Omitted and Delayed Medicines

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1 pecialist Pharmacy ervice Medicines Use and afety Omitted and Delayed Medicines A collaborative audit of omitted and delayed anti-microbial in acute, community and mental health settings Jane Hough and Jane Nicholls Medicines Use and afety Division NH pecialist Pharmacy ervice May 2012 and reviewed May 2015 pecialist Pharmacy ervices

2 Medicines Use and afety A collaborative audit of omitted and delayed anti-microbial, in acute, community and mental health care settings Executive ummary 1. 19,655 patients from 54 trusts were reviewed over a 24 hour period patients were prescribed parenteral or enteral antimicrobials and 21,825 representing 8748 antimicrobial prescriptions were audited. 2. The audit identified an average omission rate of 5.3% (1151/21825) for prescribed antimicrobial. 13.2% (802/6062) of audited patients missed at least one dose of a prescribed antimicrobial. 3. The existence of any one of the following made a dose twice as likely to be missed First dose First dose not written up as a stat dose Antimicrobial not held as ward stock 4. In the 45 acute trusts no reason was recorded for 29% of the omissions, an other reason for 26% and antimicrobial not available for 19%. Refusing a dose and no route of administration available both reported 12% of omissions and patient away from the ward only 3% of omissions % of the recorded as being unavailable were actually available on the ward at the time the dose was due to be administered. 6. When followed up by data collectors, had been given but not signed for in at least 29% of the cases where the administration records had been left blank % (565/8923) of were overdue at the time the audit took place. 7.7% (467/6062) patients were overdue an antimicrobial dose at the time of the audit. 8. Electronic prescribing sites reported the same omission rate as traditional prescribing sites but they had a higher proportion of delayed (16% v 5.4%). 9. A much smaller number of community health and mental health patients were audited compared to acute trusts and fewer antimicrobials were prescribed. 16.7% of mental health patients missed and more often through non-availability than in acute trusts. However mental health patients were found not to refuse more frequently than acute trust patients. 10. There were differences in omission rates and reasons for omission between the acute trust care areas; some care areas with high omission rates had small data sets. Omission rates were relatively high for care of the elderly patients and low for critical care and paediatric patients. 11. The issues influencing delayed and omitted antimicrobial are multifactorial, complex and require multi-disciplinary solutions. Trusts should identify specific issues locally and develop solutions with nursing and medical colleagues to ensure prescribing is clear and takes account of routes of administration available and that supply is slick and intuitive and nursing staff understand the importance of administering critical medicines on time and are helped to prioritise medicines within their other competing tasks. In general documentation needs improving and traditional methods of restricting access to antimicrobials needs to be reviewed. 2

3 Medicines Use and afety Recommendations to Trusts Trusts are recommended to review their data locally and to compare to the overall results to identify their areas of good practice and those with room for improvement. The overall results suggest trusts should in general: 1. Raise awareness of the importance of prescribing and administering critical medicines in a timely manner amongst all healthcare professionals and ensure there are clear lines of responsibility 2. Review supply processes particularly for first. upply processes need multi-professional input, need to be instinctive and take account of current situation e.g. outliers, accessing a remote Emergency Drug Cupboard 3. Traditional methods of controlling access to restricted anti-microbials such as ward stock lists may need to be reviewed 4. Adopt the Department of Health s tart mart and Focus approach 5. Put systems in place to help nursing staff locate antimicrobials on the ward area by e.g. using productive ward techniques, aide memoirs 6. Ensure that omitted are followed up particularly those recorded as not available ; as these may be on the ward and the nurse has been unable to locate 7. Work with nursing colleagues around poor documentation including blanks which is covered in Nursing and Midwifery Council (NMC) tandards for Medicines Management (tandard 8 point 2.10) 8. Be aware that solutions for one care area may not be as successful in another care area so engagement with nursing staff and understanding the difficulties they face is key (particularly competing priorities; competence to administer and familiarity with the medicine) 9. Encourage medical staff to communicate (including to the patient) when prescribing an antimicrobial (or any other medicines on local critical medicines lists); ensuring the prescription is appropriate for the route(s) of administration that are available and that it is legible (and includes indication and duration where necessary) 10. Multiple refusals of should be reported to prescribers for a review of the prescription 11. Revisit how well allergy status is documented particularly where policy states this needs to be recorded before (especially penicillin containing antimicrobials) are given 12. Revisit Nil By Mouth policies to ensure all staff give consistent advice 13. Provide guidance on timings of future where administration times have become out of synch with prescribed times 14. hare audit results and good practice 15. Embed delayed and omitted as an organisational responsibility 3

