Pharm World Sci (2007) 29:240–277DOI 10.1007/s11096-007-9100-8

PROGRESS IN PRACTICE UKCPA RESIDENTIAL SYMPOSIUM

Hotel Metropole, Leeds Friday 18th– Sunday 20

thNovember 2005

Lilly UK Critical Care Award 2005

Monitoring a high cost drug in critical care units

Wells H1, Batra R

2, McKenzie CA

1, Yassin S

1, Offord R

1, McLuckie A

3

1PharmacyDepartmentGuy’sandSt.Thomas’NHSFoundationTrust,London,

UK, 2School ofMedicine, University of Maryland, Baltimore, USA, 3Intensive

Care Unit, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK

Introduction

Drotrecogin alfa (activated), or recombinant human activated protein C

(APC) is licensed for the treatment of severe sepsis in patients already

receiving optimum intensive care support. It acts by modulating the coag-

ulation cascade and systemic inflammatory response during severe sepsis1. In

this disorder, the ability to produce APC is impaired, and patients are at

increased risk of inappropriate intra-vascular coagulation, multi-organ

failure and death1. Efficacy data for APC comes primarily from PROWESS,

a multi-centre, placebo-controlled study of 1728 patients. PROWESS

demonstrated a statistically significant absolute risk reduction in 28 day

mortality of 6.5% with a number needed to treat 16 patients1. Despite po-

sitive outcomes in the PROWESS study, the price of using APC is high, both

financially and in terms of possible adverse effects. The cost of a course of

APC for a 70 kg patient is estimated as £4,905 excluding VAT. The drug has,

however, been proven to be cost-effective if targeted to patients whomeet the

PROWESS criteria1 (Table 1). The incidence of severe bleeding events was

higher in PROWESS but did not reach statistical significance1. Its use is

therefore contra-indicated in patients at high risk for bleeding1 (Table 1).

Upon European Licensing in 2002, the South East London Critical Care

Network (SELCCN) successfully bid for funding to use APC in the setting

of severe sepsis. Due to the high cost of use and risk of adverse events, the

SELCCN believed it was essential to collect prescribing, mortality and

adverse effect data on all patients who received the drug.

Objective

To collect post-licence surveillance data of APC use in severe sepsis across a

network of six intensive care units (SELCCN). To certify adherence to agreed

prescribing guidelines, monitor outcome (mortality), adverse events and

financial data, thus ensuring best clinical practice and continued funding.

Method

Guidelines for APC were agreed upon by the SELCCN. A reporting tool

and supporting database reflecting these guidelines were designed and

implemented to prospectively collect clinical and financial data. The data

were then analysed for adherence to established guidelines, patient out-

come, adverse events and appraisal of performance against established

expenditure aims. The collated data were reported monthly and progress

was discussed at network meetings.

Results

Data were collected and analysed for 249 patients from November 2002 to

June 2005. A total of 87% of patients met the agreed criteria (Table 1) for

APC with an average expenditure of £5,210.80 ± £2,348.08 per patient.

During treatment, 30 haemorrhagic events were cited with 4 reported as

serious. Additionally, 8 cases of administration errors occurred, consisting

of miscalculated dosing and incorrect preparation. Of 249 patients receiving

APC, 85(34%) died in the ICU, 9(4%) died as post-ICU patients, 126(51%)

were discharged home and 29(11%) were still in-patients or lost to follow-

up. Of the 119 patients 48 with four or more organs in failure at the time of

APC administration survived their hospital stay (Figure 1).

Table 1 Summary of SELCCN inclusion criteria (based on PROWESS1)

Infection criteria: Modified SIRS criteria Criteria for organ dysfunction

Suspected or proven infection. Patients had to meet at least two of the following: core

temperature ‡38 or £36 �C; heart rate of ‡90/min; a

respiratory rate ‡20/min or PaCO2 £4 kPa, or mechan-

ical ventilation; white cell count of ‡12 · 109/l or

£4 · 109/l.

Patients had to meet at least two of the following

criteria: hypotension despite adequate fluid and/or

requirement for vasopressors to achieve satisfactory

blood pressure, persistent oliguria despite adequate fluid

resuscitation; acute hypoxaemia as measured by a PaO2/

FiO2 ratio £33 kPa (£26.6 in the setting of pneumonia);

platelet count £80 · 109/l or a 50% decrease over last

3 days; sepsis induced metabolic acidosis (lactate >1.5

times upper limit of normal plus either pH < 7.3 or

base deficit >5 mEq/l).

*Exclude if patient has any of the following: active internal bleeding or GI bleed in the last 6 weeks with no correcting intervention, intracranial pathology

including surgery in the last 3 months or recent trauma or haemorrhagic stroke, surgery within the last 12 h, concurrent heparin therapy >15 IU/kg/h,

known bleeding diathesis, platelet count of <30 · 109/l, epidural catheter, probable survival of less than 24 h or terminal medical condition.

Figure 1 Hospital survival in patients receiving APC stratified by organ failure.A240

Discussion

These results suggest that it is possible to develop and ensure excellent

adherence to consensus guidelines for the use of a high cost life saving

drug. By producing a simple reporting tool and database, selection cri-

teria, patient outcome, and adverse events was easily monitored across

the critical care network. As the ICU represents one of the most chal-

lenging patient populations, it is clear that this level of surveillance could

be duplicated easily in any situation requiring the use of high cost drugs.

The data suggest favourable patient outcome especially in those with

greater than 4 organs in failure (40.3% surviving) when compared to the

average survival (19.4%) of a similar group of patient in the 5 years

prior to APC introduction as measured in 91 ICU’s throughout the UK1.

The adverse event rate (1.6%), was acceptable but highlighted the

importance of strict adherence to the exclusion criteria (Table 1). Due to

excellent monitoring, administration errors were noted and have been

brought to the attention of the SELCCN and manufacturer for possible

solutions. The precise collection of both financial allowed the SELCCN

to reclaim a majority of the expenditure for APC use from the relevant

Primary Care Trusts.

References1. Green C, Dinnes J, Takeda A et al. Clinical effectiveness and cost-effectiveness

of drotrecogin alfa (activated) (Xigris�) for the treatment of severe sepsis inadults: a systematic review and economic evaluation. Health Technol Assess2005; 9: 1–126, iii–iv.

Oral Communications

1 Communication regarding medication changes in outpatient

haemodialysis patients between secondary and primary care: a risk

evaluation

Goodchild A1, Gerrett D

2

Nottingham City Hospital NHS Trust, Nottingham (now at Sherwood Forest

Hospitals NHS Trust), 2Pharmacy Academic Practice Unit, Derby

Introduction

Evidence is accumulating that errors in communication across the primary

secondary care divide may lead to patient harm.

In the largest study1 of communication across the primary secondary

care divide, researchers found 52.7% (n = 1,328) of prescribable items

had unintentional discrepancies following the standard discharge process.

Four medical consultants reviewed these discrepancies and found 3.1%

and 6.3% were classified as having a definite or possible adverse effect,

respectively.

The need for better communication between hospitals, General Medical

Practices (GPs) and community pharmacists in order to lessen the all too

frequent unintended changes in medication after hospital discharge is a

current Government priority for pharmacy intervention2.

In November 2002, a change in prescribing practice at Nottingham City

Hospital NHS Trust (NCH) meant that all chronic, long-term, oral medi-

cation for haemodialysis outpatients would subsequently be obtained from

the GP. The potential for unintentional discrepancies in this group has been

described in a small sample3 but not risk assessed.

Objectives

The present study was undertaken to quantify the number of medication

changes initiated in outpatient haemodialysis patients that were not suc-

cessfully communicated to primary care over the study period. The risk to

individual patients of any unsuccessful communication between Notting-

ham City Hospital NHS Trust (NCH) and General Medical Practice (GP)

surgeries regarding medication changes was assessed.

Method

This study was conducted in outpatient haemodialysis patients attending

for dialysis at the Main Dialysis Unit at NCH. For 6 weeks all changes to

long-term oral medication in this patient group were documented. The

investigator followed up these medication changes by telephone with the

patient’s GP surgery at an allocated follow up date. A medication change

was categorised as being successfully communicated to the GP if the

computerised medication record held at the GP practice had been updated.

Communication between NCH and the GP was deemed unsuccessful if one

of the following had occurred: the computerised medication record had not

been updated at the GP practice, no letter from NCH detailing the medi-

cation change had been received by the GP practice, a letter had been

received from NCH but had been filed by the GP practice with no action

taken to update the computer record. All cases of unsuccessful communi-

cation were documented and presented to a risk assessment panel. The

panel assessed the cases for ‘‘potential clinical significance’’ using a visual

analogue scale with 11 numbers from 0 (no effect) to 10 (death). Cronbach’s

alpha was used to determine inter-rater reliability4. Assessors were asked to

indicate the number on the scale above which the implication of

unsuccessful communication would warrant prompt intervention to prevent

patient harm.

The nature of the study was deemed to be an Audit by the Local Area

Ethics Committee. At the time of this investigation there were no clear audit

standards from either local practice guidelines or other literature that

proposed the proportion of changes made to medication in secondary care

that should be communicated accurately to primary care. All published

literature states that any medication changes made in secondary care should

be communicated to primary care. As no ‘target’ is stated we assumed this

means that 100% of changes should be communicated.

Results

During the 6 week (30 day) collection from April to June 2003, 74 medi-

cation changes made at Nottingham City Hospital for haemodialysis out-

patients were identified. Of these, 23 were excluded as the items were not

supplied in primary care or the course was started and completed in the

secondary care setting. The remaining 51 items for 40 patients were inten-

sively followed up and 11 (21.5%) medication changes were not successfully

communicated to the patient’s GP surgery. The potential clinical signifi-

cance of these cases were assessed by a panel comprising a consultant

nephrologist, a renal nurse consultant, a renal pharmacist and a staff grade

physician. Cronbach’s alpha was maximised by excluding the latter assessor

(alpha = 0.7962, F = 0.9077, p = 0.4194). The remaining three judges

assigned a mean score of 6.66 (median 7.33, range 3–7.85) for the 11 cases.

All three independently assigned seven as the value above which an inter-

vention was necessary to prevent patient harm. Of the 11 cases 6 were

assigned an average above this value.

Discussion

This is the first study known to the authors that assesses the risk of

unintentional miscommunication of medication changes specifically in

patients with renal disease. The audit finds that the current system of

communicating medication changes in outpatient haemodialysis patients

from NCH to patients’ GPs results in errors of communication, which

necessitate action to prevent patient harm. Potential remedies lie in first

identifying where a failure to communicate is likely to be important.

Having identified areas of risk, a reduction may be achieved by;

reviewing and refining communication mechanisms to include a feedback

loop to ensure that information transfer has occurred; involving and

empowering patients using constructs of concordance and written records

of changes; directly involving community pharmacists as a fulcrum

between primary care surgeries and secondary care; and, designing

Information Technology to identify risk situations and ensure accurate,

timely transfer of information.

Acknowledgements

Nottingham City Hospital NHS Trust: Shelagh French, for financial

assistance, Sandy Beatty for peer support and Dr Cassidy for access to

notes for audit purposes.

References1. Duggan C, Feldman R, Hough J et al. Reducing adverse prescribing discrep-

ancies following hospital discharge. Int J Pharmacy Prac 1998; 6: 77–82.2. Department of Health. Pharmacy in the Future–Implementing the NHS Plan.

London: Stationery Office, 2000.3. Myers E. Non-compliance with prescribed medication in patients with chronic

renal failure. Pharm World Sci 2003; 25(1): A40–1.4. MacLennan RN. Interrater reliability with SPSS for Windows 5.0. Am Statis

1993; 47(4): 292–6.

2 An audit of antibiotic use and supply under patient group directions at

a primary care centre

Bishop S

Tower Hamlets Primary Care Trust, London

A241

Introduction

The local primary care centre uses Patient Group Directions (PGDs) to

allow nurses to supply medication to patients for various conditions, based

on approved local clinical guidelines. Currently, PGDs for co-amoxiclav,

erythromycin and flucloxacillin are in place for treating animal bites and

cellulitis. Drug expenditure reports indicated that the use of co-amoxiclav,

erythromycin and flucloxacillin under PGD within the local primary care

centre was dramatically increasing.

Objectives

The aim of this audit was to determine if these PGDs were adhered to,

(100% of legal requirements followed and 100% adherence to local clinical

guidelines). The objectives were to:

� Audit the documentation of inclusion and exclusion criteria, cautions,

drug history, allergy status and records of supply against the set standard

� Make recommendations for improvement if required.

Method

A data collection form was designed based on criteria specified for each of

the three PGDs. The PGD issue record book used at the centre was used to

record antibiotic supplies made during the previous 3 months. Patient

demographics of the selected records were recorded on the data collection

form and the centre’s electronic record system was used to retrieve addi-

tional relevant information, i.e., consultation details, drug history and

treatment.

Results

A total of 82 records were identified. Of these, 11 were ineligible or partially

incorrect and were excluded from the final analysis. Medication was sup-

plied under PGD to all 71 patients despite criteria not being met in all cases,

e.g., antibiotic supplied for indication other than as specified on PGD. The

supply of individual antibiotics was as follows: co-amoxiclav to 7 patients,

erythromycin to 8 patients and flucloxacillin to 56 patients.

Table 1 shows adherence to the legal requirements in the 71 cases audited.

Forty-five patients (63%) met the inclusion criteria specified in the PGD’s.

A total of 58 patients (82%) did not have an exclusion criterion present,

however the remaining 13 patients had a criterion excluding them from

supply under the PGDs audited. Both patients who had criteria for referral

were appropriately referred to a doctor.

Adherence to patient safety criteria is shown in Table 2. Sixty-four of the

71 patients seen (90%), had a documented drug history. Among these, five

potential interactions were identified and an appropriate course of action

documented in 3 of the cases. In 2 cases, a broad-spectrum antibiotic was

supplied to women taking oral contraception (type unspecified) with no

documentation of advice given regarding additional contraception. Allergy

status was checked in 63 patients (89%). One patient with a documented

penicillin allergy received flucloxacillin – the nature of the allergy was not

specified. Of the 8 patients without a documented allergy status, 6 were

supplied a penicillin.

Documentation of all criteria required in the PGD record book ranged

from between 70% and 87%. Documentation in the electronic patient re-

cord for the required parameters varied between 66% and 96%.

Discussion

This audit found documentation to be poor when antibiotics were supplied

under PGD. The importance of documenting a complete and full drug

history, allergy status (including reaction), details of the consultation (and

advice sought) and an accurate and legible record of supply, needs to be

reinforced to the medical and nursing staff working within the centre. A

possible way to improve documentation could be to replace the current

electronic record with a template-based electronic record, which would

prompt the practitioner on exactly what needs to be recorded and flag up

any problems.

In many of the cases assessed, the antibiotics were being supplied for

conditions outside of the PGD indication. The legal limitations of

PGDs should be reiterated to centre staff to ensure that they are

working within the law, and discrepancies in working practices clarified.

Discussions should also take place to establish which other common

conditions they are treating with these antibiotics and if appropriate,

set-up PGDs for these conditions. Finally, it is important that root

cause analysis is carried out on all consultations not meeting the legal

requirements of a PGD and/or which may have compromised patient

safety in order to establish the true cause and enable corrective actions

to be implemented.

Following implementation of recommendations within the centre, the use

of these antibiotics should be re-audited in 1 year’s time.

3 An audit of the prescribing of lipid-lowering drugs in North

Glamorgan NHS Trust

Cooper SM1, Hodson KL

2, Malik UA

1, Scott-Thomas S

1, Cassidy D

3

1Department of Pharmacy, North Glamorgan NHS Trust, Merthyr Tydfil,2Welsh School of Pharmacy, Cardiff, 3Department of Biochemistry, North

Glamorgan NHS Trust, Merthyr Tydfil

Introduction

Statins are the main group of lipid-lowering drugs that are generally pre-

scribed in practice. Evidence suggests that statins benefit patients with an

increased risk of coronary heart disease (CHD) but also those patients

without CHD who have diabetes or non-occlusive arterial disease1. The

National Institute for Clinical Excellence (NICE) guidance for lipid-low-

ering is within diabetic patients and postmyocardial infarction patients2,3.

Merthyr Tydfil is a designated ‘‘black spot’’ with regards to CHD in

Wales. Anecdotal evidence suggested that not all patients who should re-

ceive a lipid-lowering drug were being prescribed one. In addition, there was

no consistency to which drug or dose was prescribed. This was acknowl-

edged by the All Wales Medicines Strategy Group in 2003/2004 who wanted

to develop a statin prescribing policy to be implemented across Wales4.

It was therefore decided to audit the prescribing of the lipid-lowering

drugs within North Glamorgan NHS Trust to identify current prescribing

patterns against the evidence. The standards developed for the audit were

100% of patients would be prescribed simvastatin 40 mg daily or an

equivalent.

Objectives

To identify the indications for the use of lipid-lowering drugs within the

hospital; to describe and compare to trial data the prescribing patterns of

these drugs; to identify whether the initiation of the lipid-lowering drugs

was by the general practitioner or the hospital doctor and to assess whether

appropriate monitoring parameters were being carried out.

Method

Permission to carry out the audit was granted by North Glamorgan NHS

Trust. A data collection form was developed and piloted on five patients;

minor amendments were made. All patients admitted onto six medical

wards and the coronary care unit from 16th February to 12th March 2004

were screened, using the prescription charts, to identify if a lipid-lowering

drug was prescribed. Further data was collected for those patients who were

either receiving the drug prior to admission or were initiated the drug dur-

ing their admission, using the prescription charts, discharge prescriptions,

Table 1 Adherence to legal requirements (n = 71)

Legal requirement No. of

patients

Standard (%) % of

standard met

Patients meeting inclusion

criteria

45 100 63

Patients without a criteria

for exclusion

58 100 82

Patients with a criteria for

referral who were referred

2 100 100

Table 2 Adherence to patient safety criteria (n = 71)

Criteria No. of

patients

Standard (%) % of

standard met

Drug history documented 64 100 90

Potential interaction 5 – –

Appropriate course of

action documented in

cases of potential interaction

3 100 60

Allergy status documented 63 100 89

Patients who received a drug

to which they were not allergic

70 100 98

A242

patient’s notes and biochemical data. Data included demographic data, the

lipid-lowering drug prescribed, reasons for the drug, patient’s past medical

history, who initiated the medication, the patient’s lipid profile and liver

function tests. All data was collected by the researcher. Data was then

coded and analysed using SPSS 11.5.1.

Results

Over the 4 week period, 90% of current in-patient prescription charts were

reviewed (1806 prescription charts reviewed from 2015 beds occupied).

From these, 155 patients on lipid-lowering agents were identified. The pa-

tient ages ranged from 23 to 91 years with the majority between 70 and

79 years. Sixty-three percent of patients were admitted to hospital with

cardiac problems; over 50% of patients had 3 or more conditions which

warranted a lipid-lowering drug to be prescribed. Ninety-four percent (147/

156) of patients were prescribed a statin and 6% (9) a fibrate. Simvastatin

was the statin most commonly prescribed (n = 71), followed by pravastatin

(n = 41) and then atorvastatin (n = 30). Simvastatin 20 mg daily was the

most frequent dose prescribed (n = 40/147); only 11% (n = 16/147) were

prescribed the recommended simvastatin 40 mg daily. Sixteen patients were

taking atorvastatin 10 mg daily compared to nine prescribed 20 mg daily.

The majority (49%) of lipid-lowering drugs were initiated by hospital

doctors; simvastatin 20 mg daily was the most frequent drug initiated

(35.5%) compared to atorvastatin 10 mg daily by general practitioners

(22.8%). Liver function tests (LFTs) for statins and fibrates were not

completed as recommended with only 77.6% having LFTs performed prior

to commencing treatment and the percentage of appropriate LFTs per-

formed decreasing for the subsequent tests.

Discussion

The results of this audit clearly demonstrated that the prescribing of lipid-

lowering drugs did not reach the required standard and therefore was not

reflecting the evidence. The choice of statin prescribed was different in

primary and secondary care and the recommendations for monitoring the

drug therapy were not being adhered to. Education with respect to the

evidence, recommended monitoring and cost of the different drugs was

required. This was undertaken by presenting the results of the audit to the

Medical Directorate at the Hospital and the Local Health Board. As a

result of a discussion during the presentation a statin–patient information

leaflet has been produced by the Trust.

Subsequent to this audit, a template on the use of statins in primary and

secondary prevention of CHD has been produced by the All Wales Medi-

cines Strategy Group4. These guidelines have recommended simvastatin

40 mg daily as first line and atorvastatin 20 mg daily as second line, based

on the combination of evidence, lipid-lowering potency, cost and safety.

This template and the specific results from the audit have been used to

produce Trust guidelines and it is the hospital’s intention to re-audit in the

next 12–18 months.

References1. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection

Study of cholesterol lowering with simvastatin in 20, 536 high-risk individuals: arandomised placebo-controlled trial. Lancet 2002; 360: 7–22.

2. National Institute for Clinical Excellence (NICE). 2001. Prophylaxis forpatients who have experienced a myocardial infarction. Drug treatment, cardiacrehabilitation and dietary manipulation. [www] http://www.nice.org.uk/pdf/clinicalguidelinemiguidance.pdf (accessed March 2004).

3. National Institute for Clinical Excellence (NICE). 2002. Management of type 2diabetes. Management of blood pressure and blood lipids. [www] http://www.nice.org.uk/pdf/NICE_INHERITE_Hv8.pdf (accessed February 2004).

4. All Wales Medicines Strategy Group. 2003. Minutes of meeting held on 2ndDecember 2003. [www] http://www.wales.nhs.uk/sites/documents/371/ACFD032.pdf (accessed 24th January 2004).

4 Use of herbal remedies by patients admitted to hospital

Franklin BD1,2, Seedat H2, Heinrich M2

1Academic Pharmacy Unit, Hammersmith Hospitals NHS Trust, London,2School of Pharmacy, University of London

Introduction

Many people use herbal remedies for different health problems. However,

we currently have little understanding of what is used, whether our current

approach to obtain a medication history on admission uncovers details of

these products, and whether any of these products are likely to interact with

the conventional remedies prescribed during the patient’s admission. Our

aim was to better understand the use of herbal remedies among inpatients at

our trust.

Objectives

� To estimate the percentage of inpatients who use herbal remedies, and

establish which products are used;

� To determine whether or not these products were documented as part of

the patient’s medication history for their current admission and pre-

scribed on their current medication chart;

� To determine how many of these products may interact with conventional

remedies.

� To understand the patients’ reasons for using such products.

Method

A sample of 15 wards was selected using a random number table. The

intensive care units, private wards and wards belonging to the mental health

trust were excluded. For each ward selected, an undergraduate student

obtained a list of all patients on the ward, and spoke to the nurse in charge

to identify and exclude any who had learning difficulties or mental illness,

were terminally ill or deemed too unwell to take part in a 15 minute

interview. Patients who do not meet any of these exclusion criteria were

asked if they would be happy to answer a series of questions about their use,

if any, of herbal remedies. Patients gave written consent to be included; the

study was approved by the local research ethics committee.

A questionnaire comprising both closed and open questions, adapted

from previous use1 was used to obtain details of any herbal remedies used.

We then used the patients’ medical notes and their current drug chart to

identify whether any of the remedies cited were prescribed and/or docu-

mented in the patient’s medication history relating to their current admis-

sion. All pharmacognostical identifications were based on the popular

names and were therefore tentative as no samples could be collected.

Results

A total of 96 patients were approached, and 88 (92%) consented to take

part. Of these, 49 (56%) were female; 58 (65%) described themselves as

White British, 9 (10%) as Asian British, 7 (8%) as Black Caribbean, 6 (7%)

as European and 4 (5%) each as African and Chinese.

Of the 88 interviewees, 45 (51%) had used herbal remedies in the last

year. Most of these related to herbal teas such as chamomile (Matricaria

recutita or possibly Anthemis nobilis) and peppermint (Mentha piperita).

Others had taken products such as ginkgo (Ginkgo biloba; n = 7), St John’s

Wort (Hypericum perforatum; n = 9), and ginseng (Panax quinquefolium;

n = 2). Specific interactions with conventional medicines have been re-

corded for some of these botanicals. Four patients had taken herbal rem-

edies on the advice of a non-conventional health care professional. These

were Echinacea purpurea for a viral infection, stinging nettle (Urtica dioica)

and benzoin (Styrax benzoin) for joint pains, milk thistle (Silybum maria-

num) for use as a laxative, and an unspecified traditional chinese medicine

for hypertension. The other herbal remedies used were all based on the

patient’s or their family’s own experience or knowledge.

Of the 45 patients who had used herbal remedies, 20 (44%) had pur-

chased one or more product from a health food store, 25 (56%) from a

supermarket and 10 (22%) from a pharmacy. Four patients grew plants at

home for medicinal use; these included coriander (Coriandrum sativum) used

for colds and influenza, sage (Salvia officinalis) for gastrointestinal com-

plaints, thyme (Thymus vulgaris) for anxiety and depression, and basil

(Ocimum basilicum) to reduce fever.

None of the remedies cited were documented in the patient’s medical

history or prescribed on their current medication chart.

Discussion

A surprisingly high proportion of the patients interviewed had used herbal

remedies in the last year. Unfortunately we do not know how many of these

were being taken at the time of admission to hospital. This was because

most patients responded ‘‘no’’ to a question asking whether they had used

any herbal remedies in the last week, month or year, but then on further

questioning later in the interview schedule, listed a range of products used.

As well as highlighting changes required to the questionnaire for future use,

this has important implications for pharmacists taking patients’ medication

histories, suggesting that patients use a range of different terms for the

products that they use. We elicited most responses from questions such as

‘‘have you used any herbal remedies based on the advice of a non-con-

ventional health care provider?’’ and ‘‘have you used any herbal remedies

based on your own experience or knowledge?’’

In conclusion, about half of the patients interviewed had used one or

more herbal remedy in the last year. These were of a wide range, and

A243

included products that can interact with conventional medicines. Our re-

sults suggest that details of the herbal remedies used are not elicited by

standard approaches to medication history taking. Further work, using a

revised questionnaire, is needed to find out how many patients were actively

taking herbal remedies at the time of admission to hospital, and to better

explore the role of herbal remedies for patients who want to manage their

own health related problems.

Reference1. Sandhu DS, Heinrich M. The use of health foods, spices and other botanicals

within the Sikh community in London. Phytother Res (in press) 2005.

Boehringer-Ingelheim Respiratory Award 2005

The pharmacist led asthma clinic a new delivery care system

Oates C, Holden K, Tadros L, Ledger-Scott M, Foden A, Williams G, Pradip

D, Alcock S

County Durham Health Care Trust, Darlington Memorial Hospital,

Darlington

Background

The Global Burden of Asthma Report1 reveals that a global increase in

asthma has occurred in both children and adults in recent decades and this

increase is likely to continue over the next 20 years. In the UK, about

20,000 new episodes of asthma are dealt with by GPs each week. An average

primary care organisation can expect to treat 25,000 people with asthma,

with over 400 people admitted to hospital and eight asthma deaths each

year.

The UK now has one of the highest prevalence rates of asthma in the

world, with a mean prevalence of 16.1% Case fatality rates per 100,000

asthma patients are 3.2 in England.

The report identified numerous areas for improvement, including

improving patient education, ensuring appropriate use of inhaler devices,

encouraging the use of peak expiratory flow meter (PEFM) and identifying

those patients who over or under use their inhalers.

An educational programme was designed around those areas identified as

causing poor asthma management with the objective of giving patients the

knowledge and skills they need to manage their own illness and share

responsibility for their treatment2,3.

Aim

To evaluate the effect of a pharmacist-led educational programme on

asthma self management, quality of life and related morbidity in adults.

Method

A total of 97 asthma patients (age 24–66) were recruited for the study.

Recruitment criteria were that the patient had more than two exacerbations

of severe asthma attack and required hospitalisation within 2003. Among

these patients, 49 (22 females and 27 males) were assigned to the inter-

vention group (pharmacist led asthma clinic) and 48 (21 females and 27

males) the control group (traditional care). The group were matched with

age, sex, severity of asthma and medications

In the intervention group the pharmacist provided three separate edu-

cational sessions (20 min each session) to each individual patient and in-

cluded information about asthma, instruction on the appropriate use of

medication, training in the use of peak flow meter, metered dose inhaler

(MDI) technique, and information about the identification and control of

asthma attacks and the recognition of early signs of exacerbation. The

pharmacist identified medicine related problems and provided individua-

lised management plans based on the disease severity, the patient’s envi-

ronment, exercise levels, any compliance problems, understanding of the

disease and the treatment to each patient.

The control group received normal traditional care either from asthma

practice nurse or medical staff.

Spirometry test results were collected at three stages: enrolment (base-

line), then at 6 and 12 months after enrolment. Peak expiratory flow volume

(PEFV) was measured in the clinic every 3 months.

Outcome measurements

The primary outcome measure was change in pulmonary function as

measured by forced expiratory volume (FEV1) and peak expiratory flow

(PEFR). Secondary outcome measures included hospital admission, and

acute asthmatic attacks, which led to unscheduled visits to either the

emergency department or hospital admission.

Results

At the end of 12 months the respiratory consultant reviewed all patients

and outcomes.

At base line there was no significant difference between both groups in

PEFR and FEV1. However at the end of the study, in the intervention

group both females and males showed a significant improvement in PEFR

(P > 001) when compared with the control group. Furthermore 58% in the

intervention group scored more than 20% improvement in FEV1 of pre-

dicted value compared to 12% in the control group.

Discussion

The patients in the intervention group showed significant improvement in

outcome measures compared to the control group.

The patients in the intervention group received individualised self man-

agement plans and three individual educational sessions from the phar-

macist. All patients were educated to use BTS guideline ‘‘step wise’’

approach with reference to their symptoms and PEFR. The control group

received traditional care, which consisted of much less individual patient

education and counselling.

The patients in the intervention group showed improved compliance with

their medication regimen, which resulted in improved lung function.

