Medicines Management
Issue no 1, pp20-22
January/February 2002

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Ways to streamline patient discharge

In early 2000, the issue of the pharmacy directorate's role in patient discharge became a priority at University Hospital Lewisham. There were three inherently linked strands:

Ward managers were of the opinion that discharge medicines (or to take-outs,TTOs, as we call them) took too long to come back from pharmacy. In their opinion, not only did this lead to patient complaints and dissatisfaction, but also to significant delays in discharging patients. In addition, nurses' time was wasted phoning the pharmacy, re-arranging transport and placating patients and relatives.

Government action on trolley waits in A&E meant that patients had to be admitted within 12 hours of arrival. As trolley waits of over 12 hours had to be explained to the Secretary of State's office by the chief executive this became a major trust priority.

Thus clearing ward beds for people in A&E and getting TTOs done rapidly for the patient already in the bed became priorities.

In addition, the trust was piloting the use of an electronic discharge computer (EDC) system. The prime aim of the system was to improve the quality and speed of information from the hospital to GPs upon patient discharge. A secondary aim was to improve the quality of information being transferred within the hospital, primarily medicine information. Prescription information was markedly improved compared with the traditional paper TTO prescriptions. A negative side to EDC was that it took longer to enter and authorise information and the process flows differed from the traditional system, creating confusion and delays. Initially the pilot was in care of the elderly where timing was not critical. In August 2000 the system was rolled out to all medical wards and subsequently to the rest of the hospital except ENT and paediatrics.

Like other hospitals Lewisham has problems with recruitment and retention. The combination of staff shortages and turnover along with increased demand meant that standing still was not an option. The manner in which medicines were managed needed change. This article describes some of these changes and their impact.

Our overall philosophy

We had encountered descriptions in the literature and presentations at conferences on new methods of managing medicines. Work on re-engineering medicines management at two nearby hospitals was examined and lessons drawn from them¹. One lesson we quickly learned was that different solutions were necessary for different patient groups. Our primary aims were to improve medicine use and provide TTOs promptly, but developments were underpinned by clinical governance principles. Basically, getting medicines right takes precedence over doing them fast.

The directorate set a performance standard of four hours from "receipt to ready" for TTOs. The standard should be met for 95 per cent of TTOs. This is a challenging standard and is thought to be one of the most exacting in London if not the country. It is used both as a driver to maintain standards and to make explicit to our users what we intend to do.

Ward-based dispensing in ENT

Most ENT patients have short admissions. They are admitted, have their operation that day and are discharged first thing the next day. Many patients are on no regular medication and those on medication rarely have it changed during the admission. Although the procedures vary, most patients go home on some combination of analgesia, antibiotics and/or topical medication, drawn from about 12–15 preparations. The ENT ward was responsible for about 10 per cent of the hospital's TTOs each day but these frequently did not go back to the ward until late afternoon. Apart from patient dissatisfaction, many patients went home intending to collect their medication later, with a sizeable proportion not doing so. The solution decided upon was a ward based discharge system. The commonly used items were agreed with medical and nursing staff and a locked cupboard in the nursing station used to store labelled TTO pre-packs. Each day the ward pharmacist deals with the TTOs first and dispenses them on the ward. Patients' own drugs are used for regular medication and topical preparations are "one stop" dispensed. Nearly all patients now go home between 9am and 10am with their medicines and are counselled by a pharmacist. A number of clinically significant interventions have taken place and evaluation of the system identified savings of around £1200 per annum by using patients' own drugs and one-stop dispensing (see p22).

Although the system took time to set up, this was relatively straightforward. The only real hitch occurred early on when a nurse decided to dispense medicines from the cupboard instead of sending charts to the pharmacy. This was resolved by removing the key to the cupboard from the ward key bunch.

The scheme is now being rolled out to the orthopaedic and gynaecology wards.

PGDs in the maternity unit

Within the maternity unit, client stays are also short, sometimes as little as six hours. Therefore even short waits for TTOs can affect admissions. The range of medicines used is limited. Patient group directions (PGDs) were prepared for common medications so midwives can issue discharge medication directly. The PGDs were prepared in a way that midwives could make the assessment, and supply to clients without recourse to a doctor. However, at present midwives still supply against a doctor's written order. As a result women do not have to wait for a TTO to be issued by the pharmacy.

Writing PGDs can be a tortuous process, particularly passing them back and forth between health professionals. The guidance in HSC 2000/0262 recommends that PGDs should be developed by a multi-disciplinary group including senior doctors, pharmacists and other professions involved. In practice much of the work falls on the pharmacist as they have the expertise. The NHS web site, http://groupprotocols.org.uk, has a number of PGDs on it, which can be adapted for local use, although none were of use to us.