4 Medicines Use and afety A collaborative audit of omitted and delayed anti-microbial, in acute, community and mental health care settings 1. Aim The aim of the collaborative audit was to gather data which would help to quantify the extent of omitted and delayed enteral and parenteral anti-microbial and the range of reasons for these in all care settings; which could then be used to target areas for improvement. 2. Objectives: To quantify the number of omitted and delayed of antimicrobials. To collect information on the reasons for being omitted To attempt to validate not available & blank administration record reasons To examine the differences between first dose omissions and those of other. 3. Background The National Patient afety Agency (NPA) issued a Rapid Response Report on Reducing harm from omitted and delayed medicines in hospital (RRR009) in February Between eptember 2006 and June 2009 the NPA received reports of 27 deaths, 68 severe harms and 21,383 other patient incidents relating to omitted or delayed medicines. Of the 95 most serious incidents, 31 involved anti-infectives. The RRR lists a number of actions organisations needed to complete by 24 th February One action was for each organisation to identify a list of critical medicines where timeliness of administration is crucial. The list should include anti-infectives amongst other medicines. Another action was to carry out an annual audit of omitted and delayed critical medicines and to ensure that system improvements to reduce harm from omitted and delayed medicines are made. A multicentre collaborative point prevalence audit was designed to allow organisations to benchmark themselves; to identify specific areas of weakness in their current practices and use these to inform system improvements. uccesses in areas of good practice would be shared to support those doing less well. Trusts would be able to use or adapt the methodology to undertake repeat audits in the future to measure improvement. Because a collaborative audit on delayed and omitted of all prescribed medicines would have been unwieldy it was decided to focus the audit on antimicrobials which are prescribed in all care settings and all sectors of care and the NPA had recommended should appear on organisations lists of critical medicines. 4. Methodology Trusts from the four original HAs (East of England, London, outh Central and outh East Coast) in the East and outh East England geography were invited to participate in the collaborative audit. 45 acute trusts, four community health and five mental health trusts submitted data. Participating trusts are listed in Appendix A. The point prevalence audit was carried out over one 24 hour period on a day of choice of the participating Trusts in December Mondays were avoided to mitigate against variations arising from different supply arrangements at weekends; and Fridays were generally too busy a day for data collection. On the nominated day antimicrobials that had been prescribed to be administered over the preceding 24 hour period were reviewed and data was collected on the form provided (this had previously been piloted). Detailed guidance was also provided on data to include and how to record it. Data collection forms and guidance notes can be found in Appendix B. Omitted were allocated to one of six categories describing the reason for omission as recorded on the drug chart. 4

5 Medicines Use and afety Categories used to describe reasons for omission Reason dose omitted Away Blank Not available No route Other Refused Explanation The patient was away from the ward at the time the antimicrobial dose was due Nothing had been recorded in the administration box by the nurse The antimicrobial was reported on the drug chart as not being available on the ward for administration The prescribed route of administration was not available for use e.g. no intravenous access Reason for omission was not covered by any of the other categories but an explanation had been recorded e.g. NBM Patient refused to take the dose The data collectors attempted to follow up the reasons for omissions recorded as not available and blank ; by looking for the unavailable antimicrobial on the ward and estimating if it would have been there at the time the dose was due and for blanks discussing with the nurse (if he/she was on duty at the time of data collection) whether he/she had given the dose but had forgotten to sign the administration record. Local audit co-ordinators ensured consistency of data collection and entered data onto the organisation s master spread sheet. This had been populated with embedded formula to provide some initial local data that could be used to help close the NPA Rapid Response. Master spread sheets from the participating organisations were returned centrally for collation, review of data and data cleansing prior to further analysis. tatistical analysis used the Chi quare test where appropriate. 5. Definitions used in the audit were: Omitted Dose Delayed Dose First Dose Last Dose tat Dose Restricted Antimicrobial Ward tock Definition A dose that had not been given before the next dose was due A dose that was overdue at the time of the audit this was measured in hours (underestimating the actual duration of the delay but identifying the number of that had been delayed) The first dose of a course of antimicrobial therapy. Including those prescribed as stat. The last dose prescribed to be administered during the 24 hours of data collection (not necessarily the last dose of a course) A single dose prescribed to be given as a one-off ; often at a specific time for example as part of surgical prophylaxis. These may be prescribed in a specific section of a drug chart. An antimicrobial that is reserved within a given organisation because of its spectrum of activity, resistance patterns or cost; or because only a specific clinical area uses it. Routinely used antimicrobials that are held as routine stock on a ward and supplied to a ward against a stock list rather than an individual prescription. 6. Results 6.1 Demographics and Overview of Omissions and Delays Overview of all data 45 acute trusts, four community health & five mental health trusts participated 6062 patients from the 54 trusts were prescribed 21,825 of antimicrobials 5.3% (1151/21825) were omitted 13.2% (802/6062) patients missed a dose 6.3% (565/8923) last were delayed 7.7% (467/6062) patients were overdue an antimicrobial dose at the time of the audit. 5

