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The challenge

Hospital pharmacists provide pharmaceutical care by checking prescriptions, working with doctors and nurses, and counselling patients on their medicines, There is increasing interest in identifying those patients who would benefit the most from the pharmacist’s intervention, typically based on a variety of metrics extracted from  patient records (digitally or otherwise). What is missing from this important development is how hospital staff and patients perceive and view this idea that pharmacists will prioritise some patients ahead of others.

The proposal

Hospital clinical pharmacists provide many pharmaceutical care activities at different steps of the medication process for inpatients, with the aim of optimising drug therapy and improving medication safety. This typically includes medication reconciliation at hospital admission and medication review prior to hospital discharge. However with ever-increasing demands on the pharmacy service there is a need to understand how efficiency can be improved while maintaining the aim of ensuring that medicines are used safely and effectively.

The traditional approach of pharmacists working through the hospital on a bed-by-bed basis to provide their services is receiving much scrutiny.  Clinical prioritisation has been suggested as a means to focus pharmacy services on those patients with the greatest need for pharmaceutical care. This could involve high risk patients being reviewed daily by a pharmacist, medium risk patients every other day and low risk patients perhaps reviewed less frequently or by a pharmacy technician.

A consequence of using a prioritisation tool is that it would direct the pharmacy team away from patients who were deemed to be low risk. However, the unintended consequence is that the opportunity for pharmacist intervention would be removed from these patients even though they may have a medication safety risk factor that is unidentified by the prioritisation risk model.

So far most existing tools have been developed locally using professional (and mainly pharmacist) opinion, and robust validation of the effectiveness of these tools is rare. Currently quantitative research in the UK and elsewhere is looking to develop a prognostic model which can be used to target or triage patients most in need of pharmacists’ input while in hospital.

We wish to understand how staff and patients feel about the use of technology to help relieve workload pressures within the clinical pharmacy department, and so enable us to better support patients with improved medication safety and medicines optimisation.  As a Trust that has access to data generated from our electronic prescribing, electronic observations and pathology systems as well as the clinical data analysis resource necessary to combine this information, we are able to extract various patient specific parameters from a range of digital records. These can then be collated to produce a patient risk score and so enable pharmacists to prioritise their workload. Until now though this developmental work has been mainly led by the pharmacy team and we want to get a much broader view of this possible approach.

Hospital management, medical, nursing staff, and the pharmacy team will be interviewed, either individually or as part of a focus group. We will also involve commissioners via the local CCG Prescribing Team.

We will also undertake interviews with patients, identified through our hospital patient experience team and/or via the R&D patient involvement group.

The key areas of interest relate to:

  • ·       The principle that hospital pharmacists should prioritise their work seeing some patients in advance of others, and seeing some patients less often during their hospital stay. What do hospital staff and patients think of this concept? For instance, managers might see this drive for efficiency as an imperative whereas healthcare professionals may argue that all patients should have the opportunity to be seen by a pharmacist.
  • ·         What do the pharmacy team, who will be expected to follow the tool (the scoring and ranking of patient risk) in their daily work, think of this concept? There has been some previous work showing that pharmacists feel confident about using such a tool, however, the use of professional judgement may override what the tool expects that pharmacist to do.  Is this finding correct? We want to explore in detail with our pharmacy team how they feel about the use of such a tool, especially if the next step in the ‘efficiency’ drive would be to monitor their performance against the tool.
  • ·         The components that make up the prioritisation tool. Do healthcare staff and patients perceive these suggested parameters as clinically valid and reliable in identifying high risk patients for pharmaceutical care?  Most of the tools that are being used elsewhere tend to be developed with mainly pharmacy input with little input from non-pharmacy staff. Because there has been little robust validation of the existing tools, it may be that medics and nurses would argue for more or less or very different components to be included in the tool.
  • ·        How do patients feel about the pharmacist possibly being directed away from seeing them in order to see another ‘more important’ patient? This is an opportunity for co-design of such a tool.
  • ·        We would also wish to gather views from the wider healthcare community – do general practitioners and pharmacists working in general practice and in the community recognise the need for a prioritisation tool does the hospital view of a priority patient resonate with primary care?

Learning will be shared to encourage spread to other organisations considering their own prioritisation process, including those planning any quantitative investigation.

How you can contribute

Are any of the Q community (who may be doing either similar qualitative or separate quantitative pieces of work) interested in collaboration?

How you can contribute

  • It would be great to have suggestions from colleagues who have experience of such a prioritisation tool.
  • What other qualitative aspects should we be shining a light on?
  • Are any of the Q community (who may be doing either similar qualitative or separate quantitative pieces of work) interested in collaboration?

Comments

  1. This looks like a useful way to prioritise pharmacy interventions using pharmacy, multi-professional and patient input. I'd be interested to know whether it is possible to validate the risk profiling using subsequent incident data or patient outcomes. It would be especially useful in environments where pharmacy resource is limited and could also potentially support a need for increased input.

  2. I think this is a really interesting idea and very timely as especially as a perceived benefit of EPMA is it's ability to support triage of patients needing pharmacist review. And as you have alluded to, it's often that these tools are designed by pharmacists with no input from the wider healthcare team. I'd be interested to see how this develops.

    1. Thanks Angela. That is our perception - in the main this notion of prioritisation of patients is through the pharmacists' 'lens', and we wish to take a reality check on that.

  3. Thanks Karen

    We would wish to consider the views of all those potentially affected by any changes to the prioritisation of clinical pharmacy services, including carers, though we are not sure how much of a direct impact there would be on the whole discharge process.

  4. I notice that throughout you don't mention carers at all (family and friends providing care), although you've mentioned healthcare professionals in the community as well as in the hospital. Carers might particularly have a view around discharge from hospital.

  5. It might be worth talking with Q member Cleo Butterworth, who convenes the pharmacy-related Community of Practice at the S London AHSN. She's also doing important work on patient safety culture.

    I'm personally getting a bit wary of some of the rational and efficient approaches - the 'drive for efficiency' that you mention.
    The Buurtzorg community care model breaks many of the rules of efficiency, yet seems to have better outcomes, happier users and lower costs. It might be a bit too far out of the box, but it's interesting to realise that *very* different approaches can prove to be far better.

    1. Thank you. We will look into this and make contact

  6. Thanks Pinkie. We understand  that Bryony is currently looking at some quantitative work on this topic in a hospital setting, and we are keen to work collaboratively if possible.

  7. Hi

    Think this is great.  There was an NIHR clinical doctoral research fellowship that was supervised by Bryony Franklin in the community that will really help you.

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