Using Technology-Supported Transfer of Care Systems: Informing Good Practice Recommendations.

The Discharge Medicines Review (DMR) referral system, Refer-to-Pharmacy (RTP), PharmOutcomes and Help for Harry are UK transfer of care systems that aim to reduce the risks associated with hospital discharge. These systems use technology to facilitate the transmission of discharge information to community pharmacy, allowing community pharmacists to provide an adherence-support service. Despite the evidence that these systems benefit patient safety, there is a paucity of literature on their use. This study aimed to describe, compare and contrast these systems to highlight areas that could inform good practice recommendations. A rapid literature review was completed, and from the twenty-six sources of literature that were synthesised, three themes were identified for further exploration in semi-structured interviews with key informants: implementation, system attributes and stakeholder engagement. The key informants were purposively sampled for their role in the development and/or strategic implementation of each transfer of care system (n = 4). Audio recordings were transcribed ad verbatim and analysed both deductively and inductively. One interview was undertaken for each of the DMR, RTP and PharmOutcomes systems. Although all systems shared the same aim, differences were identified such as automated feedback for referrals, marketing strategies and practitioner accountability. Good practice recommendations suggested in this study could be applied to the future development of such systems.

Understanding the impact of a new pharmacy sore throat test and treat service on patient experience: A survey study.

BACKGROUND: A pilot of the first NHS funded Sore Throat Test and Treat (STTT) service in the United Kingdom began in selected community pharmacies in Wales in November 2018. The aim of this research was to explore whether a pharmacist delivering consultation for sore throat that included clinical scoring and point-of-care testing was acceptable to patients and how this might influence future health-seeking behaviour. METHODS: A non-experimental design was employed using a survey research tool including a mix of closed and open questions. The patient experience survey was distributed to all patients who had completed a consultation between November 2018 and May 2019. Data from completed surveys were entered in Jisc Online Surveys® and exported to Excel® for descriptive statistics. Free-text comments were analysed using content and inductive thematic analysis. RESULTS: A total of 510 surveys were received (n = 2,839 total consultations, response rate 18%). Overall, 501 patients (98%) were satisfied with the service. Patients' confidence in managing their condition and service satisfaction was not dependent on having been supplied antibiotics. After the service, 504 patients (99%) stated that they would return to the pharmacy for subsequent sore throat symptoms. Three themes were constructed after inductive analysis of free-text comments (n = 242): convenience and accessibility; professionalism of pharmacy team; and perceived value of the service. CONCLUSIONS: Results confirmed high levels of patient satisfaction with the new service, its delivery and the choice of options offered for sore throat symptom management. Whilst this research can only discuss patients' reported future behaviour, the patient-reported stated intentions signify a potential shift in health-seeking behaviour towards a pharmacist-led service. This has important implications in supporting the long-term plan of the governments in Wales and England to redirect management of uncomplicated conditions from GPs to pharmacies.

Impact of a pilot NHS-funded sore throat test and treat service in community pharmacies on provision and quality of patient care.

OBJECTIVE: A National Health Service (NHS)-funded sore throat test and treat (STTT) service was introduced in selected pharmacies in two local health boards in Wales, as an extension to the national pharmacy common ailment scheme. The aim of this study was to evaluate the impact of STTT on provision and quality of patient care, namely antibiotic use, patient safety and general practitioner (GP) consultation rates. METHODS: Secondary analyses of STTT consultation data to describe service outcomes, and routine data to explore changes in antibiotic prescribing and the prevalence of complications. Data were also collected from one GP practice to explore the feasibility of measuring changes in sore throat consultation rates in general practice. RESULTS: Less than 20% of 1725 consultations resulted in antibiotic supply. The availability of STTT was associated with greater reductions in prescriptions for phenoxymethylpenicillin than in areas where STTT was not available (-3.8% and -3.4%, difference 0.4%). When pharmacy supplies were included, the reductions in the supply of the antibiotic were similar. No increase in the monthly number of incidents of quinsy was detected, and patients were appropriately referred to other healthcare professionals during pharmacy consultations. GP consultation rates since introduction of STTT were found to be lower than the equivalent monthly average since 2014. CONCLUSIONS: Data from the first 5 months of the STTT service suggest that it may have a role in safely rebalancing uncomplicated sore throat management from general practice to community pharmacies while continuing to promote antibiotic stewardship.

