Posters Practice Development and Audit - Wiley Online Library

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International Journal of Pharmacy Practice 2011; Supplement 2

• the prevalence of patients over 65 years with a documented eGFR < 60 ml/min/1.73 m2 on drugs not recommended to be prescribed, or which need an altered dose. (the searchable measure ‘eGFR < 60 ml/min/1.73 m2’ is as used to stage chronic kidney disease in the NICE guideline 733) • which drugs are prescribed outside the recommended use in this population?

IJPP 2011, Supplement 2: 38–64 © 2011 The Authors IJPP © 2011 Royal Pharmaceutical Society

Methods

Posters Practice Development and Audit Abstract 31 Are we over-dosing our elderly patients with renally excreted drugs in primary care? S. Wood, D. Petty, L. Glidewell and T. Raynor The University of Leeds, Leeds, UK

Patients aged 65 years and over with the latest documented eGFR < 60 ml/min/1.73 m2 at five Bradford GP practices (all at one practice and a 10% random sample at four) were included. The creatinine clearance was calculated for each patient using the Cockcroft & Gault formula (the formula used in drug company dosing recommendations and which has also been shown to be a better estimation of renal function in older patients4) and the repeat medication list was assessed for appropriateness of drug use and dosing, assessed against the recommendations given in the British National Formulary and the Summary of Product Characteristics (SPC). As this was an audit on existing data measured against standard recommendations, ethics approval was not needed.

Results

Focal points • An audit was undertaken to indicate whether there is a problem with drug use and dosing in the reduced renal function of the elderly in primary care. • It was found that 25% of elderly patients with eGFR < 60 ml/ min/1.73 m2 were on repeat medication which required to be discontinued, switching to an alternative suitable drug or requiring a dose reduction, with lipid lowering drugs accounting for 30% of errors, ACE/ARBs 26%, thiazides 17% and osteoporosis drugs 14%. • Renal impairment does not seem to be sufficiently taken into consideration when prescribing medications for elderly patients in primary care.

Introduction Renal function naturally reduces with age1 leading to decreased clearance of renally excreted drugs, increased plasma levels and reduced renal reserve to counter any nephrotoxic effects of drugs or disease and acute kidney injury. Evidence from secondary care has found that reduced renal function contributes to adverse drug reactions (ADRs) and hospital admissions; in one study, a third of ADRs causing hospital admissions of elderly patients were related to impaired renal function, generally in very elderly women2. There appears to be no published research in the UK in primary care on the adherence to recommendations or the impact of prescribing in elderly patients with reduced renal function.

Research question and objectives The aim of this project was to investigate ‘Is there a problem with drug use and dosing in elderly people with reduced renal function in primary care?’ A practice audit was conducted to assess:

There were 594 patients aged 65 yrs or over with a documented eGFR < 60 ml/min/1.73 m2 reviewed and 25% were found to be on medication which required to be discontinued, switching to an alternative suitable drug or requiring a dose reduction (range 18–34%), with a further 4% on drugs needing review (overall patients on drugs requiring alteration or review range 24–34% across the five practices). Seventy different drugs were identified to need discontinuation, dose alteration or review. Lipid lowering drugs accounted for 30% of errors, ACE/ARBs 26%, thiazides 17% and osteoporosis drugs 14%.

Discussion Renal impairment does not seem to be sufficiently taken into consideration by prescribers when prescribing medications for elderly patients in primary care. A research project is needed to investigate why prescribers do not follow recommendations for drug use in reduced renal function and what interventions may help improve this aspect of prescribing for the elderly in primary care.

References 1. Brown WW, Davis BB, Spry LA et al. Aging and the kidney. Arch Intern Med 1986;146:1790–6. 2. Helldén A, Bergman U, Hentschke M et al. Adverse drug reactions and impaired renal function in elderly patients admitted to the emergency department: a retrospective study. Drug Aging 2009: 26; 7(12); 595–606. 3. NICE clinical guideline 73 Chronic kidney disease. Available at http://guidance.nice.org.uk/CG73 accessed 1 Jun 2011. 4. Pequignot R, Belmin J, Cauvalier S et al. Renal function in older hospital patients is more accurately estimated using the CockcroftGault formula than the modification diet in renal disease formula. J Am Ger Soc 2009: 57(9); 1638–43.

