Hospital Pharmacist
Vol 10 No 3 p98
March 2003

Review of circulars and official publications
by Alex Bower, MRPharmS

Discharge from hospital: pathway, process and practice was issued by the Department of Health (DoH) in January. The document draws together examples of good practice in an attempt to improve the discharge planning process and presents them in an impressive 114-page workbook.The report notes that older people are particularly likely to experience a delay in their discharge. One of the causes of delays is stated to be "the organisation and management of medication". The need to plan for discharge at as early a stage as possible, and for this to be carried out within a multi-agency and multi-disciplinary team is noted. A "whole systems approach" is required and pharmacy is identified as a component of the key professional input. Implementing the medicines-related aspects of the National Service Framework for older people is seen as a way of ensuring that this group gain maximum benefit from their medication and maintain or increase their quality and duration of life.

The workbook contains five pages as Appendix 5.1 on medicines management. This notes that between 5 and 17 per cent of hospital admissions may be due to adverse reactions to medicines that have not been taken correctly. A total of 10 common problems, which can lead to delays in discharging patients, are listed. The appendix notes the need for the assessment and care-planning processes to take account of both a patient's medication needs and their ability to take the medicines. The assessment process should identify whether patients can take their medicines unaided at home or whether assistance is required, either personal or mechanical. Carers and labels with a large typeface are given as examples in each of these categories. There is, however, no reference to the part that monitored dosage systems (MDSs) or staff employed by appropriate organisations might play. The former is a contentious issue. Some patients are dependent on MDSs to maintain their independence at home but the continuing inability to provide a properly funded mechanism to supply the system may lead to future difficulties for patients in securing supplies.

One-stop dispensing, use of patient's own drugs and self–administration schemes are all mentioned as key issues to be further developed in the interest of improving discharge arrangements. The appendix contains a seven-point action plan and some practical examples of good practice.

There may be little new to hospital pharmacists in the medicines management appendix but its succinct summary of the role of pharmacists and its high profile as part of the significant drive to improve discharge planning make it a pivotal document. Hospital pharmacy managers will wish to ensure that they discuss the contents with their local discharge planning co-ordinator. The workbook is available as a PDF (650K).

"Pharmacy for health: the way forward for pharmaceutical public health in Scotland" was issued by the Scottish Executive in December 2002. This is a well presented document published by the Public Health Institute of Scotland (telephone 0141 300 1010, web address www.phis.org.uk). If you have ever wondered exactly what is meant by the term "pharmaceutical public health" this authoritative document will tell you. It outlines the need for pharmacists to focus on health improvement by working in partnership with colleagues and taking a population approach as well as supporting individual patient needs. The document sets out a definitive view of the contribution that pharmacists can make to public health. There is a focus on community pharmacy but the report encompasses those who work in other branches since public health roles are seen to extend across the breadth of the profession. The challenge is to deploy the full potential in a co-ordinated way. Chapter four of the report makes a total of 23 recommendations grouped under the themes of:

•  Health improvement

• Networks

• Skills development

• Evidence-based practice

Recommendations which are of particular relevance to hospital pharmacy relate to:

• Developing a needs assessment tool for out-of hours services

• Revising education and training programmes for technicians and other support staff to include public health principles and practice

• Identifying and prioritising topics for pharmaceutical needs assessment

• Improving the understanding of the links between prescribing and the emergence of patterns of anti-microbial resistance

• Improving the cost-effectiveness of prescribing

• Developing emergency plans

There will be little that is new to hospital pharmacists in the document but the assembly of the pharmaceutical contribution to public health in the way indicated make it a "must have" reference tool of importance in all countries, not just Scotland.

The Scottish Executive has also issued a glossy document, dated December 2002, on "Good practice statement for the preparation of injections in near-patient areas, including clinical and home environments". Copies can be obtained from the Stationery Office bookshop, Edinburgh (telephone 0870 606 5566). The report notes that surveys of microbial contamination rates in intravenous medicines prepared in near-patient areas have shown this to vary from 2 to 15 per cent but when an experienced operator using aseptic technique carries this out, the rate can fall below 0.1 per cent. The main sources of contamination are dirty preparation areas, omission of hand washing and failure to swab vial tops. The report gives nine good practice statements relating to the preparation of medicines for injection that cover:

• Prescribing

• The most appropriate location for their preparation

• Standards required for the environment, procedures and operators

Most hospital pharmacists will be well aware of the principles outlined in this document but it will serve as a useful checklist to identify situations where near-patient preparation, as opposed to preparation in a pharmacy aseptic unit, would be acceptable.

  * PDF files on PJ Online require Acrobat Reader 4 or later.

Mr Bower is a consultant pharmacist