Community pharmacists' perceptions of a hospital based virtual clinical pharmacy service: Findings from qualitative research

Background

A Virtual Clinical Pharmacy Service (VCPS) was introduced in selected rural and remote NSW hospitals in 2020 to address a gap in onsite clinical pharmacy services. Follow-up research determined hospital staff and patients at these locations perceived the service as a safe, effective and efficient system for delivering clinical pharmacy services. Community pharmacists are key stakeholders in medication safety and continuity of management in these regions, however, their insight on the VCPS had not yet been sought.

Objective

To understand perspectives of community pharmacists on the implementation of VCPS in rural and remote hospitals and impacts on medication management at transitions of care.

Methods

Semi-structured interviews were conducted via videoconference with seven community pharmacists with at least three months exposure to VCPS following service implementation. Thematic analysis of transcribed interviews was conducted influenced by Appreciative Inquiry.

Results

Participants identified that the VCPS had supported and enhanced their community pharmacy practice and acknowledged its future potential. Identified themes were interaction with VCPS, acceptability of VCPS, community pharmacy workflow, and involvement in patient care. Suggested improvements included involving community pharmacists early in the implementation of the service and establishing clear expectations and procedures.

Conclusions

The experiences of community pharmacists with VCPS were positive and there was a consensus that the introduction of the service had assisted interviewees in providing medication management to patients at transition of care. The ease of communication and efficiency of the service were recognised as key factors in the success of VCPS for community pharmacists.

A retrospective observational study of vCare: a virtual emergency clinical advisory and transfer service in rural and remote Australia

BACKGROUND

Provision of critical care in rural areas is challenging due to geographic distance, smaller facilities, generalist skill mix and population characteristics. Internationally, the amalgamation telemedicine and retrieval medicine services are developing to overcome these challenges. Virtual emergency clinical advisory and transfer service (vCare) is one of these novel services based in New South Wales, Australia. We aim to describe patient encounters with vCare from call initiation at the referring site to definitive care at the accepting site.

METHODS

This retrospective observational study reviewed all patients using vCare in rural and remote Australia for clinical advice and/or inter-hospital transfer for higher level of care between February and March 2021. Data were extracted from electronic medical records and included remoteness of sites, presenting complaint, triage category, camera use, patient characteristics, transfer information, escalation of therapeutic intervention and outcomes. Data were summarised using cross tabulation.

RESULTS

1,678 critical care patients were supported by vCare, with children (12.5%), adults (50.6%) and older people (36.9%) evenly split between sexes. Clinicians mainly referred to vCare for trauma (15.1%), cardiac (16.1%) and gastroenterological (14.8%) presentations. A referral to vCare led to an escalation of invasive intervention, skill, and resources for patient care. vCare cameras were used in 19.8% of cases. Overall, 70.5% (n = 1,139) of patients required transfer. Of those, 95.1% were transferred to major regional hospitals and 11.7% required secondary transfer to higher acuity hospitals. Of high-urgency referrals, 42.6% did not receive high priority transport. Imaging most requested included CT and MRI scans (37.2%). Admissions were for physician (33.1%) and surgical care (23.3%). The survival rate was 98.6%.

CONCLUSION

vCare was used by staff in rural and remote facilities to support decision making and care of patients in a critical condition. Issues were identified including low utilisation of equipment, heavy reliance on regional sites and high rates of secondary transfer. However, these models are addressing a key gap in the health workforce and supporting rural and remote communities to receive care.

Collaborative Care - empowering community in the development of rural primary health workforce and service delivery models

INTRODUCTION

Across Australia, providing sustainable primary care services in small rural communities (<1000 population) has been increasingly challenging. It is acknowledged that health system planners must take coordinated action to strengthen systems to enable a community-empowered response to such challenges. In partnership with the Australian Government, Collaborative Care is a whole-of-system approach used in five Australian rural sub-regions to align communities, organisations, policy and funding levers with a common purpose in health workforce and service planning (article here).

METHODS

A synthesis of field observations and experiences of community and jurisdictional partners in planning and implementing a Collaborative Care model.

RESULTS

In this presentation, we report on the success factors and challenges in developing models for improved rural primary health care access. Successes include sustained community participation, improved community health workforce literacy, coordination of stakeholders and resources across health and community systems combined with health service planning expertise. Challenges include the time and investment to build a coordinated partnership approach and in identifying mechanisms for ongoing financial sustainability.

