To identify drug related cost benefits of an innovative hospital led service to provide unlicensed medicines to children at home.
Methods
Actual costs of hospital led supply of unlicensed medicines (including drug costs, delivery costs and service charges) were compared with estimated costs for the same or equivalent regimens recently provided through the usual primary care supply route (general practitioner (GP) prescription dispensed by community pharmacist). Items were supplied under a novel service level agreement between Birmingham Children9s Hospital (BCH) and Birmingham East and North (BEN) PCT for unlicensed medicines. The hospital led supply pathway includes GP referral to BCH Pharmacy who determine which unlicensed product is to be dispensed at an agreed price. This is then dispensed and delivered by a community pharmacy partner. Supply was authorised using a patient specific direction signed by a registered prescriber. Estimates of primary care costs were provided by BEN-PCT using recent ePACT data of equivalent dispensed items, or average costs of the item and quantity from a composite database of 22 PCTs.1 Estimated primary care costs include net ingredient costs and dispensing fees as reported on ePACT. Data were entered into MS Excel 2007 for analysis.
Results
A total of 67 items were provided under the scheme during the period 15th December 2010 to 25th March 2011. All items were unlicensed medicines in the UK identified by the patient9s GP as suitable for the hospital led service. A total of 25 different formulations were supplied (19 different chemical entities). Savings per item ranged from minus £79 (a loss, Sodium Chloride 1 mmol in 1 ml solution) to £1 621.12 (Sildenafil liquid 25 mg in 5 ml). A total of £23 238.39 was estimated as the saving to the PCT, an average of nearly £350 per item supplied. The total cost of the supply for all 67 items via the scheme was £7 144.92 (£106.64 per item). This cost included drug costs, dispensing fee, delivery costs plus a service charge by BCH and was re-charged to BEN-PCT.
Conclusion
This study identifies for the first time drug related financial benefits of hospital led supplies of unlicensed medicines for children at home and supports this proposed innovation in National health service (NHS) processes.2 Some PCTs are known to spend more than £500 000 per annum on unlicensed medicines and therefore there is potential for large savings to the NHS.3 Further studies will be required to identify if this level of benefit is generalisable to other populations. It is acknowledged that this study only presents results for a relatively small population; multisite studies of this new innovation and related services, are in preparation.
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There have been concerns about maintaining appropriate clinical staff levels in Emergency Departments in England.1 The aim of this study was to determine if Emergency Department attendees aged from 0-16 years could be managed by community pharmacists or hospital independent prescriber pharmacists with or without further advanced clinical practice training.A prospective, 48 site, cross-sectional, observational study of patients attending Emergency Departments (ED) in England, UK was conducted. Pharmacists at each site collected up to 400 admissions and paediatric patients were included in the data collection. The pharmacist independent prescribers (one for each site) were asked to identify patient attendance at their Emergency Department, record anonymised details of the cases-age, weight, presenting complaint, clinical grouping (e.g. medicine, orthopaedics), and categorise each presentation into one of four possible categories: CP, Community Pharmacist, cases which could be managed by a community pharmacist outside an ED setting; IP-cases that could be managed at ED by a hospital pharmacist with independent prescriber status; IPT, Independent Prescriber Pharmacist with additional training-cases which could be managed at ED by a hospital pharmacist independent prescriber with additional clinical training; and MT, Medical Team only-cases that were unsuitable for the pharmacist to manage. An Impact Index was calculated for the two most frequent clinical groupings using the formula: Impact index=percentage of the total workload of the clinical grouping multiplied by the percentage ability of pharmacists to manage that clinical group.1623 out of 18,229 (9%) attendees, from 45 of the 48 sites, were children aged from 0 to 16 years of age (median 8 yrs, range 0-16), 749 were female and 874 were male. Of the 1623 admissions, 9% of the cases were judged to be suitable for clinical management by a community pharmacist (CP), 4% suitable for a hospital pharmacist independent prescriber (IP), 32% suitable for a hospital independent pharmacist prescriber with additional training (IPT); and the remaining 55% were only suitable for the Medical Team (MT). The most frequent clinical groups and impact index for the attendees were General Medicine=10.78 and orthopaedics=10.60.Paediatric patients attending Emergency Departments were judged by pharmacists to be suitable for management outside a hospital setting in approximately 1 in 11 cases, and by hospital independent prescriber pharmacists in 4 in 10 cases. With further training, it was found that the total proportion of cases that could be managed by a pharmacist was 45%. The greatest impact for pharmacist management occurs in general medicine and orthopaedics.
