Medicines Management
Issue no 3, p13-14
May/June 2002
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Medicines Management |
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Features |
Integrated medicines management breaks new ground in N. Ireland
Medicines management involves "the systematic provision of medicines therapy through a partnership of effort between patients and professionals to deliver best patient outcome at minimised cost"1. This requires selection of the most appropriate products for individual patients and ensuring that they are able to use them effectively. One of the areas where numerous problems have arisen in the past is at the hospital-community interface. Typically, there have been communication problems, because of difficulties in transferring information to all the relevant parties, and problems relating to products and brands, because different products or brands are stocked in different sectors. 
Previous projects in Northern Ireland have demonstrated the value of pharmaceutical services in medicines management. These have included improvements in patient education and compliance,2 reductions in costs and length of stay3 and improved hospital-community pharmacy liaison4. One of the most overlooked elements in the process is the appropriateness of the medicine prescribed. Many previous studies have focused on improved knowledge of medicines, and/or improved compliance. However, one of the underlying principles of medicines management is that the most appropriate medicine is selected for patients before any further steps are taken. It has been argued that if this is not done then any subsequent efforts may be misdirected, at best.5 Funding for project In 2001, funding was obtained from the Department of Health, Social Services and Public Safety under their Executive Programme Fund Scheme, to appoint a team of pharmacists and technicians to implement a medicines management project as part of the routine pharmacy service. This project, which started in late summer 2001, set out to pull together medicines management activities across the community-hospital interface and also to implement standardisation of some products in use in both sectors. A project steering group of leading pharmacists representing the stakeholders was set up. The project was endorsed by the Northern Area Prescribing Forum, a multidisciplinary group that agrees and oversees medicines policies and guidelines. The interface sub-group of the NAPF was particularly involved in working out the mechanisms of the project, especially with regard to product standardisation. Community pharmacists have been involved in the project both via the local primary care commissioning pilots and locality groups, and via the board's director of pharmaceutical services. Product review A contributing factor to interface problems is the use of different brands or products in each sector. For this project, a number of commonly-used branded products were identified, where significant savings could be made by adopting a single product across both sectors. In the first instance products were selected that were widely used in primary care, were relatively easy to adopt and that did not compromise contracting obligations in the hospital. Examples include Peptac (sodium bicarbonate, sodium alginate and calcium carbonate indigestion preparation) and Adcal (calcium carbonate) tablets. Seven different products were selected. It is anticipated that this initiative will result in savings of more than £250,000 annually. In addition, problems encountered by patients with product changes at the interface will be eliminated in these cases, thereby reducing risk of medication errors. Interface communications A key element of this project is improved communications at the hospital-community interface. When patients are admitted to hospital complete records of their current medication are obtained by the pharmacy staff responsible for medicines management. This is achieved by obtaining records from the GP by electronic screen dump, by requesting GP records by fax and from the community pharmacy by fax. The information is correlated with patients' own drugs (PODs) brought in on admission) and by questioning the patient/carer, to determine an accurate medication record. This approach enables clinical pharmacists to identify patients' medication-related needs immediately and avoids delay and potential confusion, which may lead to medication errors. When a patients is discharged from hospital, information is sent by fax to both the GP and the patient's nominated community pharmacy. This includes information about medication changes that have been made during the hospital stay and the reasons for those changes. This is an essential provision to avoid the types of errors that have commonly occurred in the past, such as reverting to previous doses or treatments or, indeed, duplicating treatment. Controlled evaluation Patients who meet the project criteria are randomly allocated into treatment and control groups and a number of output measures are being collected, such as medication appropriateness, number of interventions made, accuracy of medication records and improved ward ordering (eg, reduction in numbers of orders raised). During the hospital stay the supply of medicines is managed by pharmacy technicians. This involves compiling a medication history from the PODs, GP records, community pharmacy records and patient/carer. On admission an algorithmic approach is used by project technicians to assess the safety and suitability of PODs for return to the patient at discharge — if required. On a day-to-day basis the technician checks the patient's kardex for new medicines and makes a supply if necessary. Technicians also ensure that all medication is transferred with the patients if they are moved to another ward. The clinical pharmacist first of all ensures that the medication history is accurate. Then he/she monitors all therapy during the patient stay, recording any interventions that are necessary, in addition to carrying out in-patient counselling (this focuses on drugs that have been added, use of devices and high risk drugs) and, finally, preparing the discharge prescription. All relevant information is recorded on a working pharmaceutical care plan. In respect of inhaler devices, all counselling and assessment of clinical appropriateness is carried out by technicians who have undertaken specific training. The value of discharge prescriptions prepared by clinical pharmacists is being assessed by comparing the number of interventions required for these with those for discharge prescriptions written by junior doctors. On discharge a medicines record sheet is prepared for all patients. A further assessment is being made on appropriateness of medicines on admission and on discharge using a validated medication appropriateness index (MAI)6. This index uses criteria such as clinically significant drug-drug interactions, dosage and duplication of therapy. A further stage of the project will entail the implementation of an antibiotic switch policy with respect to respiratory and urinary tract infection. It is hoped that this will lead to improved use of antibiotics, particularly in relation to intravenous doses. Expectations We hope that the Integrated Medicines Management Project will provide robust evidence for the effectiveness of co-ordinated pharmacy services. So far, there has been positive feedback from both medical and nursing staff with respect to the new system. The MAI has demonstrated, in some early assessments, an improvement in appropriateness of medicines on discharge compared to admission. Numbers and value of ward ordering has been reduced, with resulting better use of pharmacy and nursing staff time. It is expected that the project will improve medicines management in terms of risk and optimisation of therapy, as well as having economic benefits. On the basis of the evidence collected, it is envisaged that all the key facets of an optimal medicines management system will be identified and subsequently an action plan devised to put it in place. A full report of the project will be submitted for publication in due course.
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