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Up and down the country, there are hospital wards that do not receive regular clinical pharmacy input. Budgets are under pressure and services are stretched to capacity. So decisions are made on a daily basis about which wards need a clinical pharmacist and which can do without.
The hospitals in NHS Ayrshire & Arran were once like this. Only then, in 2010, a critical incident occurred involving a patient who did not receive clinical pharmacy input. A subsequent review concluded that a pharmacist’s intervention may have prevented harm. And so things had to change. Instead of throwing resource at the problem, NHS Ayrshire & Arran came up with a rather different solution. The board’s director of pharmacy, Michele Caldwell, describes it as a development that has “totally redesigned how we run our clinical pharmacy service”.
Early warning system
The solution is called a “pharmacist early warning system” (PhEWS). The basic idea is simple: it is a risk categorisation system. Medics have long operated a similar risk scoring system in hospitals to identify when a patient needs a doctor’s attention. The pharmacist system works in the same way, with each patient being assigned a score for a number of different pharmaceutical care factors. This results in a patient being graded as a red (high risk), amber (medium risk) or green (low risk) status. A red score indicates a priority for a pharmacist review. The system also identifies any patients who are new to the hospital.
Introducing a risk scoring system for pharmacists is far from unique to NHS Ayrshire & Arran. The crucial difference – the difference that has allowed NHS Ayrshire & Arran to transform its clinical pharmacy service – is that the system is automated. Automation makes the system significantly more efficient since it extracts data from an electronic system, instead of having to manually find data and calculate a risk score. The health board has been at the leading edge of electronic prescribing for some years, and started to implement a hospital electronic prescribing and medicines administration (HEPMA) system in 2000. “Without HEPMA, it would not have been possible to automate the risk scoring system,” Mrs Caldwell explains.
Once PhEWS had been successfully piloted, the clinical pharmacy service was redesigned. Now, instead of deciding whether a ward merits a clinical pharmacist’s regular input, the decision is made on a patient-by-patient basis. All patients who are new to the hospital are seen by a pharmacist as well as those who have a “red” score, regardless of the ward in which the patient is staying. “This doesn’t necessarily mean that pharmacists are not doing ward rounds. It is just that they are not seeing every patient on a ward round,” says Mrs Caldwell. So pharmacists may visit two patients on one ward, three on the next and so on. It is a completely different way of working.
The PhEWS system is based on a list of risk factors (see Panel). Data for these risk factors are entered into HEPMA at various stages of the patient’s journey, including on initial admission to the hospital, during medicines reconciliation, and when medicines are changed or amended during the hospital stay. The final calculated risk score is a combination of all the different risk factors.
Twice a day, a report is run within HEPMA which generates the risk scores. The report is emailed to the clinical pharmacy team who then pick up their case load based on the red- and amber-graded patients. Every red patient is seen, and then as many amber patients as there is time to see.
Development of PhEWS followed standard improvement methodology, using plan-do-study-act cycles. “It has only happened because the whole team has worked together. Richard Cottrell, senior clinical pharmacist for HEPMA development, and Gillian Jardine, principal pharmacist, led the team who worked through 18 modifications of the scoring system. The testing phase also compared the high risk patients identified by the system and those picked up by a traditional ward round, and we got a match. So we are confident in the system,” says Mrs Caldwell.
An evaluation of PhEWS was published in December in the journal Hospital Pharmacy Europe. It shows that the time between prescribing and clinical pharmacist intervention has been cut for all prescriptions, but particularly for medicines considered to be high risk. “The most important outcome is that patients with significant pharmaceutical care needs are prioritised,” says Mrs Caldwell. “In addition, the system makes better use of the pharmacist resource.”
However, there have been challenges. Some pharmacists have taken longer than others to have confidence in the risk scoring approach. There was also a concern that pharmacists would lose existing relationships with wards. This has been addressed by ensuring that each ward has a named pharmacist who the ward staff know.
PhEWS is constantly evolving. The next step is to include laboratory data. The team is currently working on adding INR and platelet levels, and hopes to add further markers like creatinine clearance data in future.
The implications of PhEWS are far-reaching. In addition to extending it to other hospitals, it may work in other care settings. For example, some NHS boards are currently introducing clinical pharmacy services in care homes, and prioritisation of patients in this setting would be equally useful. However, it is the electronic underpinning that makes the system so successful in Ayrshire & Arran. While some hospitals still operate without an electronic prescribing system, PhEWS may seem like a bit of a pipe dream.
Panel: Risk factors
Some of the risk factors included in the current version of the pharmacist early warning system are:
- Number of medicines
- Specific medicines: methadone, lithium, clozapine, immunosuppressants, anticoagulants, opiates, alert antibiotics, some IV antibiotics, oral potassium, complex infusions
- Duration of specific medicines: antibiotics, antimicrobials, IV paracetamol, Pabrinex, prednisolone tablets
- Restricted supply list and high risk medicines
- Specific diseases: Parkinson’s disease, epilepsy
- Allergy status