Hospital Pharmacist
Vol 11 No 9 p397-398
October 2004

Why not ask a technician to promote better prescribing?

When the North Tees and Hartlepool NHS Trust received money from the Department of Health last year as part of the national initiative to promote the prudent use of antimicrobials, managers thought about appointing a part-time pharmacist to evaluate and influence antimicrobial prescribing at the trust. They then thought again — and decided to have a senior pharmacy technician take on the work full-time, combining it with the role of analysing the prescribing of other drugs.

This article describes how the drug use evaluation technician established standard operating procedures (SOPs) for analysing prescribing and adjusting policies and formularies to promote more effective prescribing at the two hospital sites that make up the trust.

Establishing procedures

At the time that the project started, there were no set procedures in place at the trust to analyse prescribing patterns or adjust the trusts’ policies or formulary. If better drug use (both of antimicrobials and of other medicines) were to be promoted, it was important that these be set up.

It was decided that removing co-proxamol from the formulary would be used as a “test case” to set up SOPs. Removing this drug was not particularly contentious, and so analysing the stages involved would enable basic SOPs to be built up relatively easily. These could then be used as a basis for making more controversial and larger scale adjustments to prescribing (such as those involving antimicrobials).

In order to draw up the SOPs, the processes involved in removing co-proxamol from the trusts formulary were mapped and documented in detail from start to finish. They seemed to fit into the categories of:

· Identifying the scope of an evaluation
· Obtaining information on prescribing patterns
· Developing solutions to form the basis of a report to the Drugs and Therapeutics Committee (DTC)
· Implementing the decision of the DTC
· Auditing the implementation
· Other activities

Further information about these stages is set out below.

Identifying the scope

Any member of staff at the hospital trust or primary care trust served by the hospital trust can suggest an evaluation to be carried out. Priority is given to those that relate to rationalising antibiotic use, enhancing patient safety and/or improving the cost-effectiveness of prescribing.

Once it has been decided to carry out an evaluation, its scope (ie, whether it is to apply to just one ward, several specialities, across a whole hospital site or the whole trust and associated primary care trusts) needs to be assessed. Different resources will be required, depending on how widely prescribing is to be influenced. If the time of pharmacists or other technicians is likely to be required (for example to visit some of the primary care trusts) then this needs to be planned early on.

This early stage of the process also provides an opportunity for identifying any problems areas or potential barriers (such as where particular drugs are used seemingly inappropriately more at one site than another). If these sort of issues can be resolved at the outset it will make the rest of the process more efficient.

Obtaining information

The next stage is to use the available resources, mainly the pharmacy computer system (ASCribe is used at the North Tees and Hartlepool NHS Trust) to investigate current prescribing patterns. Prescribing of the particular drug concerned is first analysed across the whole trust. Data is then broken down to ward and consultant level. One of the main aims at this stage is to establish a baseline figure of prescribing patterns so that the effects of implementation of policies or formulary changes can be audited at a later date.

Information about prescribing patterns can also be obtained from discussions with medical staff at the hospital trust. Opening up channels of communication, making communication “two-way” and having people “on board” at this early stage will help a lot later when it comes to implementing policies.

Staff at primary care trusts should also be asked for details about prescribing trends. This can help reinforce trust decisions; for example, when I approached prescribing advisors at the four primary care trusts served by North North Tees and Hartlepool NHS Trust they were all actively trying to discourage the prescribing of co-proxamol. Contacting prescribing advisors at an early stage is also important because changes made to prescribing habits in secondary care clearly have a “knock on” effect in primary care.

Developing solutions

Searching the internet for guidance produced by other hospitals or relevant groups is the next stage in the process. This might show that the prescribing trends found are appropriate or suggest that practices should be changed. Consultants and clinicians are invited to contribute to the evidence gathering. They (along with primary care prescribing advisors) are also asked to suggest ways in which policies could be amended to match the current evidence base.

Several different factors need to be taken into consideration when proposing solutions. The DUE process will question any decision based on cost alone or benefit alone. The overall picture must embrace evidence-based practice, best practice, personal experience of specialists, patient choice and cost effectiveness.

All the information is then compiled into an initial report, which is distributed for comment. Once these comments have been discussed and the appropriate actions taken, the final report is written. I then present this to the Drugs and Therapeutics Committee for final approval. Providing the communication process has been successful, this should be a formality.

Implementation

Assuming that the Drugs and Therapeutic Committee accept the report, it is my job to co-ordinate the implementation of the approved changes. This involves informing clinical staff of the decision so they can adapt their prescribing practices accordingly. Pharmacy staff involved in procurement also need to know about the changes so that they can adjust stock levels. Implementation also involves amending paperwork and the information on the pharmacy computer system and intranet as appropriate.

As pointed out above, time taken in communicating details about the potential new policies to trust staff earlier on in the process will make implementation easier.

Audit

Each change made to the formulary needs to be audited in order to check that it is being adhered to. This is done by monitoring prescribing patterns through the pharmacy computer system as an ongoing process and comparing them with the baseline figures produced earlier. Each full audit needs to be completed within an agreed time scale (usually six months from the start of the implementation process).

The drug use evaluation process itself is also to be audited on a yearly basis, so that continual improvements can be made.

Other activities

Promoting the work of a drug evaluation technician is an important part of the job, particularly because the role is new and quite an unusual one for a technician to have. At North Tees and Hartlepool NHS Trust, this has been done by giving presentations to pharmacy staff at both hospital sites.

I have also attended externally-organised conferences (such as those on antimicrobial management that took place at the Royal Pharmaceutical Society’ headquarters in London last year and earlier on this year). As well as offering opportunities to promote work, conference attendance also benefits technicians involved in drug evaluation in that they are able to learn from the experiences of others and avoid “re-inventing the wheel”.

Moving forward

Particularly because it is a new role, my job of drug use evaluation technician is developing all the time. Because nationally co-ordinated schemes are being put into place to promote better prescribing, the work I do on antimicrobial drugs is now being linked in with these. I am therefore now reviewing the antibiotic policy of certain specialities (such as, most recently, obstetrics and gynaecology) against current national guidance, linking with microbiology reports to check for local resistance. There are also plans to launch trust-wide guidance on intravenous to oral antibiotic switches, a policy on stating the length of antimicrobial treatment and a restricted list, so certain antibiotics can be prescribed only under strict criteria.

The SOPs developed at the trust, however, are still being used at a local level to analyse the prescribing patterns relating to drugs other than antimicrobials and, if necessary, adjust the trusts’ policy and formularies accordingly.

Conclusion

Taking part in national initiatives such as that to promote the better prescribing of antimicrobials is a good use of a pharmacy technician’s skills. It means that pharmacy departments can play a full part in such schemes, without exclusively pharmacists’ time being spent on them. It also allows technicians to develop careers that are not entirely dispensary-focused. I value the challenges and responsibility the role brings me.