The implementation of a Technician Enhanced Administration of Medications [TEAM] model: An evaluative study of impact on working practices in a children's hospital.

BACKGROUND: Children are frequently prescribed unlicensed and off-label medicines meaning dosing and administration of medicines to children is often based on poor quality guidance. In UK hospitals, nursing staff are often responsible for administering medications. Medication Errors [MEs] are problematic for health services, though are poorly reported and therefore difficult to quantify with confidence. In the UK, children's medicines require administration by at least two members of ward staff, known as a 'second check' system, thought to reduce Medication Administration Errors [MAEs]. OBJECTIVES: To assess the impact on working practices of the introduction of a new way of working, using Technician Enhanced Administration of Medications [TEAM] on two specialist wards within a children's' hospital. To evidence any potential impact of a TEAM ward-based pharmacy technician [PhT] on the reporting of MEs. METHODS: A TEAM PhT was employed on two wards within the children's hospital and trained in medicines administration. Firstly, an observational pre-and-post cohort design was used to identify the effect of TEAM on MEs. We analysed the hospital's official reporting system for incidents and 'near misses', as well as the personal incident log of the TEAM PhT. Secondly, after implementation, we interviewed staff about their perceptions of TEAM and its impact on working practices. RESULTS: We affirm MEs are considerably under-reported in hospital settings, but TEAM PhTs can readily identify them. Further, placing TEAM PhTs on wards may create opportunities for inter-professional knowledge exchange and increase nurses' awareness of potential MAEs, although this requires facilitation. CONCLUSIONS: TEAM PhT roles may be beneficial for pharmacy technicians' motivation, job satisfaction, and career development. Hospitals will need to consider the balance between resources invested in TEAM PhTs and the level of impact on reporting MEs. Health economic analyses could provide evidence to fully endorse integration of TEAM PhTs for all hospital settings.

An exploration of the perceptions of non-medical prescribers, regarding their self-efficacy when prescribing, and their willingness to take responsibility for prescribing decisions.

BACKGROUND: In the UK, non-medical prescribers (NMPs) are a significant part of the healthcare workforce. Little is known about their self-efficacy when prescribing, and their willingness to take responsibility for prescribing decisions. OBJECTIVE: To explore the perceptions of NMPs regarding their self-efficacy in prescribing and responsibility for prescribing decisions. METHODS: Cross-sectional survey of a purposive sample of NMPs on acute medical units (AMUs) across the UK. Bandura's Social Cognitive Theory informed the self-efficacy aspect of the questionnaire. Participants' views were also sought on responsibility for prescribing decisions. For quantitative data descriptive statistics were calculated. Hierarchical multiple linear regressions determined whether five independent variables improved the prediction of self-efficacy in aspects of prescribing: NMP's profession; length of time qualified as a healthcare professional and as an NMP; the number of items prescribed and hours worked per week on an AMU. Framework analysis was used to analyse the qualitative data. RESULTS: Ninety-nine valid responses were obtained. Self-efficacy overall was high. The longer the participant had been qualified as an NMP was associated with increased self-efficacy in certain aspects of prescribing. All physiotherapists, and more nurses than pharmacists were responsible for prescribing decisions. Where participants were not fully responsible, the responsibility was partial or shared. CONCLUSIONS: Self-efficacy of NMPs when prescribing is influenced by several factors. The variables within this study appear to account for only a small part of this self-efficacy. Self-efficacy in prescribing appears to contribute to NMPs' willingness to take responsibility for prescribing decisions; further influenced by their job role and the prescribing this entails. Stakeholders need to appreciate the full range of factors that influence the self-efficacy of NMPs when prescribing, and the association of this to take responsibility for prescribing decisions. This knowledge will assist in maximising the benefits of non-medical prescribing within the healthcare system.

Health care professionals' perceptions of a community based 'virtual ward' medicines management service: A qualitative study.

This article describes a qualitative research study using focus groups to explore the views and experiences of a medicines management team (MMT) on the service they deliver within a 'Virtual Ward' (VW); and those of the wider multidisciplinary team of healthcare professionals on the service provided by the MMT. Several themes emerged from the focus groups, including impact on patients and carers, team working and issues and challenges. A dedicated MMT was seen as a positive contribution to the VW, which potentially increased the quality of patient care, and appeared to be a positive experience for both the MM and wider multidisciplinary team.

Nonmedical prescribing: where are we now?

Nonmedical prescribing has been allowed in the United Kingdom (UK) since 1992. Its development over the past 24 years has been marked by changes in legislation, enabling the progression towards independent prescribing for nurses, pharmacists and a range of allied health professionals. Although the UK has led the way regarding the introduction of nonmedical prescribing, it is now seen in a number of other Western-European and Anglophone countries although the models of application vary widely between countries. The programme of study to become a nonmedical prescriber (NMP) within the UK is rigorous, and involves a combination of taught curricula and practice-based learning. Prescribing is a complex skill that is high risk and error prone, with many influencing factors. Literature reports regarding the impact of nonmedical prescribing are sparse, with the majority of prescribing research tending to focus instead on prescribing by doctors. The impact of nonmedical prescribing however is important to evaluate, and can be carried out from several perspectives. This review takes a brief look back at the history of nonmedical prescribing, and compares this with the international situation. It also describes the processes required to qualify as a NMP in the UK, potential influences on nonmedical prescribing and the impact of nonmedical prescribing on patient opinions and outcomes and the opinions of doctors and other healthcare professionals.

