The Pharmaceutical Journal
Vol 275 No 7356 p21
2 July 2005

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Labour-intensive team pays dividends

Introducing a ward-based pharmacy team centred around a specialist technician has enabled four general surgical wards at Royal Liverpool and Broadgreen University Hospitals NHS Trust to cut discharge time to under an hour. Tom Moberly reports

Vision for pharmacy series

Dispensing discharge prescriptions for patients on surgical wards used to cause considerable delays to discharges from the Royal Liverpool and Broadgreen University Hospitals NHS Trust, Alison Ewing, clinical director of pharmacy at the trust, says. Patients would either take up beds while they waited for their medicines to be dispensed or lose patience and leave the hospital without them.

To try to speed up the discharge process, a ward-based pharmacy team was introduced, so that a smaller group of people would look after the medicines for a particular group of wards, rather than the whole pharmacy being responsible for all wards. “The team approach allows team members to have full control of the ordering and supply of medicines to these wards. Everyone is aware that a member of the pharmacy team will deal with anything relating to these wards, so any queries can be directed to the relevant people,” Ms Ewing explains.

“The team is centred around a specialist ward checking technician, but also includes a ward pharmacist, a dispenser and an assistant technical officer (ATO). The team works in four general surgical wards at the trust, including the emergency surgical admissions unit.” Although the team-based system is labour-intensive, in its first four weeks it led, she says, to a 50 per cent decrease in delayed discharges from the four wards.

“The ward technician, Lee Williams, assesses the medicines patients have brought in and prepares a 28-day medicines pack, which acts as the patients’ discharge medicines as well. Each morning he visits the wards to assess how many patients are likely to be discharged, and so how many discharge prescriptions the dispensary should be expecting,” Ms Ewing says.

Once aware that the patient is going home, the technician will double-check that the medication in the locker is correct and that it matches what the medication chart says has been supplied, which also cuts out unnecessary dispensing, says Lena Whittall, chief technician for medicines management at the trust. If there is insufficient stock of any medicine for expected discharge prescriptions, supplies areordered.

“If a discharge is urgent and there is sufficient pharmacist time,” Mrs Whittall adds, “the technician can inform the pharmacist of the discharge and request the prescription, greatly speeding up the process. If this is not necessary he will use the information about expected discharges to prompt nursing staff throughout the day that prescriptions need to be written.”

When the prescriptions have been written the technician tells the pharmacist who checks them on the ward, rather than waiting for them be collected and then left for checking in the dispensary before being dispensed. The prescriptions are then sent down to the dispensary, where a designated area has been set up and one of the dispensing technicians is assigned to work, as a priority, on prescriptions from the four surgical wards. Once dispensed, the medicines are checked by the ward technician and delivered back to the ward.

The ATO is also responsible for keeping tabs on ward stock and stock is now topped up every week, rather than every two weeks, as had been the case. The ATO also delivers the stock to the ward. Stock requests are monitored but are no longer routinely supplied as they were in the past, Ms Ewing says. Instead, the ward technician checks that extra stock is actually needed before making any supplies. The ward technician also maintains the stocks of Controlled Drugs at the wards’ pharmacy stations, up to levels which have been agreed with ward managers. This prevents CD orders for the same items being sent down every day. Levels are topped up on Mondays and Fridays and the CD registers are also checked on Wednesdays so that, if necessary, additional orders can be made to take account of increased usage.

“Discharge prescriptions have been getting turned around in less than an hour, whereas the average in the dispensary is about two hours,” Mrs Whittall says. This means that as soon as the final decision to discharge a patient is made, the patient can leave. And preparing patients’ medicines before discharge has meant that, across the four wards, between 16 and 56 per cent of items do not need to be dispensed on discharge. The new approach has also resulted in reductions in medication errors, in patients receiving other patients’ take-home medicines and in complaints, Ms Ewing says. “The nursing staff, including matron Joyce Johnson, are delighted with the new approach because it has reduced the pressure on them by increasing the number of empty beds,” she adds.

The system also saves money, because it reduces both workload and the number of medicines dispensed, as well as minimising additional treatment required by patients going home either without their medicines or with the wrong medicines.

“We are getting towards having over 70 per cent of medicines managed by the ward team over the whole week and 100 per cent during working hours,” Ms Ewing says. There are also, she says, sufficient quantities of medicines already on the wards to fulfil almost all prescriptions.

At the moment, prescriptions are counter signed by the doctor once the pharmacist has transcribed all the medicines from the drug charts onto the prescriptions and all the medicines are ready. “The next step will be to have pharmacists actually writing and signing the discharge prescriptions,” she says. Ms Ewing is also looking to expand the pilot scheme to other, non-surgical, wards in the hospital to see if the same system, and the benefits it has brought, can be repeated there.