6 Medicines Use and afety Overview for Acute Trusts 17,470 patients from 45 acute trusts were audited 33.9% (5899) patients were prescribed of 8748 antimicrobials. The median number of prescribed per patient was 3 (range 1 to 7). 56.6% (12106) of prescribed were parenteral. 5.2% (1120/21390) of prescribed were omitted Patients missed between 1 and 4 prescribed with a median of one. 13.2% (781/5899) patients missed at least one dose ie 1 in 7 patients The rate of omissions ranged from 0% in one small trust to 9.7%; with 1.4% as the lowest rate in a trust reporting omissions. Trusts ranged between none and 100% of omitted being first % (3261/21390) of prescribed were first 9.6% (313/3261) of prescribed first were omitted 27.9% (313/1120) of omitted were first 10 trusts had no omitted first and for one trust all the first prescribed were omitted, for the remaining trusts 1.7 to 42.9% of first were omitted. 6.4% (562/8748) of last were delayed 7.9% (465/5899) of patients (1 in 13) were overdue a dose at the time of the audit 18% (1066/5899) of patients (1 in 6) had at least one omitted and/or delayed dose Overview for Community Health Trusts 651 patients from four community health trusts were audited 14.7% (97/651) patients were prescribed 265 of 109 antimicrobials. Median number of prescribed was 3 (range 1 to 4) 94.5% (250/265) of prescribed were enteral. 4.5% (12/265) of prescribed were omitted The median number of omitted was one (range 1 to 2) 10.3% (10/97) of patients (1 in 10) missed at least one prescribed dose. The rate of omissions ranged from 1.7% to 14.3% in trusts. Only one trust omitted any first and these were a quarter of all the omitted in that trust. One prescribed dose was delayed by at least four hours 11.3% (11/97) patients (1 in 9) had at least one prescribed dose omitted or delayed Overview of Mental Health Trusts 1534 patients from five mental health trusts were audited 66 (4.3%) were prescribed 170 oral of 66 antimicrobials Median number of prescribed was 3 (range 1 to 4) 11.2% (19/170) of prescribed were omitted Median number of omitted was 2 (range 1 to 3) 16.7% (11/66) of patients missed at least one dose The rate of omissions ranged from 0% in one trust to 21.1%; with 2.6% as the lowest rate in a trust reporting omissions. 25 first were prescribed and 20% (5/25) of these were omitted Trusts ranged between 0 and 75% of omitted being first Two were delayed by at least two hours these were prescribed for a patient who also missed a dose. 6

7 Medicines Use and afety 6.2 Omissions All omissions were allocated to one of six reasons for omission by the data collectors as described in the audit guidance. The categories were away, blank, not available, no route available, other and refused (see section 4 above for definitions of these terms) Acute trusts all omitted In acute trusts 5.2% (1120/21390) of prescribed were omitted. The rates of omissions ranged from 0% in one small trust to 9.7% of prescribed; with 1.4% as the lowest rate in a trust reporting omissions. The three most frequently reported reasons for omission were; a blank administration box on the drug chart (29%), followed by other (26%) and then not available (19%). The least frequently cited reason for omission was the patient being away from the ward (3%); whilst no route available and patient refusing the dose were both found to be 12%. ee Figure 1. The reasons for omission of all and first are also described in table 4 on page 10. Figure 1 Percentage of omitted for each reason in acute trusts Away Other, 26% Aw ay, 3% Blank, 29% Blank Refused No route Not available Other Not available, 19% Refused, 12% No route, 12% Acute Trusts - Omissions by reason More detail is given for each reason for omission in acute trusts starting with the least frequently reported Patient Away from ward was the least frequently reported reason for omission affecting 3% (28/1120) of omitted in acute trusts. Patients were away from the ward eg having an investigation, visiting the physio etc and missed a dose; that is the dose had not been administered by the time the next dose was due. No route available was recorded as the reason for omission for 12% (134/1120) of omitted in acute trusts. This affected patients for whom there was eg no intravenous access or their naso-gastric tube was blocked or had been removed. Refused by the patient accounted for 12% (138/1120) of omissions. Refusal to take a dose occurred over all the medically orientated care areas and less frequently in critical care, surgical areas and maternity. 7

8 Medicines Use and afety An Other reason was recorded for 26% (291/1120) of not administered; these were reasons not covered by the other 5 categories; this could be because a blood level was awaited, the prescribed requested the medicine held or there was no allergy status documented. Many of these omissions could be considered intentional. Leaving the administration box entirely blank was the most frequently reported 29% (320/1120) reason for omitting. The nurse leaving the administration box blank implied that the dose had not been given. In 20.9% (67/320) of occurrences where the administration box had been left blank; data collectors were able to speak to the nurse who confirmed she had given the dose but had forgotten to sign the chart. In 79% of instances the nurse was either not available to have the discussion, could not remember if they had given the dose or confirmed they had not given the dose. Thus it is possible that further had been given but not recorded suggesting 20.9% may be an underestimate of the number actually given with no documentation. Not available was the reason for omission recorded for 19% (209/1120) of omitted. It was possible for data collectors to locate and estimate 30% (63/209) of the antimicrobials were available on the ward at the time the dose had been prescribed to be given; but the nurse for what-ever reason had not been able to find it Omissions in acute trusts perceived as being due to the method of supply of the antimicrobials. Antimicrobials are provided to clinical areas as a stock item where they are likely to be routinely used; whilst agents that are not routinely used in a care area, have a resistance problem, are expensive, or are second or third line treatment are more typically supplied against an individual prescription. A comparison of prescribed and omissions of antimicrobials stocked on wards and those supplied against individual prescriptions is shown in Table 1. Table 1 Acute Trusts - Antimicrobial prescribed and omitted by type of supply arrangement Number (%) of kept as ward stock (%) not stocked and supplied as individual prescriptions prescribed (82.8%) 3671 (17.3%) omitted % of omitted 4.4% 9.3% (p<0.001) Doses supplied on individual prescriptions were found to be omitted twice as often (9.3%) as those routinely available as ward stock (4.4%) (p<0.001). In comparison there was no significant difference in the rates of omission for restricted antimicrobials and those available for routine prescribing see Table 2. Table 2 Acute Trusts - Antimicrobial prescribed and omitted by availability status Unrestricted Restricted antimicrobials antimicrobials prescribed (84.6%) 3290 (15.4%) omitted % of omitted 5.1% 5.8% (p<0.1) 6.3 Community Health - Omissions by reason Twelve in total were omitted in the community health setting. 4.5% (12/265) of prescribed were omitted. This was a lower omission rate than for acute trusts. In one case (8%) the patient was away from the ward; in three cases (25%) the antimicrobial was recorded on the drug chart as being not available (the data collectors did not report being able to find any of the in the care area) and in 8 cases (67%) the administration box on the drug chart had been left blank by the nursing staff. In half of these cases data collectors; were able to confirm with nurse that she had in fact given the dose but had forgotten to record it on the drug chart. Table 3 describes these results. 8

