YORKSHIRE AND HUMBER CLINICAL PHARMACY BENCHMARKING Chris Acomb BSc MPharm FRPharmS Clinical Pharmacy Manager (Professional Development) Leeds Teaching Hospitals With thanks to all my fellow Clinical Pharmacy Managers across Yorkshire and Humber
Consider: Pharmacist A: attends a consultant ward round. Contributes by advising on the correct IV vancomycin loading dose, maintenance dose, and arranging the first blood level (which was within range). Pharmacist B. visits a ward, notices a patient on vancomycin and reviews the prescription. Realises patient is on the wrong maintenance dose and levels not arranged at correct time. Pharmacist makes intervention to request urgent levels. Levels come back toxic.
Consider: Pharmacist A: attends a consultant ward round. Contributes by advising on the correct IV vancomycin loading dose, maintenance dose, and arranging the first blood level (which was within range). Contribution Pharmacist B. visits a ward, notices a patient on vancomycin and reviews the prescription. Realises patient likely to be on the wrong maintenance dose and levels not arranged at correct time. Pharmacist makes intervention to request urgent levels. Levels come back toxic. Intervention
Consider Pharmacist C: working in the dispensary on a Sunday morning. Prescription chart comes down for supply of ceftazidime IV 1g tds for a patient on a medical ward. Dose in line with BNF and for approved indication. Pharmacist D: visits a medical ward. Sees a new prescription for ceftazidime IV 1g tds. Reviews the medical notes for reason for admission and common pathophysiological parameters. Notices poor renal function and makes intervention to change dose.
Consider Pharmacist C: working in the dispensary on a Sunday morning. Prescription chart comes down for supply of ceftazidime IV 1g tds for a patient on a medical ward. Dose in line with BNF and for approved indication. Prescription validation but toxicity Pharmacist D: visits a medical ward. Sees a new prescription for ceftazidime IV 1g tds. Reviews the medical notes for reason for admission and common pathophysiological parameters. Notices poor renal function and makes intervention to change dose. Medication Review & intervention
We need clear definitions and standards If I sign a prescription chart what am I taking responsibility for? What is the difference between: Confirmation of medication history and Medicines Reconciliation (stage 1) and Are pharmacy technicians allowed to do both or either?
Remember The patient admitted to an ENT ward with sore throat...
Remember The patient admitted to an ENT ward with sore throat; They had neutropenia from daily methotrexate, not picked up, continued to get daily methotrexate died No regular pharmacist visit to the ENT ward. How many of you send a junior pharmacist to your ENT ward?
Why: Clinical Pharmacy Activity benchmarking? Which wards should we send pharmacists to? What should they do when they get there? Is the way we deliver the service in our trust as effective as the trust down the road?
Clinical Pharmacy Activities Defined 14 different direct patient care activities undertaken by pharmacists on wards, agreed across Yorkshire and Humberside A Medication History B Medicines Reconciliation C Inpatient Prescription Validation D Medication Review E Brief advice / information to patients F Comprehensive patient consultation G Responding to a request from healthcare worker H Pharmacist prescribing I Contributing to an MDT / ward round J Prescription validation of TTO K Care plan communicated to primary care L Accuracy checking of TTO drugs / PODs for discharge M Any other strange thing you do!!
Prescription Validation (Level 1) This is the checking of a prescription / chart using only the information available on the prescription / chart. The purpose is to ensure that the medicines prescribed, are (at face value) suitable for the patient. The pharmacist is taking responsibility for 2 components: The prescription is reasonable and unambiguous in terms of the medicine to be supplied and / or administered. The product to be supplied is of appropriate quality and will be made available
Medication Review (Level 2) A structured, critical examination of a patient s medicines with the objective of optimising the clinical benefit, minimising the number of medication-related problems and reducing waste. The pharmacist must attempt to access the relevant clinical information to enable them to make judgement on the suitability of the whole prescription. In addition to the criteria in Prescription Validation (Level 1) the pharmacist is expected to consider: the reason for admission, common patho-physiological factors that may alter the response to drug therapy, response to recent previous drug treatment and contraindications.
