Primary Care Pharmacy September 2000 Vol 1 No 4 p109-111
Articles
Assessing incoming discharge letters
By Jackie Duncan MSc, MRPharmS
A practice pharmacist describes a scheme for overcoming medicine-related problems arising after patients have been discharged from hospital
For the past three years, I have been working as a full-time practice pharmacist in a large urban general practice surgery in Dundee. I work at the largest single practice in Tayside, with a population of approximately 11,500 patients, looked after by six full-time partners, and a salaried general practitioner. The practice uses the New GPASS electronic medical record, which holds all appropriate clinical and prescribing information on individual patients.
The primary care pharmacists in the Tayside project (now known as Practice Pharmacists in Tayside [PPiTs]), of which I am one, was set up with funding from Tayside health board in June, 1997. The participating pharmacists were given a broad job description, which allowed them to develop their duties according to the needs of the practice. The primary and common objective was to improve the pharmaceutical care of the practice populations. This was to be achieved through:
- the promotion of rational, safe and cost-effective prescribing
- the monitoring of therapy
- the implementation of evidence based guidelines
- patient education and
- provision of advice to the primary health care team.
The transfer of prescribing information
Problems associated with the transfer between secondary and primary care of information relating to medicines, and vice versa, have long been recognised and pharmacists have addressed this problem using a number of methods. Work has been published that has concentrated on the transfer of information from secondary to primary care at the time of discharge from hospital.1-5 Despite these measures, patients continue to have medication-related admissions to hospital, an issue that we have recently been asked to address by the government.
Our surgery receives approximately 200 medication-related letters from secondary care services each month. These contain both discharge and outpatient appointment information. No defined procedure existed to address this information. Repeat prescriptions and ad hoc prescription requests were dealt with on a daily basis by one of three administrative assistants working on a rota system, none of whom have had any pharmaceutical training. A survey of activities identified that, in common with many other practices, the administrative assistant dealing with repeat prescriptions was often the person who generated the first prescription after a hospital visit or admission.6 On other occasions, particularly after outpatient visits, patients were required to make an appointment with their GP to request any changes in medication that had been recommended by the secondary care clinician. Occasionally, relevant information had not been received by the GP in time for this appointment.
In Tayside, patients are currently provided with seven days' supply of medicine on discharge from hospital. Their priority is, therefore, to obtain a further supply of the medicines that have been recommended by the hospital doctors before they run out. Since the full discharge letter is often not received by the surgery for up to 20 days after discharge, the interim discharge letter given to the patient to deliver to the surgery remains the main source of information in the first few days. However, important information regarding alterations in medication and diagnosis is frequently missing from the interim discharge document.
Many patients are seen at outpatient clinics where senior medical staff may recommend changes to the patient's medication regime. Some patients are given an outpatient communication slip, which advises the GP of recommended changes and may contain some preliminary information regarding diagnosis. This can be used as a request for new medication. The official outpatient letter, with a fuller explanation of the recommendations, can take up to six weeks to arrive.
The involvement of the pharmacist
Having realised the potential problems, and after discusssion with one of the partners, it was proposed to the other GPs that I assess all medication-related communication from the hospitals. Action would be taken on the recommendations made, computer and paper records would be updated and the patient provided with their first prescription, as appropriate, after this pharmaceutical check had been undertaken. I would then clarify the intended changes further with the hospital, if necessary.
The following procedure was set up to ensure that I saw all medication-related letters. Each morning, when the administrative staff opened and distributed the mail they scanned letters for any mention of medicines. Any that were medication-related were passed to me. I would act upon them as necessary before passing them on to the relevant GP.
The patient's current medication, as listed on the New GPASS record, was checked, and any prescriptions required generated. Where necessary, the hospital's recommendation was discussed with the GP. If the recommended change was considered to be appropriate, a prescription was produced. When it was not, the reasons were noted in the patient's notes and the hospital clinician contacted, if appropriate. When prescriptions had been produced, I contacted the patient (usually by telephone) and advised them of the change. This gave them an opportunity to discuss any questions or concerns they might have regarding their medicines. If a patient was known to use a monitored-dose device, the community pharmacist was contacted and informed of any change. This improved communication and reduced the possibility of errors being made in the provision of medicines. Before my involvement, community pharmacists often found that the first they knew of a change in medication was upon receipt of a prescription, with little, or no, supporting information. Formal lines of communication have now been established. Additionally, community pharmacists, are able to contact me at the surgery regarding any concerns they may have.