Exploring the association of the discharge medicines review with patient hospital readmissions through national routine data linkage in Wales: a retrospective cohort study.

OBJECTIVE: To evaluate the association of the discharge medicines review (DMR) community pharmacy service with hospital readmissions through linking National Health Service data sets. DESIGN: Retrospective cohort study. SETTING: All hospitals and 703 community pharmacies across Wales. PARTICIPANTS: Inpatients meeting the referral criteria for a community pharmacy DMR. INTERVENTIONS: Information related to the patient's medication and hospital stay is provided to the community pharmacists on discharge from hospital, who undertake a two-part service involving medicines reconciliation and a medicine use review. To investigate the association of this DMR service with hospital readmission, a data linking process was undertaken across six national databases. PRIMARY OUTCOME: Rate of hospital readmission within 90 days for patients with and without a DMR part 1 started. SECONDARY OUTCOME: Strength of association of age decile, sex, deprivation decile, diagnostic grouping and DMR type (started or not started) with reduction in readmission within 90 days. RESULTS: 1923 patients were referred for a DMR over a 13-month period (February 2017-April 2018). Provision of DMR was found to be the most significant attributing factor to reducing likelihood of 90-day readmission using χ2 testing and classification methods. Cox regression survival analysis demonstrated that those receiving the intervention had a lower hospital readmission rate at 40 days (p<0.000, HR: 0.59739, CI 0.5043 to 0.7076). CONCLUSIONS: DMR after a hospital discharge is associated with a reduction in risk of hospital readmission within 40 days. Linking data across disparate national data records is feasible but requires a complex processual architecture. There is a significant value for integrated informatics to improve continuity and coherency of care, and also to facilitate service optimisation, evaluation and evidenced-based practice.

Community pharmacists at the heart of public health: A longitudinal evaluation of the community pharmacy influenza vaccination service.

BACKGROUND: Influenza ("flu") is a contagious viral infection causing approximately 600 deaths/year in the United Kingdom. Annual vaccination is the most effective prevention strategy with a target of 75% uptake in 'at-risk' patient groups. Before 2012, immunisation was conducted in General Practice (GP), but uptake was below target. NHS Wales therefore introduced a programme allowing community pharmacists to administer the vaccine to certain patient groups. OBJECTIVES: This study aimed to evaluate the community pharmacy (CP) flu Vaccination Programme in Wales. METHODS: A longitudinal study was undertaken by secondary data analysis on data related to all NHS funded flu vaccinations administered in CP between 2012 and 2018 (n = 103941). Data were analysed using IBM SPSS® and Excel®. Pearson's correlation and independent sample t-test were conducted to compare the number of vaccines administered in CP vs overall numbers and those under 65 years and in the 'at risk' category in CP and GP respectively. Ethical approval was not required. RESULTS: In total, pharmacists administered 103941 vaccinations. Vaccination numbers increased each season from 1568 in 2012/13 to 36238 in 2017/18. The main risk group was those aged 65 and over (59.9% of vaccinations). The proportion of those vaccinated who were aged <65 years and in an 'at risk' category was significantly higher in CP than GP (p < 0.01). There was a shift in balance between vaccinations administered by GPs and CPs in which CPs increased their share of all vaccinations in the flu programme from 0.3% in 2012-13 to 5.7% in 2017-18. A strong positive correlation was observed between increasing CP vaccinations and total vaccination numbers (R = 0.9316, p < 0.01). CONCLUSIONS: Community pharmacists are providing increasing numbers of flu vaccinations in Wales, benefitting patients in all at-risk groups and reinforcing the valuable role of pharmacists at the heart of their communities, in terms of public choice and accessibility.

Community Pharmacist Views On The Early Stages Of Implementation Of A Pathfinder Sore Throat Test And Treat Service In Wales: An Exploratory Study.