Questionnaires showed that patients knowledge improved on the appro-

priate use of medication, metered dose inhaler (MDI) technique, identifi-

cation and control of asthma attacks, recognition of early signs of

exacerbation, how to deal with attacks, and how to control the environ-

mental trigger factors. They also reported feeling more in control, an in-

crease in physical exercise, a reduction in smoking and a reduction in the

number of disturbed nights.

The results indicate that the pharmacist clinic provided the type of sup-

port that enabled patients to improve the management of their asthma in

comparison to the way care is traditionally delivered.

Conclusion

The pharmacist led asthma clinic empowered patients with the skills and

knowledge they needed to manage their condition resulting in improved

PEFR, reduced asthmatic attacks and hospital admissions and improved

quality of life. The pharmacist led asthma clinic provides evidence that

patient education and counselling in asthma management are essential

elements in effective asthma management.

References1. The Global Burden of Asthma Report. Pharm J. May 8, 2004; 272; 562.2. Cole O. Introduction to asthma. Hosp Pharm. October 2001; 8: 237–240.3. Weinberger M, Murray MD, Marrero DG, Brewer N, Lykens M, Harris L,

Seshardi R, Caffrey H, Roesner JF, Smith F, Newell J, Collins JC, McDonaldCJ, Tierney WM. Effectivenss of pharmacist care for patients with reactiveairways disease: a randomized controlled trial. JAMA October 2, 2002; 288(13).

5 Evaluation of clinical and economic impact of antibiotic pharmacist

input in microbiology ward round to patient care in antimicrobial

prescribing

Liu A1, Reddy S

2

1Pharmacy Department, Blackpool, Fylde and Wyre Hospital NHS Trust,

Microbiology, 2Microbiology Department, Blackpool Victoria Hospital,

Blackpool

Total number of consultation over the past

12 month study

Intervention group 356 visits

Control group 292 visits

Total number of asthmatic attacks which required

medical attention

Intervention group 3 patients

Control group 27 patients

Total number of asthmatic attack

which required hospitalization

Intervention group 2 patients

Control group 11 patients

A244

Introduction

A microbiology ward round was set up in October 2004 to monitor anti-

microbial use and promote prudent antimicrobial prescribing within the

Trust in supporting the recent Department of Health (DoH) initiatives. It

was aimed to increase microbiology input in clinical areas and reduce the

unnecessary use of expensive antibiotics. The ward round was attended

weekly twice by Microbiology Specialist Registrar and Antibiotic Phar-

macist.

Objective

To evaluate the impact of Microbiology ward round over a 4-month period

(October 2004–January 2005) in terms of appropriateness of antibiotic

prescribing.

To assess the potential for cost-saving in antimicrobial drug budgets

during the Microbiology Ward Round.

Method

The Antimicrobial Alert System was set up in Summer 2004. Restricted use

of antibiotics including Tazocin�, Teicoplanin and Linezolid were reserved

for serious infections or the failure of 1st or 2nd line treatments on the

recommendation of Consultant Microbiologists. Linezolid could only be

prescribed with Microbiologist’s approval.

Patients who were on those three antibiotics during the study period were

obtained from the Pharmacy Ascribe� System twice a week (Tuesdays and

Fridays). Patients from peripheral hospitals were excluded from the study.

Interventions by the Microbiology Ward Round team were reported on a

designated audit form. The results of all findings were presented in alpha-

numeric tables and graphic charts.

Results

Sixty-eight patients were seen in the Microbiology Ward Round during

study period, 29 (43%) from the Medical Directorate and 22 (32%) from

the Surgical Directorate.

Of 68 patients 58 were on restricted-use antibiotics: Tazocin (16), Tei-

coplanin (36) and Linezolid (6). One patient who was on Linezolid was not

discussed with Microbiology.

Of the 36 patients who were on teicoplanin, 83% needed microbiology

intervention during ward round. A 63% of them were requested to dis-

continue teicoplanin treatment or change to other antibiotics, which were

expected to save £727.7 daily in total. The following table summarizes the

type of interventions.

Of the 16 patients who were on Tazocin�, only one third consulted the

Microbiologist before treatment. A 62.5% needed microbiology interven-

tion during the ward round. Of them 90% were requested to discontinue

Tazocin� or changed to other antibiotics, which were expected to save

£430.11 daily in total. The following table summarizes the type of inter-

ventions.

Discussion

This study demonstrated that teicoplanin and Tazocin� were not used

appropriately in the infections. The high incidence of microbiology inter-

vention in the use of teicoplanin was due to its inappropriate use for col-

onisation or local infection with Methicillin resistant Staphylococcus aureus

(MRSA), which illustrated that prescribers’ knowledge of basic microbiol-

ogy was limited. Six patients were recommended to adjust teicoplanin

dosage due to poor clinical response at sub-therapeutic assay level.

Tazocin was reserved as a second or third-line antibiotic therapy at the

study hospital in consultation with microbiology. In half of the patients Ta-

zocin was used as a first-line therapy and in nearly two thirds it was started

withoutmicrobiologist’s advice. This prompted an investigation intowhether

the doctors were aware of the existence of the local antibiotic guidelines and a

review of the accessibility of the current microbiology on-call service.

Encouragingly, 12 patients were able to change from intravenous anti-

biotics to oral formulation on the recommendation of microbiology during

the ward round, which showed that the ward round could potentially speed

up the discharge process and contribute cost-savings in the antimicrobial

drug budget.

Conclusion

Microbiology Ward Round is a new service in the study hospital, which has

proved to make a significant contribution to patient care by enhancing

communication between prescribers and microbiology. A collaborative

work relationship with other critical care teams should be considered as a

future development plan in order to provide high standard, multidisci-

plinary work, which promotes the prudent use of antibiotics.

References1. Department of Health. Getting ahead of the curve: a strategy for combating

infectious diseases (including other aspects of health protection). A report bythe Chief Medical Officer. London: Department of Health, 2002.

2. Department of Health. Winning ways: working together to reduce healthcareassociated infection in England. A report by the Chief Medical Officer. London:Department of Health, 2003.

3. Department of Health. 2003. Hospital Pharmacy Initiative for PromotingPrudent Use of Antibiotics in Hospitals. Professional Letter. Chief MedicalOfficer: PLCMO (2003) 3. Department of Health, London, UK.

4. Department of Health. A Vision for Pharmacy in the New NHS. London, UK:Department of Health, 2003.

5. Department of Health. Medicines Management in NHS Trusts: HospitalMedicines Management Framework. London, UK: Department of Health,2003.

Types of Intervention with Teicoplanin Prescription During Microbiology Wardround

02468

101214161820222426283032

Microbiology Intervention? Dose adjustment? Stop Teicoplanin? Alternative treatment? Oral Recommended?

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Types of intervention with Tazocin Prescription During Microbiology Wardround

02468

1012141618

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A245

GSK Advanced Practitioner Award 2005

Supplementary prescribing in intensive care

Tomlin M

Consultant Pharmacist, Southampton University Hospitals NHS Trust

Background

Nurses gained independent prescribing rights in 1992, but the formulary was

limited. In 2001, nurses could become supplementary prescribers and phar-

macists gained this right in 2003. The first Supplementary prescriber training

courses for Pharmacists became available in 2003 with the first registrations

in 2004. The focus of this legislation and training was in primary care. The

strategy was to increase access of patients to prescribers in the NHS. The

vision was that pharmacists could manage medicines for chronic conditions

as a delegated duty, releasing GP time. There was no perception that this

facility could be used for acute care, or that pharmacists would improve the

quality of the prescribing and therapeutic choices. No one believed that

supplementary prescribing had application in Intensive Care.

Many doctors still believe that pharmacists are not skilled sufficiently to

prescribe parenteral nutrition. I had previously attended a week long course

in parenteral nutrition designed for doctors. I have chosen formulations of

parenteral nutrition on Intensive Care for the last 8 years.

Aims and Objectives

The aim of my service development was to show that supplementary

prescribing by pharmacists was feasible in an acute secondary care setting.

Key objectives:

1. Finding a suitable course that was adaptable to what I do, not running a

clinic.

2. Understanding the patient consent issues of Supplementary Prescribing.

3. Investigate the consent issues in patients on ITU who were often

unconscious.

Methods

I wanted to establish a more efficient way of prescribing parenteral nutrition

and drugs that required therapeutic monitoring. These involve key phar-

maceutical skills – formulation, interactions, incompatibilities and phar-

macokinetics. I used the Workforce Development Confederation to identify

a course at Kings College London.

I chose parenteral nutrition and I was already part of a team of phar-

macists at Southampton who prescribe parenteral nutrition (PN). I was the

first to write a prescription for PN in April 2004 and the first to prescribe

PN in Intensive Care.

I chose as my designated medical practitioner a senior consultant with

experience in research and practice ethics and law. Several sessions were

spent solely on the consent issue. I also took the principle of ‘‘necessity’’ to a

patient involvement forum and gained their unanimous assent.

I achieved authorisation, from the intensive care consultants, to undertake

dose modification for drugs requiring therapeutic drug monitoring (the-

ophylline, digoxin, phenytoin, vancomycin, gentamicin, and teicoplanin).

Results

I am a registered supplementary prescriber pharmacist. I have been pre-

scribing for a year. The principle of necessity is well accepted, and has been

tested with a patient forum. Relatives are informed of what is happening

and why. I inform patients when they have recovered (retrograde consent). I

am not aware of any interference with doctor–patient relationships. The

pharmacist is cemented as a member of the clinical team, recognised as a

prescriber and not a threatening advisor to other prescribers.

All 98 patients requiring parenteral nutrition in the last had their for-

mulation and rate decided by the pharmacist. In the first 6 months a one-

third were prescribed used Supplementary prescribing. Jan 05–Apr 05, 65%

(13/20) used supplementary prescribing. Standard formulas of parenteral

nutrition are licensed products but formulations constructed individually

are not. The pharmacists formulation advice is most valued in these special

bags but the law required a doctors’ signature. Now that unlicensed med-

icines can be authorised by a supplementary prescriber, virtually 100% of

all parenteral nutrition prescriptions are ordered using this process.

Discussion

The parenteral nutrition prescribing has worked most effectively but delays

for CMP authorisation has reduced efficiency and prevented all prescrip-

tions being written by the pharmacist. The TDM prescribing has been

shown to work and seamless change from pharmacist and doctor has been

achieved, especially over the weekend. During the week the doctors wait for

the pharmacists’ advice. Showing that the doctors value the skills of the

pharmacist and assent to them undertaking the prescribing.

This work shows that Supplementary Prescribing Pharmacists (SPP) are a

reality in secondary care. That SPP can manage acute and dynamic pre-

scribing scenarios including within Intensive Care. Pharmacists not only

prescribe parenteral nutrition but also improve the quality of prescribing.

Previously the pharmacist had chosen the formulation and the doctor had

signed the form. Confidence in the pharmacists ability had reached a level

so that signing contained no added value.

This project has demonstrated an improved access for patients to pre-

scribers and made the process more efficient. In addition, because knowl-

edge of this area of therapeutics by doctors is poor, the project has

improved the quality of prescribing. The junior doctors find it more con-

venient and assists in managing their hours.

Supplementary prescribing for parenteral nutrition is suitable for because

it continues for several days. It is less suitable where clinical management

plan and consent authorisation delay treatment. It is hoped that indepen-

dent prescribing by pharmacists will be less bureaucratic and facilitate single

item prescribing.

References1. Bellingham C. How supplementary prescribing helps in both acute and chronic

hospital care. Pharm J 2004; 272: 640–2.2. Tomlim M. A year in the life of a supplementary prescriber. Hosp Pharm 2005;

12: 182–3.

Napp Pain Award 2005

Prescribing and clinical outcomes after strong opioid recommenda-

tion for chronic non-cancer pain from a pain clinic

Knaggs RD, Hobbs GJ

Pain Management Service, Queen’s Medical Centre University Hospital NHS

Trust, Nottingham

Background

Opioids have been a topic of much debate and controversy for centuries.

Use of strong opioids in cancer pain is advocated by the World Health

Organisation and is widely accepted; however, their use in chronic non-

cancer pain is more controversial. Some clinical studies have suggested that

some types of chronic non-cancer pain do not respond to strong opioids

(e.g., ref. 1), whilst others contradict this opinion (e.g. ref. 2). A recent

systematic review3 suggested a 30% mean pain intensity reduction when

used in chronic neuropathic and musculoskeletal non-cancer pains.

Concerns over safety of long-term opioid administration include adverse

effects, development of tolerance, addiction and drug diversion4. Several

guidelines for the appropriate and responsible use of opioids in chronic non-

cancer pain are available to encourage good prescribing practice (e.g., ref. 5).

Aims and Objectives

The aim of the study was to assess the prescribing and clinical outcomes in

primary care after recommendation of a trial of strong opioid therapy for

chronic non-cancer pain by our tertiary referral pain management centre.

The principal objectives were to define the clinical pathway and barriers to

prescribing for patients recommended strong opioids and assess their clin-

ical efficacy.

Methods

A retrospective cohort study was designed. All patients newly recommended

a trial of strong opioid therapy for chronic non-cancer pain over an

18 month period were invited to participate in a telephone questionnaire

administered by one investigator. The questionnaire assessed prescribing

and clinical outcomes at least 6 months after the written recommendation

was sent to the designated General Practitioner (GP). Local GPs were also

contacted to determine their views and experience of prescribing opioids for

chronic non-cancer pain.

Results

Figure 1 shows the study profile. Sixty-six patients were newly recommended

strong opioids during the 18 month study period. The mean patient age was

58 years (range 24–96 years). Most patients either had diagnoses of neuro-

pathic pain or musculoskeletal pain, largely failed back surgery syndrome.A246

Forty-one patients were willing to participate in the telephone question-

naire. Of these, 12 patients (29%) had never received the opioid recom-

mended. Either patients were unable to recall the recommendation (seven

patients) or the GP had failed to act on the clinical recommendations. The

newly recommended strong opioids by the Pain Management Service are

shown in Figure 2.

At the time of interview 20 patients (71%) were still taking a strong

opioid, either the original, or an alternative. Opioid therapy produced at

least 50% pain relief for 15 (54%) of patients, however three patients ob-

tained no pain relief from the strong opioid.

Interference with daily activities was markedly less during opioid therapy

(14% vs. 61%), although there were no improvements in sleep and mood. A

majority of patients expected a marked reduction in pain (19 patients, 68%)

on 5-point Likert scale. Twenty-five patients (89%) reported the occurrence

of adverse effects with opioid therapy, the most common being nausea or

vomiting (17 patients), drowsiness (14 patients) and constipation (11 pa-

tients). Eight patients (29%) discontinued therapy, primarily due to intol-

erable adverse effects.

All GPs felt their ability to supervise and monitor patients on strong

opioids for chronic non-cancer pain would be improved by increased

understanding of the increasing evidence for strong opioid use in non-

cancer pain. The majority of GPs thought the provision of a local guideline

for the use of strong opioids would be beneficial. Improved access to pain

management staff by telephone, electronic mail or letter, may improve

management of these patients.

Discussion and Conclusion

Strong opioid therapy markedly improved analgesia in our selected pa-

tients, as documented in randomised controlled studies (e.g., ref. 6). Overall

this increased analgesic benefit was associated with improved physical,

psychological and social functioning. In contrast to other studies, our pa-

tients did not benefit from improvements in sleep or mood. Most patients

continued strong opioid therapy despite adverse effects, primarily because

the analgesic benefit outweighed adverse effects.

Several different opioids and different opioid combinations were recom-

mended by our Pain Management Service reflecting clinician preference. At

present there are no high quality randomised controlled trials that would

support choice of one drug or formulation over another7.

We are now developing a specific guideline for pain management staff and

GP colleagues aiming to give patients realistic expectations of opioid

therapy. In those patients who do not achieve agreed treatment goals during

a trial of strong opioid, the drug should be withdrawn. Adequate infor-

mation must be provided for patients, preferably using a variety of media.

Where appropriate, we are providing our primary care colleagues with

more information about the rationale for our recommendation of a strong

opioid and providing information on how to manage these patients. We

now offer GPs greater support when recommending strong opioids or

managing these trials from our clinic where requested by the GP.

References1. Arner S, Meyerson BA. Lack of analgesic effect of opioids on neuropathic and

idiopathic forms of pain. Pain 1988; 33: 11–23.2. Moulin DE, Iezzi A, Amireh R, Sharpe WK, Boyd D, Merskey H. Randomised

trial of oral morphine for chronic non-cancer pain. Lancet 1996; 347: 143–7.3. Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer

pain: systematic review of efficacy and safety. Pain 2004; 112: 372–80.4. Ballantyne JC, Mao J. Opioid therapy for chronic pain. New Eng J Med 2003;

349: 1943–53.5. The Pain Society. Recommendations for the appropriate use of opioids for

persistent non-cancer pain. March 2004.

Figure 1 Study profile.

Figure 2 Strong opioids recommended for chronic non-cancer pain (n = 66 patients).

A247

6. Watson CPN, Moulin D, Watt-Watson J, Gordon A, Eisenhoffer J. Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial inpainful diabetic neuropathy. Pain 2003; 105: 71–8.

7. Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-actingoral opioids for chronic non-cancer pain: a systematic review. J Pain SymptomManage 2003; 26: 1026–43.

Posters Research

1 The impact of spaced review of learning on subsequent recall of

information by hospital pharmacists, following teaching on antibiotics

Hand KSP, Jubraj B

Department of Pharmacy, Chelsea & Westminster Healthcare NHS Trust,

London

Introduction

Misuse of antibiotics in hospitals is a recognised problem, with up to 50%

of antibiotic prescribing in this setting considered inappropriate1. A role for

hospital pharmacists has been promoted in the Winning Ways report on

healthcare associated infection in England, which stipulates that support for

prudent antibiotic prescribing in hospitals will be provided by clinical

pharmacists, along with medical microbiologists and infectious diseases

physicians2. However, anecdotal evidence from members of the UKCPA

Infection Management practice interest group suggests that many phar-

macists express a lack of confidence on the subject of antibiotic therapeu-

tics, often citing poor knowledge of pathogen epidemiology and antibiotic

spectrum of activity as a contributing factor.

In view of increasing government expectations that hospital pharmacists

will act as custodians of antibiotic policy and advocates of prudent pre-

scribing, it is imperative that education and training strategies in this area of

therapeutics deliver competent practitioners. A potential strategy for

improving knowledge, as one element of competency, is to utilise the

learning phenomenon known as the spacing effect. There is robust evidence

from educational psychology literature that memory for facts can be sus-

tained by revision or review at spaced time intervals following the initial

learning period, allowing students to recall information successfully,

months or years later3.

Objective

The objective of the current study is to explore the feasibility of providing

spaced review of learning in a practice setting following post-graduate

teaching for junior-grade hospital pharmacists, and to evaluate the outcome

of medium-term recall of knowledge in the intervention group in compar-

ison with a control-matched cohort.

Methods

This randomised, parallel group, case-controlled, assessor-blinded study

was carried out in NHS acute hospital Trusts in London, England, from

January to June 2005. Participants were registered pharmacists enrolled in

the post-graduate course at the School of Pharmacy, University of London,

leading to a Certificate in Pharmacy Practice. Ethics approval for the study

was granted by a multi-region ethics committee prior to study start and all

participants gave informed consent. On the first day of the study at each

site, the investigator attended the site to invigilate a 20-min assessment of

baseline knowledge of antibiotic therapeutics. Following the baseline

assessment, the investigator delivered baseline teaching in the form of a 90-

min interactive lecture on antibiotics. Participants were then randomly as-

signed to intervention or control groups in a ratio of one-to-one, stratified

by site. All participants were given a handout containing copies of the slides

from the lecture for future reference and revision. Participants randomised

to the intervention group attended review sessions at intervals spaced 1 day,

1 week and 1 month, after the original teaching. Review sessions consisted

of 30 min of protected time to read the lecture handout, followed by a 10-

min assessment with immediate feedback. At approximately 3 months fol-

lowing the initial teaching, all participants completed a 30-min final

assessment, invigilated by the investigator. Data were analysed using paired

t-tests and analysis of covariance (ANCOVA).

Results

A total of 46 pharmacists were recruited to the study from six NHS

acute hospital trusts in Greater London, incorporating eight hospital

sites. All 46 participants undertook the baseline assessment but only 39

participants completed an investigator-invigilated final assessment and

were thus eligible for inclusion in the intention-to-teach (ITT) analysis. A

significant improvement in mean assessment result was apparent between

baseline and final assessments for both the intervention and control

groups (Table 1). However, there was no significant difference in the

absolute (17%, 17%) or relative (44%, 42%) improvement in results

from baseline between the intervention and control groups, respectively

(ITT population, ANCOVA).

The distribution of results for the intervention group showed a clear shift

to the right between the baseline (range 27–61%) and final assessments

(range 41–79%). Final assessment results for the control group by contrast

were more widely variable, resulting in considerable overlap between the

baseline (range 27–58%) and final (range 28–88%) result distributions and a

failure of some individuals to substantially improve their results between

assessments.

Discussion

This study failed to find an effect of spaced review of learning upon recall

of information 3 months after a teaching session on antibiotics. This out-

come is not consistent with the literature describing the spacing effect but

may have been influenced by a number of confounding factors. Firstly, the

intervention was unblinded and participants were aware of the date of the

final assessment and may have revised the teaching material specifically to

improve performance in this assessment. Secondly, concurrent participation

in the Certificate in Pharmacy Practice introduced a strong motivation for

all participants to revise the lecture material around the same time as the

final assessment for this study. Thirdly, participants were not penalised for

guessing answers to assessment questions. Any future studies to evaluate the

spacing effect in pharmacy education should avoid recruiting from a pop-

ulation enrolled in concurrent formal education courses, should employ

negative marking to discourage guessing and should consider the use of pre-

consented covert final assessment.

References1. House of Lords Select Committee on Science and Technology. Resistance to

antibiotics and other antimicrobial agents. Lord Soulsby. London: The Sta-tionery Office, 1998.

2. Chief Medical Officer. Winning ways: working together to reduce healthcareassociated infection in England. London, Department of Health (UK), 2003.

3. Rea CP, Modigliani V. Educational implications of the spacing effect. In:Gruneberg MM, Morris PE, editors. Practical aspects of memory: Current re-search and issues, Vol. 1: Memory in everyday life. New York: John Wiley andSons, 1988: 402–406.

2 Electronic prescribing: do doctors hold the plug to its success?

Considine A, Cavell G, Dilks T

Pharmacy Department, King’s College Hospital, London.

Introduction

The government is investing heavily, through the National Programme for

Information Technology (NPfIT), in electronic solutions to improve patient

care and the efficiency of the healthcare system1. Electronic prescribing (EP)

is one solution which has been highlighted as a goal for the NHS and it is

expected that EP will be progressively rolled out across England by 20072.

Table 1 Mean (95% confidence intervals) baseline and final assessment results

Group Baseline Final Absolute improvement Relative# improvement p value

Intervention (ITT) n = 20 40%

(36–44)

57%

(52–63)

17%

(14–21)

44%

(35–53)

p<0.0001

Control (ITT) n = 19 40%

(36–44)

57%

(49–66)

17%

(12–23)

42%

(30–55)

p<0.0001

Paired t-test, Baseline versus Final results, # Relative to baseline result

A248

The benefits of electronic prescribing have been described3,4. These in-

clude a reduction in the incidence of medication errors, improved clinical

decision making and easier access to medication records. Despite these

advantages few trusts in the UK have successfully implemented EP on a

large scale. The barriers to successful implementation are multifactorial and

include physician resistance, problems with computer software, lack of

multidisciplinary working and lack of funds.

In our hospital an electronic patient record (EPR) system – iSOFT

Clinical Manager (ver 1.0) is well established. An electronic prescribing

system, which is a module of the EPR is currently being piloted on one

medical ward. However it is not achieving the level of success that initially

had been hoped for. The aim of this project is to identify the barriers to

electronic prescribing in this hospital.

Objectives

To identify what junior doctors perceive to be the advantages and disad-

vantages of the electronic prescribing system.

To identify reasons that the electronic prescribing system is not being uti-

lized.

To identify how the junior doctors feel the system could be improved.

Methods

A semi-structured questionnaire targeted at junior medical staff who are

most likely to have used the system was designed. The questionnaire aimed

to establish the extent to which they use the EP system, what motivates

them to use the system, their views of the system compared to manual

prescriptions, the usefulness of the system and how they felt it could be

improved.

Results

Out of 20 questionnaires 16 were returned representing a response rate of

80%. Three respondents had not worked on the pilot ward and had never

needed to use the EP system. A group of 13 respondents had used the

system for either 6 weeks or 8 weeks. Only one respondent was actively

using the EP system for four patients under his care. All other patients were

prescribed medication on the handwritten medication administration record

(MAR).

Respondents listed advantages of electronic prescribing as accessibility,

inclusion of useful prompts (n = 5), fewer rewrite errors (n = 4) and leg-

ibility (n = 2). Four respondents considered electronic prescribing to

confer no benefits on the medicine use process. Disadvantages described

included the system being too time consuming (n = 11), lack of computer

terminals (n = 9), unreliability (n = 6), time taken to log onto the system

(n = 3) concerns that the system is unsafe (n = 3) and difficult to use

(n = 2). Two respondents stated that they would choose writing a manual

inpatient drug chart over an electronic prescription. (Table 1).

Discussion

The results of this small study suggest that doctors do present a barrier to

implementation of EP as they perceive that there are more disadvantages to

the system than advantages. In fact some junior doctors are actively

choosing not to use the electronic prescribing system.

The results show that the doctors are opposed to the EP system for a

number of reasons, primarily that writing an electronic prescription took

longer writing a manual prescription. This makes EP difficult to use in a

ward round situation and potentially conflicts with other pressures on their

time. Time constraints have been identified as barriers by other hospitals

who have tried to implement EP systems. However this becomes less of an

obstacle when doctors become more familiar with the system. The range of

disadvantages expressed in this audit are comparable to findings in other

hospitals who have implemented an EP system and we are able to use

experiences of other hospitals to be able to tackle some of the issues at this

pilot stage5.

It is clear that the respondents do understand the potential advantages of

the EP system, especially of the benefits of clinical decision support. This

has the potential to reduce the incidence of prescribing errors and reduces

the need to find and interpret information in a reference source especially if

the system has electronic links to the hospital formulary or the British

National Formulary .

The results of this project indicate that doctors are resistant to over-

coming perceived barriers and are hence delaying the progression of the

electronic prescribing initiative. Whilst they seem aware of some of the

benefits their perceptions of its disadvantages have resulted in them being

unwilling to use it. The challenge remains to convince them that although

electronic prescribing is daunting at first they will be rewarded with per-

severance and the positive aspects of the system will be realised.

References1. Brennan S. The NHS IT Project; The Biggest Computer Project in the World

Ever; Radcliffe Publishing, 2005.2. ‘The Way Forward’. The Pharmaceutical Journal 2002; 268.3. Protti D. The Use of Computers in Health Care can Reduce Errors, Improve

Patient Safety and Enhance the Quality of Service 2004.4. ‘Electronic Prescribing and Clinical Decision Support at Southmead Hospital’

www.nhsia.nhs.uk.5. Electronic prescribing and patient records – getting the balance right. The

Pharmaceutical Journal 2005; 274.

Posters Innovation/Professional Development

Development of an electronic method for recording clinical pharma-

cist activity

McVerry M, McCoy A, Kelly P, Nelson L, Murphy L, Gribben N,

McGarrity N

Pharmacy Department, Greenpark Healthcare Trust, Belfast

Introduction

‘‘Clinical pharmacist’s activities that contribute to patient care should be

appropriately documented’’. This is one of the standards included in the

first draft of Northern Ireland Clinical Pharmacy Standards (2005)1. His-

torically pharmacists made clinical interventions that improved patient’s

quality of life and reduced the risks of drug therapy, but did not routinely

document them2. Initial records of clinical pharmacist’s interventions were

recorded using simple paper forms or intermittently to justify pharmacist’s

time on wards, to reinforce requests for increased clinical pharmacy services

and as litigation increased3. These paper records are space consuming and

retrieval of specific records can also prove problematic unless much time

and effort has been invested in efficient archiving systems.

At Greenpark Healthcare Trust, clinical pharmacists were recording their

clinical activity manually on paper. Interventions were recorded in a

booklet and activity was documented on a paper pro forma, with calcula-

tion required at the end of each month to summarise activity. The pharmacy

department applied for funding for dedicated software to deliver a personal

digital assistant (PDA) based wireless system for the recording of clinical

pharmacist interventions and clinical activities. The application was not

approved as a priority for action, therefore the pharmacy department

decided to develop an alternative affordable system for electronically

recording clinical pharmacist activity until funding for the PDA system

could be secured.

Objectives

To develop and evaluate an electronic method of recording clinical phar-

macist activity to supersede the paper-based system, with the following

attributes:

� No extra cost to the trust.

� User-friendly format.

� Easy data retrieval.

� Reproducible.

Method

The following key areas of clinical pharmacist activity were identified: hours

spent on ward, monitoring of kardexes, confirmation of drug histories,

patient counselling, generation of electronic discharge prescriptions, gen-

eration of electronic patient drug information leaflets, ward round atten-

dance, medication interventions, medicines information (MI) queries,

meetings, continuing professional development, lectures presented, medical

Table 1 Perceived advantages and disadvantages of the EP system (n = 16)

Disadvantages % Advantages %

Time consuming 69 Accessible 31

Difficult to use 69 Useful prompts 30

Lack of computers 53 Fewer rewrite errors 23

Unsafe 22 Legible 15

Time to log in 21

Lack of security 15 None 23

A249

representative visits and dispensary cover. These were then used to design a

simple template in Microsoft Excel. The template consisted of four pages:

(1) summary, (2) interventions, (3) MI enquiries and (4) other. The template

was designed so that the summary page numerically displayed a breakdown

of daily clinical activity for the given month. It automatically calculated the

total number of each activity carried out by that pharmacist in the given

month. The intervention page documented each pharmacist intervention

qualitatively with details of date, patient name, hospital number, consultant

and description of the intervention. The record of MI enquiries also dis-

played a qualitative record of queries received and responses given.

