The Pharmaceutical Journal
Vol 272 No 7293 p418
3 April 2004

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A simple discharge service that works

A pharmacist-run discharge service has made large improvements to the discharge process at a Wigan hospital. Clare Bellingham (on the staff of The Journal) reports

Vision for pharmacy series

The pharmacy discharge service at Wrightington Hospital in Wigan works: the data prove it. Perhaps that is why The Times chose to feature the services as an example of good practice recently.

What Gary Masterman, clinical lead pharmacist, has done is to start with a simple service. He collected the data to demonstrate the service’s worth and then made it something that the hospital cannot do without. “It’s not rocket science but it is making a real difference to patients,” says Mr Masterman. He was appointed in 2000 and given the job of setting up the discharge service. A year later it was clear that the service was a success. The running of the service has recently been taken over by Zoe Cottam, discharge planning pharmacist, and Mr Masterman has moved on to another position within the hospital.

When given the brief, Mr Masterman’s first step was to carry out a literature search of what systems were in place at other hospitals. Next he collected data about current discharge prescribing by junior doctors within the Wrightington Hospital, examining the quality of prescribing, errors, workload, patient satisfaction and understanding, and delays. The pharmacy-run discharge service was then piloted on one ward. A successful audit led to it being rolled out to all eight wards.

“It is a rewarding role,” says Miss Cottam. “I have more patient contact and we are able to pick things up that would probably have been missed otherwise: this makes a difference to patients. I also feel much more part of the ward team.”

How the service works

When a consultant decides that a patient is ready to be discharged, the discharge pharmacist is bleeped. “We then go along to the ward, make a clinical check, write the discharge prescription and counsel the patient,” says Miss Cottam.

The discharge prescription is written using information from the patient’s hospital drug chart, the medication history taken on admission and any special directions from the medical team. Any items that a patient already has are endorsed “patient’s own” and the remainder will be dispensed for the patient to take home. The prescription goes to the pharmacy for dispensing in the normal way: it is not dealt with any differently just because it has already had pharmacist input. The pharmacist also spends time counselling the patient, or the carer, about the discharge medication.

Pharmacists are not allowed to sign the discharge prescriptions and the doctor still has to do this. But because each prescription is prepared, the doctor only has to be spend a couple of minutes reviewing it rather than a much longer time writing it.

A new prescription form was designed for the service. It includes a space for information for GPs explaining why drug changes have been made. In addition, the name and bleep number of the discharge service pharmacist have been added to make it easier for GPs to know whom to contact. Patients can be referred to a community liaison pharmacist if particular support with medicines is needed after discharge.

Beneficial results

Comparing the discharge prescriptions written by junior doctors with those written by pharmacists shows just how well the new pharmacy discharge service works. An analysis of the service between October 2000 and March 2003 shows that 2,956 discharge prescriptions were written by doctors and 6,696 were written by pharmacists.

Time savings The proportion of patients waiting for two hours or more to be discharged was 27 per cent under junior doctors and zero under the pharmacy system. All prescriptions were completed in under 60 minutes in the pharmacy service. At 60 minutes under the doctors’ system, 55 per cent of patients were still waiting for their prescription.

Quality and error improvement Not only has the pharmacy service reduced delays to discharge but it has also improved the quality of the prescriptions. Pharmacists scored 100 per cent when it came to including the date and the patient’s address on prescriptions. This compared with 81 per cent and 89 per cent, respectively, on doctor-written prescriptions. Error rates fell dramatically in the pharmacy service: doctors made 3,134 errors on 2,956 prescriptions compared with just 159 on 6,696 prescriptions for pharmacists. Although these rates appear high it is important to note that these were errors on the prescription form itself, not in what the patient was given, and all but five were picked up in the pharmacy.

Use of generic medicines also improved: only 11 of the pharmacist-written prescriptions were not written generically compared with 988 of the doctor-written prescriptions. In only one case did the pharmacist fail to specify a brand when it was necessary compared with 159 times by doctors. Importantly, patient satisfaction was increased by the pharmacy-run service. This is probably because the pharmacist spends time counselling the patient about their medicines.

Cost savings The pharmacists’ involvement has resulted in significant cost savings, making the service self-funding. “The medical director liked the fact he was getting a pharmacist for nothing,” comments Mr Masterman. “Now we have got to a stage that there is enough money for a second pharmacist which will make things much easier for covering holidays and so on.”

Cost savings were made by use of patients’ own drugs, if they had some, rather than dispensing new ones. Doctors rarely considered patients’ own drugs, endorsing the prescription as “patient’s own” only 2 per cent of the time compared with 45 per cent for pharmacists: this resulted in pharmacists saving about £95,000 more than doctors over this two-and-a-half-year period. Close working with the primary care trust has made this arrangement acceptable and there is now a joint formulary in place.

On top of the savings made in terms of drugs, the improvement in delays to discharge has also saved £22,194 in terms of bed costs and £18,190 as a result of junior doctors’ time being saved. Adding the figures up, the pharmacy discharge service has resulted in a saving of £135,620. It cost £87,500 to run the service for the two-and-a-half-year period: a net gain of £48,120. On top of this, an estimated 7,472 potential errors were avoided.

Future developments

Future developments for the service include introducing one-stop dispensing, electronic prescribing and pharmacist prescribing.

What advice would the team give to other pharmacists thinking about setting up a similar service? “Do the research first. People can get in touch with us and we will send them information,” Mr Masterman says. “There is always resistance to change so you have to carry out a pilot to convince people it works.”