OBJECTIVES: To explore the views and opinions of community pharmacists regarding their initial experience of and levels of preparedness for the pathfinder sore throat test and treat (STTT) service in Wales. METHODS: A phenomenological qualitative approach with constructivist paradigm was adopted as the first cycle of ongoing action research. Semi-structured interviews with community pharmacists who had completed at least three consultations within the first 3 weeks of the service were conducted, with informed consent and audio recorded. Interviews were transcribed ad verbatim and data were thematically analysed both inductively and deductively. RESULTS: A total of seven interviews with pharmacists who had conducted more than three consultations identified three main themes: 1) perceived impact of the service on patient care, including the value of the structure and technology infrastructure, the role of STTT towards antimicrobial stewardship, and its potential role in rebalancing primary care resources so that workload is distributed appropriately among healthcare professionals; 2) factors that empower pharmacists to deliver the service, in particular quality and consistency of training, appropriate staffing resource and internally motivated willingness to engage; 3) interface with GP surgeries such as nature of existing relationships before implementing the service, role of GP staff and GP perceived value of STTT. CONCLUSION: The pathfinder STTT service has been well received by pharmacists who recognised the service's role in providing patient education and contributing to principles of antimicrobial stewardship and described factors that would empower them to deliver the service confidently. Results have been fed back to the service implementation team to inform future developments.

A 5-year evaluation of the emergency contraception enhanced community pharmacy service provided in Wales.

BACKGROUND: Access to emergency contraception (EC) has been a core component of attempts to address high teenage pregnancy rates in Wales. A national service was commissioned in 2011, allowing supply of EC free of charge from community pharmacies (CPs). This study investigated 5 years of the EC service, to describe its use and investigate changes in the pattern of use over time. METHODS: Secondary analyses of data from all National Health Service funded CP EC consultations in Wales between 1 August 2012 and 31 July 2017 (n=181 359). Data comprised standardised clinical and demographic information, in the form of predefined service user responses, submitted for reimbursement by CPs. RESULTS: Overall service provision remained relatively consistent over the study period, with women aged between 13 and 59 years accessing the service. An association was observed between the time since unprotected sexual intercourse and the day on which the service was accessed (Χ2(18)=16 292.327, p<0.001). Almost half (47.9%) of requests were because no contraception had been used, with a strong and positive association for teenagers and women aged 40+ years. A statistically significant and increasing percentage of consultations were accompanied by further sexual health advice (r=0.7, p<0.01). CONCLUSIONS: Access to EC through CPs is contributing to reducing teenage conceptions and termination rates. However, action is needed to increase contraception use in all age groups. Reduced availability of CP services on Sundays is a barrier to timely EC access. Findings support an expanded role for community pharmacists in provision of regular contraception.

Does an integrated information technology system provide support for community pharmacists undertaking Discharge Medicines Reviews? An exploratory study.

OBJECTIVE: The aim of this study was to explore the views of community pharmacists participating in the pilot of a secure online platform in Wales, the Choose Pharmacy application (CPA), with particular interest in the electronic Discharge Advice Letters (e-DALs) and online Discharge Medicines Review (DMR) form. MATERIALS AND METHODS: A qualitative approach with semi-structured interviews was adopted. A gatekeeper from National Health Service Wales Informatics Service identified 35 pharmacies, of the 43 pharmacies where the CPA had been implemented, that had completed at least one DMR, and these were therefore invited to an interview. RESULTS: A total of 17 pharmacists were interviewed. Overall, the results were positive and CPA and e-DAL were perceived to facilitate continuity of care between care settings. The design and usability were perceived as good as pharmacists could navigate the CPA without problems; many felt this was due to the level of training they had received. Many pharmacists were happy for other services to be included on the platform due to its ease of use and automatic reimbursement. Several pharmacists felt that communication between primary and secondary care can be further improved as the uptake of e-DAL increases. CONCLUSION: CPA was found to streamline the completion of online DMR improving continuity of care between primary and secondary sectors, which in turn should improve patient safety on discharge from hospital.

The impact of automation on pharmacy staff experience of workplace stressors.

OBJECTIVE: Determine the effect of installing an original pack automated dispensing system (ADS) on staff experience of occupational stressors. METHODS: Pharmacy staff in a National Health Service hospital in Wales, UK, were administered an anonymous occupational stressor questionnaire pre- (n = 45) and post-automation (n = 32). Survey responses pre- and post-automation were compared using Mann-Whitney U test. Statistical significance was P ≤ 0.05. Four focus groups were conducted (two groups of accredited checking technicians (ACTs) (group 1: n = 4; group 2: n = 6), one group of pharmacists (n = 17), and one group of technicians (n = 4) post-automation to explore staff experiences of occupational stressors. Focus group transcripts were analysed according to framework analysis. KEY FINDINGS: Survey response rate pre-automation was 78% (n = 35) and 49% (n = 16) post-automation. Automation had a positive impact on staff experience of stress (P = 0.023), illogical workload allocation (P = 0.004) and work-life balance (P = 0.05). All focus-group participants reported that automation had created a spacious working environment. Pharmacists and ACTs reported that automation had enabled the expansion of their roles. Technicians felt like 'production-line workers.' Robot malfunction was a source of stress. CONCLUSION: The findings suggest that automation had a positive impact on staff experience of stressors, improving working conditions and workload. Technicians reported that ADS devalued their skills. When installing ADS, pharmacy managers must consider the impact of automation on staff. Strategies to reduce stressors associated with automation include rotating staff activities and role expansions.