Supporting older people with cancer and life-limiting conditions dying at home: a qualitative study of patient and family caregiver experiences of Hospice at Home care.

AIM: To explore patients' and family caregivers' experiences and perceptions of Hospice at Home care. BACKGROUND: The public indicate a preference to be cared for and to die at home. This has inherent challenges, with a key factor being the family caregiver. Supporting end-of-life care at home has resulted in the expansion of Hospice at Home services. A wide configuration of services exists with a lack of robust evidence as to what is valued by recipients, particularly those who are older people. DESIGN: A prospective descriptive qualitative study. METHODS: Recruitment was purposive. Eligible participants were in receipt of Hospice at Home service on at least three occasions and were deemed to have a life expectancy measured in weeks rather than days. Digitally recorded semistructured interviews with 41 participants (16 patients and 25 family caregivers) were undertaken between October 2014 - July 2015. Data were analysed and organized thematically. RESULTS: Several subthemes: 'Talking about'; 'Knowing and Doing'; 'Caring for the Caregivers'; and 'Promoting Choice' contributed to the overall theme of Embracing Holism. A positive impact on emotional, psychological, social and physical well-being was apparent. CONCLUSIONS: This study has provided additional insights as to the value of Hospice at Home care where Hospice Nurses are helping to bring Hospice care into the home. This is helping to support older people who are dying and their caregivers, to live as well as possible and facilitate their wish to be cared for and die in their own home.

The epidemiology of polymyalgia rheumatica in primary care: a research protocol.

BACKGROUND: Polymyalgia Rheumatica (PMR) is the commonest inflammatory condition seen in older patients in primary care. To date, however, research has been focused on secondary care cohorts rather than primary care where many patients are exclusively managed. This two year prospective inception cohort study of PMR patients will enable us to understand the full spectrum of this condition. METHODS: Patients diagnosed with PMR in primary care will be identified via Read codes and mailed a series of postal questionnaires over a two-year period to assess their levels of pain, stiffness and functioning, as well as medication usage and other health-related and socio-demographic characteristics. In addition, participants will be asked for permission to link their survey data to their general practice electronic medical record and to national mortality and cancer registers. DISCUSSION: This will be the first large-scale, prospective, observational cohort of PMR patients in primary care. The combination of survey data with medical records and national registers will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting, in which the majority of patients are treated, but where little research on the treatment and outcome of consultation has been undertaken. This will provide information that may lead to improved primary care management of PMR.

Use of pharmacotherapy in smoking cessation.

Nurses can make a significant contribution to improving public health and reducing health inequalities by helping patients to quit smoking. This article outlines the main options to support patients, including pharmacotherapy.

Substernal epicardial echocardiography: a recommended examination sequence and clinical evaluation in patients undergoing cardiac surgery.

BACKGROUND: Substernal epicardial echocardiography is a novel echocardiography window, utilizing a modified mediastinal drain incorporating a sleeve for the insertion of a transesophageal echocardiography probe. METHODS: Forty-six patients undergoing cardiac surgery from two institutions were evaluated, and an examination sequence was developed. RESULTS: An 11-view examination is presented as a consensus between the two institutions. In clinical usage, there were no major complications attributable to use of the device. Minor air leaks occurred in 6 patients, and 2 cases of sternal wound infection occurring in a cluster of infections are reported, but causation was not attributed to use of the device. There were no significant differences in measurements of the aortic valve area, pulmonary artery diameter, left ventricular outflow tract dimension, or the sinotubular junction between substernal and transesophageal examinations. All 16 wall-motion segments were well visualized in most patients with substernal epicardial echocardiography. CONCLUSIONS: Substernal epicardial echocardiography is a safe device for use in the postoperative environment.

Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay.

UNLABELLED: Improvements in analgesia after major surgery may allow a more rapid recovery and shorter hospital stay. We performed a prospective randomized trial to study the effects of epidural analgesia on the length of hospital stay after coronary artery surgery. The anesthetic technique and postoperative mobilization were altered to facilitate early intensive care discharge and hospital discharge. Fifty patients received high (T1 to T4) thoracic epidural anesthesia (TEA) with ropivacaine 1% (4-mL bolus, 3-5 mL/h infusion), with fentanyl (100-microg bolus, 15-25 microg/h infusion) and a propofol infusion (6 mg x kg(-1) x h(-1)). Another 50 patients (the General Anesthesia group) received fentanyl 15 microg/kg and propofol (5 mg x kg(-1) x h(-1)), followed by IV morphine patient-controlled analgesia. The TEA group had lower visual analog scores with coughing postextubation (median, 0 vs 26 mm; P < 0.0001) and were extubated earlier (median hours [interquartile range], 3.2 [2.1-4.6] vs 6.7 [3.3-13.2]; P < 0.0001). More than half of all patients were discharged home on Postoperative Day 4 (24%) or 5 (33%), but there was no difference in the length of stay between the TEA group (median [interquartile range], Day 5 [5-6]) and the General Anesthesia group (median [interquartile range], Day 5 [4-7]). There were no differences in postoperative spirometry or chest radiograph changes or in markers for postoperative myocardial ischemia or infarction. No significant TEA-related complications occurred. In summary, TEA provided better analgesia and allowed earlier tracheal extubation but did not reduce the length of hospital stay after coronary artery surgery. IMPLICATIONS: We found that epidural analgesia was more effective than IV morphine for cardiac surgery. Epidural anesthesia also allowed earlier weaning from mechanical ventilation, but it did not affect hospital discharge time.