9 Medicines Use and afety 6.4. Mental Health - Omissions by reason Nineteen in total were omitted in the mental health setting. 11.2% (19/170) of prescribed were omitted. In one case there was a recorded other reason for non-administration and there were two cases where the patients refused. In seven cases the administration box on the drug chart had been left blank; the data collectors were able to confirm in two cases (28.6%) that the nurse had in fact given the dose but had forgotten to sign the chart. For the other five cases the data collectors were either unable to speak to the nurse responsible for administering the dose at the time of data collection or if the nurse was available she confirmed she had not administered the dose. A reason of non-availability was recorded for just under half (9/19) of the omitted. The pharmacy staff collecting the data found two of these in the clinical area and estimated they would have been available to be administered. Five of the nine omitted because of non-availability were first of courses. These results are described in Table 3. Table 3 Community and Mental Health Omissions by reason Reasons for Community Health Mental Health Omission % of omissions % of omissions omissions omissions Blank Other Not available Refused No route Patient Away Total Mental Health patients were no more likely to refuse a dose (11%) than physical health patients in an acute setting (12%). 6.5 Acute trusts - omitted first In acute trusts 15.2% (3261/21390) of prescribed were first. Of these 9.6% (313/3261) were omitted. The reasons for omission were of similar proportion to those for all (see Table 4) except for the non-availability category which was almost doubled in frequency; from 19% to 33% (p< 0.001). 807 were omitted and administered from the rest of the course ; an omission rate of 4.45%. First were found to be omitted twice as frequently as from the rest of the course (9.6% v 4.45% p< 0.001). This was a statistically significant difference. Table 4 Acute Trusts - Reasons for omission of all and first of antimicrobials Reason for omission All antimicrobial First of antimicrobials Number % Number % Blank Other Not available (p< 0.001) Refused No route Patient Away Total Reviewing omission rates of first for individual trusts there were ten trusts where no first were omitted and in one where all of the first prescribed were omitted. For the remaining trusts the percentage of first omitted ranged from 1.7 to 42.9%. And considering the proportion of first dose omissions as a percentage of all omissions these covered the complete spectrum from none to 100% of all omitted being first. The trust with 100% of omitted being first had a low (1.4%) overall omission rate. 9

10 Medicines Use and afety Further examination of omitted first revealed that although four trusts had very low (1.4 to 3.5%) overall rates of omission; significant proportions of these omissions (72 to 80%) in three trusts and in one trust all omissions were first. For other trusts their first dose omission rate was more in keeping with their total omission rate. 6.6 Community Health all and first dose omissions Twelve of the 265 prescribed for 97 community health patients were omitted a rate of 4.5%. Although small numbers of patients were both audited and prescribed antimicrobials the rate of omission was lower than that for the acute trusts. 9.8 % (26/265) of prescribed were first and the one (3.8% or 1/26) first dose that was omitted had nothing recorded in the administration box. 6.7 Mental Health all and first dose omissions 11.2% (19/170) of prescribed in mental health trusts were omitted. 14.7% (25/170) of prescribed were first ; 20% (5/25) of these were omitted all were recorded as not being available. The most common reason for non-administration of all was the antimicrobial not being available (49% - 9/19), this was more than double the rate for acute trusts. In 37% (7/19) of cases the administration box had been left blank and on one occasion (5%) another reason was recorded. Two (11%) were refused. Refusal of was no more common in mental health patients than in physical health patients in an acute setting. 6.8 Enteral and Parenteral all trusts All prescribed to be administered in mental trusts and 95.6% (250/265) of those prescribed in community health trusts were enteral. However 56.5% (12085/21390) of the prescribed in acute trusts were intended to be administered parenterally. In acute trusts 44% (490/1120) of omitted were parenteral and 56% (630/1120) were enteral. Enteral were more frequently omitted than parenteral and this was statistically significant (p< 0.001). Table 5 Reasons for omission for enteral and parenteral antimicrobial in Acute Trusts Reason for Enteral Parenteral Acute All Omission Number % Number % Number % Blank Other Not available Refused No route Patient Away Total In acute trusts enteral were found to be more frequently not available than parenteral (p< 0.001). But no route was more frequently cited as a reason for non-administration of parenterals than enterals (p< 0.001). Other was more frequently cited for parenterals (35%) than for enterals (18.6%). 6.9 Results by Care Areas all trusts Patients in acute and community health trusts were allocated to one of eleven pre-defined care areas by the pharmacy staff collecting the audit data according to the ward the patient was on. No allowance was made for outliers. All the community health patients were classified as rehabilitation/intermediate care, except two care of the elderly patients who received all the of antimicrobials prescribed for them. Mental health trust patients were allocated to one of six care areas that were specific to mental health. 10