The page titled ‘‘Other’’ allowed for the qualitative description of other

activities that do not easily fit into any of the given categories. Clinical

pharmacists were trained on how to use the electronic clinical activity

recording system and the package was installed on each of their personal

computers in the pharmacy department. Clinical pharmacists were required

to input their activity data on a daily basis and the package was initially

piloted for 1 month.

A satisfaction survey was designed to evaluate the electronic method of

recording clinical pharmacy activity. The survey asked clinical pharmacists

to state whether they agreed or disagreed with five statements comparing

the electronic system favourably to the paper method in terms of (1)

comprehensiveness, (2) legibility, (3) reproducibility, (4) ease of use and (5)

time to complete. The survey also gave pharmacists an opportunity to

comment on any aspect they particularly liked, or would change about the

electronic method.

Results

Out of seven clinical pharmacists surveyed the majority preferred the

electronic system to the paper method. Around 71% of pharmacists

thought that the electronic method of recording clinical activity produced a

more comprehensive report and was faster to use than the paper method,

with 29% disagreeing. A 100% of pharmacists thought that the electronic

method of recording clinical pharmacy activity was more legible and en-

abled reproducibility/transfer of data more readily than the paper method.

On average, On average, 86% of pharmacists felt that the electronic method

of recording clinical pharmacist activity was overall easier to use than the

paper method but 14% thought the paper method, was easier to use. The

results of the survey are illustrated in Table 1.

Positive comments about the electronic method of recording clinical

activity included: ‘‘It is a useful tool for clinical pharmacy business plans

when requesting extra staff cover’’ and ‘‘ the method has plenty of potential

to be extended and developed if funds permit – currently a useful starting

point.’’ Comments regarding possible future changes to the electronic

method of recording clinical pharmacy activity included: ‘‘ It would be

useful if we could further enhance the system to grade the severity of

medication errors/interventions reported.’’

Discussion

The electronic method of recording clinical pharmacy activity has clearly

been an improvement on current working practice at no additional cost. It

enables the production of an individual monthly report of clinical activity

that is fully comprehensive of work undertaken. It is legible and enables

data to be easily electronically transferred and retrieved. The electronic

method of recording clinical pharmacy activity is overall easier to use than

the paper method and is less time consuming as it is programmed to

automatically calculate monthly activity totals. It also avoids the need for

storing cumbersome paper records.

Although the electronic method is a forward step for clinical activity

reporting, it has several shortcomings. The entry of data is retrospective and

the programme is not accessible at the point of need e.g. on the ward. The

interventions are not graded according to severity, acceptance rates or

according to type of intervention, which would be useful audit tools.

However the programme is proving useful until funding can be secured for

the purchase of handheld computers with dedicated pharmacy intervention

software.

References1 Draft Northern Ireland clinical pharmacy standards ( No.15) 2005.2 Goddard J. PDA-based audit of pharmacist interventions. Hosp Pharm Eur

2003; 9: 16—18.3 Dean P, Robson, J, Waters P. Pharmacy intervention monitoring - A clinical

tool. Hosp Pharm 2004; 11: 201—202.

4 Investigating the contribution of community pharmacists in meeting

the needs of patients with atopic eczema, in collaboration with GPs.

Tinkler C, Herkes D, Holden M, Amin K, Sharma M

Pharmacy Alliance, Chessington, Surrey

Introduction

In the UK, atopic eczema affects 15% of children1,2 and up to 10% of

adults2. Treatment regimens are often complex and confusing, and patients’

concerns about using topical corticosteroids have important implications

for compliance with treatment3. Therefore, it is extremely important that

patients are appropriately educated about eczema and its treatment to

empower them to make informed decisions about their condition and self-

management. Few published studies evaluate the role of community phar-

macists in identifying and addressing the needs of patients with atopic

eczema. Therefore the Community Pharmacy Eczema Programme pilot was

developed with this in mind.

Objectives

The aim of the programme was for community pharmacists to meet the

needs of patients with atopic eczema, in collaboration with GPs. Specific

objectives were to:

1. Identify and address patients’ needs and concerns and evaluate the nature

of pharmacists’ interventions;

2. Evaluate pharmacist to GP referrals.

Method

Forty-eight community pharmacists and their staff attended a training

workshop covering therapy update and programme delivery. Group work

and case studies formed a core part of this training.

Patients aged from 2 to 18 years (patients over 18 years could also

register, however atopic eczema must be present on a sensitive area of the

body), diagnosed with atopic eczema and using a topical corticosteroid

to manage their eczema, were invited to join the programme. After an

initial consultation with the pharmacist, patients were followed-up after

8 weeks.

A written protocol, incorporating a ‘‘Patient Questionnaire’’ was used as

a tool to assist pharmacists in identifying and addressing patients’ needs and

concerns, provided a systematic patient-centred approach. A formal phar-

macist to GP referral process was followed, when patients’ needs could not

be met in the pharmacy.

Results

Three hundred and seventy patients were recruited (93% response rate,

target 400) and 61% (n = 225) subsequently followed-up.

Addressing patients’ needs and concerns� A total of 1,597 problems were identified. Of these, 20% (n = 322) in-

volved steroid concerns, 15% (n = 238) required lifestyle advice, 12%

(n = 193) unmet treatment goals, and 11% (n = 177) poor under-

standing of atopic eczema.

� Pharmacists made a total of 1,747 interventions, consisting mostly

of verbal advice (76%, n = 1,332) and written information (18%,

n = 321).

� On average pharmacists made 3.8 interventions per consultation at

recruitment, decreasing to 1.5 interventions per consultation at follow-up.

� Patients’ responses to the Patient Questionnaire improved significantly

Wilcoxon Signed Rank Test p < 0.05 following pharmacists’ interven-

tions (Figure 1); Steroid concerns reduced from 68% (n = 252) at

recruitment to 30% (n = 70) at follow up, lifestyle advice from 51%

(n = 191) to 20% (n = 47), and poor understanding of atopic eczema

from 43% (n = 162) to 6% (n = 15).

GP ReferralsPharmacists referred 9% (n = 32) of patients to their GP. Of these, 59%

(n = 19) were referred for uncontrolled symptoms and 38% (n = 12) for a

review of treatment.

Table 1 User satisfaction survey comparing the electronic method of

recording clinical activity with paper method: (n = 7 clinical pharmacists)

Pharmacist More

comprehensive

More

legible

More

reproducible

Easier

to use

Faster

to use

Agree 5 (71%) 7(100%) 7(100%) 6(86%) 5(71%)

Disagree 2(29%) 0(0%) 0(0%) 1(14%) 2(29%)

A250

Discussion

All objectives set for the programme were met. Patients/carers have access

to professional advice and support in Community Pharmacy, without an

appointment. This pilot indicated that many of the problems or concerns

patients experience with their condition or its management, particularly

around the use of topical corticosteroids, can be suitably addressed by

Community Pharmacists. However, on occasions, it is appropriate for

pharmacists to refer patients to their GP for a review of their medication

and/or to address their unmet treatment goals.

Feedback was sought from patients and pharmacists at the end of the

programme using pre-printed ‘‘feedback forms’’ in order to evaluate and

adapt the programme for future roll-out.

Over 80% of patients:

� ‘‘knew more about their condition and treatments’’ after taking part in the

eczema programme;

� ‘‘would recommend the programme to others with atopic eczema’’.

At least 70% of pharmacists thought the programme:

� ‘‘built professional GP relationships and would like to be involved in

similar programmes in the future’’;

� ‘‘should be made available to more of their patients’’.

References1. Graham-Brown R, Bourke J. Mosby’s colour atlas and text of dermatology.

Pub Mosby, London 1998: 160–9.2. McHenry P, Williams H, Bingham E. Fortnightly review: management of atopic

eczema. BMJ 1995; 311: 843–7.3. Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in

patients with atopic eczema. British Journal of Dermatology 2000; 142: 931–6.

5 Cost effective prescribing: The impact of a community pharmacy

Prescription Intervention Programme

Amin K1, Herkes D

1, Tinkler C

1, Holden M

1, Hardy N

2, Chessington, Surrey

1Pharmacy Alliance, 2Eastleigh & Test Valley South PCT

Introduction

In the UK in 2002, over 700 million prescriptions were written by GPs for

patients with a net ingredient cost of over £8 billion1–3. Repeat prescriptions

account for 75% of all prescriptions4, which patients often receive without a

consultation or medication review. This can lead to inappropriate ordering

and use of medicines, poor compliance and wastage. Ensuring that medi-

cines are used safely, avoiding wastage and supporting patients to gain the

maximum benefit from their medicines is therefore, more important than

ever.

Prescription Intervention Programmes, involving community pharmacists

and general practitioners, implemented within Primary Care Organisations

(PCOs) can successfully reduce prescribing costs, assist GP practices with

their targets, improve patient compliance with prescribed medication and

reduce medicines wastage5,6. Community pharmacists are an integral part

of the primary healthcare team and it has been widely recognised that better

use can be made of their skills and knowledge for the successful provision of

high quality, patient-centred services and the rational, cost-effective use of

medicines.

Objectives

The primary aim of this 6-month pilot was for community pharmacists to

facilitate and promote high quality, rational and cost-effective prescribing,

in line with PCT Prescribing Guidelines and local GP targets. The specific

objectives were to:

� facilitate high quality, rational and cost-effective prescribing;

� facilitate a review of therapy and referral to a GP if appropriate, in line

with PCT targets;

� support GPs in meeting their targets.

Method

Prior to service delivery, pharmacists and support staff from the 10 par-

ticipating community pharmacies attended a bespoke workshop providing

training on the programme delivery process and Pharmaceutical Care &

Consultation Skills, delivered through group work, role plays and case

studies. Pharmacists were required to brief their local GPs on the pro-

gramme and their involvement, and agree intervention criteria.

Intervention Criteria� Strength or dose optimisation, where two lower strength tablets are pre-

scribed, and cost-effectiveness and patient compliance would be better

achieved using a single, higher dose formulation (e.g. replace 2x10 mg

tablets with 1x20 mg tablet).

� Generic/brand substitution where cost savings can be made for selected

medication(s).

� Amlodipine substitution where amlodipine is prescribed as the ‘‘besilate’’

salt or as Istin�, change to ‘‘mesilate’’ or simply ‘‘amlodipine’’.

Prescriptions presented in participating community pharmacies were re-

viewed for items meeting the intervention criteria. Pharmacists discussed

any recommendations with the patient (or parent/guardian if under

18 years). Any recommendations together with potential cost savings to be

made were subsequently recorded by pharmacists on an ‘‘Intervention

Form’’ and forwarded to the patients GP for consideration and action,

prior to issue of each patient’s next prescription.

Results

Seven months into the pilot, a total of 71 prescription interventions have

been carried out in community pharmacy: 7% (n = 5) were for amlodipine

substitution; 11% (n = 8) for generic substitution (Figure 1); and the

remaining 82% (n = 58) for strength optimisation. The most frequent

Figure 1 Problems identified by community pharmacists.

A251

strength optimisations were for levothyroxine (19%, n = 11) and atenolol

(19%, n = 11).

The total potential savings identified to date amount to £8,131, equating

to an average of £114.50 per intervention made. Actual savings to date total

£5,566 (68.5% of the potential savings identified) however, as there is a time

delay between recommendations being made in the pharmacy and being

actioned at the GP practice, actual savings may increase further given more

time.

Discussion

Cost savings from the Prescription Intervention Programme to date are

encouraging and it is predicted that over 12 months this will amount to in

excess of £14,000. Reviewing patients’ prescriptions is a means of facili-

tating cost-effective prescribing, ensuring that patients get the maximum

benefit from their medicine(s) as a direct result of increased patient com-

pliance and concordance. Due to the initial success of this pilot, a 3-month

extension has been granted by the PCT. Full analysis will be undertaken

upon programme completion.

References1. Prescription Cost Analysis: England 2002. London: Department of Health;

2002. Available at: http://www.doh.gov.uk/prescription statisics/index.htm2. Prescription Cost Analysis: Scotland 2002. NHS Scotland 2003. Available at:

http://www.isdsscotland.org3. Prescriptions dispensed in the community: Wales 2002. National Assembly for

Wales, 2003. Available at: http://www.wales.gov.uk4. National Service Framework for Older People: a guide for community phar-

macists. PSNC 2002.5. Leach R et al. Investigation into the effectiveness of the Dudley prescribing

efficiency programme. Pharm J 2003; 270: 276–277.6. Galloway C. Involving pharmacists in medicines management. Prescriber 2002;

13:16–21.

6 ‘The missing million’: the crucial role of community pharmacy in

early detection of Type-2 diabetes

Amin K1, Herkes D1, Tinkler C1, Holden M1, Sharma M1, Forward J2

1Pharmacy Alliance, Chessington, Surrey; 2Durham Dales PCT, County

Durham

Introduction

Diabetes affects up to 2 million people in the UK, with numbers escalating,

as an estimated 1 million people in the UK with Type-2 diabetes remain

undiagnosed1. There is evidence to show that the onset of Type-2 diabetes

can be delayed or even prevented2. Early identification and control of

diabetes can reduce the risk of heart disease by 44%, stroke by 46%, kidney

disease by 33% and eye disease by 33%1. Therefore, early detection and

advice on preventative measures (e.g. modifiable lifestyle factors) are of

paramount importance to patients and their families, health professionals,

and to the NHS, to prevent long-term complications and premature death.

It is recognised that utilising the skills and knowledge of Community

Pharmacists, can improve patient accessibility to high quality, patient-

centred services and assist primary care organisations to achieve local and

national diabetes targets.

Objectives

The overall aim of the project was to provide a community pharmacy-based

Diabetes Screening Service that identified and supported at-risk patients,

and facilitated early diagnosis through appropriate referrals to GPs. The

specific objectives were to:

� identify patients at risk of undiagnosed diabetes;

� educate patients in healthy living;

� explore the role of community pharmacists in the primary health care

team and provision of clinical pharmacy services;

� ensure prompt referral to the appropriate health professionals.

At-risk groups were defined as:

� Caucasians >40 years and people from Afro-Carribean/African, Asian

and minority ethnic groups >25 years who have:

j a First degree family history of diabetes;

j BMI ‡25 and lead a sedentary lifestyle;

j ischaemic heart disease, cerebrovascular disease, peripheral vascular

disease or hypertension.

�Women who have had gestational diabetes or polycystic ovary syndrome

and are obese;

� Those known to have impaired glucose tolerance/ impaired fasting

glycaemia;

� Symptomatic patients (e.g. thirst, weight loss, lethargy, recurrent thrush,

cystitis, neuropathy)

Method

Pharmacists and support staff from the six participating pharmacies at-

tended specialised training consisting of clinical updates, consultation skills,

use of monitoring equipment and case studies, to ensure effective service

delivery. Following training, pharmacists were required to brief local GPs

about the service, including their involvement and the process and referral

criteria. A written protocol provided a systematic approach and included:

1. Identifying suitable patients, providing them with a patient information

leaflet and obtaining their written consent to participate;

2. Conducting a random capillary blood glucose (RCBG) test;

3. Eliciting lifestyle information from the patient;

4. Interpreting results and providing appropriate counselling including

patient advice (e.g. on modifiable risk factors such as smoking cessation/

nicotine replacement therapy, healthy eating, weight loss and exercise)

and documenting the outcome(s) of the intervention and action(s) taken,

on the Screening Form;

5. Providing patient with relevant information leaflets dependant upon the

result;

6. Inviting the patient to return for a fasting capillary blood glucose test

(FCBG) if appropriate;

7. Referral, if appropriate (Figure 1);

8. Forwarding test results to the GP Practice for input into patient records,

whether the patient is referred or not.

Figure 1. Nature of generic substitution interventions made.

Figure 1 Patient referral criteria for patients screened.A252

Results

To date, 101 patients have accessed the community pharmacy-based service

and, subsequently, been screened for Type-2 diabetes. Patient ages ranged

from 18 to 100 years, with the mean age being 56 years.

In addition to RCBG/FCBG test(s), information on contributory

lifestyle risk factors such as smoking, alcohol and exercise was also

collected from patients. A 22% (n = 22) of patients confirmed that they

smoked; 60% (n = 60) stated that they drank alcohol, ranging from

1 unit to 50 units/week (the average weekly consumption being 7.5 units).

Around 55% (n = 55) of patients stated that they exercised, the average

being three times per week. Pharmacists provided appropriate advice on

maintaining a healthy lifestyle and reducing their risks based on patients’

responses.

RCBG ranged from 3.9 to 22.5 mmol/l; 49.5% (n = 50) had a reading

<5.5 mmol/l, 49.5% (n = 50) had a reading between 5.6 to 11 mmol/l. One

patient had a measurement greater than 11 mmol/l; this patient was ‘fast-

tracked’ to their GP for an appointment.

In line with the protocol, all patients above 5.5 mmol/l were invited back

for a FCBG test. Of the 50 patients requiring a FCBG test, 96% (n = 48)

returned to the pharmacy. FCBG ranged from 1 to 10.4 mmol/l; 71%

(n = 34) had a reading <5.5 mmol/l, and the remaining 29% (n = 14)

between 5.6mmol/l and 11 mmol/l.

A total of 15 patients were referred to their GP for further tests. GPs have

consequently seen and returned data for 33% (n = 5) of these patients.

Sixty percent (n = 3) had reduced to <5.5 mmol/l. Two patients had

measurements of 6.2 and 6.4 mmol/l, respectively. GP data for the other 10

referred patients remains outstanding.

Discussion

This project demonstrates that Community Pharmacists and their support

staff are suitably placed and have the skills and knowledge to provide a

Diabetes Screening Service. Patients can access a professional and confi-

dential service in Community Pharmacy, without a formal appointment, at

a time convenient to them. This greatly increases the prospect of early

diagnosis of Type-2 diabetes, in turn, reducing any associated long-term

complications.

References1. News Update. Diabetes UK, London. 1st September 2005.2. National Service Frameworks. Diabetes. Modern Standards and Service

Models. Department of Health: London. 2002.

7 Practical prescribing the development and delivery of a teaching

package for 5th year medical students

Bowden J1, Pepperrell M

2

1Department of Pharmacy, Royal Bournemouth & Christchurch Hospitals

NHS Foundation Trust, Bournemouth; 2Southampton University Hospitals

Trust (SUHT), Southampton

Introduction

The undergraduate course is the first stage of medical education, providing

the baseline for further development as a pre-registration house officer. An

important part of the medical student education involves the understanding

of the effective and safe use of medicines as a basis for prescribing including

side-effects, interactions and antibiotic resistance1. The requirement for this

additional teaching about prescribing was identified in 2001 by South-

ampton Medical School, which felt the teaching should be practice based

whilst the fifth year students were on placement. The pharmacy depart-

ments at SUHT and the Royal Bournemouth Hospital were approached to

develop and co-ordinate a teaching package for all fifth year medical stu-

dents on placement at 13 local hospitals.

Objectives

To develop and co-ordinate the delivery of a pharmacist-led teaching

package (on practical prescribing and intravenous drug therapy) for fifth

year medical students based at Southampton Medical School and to assess

the impact of the teaching sessions.

Method

In February 2002, 13 hospital pharmacies where Southampton medical

students undertook medical placements were contacted by e-mail or letter to

assess whether they would be happy to undertake the teaching. A working

party was set up to identify the key objectives for the sessions and a draft

teaching package was produced for the practical prescribing along with

guidelines for the intravenous drug therapy session. Each medical student

undertakes a 10-week medical placement in the fifth year, so the format of

the sessions was set as two afternoon sessions on practical prescribing and

one afternoon session on intravenous drug therapy during this placement.

Due to the logistics and numbers of students the decision was made to

centralise the intravenous sessions at four locations (Bournemouth,

Chichester, Southampton and Winchester), but to hold the practical pre-

scribing sessions at each hospital. In May 2002, a demonstration of the

teaching package was given at Southampton with the lead pharmacist in-

vited from each hospital. At the end of the presentation all but one hospital

pharmacy agreed to undertake the teaching sessions.

Students were given a handbook explaining the objectives of the sessions,

listing contact numbers and including a teaching pack for intravenous

therapy to be read before the practical afternoon. As part of the review and

continual development of the teaching sessions the medical students were

required to complete an assessment of the practical prescribing and the

intravenous drug therapy at the end of the session.

The teaching sessions commenced in July 2002 and have continueduntil the

present date. The number of sessions was increased in 2005/6 to four after-

noons, with an increased emphasis on the management of risk and drugs.

Results

A total of 493 students have attended the sessions since 2002. Results of the

feedback questionnaires from the students is shown in Table 1.

Discussion

The feedback from all of the cohorts of students has been very positive and

shows that their confidence with prescribing has been increased.

The group size for the sessions ranges from 2 to 8 students, this enables

the pharmacists to adapt the teaching to the groups needs, especially during

ward visits. The design of the teaching pack which provides Powerpoint

presentations, case examples and suggested lesson plans contributes to

consistency of the training provided, which is possibly unique as it is

Table 1 Results of feedback questionnaires from fifth year medical students 2003–4

Practical prescribing sessions (%) Strongly agree Agree Not sure Disagree Strongly disagree Number

Holding the sessions during the medicine attachment

was appropriate

46 52 0 2 0 119

Quality of the teaching was mostly good 38 61 0 2 0 120

The content of the sessions was mostly good 48 48 3 0 0 120

The content increased my confidence in prescription writing 41 53 3 3 0 120

I would have liked more pharmacist-led teaching 20 49 27 2 3 120

The sessions gave me more confidence in communicating

about medicines

18 67 15 0 0 118

The sessions increased my confidence in prescription writing

about controlled drugs

33 60 6 2 0 119

The sessions helped me understand the clinical pharmacy

management of patients within medicine

48 50 3 0 0 120

very good good fair poor very poor

My overall rating for the sessions 46 53 2 0 0 118

A253

co-ordinated across 12 NHS trusts. When the authors suggested adding an

extra session to incorporate more information on reducing risk in pre-

scribing the medical school were supportive. The teaching pack was then

substantially revised, incorporating principles and examples from ‘‘Building

a Safer NHS for Patients’’2. Funding for development of the teaching packs

and pharmacists time to deliver the training was obtained from the medical

school and amounts to £34,000 for 2005–6. Although the pharmacist’s time

is funded, it still remains a challenge to incorporate the teaching into a

hectic timetable.

Future developments include discussions with an educationalist on

delivery of the training and assessment of its impact, and incorporation of

OSCE questions into the final exams to be based on ‘‘Practical Prescribing’’.

Acknowledgements

All the pharmacists involved in the teaching at the hospitals in Basingstoke,

Bournemouth, Chichester, Dorchester, Frimley Park, Isle of Wight, Poole,

Portsmouth, Salisbury, Southampton, Winchester and Worthing.

Dr Keith Hillier, Senior Lecturer, Clinical Pharmacology, Dr Chris Ste-

phens, Director of Education, School of Medicine, University of South-

ampton.

References1. General Medical Council. Tomorrow’s doctors: recommendations on under-

graduate medical education. London:GMC, 2003.2. Department of Health. Building a safer NHS for patients. London:Stationary

Office, 2001.

8 Levosimendan: safety, effectiveness and patient outcomes. The

experience of an adult intensive care unit

Lippett S1, Batra R

2, McKenzie CA

1, Beale R

3, Wyncoll D

3

1Pharmacy, Guy’s & St Thomas’ NHS Foundation Trust, London, UK;2School of Medicine, University of Maryland, Baltimore, USA; 3Intensive

Care Unit, Guy’s & St Thomas’ NHS Foundation Trust, London, UK

Introduction

The prognosis of patients with cardiogenic shock admitted to the intensive

care unit (ICU) is poor. In-house data (2003/4) indicates an annual ICU

mortality rate of 72.4% in this population. Levosimendan is a novel cal-

cium-sensitizing agent that increases myocardial contractility without

increasing oxygen consumption. It also possesses vasodilatory properties.

Studies have shown levosimendan to be effective in reducing the risk of

worsening heart failure and death in patients with left ventricular failure

(LVF) complicating acute myocardial infarction and to be well tolerated in

terms of hypotensive and ischaemic episodes1. The LIDO study2 showed an

improvement in cardiac output by ‡30% at 24 h (28% v 15%, p = 0.022)

and an improvement in mortality at 180 days significantly better than do-

butamine (26% v 38%, p = 0.029). Although levosimendan remains unli-

censed in the UK, use of this expensive drug in our high-risk ICU

population is prevalent, without any formal evaluation of benefit.

Objective

To describe the use of levosimendan on an adult intensive care unit.

Method

Data were collected retrospectively from patients who received levosimen-

dan on the ICU between January 2004 and June 2005. Details recorded

included age, reason for admission to the ICU, levosimendan dose and

duration, dose of inotropes/vasopressors and cardiac studies pre-, at end of

and 24 h post- levosimendan infusion, concurrent anti-failure drugs, ad-

verse effects and mortality. Cardiac studies and use of inotropes/vasopres-

sors were evaluated using regression analysis and wilcoxon matched pairs

testing.

Results

In total 30 patients received levosimendan on the ICU of which data were

available for 25; one patient had levosimendan on two separate admissions.

The median age was 67 years (range 30–84 years). Cardiogenic shock was

the primary reason for admission to the ICU for 20 (76.9%) of the patients,

R2 = 0.93,*p=0.029

R2 = 0.99,*p=0.041

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

t=0 t=end of infusion t=24 hr post infusionTime

CI (

Lmin

-1m

-2)

0

500

1000

1500

2000

2500

SVR

I (dy

ne s

-1 c

m-5

m-2

)

CI SVRI

*p=baseline vs. t=24 post infusion, n=17

Figure 1 Levosimendan increases cardiac index (CI) while lowering the systematic vascular resistance index (SVRI).

R2 = 0.933, *p=0.005

R2 = 0.916, *p=0.031

R2 = 0.911, *p=0.031

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

Time

Inot

rope

dos

e(µ

g kg

-1m

in-1

)

Dobutamine x10–²(n=7) Milrinone (n=8) Noradrenaline (n=17)

t=0 t=end of infusion t=24 hr post infusion

*p=baseline vs. t=24 hr post infusion

Figure 2 Levosimendan decreases inotropic requirements.

A254

of which 13 were post-cardiac surgery and 5 post-acute myocardial

infarction. The mean APACHE II score at time of receiving levosimendan

was 19 (n = 19, SE = 0.96). Eight patients (30.8%) did not undergo formal

cardiac studies, 12 (46.2%) had PiCCO� monitoring, 3 (11.5%) had LiD-

CO� monitoring and three had a pulmonary artery catheter. No patients

were given a loading dose of levosimendan. The mean maintenance dose

received was 0.12 mcg/kg/min for a median of 24 h (range 3–58 h). Thirteen

(50%) of patients were concurrently prescribed anti-failure medication, five

were prescribed only one medicine, three were prescribed two medications

and five were prescribed three. b-blockers were the most commonly pre-

scribed. A significant increase in mean cardiac index (CI) was observed

from time of starting levosimendan and 24 h post-infusion (2.49 l min-1m-2

(SE = 0.24) v 3.06 l min-1m-2 (SE = 0.19), p = 0.041). A significant de-

crease in systemic vascular resistance index (SVRI) was also observed

(1,948 dyne s-1cm-5m-2 (SE = 198) v 1,363 dyne s-1cm-5m-2 (SE = 129),

p = 0.029) (Figure 1). A reduction in mean doses of noradrenaline n = 17,

(0.3 mcg/kg/min SE = 0.08) v 0.09 mcg/kg/min SE = 0.03), p = 0.005),

dobutamine n = 7, (8.26 mcg/kg/min (SE = 0.023) v 3.77 mcg/kg/min

(SE = 0.028), p = 0.031), and milnirone n = 8, (0.22 mcg/kg/min

(SE = 0.08) v 0.12 mcg/kg/min (SE = 0.09), p = 0.031), was demon-

strated over the same time period (Figure 2). One patient developed atrial

fibrillation during administration of levosimendan. There were no reports of

new ischaemia or ECG changes. The ICU mortality was 58% of which two

patients died during administration of levosimendan.

Discussion

Levosimendan at infusion rates of 0.1–0.2 mcg/kg/min had a favourable

impact upon CI, SVRI and inotrope/vasopressor doses for patients in our

ICU. It was well tolerated in terms of arrhythmias and ischaemic events.

Our ICU has witnessed more than a 14% decrease in mortality for car-

diogenic shock since the introduction of levosimendan, suggesting benefit.

However other strategies have been implemented during this period,

including tight glycaemic control. The LIDO study2 showed a clear benefit

when levosimendan was used as an alternative to dobutamine and we were

able to replicate similar positive outcomes in a non-controlled setting. In

our experience, due to the unlicensed status and associated cost pressure,

levosimendan was never used as first-line therapy but was often employed as

a ‘rescue-agent’. We would highlight the need to possibly consider the use of

levosimendan at an earlier stage or as an alternative to dobutamine. This

retrospective review of the safety and efficacy of levosimendan has also

demonstrated a model that can be widely applied to monitor use, develop

guidelines and bid for funding of a high cost, unlicensed drug.

References1. Moiseyev VS, Poder P, Andrejevs N et al. Safety and efficacy of a novel calcium

sensitizer, levosimendan, in patients with left ventricular failure due to an acutemyocardial infarction. A randomized, placebo-controlled, double-blind study(RUSSLAN). Eur Heart J 2002; 23: 1422–32.

2. Follath F, Cleland JGF, Just H et al. Efficacy and safety of intravenous levo-simendan compared with dobutamine in severe low-output heart failure (theLIDO study): a randomised double-blind trial. Lancet 2002; 360: 196–202.

Posters Audit

9 An audit of the pharmacy admissions service at a teaching hospital

Bracey G, Miller G, Franklin BD

Hammersmith Hospitals NHS Trust, London

Introduction

Several studies have demonstrated the potential benefits of having a spec-

ialised admissions pharmacist. A recent study found that only 12.5% of

patients seen by a doctor in Accident and Emergency (A&E) had a complete

drug history (DH) taken, compared to 100% of those seen by a clinical

pharmacist1. Another study found that by attending the medical post-take

ward round (PTWR), pharmacists made an average of 1.84 contributions

per patient seen2.