DISCUSSION

Including community as a partner in design and implementation is a key enabler for achieving a tailored primary health workforce and service delivery model that is acceptable and trusted by communities. The Collaborative Care approach strengthens community through capacity building and integrating existing resources across both primary and acute care services to achieve an innovative and quality rural health workforce model built around the concept of rural generalism. Identifying mechanisms for sustainability will enhance the usefulness of the Collaborative Care Framework.

Rural health workforce response to Australia's recent natural disasters and emergencies, with a focus COVID-19

INTRODUCTION

Australia has recently been heavily impacted by natural disasters and emergencies including drought, bushfire, floods and COVID-19. The New South Wales Rural Doctors Network (RDN) and partners developed and implemented strategies to support the primary health care response during this challenging time.

METHODS

Strategies included the establishment of an inter-sectoral working group of 35 government and non-government agencies, a stakeholder survey, a rapid literature review, and broad consultation aimed at understanding the impacts of natural disasters and emergencies on primary health care services and workforce in rural NSW.

RESULTS

Several key initiatives were established, including the RDN COVID-19 Workforce Response Register and #RuralHealthTogether, a website to support the wellbeing of rural health practitioners. Other strategies included financial support for practices, technology enabled service support and a Natural Disaster and Emergency Learnings Report.

DISCUSSION

The cooperation and coordination of 35 government and non-government agencies led to development of infrastructure to support the crisis response to COVID-19 and other natural disasters and emergencies in an integrated way. Benefits included consistency of messaging, coordination of support locally and regionally, sharing of resources and collation of localised data to inform coordination and planning. Stronger primary healthcare engagement in emergency response pre-planning is required to ensure maximum benefit and use of established resources and infrastructure. This case study shows the value and applicability of an integrated approach to support primary healthcare services and workforce when responding to natural disasters and emergencies.

The Virtual Rural Generalist Service - a COVID-19 resilient support service for rural and remote communities

INTRODUCTION

Recruiting and retaining a highly skilled medical workforce in rural and remote communities is challenging1,2. In Western NSW Local Health District (Australia), a Virtual Rural Generalist Service (VRGS) was established to support rural clinicians in providing safe and high quality care. The service leverages the unique skillset of rural generalist doctors to provide hospital-based clinical services in communities without a local doctor or where local doctors request additional support.

METHOD

Presenting observations and outcomes during the first 2 years of operationalising VRGS.

RESULTS

This presentation reports on the success factors and challenges in developing VRGS to supplement face-to-face care in rural and remote communities. In its first 2 years, VRGS has provided over 40,000 patient consultations across 30 rural communities. The service has delivered equivocal patient outcomes compared with face-to-face care and has been COVID-19 resilient during a period where existing fly-in-fly-out workforce has been unable to travel due to border restrictions in Australia.

DISCUSSION

Outcomes of the VRGS can be mapped to the quadruple aim3, focusing on improving patient experience, improving the health of populations, increasing the effectiveness of healthcare organisations and ensuring sustainable health care into the future. The findings described regarding VRGS can be translated to support both patients and clinicians in rural and remote settings worldwide.References1 Humphreys JS, Jones JA, Jones MP, Mara PR. Workforce retention in rural and remote Australia: determining the factors that influence length of practice. Medical Journal of Australia 2002; 176(10): 472-476. https://doi.org/10.5694/j.1326-5377.2002.tb04518.x2 Strasser R. Rural health around the world: challenges and solutions. Family Practice 2003; 20(4): 457-463. <a href="https://doi.org/10.1093/fampra/cmg422" target="_blank">https://doi.org/10.1093/fampra/cmg4223Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ Quality & Safety 2015; 24: 608-610. https://doi.org/10.1136/bmjqs-2015-004160.

A networked approach to addressing COVID-19 in rural and remote Australia

INTRODUCTION

The COVID-19 global pandemic has been a significant challenge worldwide. This has been particularly so in rural and remote communities where largely metropolitan-based policies do not translate into the rural context. Western NSW Local Health District (Australia), a region spanning almost 250,000 km2 (slightly larger than the UK), has implemented a networked approach that spanned public health measures, acute care services and psycho-social supports for rural communities.

METHOD

A synthesis of field observations and experiences in planning and implementing a networked rural approach to COVID-19.