Record update
While new prescriptions are being generated, I make appropriate updates to the computer record. Where drugs listed on the repeat medication record have not been requested for the past six months, I inactivate the entry. This ensures that the patient cannot request another prescription without GP authorisation. It also means that it is not included on the repeat prescription list, which is often used by hospitals as a record of a patient's current medication. The result is an improvement in the medication history transferred from primary to secondary care. A summary of a patient's medical and prescribing history, containing information regarding inactivated repeat prescriptions as well as any prescriptions that have been provided on an acute basis, can be printed by the New GPASS system. This can be supplied when a patient is admitted to hospital, along with the request for admission, providing the secondary care team with a more complete history.
Pharmaceutical care issues
Various prescribing issues have been highlighted during this process. During the information collection period, 655 letters were collected. Of these, 411 letters required no action to be taken but the remaining 244 required at least an update of computer records. Of these, 33 pharmaceutical care issues (PCIs) were identified, assessed and categorised according to classifications defined and developed by me and colleagues from primary and secondary care.
Of the 33 PCIs, 12 required the generation of a new prescription. In addition, 11 involved inappropriate drug choice based on the patient's current condition or past medical history. Adverse drug reactions were identified in three instances and, as a result, yellow cards were completed and the medical records updated accordingly. Two patients were commenced on warfarin for thromboprophylaxis. This is occurring more frequently but information provided by hospitals is often poor. In the two cases above, no indication was given as to where the patient would have their warfarin monitored. We do not have an anticoagulant clinic in the surgery and the local health care co-operative (LHCC) is currently investigating a centralised primary care approach for management of these patients. Therefore, these patients were referred back to the hospital warfarin clinic and looked after by the surgery in the interim period.
The results of this project were presented to clinical pharmacists at the local hospital. In particular, the issue of warfarin initiation and monitoring was discussed. The hospital pharmacists are currently involved in the development of a warfarin monitoring chart for use on the wards. It is expected that a copy of this chart will be provided with the interim letter on discharge to ensure that information regarding the indication for and administration of warfarin is complete.
The recommendation for starting a new antidepressant in one patient led to the evaluation by myself of the drug from available information. My findings were circulated within the practice in the form of a new drug summary. This allows all members of the health care team to be informed of new developments and medical products, rather than just the individual to whom the letter was addressed.
Comparison with a similar period of time before my involvement at the surgery indicated 13 potential PCIs outstanding from 341 letters. Untreated indications were noted in five cases. One of these cases arose because of a lack of understanding by the patient of their medical condition and medication, which led to poor compliance. Becoming involved in the assessment of incoming medication-related mail allows a group of patients to be targeted for medication review and education, resulting in an improvement in the quality of care and concordance.
The GPs have expressed their appreciation and desire for my continued involvement in the assessment of medication-related mail. They have found that this process often highlights areas of new developments in medicine. We hope to address these in educational sessions. While it is difficult to prove without further research, it is felt that the quality of care provided to patients has also been improved. Patients themselves have not been asked for their opinion of the new service, as it was felt that much of it would be too "behind the scenes" for them to appreciate fully any changes. However, many more patients are now aware that there is a pharmacist in the practice available for the provision of advice on pharmaceutical matters and they use this resource well.
A good use of resources?
Should a pharmacist, who is a highly skilled and expensive resource to the NHS, be used to update computer records and provide patients with new prescriptions? This is a difficult question to answer. Would patients who require a greater understanding of their medicines and medical condition be identified if someone was not concentrating on these letters and the relevant patient notes? Many of these patients are being seen regularly by hospital clinicians but are they getting any additional benefits from the involvement of a pharmacist? Currently, only one of our local outpatient clinics has formal, regular input from a clinical pharmacist.
By assessing all medication-related mail coming into the surgery, I am providing pharmaceutical care to a wider group of patients than might otherwise be highlighted by auditing specific areas of prescribing. Additionally, benefit is extended to those patients who profit from the provision of information to the GPs. Computer record updating can be done by administrative staff but I feel that it is appropriate and worthwhile for pharmacists, with their expertise in pharmaceutical science, to be involved in the assessment of letters for PCIs and the provision of up-to-date information to GPs.
In time, computerised transfer of data across the primary/secondary care interface and within primary care may provide the opportunity for other pharmacists, for example, the patient's community pharmacist, to provide the pharmaceutical check on the recommended changes in medication. If information regarding diagnosis and medical condition are provided, it may open a doorway to pharmacist prescribing in accordance with the Crown Report. In Tayside, we are already able to access the hospitals' laboratory data from GP surgeries. Maybe this "brave new world" is not so distant.
Acknowledgement: the author would like to thank Anne Boyter and Lorna Scahill for their part in supervising this project.