Two specialised medical admissions pharmacists were established at our

hospital in August 2004. The aims of the service were to attend the medical

PTWR; confirm and document. DHs for emergency admissions and to

ensure the timely supply of medication for inpatients and at the point of

discharge (this involves the use of patients own drugs and the one-stop

dispensing system wherever possible). The aim of this audit was to measure

the impact of this service on an acute medical admissions ward.

Objectives

To measure the number and types of contributions to patient care made

during the PTWR; to determine the percentage of patients on the admis-

sions wards with drug histories checked by a pharmacist and the number

and nature of interventions made as a result; to evaluate how discharge

medications are supplied.

Method

Both pharmacists collected data over a period of 7 days, using a piloted

data collection form, relating to: number and nature of contributions made

on the PTWR; number and nature of interventions made as a result of DH

taking; the source of any items needed for the dispensing of discharge

prescriptions (TTAs) screened by the pharmacist on the ward. Contribu-

tions to the PTWR were classified using the method of Bednall et al2.

Audit standards were: (1) At least one contribution per patient should be

made on the PTWR; (2) 75% of all patients admitted to the acute medical

admissions ward should have their DH checked by an admissions phar-

macist; (3) No more than 25% of all medication should be dispensed by the

pharmacy on discharge (the rest should be available on the ward).

Results

A total of 74 patients were seen on the PTWR during the week of data

collection and a total of 83 contributions made by the pharmacist; an

average of 1.1 per patient. The most common type of contribution made

was ‘‘therapeutic choice’’, meaning that the class and dose of drug was

prescribed as advised by the pharmacist (Table 1).

Of the 93 patients admitted to the admissions ward during the audit

period (mean of 13.2 patients per day), 56% (n = 52) of patients had their

DH checked by a pharmacist – this resulted in 61 interventions; again an

average of 1.1 per patient (Table 2). The most common intervention was the

addition of a drug that had been unintentionally omitted.

In total, 19 Nineteen TTAs were screened over the 7 days, with a total of

121 items prescribed. Of these, 33% (n = 41) were patients’ own drugs

(either at home or on the ward), 30% (n = 36) had already been dispensed

for discharge and were available on the ward, and only 24% (n = 29) had

to be dispensed in pharmacy.

Discussion

The number of contributions made on the PTWR was above the audit

standard of one per patient. A large proportion of these were ‘‘therapeutic

choice’’ – suggesting that the pharmacists are making appropriate contri-

butions. Pharmacists also intervened to stop medication due to adverse

drug reactions in 12% (n = 10) of contributions, which shows they are

highlighting the potential for drug-induced problems.

The audit standard was not met for the proportion of patients with a drug

history checked by an admissions pharmacist. This was probably due to the

high number of patients admitted and the fast patient turnover (one patient

was transferred after just 2 h). It was noted that 75% may therefore be an

unrealistic target and that length of stay also needs to be considered. It is

reasonable to expect that all patients on the ward for 24 h or more have a

DH checked by a pharmacist.

Finally, the audit standard (<25%) for the proportion of items that were

dispensed by pharmacy on discharge was met, with just 24% of items

Table 1 Types of contribution made to medical PTWR (n=83 patients)

TD TC Advice on

route/formulation

DA ADR TDM Allergy status C Total

Number(%) 9(11%) 33(40%) 1(1%) 17(20%) 10(12%) 3(4%) 9(11%) 1(1%) 83(100%)

TD, therapeutic discussion; TC, therapeutic choice; DA, dose adjustment; ADR, adverse drug reaction/advised stopping; TDM, therapeutic drug

monitoring; C, counselling2.

A255

needing to be dispensed. Before the admissions team were in post most of

these would have been dispensed by the dispensary.

Several limitations to the study were identified. For ease, the audit

standards were arbitrary, and may not be entirely appropriate; rather than

specify a particular number of contributions per patient it would be more

meaningful, but much more difficult, to determine whether they were made

when appropriate. This study was conducted over 1 week and involved just

two consultants, it is likely that the type and number of interventions

change depending on the specialist knowledge of the consultant, the speed

of their PTWR and their receptiveness towards pharmacist contributions. A

longer audit period would be preferable.

Consideration needs to be given to ways to prioritise patients to ensure

those who really need a DH and medication review receive one early in their

admission. The installation of a labeller on the ward and encouraging

doctors to bleep the admissions pharmacists as soon as a complex patient

arrives in A&E should help to achieve more in the time available.

Acknowledgement

Laura Whitney for data collection.

References1. Cavin A, Sen B. Improving medication history recording and the identification

of drug-related problems in an A&E department. Hosp Pharm 2005; 12: 109–11.2. Bednall R, McRobbie D, Russell SJ. A prospective evaluation of pharmacy

contributions to post-take ward rounds. Pharm J 2003; 271: 2.

10 Audit of the supply of domiciliary oxygen from community

pharmacies in the Greater Glasgow Area

Reilly V, Millar H, Thomson DAM

Greater Glasgow Primary Care Division, Gartnavel Royal Hospital, Glasgow,

Greater Glasgow Community Pharmacy Clinical Governance Audit and

Public Health Teams

Introduction

A project conducted in the Lothian Primary Care Trust Area to assess the

management of patients receiving domiciliary oxygen (O2) from community

pharmacies1 suggested that many patients were receiving sub-optimal

standards of care compared to those recommended in professional guide-

lines 2,3. In particular not all patients received written information regarding

handling of oxygen equipment, safe storage, smoking, and emergency

contact numbers.

The O2 module from the Greater Glasgow Pharmacy Audit Programme

‘Quality in Practice’ clinical governance package which relates to the

management of domiciliary oxygen supply in community pharmacies

available at www.show.scot.nhs.uk/gghbpharmacy was used to audit the

supply of domiciliary oxygen in the Glasgow area following a collaborative

model successfully used in previous audits of ‘Advice to locums’ and

‘Dispensing’.

Objectives

To audit the supply of oxygen from community pharmacies, present results

at a multidisciplinary meeting and address any action points before

re-audit.

Method

Greater Glasgow pharmacy oxygen (O2) contractors completed the self-

audit ‘Domiciliary Oxygen’ from the Greater Glasgow Pharmacy Audit

programmes ‘Quality in Practice’ clinical governance package4 and sub-

mitted their results for analysis by facilitators.

The audit required participants to respond with ‘yes’, ‘no’ or not-appli-

cable (n/a) to 52 recommendations in 10 categories and answer additional

questions in a semi-structured questionnaire.

O2 contractors, project facilitators, Fire Safety officers and a Health

Promotion officer were invited to a meeting for presentation and discussion

of results.

Recommendations were made and re-audit was conducted after

6 months.

Greater Glasgow Ethics Committee granted approval of the project.

Results

Of 92 O2 contractors completed 43 (47%) the audit and re-audit cycle.

Around 31 (61%) contractors and 25 (58%) drivers had received oxygen

safety training. And 32 (63%) contractors had an oxygen safety and

information leaflet available for patients.

In total 17 contractors, 5 Health Promotion/Audit Facilitators, 2 Fire

Safety Officers and a Senior Health Promotion Officer for Accident Pre-

vention from Greater Glasgow NHS Health Board attended an audit

feedback meeting at which action points were identified. These involved

recommendations for contractor and staff training, transport of cylinders

and supply of patient safety leaflets and emergency contact numbers.

Table 1. demonstrates the percentage change to positive (yes) responses to

recommendations in categories after re-audit.

Discussion

The audit and meeting identified areas of practice that could be improved,

in particular the transport of oxygen cylinders, provision of service to pa-

tients and training and staff education subsequent re-audit demonstrated

improvements in practice to these areas and others.

Paediatric oxygen supply demonstrated a large change because O2 con-

tractors who considered it not applicable to their practice prior to the

feedback meeting reassessed their need for information after hearing col-

leagues report that they had such patients. Administration achieved 100%

at re-audit because a relatively minor point concerning return of a form to

the Primary Care Division (PCD) was clarified.

It was useful to have the Fire Brigade represented at the feedback

meeting. Fire Safety officers were able to highlight oxygen transport safety

points and offer assistance with oxygen storage queries. The Fire Safety

Officers felt that they too had benefited from attending the meeting.

Although it was disappointing that less than half active O2 contractors

took part in the audit and not for all of those who attended the meeting it

was possible to disseminate action points identified and training informa-

tion distributed at the meeting to all O2 contractors by Board mail out.

Community pharmacists were pro-active with other professionals to ad-

dress change and re-audit demonstrated an improvement in practice. Fur-

ther audit work suggested would focus on emergency demand for oxygen

cylinders for palliative care patients.

References1. Boyle A, Renton J, Kinnear M. An evaluation of the provision of advice to

patients receiving domiciliary oxygen. Lothian Pharmacy Practice Unit,Departments of Pharmacy, Lothian Primary Care NHS Trust, Lothian Uni-versity Hospitals NHS Trust, Edinburgh.

2. Medicines, Ethics and Practice. A guide for pharmacists (27) July 2003.3. Domiciliary Oxygen therapy services: clinical guidelines and advice for pre-

scribers. Summary of a report of the Royal College of Physicians Lond 1999; 33:445–7.

Table 2 nterventions made as a result of DH taking (n = 61 interventions)

Allergy status Drug omitted Incorrect dose Incorrect formulation Incorrect frequency Route Total

Number(%) 11 (18%) 39 (64%) 3 (5%) 1 (2%) 7 (11%) 0 (0%) 61 (100%)

Table 1 Comparison of positive (yes) responses at re-audit of ‘Domiciliary

oxygen’ self audit module

Domiciliary oxygen

self-audit module category

% Yes response % Change

Audit Re-audit

Receipt of cylinders 80 94 18

Storage of cylinders 78 78 –

Maintenance of cylinders 69 83 20

Transport of cylinders 61 80 31

Service to patients 81 93 15

Paediatric oxygen supply – 59 59

Administration 80 100 25

Education of all staff 66 83 26

Training of staff handling cylinders 82 94 15

Training of staff delivering cylinders 89 92 3

Chi squared analysis indicates p < 0.05

A256

11 An Audit of how prescribing of Zaleplon, Zolpidem & Zopiclone (‘Z’

drugs) complies with NICE guidance No. 77

Druce LA

Department of Pharmacy, North West Wales NHS Trust, Ysbyty Gwynedd

Introduction

The National Institute for Clinical Excellence (NICE) guidance document

(No. 77) states that published estimates of the prevalence of insomnia vary

from 10 to 38%1.

A drug used to induce sleep is described as a ‘hypnotic’. Although hyp-

notic agents are licensed for the treatment of insomnia, they do not treat

any underlying cause.

The level of prescribing of hypnotics in Wales is a matter of concern and

has been identified by the All Wales Medicines Strategy Group as a key area

for review due to the potential adverse effects, especially in the elderly and

due to increased cost issues.

At Ysbyty Gwynedd, Bangor, the main problem with hypnotics appears

to be that these drugs are included on discharge prescriptions as regular

medicines, which get transferred onto the repeat system without adequate

review to assess whether there is a continued need for them. Such drugs are

not always required on long-term repeat basis if only prescribed on an ‘as

required’ basis in hospital. Ongoing therapy without review is also a com-

mon problem in nursing homes and community hospitals2.

A number of hypnotic agents are licensed for the treatment of insomnia

including Zaleplon, Zolpidem and Zopiclone (‘Z’ drugs), the non-benzo-

diazepine hypnotics.

Based on a population of 250,000 for North West Wales, approximately

£200,000 was spent on ‘Z’ drugs over a 12 month period 2003/20043. The

most commonly prescribed ‘Z’ drug during this period was Zopiclone

(87%), which reflects current Joint Formulary guidance, followed by

Zolpidem, and Zaleplon was the least prescribed3.

The NICE guidance is expected to provide cost savings to the NHS with a

possible reduction in inappropriate prescribing of hypnotics.

Objectives

The main aim of this audit is to review current prescribing of ‘Z’ drugs for

people with insomnia. Adherence with criteria/standards set out by NICE

Technology Appraisal Guidance 77 were measured.

Method

A qualitative and quantitative research method was chosen for this study to

satisfy the aim of providing statistical results as well as exploring the

information given to patients from the prescriber about their medicine.

A prospective study was carried out including patients prescribed ‘Z’ drugs

on all medical wards (approximately 160 beds) which carried out the Patients

Own Drugs system (PODs) over a 10-day-period (excluding weekends).

Ward-based technicians and pharmacists identified patients for inclusion.

All patients of all ages were included whether treatment started on current

admission, previous admission or in PrimaryCare.A ‘patient detail’ formwas

developed to answer the criteria based in the NICE Technology Appraisal.

Once identified, the researcher completed a ‘patient detail’ form, which in-

cluded demographic data so patients could be followed through to discharge.

Results

A total of 62 patients were recruited for inclusion in this audit. Of these

patients, 65% were male, aged between 65 and 80 years. All patients, n=62

(100%) were prescribed Zopiclone.

It was found that Zopiclone was prescribed on an ‘as required’ basis for

47 patients (77%).

The NICE guidance states that the ‘Z’ drug of lowest cost should be

prescribed. Results were as seen in Table 1.

In the majority of patients (97%), treatment was started by Secondary

care and in 42 patients (68%) therapy began on this current admission. No

information was given to 24 patients (39%) regarding the medicine by the

prescriber.

The maximum licensed duration for use of Zopiclone is 4 weeks. Eighty-

five percent of patients were prescribed Zopiclone for a longer duration.

This took into consideration of prescription prior to admission, as inpatient

and on discharge from hospital.

Discussion

Hypnotic agents should, in general, be given only for very short periods to

alleviate distressing insomnia caused by short lasting events, illness or

upsets2. Hypnotics should be offered only as an adjunct to non-drug

treatment of insomnia such as ‘sleep hygiene’, and should ideally be re-

served for patients with the most severe symptoms.

Encouragingly, for the majority of the patients included, 77% (n = 47),

Zopiclone was prescribed on an ‘as required’ basis and not prescribed as

regular treatment whilst inpatient. As Zolpidem was not found to be pre-

scribed for any patient included, prescribing does not adhere with NICE

guidance, where the cheapest drug should be chosen; that being Zolpidem.

If these prescriptions were replaced with Zolpidem or with hypnotics with

lower acquisition costs, it could possibly signify a great cost saving to the

National Health Service.

This issue will be resolved by updating the current guidelines in the Joint

Formulary, and through newsletters to prescribers and prescribing advisers

in Primary and Secondary care.

Recommendations from this audit are to provide leaflets to inpatients

regarding non-pharmacological methods to aid sleep, to address the issue

specifically during junior doctor induction and nurse training. Discussions

with the clinical pharmacy team have resulted in a change of endorsement

for all hypnotics, encouraging them to be questioned if continued on dis-

charge from hospital.

Acknowledgement

Audit undertaken as part of Diploma in Clinical Pharmacy with Cardiff

University, Wales.

References1. Zaleplon, Zolpidem and Zopiclone for the short-term management of insomnia,

National Institute for Clinical Excellence, Technology Appraisal Guidance 77,April 2004.

2. Benzodiazepines and ‘Z’ drugs for insomnia, WeMeReC Bulletin Vol. 10, No. 3,October 2003.

3. Health Solution Wales, CASPA Data. Available from: http://howis.wales.nhs.uk [Revised 09/2004; Accessed 12/1/2005].

12 Management of potential drug-induced upper gastrointestinal

bleeding

Willms A

Department of Pharmacy, NWW NHS Trust, Ysbyty Gwynedd, Bangor

Introduction

A recent report by Pirmohamed1 highlighted that adverse drug reactions

(ADRs) still considerably contribute to hospital admissions. This study

revealed that low-dose aspirin was the drug causing the highest number of

ADRs. Upper gastrointestinal (GI) bleeding was the most common ADR

and occurred in 72% of all aspirin related admissions.

Other drugs that were identified to cause hospital admissions due to

upper GI bleeding are non-steroidal anti-inflammatory drugs (NSAIDs),

cyclo-oxygenase-2 (COX-2) inhibitors, clopidogrel, anti-coagulants, selec-

tive serotonin re-uptake inhibitors (SSRIs) and systemic corticosteroids.

As mild GI symptoms poorly correlate with the development of major

upper GI complications it is important to identify patients at risk for

developing NSAID induced upper GI bleeding2. The National Institute of

Clinical Excellence (NICE) clearly defines risk factors for serious GI ADRs

to NSAID therapy3. Although it is generally agreed that gastroprotection

should be offered to patients at high risk of developing ADRs with NSA-

IDs, national or local guidance on the number of risk factors justifying

gastroprotective medication is lacking.

Besides the identification of potentially offending drugs, clear documen-

tation, communication to primary care and reporting to the Committee on

Safety of Medicines (CSM) are important steps in the management of

ADRs.

Objectives

This audit was undertaken to assess the need for local guidelines on the use

of gastroprotection in patients at high risk of NSAID induced upper GI

Table 1 Results for NICE standard when drug of lowest cost should be

chosen

The most appropriate/lowest cost drug according to: % Achieved

Joint Formulary July 2004 ZOPICLONE 100%

Drug Tariff September 2004 ZOLPIDEM 0%

A257

bleeding. Also to identify educational needs among clinicians regarding

documentation and reporting of ADRs.

Method

Over 9 weeks (15/09/2004 to 17/11/2004) inpatients with symptoms of up-

per GI bleeding were identified on 7 medical and 3 surgical wards in Ysbyty

Gwynedd, a district general hospital.

A comprehensive drug history was undertaken to identify potentially

offending drugs and gastroprotective agents. Data on risk factors were

obtained.

For all cases of drug-induced upper GI bleeding International Statistical

Classification of Disease and Related Problems (ICD-10) codes were ob-

tained from the clinical coding department to assess the documentation of

ADRs. CSM Wales provided the number of yellow card reports on drug-

induced upper GI bleeding submitted from Ysbyty Gwynedd during the

audit period.

Results

Table 1 shows individual drugs that potentially caused upper GI ADRs.

Fifty percent of patients taking NSAIDs, of which one patient was taking a

gastroprotective agent before admission presented with at least one risk

factor.

ICD-10 codes were obtained for 21 patients. No hospital admission was

coded to be a result of an ADR.

No yellow card reports completed by a clinician were reveived by CSM

Wales during the audit period. A total of 21 yellow card reports were

submitted to the CSM by the auditor.

Discussion

Drugs contribute considerably to hospital admissions due to upper GI

bleeding in Ysbyty Gwynedd. Compared to data published in the litera-

ture1,4 the incidence of upper GI bleeding potentially caused by aspirin and

NSAIDs was found to be lower, while clopidogrel had a similar impact on

causing this ADR.

This lower incidence may be due to a difference in data collection

methods,e.g. days on which data was collected, inclusion of accident and

emergency departments, duration of audit.

The number of patients presenting with NSAID-induced upper GI

bleeding was not high enough to assess the need for local guidelines on the

use of gastroprotection in high risk patients [extrapolation of audit data to

1 year: 12 non-aspirin NSAIDs induced upper GI bleeding in patients over

65 years of age compared to an estimation of 45 cases for a Primary Care

Trust of similar size in Bandolier4] . However, after the worldwide with-

drawal of Rofecoxib in September 2004 and the current analysis of trial

data on celecoxib by the European Medicines Agency (EMEA) and the

Medicines and Healthcare products Regulatory Agency (MRHA), an

increase in the use of traditional NSAIDs may be expected.

In five cardiovascular prevention trials, low dose aspirinwas shown to have

an increased incidence ofGIADRs, includingmajorGIbleeding compared to

placebo5. However, low dose aspirin is excluded from most references

discussing risk factors for NSAID-included upper GI bleeding. Local dis-

cussions on the development of strategies to reduce the incidence of upper GI

bleeding caused by aspirin used as an anti-platelet drug are required.

Adverse drug reactions can only be coded as such with ICD-10 codes if

they are clearly documented as such in medical case notes or discharge

summaries. The lack of admissions coded as drug-related may be inter-

preted as poor documentation by clinicians.

The fact that no yellow card reports were submitted by clinicians to the

CSMWales shows the needof education onADRreporting among clinicians.

Pharmacists should establish their role in documenting and reporting ADRs

and increase the awareness of drugs as a potential cause of upper GI

bleeding in discussions of individual cases with clinicians.

Acknowledgement

This audit was undertaken as part of the Postgraduate Diploma in Clinical

Pharmacy, University Cardiff, Wales.

References1. Pirmohamed M, James S, Meakin S et al. Adverse drug reactions as cause of

admissions to hospital: prospective analysis of 18, 820 patients. BMJ 2004; 329:15–19.

2. Singh G, Triadafilopoulos G. Epidemiology of NSAID induced gastrointestinalcomplications. J. of Rheumatol. 1999; 26 Supplement (56): 18–24.

3. NICE. Technology Appraisal Guidance No 27: Guidance on the use of cyclo-oxygenase (COX) II selective inhibitors, celecoxib, rofecoxib, meloxicam andetodolac for osteoarthritis and rheumatoid arthritis, July 2001.

4. Moore A, McQuay H (eds), More on NSAID adverse effects, Bandolier 79, sep2000; 7(9): 6–8.

5. Isles C, Norrie J, Paterson J, Ritchie L et al. Risk of major gastrointestinalbleeding with aspirin, Lancet 1999; (353): 148–150.

13 Insulin prescribing by medical staff is unsafe, and education results in

a significant but insufficient improvement

Clarke NR1, Narendran P2

1Department of Pharmacy North Bristol NHS Trust, Bristol; 2Department of

Endocrinology North Bristol NHS Trust, Bristol

Introduction

Insulin prescribing is not safe in the UK1,2. Nor is it safe in the USA where

it tops the list of drugs involved in medication errors3. Common errors

involve the abbreviation of ‘units’ to ‘U’ or ‘IU’ such that 4 units can be

misread as 40 or 41 units, respectively. Alternatively insulin ratio may not

be specified, for example ‘Humulin’ or ‘Mixtard’ may be written in place of

‘Humulin M3’TM or ‘Mixtard 30’TM, respectively. The Chief Pharmaceu-

tical Officer4 and the British National Formulary have discouraged these

practices.

Objective

To audit accuracy and safety of hospital inpatient insulin prescriptions in

the North Bristol NHS Trust (NBT). To see whether education of doctors

had any effect on insulin prescribing as measured by re-audit.

Method

We audited inpatient insulin prescriptions across three hospitals in our

health authority involving 1488 beds. A total of 1156 inpatient charts were

reviewed on 1 day and scored for prescribing accuracy with respect to

abbreviation of the term ‘units’, specification of insulin ratio, and overall

accuracy.

Results

In total 57 inpatients (5%) were prescribed insulin, of which some were

prescribed more than one insulin, resulting in a total of 95 insulin pre-

scriptions (Table 1). Of these, only 33 and 74 prescriptions, respectively,

used the term ‘units’ and specified the insulin ratio correctly. The reviewing

pharmacist deemed only 28 of the 95 prescriptions (29%) accurate overall.

We undertook an education program for doctors in our trust in light of

these poor results. The audit results were presented verbally at the junior

doctors hospital induction and clinical risk meetings. They were circulated

through the pharmacy newsletter and in their own right to all doctors and

wards. Insulin prescribing practice was re-audited 6 months later. Insulin-

prescribing practice was shown to have improved considerably in all

respects following the education program (Table 1).

Table 1 Drugs potentially causing upper GI bleeding (n = 23)

Drug class Individual drug (number of cases)

Antiplatelets Aspirin [antiplatelet dose] (10); Clopidogrel (4)

NSAIDs Ibuprofen (3); Aspirin [dose for pain relief] (3);

Ketoprofen (1)

COX-2 inhibitors Rofecoxib (2); Etoricoxib (1)

Anticoagulants Warfarin (2); Enoxaparin (1)

Corticosteroids Prednisolone (2); Hydrocortisone (1)

SSRIs Fluoxetine (1)

Table 1 Total number and accuracy of insulin prescriptions across three

hospitals

Primary audit Follow-up audit

Total Inpatients 1156 1245

Inpatients prescribed insulin 57 (5%*) 55 (4%*)

Total insulin prescriptions 95 92

Prescriptions specifying ‘units’ 33 (35%+) 55 (60%+)

Prescriptions specifying insulin ratio 74 (78%+) 83 (90%+)

Prescriptions accurate overall 28 (29%+) 50 (54%+)

* Expressed as a percent of the number of in patients.+ Expressed as a percent of the number of prescriptions.

A258

Discussion

Our audit is limited by omission of outpatient and discharge prescriptions.

We also did not audit accurate prescription of insulin injection devices and

time of administration in relation to meals.

In summary, our study shows that insulin prescribing to inpatients is

unsafe but can be improved through education of prescribers. However,

only half of the prescriptions were accurate following education, and this

remains unacceptably poor. Further education may result in yet further

improvement in prescribing practice, though we suspect measures such as

non-dispensing of incorrectly prescribed insulin, or electronic prescribing,

will be required to achieve the necessary improvements. In the absence of

electronic prescribing in most NHS Trusts in the UK, we would advocate

regular education of all medical staff of this potentially lethal error.

Acknowledgement

We would like to thank all pharmacists at Southmead, Frenchay and

Blackberry Hill hospitals who helped with the execution of this audit project.

References1. Miles M, Sweeney S. Insulin dose interpretation errors. Pharm J 2001; 267: 193.2. Ridley SA, Booth SA, Thompson CM and the Intensive Care Society’s Working

Group on Adverse Incidents Prescription errors in UK critical care units.Anaesthesia 2004; 59: 1193–1200.

3. Santell JP, Cousins DD, Hicks R. Top 10 drug products involved in medicationerrors. Drug Topics Health-System 2003 December 8; 23–24.

4. Department of Health. Building a Safer NHS for Patients: Improving Medi-cation Safety. Jan 2004.

14 Veno thromboembolism prophylaxis audit

Morris DL1, Dr Britton C2

1Department of Pharmacy, 2PRHO, Royal Albert Edward Infirmary Wigan

Royal Albert Edward Infirmary Wigan;

Introduction

Patients who undergo a surgical procedure are at risk of developing a Ve-

nous Thromboembolism (VTE) due to the trauma of tissue and venous

stasis1. The risk is increased 10-fold in patients who are then hospitalised2.

The SIGN Guidelines and the THRIFT II consensus group make recom-

mendations concerning the management of VTE prophylaxis based on the

clinical trial data available2,3. The evidence suggests that routine prophy-

laxis decreases morbidity, mortality and cost4.

Patients who are admitted to hospital for trauma or surgery should be

individually assessed for their risk of VTE. The national clinical guidelines

state that it is the responsibility of each NHS Trust to implement such

guidelines as an essential part of clinical governance2.

Objectives

To audit the appropriateness of prescribing of enoxaparin (Clexane) for

VTE prophylaxis in patients undergoing surgery. To compare the pre-

scribing of Clexane on the wards to that stated in the Trust guidelines.

Method

Target population – all inpatients admitted to the surgical wards at the

Royal Albert Edward Infirmary (RAEI) over a 5-day-period. Exclusions

were any non-surgical outliers.

An audit sheet was completed for each suitable patient over the stated

period. Information collected included age, individual risk factors and

surgical procedure.

Results

A total of 97 patients were audited over the 5 days, 55% of which under-

went a surgical procedure.

The risk assessment was based on the following table, which was taken from

the Trust guidelines.

The actual risk factors of each patient were documented on the audit sheet.

In total, 22 patients were classed as high risk of which only 27% received

the appropriate prophylaxis dose.

Cancer/malignancy was the most common under prescribed patient risk

factor. Only four out of 19 patients received the appropriate 40 mg dose

and 3 of who had other risk factors.

Discussion

The audit was designed to show how Clexane was being prescribed on the

surgical wards in comparison to the current Trust guidelines. Graph 1

shows the variance of prescribing for patients classified into the risk

assessment categories. The majority of patients were prescribed Clexane

20 mg when in fact 40 mg or even no Clexane would have been more

appropriate. For patients who did not undergo a surgical procedure (no risk

group) the majority still received Clexane.

This inappropriate prescribing could have disastrous consequences

leading to prolonged hospitalisation and increased morbidity. It was

apparent that the doctors were unaware of the risk factors and that the

Trust guidelines were not being followed. A reason for this was that the

majority of junior doctors did not know the guidelines existed or if they did,

found them too complicated to follow. The outcome is therefore to simplify

and publicise the guidelines and through the use of an assessment tool on

admission, ensure that all risk factors are documented. Once implemented,

the aim was to re-audit and compare the results.

References1. Offord R, Perry D. Anticoagulation Handbook. Science Press 2002, p. 26.2. Scottish Intercollegiate Guidelines Network (SIGN). Prophylaxis of venous

thromboembolism – A national clinical guideline. Number 62 Oct. 2002.3. THRIFT II Consensus Group. Risk of and prophylaxis for venous thrombo-

embolism in hospital patients. Phlebotomy 1998; 1387–97.4. Sixth ACCP Consensus Conference on Antithrombic Therapy: Prevention of

venous thromboembolism. Chest 2001; 119: 132s–75s.

15 An audit of prescribing errors in a hospital setting

Cavell GF, Chai M-O, Scutt G

Pharmacy Department, King’s College Hospital

Table 1 Trust guidelines for VTE prophylaxis using Clexane

{Private} Definition of group Prophylaxis

Low risk Minor surgery (<30 min) + No risk factors OR

Major surgery (>30 min) AND age < 40 years + No other risk factors

Early mobilisation

Moderate Risk Minor surgery + Risk factors other than age OR

Major surgery + age >40 years OR other risk factor(s)

Clexane (enoxaprin) 20 mg starting 2 h preop and daily

until discharge

High risk Major pelvic/abdominal surgery for cancer OR

Major surgery in patients with previous DVT, PE or risk factors or

thrombophilia OR

Hip surgery/fractures, knee surgery, Plaster of Paris

Clexane (enoxaprin) 40 mg starting 12 hrs preop and daily

for 5–14 days + TED stockings

A risk assessment was assigned for each patient based on Table 1. The dose of Clexane prescribed in each case was compared to the guidelines. The

number of Clexane doses that corresponded to the Trust guidelines was 27 (28%).