RESULTS

This presentation reports on the key enablers, challenges and observations in operationalising a networked, rural-specific, 'whole-of-health' approach to COVID-19. As of 22 December 2021, the region (total population 278,000) had confirmed over 112,000 cases of COVID-19 across some of the state's most disadvantage rural communities. This presentation will provide an overview of the framework used to address COVID-19, including descriptions of the public health response, specific care needs of those with COVID-19, cultural and social support for vulnerable peoples and an approach to keeping the community well.

DISCUSSION

Responses to COVID-19 need to be 'rural proofed' to ensure that the need of rural communities can be met. Acute health services must leverage a networked approach that supports existing clinical workforce through effective communication and developing rural-specific processes to ensure best practice care can be delivered. This includes utilising advances in telehealth to ensure people can access clinical support when diagnosed with COVID-19. Managing the COVID-19 pandemic across rural communities requires 'whole-of-system' thinking and strengthening partnerships to manage both public health measures as well as an acute care response.

Virtual clinical pharmacy services: A model of care to improve medication safety in rural and remote Australian health services

Purpose

To describe a virtual clinical pharmacy service as a model of care to support rural and remote Australian hospitals that otherwise would not have access to onsite pharmacists.

Summary

Many small hospitals in Australia do not have an onsite hospital pharmacist and struggle to support and optimize patient care. To increase access to a hospital pharmacist’s specialized skills and medication knowledge, a virtual clinical pharmacy service was designed and implemented in 8 hospitals across rural New South Wales, Australia in 2020. The virtual clinical pharmacy service focuses on the core role of hospital pharmacists, including obtaining a best possible medication history, medication reconciliation at transitions of care, medication review, interprofessional team meetings, provision of patient-friendly medication lists, antimicrobial stewardship, and patient and clinician education. The model is aligned with recognized standards of practice for the delivery of clinical pharmacy services in Australian hospitals. This article details a model of care for translation across other settings. It provides the necessary details on clinical services, processes, supporting structures, an evaluation framework, and other important considerations for implementing virtual pharmacy services.

Conclusion

This research provides policymakers, health service planners, and practitioners with a model for providing comprehensive clinical pharmacy services virtually to increase the safe and effective use of medicines. Future publication of the findings of a formal evaluation of the model’s acceptability and effectiveness is planned.

"This is streets ahead of what we used to do": staff perceptions of virtual clinical pharmacy services in rural and remote Australian hospitals

BACKGROUND

The use of medications is the most common intervention in healthcare. However, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. A Virtual Clinical Pharmacy Service (VCPS) was introduced in rural and remote New South Wales public hospitals to support safe and effective use of medications. In this model clinical pharmacy services are delivered via a telehealth cart at the patient's bedside and through electronic medical and pharmaceutical record systems. The aim of this research was to understand healthcare staff perspectives of the VCPS and identify areas for improvement.

METHODS

A qualitative approach informed by Appreciative Inquiry was used to investigate healthcare staff perceptions of the VCPS. Focus group discussions (n = 15) with hospital staff and medical officers were conducted via videoconference at each study site. Focus groups explored issues, benefits and barriers 3 months after service implementation. Transcribed data were analysed using thematic analysis and team discussion to synthesise themes.

RESULTS

Focus group participants identified the value of the VCPS to patients, to the health service and to themselves. They also identified enhancements to increase value for each of these groups. Perceived benefits to patients included access to specialist medication advice and improved medication knowledge. Staff valued access to an additional, trusted workforce who provided back-up and guidance. Staff also reported confidence in improved patient safety and identification of medication errors. Enhanced compliance with antimicrobial stewardship and hospital accreditation standards were beneficial to the health service. Suggested improvements included extending virtual service hours and widening patient eligibility to include aged care patients.

CONCLUSIONS

The VCPS brought a positive, collegiate culture regarding medications. Healthcare staff perceived the VCPS was effective and an efficient way for the health service to supply pharmacy services to smaller hospitals. The ease of use, model of delivery, availability, local knowledge and responsiveness of highly skilled pharmacists was the key to user satisfaction.

TRIAL REGISTRATION

ANZCTR ACTRN12619001757101 , 11/12/2019.

Collaborative care: Primary health workforce and service delivery in Western New South Wales-A case study

OBJECTIVE

To explore how four small towns in rural New South Wales known as the 4Ts are addressing challenges accessing quality care and sustainable health services through a collaborative approach to workforce planning using the collaborative care framework.