Aims of the study included evaluation of outpatient antibiotic prescribing practices relating to good Antimicrobial Stewardship1 focusing on documentation of indication and duration.Prescriptions dispensed at the Outpatient Pharmacy over a 6 week were evaluated. Data collected include patient's hospital identification in full, the antibiotic prescribed, duration of treatment, indication (in a specifically allocated area on the prescription) and route of administration, prescriber speciality and grade. Data were entered onto Microsoft Excel and reviewed by a committee that included a medical microbiologist and antimicrobial pharmacist.Five hundred and six antimicrobial prescriptions were reviewed. Therapeutic antibiotics accounted for 484/506 (95.6%) and the remaining 22/506 (4.4%) were prophylactic therapy. Indications were documented in 186/506 (36.8%) cases and 465/506 (91.9%) documented duration of therapy. By speciality, adherence with indication and duration, respectively, for oral medication, were as follows: Haematology 2/55 (3.6%) and 12/55 (21.8%), General paediatrics 26/42 (61.9%) and 41/42 (97.6%), Oncology 4/37 (10.8%) and 34/37 (91.9%), Dermatology 12/35 (34.3%) and 35/35 (100%), Nephrology 24/30 (80%) and 30/30 (100%), Ear Nose and Throat (ENT) 9/31 (29%) and 31/31 (100%). Oral route of administration was the most frequently prescribed 391/506 (77.3%), with topical and eye/ear drops prescribed in 63/506 (12.4%) and 50/506 (9.9%) respectively. Nebulised therapy accounted for only 2/506 (0.4%) prescriptions. Most commonly prescribed antibiotics were Co-amoxiclav 83/391 (21.2%), Flucloxacillin 50/391 (12.8%), Penicillin 35/391 (9.0%), Azithromycin 27/391 (6.9%) and Trimethoprim 26/391 (6.6%). Adherence to antibiotic guidelines was seen to be appropriate with 496/506 (98%).From the ten prescriptions that did not adhere, Azithromycin accounted for 8/10 (80%) with 50% of these used for prophylaxis, with lack of clear documentation.A designated area on the Outpatient Pharmacy prescription for indication and duration can aid better Antimicrobial Stewardship. Duration of therapy was better documented than indication, however it is postulated that this was to ensure adequate supply on outpatient dispensing and not always through following good antimicrobial prescribing practice. On the whole, the most commonly prescribed antibiotics were predominantly prescribed by the specialities within the antibiotic guidelines. Azithromycin, which is restricted to respiratory team, was prescribed outside of the policy by other specialties. This study helped prioritise which specialities require further input to improve adherence with Antimicrobial Stewardship in the outpatient setting. As dermatology and ENT had 100% compliance with specifying duration, we are now reviewing their prescribing education which can be used to enhance the practice of the other specialities.
To quantify the success of a Pharmacist led paediatric commissioning service in securing individual funding requests (IFR) to Primary Care Trusts (PCTs).
Methods
Descriptive, retrospective study over a 4 month period by review of IFR sent to PCTs. The IFRs were completed by the lead clinician with support from the commissioning lead pharmacist. Inclusion criteria included (1) Patient9s who9s treatment falls outside existing service agreements with clear evidence of clinical effectiveness for the therapy applied for. (2) Where patient was considered exceptional, in that clinical features of the patient made them significantly different to that described within existing commissioning agreements and where the patient would gain an enhanced clinical benefit from the requested intervention, than might normally be expected in the general population. The IFR was sent to relevant patient9s PCT. Responses from PCTs were via email and letter and then forwarded to the patient9s clinicians. Data was entered into MS Excel 2003 for analysis and included, patient demographics, clinical categories, amount of funding, details of follow-up phone calls to PCTs. Information was sent to the finance department, so treatment costs were reclaimed. If declined, this was logged with reasons so to modify future applications and inform clinical decision making.