© 2011 The Authors. IJPP © 2011 Royal Pharmaceutical Society 2011 International Journal of Pharmacy Practice, 19 (Suppl. 2), pp. 38–64

Posters

Abstract 32 The development of a sublingual glyceryl trinitrate (GTN) advice card in collaboration with coronary heart disease (CHD) patients R. Khatiba,b and C. Keenana a Leeds Teaching Hospitals NHS Trust, Leeds, UK and bUniversity of Leeds, Leeds, UK

Focal points • We investigated whether CHD patients favoured a GTN advice card as a reminder on how to use GTN. • We involved patients in developing the card and compared their recommendations to those made by healthcare professionals (HCP). • The majority favoured the idea and made several recommendations different to those made by HCP. • The project showed that patient involvement in developing patient information is invaluable.

Introduction The most common symptom experienced by CHD patients is chest discomfort or pain which is commonly managed by GTN. Good knowledge of how to use GTN promotes improved self-management of the disease, good quality of life and decreases complications.1,2 Studies show that GTN is not used correctly and recommend reinforcing correct GTN use.1,2,3 Patient involvement in developing health services has positive outcomes.4 In our hospital we developed a GTN advice card in collaboration with CHD patients to help them recall how to use GTN at the point of need.

Methods Through convenience sampling, we asked 21 CHD patients attending an elective pre-angioplasty assessment clinic and prescribed GTN for at least 3 months about the idea of a GTN card and its content. Ten members of the cardiac rehab team (nurses, doctors and pharmacists) also provided their recommendations. All points considered practical, relevant and essential for patients to remember to ensure correct GTN use were chosen. Points deemed less relevant at the point of GTN use were eliminated. A further 20 patients with the above criteria reviewed the final draft. In accordance with the hospital’s R&D guidelines, this service development project did not require research ethics approval.

Results Of the 21 patients, 15 (71%) favoured the idea and 1 (5%) did not without giving a reason. The remainder did not comment or suggest an alternative. Five patients said that information about GTN use should be readily available. All 20 patients who evaluated the final draft thought that all information included was necessary and that it would be useful and practical reminder. One patient said that GTN expiry date should be checked. A double sided A7 size card was designed and printed in line with the recommendations. Table 1 lists the recommendations.

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Table 1 Recommendation of What Should be on the GTN Card (Ranked according to frequency mentioned) Patients (n = 21) The 15 Minute rule (5), Carry GTN at all times (5), Keep more than one GTN bottle (4), Do not hesitate to use it (4), Next of kin contact no (3), Instructions dialling 999 (2), Sit down & expect to feel lightheaded (2), Not to swallow (2), Make sure door unlocked (2)

HCP (n = 10) The 15 Minute rule (10), Instructions dialling 999 (10), Make sure door unlocked (6), Carry GTN at all times (5), Sit down & expect to feel lightheaded (4), If mouth dry, sip water to help dissolve tablet (2), Expiry (2), Can spray on tongue (1), Never use GTN with Viagra (1)

Discussion Despite an overlap between the recommendations, patients and HCP identified some different points. Patients emphasised that GTN is used on a “when needed” basis and information related to its use should be readily available. A small GTN card that can be carried at all times would be helpful. The 15 minute rule on how to use GTN was mentioned most frequently. Based on their personal experience with GTN, patients highlighted important practical issues and made invaluable contribution. We recommend that patients should be more involved in developing patient information. Further research is needed to explore some of the patients’ comments, such as their recommendation not to hesitate using GTN during an angina episode. Issuing GTN cards to patients started on GTN will be assessed in the future to evaluate impact on its correct use.