DESIGN

Descriptive case study approach.

SETTING

The collaborative care project was developed as a result of ongoing partnerships between 2 rural Local Health Districts, 2 Primary Health Networks and a non-governmental health workforce organisation. The collaboration works with 5 subregions each comprising 2 or more rural communities. This paper focuses on the 4Ts subregion.

PARTICIPANTS

Stakeholders of the collaborative design including organisations and the community.

INTERVENTION

A place-based approach to co-designing health services with community in one sub-region of Western New South Wales.

MAIN OUTCOME MEASURES

A synthesis of field observations and experiences of community and jurisdictional partners in implementation of the 4Ts subregional model. Mapping of implementation processes against the collaborative care framework.

RESULTS

The collaborative care framework is a useful planning and community engagement tool to build health workforce literacy and to impact on system change at the local level. We identify key elements of effectiveness in establishing the 4Ts model, including the need for coordinated health system planning, better integrating existing resources to deliver services, community engagement, building health workforce literacy and town-based planning.

CONCLUSION

This study adds to the body of knowledge about how to successfully develop a collaborative primary health care workforce model in practice. The findings demonstrate that the implementation of a collaborative primary health care workforce model using the collaborative care framework can improve service access and quality, which in turn might facilitate workforce sustainability.

Design, development and implementation of the virtual, coordination, access, referral and escalation service in western New South Wales

PROBLEM

People in rural and remote New South Wales experience avoidable admissions, limited access to skilled clinicians and commonly travel >400 km to access specialist services within the district and >700 km for tertiary services outside.

DESIGN

Iterative use of New South Wales Health redesign methodology in the period 2015-2020.

SETTING

Western New South Wales Local Health District is geographically the largest Health District within New South Wales and includes disadvantaged communities. Virtual Coordination Access Referral Escalation is an audio-visually enabled transport, patient flow and clinical advice unit established in 2006 to support patients and clinicians at 35 small, rural and remote hospitals.

KEY MEASURES FOR IMPROVEMENT

Right care, right place and right time by the right team the first time. Care delivery close to home and 'on country'. Safe and cost-effective transport. Performance measures to support quality, safety and clinical outcomes. Improving the human experience.

STRATEGIES FOR CHANGE

Cycles of strategic planning, innovation, productive partnerships, change management and human systems development.

EFFECTS OF CHANGE

Virtual Coordination Access Referral Escalation critical care telehealth more effectively supports rural and remote health care across large distances.

LESSONS LEARNT

Improvements include expanded/redefined management and nursing roles, integration of dedicated critical care emergency medicine specialists within the service, delegated authority to accept transfers, upgraded technology, 24-hour service provision and a central 'Virtual Support' proactive outreach model.

A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities

Background

Medication errors are a leading cause of mortality and morbidity. Clinical pharmacy services provided in hospital can reduce medication errors and medication related harm. However, few rural or remote hospitals in Australia have a clinical pharmacy service. This study will evaluate a virtual clinical pharmacy service (VCPS) provided via telehealth to eight rural and remote hospitals in NSW, Australia.

Methods

A stepped wedge cluster randomised trial design will use routinely collected data from patients’ electronic medical records (n = 2080) to evaluate the VCPS at eight facilities. The sequence of steps is randomised, allowing for control of potential confounding temporal trends. Primary outcomes are number of medication reconciliations completed on admission and discharge. Secondary outcomes are length of stay, falls and 28 day readmissions. A cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) will be conducted. The CEA will answer the question of whether the VCPS is more cost-effective compared to treatment as usual; the CBA will consider the rate of return on investing in the VCPS. A patient experience measure (n = 500) and medication adherence questionnaire (n = 100 pre and post) will also be used to identify patient responses to the virtual service. Focus groups will investigate implementation from hospital staff perspectives at each site.

Analyses of routine data will comprise generalised linear mixed models. Descriptive statistical analysis will summarise patient experience responses. Differences in medication adherence will be compared using linear regression models. Thematic analysis of focus groups will identify barriers and facilitators to VCPS implementation.

