Assessing the use of a clinical prioritisation tool at Wirral University Hospital NHS Foundation Trust

Pharmacy teams at Wirral University Teaching Hospital NHS Foundation Trust (WUTH) have moved to a shared team working model; where work is divided across specialist teams, rather than a single pharmacist seeing all patients on ‘their’ ward, thus ensuring more equitable service delivery across inpatient areas.

A clinical prioritisation tool developed in 2016 by the University Hospital of South Manchester has been implemented within some UK hospitals​[1]​. At WUTH, we reviewed and amended this tool to suit the patients using our services and to further develop the team working model.

The tool uses the patient’s acuity to stratify them into three risk categories (low, medium and high) that subsequently informs the need for an in-depth review, involving review of medical notes, patient observations, laboratory values and possible discussions with the multidisciplinary team (MDT). This categorisation also helps determine whether or not senior/specialist pharmacist input is required, as well as the frequency of these pharmacist reviews (see Appendix 1).

The clinical prioritisation tool is used in conjunction with the ‘Ward pharmacist task prioritisation’ tool, which was subsequently developed at WUTH (see Appendix 2). This describes the process of prioritisation of ward-based tasks, including a basic patient review (level 1, which involves reviewing the prescription only), compared with a thorough review (level 2, which also involves a detailed review of the patient’s case notes/interaction with the MDT). It also describes the factors to consider when undertaking such reviews.

A pilot was conducted across six wards between 14 and 18 June 2021 to determine if using the clinical prioritisation tool led to more poorly, high acuity patients having more in-depth reviews more often, with senior/specialist pharmacist input.

We also evaluated if using the tool meant that less time was spent seeing patients of low acuity, who were unlikely to benefit as much from an interaction with a pharmacist.

Two wards used the tool and were used as the study wards — one medical and one surgical — where the acuity score was used to determine the level and frequency of subsequent patient review and need for senior input (see Appendix 2). Four wards — two medical and two surgical — ignored the acuity score and used existing departmental process (individual pharmacist assessment) to determine how the patient would be reviewed. 

Training on how to use the tool to assign and document acuity scores was delivered to pharmacists working in admissions areas. Pharmacists working on the relevant six inpatient wards were trained to alter the frequency and depth of review and when to request senior input depending upon the score given to the patient on admission. They were also trained to increase or decrease the acuity score depending on the patient’s clinical status throughout their inpatient stay.

A total of 125 patients (58 surgical, 67 medical) were seen during this pilot. Acuity scoring was 100% accurate (n=125) when undertaken by a senior pharmacist and 76% (n=95) when undertaken by a junior, with 32% of patients classified as low, 47% medium and 21% high risk, respectively.

When using the tool, higher acuity patients received more senior pharmacist input, 71% (n=10/14) versus 8% (n=1/12) and had more daily reviews undertaken compared with 57% (n=8/14) versus 25% (n= 3/12) for lower acuity patients. The number of high acuity patients that had in-depth pharmacist reviews remained the same at 85%, irrespective of tool used.

The frequency of review of low-acuity patients was also similar irrespective of tool usage; 68% (n=15/22) when using the tool, versus 72% (n=13/18) when not using the tool; however, more reviews for low-acuity patients complied with the recommendation of undertaking a basic level 1 review (using the prescription only), 95% (n=21/22) versus 67% (n=12/18).

The pharmacy department at WUTH has prescribing pharmacists embedded in the elective and emergency admissions pathways. The accuracy of using the acuity scoring tool is higher when undertaken by senior admissions pharmacists compared with junior pharmacists, whose performance is comparable to that in the reported literature​[2]​.

Using the tool led to a significant shift in more reviews and more senior reviews being undertaken for sicker, higher acuity patients. This is important as these are the patients in which pharmacists can make significant contributions to patient care that are likely to positively affect patient outcomes. Less time was spent on lower acuity patients in which pharmacists were unlikely to affect patient outcome.

Senior admissions pharmacists assigning acuity scores were also able to anticipate and direct which tasks were required to be undertaken later during the inpatient phase. The junior pharmacists felt that this was extremely valuable and enabled them to focus on relevant tasks and confidently step acuity levels down appropriately later in the patient’s inpatient stay. This resulted in the appropriate use of fewer reviews that were undertaken in less depth as the patient responded to treatment and then became low acuity during their hospital stay.

Feedback collected from all pharmacists involved in this project was positive; with juniors feeling more supported by their seniors and better able to identify relevant issues to focus on. Senior pharmacists felt more confident that the junior pharmacist was identifying when a patient needed more intervention and then escalated to the relevant senior pharmacist for support appropriately. 

I recommend that clinical prioritisation tools are considered for use in hospital trusts as a useful tool to ensure that pharmacist staffing resource is focused on patients that are most likely to benefit from it and to enable better team working between pharmacists.

Chris Herring, lead divisional pharmacist — surgery, Wirral University Hospital NHS Foundation Trust