References 1. Kimble L, Kunik C. Knowledge and use of sublingual nitroglycerin and cardiac-related quality of life in patients with chronic stable angina. Journal of Pain and Symptom Management 2000; 19:109–117. 2. Fan M, Mitchell M, Cooke M. Cardiac patients’ knowledge and use of sublingual glyceryl trinitrate (SLGTN). Australian Journal of Advanced Nursing 2009;26:32–38. 3. Ingram S, Love J. Cardiac patients’ perceived education and use of sublingual glyceryl trinitrate on commencement of outpatient cardiac rehabilitation. Coronary Health Care 1999;3:128–134. 4. Department of Health. Patient & Public Involvement in Health: The Evidence for Policy Implementation. 2004. http://www.dh. gov.uk (Accessed 27 Feb 2011).

Abstract 33 Reasons for requesting and patient satisfaction with a free, non-NHS, community pharmacy-based vascular risk assessment (VRA) service S. Waheedia, M. Donovanb, R. Walkera,c and D.N. Johna a Welsh School of Pharmacy, Cardiff, UK, bBoots, Wales, UK and cWelsh Assembly Government, Wales, UK

Focal points • Reasons for requesting and patient satisfaction with a free, non-NHS, community pharmacy-based VRA


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service in South Wales were obtained via an anonymous survey. • There was high satisfaction with and acceptance of the VRA service from 124 (74%) patients. • Further research is warranted using larger numbers of subjects and pharmacies.

Introduction To implement a cardiovascular disease prevention strategy1,2 VRA services have been introduced in a variety of settings. VRA services are available via local enhanced services in some pharmacies in England,3,4 but not in Wales. Satisfaction with such services has not been reported to a significant extent. The objective was to identify reasons for requesting and patient satisfaction with a free, non-NHS VRA service provided by two community pharmacies in Wales.

could have been better’ with eight giving suggestions relating to measurement (n = 1), consultation area (n = 3), eligibility (n = 1) and additional components desired of the VRA (n = 3).

Conclusion Although the response rate was high, a limitation that may affect generalisability is that non-responders may have held different views. Using anonymous questionnaires prevented linking the data with the results. Although others4 have shown community pharmacy VRAs attracted high numbers of clients from varied backgrounds, they did not report patient satisfaction or reasons for choosing to have a VRA at a community pharmacy. However, this preliminary study has demonstrated high user satisfaction and acceptance of a free, non-NHS VRA service from pharmacies in Wales. Further research using larger numbers is warranted.

References

Method The local NHS ethics committee indicated this was a service evaluation although university ethics committee approval was obtained. From November 2009 to August 2010, all patients (n = 172) who had undertaken a VRA were provided with a self-complete, anonymous questionnaire. They were requested to return the completed questionnaire in a freepost envelope as soon as practicable after the VRA. The questionnaire was designed following a literature review and input from pharmacists with community and public health backgrounds. It contained sixteen 5-point Likert scale statements relating to reasons for requesting and satisfaction with the VRA. Open questions asked for suggestions for improvement and invited other comments.

1. NICE (2008). NICE clinical guideline 67: Lipid modification. [Accessed 9 Feb 2011] 2. Department of Health (2008). Putting prevention first: Vascular Checks: risk assessment and management. 2008 [Accessed 12 April 2011] 3. PSNC. Vascular risk assessment (vascular checks). [Accessed 12 April 2011] 4. Horgan JMP, Blenkinsopp A, McManus RJ. Evaluation of a cardiovascular disease opportunistic risk assessment pilot (‘Heart MOT’ service) in community pharmacies J Public Health 2010; 32: 110–116.

Results 127/172 patients who accessed the service returned questionnaires (74%), 74 being female (58%). Fifteen (12%) were 50%, four meeting >70% and one meeting >80% of the criteria. The majority of leaflets (25/26) and websites (7/10) reviewed were only available in English.

Discussion Although it is well recognised that patient and public education plays an important role in reducing the long term morbidity and mortality associated with diabetes, there appears to be little good quality printed material available from pharmacies in Leicester. Diabetes is more prevalent in ethnic minorities and this study has shown that there is limited information readily available in alternative languages. Research suggests tailoring education to individuals’ culture and specific needs improves their treatment and control of their type 2 diabetes3. This work suggests that the availability of information through community pharmacies could be improved.

