Service evaluation of the efficiency of moving discharge medicine request screening from the dispensary to hospital wards over a two-year period

Introduction

It is a common patient perception that their discharge from hospital is delayed by waiting for medicines (1). However, it is important to consider the entire discharge process when addressing this problem (2). In our large tertiary referral hospital, clinical pharmacy services were moved from wards to the dispensary following a staffing crisis during 2018. Ward-based services were reintroduced in 2020, but doubts remained over the practicality and benefits of doing this.

Aim

To compare the efficiency of ward and dispensary based clinical pharmacy services in our hospital in terms of interventions made and time taken.

Methods

We completed an observational service evaluation. Data on the time taken to process discharge medication requests with the dispensary-based service were collected retrospectively from the hospital electronic discharge system for 12 months (2018) for five medical wards. Equivalent data for the ward-based service were collected prospectively over three days (2020) by pharmacists delivering the service to seven medical wards, as this was considered more accurate, and several process steps did not exist in the ward-based model. For example, prescriber sending request to pharmacy and pharmacy acknowledging receipt of a request. The prospective data collection period was curtailed by Covid-19. Descriptive statistics were produced using Excel.

Results

Using the dispensary-based service (2018), 4459 medicine requests were processed from 5 medical wards, during a 12-month period. The mean time between prescribing and reaching the screening pharmacist was 175 minutes [95%CI ± 25.4]. It took an estimated time of 62 minutes [95%CI ± 2.99] to screen and resolve an intervention, with a mean of 3 interventions/ward/day. In 2020, using the ward-based approach to clinical pharmacy which screened medicine requests on the ward, 142 requests were screened over three days from seven wards, with no delay between prescribing and clinical screening. It took a mean of 17 minutes [95%CI ± 10.63] to screen and resolve an intervention, with a mean of 15 interventions/ward/day.

Conclusion

Ward based pharmacy yielded five times more interventions, took an average of 45 minutes less to screen and resolve issues per request and removed 175 minutes of process time. The additional time required to resolve issues identified in the dispensary-based screening process was thought to be the delay in contacting either the appropriate member of the ward staff referencing a particular patient for information or identifying and contacting the prescriber, or a combination of both. This study is limited by the long delay between data collection periods and the small sample size in 2020, but the differences between the two systems were large and there had been few other changes to hospital systems. Other limitations include changes related to Covid-19 and the lack of a control group, so it is not possible to establish a causal relationship between the type of pharmacy service and study outcomes.

References

(1) Wright S, Morecroft CW, Mullen R, Ewing AB. UK hospital patient discharge: the patient perspective. Eur J Hosp Pharm. 2017 Nov;24(6):338-342.

(2) Green CF, Hunter L, Jones L, Morris K. The TTO Journey: How much of it is actually in pharmacy? Pharm Man. 2015 Oct;31(4):16-20.

Assessing the impact on workflow of placing a pharmacy team in an emergency department

Introduction

The ED in our tertiary referral Hospital was working at capacity and invited pharmacy to send a team for a period to assess the impact they might have on workflow and doctor time, by carrying out detailed (level 2) medicine reconciliations and resolving medicine related issues at the outset.

Aim

To assess the impact that allocating an experienced pharmacist (Independent prescriber) together with a pharmacy technician might have on workflow and patient safety in ED.

Methods

The pharmacy team were directed to managing patients’ medicines carrying out the more comprehensive level 2 (1) medicines reconciliation (MR). This is a more thorough level of MR than that usually carried out on admission by a doctor (Level 1 MR). The time taken to conduct each MR was recorded. Interventions made were categorised by the clinical pharmacist using the MERP index. Five doctors were surveyed and asked how long they usually took to conduct a level 1 MR.