0

5

10

15

20

25

30

35

Nu

mb

er o

f p

atie

nts

no risk low moderate high

Risk assessment

none

20mg

40mg

Graph 1. Barchart to show the dose of Clexane prescribed and the surgical

risk.

A259

Introduction

The Audit Commission Report A spoonful of sugar – medicines management

in NHS hospitals1 raised awareness of medication error rates and

acknowledged the role of pharmacists in promoting safe prescribing. The

report also proposed that, as much of the prescribing in hospitals is done by

inexperienced junior medical staff, which may be prone to error.

Pharmacists often collect data on contributions they make to the medi-

cation use process including medication history taking, patient counselling

and changes to drug therapy regimens. However, such ‘intervention mon-

itoring’ activity is non-specific and data collected varies with the clinical

setting, the experience of the pharmacy practitioner and the level of clinical

service provided. A definition of a prescribing error has been published2.

Auditing prescribing errors using this definition enables intervention

monitoring to be targeted to the prescribing process. This study aims to

establish the number and types of prescribing errors identified by phar-

macists in a teaching hospital using a standard definition of a prescribing

error.

Objectives

To identify common types of prescribing errors.

To identify common drugs implicated in prescribing errors.

Methods

Pharmacy staff attending a series of seminars were informed of the agreed

definition and categories of prescribing error and the process of the audit.

Pharmacy staff were asked to document all prescribing errors identified, and

any contribution made to the prescribing process resulting in a prescription

being written, dose/frequency being changed, or drug being discontinued on

a standard data collection form. Data were collected for a period of 7 days

in November 2002. The errors were categorised by the pharmacists and a

brief description of each event was included. The data were analysed by

drug and error category.

Results

Two hundred and twenty-six prescribing errors were identified during the

study period.

One hundred and sixty-three of the errors identified were on inpatient

prescriptions, 33 were on outpatient prescriptions and 30 were on discharge

prescriptions (TTAs). Eighty-five errors were identified after one or more

doses had been given and 120 were identified before the patient received a

dose. In 20 cases where the error was an omission a prescription had not

been written. One hundred and fifty different drugs were implicated in the

226 errors. Drugs most frequently implicated included paracetamol (8),

aspirin (7), dalteparin (7), warfarin (6) ranitidine (6), beclomethasone,

coamoxiclav (4) and flucloxacillin (4). In 127 cases the prescription was

cancelled and a new prescription initiated. A new prescription was written

in 38 cases and a prescription was cancelled in 36 cases. On 7 occasions no

change was made to the prescription.

One hundred and seventeen errors were ‘errors in decision making’ (type

A), and 84 errors were ‘errors in prescription writing’ (type B). Twenty-five

errors were classified as prescribing errors due to the individual patient’s

clinical condition (type C). The 10 most frequently occurring error cate-

gories are described in Table 1.

Discussion

During the audit period 226 prescribing errors were identified and averted

by pharmacists, mostly through ward-based activities. Whilst pharmacists

aim to review prescriptions as soon as possible after they are written there is

no guarantee that patients will not receive incorrectly prescribed medicines

before their prescriptions have been reviewed. To reduce the risk of patients

receiving wrongly prescribed medicines pharmacists need to be available at

the point of prescribing to offer advice on drug therapy regimens and safe

medicines use. This will require a change in practice to enable pharmacists

to be available when patients are admitted, attend more ward rounds and

become more integrated into multidisciplinary ward-based teams.

Although the severity of the errors was not formally assessed a number

had the potential for patient harm, e.g. prescription of flucloxacillin to a

patient with a documented penicillin allergy, tacrolimus toxicity as a result

of a drug interaction, intravenous nimodipine prescribed at one-tenth of the

intended infusion rate, chlorpromazine 100 mg prescribed instead of 10 mg.

The Audit commission report1 suggests that junior doctors do not receive

sufficient training in prescribing skills before starting to work on busy

wards. The results of this audit have been disseminated within the Trust and

used to develop a pharmacy-led prescribing skills training programme for

pre-registration house officers in conjunction with the Department for

Postgraduate Medical and Dental Education.

References1. Audit Commission. A spoonful of sugar – medicines management in NHS

hospitals. Audit Commission December 2001.2. Dean B, Barber N, Schachter M. What is a prescribing error? Qual. in Health

Care 2000; 9: 232–237.

16 An initial audit of supplementary prescribing in a multi-disciplinary

specialist heart failure clinic

Williams H, deCourcey J, Kearney M

King’s College Hospital, London

Introduction

The multidisciplinary heart failure service at King’s College Hospital has

been running for the past 2 years, led by a nurse consultant with input from

a specialist cardiac pharmacist and supervision from a consultant cardiol-

ogist. Legislation to allow prescribing by nurses and pharmacists within the

context of a clinical management plan (CMP), known as supplementary

prescribing, was approved in 20031. Both nurse consultant and pharmacist

qualified as supplementary prescribers in 2004. The Trust requires that at an

audit of prescribing practice is undertaken after 6 months for presentation

to the Non-Doctor Prescribing Group. The results of this audit and an

overview of the first 8 months of supplementary prescribing within the HF

clinic are presented.

Objectives

To assess prescribing by supplementary prescribers looking specifically at:

� Drugs or drug classes prescribed

� Compliance with the CMP

� Issues related to off-CMP prescribing (i.e. issuing prescriptions for drugs

not specifically agreed by the independent prescriber)

Method

Data was collected from Nov 2004 to June 2005. Copies of all prescriptions

issued from the HF clinic were collated by the prescribing nurse and

pharmacist. Data was entered onto a spreadsheet and analysed manually.

Results

A total of 275 patients have been treated by the HF team over the past

2 years. Of these, 143 patients have been offered and agreed to management

by the supplementary prescribers. Individualised CMP’s were then drawn

up for approval by the independent prescriber. Since the implementation of

supplementary prescribing, no patient has refused to be managed by the

supplementary prescribers, although the prescribers themselves have on rare

occasions decided not to offer supplementary prescribing based on the

complexity of the case.

Table 1 Most common categories of prescribing error (n = 226)

Error

type

Definition Number of

errors (%)

A Prescription of a drug in a dose below that

recommended for the patient’s clinical condition

33 (15%)

A Prescription of a drug in a dose above that

recommended for the patient’s clinical condition

27 (12%)

B Writing a prescription for discharge medication that

unintentionally deviates from the medication pre-

scribed on the inpatient drug chart

26 (12%)

B Omitting the dose/route/frequency 17 (8%)

A Prescribing two drugs for the same clinical condition

when only one drug is necessary

12 (5%)

A Prescribing a drug for which there is no indication

for that patient

11 (5%)

B On admission to hospital writing a medication order

that unintentionally deviates from the patient’s

admission prescription

10 (4%)

B Omission of the prescriber’s signature 9 (4%)

B Writing illegibly 8 (3.5%)

C Unintentionally not prescribing a drug for a clinical

condition for which medication is indicated

8 (3.5%)

A260

During the 8 months of the audit, 284 items were prescribed by the

supplementary prescribers – 168 items by the nurse consultant and 116 by

the clinical pharmacist. On average, 2.3 items were prescribed per

prescription issued (median 2; mode 1). The most frequently prescribed

items were those used in the management of heart failure symptoms and to

improve long-term outcome. Beta-blockers, loop diuretics, angiotensin-

converting enzyme inhibitors, angiotensin receptor blockers and spirono-

lactone accounted for over 60% of all items prescribed.

Over the course of the 8-month-period, 263 items were prescribed in

accordance with the CMP (263/284, 92.6%) and 21 items were prescribed

off-CMP (21/284, 7.4%). Agents prescribed off-CMP included oral hypo-

glycaemic agents, proton pump inhibitors, laxatives, low molecular weight

heparin, vitamins and minerals. The majority of these episodes were for

continuation of non-HF related therapy in patients reporting that they had

no further supplies available or were known to the clinic to be poorly

compliant (see Table 1).

Discussion

During the audit, more prescribing was undertaken by the nurse than the

pharmacist. This reflects a difference in the time commitment to managing

heart failure between the two supplementary prescribers. The nurse runs up

to 3 clinic sessions a week, while the pharmacist is only available to attend

one clinic session.

Since implementation, the need to refine the template CMP used for this

patient group has become evident – in particular, the addition of laxatives

for symptom control and low molecular weight heparin for thrombopro-

phylaxis on long haul flights. The CMP is constantly under review as new

therapeutic options are made available. Despite that, off-CMP prescribing

did occur during the course of the audit. This may reflect the desire of the

clinicians to offer a more holistic approach to patient management. Off-

CMP prescribing has been flagged as an issue for the clinical team and will

be monitored over the next 3–6 months.

The role of supplementary prescriber is a new one for nurses and phar-

macists and there is, as yet, little data to demonstrate that this process

improves patient outcomes. For this reason, future audits will focus on

frequency and appropriateness of referral back to the independent pre-

scriber and on longer-term heart failure outcomes, such as readmission rates

and mortality.

Currently the nurse consultant has more flexibility in prescribing as, in

addition to being a supplementary prescriber, she can practice as an inde-

pendent prescriber using the nurse prescribers’ extended formulary. The

Department of Health recently consulted on extending prescribing

arrangements for nurses and pharmacists. A variety of different options are

being considered, from no change to the current arrangements to granting

full independent prescribing rights. The limitations of the supplementary

prescribing system, particularly the constraints of the CMP, make inde-

pendent prescribing appear to be an attractive option for this clinical team.

References1. Department of Health. Supplementary prescribing by nurses and pharmacists

within the NHS in England: a guide for implementation. March 2003.

17 The self-reported adherence, perceptions of and attitudes to taking

medicines in renal transplant recipients

Chai MO, Ellis P

King’s College Hospital, London

Introduction

Non-compliance or non-adherence with medication after organ transplan-

tation is emerging as a major healthcare issue with implications for future

chronic rejection and potential allograft loss1. The provision of renal

replacement therapy currently accounts for 2% of the NHS budget2. It is

predicted that there will be at least a 50% increase in the number of patients

receiving renal replacement therapy in the next 10 years1.

Early identification of non-compliant renal transplant patients therefore

may help healthcare professionals to devise interventions or alternative

treatment regimes before any damage is done to the newly transplanted

kidney. This may in turn delay patients returning to dialysis programmes,

which are expensive and associated with increased morbidity and mortal-

ity2.

It is important for healthcare professionals to understand that not all

patients are non-compliant. By understanding patients’ attitudes to and

perceptions of medicine taking, it allows healthcare professionals to devise

and to identify suitable interventions with the patient. This facilitates the

development of a medicines partnership thereby encouraging concordance

with treatment regimens3.

Objective

The aim of this exploratory study is to obtain a preliminary insight into self-

reported adherence in renal transplant recipients and into their perceptions

of and attitudes to taking medicines.

Method

A literature review was performed, and applications to undertake the

project were made to the Ethics Committee and The Research and Devel-

opment Committee. Once approved, a letter detailing the project was sent

out to patients, identified using the transplant clinic planned appointments

record, 10 days before their scheduled clinic appointment. A letter detailing

the project was also sent to the patient’s general practitioners, in case the

patient wanted to discuss the project before agreeing to participate.

Data collection was planned for Wednesdays and Fridays of each week

for a period of 5 weeks, with the aim of recruiting 30–50 patients if time

permitted. Patients were excluded from the project if English was not their

first language. To prevent bias, patients completed the questionnaires

anonymously. The data was analysed using Pearson’s, Spearman’s or

Mann–Whitney tests to identify associations between variables and a 5%

statistical significance level was applied to all results.

Results

Forty-five patients were included in the study of which 21 were male. The

mean age of the patients was 51.3 years (standard deviation 11.73). Thirty

patients (30/45, 67%) were within 3 years of renal transplantation. Forty

patients (40/45, 89%) had undergone cadaveric transplant and 5 (5/45,

11%) were living-related recipients.

Thirty-four (34/45, 76%) patients reported being satisfied with the

information provided by the clinic about medicines and 44 (44/45, 98%)

patients scored highly on the self-report adherence questionnaire. Forty

(40/45, 91%) patients held strong beliefs about the necessity of taking

medicines to maintain their health. Of these 40 (40/45, 91%) patients, 13

(13/41, 31%) were concerned about the long-term effects of taking

medicines. Of 41 patients (12/41, 29%) 12 believed that doctor’s over-

prescribed medicines and 7 (7/41, 7%) patients believed that medicines

are generally harmful.

Discussion

No association was found between satisfaction with information provided

about medicines and beliefs about medicine. However, moderate positive

correlation (Pearson’s correlation coefficient = 0.55) and a statistically

significant (p < 0.001) association was found between patients’ concerns

about their prescribed medicines and beliefs about the potential problems of

taking medicines. Patients with concerns about prescribed medication have

negative views about medicines in general. They believed that medicines are

generally overused and are harmful poisons. However, these patients still

scored highly on the self-reporting adherence questionnaire and believed in

the necessity of taking prescribed medications.

Table 1 Episodes of off-CMP prescribing

Drug or drug class Frequency

prescribed

Comments

Laxatives 5 Symptom associated with HF –

CMP template amended

Low molecular

weight heparin

2 For prophylaxis on long-haul

flights – CMP amended

Vitamins and minerals 7 Continuation therapy – available

for independent prescribing by

nurse consultant

Oral hypoglycaemic

agents

4 Continuation therapy – patients

had run out of supply

Proton pump inhibitors 1 Newly initiated in clinic – Patient

recently started on aspirin and

clopidogrel and at high risk of

gastric bleeding

Vitamin B Co Strong 1 Newly initiated in clinic – patient

malnourished and had high alcohol

intake

Proton pump inhibitors 1 Switched to formulary agent to

minimise adverse effects

A261

Results from this study also demonstrate that being better informed

about medicines does not influence adherence rates. This supports findings

from other studies, which demonstrated adherence rates may be influenced

by other patient factors, such as beliefs and social issues4.

This study has several limitations, due to the timeframe given to complete

the project. We excluded non-English speaking patients, and the number of

patient recruited may be too small to allow the results to be extrapolated to

the general renal transplant population. In addition the results may have

been biased by the greater number of cadaveric recipients recruited.

These results demonstrate the value of recognising other patient factors

that may influence adherence rates. It is therefore justifiable to conclude

that providing information about medicines only forms part of the process

of achieving good adherence.

In response to these results, the renal transplant team will aim to reinforce

all verbal information with writing information on medicines and will be

more active in referring patients to the renal counsellor when concordance

is not achieved.

References1. Butler J, Cairns H. Non-adherence in renal transplant recipients. Br. J. Renal

Med. Summer 2000; 21–4.2. Chisholm MA. Issues of adherence to immunosuppressant therapy after solid-

organ transplantation. Drugs 2002; 62(4): 567–75.3. Laederach-Hofmann K, Bunzel B. Non-compliance in organ transplant recip-

ients: a literature review. Gen. Hosp. Psy. 2000; 22: 412–24.4. Dhillon S, Duggan C, Joshua AE. What part pharmacists should play in pro-

viding medicine-related information? Pharm. J. 2001; 266(7139): 364–6.

18 Antibiotic Point Prevalence Studies – results of three annual surveys

Cooley N1, Onatade R

1, Gilchrist E

2, Cavell G

1, Perrott R

1

1Pharmacy Department, King’s College Hospital NHS Trust, London2Pharmacy Department, Guy’s and St Thomas’ NHS Foundation Trust,

London

Introduction

In 2003, the Department of Health announced funding for clinical phar-

macy services to improve antibiotic usage and prescribing within secondary

care1. As the focus of the initiative was clearly on improving quality and not

necessarily a reduction in expenditure, Trusts had a significant amount of

discretion in how they used the funding. At King’s College Hospital, it was

decided that in the first instance, in order to be able to determine where to

focus our efforts, an understanding of antibiotic prescribing patterns and

usage was necessary. A point prevalence study was deemed the best way of

accomplishing this. It was also agreed that changes in trends should be

tracked by regular annual surveys.

Objectives

� To describe the frequency with which antimicrobials (AMs) are prescribed

at King’s.

� To describe the types of antimicrobial agents being prescribed at King’s.

� To describe the routes being used for the administration of antimicrobials

at King’s.

� To describe the duration of antimicrobial courses used at King’s.

� To highlight areas where antimicrobial usage could be optimized.

Method

The surveys were conducted in November 2003, November 2004 and March

2005. Each time, all wards were surveyed over a period of 2 days. Data

collected included:

� Patient demographics

� For each ward visited, number of beds and occupied beds

� Whether drug allergies had been documented

� For each antimicrobial agent prescribed

� Name

� Dose and frequency

� Route of administration

� The number of days the patient had been on this antimicrobial by the

day of the study

� If specified, the intended length of course

Results

Unless specified, all results exclude prophylactic treatment (Table 1).

The most commonly prescribed antimicrobials were similar across all

3 years – metronidazole, vancomycin, cefuroxime, ciprofloxacin, amoxicil-

lin, clarithromycin, flucloxacillin, meropenem, piperacillin/tazobactam,

fluconazole and gentamicin. The main differences were in the numbers of

prescriptions – in 2005, the use of flucloxacillin had declined, while piper-

acillin/tazobactam was much more frequently prescribed. Gentamicin usage

also decreased. Metronidazole had the highest proportion of prescriptions

each year.

As a result of the first two studies, and after comparison with other

published results2, it was decided that areas of focus for improving pre-

scribing would be reducing course lengths, switching from the IV to oral

route and promoting antibiotic prescribing guidelines. Some of the out-

comes of the various initiatives can be seen in the 2005 results.

Discussion

The serial point prevalence studies have enabled the tracking of anti-

microbial usage over the years. King’s is a large teaching hospital and

some of its specialties, notably Liver and Haematology/Oncology mean

that we may use significantly more antimicrobials than other similarly-

sized Trusts. However, we now have a comprehensive picture of anti-

microbial prescribing and can compare with other Trusts to identify

where we fall outside the norm. We can then assess whether or not this

is justifiable. Whenever new initiatives or policies are launched, the re-

sults of the point prevalence studies can be used as baseline markers, as

well as outcome indicators. Point prevalence studies are now established

as annual surveys and in 2005, the results were linked with infectious

diseases data to prove that increased expenditure on certain antibiotics

had resulted in better quality prescribing, and a fall in some hospital-

acquired infections. Further work will include working more closely with

medical microbiologists to extend this link, including documenting indi-

cations for antimicrobials, and ensuring the surveys take place on the

same 2 days every year, to reduce variation.

References1. Department of Health. Hospital pharmacy initiative for promoting prudent use

of antibiotics in hospitals (PL/PhO/2003/3), London, 2003.2. Dean B, Lawson W, Jacklin A, Rogers T et al. The use of serial point prevalence

studies to investigate antiinfective prescribing. IJPP 2002; 10:121–5.

19 An audit of antibiotic prescribing on cardiothoracic wards at Barts

and The London Heart Centre

Virdee J1, Antoniou S1, Das S2

1Department of Pharmacy, Barts and The London Heart Centre, Barts and

The London NHS Trust, London 2Consultant Microbiologist, Barts and The

London Heart Centre, Barts and The London NHS Trust, London

Table 1 Comparative results

2003 2004 2005

Number of occupied beds 764 678 797

Gender Male 51% 52% 50%

Female 49% 48% 50%

Mean age (years) Male 52 47.5 52

Female 49 51.7 55.3

Percentage of pts on AMs 35.7% 36.6% 34.0%

2003 2004 2005

Mean no. of AMs per

treated pt

1.79 1.83 1.68

Numbers of different

types of antimicrobials

59 48 52

Allergy documentation

(inc prophylactic prescriptions)

78.9% 76.6% 83.8%

Route of administration IV:PO 55:45 52:48 53:47

Course length (oral) 5 days or fewer 58% 62% 68%

10 days or fewer 73% 77% 92%

Course length (IV) Less than 48 h 35% 35% 41%

Percentage of prescriptions

with course length specified

21.5% 13.3% 19.5%

Number of patients on

>3 antimicrobials

15.8% 17.7% 12%

Percentage of restricted

antimicrobials approved

by microbiology

76% 85%

A262

Introduction

A staggering 2.7 million people are estimated to be living with coronary

heart disease in the United Kingdom (UK). It is the most common cause of

death, causing more than 117,000 deaths in 2002 in the UK alone1.

In coronary artery disease, plaque deposits on the inner walls and lining

of the coronary arteries lead to a hardening and narrowing of the arteries

and subsequently decreased oxygen supply to the heart. This may cause

angina or myocardial infarction, and long-term weakening of the heart

muscle leading to heart failure or arrhythmia. Depending on the type and

extent of damage, cardiac surgery may need to be performed. The most

common cardiac procedures performed at Barts and The London Heart

Centre are coronary artery bypass graft (CABG) and valve surgery.

Infections are a particular complication of all types of surgery. Risk

factors contributing to post-operative infections can be divided up into host

risk factors and surgical risk factors. Host risk factors have been described

extensively in the literature and include; obesity, diabetes, advanced age,

male gender, smoking, steroids and pre-operative hospital stay >5 days.

Surgical risk factors include; duration of surgery, perfusion time and post-

operative bleeding. Readmission, prolonged treatment with antibiotics,

sternal debridement and death are some of the consequences of post-

operative infections2.

Cardiothoracic (CT) Surgery is generally considered to be a clean oper-

ation, with the reported risk of post-operative wound infection being from 2

to 20% and the accepted rate of infection being between 11 and 15%3.

The most commonly experienced infections post-CT surgery include

surgical site infections (SSIs), chest infections and urinary tract infections.

Currently, at Barts and The London Heart Centre, guidelines for both

prophylaxis and empirical treatment of post-operative infections on Car-

diothoracic wards are in place4. Empirical treatment is aimed at the most

likely causative pathogens for that specific infection. The purpose of this

audit is to establish whether such guidelines are appropriate and whether

they are being followed.

Objective

To ascertain whether prophylactic and post-operative empirical treatment

antibiotic guidelines for bypass/valve replacement surgery are being fol-

lowed at Barts and The London Heart Centre.

Method

A brief literature search confirming recommended prophylactic and

empirical antibiotic treatment for common infections encountered post-

bypass/valve replacement surgery was undertaken. A data collection tool

after a one-week pilot was then designed. Data collection over a 1-month-

period was then undertaken at both Barts and The London Chest sites with

confirmation of indication sought from the Microbiology team where

antibiotics had been started. All patients undergoing bypass/valve

replacement surgery during this period were followed up until discharge.

Results

A total of 90 patients underwent CABG/valve replacement surgery during

the audit period. In total 80 data collection forms were completed of which

56 patients (70%) had a CABG, 14 patients (17.5%) had a valve replace-

ment, 9 patients (11.25%) had a CABG and a valve replacement and 1

patient (1.25%) had a valve repair operation. It was found that antibiotic

prophylactic guidelines were followed in 87.5% of patients (n = 70);

inappropriate administration of prophylactic antibiotics lead to one definite

and possibly two post-operative infections. Of the 80 patients, 30% of

patients (n = 24) experienced a post-operative infection of which 9 patients

experienced a SSI; with the overall incidence of a SSI being 11.25%. Only

25% of all patients (n = 6) experiencing a post-operative infection received

appropriate empirical antibiotic treatment as per current guidelines.

Discussion

Most patients received appropriate antibiotic prophylaxis. The incidence of

a SSI at Barts and The London Heart Centre was found to be 11.25%

(n = 9), within the accepted range quoted in the literature3. Initial analysis

implies that CABG patients are more likely to experience a SSI than those

undergoing a valve replacement procedure. Only 25% of patients (n = 6)

experiencing a post-operative infection received appropriate empirical

treatment. It was found that guidelines for the empirical treatment of a

chest infection in particular, need to be reviewed and should specify risk

factors for Pseudomonas aeruginosa (such as a prolonged inpatient stay;

hospital acquired chest infection) where administration of ciprofloxacin

may be appropriate. Effective communication between Cardiothoracic

doctors, microbiology and pharmacy personnel is a key part to the suc-

cessful implementation of such guidelines and should be undertaken on a

regular basis. Future work undertaken in this area should involve audit

work around post-operative infections following Cardiothoracic Surgery,

with a particular reference to the appropriate empirical treatment of post-

operative chest infections; classification in addition to appropriate treat-

ment strategies for community and hospital acquired chest infections. Once

guidelines are amended, approved and implemented, future audit work can

then be carried out to assess adherence to such guidelines.

Acknowledgement

I would like to thank Luis Lorenco and the cardiac team for their help with

data collection.

References1. Peterson et al. Coronary Heart Disease Statistics June 2004; British Heart

Foundation Statistics Database. www.heartstats.org. Last accessed 16th April2005.

2. Hollenbeak et al. The clinical and economic impact of deep chest surgical siteinfections following coronary artery bypass graft surgery. Chest, (Aug 2000);118 (2): 397–402.

3. Bhatia et al. Post-operative wound infection in patients undergoing coronaryartery bypass graft surgery: a prospective study with evaluation of risk factors.Indian J. Med. Microbiol., 2003 21 (4): 246–251.

4. Das S. Management of Infections in Cardiothoracic Surgery-Guidelines forDoctors December 2003. (Refer also to: Empirical Antibiotic Therapy forCardiothoracic Surgery Patients and Barts and LCH-guidelines for MedicalMicrobiology SpRs).

20 A survey of non-antiretroviral prescribing for HIV positive patients at

two HIV clinics

Khachi H, Ladenheim D, Scott K

Barts and the London NHS Trust, London

Introduction

Barts and the London (BLT) NHS Trust comprises two HIV satellite

pharmacies; one at St. Bartholomews (SBH) and The Royal London (RLH)

Hospitals. Annually, just under 1300 patients are seen within the outpatient

HIV clinics at BLT. Following on from publications such as the NHS Plan1

and A Spoonful of Sugar2, the focus in pharmacy is to provide a service that

is patient centred and to ensure prescribing competence by ensuring

clinicians prescribe within their speciality. It has been identified that a

proportion of antiretroviral drug budget is being allocated to non-HIV

specific conditions. In line with this, and in response to an increased

workload within the HIV satellite pharmacies, we conducted a survey of

non-antiretroviral (ARV) prescribing within BLT to establish the extent of

non-ARV prescribing within the HIV outpatient clinics.

Objectives

The objectives of the survey were as follows:

� To establish the extent of non-ARV prescribing within the HIV outpatient

clinics

� To provide a breakdown of HIV specific and non-HIV specific prescribing

� To compare non-ARV expenditure with other London HIV centres

Method

Prescribing information was collated by a retrospective survey of all out-

patient prescriptions received in the HIV satellite pharmacies at SBH and

RLH. All HIV positive patients prescribed medication in an outpatient

setting from September 1st 2004 to September 30th 2004 (inclusive) had

their prescription included in the survey. Cost data were collated using data

submitted to the London Specialised Commissioning Group. HIV specific

medicines were classified as ARVs, medicines for opportunistic infections

(OIs) and antibiotics.

Data were categorised as follows: ARV medicines, medicines for Ois,

antibiotics and other medicines (as defined as all drugs in therapeutic cat-

egories, for example topical and endocrinology medicines).

Results

At SBH, 188 prescriptions were collected, containing 329 medicines.

At RLH, 363 prescriptions were collected, containing 714 medicines.

Overall, 551 prescriptions were collected, containing 1043 medicines.

(a) Prescribing habitsOur results showed disparities in prescribing between the two satellite

pharmacies as well as between clinicians within each site. These differences

were not tested statistically.A263

(b) Prescribing costsThe average expenditure across London for non-ARV drugs (for the 2004/

05 financial year) is 6.8% of the total HIV expenditure, accounting for in

and outpatient. Non-ARV medicines accounted for 13.9% of the total

annual HIV expenditure at BLT for the 2004/05 financial year, i.e. over

twice the average of our peers in London. The total HIV drug expenditure

at BLT is £9.5 million per year.

Thus 13.9% of total drug expenditure constitutes £1.31 million per year

and non-ARV drug cost at BLT does not include any Hepatitis C medi-

cation.

The most common non-ARV medicines prescribed and dispensed can be

seen in table (see below).

Discussion

There are limitations to comparisons made between HIV departments

across London. The data used is solely based on cost and may not corre-

spond to that of dispensing volume. Furthermore there is an assumption

that all HIV departments offer a comparable service and have comparable

patient cohorts.

The results of the survey showed that medicines are prescribed across a

range of clinical areas, perhaps not within the clinician’s speciality, as

originally suspected. The survey also highlighted differences in prescribing

practice between sites (SBH & RLH). In order to ensure clinical governance

and to provide a standardised service that is truly patient centred, a HIV

formulary should be developed. The benefits of such a formulary include a

standardised approach to prescribing between prescribers and sites,

appropriate utilisation of resources and expertise of the HIV team, and

would reduce the potential for clinical risk associated with clinicians pre-

scribing outside of their speciality. The cost impact of this formulary will

need to be evaluated with future audits.

As a result of this survey, an HIV formulary is being developed. Fur-

thermore, we are expanding our roles within the multidisciplinary team, and

exploring the role of the HIV pharmacists as supplementary prescribers in

chronic stable patients. This would allow greater access to patients, reduce

clinician workload, giving them the opportunity to see more complicated

patients, and utilising pharmacists’ skills to its full potential.

References1. Department of Health, NHS Plan, The Stationary Office, 2000.2. Audit Commission, A Spoonful of Sugar-Medicines Management in NHS

Hospitals, 2001.3. London Specialised Commissioning Group 2004–2005 financial year.

21 Management of hypertension and cardiovascular risk in general

medicine patients at point of discharge

Tickner N, McRobbie D

Pharmacy Department, Guy’s & St. Thomas’ NHS Foundation Trust, London

Introduction

Hypertension is the most important treatable risk factor for cardiovascular

disease1

yet in European countries less than 10% of hypertensive patients

are controlled to optimal blood pressure (BP) (<140/90 mmHg)2

. Recently,

the National Institute for Clinical Excellence and British Hyperten-

sion Society (BHS) have both published guidance on hypertension

management3, 4

. The aim of this audit was to establish how well hyperten-

sion was controlled and managed on discharge from general medicine wards

in comparison to the guidelines.