References 1. National Institute for Health and Clinical Excellence. Type 2 Diabetes (CG66). London: NICE, 2008. 2. Davies M.J., Heller S., Skinner T.C., Campbell M.J., Carey M.E., Cradock S., Dallosso H.M., Daly H., Doherty Y., Eaton S., Fox C., Oliver L., Rantell K., Rayman G. & Khunti K. (2008). Effectiveness of the diabetes eduation and self-management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: Cluster randomised control trial. British Medical Journal 336; 7642: 1–11. 3. Hawthorne K., Robles Y., Cannings J.R. & Edwards A.G.K. (2008). Culturally appropriate health education for type II diabetes mellitus. Cochrane Database of Systematic Reviews, Issue 3.

Abstract 36 A service evaluation of the manufacture of paediatric extemporaneous formulations P. McCaguea, R. Donnellya, M. McFarlandb, B. Wellsb, C. McKeownb, N. Eadieb, A. Burnsb and J. McElnaya a Queen’s University Belfast, Belfast, UK and bBelfast Health and Social Care Trust, Belfast, UK

Focal points • The objective of this study was to conduct a service evaluation of extemporaneous preparations in Royal Belfast Hospital for Sick Children (RBHSC). • Findings showed a substantial number of extemporaneous preparations are prepared for paediatric patients on a daily basis, particularly for disorders of the cardiovascular system and electrolyte imbalances. • As a consequence of the study, pharmacy staff are now more aware of the extent and range of extemporaneous prepared medicines prescribed for children and the potential benefits if more products were licensed for paediatric use.

Introduction It is generally accepted that licensed formulations are either not available or not always appropriate for paediatric patients1. Pharmaceutical companies have traditionally been hesitant to invest in developing specific treatments or adapting traditional medicines to meet the needs of young children, mainly because the market is small and, hence, of a lower priority financially2. For children who cannot take adult dosage forms, a number of medicines have to be prepared extemporaneously. There has not been a published systematic study to investigate the extent and type of extemporaneous production in the pharmacies of paediatric hospitals in Northern Ireland. Therefore, we conducted this service evaluation to investigate the above aspects and to identify the main categories of medicines which lack a licence for children.

Method Approval to carry out the study at RBHSC was obtained from the Belfast Trust. The data collection was carried out at the hospital dispensary. A pro-forma was used to collect necessary information. Data were collected for formulations prepared over a two-month period in early 2011 for patients in paediatric wards.

Results Over the study period, more than 170 items were extemporaneously prepared for over 15 different formulations for all patients in paediatric wards. The results were analysed using the Descriptive Statistics function in Microsoft Excel 2007. On average, the hospital dispensary prepared 4.6 items per day. All products were oral solutions or suspensions. Three main methods were employed to manufacture the products. These included manufacture from raw materials (41%), from


Posters

crushed tablets (33%) or using the contents of capsules (26%). In terms of drug category (based on BNF 61 classification); nutrition and blood (41%) and cardiovascular system (22%) represented the main classes of drugs extemporaneously prepared. Six formulation vehicles were used to prepare the oral liquids. These were used to either dissolve the drug, to make a solution or to suspend the drug in a suspension.

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• The majority of patients were receiving the appropriate clinical tests and medication according to the most recent guideline. • A minority of patients are still uncontrolled for HbA1C and BP and the pharmacist may have a role in helping patients achieve targets for their disease.

Background Conclusions The results show a considerable number of extemporaneous preparations are prepared for paediatric patients on a daily basis, particularly for disorders of the GI tract, blood, cardiovascular system and electrolyte imbalances. However, it is known that extemporaneous preparations can carry the risk of non-standardised formulations, a lack of uniformity in dosing, potential formulation failure and possible microbiological contamination. There is also a shortage of stability information3. Availability of more licensed products for paediatric use could potentially have a positive impact on patient care and, ultimately, may improve patient safety. More licensed products would also decrease the work burden for pharmacists as extemporaneous preparations take more time to prepare and check than a proprietary product. Licensed formulations are preferable as their efficacy is supported by clinical trial data. Through dissemination of the findings in a presentation to hospital staff, health care providers are now more aware of the extent of extemporaneously prepared medicines prescribed for children in the hospital. Further work will include repeating the service evaluation to account for any seasonal variation in results. A similar service evaluation could be carried out in all hospitals in Northern Ireland to examine the situation in all hospitals in the region.

