Friday Afternoon

Poster 1 ................................................................................................................................................. 3

Improving Patient Experience with Medicines: A Quality Improvement Initiative ........................... 3

Poster 2 ................................................................................................................................................. 4

Do Elderly Heart Failure (HF) patients with Left Ventricular Systolic Dysfunction (LVSD) Tolerate

Triple Therapy? ................................................................................................................................. 4

Poster 3 ................................................................................................................................................. 6

Effects of the medications on quality of life on one year post stroke patients ................................. 6

Poster 4 ................................................................................................................................................. 7

Personalised Dosing Review – Are we going in the right direction? ................................................. 7

Poster 5 ................................................................................................................................................. 9

Development of Local Infiltration Analgesia (LIA) formulation for Total Knee Arthroplasty (TKA). .. 9

Poster 6 ............................................................................................................................................... 10

The impact of pharmacist led reviews on optimising combination inhaler use .............................. 10

Poster 7 ............................................................................................................................................... 11

Integrated Proactive Care Homes Project: Impact of Pharmacists working in care homes. ........... 11

Poster 8 ............................................................................................................................................... 12

Identification of risk (prognostic) factors for medication related problems (MRPs) occurring during

hospital admission: a survey of healthcare professionals and patient/public representatives.. Error!

Bookmark not defined.

Poster 9 ............................................................................................................................................... 14

Creation of EMIS Web ‘Safety Dashboard’ to assist in identifying and monitoring patients at risk of

adverse medication events ............................................................................................................. 14

Poster 10 ............................................................................................................................................. 15

Releasing clinical pharmacist time from dispensary-based duties: evaluation of a change in

evening rota .................................................................................................................................... 15

Poster 11 ............................................................................................................................................. 16

An audit on geriatric prescribing and anticholinergic drug use pre- and post-hospital admission . 16

Poster 12 ............................................................................................................................................. 18

Does a structured protocol increase implementation of biologic therapy dose reduction amongst

clinicians and patients? A pilot study. ............................................................................................ 18

Poster 13 ............................................................................................................................................. 19

Safe prescribing of hypnotics and high dose antipsychotics on a Psychiatric Intensive Care Unit

(PICU): Interventional role of the Pharmacist ................................................................................. 19

Poster 14 ............................................................................................................................................. 21

Review of current management of blood glucose control in Type 2 Diabetes in Primary Care ...... 21

Poster 15 ............................................................................................................................................. 22

STOPP START medication review: common drug class and potential financial savings in secondary

care ................................................................................................................................................. 22

Poster 16 ............................................................................................................................................. 24

Optimisation of medication to prevent microvascular complications of diabetes in Primary Care 24

Poster 17 ............................................................................................................................................. 25

Does an Integrated Information Technology System Provide Support for Community Pharmacists

Undertaking Discharge Medicines Reviews?................................................................................... 25

Poster 19 ............................................................................................................................................. 26

A Pilot Study Investigating the Effectiveness of Pharmacist-led Medication Reconciliation in

General Practice .............................................................................................................................. 26

Poster 20 ................................................................................................. Error! Bookmark not defined.

Exploring the effectiveness and impact of pharmacist-led prescribing error feedback in an acute

hospital setting ............................................................................................................................... 12

Poster 21 ................................................................................................. Error! Bookmark not defined.

Drug utilisation review of rivaroxaban for treatment of venous thromboembolismError! Bookmark

not defined.

Poster 1 Improving Patient Experience with Medicines: A Quality Improvement Initiative Anna Robinson, Northumbria Healthcare NHS Foundation Trust, Northumberland

Introduction:

Patient Experience is a recognised component of high-quality care in the RPS Professional Standards for Hospital Pharmacy Services.1 However, National Inpatient Survey (NIS) scores for patient experience with medicines are notoriously low; often due to the poorly answered ‘medication side effects’ question. NIS Data 2014 shows that only 39% of patients answered ‘yes’ when asked if a member of staff told them about medication side effects.2

Objectives: To improve patient experience with medicines in a NHS acute care organisation, using a continuous Quality Improvement model. Co-design patient-focused interventions with patients and staff, to improve patient experience.

Methods: A Quality Improvement model underpins this project. Twelve target wards were randomly targeted, all having patient experience scores ≤5/10. The project used patient experience scores to measure success. Real time data is collected monthly on every ward across the Trust. Qualitative patient and staff feedback was used to help co-design interventions. PDSA cycles were implemented, and data was closely analysed on a monthly basis so that real-time responses to interventions could be established. Strong multidisciplinary team working was established across pharmacy, medical, and nursing teams. Patient-focused interventions (medicines leaflets, posters, and counselling sheets) were trialled. Staff counselling and education materials were distributed Trust-wide, encouraging an enthusiastic push towards medication counselling.

Results: Throughout the eight month campaign, the total number of wards achieving (and exceeding) patient experience scores ≥7 increased from 50% to 91.7%. Aggregate Trust-Wide scores increased from 7.65/10 to 8.65/10 over the same period.

Discussion: Real-time scores showed consistent improvement throughout this project. This work has been adopted by the Trust as a rolling quality improvement initiative; interventions are implemented Trust-Wide across acute hospitals and community hospitals. There is strong potential to promote continuity of care and transfer these findings to primary care; the work is being piloted by GP pharmacists post-discharge from hospital. Acknowledging how patients experience their care around medicines was paramount in this Quality Improvement strategy, enabling the delivery of a higher-quality healthcare service with more satisfied and engaged patients. References: 1. Royal Pharmaceutical Society, 2013. Medicines Optimisation: Helping Patients to make

the most of medicines. PDF available online via: https://www.rpharms.com/promoting-

pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf. Accessed on 30/03/16.Care

2. Quality Commission National Inpatient Survey Data, 2015. Trends in the Adult Inpatient Survey 2005-2014. Available online via: http://www.cqc.org.uk/content/trends-adult-

inpatient-survey-2005-2014. Accessed on 30/03/16.

Poster 2 Do Elderly Heart Failure (HF) patients with Left Ventricular Systolic Dysfunction (LVSD) Tolerate Triple Therapy? [Ahmed, A], Sunderland Royal Hospital, Sunderland, [Baxter. J], Sunderland Royal Hospital,

Sunderland, [Oliver, J], Sunderland Royal Hospital, Sunderland, [Beezer, J], Sunderland

Royal Hospital, Sunderland

Introduction

Triple therapy in HF due to LVSD consists of an Angiotensin Converting Enzyme inhibitor

(ACEi) or Angiotensin Receptor Blocker (ARB), a beta blocker (BB) and a Mineralocorticoid

Receptor Antagonist (MRA). Introduction of the MRA is initiated when first line management

with ACEi/ARB and BB have been insufficient in treating HF symptoms in patients who have

had a myocardial infarction within the last month or have moderate to severe HF 1

Objectives

To determine 12 month tolerability of triple therapy in patients over the age of 75 years old

admitted with a primary diagnosis of HF due to LVSD.