Results

132 MRs were carried out over 5 days. The pharmacist conducted 65 MRs mean time per MR 13.8 minutes SD 6.84 CI 90% (+/- 0.11) and the technician conducted 67 MRs mean time 23.73 minutes SD 11.07 CI 90% (+/- 0.17). The doctor group took 15 minutes (estimated) to conduct a level 1 MR SD 34.85 CI 90% (+/- 0.81). 1013 interventions were made, 15 were judged to be significant in terms of harm or potential harm and a further 128 related to non-prescribing of critical items (see table). A 90% Confidence interval was used reflecting the significant variance in time that a medicine reconciliation can take.

Conclusion

This project had limitations; it was brief, and the number of doctors surveyed few. However, it was adjudged to be a success in terms of doctor time saved (33 hours) and patient safety identifying 14 harm or potential harm occurrences and 128 critical medicines omissions at the outset of the patient journey. Following the project, the trust recognised the impact the team had and has subsequently funded an ED pharmacy team.

References

(1) Improving the Quality of Meds Reconciliation: A Best Practice Resource and Toolkit: V1.1 June 17 Specialist Pharmacy Service. Accessed Oct 2021 Medicines_Reconciliation_Best_Practice_Standards_Toolkit_Vs1.1_June-15-links-updated-Aug-17.pdf (sps.nhs.uk)

(2) Types of Medication Errors | NCC MERP, accessed 7/10/2021. https://www.nccmerp.org/types-medication-errors

On-chip manipulation of single photons from a diamond defect

Operating reconfigurable quantum circuits with single photon sources is a key goal of photonic quantum information science and technology. We use an integrated waveguide device containing directional couplers and a reconfigurable thermal phase controller to manipulate single photons emitted from a chromium related color center in diamond. Observation of both a wavelike interference pattern and particlelike sub-Poissionian autocorrelation functions demonstrates coherent manipulation of single photons emitted from the chromium related center and verifies wave particle duality.

A surface-patterned chip as a strong source of ultracold atoms for quantum technologies

Laser-cooled atoms are central to modern precision measurements. They are also increasingly important as an enabling technology for experimental cavity quantum electrodynamics, quantum information processing and matter-wave interferometry. Although significant progress has been made in miniaturizing atomic metrological devices, these are limited in accuracy by their use of hot atomic ensembles and buffer gases. Advances have also been made in producing portable apparatus that benefits from the advantages of atoms in the microkelvin regime. However, simplifying atomic cooling and loading using microfabrication technology has proved difficult. In this Letter we address this problem, realizing an atom chip that enables the integration of laser cooling and trapping into a compact apparatus. Our source delivers ten thousand times more atoms than previous magneto-optical traps with microfabricated optics and, for the first time, can reach sub-Doppler temperatures. Moreover, the same chip design offers a simple way to form stable optical lattices. These features, combined with simplicity of fabrication and ease of operation, make these new traps a key advance in the development of cold-atom technology for high-accuracy, portable measurement devices.

Wide spectral range confocal microscope based on endlessly single-mode fiber

We report an endlessly single mode, fiber-optic confocal microscope, based on a large mode area photonic crystal fiber. The microscope confines a very broad spectral range of excitation and emission wavelengths to a single spatial mode in the fiber. Single-mode operation over an optical octave is feasible. At a magnification of 10 and λ = 900 nm, its resolution was measured to be 1.0 μm (lateral) and 2.5 μm (axial). The microscope's use is demonstrated by imaging single photons emitted by individual InAs quantum dots in a pillar microcavity.