References 1. Yeung V, Tuleu C, Wong, I. National Study of Extemporaneous Preparations in English Paediatric Hospitals. Paediatric and Perinatal Drug Therapy, 2004; 6 (2):75–80. 2. Wong I, Sweis D, Cope J, Florence A. Children medicines research in the UK – How to move forward? Drug Safety 2003; 26: 529–537. 3. Stevenson J. How to ensure the safe supply of unlicensed medicines for children. Pharmaceutical Journal 2008; 281:197.

Abstract 37 Adherence to NICE guidance for prescribing in type 2 diabetes in primary care M.J. Twigg, D. Bhattacharya, J.A. Desborough and D.J. Wright University of East Anglia, Norwich, Norfolk, UK

Diabetes is a disease that affects 2.1 million people in the UK1 with type 2 accounting for 85% of these diagnoses. In order to optimise patient outcomes and NHS resource use, it is recommended that prescribers follow treatment guidelines as described by NICE2. There is currently evidence regarding the extent to which prescribers adhere to guidance for other conditions such as type 1 diabetes in children3 and the use of COX-2 NSAIDs4 but no reports relating to type 2 diabetes. The purpose of this audit was to examine whether prescribers are adhering to NICE guidance for prescribing in patients with type 2 diabetes.

Method Approval for the audit was obtained from the PCT research & development department. In collaboration with the local PCT, nine GP practices were identified for audit participation. Practices in Norfolk were chosen according to the number of patients achieving an HbA1C < 7.5% to achieve a range of performance. Patients meeting the inclusion criteria (type 2 diabetes diagnosed within the last five years and not prescribed insulin) were identified by practice staff. A random number generator selected 25 patients from the alphabetical list for audit inclusion. The audit examined the medicines that were used to treat diabetes and other co-morbidities covered by the NICE guidance. It also noted the time and frequency of clinical tests that had been conducted.

Results 194 patient records were audited in nine practices. The mean (SD) age for patients was 65.1 (12.1) years and the mean (SD) length of time since diagnosis was 29.0 (17.4) months. 79.4% (95% CI: 73.7–85.1) and 71.6% (65.3–77.9) of patients received an HbA1C and BP test respectively every six months. Cardiovascular risk assessment was only completed in 31.4% of patients. The percentage of patients not reaching targets for HbA1C and blood pressure was 17.6% (12.2–23.0) and 38.7% (31.8–45.6) respectively. 71.6% of patients were prescribed oral antihyperglycaemic medication; all of which was prescribed according to NICE guidance. Initiation of secondary and tertiary therapy was conducted at the appropriate timings with reference to diabetic control. ACE inhibitors were prescribed to 87.4% of those patients with co-morbid hypertension. Finally, 74.7% (68.6–80.8) of patients were prescribed a lipid-lowering drug and 39.7% (32.8–46.6) prescribed an anti-thrombotic agent e.g. aspirin.

Focal points

Discussion

• To determine if prescribers are adhering to NICE guidelines for prescribing in patients with type 2 diabetes. • An audit of prescribing was conducted in 194 patients in nine GP practices.

This audit of prescribing in nine medical practices in Norfolk shows that adherence to the national guidance for type 2 diabetes is generally good. However, there still remains a significant minority of patients who are not controlled on their


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current therapy as demonstrated by HbA1C and blood pressure measurements. There could be one of three explanations for this: either the patient’s dose has not been titrated accordingly, their therapy needs altering to include another medicine or the patient is non-adherent to prescribed therapy. If these uncontrolled patients are non-adherent the pharmacist, through a pharmaceutical intervention such as an MUR could potentially assist in helping them achieve their targets.

rural patients with local care. Such medicines are currently administered in the cancer centre in Inverness. Personal experience of the community hospital suggested infrequent use of the parenteral route of for any drug administration. This study aimed to determine the current provision of parenteral bisphosphonates, monoclonal antibodies and cytotoxic chemotherapy and explore the nurses’ views towards providing these therapies from SE Highland community hospitals.