Medicines management project

Although the provision of TTOs was a priority, this is only one component of medicines management. A traditional, stock/non stock system was in place supported by technician top up.

The medicines management project was set up, with funding for a D grade pharmacist provided, to re-engineer the way medicines were managed across the entire hospital. Although designed to address the whole medicines use chain, benefits have also accrued for the discharge process.

The project uses patients' own drugs (PODs) where appropriate and there is a programme of installing POD boxes on patients' lockers. There are a number of benefits; patients' treatment is not interrupted when admitted, medication is available to aid taking medication histories, and patients are less likely to be confused by brand changes, etc. The main advantage is that PODs minimise the number of items to be dispensed on discharge and for some patients it means that no additional dispensing is necessary.

The main barriers to overcome are getting the POD boxes installed as this has to be shoehorned into the works department's schedule. Also, there is a significant amount of training needed for nursing staff. Only one ward has been resistant to the use of the POD boxes. It is very easy to underestimate installation time. Our estimate was 10 months but after 18 months, installation is still not complete.

"One stop" dispensing has been introduced throughout the hospital; one supply is provided for the patient's anticipated stay in hospital and sufficient for discharge.

Patient packs have been introduced throughout the trust. This ensures that patients are provided with a patient information leaflet and speeds up the dispensing process. These two processes were easy to introduce but from time to time blips still occur with pharmacy staff splitting packs inappropriately and nursing staff losing a patient's medication.

Although the local health authority and primary care groups are supportive, the time to transfer funding to pay for patient packs has taken longer than expected.

Increased clinical pharmacist activity at ward level means that many medicine related problems are solved before discharge, minimising delays for patients. Activity has centred at or near admission (eg, taking medication histories). As well as identifying a number of clinical problems, PODs can be identified and checked for suitability for continued use both in hospital and on discharge.

Even patients who have not brought their medication with them can be assessed to see if they have sufficient supplies at home to continue therapy. If carried out early enough it will identify if dispensing is necessary at discharge. It also enables a replacement supply to be provided if necessary. The activity depends on staff availability so training electives and protecting senior staff's clinical time have helped facilitate this. Money from vacant posts is used to employ agency or "bank" locums to underpin core activity.

Controlled Drugs (CD)

A problem that applied to a relatively small number of TTOs was that junior doctors were not fully aware of the legal requirements for prescription writing. Despite information in the formulary and induction briefing, many CD TTOs had to be returned for correction. A new CD form was devised. to include detailed guidance for doctors; it is laid out in a way that guides them into entering the appropriate legally required information. TTOs containing a CD having to be re-written was formerly a common reason for the TTO being delayed and the incidence has much reduced.

Vacuum tube system

A vacuum tube system was installed throughout the hospital to receive TTOs and return suitable TTOs from and to wards. This reduced delivery time.

Impact

There is objective evidence for all these initiatives having a significant effect. An audit of TTO throughput was carried out for October 2001.

This was a particularly difficult month for the pharmacy as there were two weeks when locums were not available to cover basic activities and cover came from senior staff. It was also the month of half term, where demands on staff with children meant that there were higher than normal numbers were on annual leave.

Data for 953 TTOs were available for analysis. The mean time from receipt to ready was 1.68 hours (median time = 1.5 hrs, modal value = 0.1 hrs). The four-hour standard was met for 94 per cent of TTOs. (The four-hour standard was applied to all TTOs in the analysis and does not take into account TTOs that were not required within that period, had "dossette" boxes to be filled, required Controlled Drugs or were delayed because they had queries extant on them).

This compares favourably with November 2000 ( mean = 2.71 hrs, median = 2.5 hrs, mode = 1.6 hrs). In statistical terms this is highly significant (p < 0.00001). The four-hour standard was only met for 82 per cent of TTOs. A more detailed breakdown is provided in Table 1.

Key lessons

There are a number of lessons that can be learned from our experience:

1. Do not re-invent the wheel. Be prepared to use others' experiences and build on them.

2. One size does not fit all — be prepared to be flexible with thoughts and ideas.

3. Try to put patients' needs at the centre of the changes.

4. Dedicated resources are necessary.

5. Be prepared to take time and effort over the change; Rome wasn't built in a day.

6. Get support in the hospital at the highest level possible. Support from our Chief Executive was invaluable.

Thanks must go to the staff of the pharmacy departments at William Harvey Hospital in Kent and Guy's and St Thomas Hospital in London for their time and assistance.