Method

Consecutive patients admitted into Sunderland Royal Hospital between April 2013 and

March 2016 with a primary diagnosis of HF was identified. Of the 1352 patients admitted

over this time period, 75 patients were found to be over 75 years old with LVSD HF and on

triple therapy. Each patient’s electronic records were evaluated, analysing online hospital

documentation to determine whether patients were still on triple therapy throughout the year.

Results

Number of

Patients

% of Cohort

Number of patients who died within 12 months 15 20%

Number of patients for whom further information

could not be obtained

17 23%

Number of patients who tolerated triple therapy 22 29%

Number of patients who did not tolerate triple

therapy

21 28%

Table 1: Overall results for the patients analysed in this audit

Table 1 shows the breakdown of the results of the 75 patients analysed. 28% of patients

analysed were stopped on triple therapy within an average of 120 days of initial discharge.

The main agent being stopped being MRA’s and ACEi/ARB with 52% stopped these agents

due to AKI and deranged U&E’s and 19% due to low blood pressure.

Discussion/Conclusion

At least 28% of patients were intolerant to triple therapy in patients over 75 years old,

discharged from hospital on a BB, ACEi/ARB and MRA after an acute admission with HF

due to LVSD as a primary reason for admission at one year. With high expected intolerance,

these patients require close, frequent monitoring which could be delivered by specialist

pharmacists.

Statement

Advice from the hospital audit committee was sought and concluded that ethical approval is

not required

Reference

1) National Institute for Health and Care Excellence (NICE). Chronic Heart Failure in

Adults: Management. (2010). https://www.nice.org.uk/guidance/cg108/chapter/1-

Guidance#treating-heart-failure [accessed 26th January 2017]

Poster 3 Effects of the medications on quality of life on one year post stroke patients Ahmed Elzubair, Hamad Medical Corporation, Qatar

Background:

Stroke is a major health problem in all industrialized countries. It is the third leading cause of death and leaves many of its survivors with physical and mental disabilities, Thus creating a major social and economic burden. Objective: To assess the quality of life in one year post stroke patients. To see the effect of antidepressant in the patients who are taking this medication and its Effect in their QOL. Methods: The study is descriptive one, carried in Hamad general hospital in Doha ,Qatar the Method as self- completed questionnaire to be distributed to respondents , Our Study is based on the 55 surviving (45 male , 10 female patients, from 13 Years And older of the people with one year post Stroke patients. Who were able To Answer the questionnaire. Result: One year post stroke patients in the State of Qatar are predominantly married, non-Qatari males with under secondary school level of education. All post stroke QOL Domains were negatively affected in the participants of this study. 92.7% of the patients Have a persistent and severe limitation of their physical abilities, 74.5% has limited Social life and activities, and 16.4% were pessimistic about their health and the Prospective of their condition to improve.

Effect of stroke in psychological quality of life Depression was well controlled in only 1.8% of the patients, fairly controlled in 5.5% and Not at all in 5.5% of the patients. Overall compliance with medication was seen in 70.9% Of the cohort group evaluated in this current study. Conclusion:

Quality of life domains during the Year following stroke are significantly impaired. Education level improves compliance With medication during the first year that follows Stroke. In one year post stroke Patients, also there is significant relationship between Education level and regularity of taking the medications.

12.7

43.6

16.4

38.2

30.9

36.4

20

34.5

56.4

20

63.6

27.3

0

10

20

30

40

50

60

70

80

Seem to get ill more

easily than other

people

Healthy as any one

I know

Expect my health to

get w orse

Health is excellent

Perc

enta

ge

Definitely true

Not sure

Definitely false

Poster 4 Personalised Dosing Review – Are we going in the right direction? Mandane B[1]*, Mulla H[1]

[1]Department of Pharmacy, The University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.

Background

Precision-medicine has been hailed as the future of medicine in cancer-care and beyond. It aims to select a prevention- and treatment-strategy that is suitable for the subgroup or individual as opposed to the ‘one-size-fits-all’ approach, and to provide the right-drug to the right-person at the right-time. In terms of pharmaceutical-care, the corollary is ‘personalised-dosing’. Personalised-dosing is a step-up from population-based dosing in that patient-specific information such as pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenomics are utilised to individualise doses to each patient.

Objectives

1) To provide an overview on the potential benefits and challenges of personalised-dosing in therapy areas such as cancer and critical-care;

2) To encourage critical-discussion around currently available technologies aiming to facilitate its transition into clinical-practice;

3) Stimulate critical-debate: What are the disadvantages of the traditional-approaches to dosing? What are the benefits of personalised-dosing? What evidence is there that personalised-dosing can improve health-outcomes?

Method

Search-databases: Medline, PubMed, Embase, EBSCO, ScienceDirect, Scopus. Key-words: precision-medicine, Bayesian-statistics, pharmacodynamics, pharmacokinetics, critical-care.**

Results

Personalised-dosing is already being experimented in practice, with examples of antibiotic dose-optimisation in critically ill-patients and cytotoxics in cancer-patients.1-4 PK-PD models incorporated into sophisticated Bayesian-statistic forecasting algorithms determine individualised-dosages taking into consideration patient-specific characteristics.1,2 However barriers to more wider implementation into clinical-practice include the limited availability of PK-PD models for high-risk medicines, lack of convincing clinical-evidence to support their use, lack of cost-effective point-of-care technologies providing real-time PK/PD data, compatibility with existing healthcare IT-systems as well as appropriately trained- and resourced-personnel.

Discussion

In a limited number of settings, personalised-dosing has demonstrated the potential for significant clinical-advantages in improving patient-outcomes through improved efficacy (e.g. infection-resolution) and safety (reduced-toxicity).1-4 However, in addition to more evidence of clinical-benefit, there is a need for simpler, user-friendly and effective point-of-care testing-technologies to enable the power of PK-PD models to be leveraged and personalised-dosing to be translated into real-life clinical-practice.

**Ethics approval was not required in this instance, as this abstract describes a review project.

References

1 Felton T., Roberts J., Lodise T, et al. Individualization of Piperacillin Dosing for Critically Ill Patients: Dosing Software To Optimize Antimicrobial Therapy. Antimicrobial Agents and Chemotherapy; 2014; Volume: 58 (7); 4094-4102

2 Guo E., Ji Y., Catenacci D. A subgroup cluster-based Bayesian adaptive design for precision medicine. Biometrics. 2016; Volume: not indicated, ahead of print.