References

Method

1. The Health and Social Care Information Centre & The Yorkshire and Humber Public Health Observatory. Prescribing for diabetes in England – An update: 2002–2008. Vol ISBN: 978-1-84636306-1; June 2009. 2. NICE. Type 2 diabetes: the management of type 2 diabetes. Clinical guideline 87. London: National Institute of Health and Clinical Excellence; 2009. 3. Edge J, Swift P, Anderson W, Turner B. Diabetes services in the UK: fourth national survey; are we meeting NSF standards and NICE guidelines? Arch Dis Child. 2005;90(10):1005–1009. 4. Price-Forbes A, Callaghan R, Allen M, Rowe I. A regional audit of the use of COX-2 selective non-steroidal anti-inflammatory drugs (NSAIDs) in rheumatology clinics in the West Midlands, in relation to NICE guidelines. Rheumatology (Oxford). 2005; 44(7):921–924.

Following design and piloting, data was collected using a self-completed anonymous questionnaire. Open and closed questions were used to determine demographics and current service provision. Likert scale attitudinal statements elicited nurses’ views towards service development, training and perceived barriers to administering specified drug therapies. All fully qualified registered nurses working on a permanent contract in the community hospitals in SE Highland CHP were included in the study, providing a sample of 77 participants. The internal mail system was used to distribute the questionnaire. One reminder letter and questionnaire was sent to all participants three weeks later to improve the response rate. Data analysis used SPSS v15. The study was reviewed by Robert Gordon University ethical review panel and the North of Scotland Research Ethics Committee. Submission for full NHS ethics approval was not required.

Abstract 38 Exploration of the current provision of specified parenteral therapies and views of community hospital nurses’ towards such provision in South East (SE) Highland community hospitals A. Warren NHS Highland, Inverness, UK

Focal points • The aim was to explore nurses’ views towards providing parenteral drug therapies to cancer patients from community hospitals. • Nurses have a positive attitude towards administrating these therapies whilst identifying barriers and training needs to service development. • Contributions from the wider healthcare team are required to address training needs and identified barriers at the outset of service development.

Introduction The numbers of patients surviving cancer is increasing.1 As new drug treatments are approved for use and the government strives to ensure prompt diagnosis and treatment cancer services are under pressure to support the rising patient numbers.2 Shifting the Balance of Care proposes moving specialist services from acute hospital-centred activity to community health partnerships (CHP).3 Delivering specified parenteral drug therapies to cancer patients in SE Highland CHP community hospitals could help address capacity issues and provide

Results There was a 53.2% (n = 41) response rate to the questionnaire. 4 (10.3%) respondents reported parenteral bisphosphonates or chemotherapy is administered from two community hospitals. The majority of nurses (83.3%, n = 30) agreed that such a service should be provided from community hospitals commenting that this may be “more relaxed” and “less stressful than acute setting” for patients. Many nurses (71.8%, n = 28) disagreed with the statement that they “would be worried about risks to myself from administering these drugs”. Training would increase most nurses’ confidence (68.4%, n = 26) to administer the specified drugs, expressing preference for training at a specialist centre or in small group workshops. Lack of on-site medical staff is the main perceived barrier (69.2%, n = 27) to service development although lack of essential equipment, on-site pharmacy and laboratory facilities were also frequently identified.

Discussion Administration of specified parenteral drug therapies is a relatively infrequent event in all study hospitals. Overall nurses have a positive attitude towards providing such a service perceiving patient benefit in terms of reducing travel to the specialist centre and receiving treatment in a more favourable environment. It is recommended that the Shifting the balance group consider each hospital site individually and invite contributions from medical, pharmacy, laboratory and transportation staff at the outset of service development to address barriers identified by the nurses. Previous research indicates that rural nurses prefer to learn through electronic methods.4 This study has contrasting results and recommends that specialist cancer nurses are utilised to design training


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programmes which incorporate practical workshops to educate generalist nurses involved in the care of cancer patients.

documentation of medication changes at one of the Trust sites, and if necessary, to improve it.