Results
Responses relating to 15 IFRs, to 10 different PCTs across the country with each PCT receiving 1 or more request (n=1–2). Six specialities, gastroenterology 53.3% (n=8), haematology 13.3% (n=2), respiratory 13.3% (n=2), neurology 6.6% (n=1), rheumatology 6.6% (n=1) and ophthalmology 6.6% (n=1) had made IFR requests during the study period. 73% (n=11) had funding approved, 20% (n= 3) were declined and 7% (n=1) for which a response is still awaited. Of the three declined, there were two cases where the PCT had refused due to the request being retrospective and the other case was determined not to meet criteria as an exceptional case. We received seven responses within 3 weeks, with 53.3% (n=8) of the cases having to be chased on at least one occasion. In monetary terms, a projected benefit of £459k was made as a result of the Pharmacy commissioning service from the 11 approved cases although further work will be required to identify and difference to conventional commissioning arrangements.
Conclusion
The pharmacy led paediatric drug commissioning service is highly successful with a 73% success rate and recovering IFR related monies per annum of approximately £459k for the 11 approved cases, with a potential annual value of £1.37M on the basis of the same kind of claims each quarter.
Background There are concerns about maintaining appropriate clinical staffing levels in Emergency Departments. Pharmacists may be one possible solution. Objective To determine if Emergency Department attendees could be clinically managed by pharmacists with or without advanced clinical practice training. Setting Prospective 49 site cross-sectional observational study of patients attending Emergency Departments in England. Method Pharmacist data collectors identified patient attendance at their Emergency Department, recorded anonymized details of 400 cases and categorized each into one of four possible options: cases which could be managed by a community pharmacist; could be managed by a hospital pharmacist independent prescriber; could be managed by a hospital pharmacist independent prescriber with additional clinical training; or medical team only (unsuitable for pharmacists to manage). Impact indices sensitive to both workload and proportion of pharmacist manageable cases were calculated for each clinical group. Main outcome measure Proportion of cases which could be managed by a pharmacist. Results 18,613 cases were observed from 49 sites. 726 (3.9%) of cases were judged suitable for clinical management by community pharmacists, 719 (3.9%) by pharmacist prescribers, 5202 (27.9%) by pharmacist prescribers with further training, and 11,966 (64.3%) for medical team only. Impact Indices of the most frequent clinical groupings were general medicine (13.18) and orthopaedics (9.69). Conclusion The proportion of Emergency Department cases that could potentially be managed by a pharmacist was 36%. Greatest potential for pharmacist management was in general medicine and orthopaedics (usually minor trauma). Findings support the case for extending the clinical role of pharmacists.
The aim of this study was to evaluate the impact of an organisation wide paediatric antibiotic surgical prophylaxis guideline.
Method
A before and after study was conducted during the period Jun to Aug 2012 (pre-guideline implementation) and Jun to Dec 2013 (post-guideline implementation) on six surgical wards (two general surgery wards, neurosurgery, urology, intensive care and neonatal surgery). A random sample of ten patients per month were identified by ward pharmacists. The patients9 drug charts, operation records and medical notes were reviewed and data collected using a standardised data collection tool. Data were collected on the patients9 procedure undertaken, prescribed surgical prophylactic antibiotic(s), antibiotic administration time, the number of doses administered and whether an indication for use and duration was specified when the antibiotic was prescribed. The data were reviewed by an antimicrobial pharmacist and medical microbiologist to determine appropriateness of therapy. The data were collated using Microsoft Excel and analysed using descriptive statistics.
