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Mohamed Elfellah, PhD, MRPharmS,
is clinical cardiovascular pharmacist
Graham S. Hillis, MB ChB,
is senior lecturer in cardiology
Brian Jappy, MSc, MRPharmS, is
chief pharmacist, at Aberdeen Royal Infirmary.
Correspondence to:
Dr Elfella
e-mail mohamed.elfellah@arh.grampian.scot.nhs.uk
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Clinical management plan
The clinical management plan is an essential
component of supplementary prescribing. It must be agreed by
the independent prescriber,
the supplementary prescriber and the patient. It is based on a
generic
treatment plan and contains the patient’s name, date of birth
and identification numbers, the name of the independent and supplementary
prescriber, and the diagnosis. It also contains reference to the
guidelines or protocols supporting the treatment plan, details
regarding monitoring and confirmation of the patient’s
verbal consent, with the date. (As yet we have not faced a situation
where
a patient is unable to give consent. Were we to, approval of
the next of kin would be sought.) |
Supplementary prescribing has mainly been adopted in primary care and
in outpatient clinics. There is, however, increasing interest in its
application in secondary care. We have adapted supplementary prescribing
to the discharge process in the cardiac unit at Aberdeen Royal Infirmary.
As a result, the pharmacist’s role has changed. It is expected
that these changes will improve patient care.
Our previous work has demonstrated that review of the discharge prescription
at ARI by the ward clinical pharmacist reduced errors, decreased waiting
times for discharge medicines and minimised medicines wastage.1 This
has led to a change in cardiac ward practice, whereby the clinical pharmacist
now writes 80 to 90 per cent of discharge prescriptions. Such practice
is encouraged at ARI because it is seen to reduce junior doctors’ workload,
speed up patient discharge and increase bed turnover. Work from other
hospitals has reached comparable conclusions.2
One problem, however, persists: a doctor must sign the discharge prescription
before it is sent to the pharmacy for dispensing. This can lead to delays
and duplication of work. Some hospitals have tried to overcome this problem
by dispensing directly from the in-patient drug prescription, but this
system has not been widely accepted.2
The aim of supplementary prescribing (ie, by prescribers other than doctors)
is to provide patients with quicker and more efficient access to medicines,
and to make the best use of skilled trained nurses and pharmacists. Over
time, supplementary prescribing is also likely to reduce doctors’ workloads,
freeing their time to concentrate on patients with more complex treatments.
In Scotland, the main role of supplementary prescribing has been in the
management of chronically ill patients in primary care. However, pharmacists
entrusted with the discharge planning of patients in acute services have
similar goals to those in primary care. Supplementary prescribing, therefore,
offers hospital pharmacists a historic opportunity.
In our unit, we have used the autonomy offered to supplementary prescribers
to begin prescribing drugs for cardiovascular and some other specified
conditions. Using protocols and guidelines which are already in place
in the cardiac unit, we produced a clinical management plan which was
approved by the supplementary prescribing committee in NHS Grampian (copies
available on request). They were written and approved by both the supplementary
prescriber and local consultants. Agreements are also in place for treatment
plans for non-cardiac conditions. They are used as a basis for prescribing
during admission and on discharge.
Daily monitoring of treatment is carried out by the pharmacist and the
independent prescriber throughout the patient’s hospital stay.
Once a date for discharge is set, the pharmacist supplementary prescriber
writes the discharge prescription, usually at the patient’s bedside,
where drug history is confirmed. Diagnoses and past medical history are
recorded in the discharge report from the medical notes. Discharge medicines
are prescribed with reference not only to the inpatient prescription,
but also taking into consideration the prior clinical and drug history.
Medicines that are no longer required are omitted on discharge. Optimising
therapy on discharge may involve alteration of dosages (for example,
titrating angiotensin converting enzyme inhibitors and adjusting doses
of warfarin) and adding medicines that are appropriate for the condition
(for example, aspirin, a beta-blocker and a statin following myocardial
infarction). Any changes made by the supplementary prescribing pharmacist
are based on agreed protocols and guidelines. Medicines prescribed before
or during admission and not covered by the agreed protocols are transcribed
from the inpatient prescription. Major changes are recorded in the medical
notes of the patient. The discharge report, together with the CMP, is
then sent to the pharmacy to be dispensed. The pharmacy dispenses the
discharge drugs against the signature of the supplementary prescriber
and sends a copy of the discharge report together with the CMP for filing
in the medical notes of the patient. From March 2004 to January 2005,
the supplementary prescriber wrote 825 discharge prescriptions on the
cardiac ward. This was equivalent to approximately 80 per cent of total
prescriptions written there.
The CMP is a useful document to assist the supplementary prescriber when
running a clinic for chronic disease. The situation is different in hospital,
where the pharmacist is a member of a team caring for the patient daily
and where the medical notes and the inpatient prescription are easily
accessible. In addition, most of the information contained in the CMP
is also written in the discharge report. Therefore, in secondary care
the CMP is a somewhat repetitive document. In this setting its main function
is to fulfil the legal requirements for supplementary prescribing.
Supplementary prescribing increases the accountability of the pharmacist:
transforming them from a prescribing adviser to a prescriber. It also
adds to the workload of the pharmacist. Nevertheless, it does create
a unique opportunity for hospital clinical pharmacists. Their knowledge
and experience places them in an excellent position to prescribe not
just for single but for multiple conditions and illnesses. This should
strengthen the role of the pharmacist as an important member of the health
care team. Moreover, taking this responsibility may facilitate the discharge
process and improve communication with colleagues in primary care. Most
importantly, these changes should improve patient care. Further work
is required to verify and quantify these benefits, thereby ensuring the
full potential of the hospital supplementary prescriber is realised.
References
1. Elfellah MS, Jappy B. Outcomes following discharge prescription
monitoring by the ward pharmacist. Pharmaceutical Journal 1996;257:156.
2. Hobson RJ, Sewell GJ. UK survey of discharge prescriptions, transcribing
and development of hospital pharmacist prescribing role. International
Journal of Pharmacy Practice 2002;10(Suppl):R12 PDF (50K) |
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