Major step forward in our thinking Don t use clinical check when you mean prescription validation. Record what level of check you have done Level 1 Prescription validation Level 2 Medication Review
Front page of Yorkshire Drug Chart Pharmaceutical Care Record Sign Date Drug hist A Tech 1/1/13 Med rec A Phrm 1/1/13 Disch Rx Pharmacist medication review Level 2 1 1 2 Sign A Phrm B Phrm C Phrm A Phrm date 1/1/13 2/1/13 3/1/13 4/1/13
How we measured activity Developed data collection form One form per pharmacist per ward for 7 days Included time spent on ward & clinical speciality of the ward Activity is always counted as Number of patients Defined minor and significant interventions Counted the number of minor interventions Documented significant interventions - more details Defined clinical specialities into groups
Data collected during one week in July 2012 All data expressed as No. of patients per hour This is inpatient data only (NOT day case / OP) Attempted to also relate data to admission data
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity A: Medication History Confirmation per hour 2.00 1.80 1.60 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Harrogate Leeds Sheffield Hull York Median value Airedale Mid Yorks Calderdale Scarborough
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity B: Medicines Reconciliation per hour 1.60 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Sheffield Leeds Hull York Median value Harrogate Airedale Scarborough Calderdale Mid Yorks
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity C: Level 1 Prescription review per hour 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Sheffield Leeds Hull York Median value Airedale Harrogate Scarborough Calderdale Mid Yorks
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity D: Level 2 Medication Review per hour 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Hull Harrogate Leeds York Sheffield Median value Calderdale Scarborough Mid Yorks Airedale
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity E: Brief Advice to Patients per hour 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Airedale Leeds Sheffield York Median value Mid Yorks Hull Scarborough Harrogate Calderdale
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity F: Comprehensive consultation with a patient / hour 0.25 0.20 0.15 0.10 0.05 0.00 Mid Yorks Scarborough Leeds Calderdale Airedale Sheffield Median value York Harrogate Hull
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity G: Advice to healthcare professionals per hour 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Sheffield Harrogate Leeds Airedale Median value Scarborough Calderdale Hull York Mid Yorks
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity H: Pharmacist prescribing per hour 0.35 0.30 0.25 0.20 0.15 0.10 0.05 0.00 Scarborough Mid Yorks Calderdale Leeds Sheffield Median value Hull Harrogate Airedale York
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity I: MDT / ward round per hour 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Scarborough Airedale Calderdale York Median value Harrogate Sheffield Mid Yorks Hull Leeds
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity J: TTO validation at ward level per hour 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Calderdale Hull Airedale Scarborough Median value Leeds Sheffield Mid Yorks Harrogate York
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity K: Contact primary care / care plan per hour 0.18 0.16 0.14 0.12 0.10 0.08 0.06 0.04 0.02 0.00 Hull Mid Yorks Calderdale Sheffield Leeds Median value Scarborough Harrogate York Airedale
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity L: TTO / POD accuracy check at ward level per hour 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Hull Sheffield Leeds Scarborough Mid Yorks Median value York Calderdale Airedale Harrogate
Yorkshire and Humber Clinical Pharmacy Benchmarking Activity N: Technician drug chart screening per hour 5.00 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Mid Yorks Scarborough York Calderdale Median value Sheffield Hull Leeds Harrogate Airedale
Which activity leads to significant interventions A Medication History 17 (8%) B Medicines Reconciliation 31 (15%) C Inpatient Prescription Validation 3 D Medication Review 100 (50%) E Brief advice / information to patients 2 F Comprehensive patient consultation 9 (4%) G Responding to healthcare worker 16 (8%) H Pharmacist prescribing 1 I Contributing to an MDT / ward round 7 (3%) J Prescription validation of TTO 8 (4%) K Care plan communicated to primary care 1 L Accuracy checking of TTO drugs 6 (3%) M Any other strange thing you do!! 1
Which speciality group has the most significant interventions Med Rec L2 Med Rev Elderly 12 (39%) 4 General Medicine 3 11 General Paediatrics 1 2 General Surgery 6 (19%) 4 Intensive Care 0 5 Oncology & Haematology 2 54 Orthopaedics 1 2 Other 1 0 Specialist Medicine 4 6 Specialist Paediatrics 0 10 Specialist Surgery 1 2
Significant interventions per hr by Trust Leeds Sheff Hull Mid Yks Harrog General Medicine 0.10 0.07 0.13 0.13 0.21 Specialist Medicine 0.18 0.20 0.00 0.00 0.00 Elderly 0.15 0.10 2.37 0.04 0.58 Oncology & Haematology 0.42 0.21 0.12 0.00 0.00 General Surgery 0.17 0.03 0.17 0.18 0.21 Specialist Surgery 0.12 0.11 0.00 0.00 0.00 Intensive Care 0.32 0.27 0.00 0.07 0.67 Orthopaedics 0.59 0.24 0.24 0.00 0.18 General Paediatrics 0.05 0.00 0.33 0.19 0.00 Other 0.59 0.41 0.00 0.09 0.00
Who makes the significant interventions Band Hours Significant interventions / hour 7 66 0.23 8A 115 0.35 8B 19 0.64 8C 0 0.00 8D 1 0.50
Minor interventions Classed as minor or moderate using risk matrix Details not recorded but did record Which activity led to the intervention How the issue was resolved
Which activity leads to minor interventions A Medication History 142 (9%) B Medicines Reconciliation 248 (15%) C Inpatient Prescription Validation 142 (9%) D Medication Review 496 (30%) E Brief advice / information to patients 15 F Comprehensive patient consultation 61 G Responding to healthcare worker 90 H Pharmacist prescribing 22 I Contributing to an MDT / ward round 71 J Prescription validation of TTO 320 (20%) K Care plan communicated to primary care 9 L Accuracy checking of TTO drugs 12 M Any other strange thing you do!! 11
Minor interventions - how resolved Med Rec TTO validation Prescriber contacted 280 107 Prescriber not contacted 85 193 Monitoring recommended 95 6 Other 35 14
Which speciality group minor interventions PC PNC Mon Oth Total Per Hr General Medicine 158 122 55 44 379 1.2 Specialist Medicine 24 12 21 2 59 1.1 Elderly 136 134 44 8 322 1.8 Oncology & Haematology 193 57 84 20 354 2.4 General Surgery 68 44 36 14 162 1.3 Specialist Surgery 49 50 14 6 119 4.7 Intensive Care 27 0 15 2 44 1.6 Orthopaedics 0 0 0 0 0 0 Obstetrics 0 0 0 0 0 0 General Paediatrics 32 15 4 0 51 0.7 Specialist Paediatrics 31 3 8 2 44 0.8 Other 90 14 0 0 104 15 Total 808 451 281 98 1638
Minor interventions Overall during the 7 day data collection period we changed 451 prescriptions without contacting the prescriber. Does this matter?
Summary Agreed definitions across Yorkshire & Humberside Activity measured during one week allows trust to trust comparison Interventions broken down by speciality and by activity Data has been used by trust chief pharmacists in their reports and in justification of pharmacy services
Criticisms Incomplete data collection Variability in interpretation of different activities Capturing both technician and pharmacist activities Mass of data needs to be electronic Admission data variable across trusts
Questions Does it help us as Clinical Pharmacy Managers direct our resources? Speciality? Activity? Does it help us compare trusts? How do we better collect data on contributions as well as interventions to prevent near misses?