Using pharmaceutical prioritisation tools to improve patient care

Introduction

The demand for clinical pharmacy services continues to outstrip the resources available within healthcare organisations. This has driven pharmacists across the globe to develop tools or processes that support them in identifying patients who require greater pharmacy input. The use of prioritisation tools to target the delivery of pharmaceutical care is one approach that has garnered increasing interest globally^​1–6​. Such tools seek to improve patient outcomes by mitigating the challenges of delivering increasingly complex care to rising numbers of patients within a resource-limited healthcare landscape. Pharmaceutical prioritisation tools are designed to categorise patients into risk groups based on predefined clinical criteria, determining how frequently each group should receive pharmacy review. Although innovative for pharmacy, prioritisation of patients is a well-established approach to the delivery of care in nursing^​7,8​. 

The Safer Nursing Care Tool was developed to assess patient complexity and inform staff distribution across wards^​9​. According to the results of a multi-centre observational study, published in 2020, the Safer Nursing Care Tool was found to be reliable in estimating the number of nurses needed per ward^​10​. While pharmaceutical prioritisation tools have the potential to improve the delivery of pharmacy services across a range of settings, their use beyond hospital care remains limited and underexplored. The findings of a review of the international literature, published in 2020, only uncovered 13 studies of tools that were used to direct pharmacist-led services, such as medication review; however, none of those studies were based on work in the UK^​11​. This article will focus on pharmaceutical prioritisation within inpatient settings. 

Benefits of patient prioritisation tools

The prioritisation of patients for clinical pharmacy services could play a significant role in reducing and preventing medication-related problems^​5​, particularly in a resource-stretched NHS. Structured patient prioritisation approaches may improve patient care and ensure that the right patients are seen at the right time, improving pharmacy service delivery and workload efficiency^​1,6,12​. Adopting such approaches has numerous potential benefits, the chief one being a reduction in medication harm, as those who are at higher risk of medication-related problems are targeted for a pharmacy review^​13​. Other possible benefits are an increase in pharmacy staff’s confidence in prioritising and reviewing patients, more seamless handover between pharmacy staff, improved time-management, and support for less experienced staff in learning and enhancing their skills^​1,12​.

From a managerial perspective, prioritisation tools support pharmacy managers in visualising workforce and clinical demand, which, in turn, can support delegation and efficient workload management^​12​. In some organisations, complex patients have been allocated to pharmacists who possess the most relevant knowledge or expertise^​1​, ensuring appropriate use of pharmacists’ skillsets. Dynamic and digital prioritisation tools — linked to electronic patient records — may have additional benefits owing to their ability to respond dynamically to changes in patient care, such as the prescribing of new medicines^​12​.  

It is important to understand that the benefits of pharmaceutical prioritisation tools extend beyond prioritising patients for review during staff shortages or low capacity. Pharmaceutical prioritisation tools may shift the way that pharmacy ward services have traditionally been provided, moving away from daily, yet superficial, review of all patients, towards an approach where pharmacy professionals allocate their limited time to those patients at heightened risk of harm from medicines. This is an approach that might be more fruitful for improving patient outcomes^​14​. Studies from the UK and Ireland have reported that deprioritising lower-risk patients is beneficial in saving both time and resources^​15,16​, which aligns with NHS healthcare priorities by promoting equity, ensuring that care is responsive, proportionate and tailored to patients’ differing needs and circumstances.

In the UK, the need for targeted clinical pharmacy services was highlighted by NHS England’s report ‘Transformation of seven day clinical pharmacy services in acute hospitals’^​17​, published in 2017, as well as the Royal Pharmaceutical Society’s ‘Professional standards for hospital pharmacy services’, published in the same year^​18​. Recent studies reported that more than 50% of acute and around 30% of mental health trusts and boards had utilised pharmaceutical prioritisation approaches to facilitate clinical pharmacy services in their institutions^​12,19​. Pharmacists reported that such approaches were needed to reduce patient safety events, enhance pharmacy service delivery and standardise care, especially considering that reviewing all patients daily and achieving national targets for some services (e.g. medication reconciliation) were difficult to accomplish^​12,19​. The pharmaceutical prioritisation approaches used were reported to be valuable in improving pharmacy service delivery and patient outcomes^​12,19​. In addition, some organisations reported that prioritising specific pharmacy services (i.e. prioritising medication reconciliation), either alone or alongside individual patient prioritisation, may have additional benefits^​12​.

Existing pharmaceutical prioritisation tools

Several pharmaceutical prioritisation tools have been developed for use in hospitals^{​1–6,20​}. The Table^{​16,20–27​} summarises some of these published tools.

