Notes from the
Technology Workshop
On Automated
Storage for Medicines
Held on 23rd November
2017 at Morriston Hospital, Swansea SA6 6NL Introduction
Over the last few years Health Boards within NHS Wales have
implemented ward medicines automation systems to highly varying
degrees. Some Health Boards have been the early pioneers
within Wales (and indeed across the NHS). These initiatives have
been largely led by individual senior pharmacists within pharmacy
services enthusiastic for their adoption rather than on any
coordinated and cohesive approach or development plan across the
Health Boards within Wales. The current systems in situ have
largely been funded from capital bids against pharmacy
modernisation funds within Welsh Government.
The main but not sole drivers for implementation has been the
desire to improve security of medicines and improve the efficiency
of medicines management in clinical areas. By their very design
automated systems significantly improve security and accountability
of use of medicines and support adherence to the Welsh Patient
Safety Notice 030, April 2016.
However, in practice, the implementation and
development of these systems has been challenging and
time-consuming for pharmacy staff in those Health Boards where
there have been installed. Additionally, whilst these initiatives
may have been led by pharmacy personnel, ward automated systems
will largely beneficially impact on the working of nursing staff
who use them, and, on the patients, who receive medicines from them
directly. These factors may have led to some disparity in ownership
and organisational leadership and a detrimental impact on the
capacity to develop meaningful and specific research into
beneficial (or otherwise) outcome measures.
As such, despite much anecdotal evidence and obvious design
benefits of these technologies, there remains a dearth of robust
evidence or published research papers within NHS Wales to further
support their wide-scale implementation. This situation is
largely mirrored and recognised within the rest of the
NHS.
In recognition of this lack of meaningful outcome data and the
variation in use across NHS Wales, the Chief Pharmaceutical Officer
for Wales, Andrew Evans requested the Chief Pharmacist
Committee to consider the development of a strategic framework and
development plan for the use and evaluation of automated storage
systems across NHS Wales.
The workshop was designed for key stakeholders within Health Boards
to include senior nursing staff, chief and senior pharmacists,
estates personnel and academic representatives to consider and
initiate this development plan.
Objectives
•
To gain appreciation to how ward automation has been applied and
developed in NHS England
•
To gain an understanding of the Medicines Automation Evaluation
Framework developed for the HPMOP group
•
To review the current applications in Health Boards and consider
current benefits realisation and difficulties identified in
practice.
•
To consider a cohesive research strategy to support the development
of business cases.
Workshop Content
The workshop commenced with an introduction from
the Chair, Dr Berwyn Owen and then an opening address from
Andrew Evans, Chief Pharmaceutical Officer appraising the
variation in deployment of automation, the need for a robust
strategy for automation amid the tight fiscal environment in NHS
Wales. There then followed a number of brief presentations and case
studies from around Wales to provide the attendees with better
insight into potential research/evaluation projects and some key
examples of current applications.
Don Hughes, retired Chief Pharmacist, BCUHB provided some
detail of the Medicines Automation Evaluation Framework developed
for the Hospital Pharmacy and Medicines Optimisation programme
(HoPMOp) in NHS England during 2016. (The HoPMOp programme was set
up to support the implementation of the recommendations of Lord
Carter’s review). The framework contains five principal
domains in which automation may benefit including: -
•
Safety
•
Governance
•
Operational productivity and efficiency
•
Patient and staff experience
•
Data and information
Details of specific attributes in each domain were provided to
assist Health Boards to prioritise any research or evaluation
projects as deemed appropriate to support any considered
strategy.
Case studies/Vignettes from Health Boards
Chris Moore from the Welsh Ambulance Service NHS Trust
described the WAST experience the ongoing project of replacing
existing drug cupboards with 20 customised Omnicell cabinets across
the region. The software has been designed to facilitate drug
selection for each vehicle, is intuitive and easy to use and has
been well received by WAST staff. The project has been an excellent
collaboration between WAST, pharmacy and estates. Challenges
include securing non WAST locations, estates work and differing
drug codes between hospitals. Thus far the systems have improved
security, accountability with better stock management and auditable
assurance. Post implementation tasks include the need to focus on
efficient stock levels and producing meaningful reports.