3 Guo B., Yuan Y. Bayesian Phase I/II Biomarker-based Dose Finding for Precision Medicine with Molecularly Targeted Agents. Journal of the American Statistical Association. 2016; Volume: not indicated.

4 Cremers S., Guha N., Shine B. Therapeutic drug monitoring in the era of precision medicine: opportunities! British Journal of Pharmacology. Volume: not indicated.

Poster 5 Development of Local Infiltration Analgesia (LIA) formulation for Total Knee Arthroplasty (TKA). Hiom S1, Cosslett A2, Sully A1, Dooey S2, Meredith M1, Spark P1 and Williams S1. 1St Marys Pharmaceutical Unit (SMPU), Cardiff and Vale UHB. 2Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University.

Introduction LIA use in TKA is associated with reduced post operative pain, more rapid mobilisation, earlier discharge and decreased NHS costs1. It’s use in Enhanced Recovery After Surgery (ERAS), with preparation in theatres prior to administration, introduces risks from potential microbial contamination, administration and drug calculation errors. “Ready to use” formulations have been requested by Clinical Practitioners.

Objectives A literature search and survey seek to determine any standardised LIA practices, followed by formulation and manufacture of an appropriate product as an innovative “special”.

Methods A literature search was completed using LIA and TKA keywords. An electronic survey distributed via pharmacy orthopaedic networks used quota, purposive and snowballing techniques. Ethics and Service Evaluation approvals were obtained. Subsequent formulation and manufacture under Manufacturers “Specials” Licence met local LIA clinical needs. A stability study was designed using International Committee of Harmonisation (ICH) guidelines. Solutions were stored (25°C/60% relative humidity) and tested over 12 months using a validated stability method2.

Results The literature search and survey (60% response rate) found no standardised practices for LIA in TKA. Table 1 indicates different ingredients used by authors or survey respondents. Table 1 – Variety of LIA Ingredients

Optional

ingredients

Literature Search (n=18) Survey (n=4)

Anaesthetic: bupivacaine, levobupivacaine, ropivacaine bupivacaine,

levobupivacaine

Additions: adrenaline, saline, ketorolac, morphine, methylpred,

cefazolin, magnesium sulphate

adrenaline, saline

Total volume: 30ml to 190ml 130ml-150ml

A terminally sterilised solution of Bupivacaine 0.1% w/v and Adrenaline 6mcg/ml was subsequently developed and assigned a 6 month expiry.

Discussion The manufacture of pharmaceutical “Specials” is one way to manage medicine use risk. Terminally sterilised products are ideal with assured microbial and chemical qualities and extended shelf lives compared with aseptic preparations. The literature search and survey indicated a lack of standardised practices for LIA use. A ready-to-use formulation has subsequently been developed using ICH Guidelines and Good Manufacturing Practices and is now available for use across the UK, enhancing patient safety. Further work is required to standardise UK practice.

References 1Kosev, P. et al. 2015. Fast track surgery in TKA – A review. Journal of IMAB – Annual Proceeding (scientific papers) 21(3), pp. 937-839. 2British Pharmacopoeia. Vol 3. 2015. Bupivacaine and Adrenaline Injection [ONLINE] Available at: https://www.pharmacopoeia.com/Account/Login?ReturnUrl=%2FPublication%2Fbp-2015%2Fformulated-specific%2Fbupivacaine-and-adrenaline-injection---bupivacaine-and-epinephri.html%3Fdate%3D2015-01-01%26text%3Dbupivacaine. [Accessed 03.08.2015].

Poster 6 The impact of pharmacist led reviews on optimising combination inhaler use Boyd, C, Arden and GEM CSU, Warwick

Introduction:

As part of this year’s prescribing incentive scheme, Warwickshire practices were asked to review generically prescribed fluticasone and salmeterol inhalers. Support was offered by a pharmacist with an interest in respiratory medicine and tailored to the needs of the practice.

Ethics approval was not required.

Objectives

Highlight patients who may benefit from a review

Educate clinicians of the new combination inhalers and devices available to increase confidence in proactively reviewing patient inhalers

Ensure patients are consistently receiving the same brand of inhaler, or offered an alternative suitable device

Method

Pharmacist support provided to practices include:

clinical audit

contacting patients to confirm the current brand of fluticasone and salmeterol inhalers dispensed and to amend GP records

Switching to practice preferred alternative licensed inhaler device

Inhaler counselling sessions

Inhaler review clinics

Results

477 patients’ medication records were reviewed across 8 practices. 231 interventions were made following the reviews at the request of individual practices.

Pharmacist intervention Number of patients

Patient contacted to confirm inhaler brand 54

Medication record amended to ensure inhaler is prescribed by brand 44

Patient flagged up for GP review due to non-compliance 25

Patient flagged up for GP review due to off-label prescribing of inhalers

33

Patient switched to licensed alternative treatment and new inhaler counselling offered

56

Patient seen in COPD inhaler review clinic to discuss licensed inhaler options

19

Figure 1: table of interventions

Conclusion

This project demonstrated the flexibility and potential of the medicines optimisation pharmacist in supporting practices to review inhalers. Feedback from practices and patients has been positive, with many patients voicing their appreciation of feeling they have been supported to making an informed choice in their treatment.

Poster 7 Integrated Proactive Care Homes Project: Impact of Pharmacists working in care homes. Goh C, Dave K, Le Morgan N, Medicines Management Department, Central London Community Healthcare NHS Trust, London This project did not require ethics approval.

Context The North West London Integrated Care Programme Innovation Fund was set up to test new integrated services for high risk patients, with a view to reduce non-elective hospital admissions. A local review of ambulance calls outs and audit of selected care homes showed inequity of provision and access to services. The Central London Community Healthcare NHS Trust was commissioned to deliver proactive, integrated and multidisciplinary care to 1000 care home residents. The project was commissioned across Hammersmith & Fulham and West London boroughs.

Objective Improve access to care by delivering the standards as agreed for the project.

Method Two Band 8a Clinical Pharmacists delivered proactive care by visiting the care homes and providing level 3 medication review1, medicines optimisation, medicines reconciliation, reducing medication errors and wastage, providing training, supporting development of medication policies, attending multidisciplinary team meetings and working in partnership across different healthcare sectors. Interventions were recorded and graded using a tool adapted from King’s College NHS Foundation Trust2.

Results The preliminary results from December 2013 to July 2016 showed 9922 interventions were made for 981 residents, with 213 grade IV (Reversible harm or admission to hospital) and 2 grade V (Averted death or major permanent harm)2 with total net cost savings of £160K per annum by reduction in polypharmacy and implementing other cost saving strategies. Positive qualitative feedback was collected independently by the Collaboration for Leadership in Applied Health Research and Care North West London which showed the benefit of care homes pharmacists.