Objectives

To determine:

� Proportion of patients being discharged that have sub-optimal BP control

� Prescribing habits around the use of anti-hypertensive agents

� Co-prescribing of aspirin and statins with respect to the guidelines

� Extent of general practitioner (GP) referrals/follow-ups with respect to

anti-hypertensive therapy

Audit standards for BP levels for hypertensive patients recommended by

BHS are:

� Diabetic patients: SBP < 140 mmHg, DBP < 80 mmHg

� Non-diabetic: SBP < 150 mmHg, DBP < 90 mmHg

Method

Patients were identified via discharge prescriptions dispensed over a 14-day

period on general medicine wards. Demographic information, BP control

(lowest of previous three readings) and information about anti-hyperten-

sives, anti-platelet agents and statins were collected from medical notes and

analysed using Microsoft Access.

Results

One-fifth of patients were diabetic and two-thirds were aged over 60 years

(Table 1). A total of 11 (5.9%) patients discharged from hospital during the

data collection period had unsatisfactory BP control as defined by the audit

standards.

Of 84 patients discharged on anti-hypertensives, 48 (57%) received

mono-therapy, 26 (31%) double therapy and 10 (12%) three or more

agents. Forty-two (50%) of these patients underwent changes to their

anti-hypertensive medication during hospital stay.

Over two-thirds of type 2 diabetic patients over 50 years of age received

anti-hypertensives and a similar proportion statins, however less than half

of these were prescribed aspirin compared to 71% a statin and four were

receiving neither agent (Table 2).

Of all patients taking anti-hypertensives 18 (18/84, 21%) had recom-

mendations on the discharge prescription for the GP relating to ongoing

management of their hypertension.

Of the 11 patients who had unsatisfactory hypertension on discharge,

only one (1/11, 9%) had recommendations to the GP.

Discussion

Not all discharges from medical wards were reviewed due to time con-

straints, however demographic and prescribing data captured are in line

with local and national data. Blood pressure readings over a short time

period may not have given an accurate picture of the patients’ long-term

antihypertensive control.

Blood pressure management in this audit was generally good, but potential

improvements to practice were highlighted:

� As half of the patients underwent changes to BP medication, better

information could be given to GPs on discharge communications

regarding changes to medication, dose titration and BP monitoring.

� In particular GPs should receive more information for patients not

achieving target BP before discharge

Prescribing breakdown from the outpatient clinics at sbh & RLH

ARV Medicines: Medicines for OIs: Antibiotics: Others:

SBH, % 19 (n = 62) 11 (n = 36) 2 (n = 7) 68 (n = 224)

RLH, % 35 (n = 249) 11 (n = 79) 6 (n = 43) 48 (n = 343)

Top 5 (as an expression of cost) non-ARV drugs prescribed for HIV in and

outpatients at BLT

Drugs prescribed Percent of total non-ARV

drug cost 2004/05

Valaciclovir & aciclovir 5

Gabapentin 2

Valganciclovir, ganciclovir,

foscarnet and cidofovir

13

Doxorubicin 4

Ambisome & caspofungin 11

Other 65

Table 1 Demographics of patient sub-groups

Patient demographics n = 188 (%)

Diabetics 40 (21%)

Type 1 10 (5%)

Type 2 (including diet-controlled) 30 (16%)

Ethnic origin

Black (African or Caribbean) 25 (13.3%)

Asian 8 (4.3%)

White 155 (82.4%)

Age

<50 years 48 (25.5%)

50–59 years 19 (10.1%)

>60 years 121 (64.4%)

A264

� Recognised guidelines should be utilised when prescribing and reviewing

medication that modifies cardiovascular risk, especially in the older and

diabetic population.

Education of junior medical and pharmacy staff is currently being under-

taken to raise the awareness of the new guidelines, including choice of

therapy and prescribing of aspirin and statins, particularly in diabetic

patients.

References1. He FJ, MacGregor GA. Cost of poor blood pressure control in the UK: 62,000

unnecessary deaths per year. J Hum Hypertens. 2003 Jul; 17(7): 455–7.2. Wolf-Maier K et al. Hypertension treatment and control in five European

countries, Canada, and the United States. Hypertension. 2004; 43: 10–17.3. Williams B et al. Guidelines for management of hypertension: Report of the

fourth working party of the British Hypertension Society, 2004 – BHS IV. JHum Hypertens. 2004; 18: 139–85.

4. NICE Guidance No. 18. Management of hypertension in adults in primary care.August 2004.

22 The impact of a patients’ own drugs scheme on drug expenditure and

medication error rates on a renal ward

Curwood R

Pharmacy Department, King’s College Hospital

Introduction

The optimisation of medicines use in hospitals is essential for quality

pharmaceutical care of patients. Following the publication of ‘‘A Spoonful

of Sugar’’1 the use of patients’ own drugs (PODs) has been implemented in

many NHS hospitals. It has also been identified that due to increased de-

mand for services, the use of medicines in hospital is not always optimised.

The Department of Health stated that hospital pharmacists must ensure

that all patients have a medication review on admission, and patients have

access to their medication as soon as they are ready to be discharged2. To be

able to implement these tasks, the traditional role of pharmacists solely as

prescription monitors needs to be further developed, to assure effective

clinical practice and minimise the risk of medication errors.

At King’s College Hospital (KCH) the need to introduce the use of PODs

on the renal ward was identified. Renal patients have long medication lists

often resulting in long waiting times for discharge prescriptions (TTAs),

which could be reduced by reusing PODs and dispensing for discharge

newly prescribed items (DFD). The use of PODs on the ward could also

reduce the cost to the renal care group of medication issued at discharge

and prevent missed, or late administration of doses on the ward. The

scheme, supported by a technician, was implemented in November 2004

following a training programme for nursing staff. The aim of this audit is to

investigate the impact of a POD policy on discharge drug expenditure on a

renal ward.

Objectives

The objective of the audit is to identify the cost implications of the use of

PODs and DFD for the renal care group.

Method

Data were collected between 1st November 2004 and 24th December 2004

using a newly designed data collection form. The inclusion criteria for the

audit were: admission and discharge from the renal ward between 1st

November and 24th December 2004. The exclusion criteria were: outliers on

renal ward (medication prescribed on TTAs of outliers is charged to

appropriate care group) transfer to another hospital, hospice or death. All

discharge prescriptions for patients meeting the inclusion criteria were as-

sessed.

On admission to the renal ward, each patient had a drug history taken by

the renal pharmacist. The pharmacy technician assessed the PODs for

suitability for reuse in line with the local POD policy. The audit data col-

lection form was initiated for each renal patient on admission to the ward.

During the hospital admission medication was supplied to the patient,

either as an inpatient item, or as a pack suitable for discharge (DFD) at the

discretion of the renal pharmacist. At the point of discharge, after the TTA

had been clinically screened, either the renal pharmacist or technician

assessed the contents of the POD locker against the discharge prescription

and items were either dispensed or the POD reissued. A record was made of

all PODs brought into hospital and reused by the patient, during the

inpatient stay and on discharge on the audit data collection sheet. The audit

data was completed by recording the values of PODs reused, items prepared

in advance for discharge and medicines dispensed against TTAs. The

costing of medication was calculated using the dispensary computer system,

Ascribe, which gives the most recent price as received by the procurement

department. VAT at 17.5% was added. Savings were calculated by

recording the total cost saved by reusing PODs on the ward and at

discharge for all patients included in the audit as these medicines would

previously have been supplied at discharge. Erythropoietin classified as

POD was not included in the costing process as prior to the implementation

of the POD scheme, patients were not routinely redispensed this item on

discharge.

Results

During the study period 906 items were prescribed on 101 discharge pre-

scriptions. Fourty-four percentage of items (393/906) prescribed on TTAs

needed to be dispensed at the time of discharge. Fifty-one percentage of

items (469/906) prescribed on discharge prescriptions were re-issued from

PODs. The remaining 5% of items (4/906) were prepared during hospital

admission as DFD.

The value of PODs reused by the patients during the inpatient stay was

calculated to be £6669.28 (excluding erythropoietin classified as POD). The

value of drugs dispensed for discharge for use during the inpatient stay and

dispensed against TTAs were £1.939.84 and £4750.34 respectively (Table 1).

Reasons that patients needed medication to be dispensed at the time of

discharge instead of reusing PODs included change of dose when a POD

could not be relabelled and reused or change of therapy at the point of

discharge. Other reasons included short length of stay in hospital (<1 day)

giving no opportunity to prepare medication in advance of discharge, and

medication supplied to the ward as inpatient items requiring redispensing at

discharge, for example antibiotics.

Table 2 Aspirin, statin and anti-hypertensive prescribing at discharge

Patient group Total

patients (%)

Aspirin

prescribed (%)

Statin

prescribed (%)

Neither aspirin nor

statin prescribed (%)

Anti-hypertensive(s)

prescribed (%)

All Patients 188 71 (38%) 52 (28%) 102 (54%) 84 (45%)

<50 years 48 1 3 45 11 (22.9%)

>50 years 140 70 49 57 73 (52.1%)

Type 2 diabetic 28 11 (39%) 19 (68%) 6(21%) 18(64%)

<50 years 4 0 2 2 1 (25%)

>50 years 24 11 17 4 17 (70.8%)

Type 1 diabetic 10 2 (20%) 1 (10%) 8 (80%) 2 (20%)

<50 years 7 0 0 7 2 (28.6%)

>50 years 3 2 1 1 0 (0%)

Table 1 Cost of medication excluding patients’ own erythropoietin

(n = 101)

POD DFD Dispensed

Cost of medication £6669.28 £1939.84 £4750.34

VAT at 17.5% £1167.124 £339.472 £831.301

Total cost £7836.40 £2279.31 £5581.65

Grand total cost £7836.40 £7860.96

Saving to renal care group

by using PODs (excluding

patients own erythropoietin)

£7836.40

A265

Discussion

The renal care group saved £7,836.40 on TTA medication over the 2

month audited period by using PODs even though these only accounted

for 14.85% of total discharge prescriptions when patients did not require

further medication dispensed at discharge. In order to maximise savings

achieved by the scheme there is a need for patient education to ensure

that PODs are brought into hospital with them, or by their relatives for

emergency admissions. A high percentage of items required dispensing at

the point of discharge (44%) thus increasing the waiting time for TTAs

(average time taken to dispense TTAs was 151 min, Std. dev. of mean

166 min). To reduce this waiting time the proportion of DFD items will

need to be increased so that TTAs are ready in advance of the patients

needing them. The saving was achieved by increasing the amount of time

spent by pharmacy staff, including the renal specialist pharmacist and a

technician, on the wards who specifically targeted discharge counselling.

However, in addition to the financial advantages of the scheme there were

concerns about the way in which the POD lockers were being used espe-

cially failure to empty the POD lockers when patients were transferred and

to remove items discontinued during the inpatient stay. This identified a

need for further training of the nursing staff and an area for further audit in

the future.

References1. Audit Commission 2001. A Spoonful of Sugar – Medicines Management in

NHS Hospitals.2. Department of Health. Pharmacy in the Future. London 2001.

23 The use of clopidogrel in the secondary prevention of stroke

Mok P, Maule E

Sunderland Royal Hospital

Introduction

Stroke is the third highest cause of death as well as the largest cause of

major disability in the United Kingdom, continuing to increase the

burden on the National Health Service (NHS) expenditure each year.

Subsequently, stroke became one of the set standards within the National

Service Framework (NSF) for the elderly. Aspirin is the recommended

drug choice for anti-platelet therapy in secondary prevention of stroke as

it is cost effective with an evidence base according to the recent National

Institute of Clinical Excellence (NICE) guidelines. The cost of aspirin for

1 year at a dose of 75 mg is £2.37 whereas the cost of prescribing

clopidogrel 75 mg is £460.29 (Drug Tariff, November 2004). Their role

and effectiveness in secondary prevention of stroke are similar; to prevent

further occlusion of blood supply to the surrounding areas of brain

tissue. Due to the cost effectiveness and weight of evidence base, aspirin

is the drug of choice unless patients are allergic, have a history of gas-

trointestinal (GI) bleeding, or are suffering from peripheral vascular

disease. However, a trend has been identified recently of increased use of

clopidogrel at Sunderland Royal Hospital (SRH), hence it was appro-

priate to audit the use of clopidogrel as it increases the cost of pre-

scribing and it only confers additional benefit to a small group of

patients.

Objectives

To identify the extent of clopidogrel initiation on the stroke unit, and its use

in accordance with current NICE guidelines and best evidence.

Method

A retrospective observational analysis of anti-platelet treatment in sec-

ondary stroke prevention on an acute stroke unit over a 4-week period in

December 2004. A data collection form was used to record relevant infor-

mation from the patient case note review.

Results

One hundred and eight patients were admitted during the 4-week period.

Ages ranged from 36 to 94, with the average age being 72.3. Eighty-three

percentage (n = 90) of patients were admitted having suffered their first

event.

Forty patients were discharged on clopidogrel, with 80% of this being

newly prescribed. Sixty-two percentage of this new prescribing (n = 20)

was not appropriate. The unsuitable indications for the prescribing are

detailed above in Figure 1.

Discussion

The prescribing of clopidogrel was found not to be satisfactory. In partic-

ular almost two thirds of new prescribing was inappropriate and over 50%

of this cited aspirin failure as an indication. There is no proven evidence or

publication that suggests clopidogrel is more effective than aspirin, resulting

in an unnecessary increase in drug costs.

Since this study, however, a new local guideline in the use of anti-platelet

therapy in the secondary prevention of stroke have been devised and

implemented. In the near future, the prescribing of clopidogrel should be re-

audited to ensure the guidelines are followed.

For patients taking clopidogrel on admission, it was not possible to

determine if the prescribing was appropriate or not. This was a limitation of

the study and in a reaudit the data collection forms would be extended to

include this information. The accuracy of the study is also dependent on the

indications for prescribing being accurately documented in the notes.

References1. World Health Organisation: http://www.who.int/csr/sars/en/. Accessed March

2005.2. NICE: Clopidogrel and modified-release dipyridamole in the prevention of

occlusive vascular events, October 2004.3. Medline Plus Health Information from the National Library of Medicine.

http://www.nlm.nih.gov/medlineplus/encyarticle/000170.htm. Accessed March2005.

4. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrelversus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348: 1329–39.

5. Weil J et al. Prophylactic aspirin and risk of peptic ulcer bleeding. Brit. Med. J.1995; 310: 827–30.

6. Chen M et al. CAST: Randomised placebo-controlled trial of early aspirin usein 20,000 patients with acute ischaemic stroke. Lancet 1997; 349: 1641–9.

7. Sandercock P et al. The International Stroke Trial: A randomised trial ofaspirin, subcutaneous heparin, both, or neither among 19 435 patients withacute ischaemic stroke. Lancet 1997; 349: 1569–81.

8. Diener H et al. Management of Atherothrombosis with Clopidogrel in High-risk patients. Lancet 2004; 364: 331–7.

9. Sacco R, Sivenius J, Diener H. Efficacy of aspirin plus extended-release dipy-ridamole in preventing recurrent stroke in high-risk patients. Arch. Neurol.2005; 62/3: 403–8.

10. Chan F et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrentulcer bleeding. N Eng J Med 2005; 352: 238–44.

24 The use of pharmacist managed discharge prescriptions distributed to

community pharmacists

Fleck L, Holden K

County Durham & Darlington Acute Hospitals NHS Trust, Bishop Auckland

General Hospital

Introduction

One of the key roles for modern clinical pharmacy services is ‘to contribute

to seamless and safe medicines management throughout the patient jour-

ney3.’ To achieve this information flow between secondary and primary care

needs to be improved in order to benefit patients by helping to reduce

medication errors. Problems often occur when doctor written discharge

prescriptions are illegible or include inaccurate prescribing information,

which can be misinterpreted easily by GPs and therefore can have a

Reasons for inappropriate

prescribing of clopidogrel30%,6

10%,2

5%,1

55%,11

Aspirin failure

Aspirin + dipyridamole failure

GI intolerance but PPI was not prescribed

Unknown reason

Figure 1 Reasons for inappropriate prescribing of clopidogrel.

A266

detrimental effect on patient’s care. It has been recognised that hospital

pharmacists have an important role in the effective communication of pa-

tients’ treatment when they are discharged from hospital. Providing GP

surgeries and community pharmacies with information on medication

changes, dosage changes and discontinuation plans, helps to smooth the

transition from secondary to primary care. The lack of such information

may result in inappropriate prescribing or unintended discontinuation of

treatment1.

Pharmacists working within the County Durham and Darlington Acute

Hospitals NHS Trust have been empowered to manage patients’ hospital

discharge prescriptions. This allows pharmacists working on medicine

management wards to transcribe any given patient’s hospital kardex onto a

specially designed pharmacist discharge prescription and letter. The phar-

macist can add any additional clinical information if necessary and also

provide information on the patient’s pharmaceutical needs. Medication

changes are indicated clearly on the prescription. A copy of this prescription

is forwarded to the patient’s GP surgery and the patient’s regular com-

munity pharmacist, if known. At present it is uncertain if community

pharmacists have robust systems in place or if they are prepared to use

information available to them to ensure that patients’ current therapy is

accurately prescribed.

Objectives

To assess whether or not community pharmacists are using the pharmacist

written discharge letters. As a secondary aim it is intended to explore how

the information on the discharge letters is being used and to consider

pharmacists’ views on the system and how they think the system could be

improved from their perspective.

Method

A postal questionnaire was designed to establish how community phar-

macists are using the discharge letters and to find out their views on the

service. The questionnaire was sent to 36 community pharmacies in two

local Primary Care Trusts (Dales PCT and Sedgefield PCT). The patients of

these two local PCTS are the main consumers of the secondary care facil-

ities at Bishop Auckland General Hospital. The data from the question-

naires that were returned was entered into the Microsoft Excel package and

descriptive and quantitative methods were used to analyse the results.

Results

Seventy-five percentage of the questionnaires were returned.

(1) Are community pharmacists using the pharmacist discharge letters?

Yes, the majority of the community pharmacists are using the discharge

letters.

On average the community pharmacists are receiving 1–20 discharge letters

(in 6 months). Seventy percentage estimated that they had used the dis-

charge letters between 1 and 10 times (in the last 6 months). Ninety-six

percentage of the pharmacists are willing to query prescriptions if they differ

from the discharge letter.

(2) How is the information on the letters being used?

The information is mostly being used to clarify medicines, dose, frequency,

strength and medicines stopped. This was confirmed when the respondents

reported that they think that details of discharge medicines and medication

stopped are the most important information on the letter. Seventy per-

centage of the respondents do not have systems in place to indicate letters

have been received for patients.

(3) What are pharmacists’ views on the system?

The majority of the pharmacists (93%) find it useful to receive discharge

letters and 89% of the pharmacists think it is worthwhile continuing the

service.

Some pharmacists were concerned that they often do not receive dis-

charge letters before patients first visit post discharge.Most of the respon-

dents think it would be worthwhile patients having a copy of the discharge

letter to give to their community pharmacist.

Discussion

It is encouraging to find that the majority of the community pharmacists in

the two local PCTs are using the pharmacist managed discharge prescrip-

tions and think that the service is worthwhile. Most of the pharmacists

questioned do not have systems in place to indicate discharge letters have

been received for patients, this may mean that a large number of possible

interventions are being overlooked, as the information is not available at

the point of dispensing. A number of pharmacists reported that they often

do not receive discharge letters before the patients first visit post discharge,

which prevents the pharmacists from using the information effectively. To

improve the service, it is necessary to assess why the letters are not being

sent out straightaway. (Faxing the letters may be a possibility to speed up

the service.) Further research is required to decide whether giving a copy of

the discharge letter to the patient to give to the community pharmacist

would be feasible. To encourage community pharmacists to use the dis-

charge letters, an information sheet could be sent out to remind the phar-

macists of the benefits of using the discharge prescriptions and also to

provide practical advice on how to use the prescriptions effectively.

References1. Morrison P, Abu-Arafeh I, Davison J, Chapman S. Optimum prescribing of

discharge medicines: roles of hospital and community pharmacists. Pharm J2004; 272: 224–7.

2. Audit Commission. A Spoonful of Sugar. London, April 2001.3. Department of Health. A Vision for Pharmacy in the New NHS. Crown

Copyright, London, July 2003.4. Department of Health. Pharmacy in the Future-Implementing the NHS Plan.

Crown Copyright, London. September 2000.5. Edgar C, Oates C, Holden K. Prescribing continuity following hospital dis-

charge: the Impact of a pharmacist managed discharge service. 2004. Proceed-ings of the UKCPA Symposium, November 2004.

A An audit into prophylactic enoxaparin prescribing for hospital

in-patients with suspected venous thromboembolism

Chiu M

Pharmacy Department, University Hospital of North Durham, Durham

Background

Venous thromboembolism (VTE) is a common complication in hospitalised

patients. In a report by the House of Commons Health Committee it was

identified that hospital in-patients were 25 times more likely to die from

VTE than with Methicillin resistant Staphylococcus aureus (MRSA) infec-

tion1. Clearly thromboprophylaxis prescribing practices are subjective and

guidance is needed.

Objectives

Identify current national or local guidelines or recommendations for VTE

prophylaxis.

Identify patients with suspected or confirmed events.

Identify risk factors in hospitalised patients with suspected or confirmed

VTE.

Identify hospitalised patients who were and were not prescribed prophy-

laxis.

Determine whether prophylaxis has been prescribed appropriately accord-

ing to protocols.

Method

Performed web-based search for national and local guidelines or recom-

mendations for thromboprophylaxis prescribing. January to March 2005

were assigned for data collection. In a web-based search and of The

Pharmaceutical Journal2 in particular, risk factors associated with VTE

were identified. Davis’s Textbook of Adverse Drug Reactions3 and the

British National Formulary4 identified medicines associated with VTE.

Designed a pro-forma to record patient name, risk factors, current medi-

cation, test results and whether enoxaparin was prescribed. Liased with

haematology, X-ray and medical physics departments to identify patients

with high d-dimers, ultrasound (US) and ventilation perfusion (VQ) scans.

Excluded patients from General Practitioner (GP) referrals, Accident and

Emergency and outpatient clinics. Medical notes of identified patients were

analysed and appropriate information was recorded.

Results

Scottish Intercollegiate Guideline Network (SIGN) recommendations based

on clinical trials were identified. No formal local guidelines were identified

but reminder cards issued to all wards of the hospital provided the stan-

dards to audit. Patients at risk included those with immobility, cardiac

disease, respiratory disease, infectious disease/sepsis and active cancer.

Thromboprophylaxis should be considered unless contra-indicated. Contra-

indications included major bleeding disorders, active gastric/duodenal ulcer,

hypersensitivity to enoxaparin, stroke (unless due to systemic emboli) and

other patients with increased risk of haemorrhage.

In total, 301 patients were identified, with 262 patients excluded leaving

39 patient profiles for analysis. Of 39 patients, 17 received prophylaxis ofA267

which three experienced confirmed events and had at least two risk factors.

One patient received prophylaxis 14 days after admission and if prophylaxis

was prescribed earlier the event could have been prevented.

Twenty two patients did not receive prophylaxis. Of these, nine patients

had contraindications (56% suspected stroke, 33% low haemoglobin and

11% rectal bleed). Thirteen patients had no clearly documented contrain-

dications (40% were immobile and had at least one additional risk factor)

and should have been prescribed enoxaparin according to the protocol on

the reminder card.

Out of 22 patients not receiving prophylaxis, 12 did not have an event,

one was transferred to another hospital and nine had confirmed events

(with US or VQ scans) or high clinical suspicion. Of these, five patients had

contraindications (40% suspected stroke, 40% low haemoglobin and 20%

rectal bleed). Three patients experienced deep vein thrombosis (DVT), one

experienced pulmonary embolism (PE) and one experienced both DVT and

PE. Of the four patients without contraindications (25% had two risk

factors and 75% had three risk factors), three patients experienced PE and

died and one patient experienced DVT.

Discussion

It is unclear whether deaths were as a result of PE but enoxaparin should

have been prescribed and the events could have been prevented. Most

common risk factors include malignancy, severe infection and immobility.

These were all listed in the reminder card suggesting that prescribing of

enoxaparin from the recommendations has not been adhered to. Three

patients were taking corticosteroids. VTE contributory medicines were not

included in the reminder card. Therefore, these risk factors were overlooked

on admission and enoxaparin was not prescribed, which may have con-

tributed to one patient’s event.

There are a number of changes, which could be initiated. Publish results

into trust wide bulletin allowing prescribers to be more aware of option of

prophylactic enoxaparin. Issue re-designed reminder cards to include VTE

contributory medicines. Develop Risk Assessment Models to help identify

patients most likely to benefit from prophylactic enoxaparin. Include

checklist in the Integrated Care Pathways to prompt risk assessment when

clerking on admission and clear documentation. Initiate changes and collect

data in 3 months time to complete audit cycle.

Thirty-three percentage (13 patients) had at least one risk factor, with no

clearly documented contraindications and did not receive thrombopro-

phylaxis. Enoxaparin prescribing can be improved through increasing

awareness of risk factors and current medication.

References1. Great Britain. The House of Commons Health Committee. The prevention of

Venous Thromboembolism in Hospitalised Patients. London: The StationaryOffice Limited, 2005, pp. 1–112.

2. Elwood, P. An update on risk factors for vascular disease. Pharm. J. 2001; 267:194–6.

3. Davies, D.M. et al. Davies’s Textbook of Adverse Drug Reactions, 5th edition.London: Chapman and Hall Medical 1998, pp. 184–186.

4. British Medical Association and Royal Pharmaceutical Society of Great Britain2004. The British National Formulary, 48th edition September 2004.

B An assessment of packing materials and development of evidence

based guidelines for transport of cold chain vaccines

Warren A

Department of Pharmacy, Raigmore Hospital, Inverness

Introduction

Many vaccines require continual storage between 2 and 8 �C. The cold

chain ensures that this temperature range is maintained during trans-

portation to minimise loss of potency. This is important because once

lost potency cannot be regained or restored, thus reducing the success of

vaccinations. Potency loss due to breaks in the cold chain has been

identified as the cause of a polio outbreak in South Africa and a measles

outbreak in New York.1

Proper packing of a vaccine carrier box is crucial to maintain cold chain

temperatures and many factors need to be considered to ensure that a

suitable temperature is sustained throughout the journey.

Objective

The purpose of this study was to develop evidence-based guidelines for the

packing of cold chain vaccines for transport from Raigmore hospital.

Method

The study was carried out from November 2004 – March 2005. Data were

collected using electronic temperature recording devices (Comark Diligence

EV model N2001) and processed using Evolution software.

Time–temperature graphs were produced.

The current method of packing vaccines (cardboard or polystyrene box,

containing one fridge temperature ice pack and insulating chips) for

transport from Raigmore hospital was evaluated. This was done by mon-

itoring the temperature of a dummy package (empty boxes in a paper bag)

sent to hospitals and surgeries in Highland.

Variables (Table 1) were then assessed for their ability to maintain cold

chain temperatures. Tests ran for at least 48 h at room temperature. From

the collected data recommendations on packing vaccines for transport were

made and incorporated into a standard operating procedure (SOP).

Results

Periods of elevated temperature (>8 �C) were experienced in all transport

runs when testing the current method of packing vaccines. Assessing the

effects of different variables found that:

� Direct contact with a frozen ice pack (Figure 1) resulted in subzero

temperatures.

� Temperature varies throughout the load if a single ice pack is located at

the bottom of the container (Figure 1).

� Increasing the number of ice packs in the carrier box increases the vaccine

‘‘cold time’’.

� The polystyrene carrier boxes’ thicker walls provided better insulation

than the cardboard and plastic boxes.

� Cardboard was the best insulating material.

� Pre-cooling both the polystyrene box and insulating chips increases vac-

cine cold life.

Discussion

This study highlighted that there are many factors to consider when packing

a vaccine for transport. Insulating materials are necessary to prevent vac-

cine – ice pack contact. Frozen ice packs should be warmed to 0 �C in the

fridge overnight to reduce the risk of freezing the vaccine load. Ice packs

should be evenly distributed in the box to ensure a uniform temperature

within the load. Suitably packed cardboard and plastic boxes can be used to

deliver vaccines to destinations requiring shorter journeys. Polystyrene

boxes can be used to maintain temperatures below 8 �C for longer than

12 h. Ambient temperatures2 affect the temperature of the vaccine load. To

ensure relevance of the packing recommendations in all seasons the cold

chain should be audited in a variety of weather conditions.

References1. Hedenstrom M, Kahler W. The cold chain from manufacturer to vaccinator:

experiments and experiences. Vaccine 1992; 10(13): 949–51.2. Brown DR, Sansum CJ. The transportation of vaccines: Is the cold chain

integrity maintained? Pharm J 1992; 249: 267–9.

Table 1 Variables considered when packing vaccines for cold chain

transport

Ice pack � Number

� Position in box

� Temperature

Carrier box � Size� Material: polystyrene, cardboard and plastic

� Temperature

Insulating material � Material: polystyrene chips, bubble wrap and

cardboard

� Temperature

0

2

4

6

8

10

10 30 50 70 90

Time (minutes)

Tem

pera

ture

(D

eg C

)

BottomTop

Figure 1 Temperature distribution of a vaccine load in a carrier box.

A268

C Audit of drug history taking, prescribing and documentation of

changes to anti-convulsant drugs within Royal Hallamshire Hospital,

Sheffield

Badham H.J., Dorward B.J., Thomas N

Pharmacy Department, Royal Hallamshire Hospital, Sheffield Teaching

Hospitals

Introduction

Epilepsy seizure control is obtained by the use of anti-convulsant drugs

(ACD). There are several types of ACD and a modification in ACD regime

may lead to loss of seizure control or toxicity1. Recent guidelines state all

changes to an ACD should be planned and undertaken with adequate

medical supervision2–4.