Discussion

We aim to demonstrate the effectiveness of virtual pharmacy interventions for rural populations, and inform best practice for using virtual healthcare to improve access to pharmacy services. It is widely recognised that clinical pharmacists are best placed to reduce medication errors. However, pharmacy services are limited in rural and remote hospitals. This project will provide evidence about ways in which the benefits of hospital pharmacists can be maximised utilising telehealth technology. If successful, this project can provide a model for pharmacy delivery in rural and remote locations.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) -ACTRN12619001757101 Prospectively registered on 11 December 2019. Record available from: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378878&isReview=true

Formation and turnover of long-chain fatty acid esters of 5-androstene-3 beta, 17 beta -diol in estrogen receptor positive and negative human mammary cancer cell lines in culture

Microsomal preparations derived from bovine placenta cotyledons, previously investigated as a convenient source of fatty acyl coenzyme A: estradiol-17 beta-acyl transferase, have been shown to acylate other steroids bearing 3 beta- or 17 beta-hydroxyl groups. In the presence of 0.1 mM oleoyl CoA, the apparent Km values for dehydroepiandrosterone, testosterone, and 5-androstene-3 beta,17 beta-diol (delta 5-DIOL) were 45, 67, and 20 microM, respectively. Acylation of delta 5-DIOL occurred at either the 3 beta- or 17 beta-positions to give monoesters. Testosterone, estradiol-17 beta, and delta 5-DIOL acted as competitive inhibitors for the acylation of the 3 beta-hydroxyl group of dehydroepiandrosterone (Ki values 71, 75, and 41 microM, respectively). Such data indicate that a single enzyme of wide substrate specificity may be involved in these acylation reactions. When estrogen receptor (ER) positive and negative human mammary cancer cell lines were incubated with 10 nM [3H]delta 5-DIOL, intracellular accumulation of delta 5-DIOL long-chain fatty acid esters occurred; rates being higher (p less than 0.001) in ER negative cells (MDA-MB-231 and MDA-MB-330) compared to MCF-7 cells (ER positive), and higher (P less than 0.005) in MDA-MB-231 cells compared to ZR-75-1 cells (ER positive). After exposure to 10 nM [3H]delta 5-DIOL for 16 h, the total labeled steroid fatty acid fraction was composed predominantly of delta 5-DIOL-3 beta- and 17 beta-monoesters (approximately 85%), the remainder containing approximately equal amounts of delta 5-DIOL-diesters and dehydroepiandrosterone-3 beta-esters. Subsequent transfer to medium lacking delta 5-DIOL was accompanied by a breakdown of the labeled esters, which was more rapid in the ER positive cell lines. During this period, intracellular free delta 5-DIOL levels rapidly declined in MDA-MB-330 cells but were maintained in MCF-7 cells, presumably by binding to ER. This behavior parallels that of estradiol-17 beta previously observed in these cell lines and further emphasizes the potential importance of the adrenal-derived estrogen delta 5-DIOL in consideration of a hormone-based etiology of human breast cancer.

Esterification-deesterification of estradiol by human mammary cancer cells in culture

Formation of lipoidal derivatives of estradiol-17 beta (E2) esterified to long-chained fatty acids has been reported to occur in estrogen target tissues. Employing human breast cancer cells in culture, we have detected the rapid synthesis of such compounds upon exposure of the cells to concentrations of [3H]E2 as low as 1 nM. When exposed to 10 nM [3H]E2 in the culture medium, synthesis of E2-lipoidal derivative (E2-L) reached 270 fmol/mg DNA in 2 h in the estrogen receptor positive MCF-7 human mammary cancer cell line. Higher rates (approximately 900 fmol/mg DNA in 2 h) were reached in 2 estrogen receptor negative human mammary cancer cell lines; MDA-MB-231 and MDA-MB-330. E2-L was the major form of estrogen in the latter cells at this time interval (E2-L/E2 approximately 3.0). Far higher concentrations of E2 were found in MCF-7 cells compared to 231 and 330 cells, and, in contrast to the latter, this was mostly specifically bound. Upon subsequent withdrawal of E2 from the medium, intracellular concentrations of E2-L decreased very rapidly in the first 5 h period, then declined more slowly to approximately 50 fmol/mg DNA at 24 h. Intracellular concentrations of E2 were maintained over this time period. E2-L was not present in the medium. Thus, accumulation of E2-L in cells upon continuous exposure to E2 represents the net result of esterification and deesterification reactions. These hydrophobic E2-derivatives may then be involved in the "capture" of E2 for transport through membranes and subsequent regeneration of E2 to maintain occupancy of the nuclear receptor.