Conclusions Following the end of the project in West London a pharmacist has been commissioned to

continue the service. The project will be ending in Hammersmith and Fulham in March 2017

with a view to embed the activities undertaken by the project team and outcomes achieved

into practice to sustain long term benefits.

References 1. Petty D et al. Medication review by pharmacists- the evidence still suggests benefit. The

Pharmaceutical Journal 2005; 274(7350): 618-619 2. Specialist Pharmacy Service. SPS: Capturing and Using Pharmacy Contribution Data.

https://www.sps.nhs.uk/articles/capturing-and-using-pharmacy-contribution-data/ (accessed 8th August 2016)

Poster 8 Exploring the effectiveness and impact of pharmacist-led prescribing error feedback in an acute hospital setting Lloyd M, St Helens & Knowsley Hospitals NHS Trust, Whiston, UK Watmough S, University of Liverpool, Liverpool, UK O'Brien S, St Helens CCG, St. Helens, UK Furlong N, St Helens & Knowsley Hospitals NHS Trust, Whiston, UK Hardy K, St Helens & Knowsley Hospitals NHS Trust, Whiston, UK Introduction/Background/Context Prescribing errors (PEs) are prevalent and a prominent cause of patient safety incidents in hospital settings.1 Feedback is one potential prescribing error (PE) reduction intervention but evidence on its application, and use of pharmacists as PE feedback facilitators in hospital settings is limited.2

Objectives

To determine the impact of delivering constructive feedback on prescribing and explore the views of pharmacists to delivering formalized PE feedback.

Method

Pharmacists were trained in delivery of constructive feedback.3 Written and verbal feedback was provided to prescribers (n=37) on intervention wards for overall prescribing and any ongoing significant PE. Control group prescribers (n=41) continued with existing practice. Prescribing was audited at baseline and 3 months following the intervention. Results were analyzed using relevant statistical tests.

Nineteen pharmacists were interviewed to explore their views of the intervention with interviews transcribed and analyzed thematically using a framework approach.

Results

There was a mean increase in error free prescriptions (EFP) and a reduction in mean PE rate (PER) in the intervention group compared to the control group as outlined in table 1 below. Significant reductions were reported for all error types and severities.

Table 1: Pre- and post-intervention error rates in intervention and control group prescribers

Pre-intervention Post-intervention Mean difference Difference

Intervention Control Intervention Control Intervention Control

EFP% 48.4% 53.7% 72.1% 47.9% +23.7% -5.8% 29.5% (p<0.05)

PER% 25% 19.7% 6.7% 25.2% -18.3% +5.5 23.8% (p<0.05)

The intervention was valued by pharmacists and considered sustainable. Feedback accelerated rapport building and team-work with increased information and feedback seeking behavior noted from prescribers. Pharmacists expressed feeling more integrated in the clinical team and prescribing decisions with increased self-confidence and self-worth. These outcomes enhanced integration further and catalyzed development of ancillary initiatives with clinical teams.

Discussion/Conclusion

Pharmacist-led PE feedback positively influences prescribing and pharmacist-prescriber working relationships for more collaborative prescribing decisions. This intervention can enhance team-work, utilise the skills of pharmacists more effectively, and enhance patient safety. PE feedback is now part of routine pharmacy practice at the study hospital with ward pharmacists working less in parallel and more integrated within clinical teams.

Ethical approval

Approval was obtained from relevant ethics committees at the study hospital and University of Liverpool.

References

1. Ross S, Bond C, Rothnie H, et al. What is the scale of prescribing errors committed by junior doctors? A systematic review. British Journal of Clinical Pharmacology 2009; 67: 629–40.

2. Bertels J, Almoudrais AM, Cortoos PJ, et al. Feedback on prescribing errors to junior doctors: exploring views, problems and preferred methods. International Journal of Clinical Pharmacy (2013):35;332-338

3. Lloyd M, Watmough SD, O’Brien SV, et al. How to give and receive constructive feedback. The Pharmaceutical Journal, 2016; Vol 296, No 7887, online | DOI: 10.1211/PJ.2016.20200756

Poster 9 Creation of EMIS Web ‘Safety Dashboard’ to assist in identifying and monitoring patients at risk of adverse medication events Mellings R, Stephens D. NHS North Somerset Clinical Commissioning Group, Clevedon

Introduction/Background/Context

The MHRA/CHM regularly issue advice and alerts to healthcare providers to help minimise the risk of adverse events when prescribing. This review demonstrates how EMIS Web can be utilised to reduce the risk of adverse events from prescribing contrary to MHRA advice.

Objectives

To create a resource within EMIS Web which would present collated and prioritised prescribing advice, whilst simultaneously highlight affected patients to all primary care prescribers.

Method

Using the global Population Reporting function, a ‘Safety Dashboard’ folder was created and made accessible to all users across North Somerset CCG containing 64 individual searches added by CCG Pharmacists. Each search pertained to a piece of prescribing advice issued by the MHRA/CHM, and this was summarised under the corresponding description tab along with a link to the original source. Using multiple rules managing the inclusion or exclusion of patients, the results in the ‘Patients Included’ tab was limited to those subject to the advice. Ethics approval was not required.

Results

Overall 367 patients who were receiving prescriptions contrary to MHRA/CHM advice saw their treatment changed to comply with advice between October 2015 and April 2016.

The five biggest changes are shown below:

Search Title 6-Month Change Patients Switched

Simvastatin with Calcium channel blockers -35.4% 68

ACE inhibitor and A2RA -30.4% 56

Domperidone Repeat Prescriptions -26.4% 53

Metoclopramide Repeat Prescriptions -12.0% 42

Prescribed Dosulepin -9.2% 32 Discussion/Conclusion

GPs were supported by CCG funded Practice Support Pharmacists to introduce protocols which allocated responsibility and defined roles for regular reviews of the safety dashboard searches. Of the 64 searches, 24 saw reductions in patients affected with a further 16 remaining constant over a 6 month period. Searches monitoring the prescribing of NOACs showed some increase. Feedback from users suggests that the convenience offered by the format and presentation – with the advice and list of patients presented together, encouraged regular review and compliance.

The results from the dashboard can also be used to monitor prescribing performance, either by direct comparison to other surgeries within the CCG as a snapshot, or to track progress or change over time.

Additionally, the Safety Dashboard is a useful resource for monitoring and highlighting prescribing of new drugs which is not in line with best practice or contrary to specialist advice.

