Utilising the skills of the clinical pharmacist within the MDT for improved medicines optimisation

The aim of this project was to change the way in which the pharmacists work, to integrate them in to the multi-disciplinary team and to ensure medicines optimisation for patients at the earliest opportunity. Clinical pharmacists are a useful members of the multidisciplinary team and are responsible for ensuring the prescribing of medications is appropriate, complies with local and national guidelines and above all, safe. The most common interventions made on the surgical wards revolve around the prescribing of venous thromboembolism prophylaxis and antibiotic prescribing.

The intention of integrating the pharmacists in to the daily ward rounds with the surgical team was to improve compliance for prescribing against the relevant guidelines in these areas.

The hope was that the presence of the pharmacist would ensure prescribing of medications was correct and appropriate within the first few hours of the patient’s hospital admission. Also, where Independent Prescribing (IP) pharmacists were able to attend the ward round they could facilitate a timely discharge from hospital through the prescribing of discharge medications at the end of the ward round.

The role of the clinical pharmacist at WSHT has traditionally been reactive rather than proactive. Pharmacists visit wards and screen drug charts using information gleaned from medical notes, nursing handovers and various IT programmes (e.g. for blood results and physical observations).

Using this information, pharmacists scrutinise the electronic drug charts and record potential issues, such as drug interactions and inappropriate dosing. They will also look to ensure medicines reconciliation has been carried out and contact the prescriber where there are discrepancies between the drug chart and the medicines reconciliation.

This process can be time consuming and pharmacists often have to contact doctors to confirm details of treatment plans for patients. Where the prescriber is not available they will document interventions in the medical notes and on the electronic drug chart. These notes are often unintentionally overlooked by the medical team which leads to a delay in the appropriate update of medications.

Many of the interventions made by pharmacists follow the same themes; most commonly, poor compliance to the Trust VTE prophylaxis guidelines and NICE’s CG92 recommendations for ensuring assessment and prescribing of VTE prophylaxis for all patients takes place as appropriate.

A baseline audit showed that as many as 33% of surgical patients did not have a full VTE assessment on admission and approximately 20% of patients did not have appropriate VTE prophylaxis prescribed. Another common theme centres around the appropriate prescribing of antibiotics. With antibiotic awareness at the forefront of the NHS and worldwide health agenda, it is essential that the antibiotics are prescribed in line with the trust formulary and reviewed regularly. This is highlighted in NICE’s guidance for antimicrobial stewardship (NG63).

As a dual-site trust we decided to trial the project on one site. The project was proposed to the consultant team on the chosen site (St Richards Hospital) and it was decided that the pharmacist input would be most beneficial on Mondays (to catch patients who were admitted over the weekend) and Fridays (to help facilitate discharge of patients before the weekend).

Three senior pharmacists took it in turns to attend the ward rounds on the proposed days of the week from July 2017. An intervention log was kept for each ward round. The intervention log specifically recorded interventions made by the pharmacist which directly improved compliance with NG5, NG63 and CG92.

Initially the role of the pharmacist on these ward rounds was not fully understood by the consultant team. However, within the first month of regularly attendance the consultants described the role of the pharmacist as essential and requested pharmacist to attend the ward round every day of the week.

The intervention data was presented to the cross-site surgical directorate meeting where a plan was made to roll-out the ward rounds to the Worthing Hospital site and also to try and increase the ward rounds at St Richards to daily.

Interventions will continue to be recorded using a simplified checklist on all ward rounds attended by a pharmacist. This will demonstrate the continued value of the role of the pharmacist and also to act as a prompt for the pharmacist in reviewing patients. Pharmacy colleagues working in clinical areas outside of surgery have used our model to initiate pharmacist participation in ward rounds. The result is an increase in compliance against NG5 in all acute inpatient areas across the Trust.

• A pharmacist attended the Monday and Friday post-take ward round (PTWR) 3^rd July -6^th November 2017.
• A pharmacist was available to attend 30 of the 37 PTWR’s that took place between these dates.
• Non-attendance was due to lack of staff availability (sickness, staffing pressures, annual leave).

Total number of patients seen on 30 PTWR: n=492

Total number of interventions: n=625

Interventions per patient: n=1.3

Antibiotic Interventions

• Total number = 105
• Main interventions include;
• Review to stop antibiotics.
• Prescribing of gentamicin to AMG protocol for intra-abdominal sepsis.
• Switch from IV to PO.

Significant interventions

• Patient treated for abdominal sepsis but no signs of infection. On teicoplanin and metronidazole. Stopped all antibiotics.
• On one round three patients on abdominal sepsis treatment but not prescribed gentamicin. Gentamicin added and discussed with team the importance of gent to ensure adequate cover
• Patient complaining metronidazole upsetting her orally so was given intravenous broad spectrum antibiotics. Actually patient’s oral antibiotics were prescribed 8 hourly and she had had a dose given at 2am on an empty stomach which would have caused the nausea. Suggested rather than changing regime to change schedule and counselled patient to take with food.
• Patient admitted with hiatus hernia. She mentioned having a cough on round and was diagnosed with suspected community acquired pneumonia. Consultant wanted to prescribe amoxicillin but the pharmacist pointed out a penicillin allergy and recommended an alternative regimen.

VTE Interventions

Total number of interventions relating to VTE: n=86

VTE risk assessment prompt: n=35

VTE Prophylaxis initiated: n=42

VTE dose adjustment: n=9

Significant interventions

• Patient due for discharge who had not received their usual warfarin during admission. Medicines reconciliation completed. Discussion with anticoagulation clinic regarding appropriate dose for discharge and plans for INR check in community. All completed by the pharmacist to prevent delay for discharge.
• Patient diagnosed with bilateral pulmonary embolisms. Dose of VTE prophylaxis drug too low for patient weight. Changed by the pharmacist.
• Patient admitted with rectal bleed. Usually takes warfarin for metallic heart valve. In A&E the patient had been review by a haematology consultant who wanted warfarin to continue alongside tranexamic acid. During the ward round the pharmacist notices the warfarin had not been prescribed for the previous 48 hours. Drug history completed. Warfarin added to drug chart. The pharmacist advised team to contact haematology with regards to cover until INR back in range. The junior doctor contacted haematology and patient was prescribed an iron infusion and a higher dose of VTE prophylaxis.

Pharmacist Interventions

• Ensure safety and improve quality and continuity of care.
• Demonstrates the role of the pharmacist’s professional input into the multidisciplinary team.
• Allows for a critical review of prescribing for newly admitted patients.
• Allows for monitoring of near-misses in relation to the prescribing and administration of medication.

Moving Forward

• PTWRs are being rolled out across both sites at WSHT in to other acute inpatient areas.
• We have increased the number of prescribing pharmacists within the Trust to increase the number of significant interventions possible on ward rounds and improve the timeliness of interventions.

Colleagues outside of pharmacy had difficulty in understand the clinical value of the pharmacist attending ward rounds until the benefit was demonstrated to them. This should not deter pharmacy teams from implementing these changes. The impact that the pharmacist had on the MDT was significant and considered essential within a very short space of time.

As the project has progressed the traditional role of the pharmacist has evolved and become closely aligned with Carter Report recommendations. The impact on patients has been to improve safety and improved processes around discharge in terms of efficiency and communication. This is forming the basis for future Advanced Practitioner roles for pharmacists within our Trust.