Prescribing & Medicines Management
page PM1
September 2005

Features

Helping to avoid hospital admissions

A number of initiatives and pilot sites have been set up in hospitals and primary care trusts across England to address how better medicines management can help reduce the number of medicines-related hospital admissions. The initiatives are supported by the National Prescribing Centre (NPC) medicines management team and are mainly aimed at patients at high risk of readmission. It is known from the national service framework document “Medicines and older people” that problems with medicines are implicated in between 5 and 17 per cent of hospital admissions. In vulnerable groups, such as people over 75 years of age, the number may be even higher.

According to Richard Seal, director of medicines management, NPC: “Better medicines management in both primary and secondary care can help reduce the number of people admitted to hospital as a result of a problem related to their medicines”. Although it is sometimes difficult to attribute an admission to medicines, the primary reason may be medicines-related, he says. For example, a patient fractures a hip as a result of a fall that was precipitated by the drugs being taken.

Mr Seal also points out that people are not only “admitted to hospital as a result of medicines-related problems but they are also readmitted.” Patients spend a few days in hospital, their “medicines are perhaps not sorted out in a way that would be best for them and they end up coming back shortly after discharge,” he explained. This has a knock-on effect on blocking beds and access to services. However, in terms of the initiatives that are under way in cooperation with the medicines management collaboratives to improve the situation, Mr Seal added: “What will surprise some, perhaps, is the amount of good work that is already going into making sure that these vulnerable people do not end up being readmitted again and again for similar problems.”

Elizabeth Witherington, a doctor at Nottingham City Hospital, has been working alongside pharmacist Emma Grace, in collaboration with the Hospital Medicines Management Collaborative (HMMC), to try to reduce the chance of patients over 75 years of age being readmitted to hospital after discharge because of medication issues. Dr Witherington said that the readmission audits she has been involved in showed that patients were running into problems with their medicines within four days of discharge.

Better records

The audits carried out so far at Nottingham City Hospital show that at every step of the admissions and discharge process, health care professionals are making assumptions about patients’ medicines (eg, when reviewing drug histories or writing a TTO). This results in opportunities for error not only during the patient’s stay but also when the patient goes home. Dr Witherington said that better ways of recording medication changes as people go through their hospital stay are needed so that it is easier to compile on discharge an accurate record of which medicines have been started or stopped. She encourages TTO forms to be thought of as “a referral to primary care” rather than a record of a patient’s stay.

In addition, discharge information should include base line parameters. For example, for patients taking antihypertensives, blood pressure readings before discharge should be included so that GPs can continue to monitor the patient appropriately.

Another problem is that TTO forms could “be processed in GP practices by receptionists who have little or no knowledge of drugs” and are unaware of medicines being stopped or doses changed, she said. Other medicines management issues that need addressing include medication compliance — found in one audit to be a contributory factor in 12 out of 41 readmissions — and identifying on admission whether or not people are taking over the counter products such as herbal medicines.

At George Elliot Hospital NHS Trust, Warwickshire, a patient’s own drugs (PODs) scheme is running on five wards. Patients are being encouraged to bring their own medicines into hospital and the use of a green bag is being promoted to help them. Bags are available free on hospital wards and from the trust’s pharmacy and accident and emergencies departments, in local ambulances, nursing homes and shelters, local Age Concern shops and social services. According to Melanie Liggins, HMMC project facilitator for the trust, the bags help achieve proper drug history taking on admission, which is one way hoped to avoid readmissions.

Another aim at George Elliot Hospital NHS Trust has been to increase patients’ knowledge about their discharge medicines. Thirty patients were followed up at home one month after discharge to assess how much knowledge they retained about their medicines. According to Mrs Liggins, the audit identified that patients are not told much about their medicines when they leave hospital, unless they are on a PODs scheme ward. To help rectify this, a medicines information card, which is completed by a pharmacist or pharmacy technician when counselling patients on discharge, has been piloted on these wards.

Redditch and Bromsgrove Primary Care Trust has been working with vulnerable patients to enable them to take their medicines appropriately and to understand them better. Such patients are identified just before discharge from the local community hospital by an acute trust pharmacist, a PCT pharmacist or a pharmacy technician. Post-discharge, a medication review may be undertaken by the PCT pharmacist. If a compliance aid, such as a medicines reminder chart or medicines dosage system, is required, the patient is admitted onto a vulnerable patients’ scheme whereby a community pharmacist of the patient’s choice is asked to take over his or her pharmaceutical care. An audit carried out at the end of last year showed that interventions were made for 91 out of the 111 referrals to the scheme. Sue Bosworth, the PCT medicines management project and development manager, told The Journal that through this scheme hospital medicines-related readmissions have been prevented. It has enabled health professionals to work in partnership with patients, which helps reduce the risk of problems with patients’ medicines, Ms Bosworth added.