Objectives

To assess the continuation of ACD therapy for patients diagnosed with

epilepsy during hospitalisation by reviewing drug history taking, drug cards

and medical records.

Drug history� To investigate when patients admitted taking ACD have a drug history

taken.

� Standard: 100% of patients will have a drug history documented in

the notes within 24 h of admission4

� To assess the completeness and accuracy of the ACD history documented.

� Standard: 100% of ACD drug histories will state the brand, dose,

form, formulation, generic name and strength2,3.

Drug cards� To assess completeness of the prescription for ACD.

� Standard: 100% of drug cards will state ACD brand, dose, form,

formulation, generic name and strength2,3

Patient records� To identify cases where ACD prescription is different to the drug history

taken

� To identify all documented reasons that justify changes to ACD therapy.

� Standard: 100% of medical notes will contain documented reasons

for changes in ACD2–4.

Method

An anonymous pro forma was designed to gather information on the

accuracy of written drug documentation in the medical notes and drug card.

The pro forma also recorded interventions made by the pharmacist. An

exclusion criterion was adopted (ACD use other than epilepsy, cerebral

malignancies and under 18-year olds). The pro forma was successfully

piloted.

Patients admitted to the Royal Hallamshire Hospital receiving an ACD

during a 3-week period in December 2004 were identified via the pharmacy

dispensing system. Patients who met the inclusion criteria were visited to

review ACD history documentation in the medical notes and on drug cards.

Medication discrepancies were highlighted to the clinical pharmacist for

action in the same episode of patient care.

All data collected was coded and entered into a password-protected

database. Data was analysed using Microsoft Access� and individual case

analysis.

Results

In total, 68 patients met the inclusion criteria and a pharmacist had seen 62

(91%) of these patients. A total of 108 ACD were prescribed. A summary of

the results can be found in table one.

Discussion

Pharmacists have an important role in accuracy of drug history documen-

tation and highlighting medication discrepancies. The audit results have

been summarised and presented to the epilepsy multidisciplinary team for

assessment and to potentially implement change in practice. Following the

meeting, it was decided to review the training in drug history collection

skills as part of the junior doctor induction programme and all pharmacists

to receive a presentation on the project plus guideline updates. Following

these actions it is recommended that the audit will be repeated in 1 year

across the Trust sites.

References1. Hall W. Switching anti-epileptics; a change for the worse. Prescriber 1996; 6; 23.2. Drugs for adults with epilepsy. National institute for clinical excellence. Health

technology appraisal. January 2002. www.nice.org.uk (accessed 15/09/05).3. Department of Health. Long Term Conditions National Service Frameworks.

Quality requirements. www.dh.gov.uk/policyandguidance/healthandsocialcare-topics/longtermconditions (accessed 15/9/05).

4. Sheffield Teaching Hospitals National Health Service. Clinical PharmacyStandards. Clinical Endorsing standards. March 2001.

D An audit into the quality of chart endorsing by pharmacists

in the Gwent NHS Trust

Llewellyn KJ

Royal Gwent Hospital, Newport

Introduction

Clinical audit is a key mechanism for facilitating the continuous improve-

ment of health services. It involves the systematic measuring of clinical

performance against agreed standards, and thus the action taken to correct

any shortfalls found1. The quality of chart endorsing by pharmacists is a

prime example of clinical performance that requires continuous monitoring

to ensure consistently high standards are achieved. Pharmacists have a duty

of care to patients to ensure all prescribed drugs are safe and effective2 and

in concordance with the ‘Pharmacy procedures for Chart Endorsing’ set out

by the Gwent NHS Trust, they are responsible for endorsing this infor-

mation on patient charts. In order to ensure that the endorsing procedures

carried out by all pharmacists within the trust are consistent and of an

acceptably high quality, a clinical audit has been implemented to monitor

and record these actions.

Objective

This study was undertaken to assess the quality of chart endorsing by

pharmacists at the Royal Gwent Hospital, whilst addressing any areas that

are unsatisfactory and suggesting any possible improvements to the pro-

cedures. The results produced can then be used as a comparison with the

chart endorsing audit carried out simultaneously at Nevill Hall Hospital, in

the Gwent NHS Trust.

Methods

A data collection form addressing the 11 standards outlined in the trust’s

‘Pharmacy Procedures for Chart Endorsing’ was designed and piloted. A

total of 204 in-patient medication charts were chosen at random and au-

dited across each of the 29 wards at the Royal Gwent Hospital base

(including all medical, surgical and critical care departments). For each of

the medication charts collected over the 14-day period, they were assessed

for quality of endorsing by pharmacists using this data collection form. In

Table 1 Summary of the standards and results obtained

Standard Result

100% of patients will have a drug

history documented in the notes

within 24 h of admission4

36 (53%) patients had a drug

history documented in the notes

within 24 h of admission

100% of ACD drug histories will

state the brand, dose, form, for-

mulation, generic name and

strength2, 3

34 (32%) of ACD drug histories

stated the brand, 57 (53%) stated

the dose, 13 (12%) stated the form,

21 (19%) stated the formulation,

59 (87%) stated the generic name

and 99 (92%) stated the strength.

100% of drug cards will state ACD

brand, dose, form, formulation,

generic name and strength2, 3

56 (52%) of drug cards stated the

brand, 108 (100%) stated the dose,

19 (18%) stated the form, 36 (33%)

stated the formulation, 95 (88%)

stated the generic name and 98

(91%) stated the strength.

100% of medical notes will contain

documented reasons for changes in

ACD2–4

42 (62%) patients had a difference

between the drug history and med-

ication on the drug card. 27 (64%)

of these patients with a difference

in documentation had explanations

in the notes.

A269

addition to this, an anonymous questionnaire was designed and handed out

to all pharmacists within the hospital and used as a tool to obtain feedback

on the trust’s procedures for chart endorsing.

Results

The major findings of the audit project involved parts 1, 2, 4, 5 and 6 of the

pharmacy procedures for chart endorsing. The results for part 1 of the

procedures showed that only 35% of the overall charts were endorsed in

green ink. In contrast, for standard 2, which requires the generic name of

the drug to be written in full this revealed consistently high results

throughout all wards; achieving an average of 80.5% on the ‘as required’

section of charts and 77.7% on the regular side. Further results relating to

standard 3 of the procedures demonstrated that only 57.5% of the ‘as

required’ and 64.4% of the ‘regular’ side of charts had the supply boxes

endorsed by pharmacists, with the endorsement of liquid strengths

achieving only 8.3%.

The results produced from all wards for standard 4 of the procedures,

requiring the dose, route, and frequency of administration to be present and

clear were excellent, with the majority of wards achieving 100% for all three

criteria.

A significant observation from the audit is that there are no guidelines to

assist pharmacists with parts 5 and 6 of the pharmacy procedures for chart

endorsing. Consequently, there were no standards to audit the requirement

for additional drug information to be provided (standard 5) and parenteral

administration advice (standard 6). In order to overcome this part of the

audit, 3 drugs commonly endorsed with extra administration details i.e.

NSAIDs (with food), aspirin (with food) and bisphosphonates (full

administration details as according to the BNF) were chosen and audited.

Similarly, part 6 of the procedures involving parenteral administration

advice had no guidelines in the pharmacy procedures and the results showed

variation in the type of drugs and parenteral administration advice provided

by different pharmacists.

Discussion

The audit demonstrated that the majority of pharmacists do not fulfil every

requirement set out by the trusts ‘pharmacy procedures for chart endorsing’

and that there is substantial variation between their endorsements. For

procedure 1, whereby pharmacists are required to endorse using green ink

for the purpose of differentiating between information provided by the

doctor and the pharmacist, 65% overlooked this requirement. Also, the

endorsement of liquid strengths (standard 3) was an unacceptable 8.3% and

I therefore strongly recommend all pharmacists familiarising themselves

with these parts of the procedures and including them in their daily chart

endorsing routines.

Due to the lack of guidance with procedure 5 (requiring the provision of

extra administration details) major recommendations are to compile an

agreed list of drugs together with the additional information required for

pharmacists to use as a reference when endorsing charts. The results from

the 3 drugs audited were unacceptably low and the consequences of omit-

ting this information includes possible GI irritation/bleeds with NSAIDS

and aspirin, and oesophageal erosion if the bisphosphonates are not

properly administered. These were just three examples of many and even

though it would make ward rounds more time consuming, it would mean all

pharmacists consistently providing the correct and appropriate adminis-

tration details for drugs, and thus optimising patient care.

Similarly for procedure 6, requiring parenteral administration advice, I

strongly recommend producing a list of drugs that require this extra

information to enable pharmacists to consistently endorse charts with the

relevant and accurate details. Further recommendations from the audit are

to list the drugs or patient types requiring patient weight to be present on

the charts and also to address any drug-monitoring strategies. Communi-

cation of any amendments with all pharmacists working within the trust is

also essential to encourage chart endorsing procedures to be carried out

effectively and consistently on all wards.

References1. http://www.show.scot.nhs.uk/isdonline/clinical_gov/clinical_audit/

clinical_audit.htm2. Royal Pharmaceutical Society of Great Britain. Medicines, Ethics and Practice,

29th edn, July 2005: 85.

E Audit of nebuliser prescribing for acute exacerbations of chronic

obstructive pulmonary disease on specialist respiratory wards

Russell-Hobbs K

Pre-registration Pharmacist, Department of Pharmacy, Leeds Teaching

Hospitals NHS Trust, Leeds.

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is the fourth most com-

mon cause of death in the world1. The progressive course of the disease is

complicated by exacerbations of symptoms, which if severe, require hos-

pitalisation. The historical mainstay of treatment involves the use of neb-

ulised short acting b2 agonists such as salbutamol and/or anticholinergics

such as ipratropium.

Objectives

� To quantify the quality of prescribing & administration of nebulised

bronchodilators for acute exacerbations of COPD on specialist respiratory

wards compared to recommended best practice over a 2 month period.

� To produce recommendations to improve practice.

Method

A set of four audit standards were developed using national clinical

guidelines.1–3

Audit standard 1: All patients with a severe exacerbation require nebulised

treatment with both salbutamol and ipratropium.

Audit standard 2: Patients receiving ipratropium to manage chronic disease

require both nebulised salbutamol and ipratropium to manage an exacer-

bation.

Audit standard 3: All non-severe exacerbations should initially be prescribed

nebulised salbutamol alone (i.e. not with ipratropium) and their response

reviewed.

Audit standard 4: All prescriptions for nebulised drugs must specify a

driving gas, fill volume and flow rate.

Patients were targeted on the specialist respiratory wards at the Leeds

General Infirmary. A standardised data collection sheet was developed and

piloted to ensure it was suitable for use. The severity of each patient’s

exacerbation disease was staged according to GOLD criteria.3 Patients’

drug charts, notes and the nursing staff were used to collect data including;

how the nebules were administered and which driving gas was used to drive

the nebuliser unit. The main outcome measure was deviation from the audit

standards. The results were analysed using Fischer’s Exact Test.

Results

Out of 23 patients audited 39% (9) patients were classed as having a severe

exacerbation.

Audit standard 1: 78% (7) of severe exacerbations were initially prescribed

ipratropium and salbutamol. This was not statistically significant different

from the audit standard (p>1).

Audit standard 2: One patient prescribed ipratropium at home was not

prescribed ipratropium in hospital.

Audit standard 3: All patients were prescribed regular nebulised salbutamol.

Around 93% (13) of non-severe exacerbations were initially prescribed

ipratropium. This is a statistically significant deviation from audit standard

3 (p<0.001).

Audit standard 4: A 0% of drug charts stated a driving gas or fill volume and

2 drug charts specified a flow rate.

Discussion

Actual practice complied with only one of the audit standards; for the

prescribing of salbutamol and ipratropium nebules in combination for

severe exacerbations of COPD, therefore the prescribing met the national

guidelines1–3. One patient who was prescribed ipratropium at home but not

in hospital could potentially be an oversight and may have been corrected

during their inpatient stay.

Table 1 % of charts endorsed with additional administration details for

NSAIDS, aspirin and bisphosphonates

Drug % of charts containing

appropriate additional

information

Additional information

provided

NSAIDS 20 With food

Aspirin 33.5 With food

Bisphosphonates 25 Full administration details

A270

One of the main deviations of the audit standards was the inappropriate

prescribing of ipratropium nebules for non-severe excerbations of COPD.

This study has shown that ipratropium nebules are generally prescribed in

combination with salbutamol nebules in the vast majority of exacerbations.

This is not necessary for mild exacerbations, since there is minimal evidence

that the addition of ipratropium to salbutamol in the treatment of exac-

erbations of COPD has any further benefit4.

The need for the correct driving gas in COPD patients is well docu-

mented. If oxygen is given to a carbon dioxide retaining COPD patient then

this could potentially cause a suppression of respiratory drive, worsening

hypercapnia and ultimately worsen to respiratory failure. On discussion

with the nurses on the specialist respiratory wards, it was found that they

always use air to drive nebulisers for COPD patients. However it should be

noted that this may not be common practice on non-specialist wards.

The fill volume and airflow rate can both alter the properties of respirable

particles. If the fill volume is increased then the proportion of drug nebu-

lised is increased. After interviewing the nurses on the wards it was found

that if the ipratropium and salbutamol are prescribed as concomitant

therapy, then the nebules are always mixed together, thereby increasing the

fill volume, which is a good practice. The optimum flow rate of 6–8 l/min is

used to nebulise 50% of particles to 2–5 lm 2. If the flow rate is increased,

then the drug output is increased with a decrease in particle size. The size of

nebulised particles is important because it affects where the drug particles

are deposited in the airways, particles in the range 2–5 lm will be deposited

in the small airways, where they exert the desired therapeutic effect2.

Despite the air flow rate never being prescribed, it was found the Hospital’s

Medical Physics department test the compressor and nebuliser unit for the

optimum flow rate to ensure that they work at the optimal flow rates,

therefore it is not necessary for the drug chart to be endorsed with pre-

scribed flow rate.

In conclusion there were deviations from audit standards. In order to

streamline patient care it is suggested that a standardised care pathway with

treatment algorithms derived from best practice are developed and audited.

An area of future study would be to audit the use of nebulisers in ambu-

lances and other specialities in order to compare practice with cinical

guidelines in non-specialist areas.

References1. National Institute for Clinical Excellence (NICE). Chronic Obstructive pul-

monary disease: national clinical guideline for management of chronicobstructive pulmonary disease in adults in primary and secondary care. Thorax2004; 59(Suppl 1): 1–232

2. British Thoracic Society. BTS guidelines for the use of nebulisers for chronicobstructive pulmonary disease. Thorax 1997; 52(Suppl 2): S49–52.

3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for thediagnosis, management and prevention of Chronic Obstructive PulmonaryDisease-Executive summary updated 2004:Accessible from www.goldcopd.com

4. Brown CD, McCrory D, White J. Inhaled short-acting b2 agonists versusipratropium for acute exacerbations of chronic obstructive pulmonary disease(Cochrane Review). The Cochrane Library, Issue 3, 2004. John Wiley & SonsLTD: Chichester, UK.

F A survey of patient satisfaction with the information they receive

about their medicines

Mohammadi L, Voruganti R

Whiston Hospital, Prescot, Merseyside

Introduction

At any time, a third of the population is self-medicating and another third is

taking prescribed medicines. An essential part of such health care delivery is

the communication of information on safety, appropriateness and efficacy

of medicines2. Studies have shown that satisfactory levels of communication

between health care professionals and patients result in increased patient

concordance3,4. In providing patients with information about medicines, we

must work out how much a patient wants to be involved so that the level of

information is tailored to suit them5.

The government has launched initiatives to ensure public access to infor-

mation when they need it3. Projects such as ‘‘ Ask about medicines week’’

promote better use of medicines5. As a result patients are more aware of the

availability of medicines information and their right to knowledge.

Consumer surveys report that health professionals are the most popular

source of drug advice5 but that they are often unwilling to provide patients

with as much advice as they would like1. This project seeks to investigate

patients’ views on the way in which medicines information is given.

Objectives

� To assess the satisfaction of hospital inpatients with the information that

they had received about their medicines

� To assess how various factors may affect a patients level of satisfaction

� To obtain patients’ views on additional services that could be provided to

improve the way in which information about medicines is provided within

the hospital setting

Method

This study was carried out within the discharge lounge at Whiston Hospital.

Two questionnaires were used to carry out the research.

The first questionnaire (Appendix 1) used the ‘satisfaction with information

about medicines scale’ (SIMS). This validated questionnaire consists of 17

questions derived from the ABPI recommendations for the ‘type of infor-

mation that patients require in order to self-manage medication’6. The re-

sponse to each question is converted into a score and the total score

calculated. A low score indicates a low level of satisfaction and conversely a

high score indicates a high level of satisfaction. The maximum score that

can be achieved is 17.

The second questionnaire (Appendix 2) was designed to map the demo-

graphic details of each patient. This included who had provided patients

with information, in what form that information was provided, how useful

they found that information, and how well informed they felt about med-

icines.

Data was collected over a 10-day period in February 2005. The study was

carried out in the discharge lounge, where patients from all wards are

transferred to prior to discharge, to provide a cross section of patients from

all specialities. This also ensured that patients were seen at the end of their

hospital stay when all counselling should have taken place. The nurse in

charge was asked to identify unsuitable patients and those that were unfit or

unable to answer questions were excluded from the study. Data was anal-

ysed using Microsoft Excel.

Results

Of the 52 patients that were received into the discharge lounge 81% were

suitable to be interviewed. Patients deemed as unsuitable were confused

patients (6), patients not feeling well enough (3), and a patient who did not

speak English (1).

Around 34% of patients had a low SIMS score, 44% had a medium

SIMS score, and 22% had a high SIMS score. Using the second ques-

tionnaire patients were asked ‘‘how well informed do you feel?’’ A 30% felt

that they were not well informed, 2% felt moderately informed, and 55%

felt well informed.

When asked which sources of information they would like to be made

available to them, patients responded as follows: 64% wanted a pharmacist

present on the ward for longer periods, 43% wanted a private area on the

ward for discussion, 31% wanted leaflets made available to them, 7%

wanted a helpline, 2% wanted to be able to access information via the

internet, and 2% wanted to text queries. None of the patients chose the

option of faxing queries, or gave any other suggestions. Of those dissatisfied

(low SIMS score), 100% wanted a pharmacist present on the ward for a

longer period, 79% wanted a private area on the ward, 43% wanted leaflets,

and 21% wanted a helpline available.

There was a correlation between patients’ age and their level of satis-

faction. A 75% of patients in the age range 16–30 and 50% of patients in

the 31 –45 age range had a low score compared to only 25% of the patients

aged over 65 years. None of the patients in the 16–45 age group had a high

satisfaction score, compared to 25% of those in the over 65 group and 25%

of those in the 46–65 group.

Of those who felt uninformed (according to second questionnaire), 67%

had not received any information about their medicines, 17% had been

given information by a doctor only, 8% had been given information by a

nurse only, and 8% had been given information by a pharmacist only. Of

those who felt well informed, 21% had received no information, 17% had

received information from a pharmacist only, 13% from a doctor only,

13% from a nurse only, and 36% from a combination of two or more of a

doctor, nurse or pharmacist.

The average SIMS score was 7.32 for patients who had been newly pre-

scribed medicines and 7.5 for those who had not.

Discussion

The SIMS questionnaire assessed a number of factors determining patient

satisfaction, whereas the second questionnaire enquired how informed the

patient felt, and aimed to achieve a more simple indicator as to whether they

had received enough information or not. There was a correlation between

the responses to the two questionnaires, in that most patients who had a low

A271

SIMS score said that they felt uninformed. There were, however, some

patients who had a low SIMS score who felt that they were well informed.

This suggests that not all patients want to receive information about their

medicines in order to feel satisfied, and therefore patient counselling must

be tailored to patients needs.

A higher proportion of patients had low SIMS scores than had high

scores with a large proportion of patients in the medium score band. This

suggests that the way in which information is provided to inpatients needs

to be improved. This could be done by implementation of the resources that

patients felt would be helpful (as stated above).

Patients who felt well informed about medicines had usually received

information from a healthcare professional, in 36% of cases they had been

counselled by more than one member of staff. This suggests that receiving

information from a number of different members of the multidisciplinary

team is beneficial and improves patients’ knowledge.

Older patients tended to feel less of a need for information to be pro-

vided, and were generally more satisfied than younger patients. This was

reflected in the younger patients having lower SIMS scores and further

suggests that the level of information that is provided should be patient

specific.

Patients felt that having a pharmacist on the ward would improve the way

in which they received medicines information, and this indicates that there is

a clear role for ward pharmacists to identify inpatients who require coun-

selling and provide them with the information they need.

The fact that the average SIMS score was similar for patients who had

been newly prescribed medicines, and for those who had no new prescribed

medication, suggests that patients want more information about their

medicines whilst in hospital, irrespective of whether or not they have been

given new medication to take.

The findings from this study could be used to guide further research into

the economic effects that patient counselling could have on hospital trusts

e.g. the effect that patient counselling has on reducing re-admission rates.

References1. Semchuk W. Empowering providers to meet patient information needs, reduce

patient anxiety to support adherence. CPJ/RPC 2004;137: 46–9.2. Dhillon S, Duggan C, Joshua AE. What part pharmacists should play in pro-

viding medicines information. Pharm J 2001;266: 364–6.3. Gibbs S, Waters WE, George CF. The benefits of prescription information

leaflets. Br J Clin Pharm 1989; 27: 723–39.4. Oborne CA, Dodds LJ. The quality and quantity of drug related information

provided to hospital inpatients and its effect on seamless care. Pharm J 1993;251 (Suppl): R5.

5. Dickinson D, Raynor DKT. Ask the patients- they want to know more thanyou think. BMJ 2003; 327: 861.

6. Horne R, Hankins M, Jenkins R. The satisfaction with information aboutmedicines scale (SIMS): a new measurement tool for audit and research. QualHealth Care 2001; 10: 135–40.

G An audit of prescribing of prophylaxis against venous thromboem-

bolism in medical patients

MacLeod LM

Royal United Hospital, Bath

Introduction

Pulmonary emboli remain a significant cause of death amongst hospital

patients in the developed world. The Thromboembolic Risk Factors

(THRIFT) Consensus Group recommend that all patients should be as-

sessed for risk of venous thromboembolism (VTE) on admission to hospital

and patients should receive prophylaxis appropriate for this risk1. In

addition the guideline stipulates that individual hospitals in the United

Kingdom should develop written policies for prophylaxis and these should

be included in clinical audit and plans for patient care. Since the publication

of the THRIFT guidance, further evidence has been published in the

MEDENOX study2 and this has been reflected in the International Con-

sensus Group (ICG) statements3. Anecdotal evidence from the Royal

United Hospital (RUH), suggested that whilst surgical patients are rou-

tinely considered for prophylaxis, its role in medical patients is frequently

overlooked. Necropsy studies have shown that only one in four patients

dying of pulmonary embolism have had recent surgery, highlighting the

necessity for guidance in medical patients1.

Objective

This study aims to assess current practice of risk assessment and prescribing

of prophylaxis in medical patients admitted to the RUH against interna-

tionally published standards.

Method

Data was collected over a 7-day period in February; all patients admitted to

the RUH Medical Assessment Unit were reviewed after examination by a

senior house officer and a consultant physician. Patients under 40 years of

age, who were fully mobile, were excluded, as were patients receiving a

treatment dose of enoxaparin, heparin or oral anticoagulant therapy. A risk

assessment tool founded on the ICG Guidelines3 was used to design data

collection forms. The key standards state that all patients should have a risk

assessment on admission and all moderate to high risk patients should

receive prophylaxis with enoxaparin 40 mg daily unless they have a con-

traindication to enoxaparin4. Patients at risk of VTE with concurrent

chronic renal failure should have their dose of enoxaparin reduced to 20 mg

daily4. Patients diagnosed with one or more risk factors were categorised as

moderate to high risk. Evidence based risk factors were: acute myocardial

infarction, acute heart failure, active cancer requiring therapy, severe

infection/sepsis, respiratory disease, rheumatic disease, ischaemic stroke,

paraplegia, history of VTE, history of cancer and aged over 75 years1,3.

Results

There were 188 patients admitted to MAU reviewed by medical staff and

pre-registration pharmacist. After exclusions, data was collected on 127

patients. Risk assessment was carried out according to the ICG guidelines,

the results are summarised in Table 1. Of the patients identified as moderate

to high risk for whom prophylaxis was appropriate 12 (6%) received some

form of prophylaxis, only 6 (8%) received prophylaxis appropriate to their

risk.

Discussion

This study showed that the current practice does not meet the standards set

by THRIFT or the International Consensus Group. Medical staff docu-

mented risk assessments for 15 (12%) patients; by comparison the pre-

registration pharmacist reviewed the same group and identified 118 (63%)

at moderate to high risk of a VTE. The medical staff may have undertaken

more risk assessment but without documentation these could not be in-

cluded. The audit results imply that awareness of the evidence - based risk

factors for VTE in medical patients should be raised. In addition a prompt

in the clerking documentation or drug chart may help to prompt risk

assessment by medical staff on admission.

The MEDENOX study has shown that enoxaparin 40 mg once daily is

effective in reducing VTEs in medical patients2. The medical staff identified

15 (12%) patients at moderate to high risk of VTE of which 9 (5%) had no

contraindications to enoxaparin. Out of this group, 3 were prescribed an

inappropriate dose of enoxaparin for their risk. The audit identified 76

(40%) patients who should have received prophylaxis with enoxaparin but

observed appropriate prescribing of prophylaxis in 6 (3%) cases. These

results show that prophylaxis should have been prescribed in a greater

number of cases. In addition, where medical staff successfully assessed the

risk of a patient, the prophylaxis prescribed was not entirely appropriate for

the patient. These results suggest there is a need to educate all staff of the

appropriate dose of enoxaparin to prescribe for medical patients.

Local guidance for RUH patients based on the ICG guidelines and the

results of this audit are due for distribution this autumn. Re-audit has been

proposed for March 2006 to investigate the impact of guidelines on practice.

References1. Lowe GDO, Greer IA, Cooke TG, Dewar EP et al. Risk of and prophylaxis for

venous thromboembolism in hospital patients. Br Med J 1992; 305: 567–74.

Table 1 Results of venous thromboembolism risk assessment

Medical staff

admitted

Pre-registration pharmacist

reviewed

Total patients 188 (100%) 188 (100%)

Patient assessed for risk 15 (12%) 127 (68%)

Moderate to high risk

patients identified

15 (12%) 118 (63%)

Moderate to high risk

patients identified

with contraindication

to enoxaparin

6 (3%) 42 (22%)

Patients suitable for

prophylaxis with enoxaparin

9 (5%) 76 (40%)

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2. Samama MM, Cohen AT, Darmon J-Y, Desjardins L et al. A comparison ofenoxaparin with placebo for the prevention of venous thromboembolism inacutely ill patients. New England J Med 1999; 341(11): 793–800.

3. Nicolaides AN. Prevention of venous thromboembolism. International Con-sensus Statement. Guidelines compiled accordance with the scientific evidence.Inte Angiol 2001; 20(1): 1–37.

4. www.emc.medicines.org.uk, summary of product characteristics for Clexane,accessed 12/05/055.

H An audit of the prescribing of clopidogrel for patients seen on

post-take ward rounds and medical admissions unit at University

Hospital Lewisham

Hoad M, Eagle M, Cairns CJ

Department of Pharmacy, University Hospital Lewisham NHS Trust,

London

Introduction

Clopidogrel is licensed for the prevention of ischaemic events in patients with

a history of symptomatic atherosclerotic disease defined by ischaemic stroke,

myocardial infarction or established peripheral arterial disease; and in

combination with low-dose aspirin for acute coronary syndromes without

ST-segment elevation1. For management of non-ST-segment elevation acute

coronary syndromes, a 300 mg loading dose of clopidogrel should be given

immediately and then a maintenance dose of 75 mg daily thereafter2, 3, (in

addition to a 300 mg stat dose of aspirin and 75 mg daily thereafter).

The need for an audit of clopidogrel prescribing was identified by phar-

macists working on the medical admissions unit (MAU). It was observed

that clopidogrel was not being prescribed according to guidelines or subject

to the available evidence base.

Objectives

The objective of this audit was to evaluate the prescribing of clopidogrel to

establish if NICE guidance2 and local guidelines3 were being followed, and,

in response to findings, make recommendations to improve prescribing and

identify education requirements.

Method

Anauditwasundertakenon theprescribingof clopidogrel for patients seenon

post-take ward rounds and on the medical admissions unit, whether newly

started on, or already taking, the medication. The primary standard set was

that 100% of patients diagnosed with Acute Coronary Syndromes (ACS)

should be prescribed and administered a loading dose of 300 mg immediately

and then 75 mg daily doses of clopidogrel, unless contraindicated. Data was

collected over a total of 4 weeks during which time a total of 36 prescriptions

were analysed for 18 females (aged 44–93) and 18 males (aged 28–90).

A data collection form was used to gather information on the presenting

complaint, past medical history and diagnosis of the patient, and the

indication for clopidogrel and the time at which it was commenced (i.e.

based on present diagnosis or prior to admission). The prescription was

assessed for loading dose 300 mg stat (if required) and maintenance dose

75 mg daily of clopidogrel. Details were recorded of any monitoring con-

siderations, side effects or potential drug interactions. It was also docu-

mented on the form if the period to take clopidogrel had been defined and

whether a pharmacist was involved in initiation of the drug.

Results

A total of 36 prescriptions were assessed during the audit period. Twenty-

nine patients were newly diagnosed with ACS, requiring a loading dose

(300 mg) of clopidogrel, however only 69.0% of the patients were admin-

istered that dose. In total 33 patients were being treated with clopidogrel for

ACS and required a maintenance dose of 75 mg daily, however only 90.9%

of patients received these doses. Three patients were started on clopidogrel

for secondary prevention of atherothrombotic events, requiring only the

75 mg daily dose of clopidogrel, however one patient was prescribed a

loading dose unnecessarily.