11 Medicines Use and afety Acute Trusts Care Area Demographics The numbers of patients prescribed antimicrobials in the different care areas varied widely; with quite small numbers from surgical admissions (68), maternity (70) and intermediate care (71) and over a thousand in both general surgery (1132) and specialist medicine (1517) which included infectious diseases patients. Details are given in Table 6. Table 6 Demographics of patients and prescribed antimicrobials by acre areas in acute trusts Care Area patients prescribed antimicrobials antimicrobials prescribed antimicrobial prescribed Proportion of that were parenteral (%) Admissions surgical Admissions medical Care of the elderly Critical Care General Medicine General urgery Maternity Paediatrics Intermediate Care pecialist Medicine pecialist urgery Overall data Note 1 covers eg cardiology, gastro, infectious diseases, respiratory patients Intermediate care had the smallest proportion of parenteral prescribed (16.7%); followed by maternity at 36%. Critical Care at 89.6% had the highest proportion of parenteral prescribed Acute Trust Omissions by Care Areas Information on antimicrobial prescribed and omitted are described in Table 7. The table is ranked with highest omission rates at the top. The ranking for omissions of first remained the same as all except for surgical admissions which moved into second place ahead of care of the elderly. Both intermediate care and surgical admissions had relatively small numbers of patients prescribed antimicrobials but high omission rates. In contrast maternity the other care area with small numbers of patients prescribed antimicrobials had low omission rates of both first and all. Both critical care and paediatrics had large numbers of antimicrobial prescribed but low rates of omission. 11

12 Medicines Use and afety Table 7 Acute Trust numbers of antimicrobial and first prescribed and omitted by care areas Care Area prescribed omitted % of all omitted first prescribed first omitted % first omitted Intermediate Care Care of Elderly Admissions urgery General urgery pecialist Medicine General Medicine pecialist urgery Admissions Medicine Critical Care Maternity Paediatrics Overall data Acute Trust Care Areas Reasons for Omission Table 8 Acute Trusts Reasons for omission by care area as percentages of all omitted in the care area Care Area Away Blank Refused No route Not Other Total available Admissions medical Admissions surgical Care of the elderly Critical Care General Medicine General urgery Intermediate Care Maternity Paediatrics pecialist Medicine pecialist urgery Overall Patient s being away from the ward was the least frequently reported reason for admission in all care areas except critical care where patient refusal was the least frequently reported (would correlate with most critical care patients being sedated). Refusal was reported for a quarter of medical admissions omissions. No route available appeared not to be more of an issue in any one care area compared to another. Leaving the administration box blank was the most frequent reason for omission for five of the care areas (admissions medical, care of the elderly, maternity, specialist medicine and specialist surgery). But was less of an issue for critical care areas. For four care areas other was the most frequently reported reason for omission and for two areas intermediate care and surgical admissions not available was the most frequently reported reason with admissions surgical areas reporting 50% of omitted for this reason Acute Trust tat dose prescribing ingle to be administered eg as part of surgical prophylaxis are often prescribed as stat ; trusts may have a specific section of the drug chart to accommodate this. First of a course of treatment can also be prescribed as stat and indeed are advocated in some trusts. A single dose for treatment or prophylaxis was also considered as a first dose for this audit. 12

13 Medicines Use and afety 3261 first prescribed 9.5% (313/3261) first omitted 21.3 % (695/3261) of first were prescribed as stat 5.2% (36/695) of stat were omitted 2566 first were prescribed as regular medication 10.9% (279/2566) of first prescribed on the regular side of drug chart were omitted. Table 9 Acute trusts - Administration of first prescribed as stat or as regular medication Prescribed as stat Prescribed as regular medication Administered 695 (95.1%) 2566 (89.1%) Not administered 36 (5.2%) 279 (10.9%) p< The first dose of a course of antimicrobials were omitted twice as frequently when prescribed on the regular side of the drug chart compared to the stat section of a drug chart. This was a statistically significant difference. (p<0.001) A detailed table of omissions of first, stat and first prescribed as stat by acute trust care areas is in Appendix C Omissions by care area for Community and Mental Health patients All but two of the community health patients were from the rehabilitation /intermediate care area and all twelve omissions related to this care area. The two care of the elderly patients received all of the prescribed of antimicrobials. 4.5% (12/265) of all antimicrobials were omitted and 3.8% (1/26) of first were omitted. For mental health patients no data was recorded for Child and Adolescent nor for Eating Disorder patients. No were omitted in Learning Difficulties and only two (and no first ) in ecure and Forensic Health patients. Details of the omissions for the four mental health care areas where omissions occurred are described in Table 10. The table is ranked with the highest omission rate at the top. Table 10 Mental Health All and First dose omissions of antimicrobials by care areas Care Area prescribed omitted % omitted first prescribed first omitted % first omitted Working Age Mental Health Older Peoples Mental Health ecure & Forensic Health Learning Disabilities Overall Results for delayed last The last dose prescribed to be given was assessed by the data collectors as to whether it had been given or if was overdue in which case it was considered delayed. The delay at the time of the audit was measured in hours (underestimating the duration of the delay but identifying the number of that had been delayed) 13