References 1. Drug Safety Updates, MHRA/CHM https://www.gov.uk/drug-safety-update

Poster 10 Releasing clinical pharmacist time from dispensary-based duties: evaluation of a change in evening rota Macdonald, D, Kearney, D; University Hospitals of Leicester; Leicester

Introduction/Background/Context The evening dispensary service at a large teaching hospital is staffed by pharmacists and technical staff from 5-7pm and junior pharmacists thereafter (on-site until 10pm). The Carter report1 challenges hospital pharmacy to increase the proportion of pharmacist time spent in clinical roles. This prompted a review of the current arrangements with the aim of reducing pharmacist commitment to late clinic, effectively releasing the time for clinical duties.

Objectives To pilot an alternative rota and assess the impact of this change on pharmacist time released to clinical duties, shift finish time, prescription turnaround, on-call workload, and staff satisfaction.

Method Finish time was collected prospectively during baseline (21 Sep – 28 Oct 2016) and pilot periods (31 Oct – 29 Dec 2016). Prescription turnaround and on-call workload were obtained retrospectively for each period from the prescription tracking and on-call systems. Staff satisfaction was examined via an online questionnaire. Ethics approval was not required.

Results An estimated 15.4 hours of pharmacist time per week were released for other duties. Mean finish time improved slightly (19:11 baseline, 19:08 pilot). Table 1 shows finish times to nearest 15 minutes, demonstrating reduced variation in the pilot period. The proportion of finishes at or before 19:00 increased (52% baseline, 60% pilot). Table 1: Finish time frequency (%)

Finish time

(hh:mm) 18:30 18:45 19:00 19:15 19:30 19:45 20:00

Baseline 4.0 4.0 44.0 24.0 8.0 12.0 4.0

Pilot 0.0 10.0 50.0 27.5 5.0 5.0 2.5

There was minimal change in prescription turnaround (63 mins baseline & pilot) and on-call workload (25.8 calls/evening baseline, 24.4 pilot). Questionnaire responses (n=37) showed staff favoured the pilot rota in terms of staff arrival time, overall experience of late clinic, impact on main job role and work-life balance. Despite the data showing otherwise there was a perception that finish time and skill-mix were worse during the pilot.

Discussion/Conclusion Following a successful pilot, this system has been permanently implemented, representing a modest but cost-free increase in the proportion of pharmacist time spent on clinical duties.

References 1. Lord Carter of Coles; Operational productivity and performance in English NHS acute

hospitals: Unwarranted variations; 2016

Poster 11 An audit on geriatric prescribing and anticholinergic drug use pre- and post-hospital admission Du, HCT, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust, Lincoln

Vettasseri, M, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust, Lincoln

Introduction

Polypharmacy is common in the elderly population1 and is associated with negative clinical

consequences, including adverse drug events and medication non-adherence2. Drugs with

anticholinergic properties (herein referred to as ACDs) are particularly problematic due their

association with cognitive impairment, falls and all-cause mortality3. The anticholinergic

burden (ACB) score provides guidance on the use of ACDs in older adults4.

Objective(s)

(a) Compare the number of medication prescribed, and (b) determine the change in number

of ACDs and ACB scores pre- and post-hospital admission.

Method

108 consecutive admissions across three Geriatric wards at a district general hospital were

audited over a 5-week period (June-July 2016). 28 patients were treated palliative or died and

were excluded. Non-medicated topical agents (e.g. aqueous cream), short-term medication

(e.g. antibiotics) and nutritional supplements (e.g. Fresubin®) were not included in the results.

A locally adapted list of ACDs and ACB score based on a previous study4 was used. Ethics

approval was not required.

Results

51% of patients were discharged with ≥1 additional regular medication compare to their pre-

admission state (Table 1). The average increase in regular medication prescribed was 1.1

items. Patients prescribed with at least one ACD pre- and post-admission were 68% (n=54)

and 73% (n=58) respectively. At least one-point increase in ACB score was observed in 33%

(n=26) of the patient at discharge. Of those patients who were discharged with more regular

medication than pre-admission, 78% (n=32) involved at least one ACD.

Table 1: Proportion of patient and change in number of medication prescribed

Number of medication prescribed

pre- versus post-hospital admission Number of

Patients (%)

Re

gu

lar

me

dic

ati

on

No Change 13 (16)

Reduced 26 (33)

Increased 41 (51)

Total 80 (100)

Wh

en

req

uir

ed

me

dic

ati

on

No Change 44 (55)

Reduced 24 (30)

Increased 12 (15)

Total 80 (100)

Discussion/Conclusion

The audit found more than half geriatric inpatients were discharged with ≥1 additional regular

medication and ACDs versus their pre-admission state. This could lead to adverse patient

outcomes5. Work is being explored locally to minimise polypharmacy, including a Medication

MDT meeting to improve communication between pharmacists and the medical teams.

References

1. Guthrie, B. Makubate, B. Hernandez-Santiago, V. et al.; The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995-2010; BioMed Central; 2015; 13(74) DOI 10.1186/s12916-015-0322-7.

2. Robert, M. Hanlon, J. Hajjar, E.; Clinical Consequences of Polypharmacy in Elderly; Expert Opinion on Drug Safety; 2014; 13(1): DOI:10.1517/14740338.2013.827660.

3. Ruxton, K. Woodman, R. Mangoni, A.; Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: a systematic review and meta-analysis; British Journal of Clinical Pharmacology; 2015; 80(2); 209-20.

4. Boustani, MA. Campbell, NL. Munger, S. et al.; Impact of anticholinergics on the aging brain: a review and practical application; Aging Health; 2008; 4(3); 311-20.

5. Fox, C. Richardson, K. Maidment, I. et al; Anticholinergic medication use and cognitive impairment in the older population: the Medical Research Council Cognitive Function and Ageing Study; Journal of the American Geriatric Society; 2011; 59(8);1477-83.