Changes in piglet tissue composition at birth in response to increasing maternal intake of long-chain n-3 polyunsaturated fatty acids are non-linear

Addition of marine oils containing long-chain n-3 polyunsaturated fatty acids to the diet of pregnant sows may reduce piglet mortality. In previous experiments, when marine oils have been fed to pregnant sows, improvements in piglet tissue 22 : 6n-3 status have been accompanied by potentially undesirable decreases in 20 : 4n-6. The objective of the present experiment was to establish an amount of dietary salmon oil which would enhance piglet 22 : 6n-3 status while minimising reductions in 20 : 4n-6. Twenty-four pregnant multiparous sows were used in the experiment which began on day 60 of pregnancy (gestation length 115 d). To give four diets, salmon oil was added in increasing amounts (0, 5, 10 and 20 g/kg diet) to a basal diet; the diets were made isoenergetic by adding palm oil to each diet to give a total of 20 g oil/kg diet. Diets were offered to the sows in fixed amounts (2.5 kg/d) until parturition. Piglet tissue samples (brain, liver and retina) were obtained at birth before consumption of colostrum. The greatest increase in piglet tissue 22 : 6n-3 proportions occurred between 0 and 5 g salmon oil/kg diet, with only small increases between 10 and 20 g salmon oil/kg diet. In contrast, tissue 20 : 4n-6 proportions declined progressively as the amount of salmon oil fed to the sow increased. In brain, the change in the value 22 : 6n-3/22 : 5n-6 was greatest between 0 and 5 g salmon oil/kg diet, whereas in liver the value increased linearly with added salmon oil. In addition, piglet brain weight (g/kg live weight) increased to a maximum at 10 g salmon oil/kg diet. The optimum amount of supplementary salmon oil in the current experiment, defined as that which gave the greatest response in brain 22 : 6n-3 proportions with minimum reduction in 20 : 4n-6,was 10 g salmon oil/kg diet. This corresponds to an intake of approximately 2.4 g 20 : 5n-3 plus 3.6 g 22 : 6n-3/d or 0.6 % digestible energy.

The influence of gestation feeding strategy on body composition of gilts at farrowing and response to dietary protein in a modified lactation

Previous experiments have indicated that reproductive function in lean, modern genotypes may be more dependent on body protein mass than, as previously believed, on body lipid reserves. This was investigated in a 3 x 2 factorial arrangement of treatments, involving 60 first-parity sows, comparing three pregnancy feeding strategies and two lactation diets. During pregnancy, sows were fed either a basal diet (5 g lysine/kg, 13 MJ of DE/kg [C]) or the same quantity of basal diet + energy source [E], or additional basal diet supplying both protein and energy [A]. The level of supplement for E and A was adjusted weekly to achieve a backfat thickness measurement (P2 position) of 28 mm at farrowing. Isoenergetic lactation diets were fed to appetite and provided either high (180 g CP/kg, 9 g lysine/kg [H]) or low lysine (120 g CP/kg, 6 g lysine/kg [L]). From d 21 of lactation, sows were separated from their litters and housed next to a boar for 8 h each day; final weaning occurred on d 31. Pregnancy treatment differences in backfat and weight were achieved, with C sows having less backfat on d 1 of lactation than E and A sows (E = 28.1, A = 28.0, C = 22.7 kg, P < 0.001). Sows fed additional basal diet were heavier than E sows, which were heavier than C sows (E = 190, A = 201, C = 178 kg, P < 0.001). Average feed intake over lactation showed a pregnancy feeding effect, with E sows eating less than A or C sows (E = 4.9, A = 5.2, C = 5.4 kg/d, P < 0.005). Total lactation weight loss was affected by pregnancy feeding (E = 18.0, A = 19.0, C = 8.4 kg, P < 0.05) and by lactation diet (L = 19.0, H = 11.3 kg, P < 0.05), whereas total lactation backfat loss was affected only by pregnancy treatment (E = 6.9, A = 6.5, C = 4.6 mm, P < 0.05). No pregnancy treatment or lactation diet effects were observed for litter performance. Lactation diet affected weaning-to-estrus interval, with more sows on the H diet coming into estrus within 6 d of partial weaning (P < 0.05), but there was no pregnancy treatment effect. Therefore, voluntary feed intake during lactation was suppressed by increased fat reserves at a limited body protein mass but not when body protein mass was also increased. Partial weaning-to-estrus interval was increased by reduced dietary protein.