14 Medicines Use and afety Delays - Acute Trusts 8748 last were prescribed 6.4% (562/8748) were recorded as delayed 28% (157/562) of delayed were delayed by up to 1 hour at the time of the audit. 54% (302/562) of delayed were delayed by up to 2 hours at the time of the audit 80% (454/562) of delayed were delayed by up to 4 hours at the time of the audit 7.9% (465/5899) of patients (1 in 13) experienced a delayed dose Figure 2 Acute Trusts delayed antimicrobial by length of delay at time of audit A first dose prescribed to be given could also be the last dose due to be given during the audit period. 42% (236/562) of the delayed were first. 7.2% (236/3261) of first were delayed. First dose delays followed a similar pattern of length of delay to that seen with all dose delays Acute Trust Delayed Parenteral and Enteral antimicrobial There was no statistically significant difference in the frequency of delays between enteral and parenteral. Table 11 Acute Trusts delayed parenteral and enteral antimicrobial Parenteral antimicrobials Enteral antimicrobial prescribed delayed % of delayed 2.56% 2.7% Acute Trust Delays by Care Area All care areas experienced delayed last, maternity and paediatrics had higher proportions of delays compared to other care areas; although both of these care areas had low omission rates compared to other care areas. Table 12 ranks the care areas by percentage of last delayed. 14

15 Medicines Use and afety Table 12 Acute Trusts delayed by care areas Care Area last prescribed delayed last % of last delayed % patients who had a delayed dose Paediatrics Maternity Care of the elderly Intermediate Care Admission surgical General Medicine pecialist Medicine General urgery Admission medical pecialist urgery Critical Care Overall data Delayed Doses Community and Mental Health Patients Only one Community Health dose was delayed; which was by at least four hours and this was a rehabilitation/intermediate care patient. There were two Mental Health delayed by at least two hours; these were in Older People s Mental Health Electronic prescribing sites compared to traditional prescribing As electronic prescribing is thought to bring benefits to patients a sub-analysis of electronic prescribing versus traditional prescribing sites was performed to see if electronic prescribing reduced the number of omissions and delay. The omission rate for both types of prescribing was exactly the same (5.2%) However the omission rate for electronic prescribing sites was lower for first (8.7%) compared to traditional prescribing sites (9.7%) however this difference was not statistically significant. A greater proportion of first are prescribed as stat in electronic prescribing sites compared to traditional prescribing (32.1% v 20.4%). And changing the route eg from parenteral to oral creates a new prescription in electronic prescribing systems whilst for many trusts multiple routes of administration would count as one prescription when prescribed on paper. Table 13 Acute Trusts Antimicrobial dose omission by electronic and traditional prescribing sites % of antimicrobial administered % of antimicrobial omitted Electronic Prescribing sites 1805/1904 (94.8%) 99/1904 (5.2%) Traditional Prescribing sites 18465/19486 (94.8%) 1021/19486 (5.2%) All 20270/21390 (94.8%) 1120/21390 (5.2%) The reasons for omission were similar between electronic prescribing and traditional prescribing sites; see Table 14. Despite having an electronic prescribing system 19% of administration records were left blank. 15