Poster 12 Does a structured protocol increase implementation of biologic therapy dose reduction amongst clinicians and patients? A pilot study. Rose, E – Rheumatology Specialist Pharmacist, North Bristol NHS Trust Creamer, P – Consultant Rheumatologist, North Bristol NHS Trust Jamal, SM – Specialist Registrar, North Bristol NHS Trust NB Ethics approval not required as a service development project. Background: Biologic therapies (e.g. tumour necrosis factor inhibitors (TNFi)) used in the management of inflammatory arthritis are associated with potential risks (including local reactions, infections and possible malignancy). Increasing RCT evidence suggests stable patients can dose-reduce without increased disease activity (1-3) and a previous patient engagement event (4) explored patient perceptions of dose reduction. There are no clear guidelines or strategies reported in literature to facilitate implementation in clinical practice. Objective: For 2 years at North Bristol NHS Trust, stable patients (out of the 460 patients on subcutaneous TNFi) have been offered the opportunity to reduce their dose on an ad hoc basis with variable regimes. The purpose of this pilot study was to develop a structured, program for standardising dose reduction of subcutaneous TNFi therapy to support implementation amongst clinicians and patients. Method: The rheumatology specialist pharmacist developed an inflammatory arthritis TNFi 5-

step dose reduction program (30% interval extension for 3 steps, followed by a 60% extension, before stopping treatment), with a patient information and compliance record (informing of treatment escalation following a disease flare up). The program was reviewed by a Consultant Rheumatologist, specialist nurse and patient representative group and presented to the clinical team and treatment checklists were updated to include a prompt. Patients started on dose reduction schemes were recorded. Results: In the 2 years preceding the pilot, 27 patients attempted TNFi dose reduction

(average rate of 1.1/month). In the first 6 months following introduction of the program, an additional 42 patients (56% increase) were initiated on dose reduction schemes (average rate of 7/month). Of the 42 additional patients, 31 (74%) were initiated on the formal BTRIM program and 11 (26%) were extended via an alternative schedule. Discussion / conclusion: The pilot showed adopting a structured dose reduction program increased implementation in clinical practice. It is unclear whether this was attributable to increased patient and/or clinician confidence or raised clinician awareness. Reasons for opting out were not assessed. Further work has been identified following the pilot, including potential gainshare discussions with commissioners and approval of a research grant to conduct a qualitative study assessing patient perceptions of biologic therapy dose reduction (of which the rheumatology specialist pharmacist is a co-applicant). Acknowledgments: Rheumatology patient representative group, North Bristol NHS Trust References: [1] van Herwaarden et al., 2014. Down-titration and discontinuation strategies of tumour necrosis factor-blocking agents for rheumatoid arthritis in patients with low disease activity. The Cochrane database of systematic reviews. 9/(CD010455), 1469-493X [2] Fong W, Holroyd C, Davidson B et al., 2016. The effectiveness of a real life dose reduction strategy for TNF inhibitors in ankylosing spondylitis and psoriatic arthritis. Rheumatology; doi: 10.1093/rheumatology/kew269 First published online: June 28, 2016 [3] Závada J, Uher M, Sisol K et al., 2016. A tailored approach to reduce dose of anti-TNF drugs may be equally effective, but substantially less costly than standard dosing in patients with ankylosing spondylitis over 1 year: a propensity score-matched cohort study. Ann Rheum Dis; 75:96-102 [4] Wallis D et al., 2016. Biologic dose reduction in Rheumatoid arthritis: what do patients think? Results from a patient and public involvement event. BSR eposter.

Poster 13 Safe prescribing of hypnotics and high dose antipsychotics on a Psychiatric Intensive Care Unit (PICU): Interventional role of the Pharmacist Francis E, North East London NHS Foundation Trust (NELFT), Essex

Background NICE1 provide guidance on safe hypnotic prescribing, while the Royal College of Psychiatrists (RCPsych) provide guidance on prescribing high dose antipsychotics2. In 12/2014, the Care Quality Commission (CQC) carried out an unannounced inspection on PICU in NELFT, finding non-compliance with safe Prescribing of Medicines which was contrary to the Health and Social Care Act 2008 (Regulated Activities) Regulations 20103. Findings included patients prescribed regular hypnotics for several weeks (without evidence of review), medication charts not highlighted for patients on high dose antipsychotic(s). Rapid Audit Cycle (RAC) re-audits

were undertaken (May-2015, Sep-2015, Nov-2016) to monitor outcomes following implementation of a CQC action plan.

Aim The aim of RAC re-audits was to measure the extent to which actions implemented following

the CQC inspection (12/2014) and the first RAC audit (May-2015) were being sustained on PICU and report the resulting outcomes.

Objective Ensure safe prescribing of hypnotics and high dose antipsychotic(s)

Standards [Target 100%] Standards were derived from CQC findings on PICU (12/2014), RCPsych2, and Trust policies4,5.

Method An audit tool/questionnaire was developed as an online SNAP survey. Data was collected on a determined day, and analysed using Excel. Ethics approval was not sought as the project was classified as a clinical audit.

Results Sustained improvement was noted, in keeping with all 5 standards set out in Table 1. 100% compliance was evidenced by RAC2 (Sep-15), which showed sustained improvement by RAC3 (Nov-16). Table 1 Compliance with audit standards (1-5): RAC audits May-2015; Sep-2015,

Nov-2016

No.

Standard

Compliance (%)

May-15 (RAC1)

n*=8

Sep-15 (RAC2) n=12

Nov-16 (RAC3) n=11

*n=total number of patients

1 Hypnotic prescribing practice - pharmacist intervention for review of regular hypnotics

100 100 100

2 Percentage BNF maximum dose against each prescribed antipsychotic – stated, signed, dated

- - -

2.1 Percentage BNF maximum dose stated 80 100 100

2.2 Entry signed 10 100 100

2.3 Entry dated 10 100 100

3 Front of medication chart highlighted: “On high dose antipsychotic therapy”

- - -

3.1 Statement on the front of the medication chart na** 100 100

3.2 Entry signed na 100 100

3.3 Entry dated na 100 100

4 Doctors complete the High Dose Antipsychotic Monitoring Form***

na 100 100

5 High dose antipsychotic(s) plus regular hypnotic prescribed: pharmacist intervention for review

na 100 100

**not applicable [no patients on high dose antipsychotic therapy at the time of the audit] ***Includes documented evidence of ECG, routine blood tests, physical health monitoring

Conclusion The RAC re-audits showed overall improvement in compliance with standards 1-5.

Specific patient safety concerns raised by the CQC (12/2014) were addressed by the RAC re-audit findings, which showed improved patient outcomes following a collaborative approach between doctors, nurses and pharmacist’s interventions. Together they ensured implementation of the RAC SMART‡ action plan for safe prescribing of hypnotics and high dose antipsychotics. A scheduled CQC re-inspection in 04/2016 concluded no further concerns. ‡Specific/Measurable/Appropriate/Realistic/Time limited

References 1. Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term

management of insomnia. National Institute for Clinical Excellence [NICE]. Technology Appraisal 77; April 2004. Accessed 07/01/2017 https://www.nice.org.uk/guidance/ta77/resources/guidance-on-the-use-of-zaleplon-zolpidem-and-zopiclone-for-the-shortterm-management-of-insomnia-2294763557317

2. Consensus statement on high-dose antipsychotic medication. Royal College of Psychiatrists. College Report CR190, 2014 http://www.rcpsych.ac.uk/files/pdfversion/CR190.pdf

3. Health and Social Care Act 2008. Accessed 07/01/2017 http://www.legislation.gov.uk/ukdsi/2010/9780111491942/contents

4. High Dose Antipsychotic Prescribing Policy. March 2015. Dr Elizabeth Francis 5. Benzodiazepine and Z-hypnotics Prescribing Policy. June 2015. Dr Elizabeth Francis

Poster 14 Review of current management of blood glucose control in Type 2 Diabetes in Primary Care Jonas E. NHS North Somerset Clinical Commissioning Group, Clevedon

Introduction/Background/Context

Obtaining an understanding of current practice in the management of blood glucose in North Somerset allows practice pharmacists and GP practices to implement improvements and assist the implementation of updated NICE guidelines1.