Colin Powell, Chief Pharmacist, acute services at Aneurin Bevan
University Health Board described their experiences of
automation in acute and community hospitals within the Health
Board. Since 2011, 42 Omnicell units have been installed across a
whole range of admission areas, acute wards, critical care units,
GP out of hours, mental health, theatre suites and for WAST use.
Their use has significantly improved security of medication storage
and accountability. Colin shared a number of key lessons that they
have learnt. These include: -
•
The need for nursing staff buy-in at all levels
•
Their installation can be time-consuming and protracted due to
factors such as enabling works and their associated costs
•
Certainly, do not use these systems to correct poor practice
•
Need to consider maintenance costs
•
Staff do not have time to develop the systems to their full
potential – need a systems manager
Adam Griffiths, Head of Nursing for Medicine, Glan Clwyd
Hospital described his experience of the development and use of
automation in the A&E from a position as a charge nurse through
his current role as head of nursing. He described some of the
safety and governance benefits including reductions in serious
incidents and how he works with pharmacy staff to gain detailed
usage reports, which have been invaluable to him in a management
role to provide information impossible to generate with existing
manual systems.
Karen Pritchard, Patient Safety Lead
Pharmacist, Wrexham Maelor Hospital detailed the wider use
across BCUHB including critical care units, admission areas and
acute wards and concurred with ABUHB experience regarding the
pharmacy staffing issues and the need for ward ownership. She
provided some examples of how security had improved with medicines
of potential abuse and how staff have utilised the systems to
improve safety e.g. allergy alerts and patient safety notices.
Queuing can be problematical particularly on wards with high
medication usage e.g. admission areas. Karen also raised concerns
about the use of live stock control at ward level – a
“blessing and a curse!” There are cultural issues to
overcome relating to understanding with emphasis on
ownership.
Workshop
Break-out sessions took place with mixed three groups of attendees
to consider the next steps in NHS Wales including: -
•
To develop a vision for the development of automated storage of
medicines across NHS Wales.
•
To consider a multi-disciplinary evaluation/research strategy to
support the vision and further implementation and development.
•
To consider the management arrangements to support the vision and
evaluation strategy
The groups provided several key themes to provide some basis of a
structured strategy and development plan for use of automated
systems. These included: -
Vision
There needs to be some consolidation
and developments required in what is currently in situ. The systems
work better in some areas and there are several challenges to be
overcome to effect better use. Lack of ownership is common problem
and this is not helped by the level of bank and agency staff at
ward level which can lead to poor use. The strategy should
consider priority clinical areas where the systems work well and
where clear benefits are accrued. On-going training and
support need to be considered within Health Boards, particularly in
pharmacy services.
Any developed vision should be
undertaken jointly with nursing and estates. These systems are now
well established and provide a more modern secure platform and will
continue to evolve and improve. Any new builds in NHS Wales should
now include provision for automated storage and Welsh Government
need to be aware of this. There needs to some collaboration with
HIW to consider the safe location of systems within buildings and
whether there are secure enough for placements in
“open” areas
Pharmacy services in Wales need to
develop a vision for application of technologies supporting better
medicines management to include ePMA, ward automation and use of
bar-coding to deliver better quality, efficiency and production.
Needs to a strong focus on quality and less focus on financial
management. The vision should include local management arrangements
in pharmacy services perhaps consideration of system manager with a
joint role in any EDS replacement.
Exert from
National Prescribing Indicators 2018–2019
1.0
SAFETY INDICATORS
1.1 PRESCRIBING SAFETY INDICATORS
Purpose:
To identify patients at high risk of adverse drug reactions and
medicinesrelated harm in primary care.
Unit of measure:
1.
Number of patients with a peptic ulcer who have been prescribed
NSAIDs without a PPI as a percentage of all patients.
2.
