Trialling dedicated ward pharmacy services at a district general hospital

Dedicated ward pharmacy services were originally piloted at East Lancashire Hospitals NHS Trust, using an innovative model of one pharmacist per ward with appropriate support from pharmacy technicians and assistants​[1]​. 

With reduced pharmacy staffing levels impacting pharmacy service delivery at ward level, Kettering General Hospital (KGH) NHS Foundation Trust decided to undertake a quality improvement project to trial this innovative model. 

In October 2021, alongside the roll-out of a new electronic prescribing system, the number of patients seen each day had reduced — with junior pharmacists seeing around 11 patients on average — and the medicines reconciliation dropped to 32%.

In addition, the trust faced difficulty in recruiting nurses and medics and carried a high vacancy rate. Previous studies have shown that pharmacists, pharmacy technicians and assistants are able to reduce the workload of healthcare colleagues by supporting ward-based medicines management activities​[2–4]​. 

The pilot aimed to:

• Determine the impact of dedicated ward pharmacy services on quality and financial indicators;
• Provide data which could support the development of a business case for dedicated ward pharmacy services.

A team consisting of one prescribing pharmacist, one medicines management pharmacy technician (MMT) and one medicines management assistant (MMA) were appointed to run a continuous three-week pilot on a 27-bed medical ward from October 2021. 

The MMT and MMA took medication histories, counted patients’ own medicines, dispensed and relabelled medicines on the ward and provided medication counselling. Prescribing pharmacists attended daily ward and board rounds on weekdays, performed medication counselling, prescribed medicines on the electronic prescribing system and for the discharge letter, amended the discharge letter and referred patients to the discharge medicines service. The team were provided with three computer on wheels, two labelling machines and up to three additional laptops.

Data were captured using a live Microsoft Excel spreadsheet using Microsoft SharePoint to avoid duplication of data. Clinical interventions, such as correcting prescribing errors and the number of intravenous (IV) to oral antibiotic switches made, were collected by the ward pharmacy team on paper and inputted into a Microsoft Excel database at the end of the pilot. Venous thromboembolism risk assessment baseline and pilot data was collected by the Newton team, an external consultancy company, on Microsoft Excel. Baseline data was collected on the same ward for two weeks immediately preceding the pilot. Pharmacy staffing on the ward during this phase consisted of only one pharmacist who was also covering other wards, representing the typical pharmacy staffing level. 

Service user feedback was collated through a paper questionnaire provided to the doctors and nurses to evaluate ward-based pharmacy clinical services prior to and throughout the pilot. 

Cost savings resulting from avoiding the supply of 212 medicines through prudent use of patients own medicines and medicines optimisation totalled just over £1,400. If dedicated ward pharmacy was to be rolled out across all medical wards at the trust for one year, total cost savings would be around £390,000.

There were 80 discharges over the three-week period, of which the prescribing pharmacist, prescribed 755 medicines on the discharge letters to improve the accuracy of data being transferred to GP surgeries. Accuracy rose from 40% to 85% during the pilot. The pharmacist added 56 comments to the discharge letters and discontinued 12 medicines at the point of discharge, contributing towards safer and improved transfer of care from secondary to primary care. In addition, 21 patients were counselled by the pharmacy team, which otherwise would have been undertaken by a member of the nursing team. 

The rate of medicines reconciliation carried out within 24 hours on the ward during the pilot was 100%, achieving the National Institute for Health and Care Excellence (NICE) quality standard recommendation​[5]​. This was considerably higher to the average medicine reconciliation rate in October 2021 (32%). 

A total of 125 prescriptions for IV antibiotics were reviewed by the pharmacist and 36 were suitable for IV to oral switch. The prescribing pharmacist was able to switch 58% (n=21) of the IV prescriptions to oral therapy, leading to earlier discharge.  

The average length of time medicines for discharge took to reach the ward after being requested was reduced from a baseline of 168 minutes to 50 minutes. As the team were also dispensing medicines on the ward, some patient’s medicines were ready within two minutes. 

A t-test was conducted to determine whether the length of stay for the patients during the pilot was significantly reduced compared to the baseline period. The t value was 1.74975 with a P value of 0.04 (p<0.05). 

Data regarding missed doses of critical medicines owing to medication not being available on the ward and late doses administered were captured from the ePMA system. Data collected for missed doses showed a reduction in the percentage of missed doses owing to medication not being available on the ward during the pilot weeks compared to the baseline period. The percentage of missed doses of critical medicine reduced from 1.24% in the baseline week to 0.07% in the second week of the pilot.

There was a 347.6% increase in clinical contributions made by the dedicated ward pharmacy team compared with those made during the baseline period.

During the three-week pilot, 24 hours were estimated to be freed up for nursing staff and 76 hours for doctors to care for patients. This was extrapolated to 6,517 hours for nursing staff and 21,054 hours for doctors if dedicated ward pharmacy services were rolled out across all medical wards for one year. 

Completed VTE risk assessments rose from 41% in the baseline period to 78% when conducted by the prescribing pharmacist. 

Feedback from patients, nurses, and doctors during the pilot was very positive. 

The data obtained during the pilot demonstrated improvements compared to baseline for all KPIs, supporting the case to roll out dedicated ward pharmacy services across all medical wards. The next steps will be to determine whether this model of working would be suitable for surgical and women’s and children’s wards. 

Meticulous planning around late night and weekend working, and any planned annual leave was required to ensure staff consistency. Additional funding of 21% has therefore been added to the overall staffing costs to support roll out.

It was difficult to measure and collect some of the manual data and diverted the dedicated ward pharmacy team away from service delivery. The results are expected to be even better if the team did not spend as much time collecting and recording data. 

Further support with data collection was sought from the trust quality improvement team, and clinical commissioning group pharmacists were asked to support auditing the accuracy and quality of the information provided within discharge letters. This is something to consider for future quality improvement projects.

Emma Cramp, lead pharmacist for professional development

Yasmin Farhat, lead pharmacist for medicine

Olivia Gunapalan, rotational pharmacist and Demisha Vaghela, specialist pharmacist

All at Kettering General Hospital NHS Foundation Trust