Is the 7 day service the future of pharmacy in acute medicine? David Young

Contents What is the current situation with week- end pharmacy cover? Is there a need for a 7 day pharmacy service? What would be the benefits? What are the challenges with setting up a 7 day service?

Current week-end pharmacy service to AMU Pharmacist visit for 1-2 hours about 10:30 & pharmacy open until 12 –Current set up allows supply of routine medicines only –Unrealistic for getting TTOs ready by this time PTWR, reviewing sick patients, organising urgent investigations etc. –Pharmacist often not recognised by the nursing staff This and time constraints limits ability to be involved with helping to solve pharmaceutical problems –For the charts that do go to pharmacy they can be off the ward for up to 5 hours and so medicines are often administered late, if at all (likely to miss a drug round while chart off the ward)

Current week-end pharmacy service to AMU TTO service available Saturday afternoon but nurses generally unaware of the service and usually run from the pharmacy –Unable to check notes for omissions or check with patient for an accurate drug history & to identify medicines available at home –Chart in pharmacy all afternoon and TTO unlikely to be back before the end of the day Service cancelled on Sunday as insufficient TTOs around the hospital to make it worthwhile → Poor patient experience

Is there a need for a 7 day service? There is already a move to encourage acute medicine to “embrace” 7 day working –Known benefits: Rapid assessment allowing a reduced length of stay Reduced morbidity and mortality with rapid treatment Lower rates of hospital acquired infections Improved patient experience Patients are known to be more vulnerable at week-ends and out-of-hours Demand doesn’t fall significantly at week-ends

AMU admissions by day of the week (April – May 2011) Average = 40 Average = 35

AMU discharges by day of the week (April – May 2011) Average = 17 Average = 14

Benefits – medicines reconciliation Recognised as one of the most important processes to improve patient safety Error in about 50% of initial drug histories –Problems that occur because of inaccurate DHx: Fail to identify toxicity or medicines related admissions Patients miss critical medicines (e.g. anti-rej, B-bloc) Improved compliance with NICE (& WHO) medicines reconciliation target (within 24 hours) –Admitted late Friday will not have their medicines reviewed by a pharmacist until the Monday (possibly the Tuesday or Wednesday if there is a bank holiday)

Reason for medicines not being reconciled within 24 hours of admission

Benefits – medicines use Improving quality of medicine use –Optimal dosing –Interactions –Therapeutic drug monitoring Staff working at the week-end less familiar with AMU, or even SUHT, policies A significant proportion of the interventions made by pharmacists are made on admission Patients less likely to miss significant medicines, either because of unavailability or prescribing issues

Benefits – discharges Reduce delayed & unsafe discharges –Nurses will prepare simple TTOs but involves risk and complicated patients end up staying in hospital –Medication errors not identified (e.g….) –Less patients have to visit GP or return to hospital to collect TTOs Improved counselling on medicines, including changes made to their regimen while in hospital –CQUIN & the National Inpatient Survey –Opportunity to ask questions Better documentation of changes to medicines and more timely communication of discharge summary to the GP

Impact on other areas Ward staff would get to know the pharmacists working at the week-end and would be more likely to involve them Development opportunity for pharmacists participating Less need for on-call service and dispensary service Week likely to be more efficient on AMU and general medicine wards

Challenges & practicalities Cost –Mid-point of band 7 £35, % (costs) + week-end enhancement £200/ £250 (Saturday/ Sunday) for a 7.5 hour day –Possibility this would be offset by efficiency savings Change hours and need more week day hours –Would people be prepared to work more at the week-end? Especially those with families –Would need to modify rotas –Would possibly involve partnership with directorates other than medicine Would need sufficient people to be able to cover holiday, sickness, maternity leave, recruitment delays etc.

Conclusion Cost & faff vs. efficiency savings and improving quality, safety and patient experience Would reduce LoS by directly influencing discharges and indirectly by preventing medication errors starting on AMU