|
Maria Vilasuso is specialist registrar,
and Nina
Barnett is
specialist pharmacist for older people, at Northwick Park Hospital,
Harrow, Middlesex
|
Self-medication (or self-administration of medicines) for patients in hospital has once again been highlighted as a key issue for implementation in the NHS. The Health Care Commission (HCC) has included self-medication
as an indicator within the “medicines management” section
of the “acute hospital portfolio”. In addition, the National
Service Framework for Older People, a 10-year plan that started in 2001,
included a medicines management milestone, for achievement by April 2002,
requiring hospitals to implement self-administration of medicines for
older patients to support optimal medicines use by older people.
Self-medication for hospital patients is not a new concept. A number
of small studies in the 1970s and 1980s explored the benefits of such
schemes, although there was no standard definition of self-medication.
Currently, neither the NSF nor the HCC acute hospital portfolio define
self-medication, leaving local trusts to create their own definition.
These usually include reference to the desire to promote complete or
staged
patient autonomy in medication taking for hospital patients.
Is self-medication by patients is an ideal to aspire to for all patients
in hospital? The evidence for this is poor. A recent critical review
of the self-medication literature on patient compliance, medication knowledge,
satisfaction, treatment failures and medication-related admissions suggested
that most of the 51 studies included were poorly designed and had methodological
flaws. Another proposed benefit
of self-medication in hospital is that it promotes and maintains patient
independence and autonomy, in the hope that patients are discharged from
hospital with sufficient knowledge to take their medicines correctly
and safely. In this way, readmissions due to non-compliance with medication
(highlighted as a problem in the NSF) or medication errors may be reduced.
However there is no evidence to support this. In addition, there are
no long-term studies demonstrating an improvement in concordance following
discharge, or any evidence directly linking self-medication with reduced
readmission rates.
For self-medication schemes to be safe and effective, patients must be
carefully selected. Patients require adequate manual dexterity and cognitive
function and the ability to demonstrate sufficient knowledge of their
regimen to remain in control of their own medication during their inpatient
stay. It is important to target patients taking an established regimen,
rather than a rapidly changing prescription, and those who will be responsible
for their own medicine-taking once they leave hospital.
Nevertheless, hospitals are now mandated to attempt to introduce self-medication
schemes again. The current system for hospital inpatients in the NHS
does not routinely assess a patient’s ability to comply with prescribed
regimens. Consequently, patients may be discharged with little knowledge
of their drug therapy or without identification and resolution of practical
barriers after discharge, such as difficulty with blister packs. Therefore,
in response to the national directives, self-medication schemes have
been tested in a number of hospitals around the UK that have produced
detailed self-medication policies to support implementation. However,
the most recent HCC report indicates that most hospitals have not fully
implemented
this NSF 2002 milestone and, anecdotally, it seems that few hospitals
that have started this initiative have been able to maintain it in the
long term for most of their wards. Our local experience provides some
insight as to why this might be.
At Northwick Park Hospital, we set up a self-medication scheme for older
people, supported by a hospital self-medication policy. Patients were
assessed by the medical team for suitability for entry into the self-medication
pilot scheme, using criteria expanded from Trewin and Veitch’s
original criteria in 1987 and, where appropriate, the self-administration
of medicines scheme was explained to the patient and the process was
agreed with the patient. Nurses or pharmacists completed
the patient assessment and a staged self-medication programme was started.
Patients would first take their medicines from their bedside lockable
cabinet with the help of nursing staff. Once confident and competent
to take their own medicines, they were given custody of the locker key.
Patients’ progress with self-medication, including compliance issues
and education needs, were addressed at every ward round during their
inpatient stay and recorded by the nurse.
Several issues were highlighted as a result of the pilot study. Few patients
were able to self-medicate in hospital. For the older patients studied,
some could not be offered self-medication because of their physical or
cognitive state, and a number would not assume responsibility for medication
on discharge anyway. Many were too unwell during their admission and,
once well enough to self-medicate, were rapidly discharged. A number
of patients were unable to self-medicate because their medication or
medical condition changed rapidly.
This was reflected in the results, which showed that only two patients
on a ward of 30 patients over a six-week period were able to self-medicate.
In addition, nursing staff expressed concerns about the risk of overdose
and drug errors among self-medicating patients where their cognitive
function was changing. Concerns were also expressed about the time required
to train nursing staff and patients to facilitate safe self-administration
as well as the nursing time required to supervise and assess patients
taking their own medicines.
In practice, self-medication schemes are labour- and time-intensive exercises
that have the potential to increase anxiety among nurses, doctors, pharmacists
and patients. Self-medication in hospital cannot emulate the patients’ home
scenario due to legal and clinical governance limitations that apply
in hospitals, such as the storage of Controlled Drugs and the requirements
for keeping all medicines in a locked cupboard. There are also inherent
medico-legal issues that need to be addressed with the potential risk
of increasing the number of drug errors, eg patients taking the wrong
dose.
Self-medication for hospital patients is something that we should aspire
to provide. However, in an acute hospital, with pressure to reduce length
of stay, it seems impractical to implement a scheme which by its nature
requires time for the patient to benefit. Criteria for inclusion must
focus on stable patients who are to remain in hospital for a number of
days before discharge to allow appropriate self-medication assessment
and trial. Most patients will have an average hospital inpatient stay
shorter than that required for a successful self-medication scheme to
operate.
It seems prudent to target self-medication as an intervention for longer-stay
care (eg, intermediate care, where patients may be discharged home).
Use in long-term care has been shown to be effective. In the meantime,
there is no substitute for good communication between primary and secondary
care to ensure that medication-related discharge planning occurs well
in advance of discharge and is followed up from hospital to community
and vice versa. |
The
Pharmaceutical Journal