The impact of automation on workload and dispensing errors in a hospital pharmacy.

OBJECTIVES: To determine the effect of installing an original-pack automated dispensing system (ADS) on dispensary workload and prevented dispensing incidents in a hospital pharmacy. METHODS: Data on dispensary workload and prevented dispensing incidents, defined as dispensing errors detected and reported before medication had left the pharmacy, were collected over 6 weeks at a National Health Service hospital in Wales before and after the installation of an ADS. Workload was measured by non-participant observation using the event recording technique. Prevented dispensing incidents were self-reported by pharmacy staff on standardised forms. Median workloads (measured as items dispensed/person/hour) were compared using Mann-Whitney U tests and rate of prevented dispensing incidents were compared using Chi-square test. Spearman's rank correlation was used to examine the association between workload and prevented dispensing incidents. A P value of ≤0.05 was considered statistically significant. KEY FINDINGS: Median dispensary workload was significantly lower pre-automation (9.20 items/person/h) compared to post-automation (13.17 items/person/h, P < 0.001). Rate of prevented dispensing incidents was significantly lower post-automation (0.28%) than pre-automation (0.64%, P < 0.0001) but there was no difference (P = 0.277) between the types of dispensing incidents. A positive association existed between workload and prevented dispensing incidents both pre- (ρ = 0.13, P = 0.015) and post-automation (ρ = 0.23, P < 0.001). Dispensing incidents were found to occur during prolonged periods of moderate workload or after a busy period. CONCLUSION: Study findings suggest that automation improves dispensing efficiency and reduces the rate of prevented dispensing incidents. It is proposed that prevented dispensing incidents frequently occurred during periods of high workload due to involuntary automaticity. Prevented dispensing incidents occurring after a busy period were attributed to staff experiencing fatigue after-effects.

Measuring dispensary workload: a comparison of the event recording and direct time techniques.

OBJECTIVES: To compare dispensary workload, determined using the Welsh benchmarking event recording technique and the direct time technique, at two district general UK National Health Service hospitals within different university local health Boards (hospital A--manual dispensing system; hospital B--automated dispensing system). METHODS: Data on dispensary workload were collected, over a period of 6 weeks (hospital A: 8 May-18 June 2007; hospital B: 1 October-11 November 2007), by a non-participant observer using two simultaneous methods of workload measurement: direct time and event recording. Direct time technique involved timing each task involved in dispensing a sample of prescriptions from receipt to issue of dispensed medicines to patients. Welsh benchmarking event recording involved continuously logging staff activities that deviated from the dispensary rota on a data collection form to enable calculation of total staff time involved in dispensing activities. Data on number of items dispensed were obtained from the pharmacy computer system and also by manual counting of prescription items. The mean dispensary workloads were calculated as the number of items dispensed per person per hour. Two-sample t-tests were used to compare dispensary workload measurements determined using direct time and event recording technique reported by each individual hospital. Mean workloads for hospitals A and B were compared using a two-sample t-test. Statistical significance was taken as P≤0.05. KEY FINDINGS: Hospital A was associated with a lower workload (direct time: 7.27±7.16 items per person per hour; event recording: 9.57±10.6 items per person per hour). In contrast, hospital B gave a higher workload (direct time: 11.93±8.3 items per person per hour; event recording: 12.6±8.80 items per person per hour). There was a significant difference between workload (direct time: P<0.01; event recording: P<0.01) reported for both hospitals. The direct time and event recording techniques produced consistent results at each hospital (hospital A: t=0.02, P=0.99; hospital B: t=0.004, P=0.1). CONCLUSION: The direct time and Welsh benchmarking event recording techniques produced consistent results at both hospitals. Thus the Welsh benchmarking event recording technique is a valid and reproducible method of measuring dispensary workload. Hospital B (automated) had a higher workload than hospital A (manual). Further work is required to investigate the impact of automation on dispensary workload.