Number of patients with asthma who have been prescribed a
beta-blocker as a percentage of all patients.
3.
Number of patients with concurrent prescriptions of verapamil and a
betablocker as a percentage of all patients.
4.
Number of female patients with a past medical history of venous or
arterial thrombosis who have been prescribed combined hormonal
contraceptives, as a percentage of all female patients.
5.
Number of female patients with a current prescription of
oestrogen-only hormone replacement therapy without any hysterectomy
READ/SNOMED codes, as a percentage of all female
patients.
6.
Number of patients with concurrent prescriptions of warfarin and an
oral NSAID as a percentage of all patients.
7.
Number of patients under 12 with a current prescription of aspirin,
unless due to a specialist recommendation, as a percentage of all
patients.
8.
Number of patients aged 65 years or over prescribed an NSAID plus
aspirin and/or clopidogrel but without gastroprotection (PPI or H2
receptor antagonist), as a percentage of all patients aged 65 years
or over.
9.
Number of patients aged 65 years or over prescribed an
antipsychotic, as a percentage of all patients aged 65 years or
over.
10. Number
of patients aged 75 and over with an Anticholinergic Effect on
Cognition (AEC) score of 3 or more for items on active repeat, as a
percentage of all patients aged 75 and over.
11. Number
of patients on the CKD register (CKD stage 3–5) who have
received a repeat prescription for an NSAID within the last 3
months, as a percentage of all patients on the CKD
register.
12. Number
of patients who are not on the CKD register but have an eGFR of
< 59 ml/min and have received a repeat prescription for an NSAID
within the last 3 months, as a percentage of all patients who are
not on the CKD register but have an eGFR of < 59
ml/min.
Target for 2018–2019:
No target set
Background and evidence
There were 2,330 Yellow Card reports submitted in Wales in
2016–2017, an increase of 28% on the previous year. In the
UK, it is estimated that around 6.5% of hospital admissions are
related to adverse drug reactions3. Adverse drug reactions can
often be predictable, making it possible to identify and address
them before actual patient harm occurs. Therefore, a process of
identifying patients electronically could enable intervention and
help to avoid harm.
In 2012, The Lancet published a paper entitled “A
pharmacist-led information technology intervention for medication
errors (PINCER): a multicentre, cluster randomised, controlled
trial and cost-effectiveness analysis”. This study
investigated the differences in a series of outcomes between
intervention and control groups. It demonstrated that such an
approach is an effective method for reducing a range of medication
errors4. Some of the prescribing measures utilised in the PINCER
trial have been incorporated as measures in this NPI. In addition,
other measures have been added to make a series of 12. Some brief
explanation for these is provided below. No target has been set for
this NPI for 2018–2019 as data from this year can provide a
baseline for future years.
NSAIDs in peptic ulcer patients
without a PPI
NSAIDs have been shown to be the medicine group most likely to
cause an adverse drug reaction requiring hospital admission due to
such events as gastrointestinal bleeding and peptic ulceration. A
PPI can be considered for gastroprotection in patients at high risk
of gastrointestinal complications with an NSAID e.g. previous
peptic ulcer.
Beta-blockers in asthma
patients
Beta-blockers should be avoided in patients with asthma due to the
potential to precipitate bronchospasm. If the benefits of using a
beta-blocker in an asthma patient are justified the patient should
be monitored closely.
Verapamil in combination with
beta-blockers
Beta-blockers are associated with adverse drug reactions such as
bradycardia and atrio-ventricular conduction disturbances. A
co-prescription of a calcium channel blocker, such as verapamil,
with a beta-blocker is generally not recommended due to an
increased negative effect on heart function compared with
beta-blocker therapy alone.
Combined hormonal contraceptives in
thrombosis patients
There is an increased risk of venous thromboembolic disease and a
slight increase in the risk of arterial thromboembolism in people
using combined hormonal contraceptives5. Any patients with a
history of venous or arterial thrombosis who have been prescribed
combined hormonal contraceptives are therefore at an increased
risk.
