randomised, controlled study in the UK to assess the impact of a multidisciplinary, cross-sector process designed to improve the effectiveness of medicines usage.

Part of the impetus for the project was the realisation that morbidity due to the unwanted effects of medicines created an additional raft of work for the health service, said Norman Morrow, chief pharmacist, Department of Health, Social Services and Public Safety, Northern Ireland. He estimated that the combined costs of adverse reactions to medicines (at least 50 per cent of which were preventable) and adverse events involving medicines amounted to 1 per cent of the overall NHS expenditure in Northern Ireland. Therefore, he argued, although 12 per cent of NHS expenditure was for medicines, this was, itself, giving rise to additional costs. He explained how the IMM project was part of a strategic initiative to bring clinical pharmacy skills to bear at every stage of the patient-care journey and thereby to make the use of medicines safer and more effective. The project was conceived as a multidisciplinary team effort from the beginning. It was to empower people to use their skills to do things they had not done before and also to release others to take on different tasks.

In Northern Ireland the DHSSPS allocates executive programme funds for suitable innovation and modernisation projects and the IMM project was funded through this route. This meant that additional staff could be appointed for the project. In the event, the project was based at United Hospitals in Antrim, where there was a well-established clinical pharmacy service, and a team of five pharmacists and five technicians was appointed.

The admission medication history is often critical to a patient’s future progress, explained Anita Hogg, pharmacist project co-ordinator. Omissions or inaccuracies can be perpetuated during the hospital stay and for a long time after if they are not identified and corrected. For this reason the IMM process uses several sources, including GP and community pharmacy records, to compile a complete medication history.

Inpatient monitoring is a proactive process that includes checking that treatment outcomes are appropriate and acceptable and that medicines are tolerated. “We pay special attention to medication changes and take time to explain to the patients what the changes are and why they have been made,” said Mrs Hogg. We also provide as much written information as possible, she added. At the time of discharge, the pharmacist prepares and signs off the discharge prescription. The discharge documentation also includes a list of medication changes, up-to-date relevant laboratory test results and education points that need to be reinforced for the patient. This information is faxed to the GP and community pharmacist on the day of discharge. In addition, patients are educated about their treatments and medication record sheets are provided for reference.

IMM project helps patients and carers and benefits the whole health care team from both sectors

“Dispensary work is a waste of what I have learnt — robots can dispense,” said Alison Woods, technician project co-ordinator. Typically, Miss Woods spends all her time on wards where she is responsible for the management of the ward stocks of medicines. Each day she reviews the medicines Kardexes to check what is required and deals with discrepancies, alerting the pharmacist if necessary. One important task is servicing the medicines trolley in time for the 10am medicines round — after a busy weekend this can be cluttered with unnecessary items, expired products and even items that should have been refrigerated. She ensures that the products that are required are ready and available and removes products that are no longer required. She checks patients’ own drugs and identifies those that are suitable for reuse and also processes discharge prescriptions. In addition, Miss Woods educates patients about inhaler use, when required.

Carer’s perspective
“The medicines record [document] has given me a better understanding of mum’s medicines and the side effects and what to watch for,” said Heather Laverty, describing her mother’s experience of the active arm of the IMM project. Mrs Laverty’s mother is 82 years old and has numerous medical problems. Daily contact with the pharmacist during the inpatient stay and help with sorting out two carrier bags full of hoarded medicines had been valuable, said Mrs Laverty, but the medicines record had become her “bible”. “This has given me the information to keep mum in better shape,” she said. For example, when her mother recently became constipated she discovered that the cause was “helping herself to Imodium,” said Mrs Laverty.

Nurse’s perspective
Linda Ferris described how she felt threatened at first when, in 2002, she took up her appointment at Whiteabbey Hospital [part of United Hospitals Trust] and found a pharmacist “doing her job”. On her 24-bed medical ward there are an average of 80 admissions each month. Most patients are frail, elderly and receiving five or six medicines. The 10am medicines round can take two nurses up to two hours to complete. “There are numerous interruptions,” said Sister Ferris. “One benefit of the IMM project is that we can get accurate drug histories, including allergies and blood levels where appropriate, with a single phone call to our pharmacist or technician.” Other major benefits are the maintenance of the medicines trolley, “dedicated staff who know our ward” and the readily available information resource. The possible drawbacks are complacency and deskilling among nurses, said Sister Ferris.

SHO’s perspective
“We spend more time with patients and less time writing Kardexes, discharge letters and answering queries from the pharmacy,” said Nicola Brown, senior house officer, Whiteabbey Hospital, describing the impact of the project on her practice. The IMM process often reminds us that we need to monitor, stop or change medicines, she added. Another advantage is that GPs receive legible discharge information. “Patients get the medicines they need and we don’t get called by the pharmacy or the GP to query the discharge prescription,” she said.

GP’s perspective
John O’Kane, a GP at The Oaks Practice, Cookstown, said that GPs particularly welcome the use of 28-day packs and the legible documentation. They are also pleased to have the opportunity to contribute to a joint formulary and product standardisation initiatives. “We cannot see any disadvantages and we would like to give total support,” he said.

Community pharmacist’s perspective
The IMM process is “a very large step forward in achieving the level of communication that we need,” said Alwyn Beresford, community pharmacist, Greenisland Pharmacy. The discharge information provided by the IMM process is particularly helpful because it enables him to ensure continuity of supply. He predicted that community pharmacists would soon be providing similar services and believes that they would dovetail well with this service. He suggested that pharmacists in the two sectors should be able to alert each other to the more vulnerable patients.