Results
One hundred and forty four patients were reviewed prior to implementation of the guidelines and 171 patients following guideline introduction. Prior to the introduction of the guidelines, an antibiotic indication and duration, respectively, was documented in 93/144 (64.6%) and 77/144 (53.5%) procedures compared with 142/171 (83%) and 102/171 (59.6%) post guideline. The time of antibiotic administration was recorded in 109/144 (75.7%) procedures pre-guideline and 167/171 (97.7%) post guideline. Where the time of administration was recorded, in 104/109 (95.4%) procedures, antibiotics were administered within 60 minutes of incision pre-guideline compared with 126/167 (75.4%) post guideline. The choice of antibiotic for surgical prophylaxis was considered to be appropriate in 93/144 (64.6%) patients pre-guideline and 142/171 (83%) post guideline. The duration of prophylaxis was considered appropriate in 77/144 (53.5%) procedures pre and 103/171 (60%) procedures post guideline. The number of single prophylactic doses prescribed was 32/144 (22.2%) prior to the guidelines compared with 48/171 (28.1%) following guideline introduction.
Conclusion
An organisation wide antibiotic surgical prophylaxis guideline can have a positive impact on practice. The availability of the guideline has improved choice of antibiotic, duration and over all documentation. Use of multiple doses can be partially explained by complex surgical patients however further work is required to explore the reasons for prolonged surgical prophylaxis in paediatrics as well as optimisation of the choice of therapy. Whilst the evidence for paediatric antibiotic surgical prophylaxis is limited1 this study demonstrated that an improvement in antimicrobial stewardship against national guidance2 can be achieved.
Background There have been concerns about maintaining appropriate clinical staff levels in Emergency Departments in England. 1 One possible solution to alleviating the workforce pressure is the extension of clinical activity performed by non-medical staff – including pharmacists. 2 Aims and objectives To determine if Emergency Department attendees aged from 10–25 years (adolescents) could be clinically managed by community pharmacists or hospital pharmacist independent prescribers with or without further advanced clinical practice training. Method A prospective 49 site cross-sectional observational study of patients attending Emergency Departments (ED) in England, UK. Each site was requested to collect data for 400 admissions of all ages. Pharmacist independent prescribers (one for each site) were asked to identify patient attendance at their Emergency Department, record anonymised details of the cases – age, weight, presenting complain, clinical grouping (e.g. medicine, orthopaedics) and categorise each one into one of four possible categories: CP, Community Pharmacist, cases which could be managed by a community pharmacist outside an ED setting; IP – cases that could be managed in ED by a hospital pharmacist with independent prescriber status; IPT, Independent Prescriber Pharmacist with additional training – cases which could be managed in ED by a hospital pharmacist independent prescriber with additional clinical training; and MT, Medical Team only – cases that were unsuitable for the pharmacist to manage. An Impact Index was calculated for the two most frequent clinical groupings using the formula: Impact index (I)=proportion of the total workload of the clinical grouping (w) multiplied by the percentage ability of pharmacists to manage that clinical group (a). I=wa. The higher the Impact Index the greater potential for pharmacists to support the clinical workload related to that group. Results 2993 out of 18 613 (16%) attendees were young patients aged from 10 to 25 years of age (median 20 years, interquartile range 17–22 years) of which 1530 were female and 1463 were male. Of the 2993 patients, 6% of the cases were judge to be suitable for the community pharmacist (CP), 5% suitable for a hospital pharmacist independent prescriber (IP), 37% were deemed as suitable for a hospital independent prescriber with additional training (IPT) and the remaining 52% were only suitable for the medical team (MT). The most frequent clinical groups and Impact Index were general medicine=16.97 and orthopaedics=15.51. Conclusion Emergency Department attendees who were young patients were judged by independent prescriber pharmacists to be suitable for clinical management by community pharmacists outside a hospital setting in approximately 1 in 16 admissions, and by a hospital independent prescriber pharmacists in 1 in 20 cases. With further training, it was found that the total proportion of cases that could potentially be managed by a pharmacist (CP, IP or IPT) came to 48%. The greatest potential impact for pharmacist management occurs in general medicine and orthopaedics. References Paw RC. Emergency Department Staffing in England and Wales. Emer Med J 2008;24:420–23. Hughes E, et al . Future enhanced clinical role of pharmacists in Emergency Departments in England: Multi-site observational evaluation. Int J Clin Pharm 2017;39:960–968.
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