Feeding tuna oil to the sow at different times during pregnancy has different effects on piglet long-chain polyunsaturated fatty acid composition at birth and subsequent growth

In an attempt to prevent decreases in piglet 20 : 4n-6 status at birth while increasing 22 : 6n-3 status, multiparous sows (eight per treatment) were allocated to one of three different treatments: a basal diet fed from day 63 of pregnancy to term; basal diet supplemented with tuna oil (17.5 g/kg) from day 63 to day 91 and then basal diet alone from day 92 to term; basal diet alone from day 63 to day 91 and then basal diet supplemented with tuna oil from day 92 to term. Tuna oil supplementation increased mainly 22 : 6n-3 intake. Supplementation with tuna oil between day 92 and term increased 22 : 6n-3 to a greater extent in all piglet tissues (brain, liver, retina and the remaining carcass) at birth than supplementation with tuna oil between days 63 and 91. However, while piglet 20 : 4n-6 decreased to a greater extent in liver and carcass when diets were supplemented with tuna oil between days 92 and term than between days 63 and 91, in the brain and retina, the reverse was true; 20 : 4n-6 was decreased to a greater extent between days 63 and 91 than between 92 and term. The effect of pregnancy nutrition on the growth of piglets until 7 d postweaning (35 d of age) was assessed after removing any residual effects of pregnancy treatment by cross-fostering some piglets at birth. Piglets, the diets of whose dams had been supplemented with tuna oil during pregnancy, grew faster during the first 35 d of life than the progeny of sows fed only the basal diet. Feeding tuna oil to sows at different times during pregnancy therefore did not prevent decreases in piglet 20 : 4n-6 status at birth, but did suggest that changes in piglet brain 20 : 4n-6 status between days 63 and 91 of pregnancy were not reversible by later nutrition. Supplementing the diet of the pregnant sow with tuna oil had beneficial effects on postnatal piglet growth.

The interaction of liveweight and the degree of competition on drinking behaviour in growing pigs at different group sizes

The pattern of drinking behaviour in pigs, and the influence of social factors such as competition on this behaviour, have been poorly documented. If competition for access to a limited resource is substantial, access to that resource may be allocated disproportionately to different members of a group. Priority may be based on a dominance hierarchy, or on physical characteristics, such as weight. The pattern of drinking behaviour was examined and the effect of pig liveweight on drinking behaviour under conditions likely to produce different levels of competition was investigated. Four replicates of a 2x2 factorial design of two group sizes (20 vs. 60) and two drinker:pig ratios (1:10 vs. 1:20) used a total of 640 growing pigs (start weight 36+/-5.0 kg). The drinking behaviour, skin lesion score and performance of nine focal pigs (three each of heavy (41.9 S.E.M. 0.57 kg), medium (35.7 S.E.M. 0.51 kg) and light weight (30.9 S.E.M. 0.63 kg)) per pen were recorded. For all focal pigs, the maximum time spent at the drinkers occurred between the 1800 and 1900 h and the minimum time between 0700 and 0800 h. The mean number of drinking bouts per pig per day was 30.9 S.E.M. 1.41, the median bout length was 21 s and the mean daily duration spent at the drinkers was 832 s. The frequency of visits to the drinkers, drinking bout duration and daily drinking time were affected by group size and drinker allocation, but not by weight or the interaction of treatments and weight. The diurnal spread of drinking was similar for each of the four treatment combinations and each weight category. Heavy pigs had the greatest number of lesions, and light weight pigs the least (13.2 vs. 8.8 S.E.D. 1.18, P<0.005), but this was not affected by the four treatment combinations. Lesion score correlated poorly with the parameters of drinking behaviour. The treatments, in isolation, or in interaction with weight, did not affect performance. No treatment encouraged sufficient competition to compromise the drinking behaviour, social behaviour or performance of the lightest animals in the pen.