Objectives

To review current practice in blood glucose management.

Method

EMIS Web search identified patients with Type 2 Diabetes a proportion of these (depending on practice size) were reviewed by the practice support pharmacist. Ethics approval was not required. Results

95% (of 125 patients) had annual diabetes reviews over 2 years.

Documentation of compliance with medication occurred in 36% of reviews.

Documentation of dietary advice occurred in 84% of reviews but only 9% of patients with a BMI above 30 had undertaken a weight loss program.

56% of patients had their HbA1c rechecked in line with NICE1

33% of patients with a high HbA1c did not have it rechecked within a year.

14% of patients who were testing blood glucose did not meet the NICE1 criteria for this, 88% of these had it stopped.

Discussion/Conclusion

A variation of care within in the practices was noted and practice pharmacists are key to ensuring good practice is shared and that more standardised models of care are introduced.

Following the review practices were recommended to have a protocol for recalling patients for HbA1c tests especially if they have a high HbA1c; ensure patients are signposted to weight loss programs and to add compliance with medication to their diabetes template, leading to greater emphasis and ensuring changes in medication are only made if compliance is assured. Patients who do not meet the NICE criteria for blood glucose monitoring should be reviewed.

References

1. NICE NG 28 (2015). Type 2 diabetes in adults: management Available at: https://www.nice.org.uk/guidance/ng28

Poster 15 STOPP START medication review: common drug class and potential financial savings in secondary care Du, HCT., Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust, Lincoln

Introduction

Inappropriate polypharmacy is a well-recognised problem and various assessment tools have

been developed to improve medication appropriateness1. The Screening Tool for Older

People’s Potentially Inappropriate Prescriptions (STOPP) and Screening Tool to Alert to Right

Treatment (START) are two instruments for detecting potentially inappropriate prescribing in

elderly patients2. It has been reported that medication reviews (MRs) based on the STOPP

START (SS) criteria may help to improve patient care and reduce drug-related costs3

Objective(s)

The objectives were to (a) identify common class of drugs prescribed inappropriately, and (b)

estimate the financial impact of MRs on drug costs at four district general hospitals using a

locally adapted version of the SS tool.

Method

Opportunistic MRs were performed by 34 clinical pharmacists between March and December

2016. Adult inpatients (≥16 years) were reviewed during daily pharmacy ward visits; data

recorded included patient and intervention details (i.e. name/dose/frequency of the medication

implicated). For any 'regular' and/or 'when required' medication stopped/started, the

equivalent cost for 365 and 28 days’ worth of supply, respectively, was calculated. All parental

preparations, medication for short-/fix-term duration (e.g. antibiotics) and topical drops were

excluded from the cost analysis. Drug prices were obtained from NHS Drug Tariff4. Ethics

approval was not required for the audit.

Results

A total of 1,108 inpatients (average age 74 years old) received a MR. Results are shown in

Table 1. Overall, an estimated net saving of £117,957/year was observed, which approximates

to £106/patient/year.

Table 1: STOPP and START interventions performed and common drug class

Drug Class

(British National Formulary Chapter)

Number of

interventions

Savings/Costs

(per year)

ST

OP

P (

sa

vin

gs

)

Laxatives (1.6) 201 £10,780

Analgesics (4.7) 137 £27,822

Anti-secretory & mucosal protectants (1.3) 125 £3,826

Anticoagulants & protamine (2.8) 116 £13,542

Anti-bacterial (5.1) 82 £0

Other 749 £100,824

Total 1410 £ 156,794

S T A R T

(c os

ts ) Anticoagulants & protamine (2.8) 91 £7,063

Anti-secretory & mucosal protectants (1.3) 73 £1,734

Anti-bacterial (5.1) 43 £0

Analgesics (4.7) 31 £2,358

Vitamins (9.6) 29 £1,352

Other 274 £26,330

Total 541 £38,837

Discussion/Conclusion

Most common interventions involved medicines for acute symptom relief and/or disease

management. This potentially reflects the uncomplicated nature of such intervention and

determination of clinical appropriateness. Secondly, the scale of cost-saving is comparable to

that reported previously3. Further work is needed to determine the real-world impact of MRs

on patient outcome.

References

1. Duerden, M. Avery, T. Rupert, P.; Polypharmacy and medicines optimisation - making it safe and sound [online]; 2013; Available at: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf [Accessed: 15/01/2017].

2. Gallagher, P. Ryan, C. Byrne, S. et al.; STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation; International Journal of Clinical Pharmacology and Therapeutics; 2008; 46; 72–83.

3. Baqir, W.; Shine 2012 final report: A clinico-ethical framework for multidisciplinary review of medication in nursing homes [Online]; 2012; Available at: http://bit.ly/2iFnNCJ [Accessed: 15/01/2017].

4. NHS Business Services Authority; Drug Tariff March 2016 [Online]; 2016; Available at: http://www.nhsbsa.nhs.uk/PrescriptionServices/Documents/PPD%20Drug%20Tariff/March_2016.pdf [Accessed: 03/01/2017].

Poster 16 Optimisation of medication to prevent microvascular complications of diabetes in Primary Care Vincent K, Jonas E. NHS North Somerset Clinical Commissioning Group, Clevedon

Introduction/Background/Context

NICE1 recommends that patients who have raised ACR or microalbuminuria have their blood pressure, HbA1c and cholesterol optimised. This review shows that practice pharmacists can be utilised to ensure this occurs.

Objectives

To highlight patients with early evidence of microvascular complications of diabetes such as microalbuminuria or early signs of retinal damage. To optimise blood pressure, blood glucose and serum cholesterol in line with NICE guidance1

Method

EMIS Web search identified patients on practice diabetes register with microalbuminuria or abnormal retinopathy screening in the last 2 years. These patients were reviewed by the practice pharmacist and recommendations made to a GP to optimise blood pressure, blood glucose and cholesterol. Ethics approval was not required. Results

357 patients were reviewed. The table below shows the number with adequate control and the number of interventions made.