References

Method

1. Scottish Executive Health Department. Cancer in Scotland: Sustaining Change: Cancer Incidence Projections for Scotland (2001–2020) – An aid to planning cancer services. Edinburgh: Scottish Executive; 2004 [cited 2009 Mar 12] Available from: http://www.scotland.gov.uk/Publications/2004/12/20257/46697 2. Scottish Executive. Fair to All, Personal to Each – The next steps for NHSScotland. Edinburgh: Scottish Executive, 2004. 3. Johnston L, Lardner C, Jepson R. Overview of evidence relating to shifting the balance of care: a contribution to the knowledge base. Edinburgh: The Scottish Government, 2008. 4. Ward J, Wood C. Education and training of healthcare staff: the barriers to its success. Eur J Canc Care 2000; 9: 80–85.

The study was conducted over 5 weeks. Data were collected prospectively by a postgraduate student twice a week. Eligible patients had to be admitted to one of five study wards (1 surgical, 3 medical and 1 cardiology), be discharged during the study period, and have medication changes during their hospitalisation. “When required” drugs were excluded. The first phase of the study involved assessing baseline documentation status. Measures obtained were percentages of inpatient medication changes documented in medical notes, drug charts and electronic To Take Away summaries (eTTAs) as well as the percentage changes for which reasons were documented on drug charts and eTTAs. In the second phase, three quick PDSA cycles were implemented. These focused on education, awareness, and delivering feedback to doctors and pharmacists respectively. Presentations and one-to-one sessions with junior doctors were delivered during the education cycle. The awareness cycle comprised distribution of posters and briefings in departmental multidisciplinary meetings. In the feedback cycle, charts illustrating preliminary results were distributed. All measures were reassessed following each PDSA cycle. Statistical analysis using two sided Fisher’s exact test was performed. The study was classified as audit and did not require NHS ethics approval; however ethics approval was obtained from the relevant school of pharmacy.

Abstract 39 Improving documentation of medication changes in hospital using a quality improvement approach Z. Ahmeda,b, K. Thakkarb, S. Clifforda, Y. Hanssensc and B.D. Franklina,b a School of Pharmacy, University of London, London, UK, bImperial College Healthcare NHS Trust, London, UK and cHamad General Hospital, Doha, Qatar

Focal points

Results

• Objectives were to assess the documentation of inpatient medication changes, and if necessary, make improvements. • Implementing quick Plan-Do-Study-Act (PDSA) cycles was found to be of benefit. • Feedback to healthcare providers was found to be the most effective of the interventions tested in this study.

Introduction There has been a recent focus on improving quality of care within the NHS. The Commissioning for Quality and Innovation (CQUIN) payment framework is part of this wider focus on quality and outcomes in England1. Increasing the effectiveness of inpatient discharge information was selected as one of the CQUIN framework goals of the Trust in 2010/2011. To fulfil this goal, 100% of medication changes must be documented at discharge, including reasons for change. This study aimed to determine the current status of

Records of 167 patients were reviewed; 70 patients (42%) met the inclusion criteria. Of these, 15 (22%) were included at baseline; 22 (32%), 16 (23%) and 17 (24%) patients were included in the three respective PDSA cycles. Patients had a total of 221 medication changes while hospitalised. Baseline status of documentation was below the standard of 100% (Figure 1), which improved after implementation of PDSA cycles. Documentation of medication changes on drug charts and documentation of reasons for change on drug charts and eTTAs showed statistically significant improvements (p = 0.001, 0.021, 0.000 respectively). Feedback was the most effective intervention as it was the only cycle associated with improvement in all measures assessed (Figure 1).

Discussion Effective communication is required to ensure seamless care and deliver effective medicines management². Implementing

100

Baseline

80 PDSA1 (education)

60 40 20 0 Medication changes in medical notes

Medication changes in drug charts

Reasons for change in drug charts

Medication changes in eTTAs

Figure 1 Percentage of medication changes documented at baseline and following each PDSA cycle. © 2011 The Authors. IJPP © 2011 Royal Pharmaceutical Society 2011 International Journal of Pharmacy Practice, 19 (Suppl. 2), pp. 38–64

Reasons for change in eTTAs

PDSA2 (awareness) PDSA3 (feedback)

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Introduction

PDSA cycles to improve documentation of medication changes can be of benefit. Delivering feedback to healthcare providers was found to be the most effective of our interventions. However, ensuring the sustainability of this change will be a challenge and will require further study. The short time gap between successive cycles was a limitation to this study as the effect of the later interventions could have been augmented by previous ones.