It was found that minimal consideration was given to the safety of pre-

scribing clopidogrel as no documentation was made in patient notes con-

cerning additional monitoring that should be carried on initiating

clopidogrel, and potential drug interactions had remained unidentified. In

addition, the period for which clopidogrel was to be taken was rarely

documented on initiation of the therapy.

Discussion

Information was gathered on the prescribing of clopidogrel for patients seen

on post-take ward rounds and medical admissions unit. From the data

collected it was identified that prescriptions for clopidogrel were not always

correct or considered for safety prior to initiation. In particular 31.0% of

the patients newly diagnosed with ACS did not receive the appropriate

loading dose. Additional monitoring was rarely undertaken and the period

to take the medication largely undefined.

Recommendation has been made to arrange education sessions for doc-

tors and nurses on the importance of accurately prescribing clopidogrel and

the safety issues that must be considered when prescribing the drug. Also, it

has been suggested that a quick reference guide to the prescribing of

clopidogrel be provided to doctors such that they have access to informa-

tion at the point of prescribing. Finally, it would be prudent to form an

agreement between doctors and pharmacists, such that, on discharge the

period for which the patient should remain taking clopidogrel is defined on

the discharge letter, to prevent continuation of the medication indefinitely.

References1. British Medical Association and Royal Pharmaceutical Society of Great Britain.

British National Formulary 48 September 2004.2. NICE Technology Appraisal 80. Clopidogrel in the treatment of non-ST-seg-

ment elevation acute coronary syndrome July 2004.3. King’s College Hospital Cardiac Care Group. Guidelines for the management

of cardiology patients September 2003.

I An audit of one stop dispensing (OSD) for in-patients at Darent

Valley Hospital

Williams M

Department of Pharmacy, Darent Valley Hospital, Dartford

Introduction

In response to the implementation of patient-focused pharmacy services as

described in ‘‘The NHS plan: pharmacy in the future’’, (DOH, pharmacy in

the future)1, several United Kingdom hospitals have implemented a one-

stop/near patient dispensing service, whereby inpatient and discharge dis-

pensing have been combined into a single supply on admission, already

labelled with administration instructions for the patient2.

Traditionally, medicines for the patient to take home after leaving hos-

pital are usually dispensed just before discharge. Using one stop dispensing,

(OSD), medicines labelled with full patient directions can be supplied upon

admission to hospital.

Such OSD schemes generally involve the use of patient own drugs

(PODs), so that following assessment by pharmacy staff these can be used

during the inpatient stay and at discharge. If all medicines are either

available as a POD or dispensed with administration instructions, patients

should not have to wait for a separate supply of medicines to be dispensed

at discharge, thus speeding up the discharge process2.

The use of PODs and OSD are two schemes promoted by both the ‘‘NHS

plan’’ and ‘‘A spoonful of sugar’’ as mechanisms which act to enhance

medicines management

Objectives

� To determine the percentage of TTO’s written which do not require any

dispensary input when the patient is ready to be discharged.

� To ascertain the percentage of dispensed items on a TTO which are ready

24 h prior to discharge in accordance with the trust OSD guidelines.

� To ascertain the percentage of items on a TTO which require dispensing

on the day of discharge.

Standard of auditing

� 90% of items on a discharge letter should be ready 24 h before discharge

� Local Guidelines: guidelines on one stop dispensing (DVH Trust guide-

lines)

Method

After carrying out a pilot study, Data was collected to include discharge

summaries of patients that were discharged between 04-01-05 and 11-01-05.

Of the patients that were discharged over this period, 49 of these were

randomly chosen and their discharge summaries were analysed for the

number of items that were ready, the number of items that could have been

ready and the number of items that were outside the one stop dispensing

(OSD) guidelines.

Results

Only 16% of the discharge summaries included in the audit required no

further dispensary input on the day of discharge. A total of 318 items were

A273

present on the 49 discharge summaries included in the audit. Of the 318

items, 169 (53%) item were ready and did not require further dispensing, 53

(17%) items could have been ready following OSD guidelines and 96 (30%)

items were outside the OSD guidelines.

Discussion

Time constraint is the biggest factor leading to items not being ready.

Locker top ups are carried out by the ward-based technicians once a week.

These technicians have allocated wards times they need to carry out this

task, they also have periods during the day in which they need to carry out

dispensary duties. Most technicians complain that the time they need to

carry out a thorough locker top up is not available and most times will only

see those patients who are priority as opposed to everyone. This in addition

to staff shortages and holidays mean that the technicians do not have en-

ough time to do a thorough locker top up for all the wards allocated to

them. The ward pharmacists endeavour to look through every patient’s

drug chart on a daily basis but due to time constraint, more than one ward a

day to cover, dispensary duties and resolving clinical issues on the wards,

they are unable to thoroughly look through each drug chart everyday and

usually prioritise work which means medication which can be one stopped

are missed.

The patient’s length of stay in hospital will determine whether one stop

dispensing can be implemented. If a patient is admitted on a Friday evening

and is discharged on Monday afternoon, it is unlikely that this patient will

have been seen by either a technician or a pharmacist and their PODs (if

they have any) will not have been assessed and none of their medications

will have been dispensed. Therefore, in this category of patients, OSD

cannot be implemented and in this audit, they account for 5% of the dis-

charge summaries not ready.

Some of the items that are outside the guidelines could have been ready

but due to lack of training, some of the technicians are unaware of this. For

instance, for a patient admitted to a surgical ward for a procedure and who

normally takes ACE inhibitors, it is highly unlikely that the surgical team

will alter the dose of his/her ACE inhibitors but as the guidelines state that

technicians should not supply ACE inhibitors as one stop items as the dose

can be variable in an acute admission setting, this is not done. If appro-

priate training is given, the technicians will know in what circumstances

such as above where they should be dispensing the items which normally

they will not and which could in turn can speed up the discharge process.

Only 16% of TTO’s were ready as opposed to the 90% standard set at the

start of the audit. As a result of the factors listed above, OSDwill only work if

these can be eliminated or minimised. Some of them are unavoidable while

others can be tackled. OSD only works in straightforward circumstances

when none of the factors listed above are present or when the patients have

brought all their PODs in and they have not had any medication changes

during admission. Availability of pre-packs of certain medication especially

on the surgical wards can also improve one-stop dispensing.

Acknowledgement

Susan Boorman (Clinical Services Pharmacist) Dartford and Gravesham

NHS Trust, Darent Valley Hospital.

References1. Department of Health. Pharmacy in the Future – Implementing the NHS Plan.

London: Crown Copyright, 2000.2. Franklin et al. One-stop dispensing – does one size fit all? Pharmaceut J 2003;

271: 365.3. The Audit Commission. A Spoonful of Sugar – Medicines Management in NHS

Hospitals. London: Audit Commission Publications, 2001.

J Audit on the preparation of intravenous antibiotics at ward level (with

the introduction of a CIVA service)

Chan SM, Evans N, Walton, R

Warwick Hospital, Warwickshire

Introduction

The use of aseptic technique during the preparation of intravenous (IV)

infusions or injections is essential to avoid the risk of contamination from

the surrounding environment. A major factor to take into consideration is

the operator’s technique. It is important to determine whether the operators

are appropriately trained and deemed competent by a suitable supervisor.

Their method must be correct, efficient and safe. An appropriate method of

assessing each operator throughout their career may also be required to

ensure appropriate standards are maintained.

It is important to adopt an aseptic technique when preparing IV products

as it is essential to ensure that all steps are taken to minimise contamination.

Major types of contamination may include microbiological, particulate or

others. Sources of contamination may include the operator, equipment, the

ingredients, preparation surface and particles in the surrounding environ-

ment1, 2. A contaminated product can potentially cause great harm to the

recipient. This is especially important in immunocompromised patients.

The possibility of providing a dispensing service for IV products to be

aseptically prepared in a pharmacy environment needs to be carefully

examined. Pharmacists are traditionally used to the idea of being held

accountable for their actions. Risk management, audit and monitoring are

established activities within pharmacy3. Therefore, the preparation of IV

products that are commonly prepared and used at ward level could rea-

sonably be undertaken by pharmacy. The exact products to be prepared as

part of a centralised intravenous additive (CIVA) service from pharmacy

need to be identified. It would not be possible to provide a CIVA service for

every product required for every ward within a busy hospital environment.

Therefore, this audit concentrates on the provision of intravenous antibiotic

products for in-patients within the oncology department.

Objectives

(1) To determine the opportunities for risk to patients occurring during the

preparation of IV antibiotics at ward level.

(2) To identify which IV antibiotics are used within the oncology depart-

ment (for inpatients) and the level of usage of each antibiotic.

(3) To establish whether a CIVA service provided by the pharmacy

department may reduce the risks to patients and whether the service

would be suitable for this department.

Method

(1) The standard operating procedure (SOP) for IV preparation written by a

senior nurse for a nurse at ward level and the SOP written by a phar-

macist for a pharmacy technician in an aseptic suite were compared and

contrasted on a step-by-step basis. The standard was set to be the pro-

cedure followed in an aseptic suite. Each step omitted in the nursing

procedure that could potentially cause harm to the patient was measured

as a risk. The risk of bias may occur if the procedures were to be com-

pared on an observational basis, as one staff member may follow the same

SOP differently to another staff member. Therefore, by comparing the

two written SOPs, the risk of bias for either procedure was avoided.

(2) A survey was carried out daily during the pharmacist’s ward visit over 6

weeks. The usage of IV antibiotics was measured by counting the number

of IV antibiotics prescribed each day on each inpatient drug chart. The

results of this survey would aid the identification of suitable drugs to pilot

in a CIVA service.

Results

On comparing the two SOPs, 15 potential risks that could lead to micro-

biological or particulate contamination were identified in the nursing pro-

cedure.

The survey on IV antibiotics (prepared at ward level) showed that in a

total of 64 patients that were prescribed IV antibiotics within a 6 week

period, the most commonly prescribed antibiotic was ceftazidime 2 g

infusion (for 20 patients).

Discussion

A simple review of the nursing procedure to incorporate additional steps is

required. This would enable each potential risk of contamination identified

to be addressed and therefore reduce the risk to patients. Reducing the

opportunities of risk to patients would also impact on other considerations

such as the length of hospital stay and total costs of medication received

during admission per patient.

A CIVA service should be considered for the most commonly used IV

antibiotics (in this case, ceftazidime) in order to improve sterility of the

products. This would be a better and more efficient use of both nursing time

and the available resources within pharmacy.

The variation between the SOPs highlights the differences in approach to

the meaning of ‘aseptic technique’ during IV preparation. It also shows the

difference in methods of producing SOPs by different healthcare profes-

sionals.

Aseptic pharmacy is a department within itself that focuses on aseptic

manufacturing with guidelines that specify appropriate standards. How-

ever, the preparation of IV products at ward level is one of many tasks

conducted by trained nurses. The pharmacy department have the capacity

to provide an aseptic environment not available at ward level along with

specially trained staff.

A274

In summary, a review of the nursing procedure is required in an attempt

to minimise the opportunities of risks to patients. Also, a CIVA service

should be considered for the oncology department. It is an opportunity to

fully utilise the aseptic manufacturing service available from the pharmacy

department, freeing up valuable nursing time for direct patient care.

References1. http://www.allaboutpharmacy.co.uk/aseptics.htm <24.04.05>2. Munro MJ, Millar BW, Radley AS. A risk assessment of the preparation of

parenteral medicines in clinical areas. Hospital Pharmacist 2003;10: 303–5.3. Clinical governance in aseptic compounding. Hospital Pharmacist 2000;7: 192.

K Retrospective audit of actions taken following the receipt of toxic

medication blood levels report

Goh SY*

Pharmacy Department, Queen Mary’s Sidcup NHS Trust

*Audit was conducted during pre-registration in Royal Hospital Belfast

Introduction

Therapeutic drug monitoring (TDM) is an application of clinical pharma-

cokinetics and is a process of observing drug effects on a patient. It is

undeniable that TDM plays a great role in ensuring therapeutic efficacy as

well as preventing adverse drug reactions. This in turn contributes to risk

management process, which is one of the fundamental components of

clinical governance. However there are potentially major clinical manage-

ment and resource implications if TDM is performed inappropriately. An

audit to assess the appropriateness of digoxin TDM in Christchurch Hos-

pital, New Zealand found that 19% of the samples did not represent steady

state concentrations. In 5% of occasions, the subsequent decisions

regarding dose adjustment was felt to be clearly inappropriate1. A similar

study performed at Brigham and Women’s Hospital in Boston discovered

that 87% of patients underwent early routine monitoring before steady

state was achieved2.

Objectives

This audit was undertaken to assess how medical staff addresses toxic

medication blood levels, to evaluate the appropriateness of their actions and

to identify measures to improve TDM service.

Methods

Toxic digoxin and phenytoin levels recorded between 1st Nov 04 and 30th

Apr 05 were provided by Belfast Link Laboratory Service. Relevant

patients’ case notes were then obtained from Medical Records Department.

For practical reasons, paediatric patients were excluded from this study.

Patients’ details recorded included age, gender, medical history, drug his-

tory, laboratory data and issues relating to TDM such as sampling time.

Data collected were analysed and compared against the audit standards set.

It is expected that all actions taken by medical staff achieved 100% when

measured against the following standards:

1. Blood results are signed and acknowledged by medical staff

2. A record is made in patient’s notes

3. Actions are taken following the receipt of toxic medication blood levels

4. Plasma drug concentration is back to target range within a reasonable

time

5. Plasma drug concentration measured represents steady state

6. Actions taken are appropriate

Results

Between 1st Nov 04 and 30th Apr 05, 70 adult patients (median age

82 years) had toxic digoxin levels (>2 mcg/l) detected while another 23

adult patients (median age 46 years) had toxic phenytoin levels (>20 mg/l).

However, only 29 digoxin patients and 9 phenytoin patients were audited.

The patients’ notes for the rest of the patients were unavailable from

medical records as they were either being used by other researchers or have

been transferred to other hospitals.

As evident from Table 1, blood results are not routinely signed and re-

corded in patients’ notes. Although actions were taken in all cases implying

that medical staffs were indeed aware of toxic blood results, this is only a

small audit with a total sample size of 38 patients hence it may not be a true

reflection of what really happens in practice. It is encouraging to note that

majority of toxic blood results return to target range within a reasonable

time (defined as five half-lives). The reason why the remaining 7.1% (di-

goxin) did not meet the audit standard was because the patient concerned

was being treated under palliative care whereas the remaining 11.1%

(phenytoin) was unaccountable for due to patient being discharged and

followed up by his GP.

The results of this audit also revealed that sampling time is not routinely

recorded. This is not ideal because sampling time is one of the crucial

factors that need to be considered when evaluating plasma drug concen-

tration especially with digoxin. Inappropriate sampling time can lead to

falsely high or low plasma drug concentrations and subsequently erroneous

clinical decision. Due to the lack of information on sampling time, it is

inconclusive whether steady state concentrations were measured and whe-

ther actions taken were appropriate. Hence this explains the low score when

measured against the audit standards.

Discussion

Interventions to improve TDM could potentially save substantial resources

without missing important clinical results. Possible measures to improve the

practice of TDM include having a standard operating procedure which

outlines the procedure that needs to be taken upon receipt of toxic blood

level as well as the relevant sampling time for specific drugs; setting up a

toxic blood level alert between the pharmacy and the laboratory as a form

of safety net; and having ward pharmacists to follow up on patients with

toxic blood levels to ensure appropriate actions have been taken.

References1. Sidwell A, Barclay M, Begg E et al. Digoxin therapeutic drug monitoring: an

audit and review, NZ Med J 2003; 116; 708–13.2. Canas F, Tanasijevic M, Maluf N et al. Evaluating the appropriateness of

digoxin level monitoring, Arch Intern Med 1999; 159; 363–8.

L An audit on the monitoring of intravenous vancomycin at a district

general hospital

Odubanjo E

Milton Keynes General Hospital, Milton Keynes

Introduction

The increasing rate of antimicrobial drug resistance is a significant public

health issue worldwide. The World Health Organisation (WHO) has defined

the appropriate use of antimicrobial agents as ‘‘the cost effective use of

antimicrobials which maximizes clinical therapeutic effect while minimising

both drug related toxicity and the development of antimicrobial resis-

tance’’1.

In England, antibiotic resistance has been identified as a priority by the

present government in a report by the Chief Medical Officer in 2002

‘‘Getting ahead of the curve’’2. In addition, in December 2003, a new

Department of Health (DoH) hospital pharmacy initiative – ‘‘Winning

ways’’ has seen the injection of additional funds (£12 million over a period

of 3 years) to promote the prudent prescribing and monitoring of antibiotic

use3. These publications amongst others highlight a number of roles for

clinical pharmacists in tackling anti-microbial resistance and improving the

prudent use and monitoring of antibiotics in hospitals.

Vancomycin is a glycopeptide antibiotic with a narrow spectrum of

activity primarily against aerobic and anaerobic Gram-positive bacteria1–4.

Clinical use of vancomycin has increased significantly over the years with

the emergence of Methicillin Resistant Staphylococcus Aureus (MRSA)

and there have been reports of the emergence of vancomycin resistance

among microorganisms4,5. Coagulase-negative staphylococci, enterococci

and more recently, staphylococcus aureus have all been reported to exhibit

varying degrees of resistance to vancomycin6. Given its therapeutic

importance, it is vital that vancomycin resistance does not become

unmanageable. As optimal use of antibiotics is required to dampen the

emergence of bacterial resistance, it is imperative that vancomycin is

Table 1 Summary of audit results

Audit Standards Digoxin Phenytoin

Blood results are signed off 50.0% 36.8%

Blood results recorded in patients’ notes 35.7% 47.3%

Actions are taken following receipt of results 100% 100%

Levels return to target range within reasonable time 92.9% 88.9%

Steady state concentration measured 62.0% 31.6%

Actions taken appropriate 57.0% 31.6%

Sample size 29 9

A275

prescribed and monitored appropriately as the success of therapy may hinge

increasingly on this4,5.

In view of the above, various hospitals across England have developed

and implemented strategies such as hospital policies and guidelines

regarding the use of antibiotics/antimicrobial agents.

In a bid to incorporate the national strategies for prudent use and moni-

toring of antimicrobial agents into the ‘‘local setting’’ at Milton Keynes

General Hospital (MKGH), an audit of the prescribing of vancomycin as a

narrow spectrum antibiotic was identified as a priority.

Objective

To evaluate the prescribing and monitoring of vancomycin therapy at

Milton Keynes General NHS trust against the local trust protocol with a

view of making recommendations if the current hospital practice does not

meet the required standards set in the trust protocol.

Method

A prospective study was carried out on patients who were prescribed

intravenous (IV) vancomycin between October 2004 and January 2005. A

data collection tool was used to record details of drug dosing, frequency and

monitoring for each patient during the study period.

The main outcome measure was the consistency of the prescribing and

monitoring of intravenous vancomycin with the trust protocol.

Results

A total of 20 patients were recruited through the various wards at Milton

Keynes General NHS trust (MKGH) during the study period, of these;

� Seventy percent (70%) of the IV vancomycin doses prescribed complied

with the local protocol.

� Sixty percent (60%) of blood samples for TDM were done according to

local guidelines

� Fifty-five percent (55%) of patients on IV vancomycin had their dosages

adjusted according to the local guidelines in response to blood levels.

Discussion

The prescribing and monitoring of intravenous vancomycin was not fully

compliant with the recommendations from the trust protocol. The results of

this audit show that a lack of understanding of therapeutic drug monitoring

(TDM) and subsequently its application to clinical practice in the area of

vancomycin are the main issues affecting the optimal use of IV vancomycin

at MKGH.

References1. World Health Organisation (WHO). Global Strategy for Containment of

Antimicrobial Resistance, Executive summary, 2001. whqlibdoc.who.int/hq/2001/WHO_CDS_CSR_DRS_2001.2a.pdf. Date accessed 5th December 2004.

2. Chief Medical Officer. Getting ahead of the curve: a strategy for combatinginfectious diseases (including other aspects of health protection). A report bythe Chief Medical Officer, Department of Health, January 2002. http://www.publications.doh.gov.uk/cmo/idstrategy/index.htm. Date accessed: 5thDecember 2004.

3. Chief Medical Officer. Winning Ways: Working together to reduce healthcareassociated infection in England. Report from Chief Medical Officer. Depart-ment of Health, December 2003. http://www.dh.gov.uk/assetRoot/04/06/46/89/04064689.pdf. Date accessed: 13th November 2004.

4. Palmer –Toy DE. Therapeutic monitoring of vancomycin. Arch Pathol lab Med2000; 124: 322–3.

5. Robertson MB, Dartnell JGA, Koran TM. Vancomycin and Teicoplanin use inVictorian hospitals. Med J Aust 1997; 17:127–31.

6. Keyserling HL, Sinkowitz-Cochran RL, Harris JM, Levine GL, Siegel JD,Stover BH et al. Vancomycin use in hospitalised paediatric patients. Paediatrics2003; 112(2): 104–111.

M The prescribing of enoxaparin for the treatment of deep vein

thromboses, pulmonary emboli, and unstable angina

Lynch PJ, Print A

Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation

Trust

Introduction

Effective and efficient thrombolysis is essential to provide a favourable

outcome in patients diagnosed with deep vein thromboses (DVT) or pul-

monary emboli (PE). Similarly, anticoagulant cover during episodes of

unstable angina (UA) is a proven success1. Enoxaparin is a commonly used

agent for this purpose. Low molecular weight heparins have become a

standard as a means to treatment of DVTs and PEs. Their efficacy, cost and

safety has allowed them to enjoy extensive clinical usage in comparison to

standard heparins and other thrombolytic agents such as streptokinase and

the rt-PAs (plasminogen activators). However, appropriate dosing is key to

providing a good outcome in potentially life-threatening conditions, in

addition to avoiding morbid complications of dosing – such as bleeding. Up

until recently enoxaparin dosing regimes were standardised and did not take

into consideration the mass of the patient and or the patient with impaired

renal function2, 3. These two important parameters must be assessed in

order to provide effective and safe thrombolysis with enoxaparin. To this

regard the staff prescribing and administering this therapy must have clear

and comprehensive guidance. Therefore the design of the relevant areas of

the anticoagulant chart could have potentially serious ramifications for the

safe and efficacious use of enoxaparin. Indeed if the charts were difficult to

interpret or convey information on then this could lead to serious compli-

cations via sustained emboli or haemorrhage, increased inpatient residency,

increased costs and increased mortality potential. This audit was conducted

across the entire directorate of medicine. Patients receiving enoxaparin

treatment doses for DVT/PE or UA were identified. The anti-coagulant

charts were assessed for appropriate completeness. A relevant qualitative

data study of medical and nursing staff was run in parallel.

Objectives

To assess the degree to which enoxaparin sections of the anticoagulant

charts are being completed correctly and fully.

To determine if the charts design is misleading practitioners into making

errors.

To determine if renal function is being taken into consideration when

prescribing enoxaparin.

To ascertain the medical and nursing staffs level of competence using the

chart and to acquire their feedback regarding it.

To identify ‘off label’ usages of enoxaparin being prescribed on the

anticoagulant chart.

Methods

A data acquisition form was designed in conjunction with the clinical audit

and risk governance department. This form was piloted on a short-stay

medical ward and on the cardiology ward over a one day audit. The data

form collected information on the indication for treatment, weight, serum

creatinine, drug chart cross referencing, in addition to assessing the quality

of chart endorsement. The post pilot analysis revealed that the data form

was sufficient to use during the main audit. All pharmacists covering the

medical wards were issued with audit packs containing questionnaires for

the respective medical and nursing staff and data acquisition forms. The

audit was run over 1 week across the entire directorate of medicine. Phar-

macists whom identified patients on treatment doses of enoxaparin com-

pleted the forms and returned the completed forms in the pack at the end of

the audit week. In order to assess the staff comprehension and contentment

with the chart a qualitative data study was run in parallel. A cohort sample

of medical and nursing staff were given MCQ style questionnaires to

complete. These data forms also included sections whereby the staff could

give their written opinion of the chart and its ease of use.

Results and discussion

Collected data was analysed. It was found that only 7 (25%) charts were

completed fully, and without error. Poor and inconsistent recording of the

patients weight, thus leading to an ambiguous and/or an inappropriate

dose, accounted for 70% of the errors recorded. Interestingly, the majority

of errors occurred in the DVT/PE group patients which accounted for 66%

of total errors. This group exhibited an 83% error rate in comparison to the

UA group at 38%.

Administration of enoxaparin for treatment regimes is reported to be

difficult and confusing, most probably due to the wide range of syringe

sizes, volumes and concentrations available. Nursing staff have also com-

plained over the misleading ‘air bubble’ in enoxaparin syringes that causes

further confusion. Misinterpreting the weight of a patient leads to errors in

dose calculations; poor guidance on syringe strength and size can also lead

No. patients Charts with errors Weight related errors

DVT 9 9 8

UA 13 7 3

Off License 5 n/a n/a

Total 27 16 11

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to dosing errors, for example: a volumatic administration error of just

0.2 ml of the 150 mg/ml strength 120 mg syringe in a 70 kg patient can

result in a 30 mg (28%) dose variation. Taking into consideration the

confounding problems the aim of the anticoagulant chart should be to

provide medical and nursing staff with clear, unambiguous dosing schema

with a view to minimising risk and maximising beneficial clinical outcomes.

However the qualitative study run in parallel with the main audit showed

that whilst most medical and nursing staff used the chart on a daily or

weekly basis, 90 and 85% respectfully, few exhibited competence when

asked to derive dosing schema and endorse these on the chart, 35 and 0%,

respectfully. The qualitative data study indicated the DVT/PE chart section

to cause the most confusion and this probably accounts for the relatively

large error rates attributable to this section. Another key finding of the

qualitative audit was that medical staff were being lead to believe that the

maximal dose of enoxaparin prescribable was 150 mg. This was probably

due to the fact that the chart gave no clear guidance on dosing schema for

patient greater than 100 kg in weight.

Conclusions

The standard of prescribing and administration accuracy is less than

optimal when enoxaparin is being used at treatment doses for UA and

this is especially true in the clinical settings of DVT and PE. Accurate,

consistent and up-to-date recording of the patients’ weight is key in

providing the patient with maximal benefit from enoxaparin thrombolytic

therapy. Whilst medical and nursing staff deem themselves familiar with

the chart, many find it confusing. This audit has shown that the charts’

design could mislead medical staff into prescribing under-doses, especially

in patients greater that 100 kg. This audit has invoked remedial concepts,

such as limiting the ranges of Clexane� and Clexane Forte� syringes

available, staff education, redesign of the trusts’ anticoagulant chart and

treatment monitoring via factor Xa levels4. Unfortunately this audit is

limited in statistical power and an ability to relate its findings to any

definitive clinical endpoint. To this regard, post-remedial audits should

be executed over longer periods and the clinical outcome of risk events

should be quantifiable.

References1. Hodgson J. An audit of enoxaparin usage in the management of unstable an-

gina. Pharm world Sci 2002; 24(3): A36–7.2. Antman EM, McCabe CH et al. Circulation 1999: 100: 1593–6013. Nagge J, Crowther M, Hirsch J. Is impaired renal function a contraindication to

the use of Low-molecular-weight heparins? Arch Intern Med 2002; 132:Dec 9/23.

4. Committee on Safety of Medicines, Dose adjustment and monitoring of lowmolecular weight heparins. Curr. Prob. Pharmacovig 2004; 30(Oct): 11.

N Baseline measurements and ongoing monitoring of valproate

in psychiatry

McManus J, Sie M

Hammersmith Hospitals NHS Trust, London

Background

Valproate is being increasingly used in psychiatry for the treatment of acute

mania. Semi-sodium valproate has been licensed for this indication and

sodium valproate liquid is also used off-license as well. Due to valproate’s

possible serious adverse effects of liver failure and blood dycrasias, proper

liver function and blood count monitoring should be conducted at the

baseline and at least every 6 months throughout treatment. For good

therapeutic response to occur a steady state plasma level of between 50 and

100 mg/l is required. Therefore valproate monitoring should also be

undertaken until a plasma level between these parameters has been reached.

Objectives

This audit sets out to investigate if valproate therapy is being properly

monitored within the West London Mental Health Trust. To achieve this

the following audit standards were developed:

(1) 100% of patients who are started on valproate must have their full blood

count and liver function assessed at baseline and at least every 6 months

thereafter.

(2) Patients’ valproate levels should be monitored until a therapeutic steady

state plasma concentration of 50 and 100 mg/l has been achieved.

Both these standard should have been reached in a patient to achieve proper

monitoring of an individual’s valproate therapy.

Method

The data required was gathered by first flagging up all mental health in-

patients that were on valproate by checking the drug charts on each ward.

The start date of each patient’s valproate was elucidated from the notes.

The lab result dates of each patient were then investigated against this start

date to assess whether proper therapeutic monitoring had occurred (at the

baseline and at every 6 months there after). For valproate; the laboratory

results were scrutinised to see if monitoring had occurred and if the patient’s

plasma levels had reached the required level above.

Results

As regards standard one, out of a total of 18 patients who had definite start

dates only 10 (55%) had correct baseline monitoring conducted and out of

19 patients who had been using valproate over prolonged periods, only 12

(63%) had had proper on-going monitoring. Out of the total sample of 24

patients’ 20 (83.33%) had valproate plasma monitoring done, of these only

14(58%) had returned plasma levels of between 50 and 100 mg/l. Required

therapeutic monitoring is when a patient’s monitoring achieves both stan-

dards in the audit; only 3(12.5%) of the 24 patients’ valproate monitoring

met the two audit standards.

Conclusions

The valproate monitoring of the patients fell far short of the 100% de-

manded by the audit standards. There needs to be action to address these

serious shortfalls in monitoring to prevent both harm to the patient and

potential waste of money caused by sub therapeutic doses and treatment of

adverse effects. There needs to be staff awareness as regards the proper

monitoring of valproate. Staff education and guideline development will be

needed to address the problem, followed by further auditing of the situation.

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