Target Adequate

control at

time of

review

Inadequate

control at

time of

review

Changes made to

management during review

(percentage of inadequate

control)

Blood pressure

control

<130/80 214 143 52 (36%)

Blood glucose

control

HbA1c <6.5% 130 227 30 (13%)

Lipid control Cholesterol

<4mmol/L

223 134 31 (34%)

This review did not capture if the patients reached acceptable levels after changes had been made.

Discussion/Conclusion

A large number of patients with early microvascular complications of diabetes were not within target ranges putting them at high risk of progression of diabetic nephropathy and retinopathy. This review has shown that there is a large amount of work to optimise medication to reduce risk of progression of diabetic complications. Following this review it was recommended that all practices within the CCG should have a pathway for management of patients with microalbuminuria to ensure they are reviewed regularly to optimise blood pressure, blood glucose and lipid control; practice diabetes templates should be updated to record retinal screening results rather than just recording attendance and if abnormal retinal screening is detected the practices should have a pathway that includes review to optimise medication. References

1. NICE Clinical Guideline 87 (2009). Type 2 diabetes: The management of type 2 diabetes. Available at: https://www.nice.org.uk/Guidance/CG87.

Poster 17 Does an Integrated Information Technology System Provide Support for Community Pharmacists Undertaking Discharge Medicines Reviews? Hodson K, Cardiff University, Cardiff, Wales, UK Way C, NHS Wales Informatics Service, Cardiff, Wales, UK Jones G, Cardiff University, Cardiff, Wales, UK Ellis L, Cardiff University, Cardiff, Wales, UK Mantzourani E, Cardiff University, Cardiff, Wales, UK

Introduction

The Discharge Medicines Review (DMR) service in Wales aims to provide support to patients

recently discharged from hospital ensuring that changes made to their medicines are enacted

as intended in the community. A precious evaluation of the DMR scheme recommended a

number of improvements: as a result, an integrated information technology system was

developed. From 2015 the community pharmacist received automatic notifications and could

securely access information in the patient’s electronic discharge advice letter (e-DAL) through

the new system and import the medication information into the DMR form, which was then

automatically submitted for reimbursement. The system was installed in 43 community

pharmacies.

Objective

To explore community pharmacists’ views on access to the e-DAL and the on-line DMR form.

Methods

Face-to-face semi-structured interviews with community pharmacists who had used the new

integrated system, between November and December 2015. The schedule explored opinions

on the system, e-DALs and DMRs generally. The audio recordings were transcribed ad

verbatim and were thematically analysed. Ethical approval was granted by a University’s

School Research Ethics Committee.

Results

Seven main themes were identified from 17 interviews: up-take of e-DALs, information in e-

DAL vs. DAL, usability, patient confidentiality, impact of e-DMR, communication and further

improvements to the system. Participants found the system secure, easy to use and felt it

reduced transcription errors and saved pharmacists’ time. Users would like to be able to share

information within the system with patients’ General Practitioners and with their Patient

Medication Record systems. Pharmacists also stated that they would like the system

developed to support additional services they provide.

Discussion

The new system has overcome the main barriers identified in a previous evaluation for

undertaking DMRs. Due to the successful implementation of this information technology

advancement it will now be rolled out to 350 community pharmacies around Wales.

Poster 18 A Pilot Study Investigating the Effectiveness of Pharmacist-led Medication Reconciliation in General Practice Abbiss, H. & Beer, N., Greenlight Healthcare Ltd (GP Connect) & The Jubilee Street Practice, London

Background Transfer of care between sectors is associated with a high risk of medication errors that present a risk to patients1. As many as 43% of patients may have discrepancies between the medications prescribed on their discharge letter and those subsequently prescribed on their GP record2. Medicines reconciliation (MR) led by pharmacists is standard practice in secondary care. With pharmacists becoming an integrated member of a growing number of primary care teams, it is suggested that they could also be utilised to improve prescribing accuracy and safety in this sector3.

Aims & Objectives To assess the usefulness of a practice-based pharmacist carrying out MR and follow-up at a single GP practice. To reduce medication errors and GP workload.

Method During the study period (31/10/16 – 21/01/17), data was recorded for 31 discharge letters reconciled by the pharmacist. The need for MR was identified via a combination of GP referrals, patient/carer requests and electronic searches. This was a retrospective analysis, using standard care as the comparator, therefore ethics approval was not required.

Results

Discussion This study provides evidence that practice-based pharmacists are in an excellent position to accurately carry out MR in primary care. The pilot heightened GP awareness of the pharmacist’s ability to assist with MRs, especially those requiring time-consuming repeat prescription updates. Areas for improvement were identified following the pilot:

To ensure all records are updated promptly (NICE recommends 100% within 7-days4 compared to 74% achieved)

To improve patient/carer understanding of changes. (Without identification of outstanding discharges through searches and the consultations offered, several patients would have run out of medicine, or lacked adequate understanding.)

The study was limited by its small size and restricted time period. A larger, more comprehensive study is required to further support the benefits of involving practice-based pharmacists in MR processes.

References

0 5 10 15 20 25 30 35

Medication record updatedRx requested from GP

Pharmacy informed of changesReferral to GP/other

Post d/c med review F2F or tele consultBlood tests arranged

Rx management activities

Number of patients

Post-discharge Folllow-up Performed by Practice Pharmacist

Pharmacist MR demographics: patients with at least 1 new med started 81%, patients with ≥4 med

changes 61%, care home residents 16%, requiring medicines in compliance aid 45%.

1. Care Quality Commission. National study: Managing patients’ medicines after discharge from

hospital. October 2009 [online] Available from: webarchive.nationalarchives.gov.uk/20101201001009/http:/www.cqc.org.uk/_db/_documents/Managing_patients_medicines_after_discharge_from_hospital.pdf [accessed 14/01/2017]

2. Avery T, Barber N, Ghaleb M et al. An Investigation into the prevalence and cause of prescribing errors in general practice: The PRACtICE study, a report for the GMC. May 2012 [online]. Available from: www.gmcuk.org/Investigating_the_prevalence_and_causes_of_prescribing_errors_in_general_practice_The_PRACtICe_study_Reoprt_May_2012_486 05085.pdf [accessed 26/12/16]

3. Royal College of General Practitioners & Royal Pharmaceutical Society. Joint Policy Statement on GP Practice Based Pharmacists. February 2015 [online]. Available from: www.rpharms.com/ promoting-pharmacy-pdfs/rcgp-joint-statement-for-pharmacists-in-gp-surgeries-version-2.pdf [accessed 14/01/2017]

4. National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. March 2015 [online] Available from: www.nice.org.uk/guidance/ng5 [accessed 26/12/2016]