Pharmaceutical prioritisation tools are generally categorised into clinical prediction models^​5​ (or prognostic prediction model^​6​, where predictors are statistically combined to estimate the risk of medication harm and risk assessment tools^​5​) or clinical prioritisation tools^​6​, where the tool is developed through expert consensus alongside existing literature and NHS priorities.

There are different terminologies used to describe pharmaceutical prioritisation tools, such as ‘clinical prioritisation tools’^​6​, ‘clinical pharmacy patient triage tools’^​21​, ‘pharmacy risk screening tools’^​22​, ‘prediction tools’^​5​, ‘risk assessment tools’^​1​, ‘risk screening tools’^​1​ and ‘pharmaceutical care complexity screening tools’^​20​. Yet, they are all used to determine ‘pharmaceutical acuity’ of patients to target pharmacy services to patients with higher acuity^​28​. Pharmaceutical acuity was defined as: ‘An attribute of a patient, determined by an assessment of the likely requirement for pharmacy services, and used to direct and prioritise pharmacy workflow and workforce to ensure the right patient is seen by the right pharmacy professional at the right time — an approach that seeks to reduce medication-related problems and ensure person-centred care.’^​28​.  

Considerations for using pharmaceutical prioritisation tools

When using pharmaceutical prioritisation tools, it is important to acknowledge their limitations. For example, there is a lack of high-quality evidence on effectiveness and external validation of these tools^{​1,2,5,6,29,30​}. Tools also use different criteria to prioritise patients, while individual tools may lack important criteria such as comorbidity or drug overdose^​1​.

In addition, when adopting pharmaceutical prioritisation tools, it is important to consider their utility and relevance. While tools are needed to accurately classify patients into risk groups, their value may not be realised if they are impractical (e.g. owing to complexity), leading pharmacy staff to avoid their use^​2,5,31​. Having a pharmacy lead to champion the implementation and use of a tool, as well as gain engagement from the wider pharmacy team, is vital to ensuring its uptake and sustained use^​19​. It is also important to use prioritisation tools alongside existing resources, such as care plans, while maintaining clear communication and collaboration with other ward staff to support consistent and coordinated patient care^​22​.

Pharmaceutical prioritisation tools should be used in conjunction with clinical judgement and experience to ensure accurate interpretation of results, appropriate tailoring of decisions to individual patient needs and avoidance of overreliance on standardised measures^​19​. For example, prioritisation tools usually rely on set, predefined criteria such as blood test results. To identify patients for a review, clinical judgement requires the interpretation of criteria within a broader clinical context, taking into account patient-specific factors in a holistic way that may influence their significance^​32​. Care must be taken not to over-rely on tools neglecting the important interaction with the patients^​12​.

Lastly, it is important to consider the use of a tool in context, as differences in pharmacy service delivery and patient characteristics influence their design and use. For example, different specialities may require speciality specific prioritisation criteria. A 2023 systematic review of risk factors for medication-related problems within mental health wards identified several risk factors that differed from those reported in acute care studies^​33​, which influenced the development of the ‘Inpatient Mental Health Pharmaceutical Assessment and Care Tool’ (IMPACT) described in the Table. In addition, the frequency of review for patients may be influenced by staffing levels, as pharmacy staff in certain sites may have the capacity to review all high-risk patients daily, whereas other sites may not have the same capacity. 

Guidance on implementation and use of pharmaceutical prioritisation tools

The potential benefits of pharmaceutical prioritisation tools rely on successful implementation. Generally, pharmacy professionals who want to use prioritisation tools should:

• Familiarise themselves with the concept of pharmaceutical prioritisation, the benefits and limitations of existing tools and how to use them effectively;
• If necessary, adapt the tool to the context in which they will be used;
• Ensure the tool is used alongside existing resources and aligns with existing processes;
• Maintain clear communication and collaboration with other ward staff to support consistent and coordinated patient care;
• Reflect on how clinical judgement will be applied alongside tool use;
• Ensure accurate and timely documentation and handover of the tool;
• Keep up to date with new evidence and best practices related to pharmaceutical prioritisation;
• Continuously monitor the use and impact of the tool through audit and evaluation.

The steps required for successful adoption and implementation of patient prioritisation tools are presented in Box^​26​ and have been adapted from the IMPACT patient prioritisation tool development work^​34​.

Below is a case scenario of a hospital adopting a pharmaceutical prioritisation tool following these steps.

Conclusion

Pharmaceutical prioritisation tools have the potential to enhance the delivery of more structured and equitable care; however, their success relies on effective integration into daily practice. Achieving this requires attention to usability, staff communication and finding a balance between standardised guidance and professional judgement to ensure truly patient-centred outcomes.