16 Medicines Use and afety Table 14 Acute Trusts Comparison of reasons for omission for electronic and traditional prescribing sites Reasons for Omission Omitted antimicrobial Electronic Prescribing ites Traditional Prescribing sites Number % Number % Blank Other Not available Refused No route Patient Away Total A larger proportion of were reported as delays by trusts using electronic prescribing (16% 133/831) than traditional prescribing 5.4% (429/7919). This difference was statistically significant (p< 0.001). 1 in 3.6 patients from electronic prescribing sites experienced a delayed dose whilst for traditional prescribing sites the number reported was 1 in 12. Table 15 Acute Trusts comparison of delayed last for electronic and traditional prescribing sites Electronic Prescribing ites Traditional Prescribing ites Number % Number % Last prescribed Delayed Last % % patients prescribed antimicrobials No of patients with a delayed dose % % 7. Discussion Was it appropriate to focus on antimicrobials rather than all medicines? The NPA recommended trusts should have a list of medicines where delays or omissions were considered to be critical; they also advised that antimicrobials (along with anti-coagulants, insulin, resuscitation medicines and medicines for Parkinson s Disease) were included on the list. Antimicrobials are used by all care areas in all types of trust which allowed a wide range of organisations to participate. Antimicrobials are frequently prescribed agents and all health care staff should have an awareness of the importance of administering antimicrobials; suggesting that performance with antimicrobials is likely to reflect similar performance with other medicines. Focusing on antimicrobials made the data set more manageable. What were the most frequently reported reasons for omission in acute trusts? Leaving the administration box blank was the most frequently reported reason for omission (29% of cases of missed ). Where possible Pharmacy taff followed up whether the nurse had given the dose but had forgotten to sign the chart. For 20.9% of the blank administration boxes it was possible to confirm with the nurse this was the case. The data may have been skewed by the way the information was obtained and the pharmacy staff were not always able to complete the task. However this was such a large proportion of the missed that work needs to be undertaken locally with nursing staff to improve record keeping (tandard 8 point 2.10 of the Nursing and Midwifery Council s tandards for Medicines Management 2 states you must make a clear accurate and immediate record of all medicines administered, intentionally withheld or refused by the patient ensuring the signature is clear and legible.. In addition.. where medication is not given the reason for not doing so must be recorded..). Raising the awareness of the importance of patient s receiving their medication on time is also key. 16

17 Medicines Use and afety The second most frequently reported reason for omission was Other at 26% these were omissions where a recorded reason for omission had been made but it was not covered by one of the remaining five reasons. Other could include waiting for a level; withheld on prescriber s instructions, unable to read the prescription etc. ome of these omissions could be considered intentional and therefore justified but more local investigation is required and solutions implemented to reduce the risk to patients. 19% of omitted were recorded as Not available. Where this was the case auditors searched for the dose on the ward to see if it had been available at the time the dose was due. In 30% of cases the dose was assessed as being available for administration. This figure may be an under-estimate because the search for all non-available may not have been completed. Further analysis of the not availables was undertaken to see if the method of supply affected the omission rates; and these results are discussed later. Overall 12% of omitted were due to patient s refusing. The proportion of missed for this reason was higher in care of the elderly and in medical admissions. Clear explanations to patients about new treatments started may help adherence. The same percentage of omitted was due to the route of administration not being available to use, this would include no intravenous access or no nasogastric (ng) tube in place. Prescribers need to be aware of routes available at the time of prescribing and where necessary plan ahead if a route this likely to become unavailable eg poor veneous access or confused patient s removing ng tubes. Nursing staff must liaise promptly and medical staff must respond promptly to such situations. Patients being Away from the ward provided the smallest percentage (3%) of omitted. However Trusts must have clear processes for catching up with omitted or delayed. Are first omitted more than other? First were found to be omitted more often than other. In acute trusts patients were found to miss first twice as often as other and this was the case across all care areas. This was an important finding because first of antimicrobial courses may be critical (eg in sepsis). This was a particular issue for surgical admissions where timely administration of antimicrobial prophylaxis and therapy is vital. A smaller proportion of first were audited in community health and mental health settings it is therefore more difficult to draw conclusions. The audit showed acute trust patients were twice as likely to miss a first dose because it was not available (33%) compared to all (19%) and this was a statistically significant finding. hould the first dose of a course of treatment be prescribed as a stat dose? The audit suggests prescribing first as stat does reduce the omission of. First were omitted twice as frequently when prescribed on the regular side of the drug chart (10.9% - 279/2566) compared to prescribing as a stat dose (5.2% - 36/695). The omission rate of first in Electronic Prescribing sites was lower than traditional prescribing sites (8.7% v 9.7%) but was not statistically significantly different. However a greater proportion of first are prescribed as stat in electronic prescribing sites (32.4% v 20.4%) and these tend to be omitted less frequently than first prescribed as part of a regular prescription. ome trusts have a policy that first of courses of treatment should be prescribed as a stat dose; as the omission rate was lower than for first prescribed on the regular part of the drug chart the audit results suggest all trusts should adopt such a policy. A review of local policies where they do exist is also recommended as anecdotally it would appear that although such a policy may exist it is not always adhered to. Are omitted more often from some care areas than others? Omission rates varied in care areas from 2.4% in paediatrics to 8.6% in intermediate care. Omission frequencies were highest in intermediate care, care of the elderly and surgical admission care areas in acute trusts (although the small numbers of intermediate care patients make the findings in this care area less reliable). Local actions on omitted should be prioritised to the areas that have particular issues for individual trusts. 17

