As with many hospitals, there is substantial wait time from when a patient is informed of discharge until they leave the hospital. Unfortunately, the belief that pharmacy is often responsible for this delay is commonly shared by staff and patients. The ‘Creating our Culture’ scheme held at Mid Essex Hospital Trust (MEHT) highlighted that patients held a negative view of the ‘discharge process’ and that ‘pharmacy’ was one of their desired areas of improvement.
Frustrated by the constant chasing of discharge medications from the wards and the continuous asking from patients ‘why does it take so long? You are only sticking a label on it’, it was time to squash the portrayed image of pharmacy and re-define our role within the hospital.
Although ward based dispensing is not a novel idea, it all began at MEHT when a determined ward based-technician highlighted to the ward sister that she was unable to complete her ward work due to a lack of computers on the Acute Medical Unit (AMU). Before we knew it, a laptop had been wheeled onto the ward and allocated to the pharmacy department. This generosity triggered a whole motion of events and before the ward round was completed a dispensing labeller had been relocated to the Emergency Floor.
In March 2018 the pharmacy service to the Emergency Village — which encompasses A&E, Ambulatory Care Unit (ACU), Acute Medical Unit (AMU), Emergency Short Stay (ESS) and the Frailty Unit — was extended to provide 7-day support from 8am to 8pm. Since then, we have conducted an audit to determine the impact of this new and expanded service which found improved safety and clinical outcomes for patients. The development of the service, alongside the implementation of the ward-based dispensing, has also been able to facilitate evening discharges (past 6pm) for patients within the Emergency Village. Previously these patients would have either had to remain the night in hospital to have their medication ordered in the morning or return the next day to collect their medication. This has improved the patient experience in the hospital through increased individualised pharmaceutical care and helps complete the patient journey.
This minor introduction of a dispensing system on the Emergency Floor has brought improved patient flow throughout the hospital resulting in increased patient satisfaction as well as cost-saving benefits.
Ward-based dispensing is particularly useful when processing last-minute discharges or re-labelling Patient Own Drugs (PODs) for discharge to prevent them being misplaced when being sent down to the dispensary. By re-labelling and recycling PODs, this helped to reduce medication wastage and reduce expenditure on medication.
Prior to the pilot, we did not have any baseline data for pharmacy discharge counselling. Data was collected as part of our pilot which found a positive impact of ward-based dispensing on the emergency floor, with 85% (CI± 8) of patients being counselled about their discharge medication. Educating patients about their medication is a growing area at MEHT— we are now looking into patient satisfaction in regards to the counselling they receive.Within our trust it is often the case that when patients are initiated on high risk medications they are counselled at initiation rather than discharge as current policy places the responsibility of discharge counselling with the nurse. This task is better suited to a pharmacist – the medications expert.
Pharmacists/ward-based technicians are trained to establish each patient’s level of understanding, educate them accordingly as well as answer any queries they may have. This increases patient confidence and can lead to an improvement in compliance. One major cause of patients not taking their medication is that they do not understand its intended purpose. The Carter Report encourages ward-based pharmacy staff to spend more time on clinical activities involving patient-facing care hence giving staff more time and opportunities to counsel their patients. It is also an opportunity to educate patients on lifestyle choices such as smoking cessation and healthy living, which can improve the health of the local community.
Dispensing at ward level has received positive feedback from the multidisciplinary team who report that it “has allowed pharmacy staff, in collaboration with the nursing staff, to improve the services delivered to our patients and facilitate an easier and quicker discharge process.” One junior sister mentioned that the emergency ward benefits from this service and it provides a better experience for the patients and all clinical staff, as well as highlighting that she had not received any complaints about waiting for medication since this has started.
The average time taken for a prescription to be dispensed at ward level on the emergency floor was 19 minutes. Although this time demonstrates that items could be dispensed quickly and efficiently, it is important to note that the medication request is not always the rate-limiting step in a patient’s discharge; for example, they could often be waiting for advice from another speciality or to be discharged from another service such as occupational therapy or physiotherapy. The results from the pilot show that 90% of medication requests dispensed on the ward were done in 30 minutes or less compared to the average time of 2 hours and 40 minutes for medication requests coming down to pharmacy to be processed. This exceeds the target set within pharmacy for processing discharge medications/urgent requests.
Ward-based dispensing has brought great benefits to the Emergency Village at MEHT which has now resulted in the original pilot being expanded to other areas of the hospital. It is hoped that the benefits experienced will be reflected across the trust.
About the Auhors:
Amira Chaudry is an emergency care pharmacist at Mid Essex Hospital NHS Trust.
Wendy Forster is a registered pharmacy technician based on the Acute Medical Unit (AMU) at Mid Essex Hospital NHS Trust.