Performance standards for pre-registration pharmacists require that they must learn to effectively check prescriptions dispensed by others. A bespoke Pre-registration trainee pharmacist Accuracy Checking Evidence (PACE) programme was implemented across NHS Wales pre-registration training sites.1 Unlike accredited technician checking programmes, PACE requires completion of a reflection log after making an error. The aim of this study was to compare the responses of trainees undertaking such a programme with their tutors/dispensary managers on the value of error reflection logs.

Reference 1. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_091435.pdf. Accessed 30 March 2010.

Method Following NHS Research and Development Office approval as a service evaluation, two semi-structured group interviews were held; one with pre-registration pharmacists (n = 6) and one with pre-reg tutors/dispensary managers (n = 3). These informed the development of two self-completion questionnaires. Following piloting, in Spring 2009 one questionnaire was distributed to all NHS hospital pre-registration pharmacists (anonymously) and one to their tutors/dispensary managers (confidentially). Questions related to aspects of the PACE programme including, for the purpose of this abstract, a section on the error reflection log to be completed after a checking error was made. Responses from trainees and their trainers were compared using the Mann-Whitney test using SPSSv18. Statistical significance was when P ≤ 0.05.

Abstract 40 In what ways are error reflection logs useful to hospital pre-registration pharmacists undertaking a prescription accuracy checking programme (PACE)? D.N. Johna, J. Gilbertsonb, C.M. Treharnec and S.A. Coulmana a Cardiff University (Welsh School of Pharmacy), Cardiff, UK, bCwm Taf Local Health Board (Royal Glamorgan Hospital), Lantrisant, UK and c Hywel Dda Local Health Board (Prince Philip Hospital), Llanelli, UK

Results Focal points

Response rates of 100% (35/35) for trainees and 83% (45/54) for pre-reg tutors/dispensary managers were obtained. Findings are shown in Table 1. (Statements in Table 1 are those used in the pre-registration trainee version. Statements in the trainer questionnaire were written to read as applying to their trainee.) Not all respondents answered all questions.

• To compare the views of Wales hospital pre-registration pharmacist trainees and their trainers on the value of accuracy checking error reflection logs. • Response rates of 100% for trainees and 83% for tutors/ dispensary managers were achieved. • Pre-registration pharmacists and their tutors/dispensary managers found the reflection logs valuable in a number of ways including thinking more about patients, potential consequences of errors and the factors contributing to errors.

Discussion The error reflection log within PACE was perceived to be useful to both hospital pre-registration pharmacists and to

Table 1 Views of pre-registration graduates (P) and trainers (T) on the value of error reflection logs in accuracy checking – numbers (%) Statements It made me think about the implications of my error(s). Rating the seriousness of the error was useful. Having to consider the consequences of the mistake helped me learn more about the products. It increased my awareness of factors that contribute to dispensing errors. It made me think more about the patient. I think a reflective log should be undertaken for every error. Reflecting on my error helped me to identify how I needed to change my way of checking.

Strongly Agree

Agree

Not sure

P T P T P T

9 (30) 21 (47) 7 (23) 18 (40) 8 (26) 21 (47)

21 (70) 22 (49) 17 (55) 23 (51) 17 (55) 20 (44)

2 (4) 2 (6) 4 (9) 1 (3) 4 (9)

P T P T P T P T

8 17 4 12 3 19 8 14

21 26 15 17 9 20 21 27

(26) (38) (13) (27) (10) (42) (26) (31)

(68) (58) (50) (38) (29) (44) (68) (60)

1 (3) 2 (4) 9 (30) 11 (24) 6 (19) 3 (7) 1 (3) 4 (9)

Disagree

Strongly Disagree

Other

5 (16)

P if ≤0.05

0.038

3 (10)

2 (6)

0.035

1 (3)