18 Medicines Use and afety A smaller proportion of community health care area patients (14.7%) were prescribed antimicrobials but were missed less frequently (4.5%) compared to acute care settings (5.2%). There is however a problem to be addressed. An even smaller proportion of patients in mental health settings (4.3%) were prescribed antimicrobials but these patients missed more frequently than those in acute care settings (11.2% of omitted compared to 5.2%) and more often because the dose was not available (49% v 19%). Mental Health Trusts are encouraged to review supply processes locally. Does being on a stock list improve the likelihood of a dose being given? Patients were found to miss twice as many if the antimicrobial was supplied against an individual prescription compared to those available in the clinical area as stock. This was statistically significant. Locally trusts must review supply processes including access to anti-microbials out of hours. And stock lists must be reviewed regularly. Traditional methods of controlling access to antimicrobials (ie requesting an individual prescription to dispense against) appear to lead to more missed. Concerns about resistance developing could be reduced by adopting the Department of Health s approach of tart mart then Focus 3 where prompt effective anti-microbial treatment is initiated against local guidelines within an hour of diagnosis then a Focus is made by reviewing by 48 hours to top, witch, Change Continue or OPAT (outpatient parenteral antibiotic therapy) Are restricted antimicrobials missed more often than freely available agents? No there was no statistically significant difference between omissions of restricted antimicrobials and those freely available; unlike those that are not stocked onwards. Were delayed less of a problem than omitted? Unfortunately not there were fewer last prescribed (8923) however a greater proportion of these were delayed (6.3% - 565/8923) compared to being omitted (5.3% /21825). The audit identified the number of that were delayed but the length of the delays was an underestimate as the duration of the delay was measured at the time of data collection rather than up to when the dose was eventually given (a number of these delays would go on to become omissions if the delay lasted until the next prescribed dose was due). The audit did not identify the number of patients whose dose was delayed because they were away from the ward so it was not possible to contrast those patients missing a dose and those catching up with dose when they returned to the ward later What can be done to reduce delays? imilar actions as those needed to reduce omissions will help reduce the number of delays; including raising awareness to ensure are given on time; particularly for first. A higher proportion of first were delayed (7.2% - 236/3261) compared to all (6.3% - 565/8923). Providing guidance on what do to about that get out of synch with their prescribed times may be helpful. Was patients being away from the ward an issue for delays and omissions? Patients being away from the ward accounted for a relatively small percentage of omissions (3%). Reasons for delayed were not recorded but could include being away from the ward. The delayed dose data was not sensitive enough to identify if patients being away from the ward caught up with later and therefore did not turn into an omission. Are parenteral delayed or omitted more often than enteral ones? Although the overall data showed there was no difference in delays of parenteral and enteral ; a closer look at local data would be helpful in trusts where the practice is to give enteral medication first and then give the parenteral. Enteral were more frequently omitted than parenteral ones this could be because more importance is given to parenteral than enteral because the route of administration implies the patient is sicker. 18

19 Medicines Use and afety Does electronic prescribing reduce the frequency of omissions and/or delays? No difference was found in the omission rates for electronic prescribing and traditional prescribing sites. There were slightly fewer first dose delays in electronic prescribing sites. Electronic prescribing sites like traditional prescribing sites had a significant proportion of omissions where the administration box was left blank. There was however a higher proportion of delays reported for electronic prescribing sites, this data would have been easier and more accurate to collect and may be a more true representation of delays. Was the methodology robust? Point prevalence data collection is a well recognised methodology and is already in place in many trusts for collecting antimicrobial prescribing data. The data collection forms and spread sheets can be used per se or adapted for use by organisations to repeat delayed and omitted dose audits; there are examples of this happening. What were the limitations of the audit? A large number of people collected the data from clinical areas and then a smaller number of people entered data onto the trust s spread sheets. It was assumed data had been collected and entered as intended. Despite detailed guidance being given; there could have been local interpretation and there was a need to cleanse the data submitted and ensure all the relevant boxes had an entry. The number of omissions and delays could be an under-estimate of the true picture as data was not collected on Mondays to mitigate against different supply mechanisms at the weekend. The study design allowed for an accurate record of the number of delayed to be measured but it was not possible to measure the exact duration of the delays as the data was collected at a specific point in time. Different methodology (such as an observational study) would need to be used to measure the delays accurately. However, it is generally recommended that first should be administered within an hour of the prescribed time and other within two 2 hours. This audit was sensitive enough to show that there is an issue with delayed. Trusts decided whether to audit all occupied beds or to target care areas; this may have skewed data particularly for those care areas with small numbers. The audit did not distinguish between prescribed for treatment or for prophylaxis. For electronic prescribing sites the number of courses of treatment given may appear high as stat and change of route prescribing is recorded as a separate prescription. 8. ummary Omitted and Delayed were found to be affecting 13.2% and 7.7% of the patients audited who had been prescribed antimicrobial agents during a 24 hour period in December In acute trusts 5.2% of prescribed were omitted; the commonest reason was because nothing was documented in the administration box (29%); non-availability of the dose was recorded in 19% of cases; no route and refusal were both 12% and away from the ward just 3%. In 26% of cases the omission was due to a reason not covered by the other categories. First of a course; first not prescribed as stat and antimicrobials not stocked on the ward were twice as likely to be missed. 19% of reported as not available were found on the ward and would have been available to administer. On follow up at least 29% of not signed as being administered had been given. There were differences in omission rates for different care areas in acute trusts; care of the elderly patients had a high omission rate and critical care and paediatrics a low omission rate. Electronic prescribing sites had the same omission rate as traditional prescribing sites. Mental Health and Community Health patients were prescribed fewer antimicrobials compared to acute trusts. 16.7% of mental health patients missed at least one dose more often through non-availability than in acute trusts. 19

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