Oestrogen-only hormone replacement
therapy without a record of hysterectomy
Where hormone replacement therapy is indicated, hysterectomy status
of the woman will determine which type is appropriate. All women
with an intact uterus need a progestogen component in their hormone
replacement therapy to prevent endometrial hyperplasia, which can
occur after as little as six months of unopposed oestrogen therapy.
Conversely, women who have undergone a hysterectomy should not
receive a progestogen component. However there may be instances
where patients with an intact uterus may be prescribed
oestrogen-only HRT in conjunction with a levonorgestrel containing
IUD (e.g. Mirena®) for the prevention of endometrial
hyperplasia during oestrogen replacement therapy.
Warfarin and oral NSAIDs
Anticoagulant medicines such as warfarin can cause haemorrhage.
NSAIDs can reduce platelet aggregation, which can worsen any
bleeding event in warfarin treated patients. Therefore, wherever
possible, in patients taking warfarin, NSAIDs should be
avoided.
Aspirin in under 12s
Reye's syndrome is a very rare disorder that can cause serious
liver and brain damage. If it is not treated promptly, it may lead
to permanent brain injury or death. Reye's syndrome mainly affects
children and young adults under 20 years of age. Owing to an
association with Reye’s syndrome, aspirin should not be given
to children under the age of 16, unless specifically indicated e.g.
for Kawasaki disease. NSAIDs in combination with aspirin or
clopidogrel without gastroprotection
Based upon work by NHS Scotland two additional measures have been
included within this NPI due to their focus on patient safety. The
first of these will look at the use of gastroprotection in patients
aged 65 years or over and prescribed an NSAID plus aspirin and/or
clopidogrel. Hospital admission due to gastrointestinal bleeding
has been associated with aspirin and clopidogrel, as well as
NSAIDs. The harmful consequences of bleeds due to antiplatelet
therapy increase with age. PPIs are recommended in older patients
undergoing antiplatelet treatment. PPIs are preferred to
H2-receptor antagonists because there is less evidence to support
use in conjunction with low dose aspirin.
Over 65s prescribed an antipsychotic medicine
A second measure that has been based on work by NHS Scotland will
consider the use of antipsychotics in patients aged 65 years or
over. In 2009 the Banerjee report called for a review of the use of
antipsychotic medicines in elderly patients with dementia. These
medicines have only a limited benefit in treating behavioural and
psychological symptoms of dementia and carry significant risk of
harm.
Over 75s with AEC score of 3 or more
A high proportion of the older population are exposed to multiple
medicines with low anticholinergic activity and the cumulative
burden of these medicines over many years may be associated with
accelerated cognitive decline and mortality. The AEC scale (see
Appendix 1) was developed to illustrate the negative
anticholinergic effects of drugs on cognition. It is good practice
to use medicines with AEC scores of zero and to avoid those scored
1, 2 or 3. The clinician should discuss with the patient and carer
the benefits and potential risks of continued use of these
medicines with the aim of either stopping them or switching to an
alternative drug with a lower AEC score (preferably
zero)
.
Use of NSAIDs in patients with renal impairment
The final two measures in this NPI consider the use of NSAIDs in
patients with renal impairment.
The first of these considers NSAID use in known CKD patients. The
aim is to identify patients on the CKD register (CKD stage
3–5) who have received a repeat prescription for an NSAID
within the last three months. NICE Clinical Guideline (CG) 182
highlights that in patients with CKD, the long-term use of NSAIDs
may be associated with disease progression. NICE recommends
caution, and monitoring of the effects on GFR, when using NSAIDs in
people with CKD over prolonged periods of time.
The second measure will consider patients not on the CKD register
but who have renal impairment identified via their estimated
glomerular filtration rate (eGFR) and who have received a repeat
prescription for an NSAID within the last three months. NSAIDs may
precipitate renal failure, and vulnerable (particularly elderly)
patients may be at increased risk. Regular review of the ongoing
need for an NSAID and reassessment of the risk versus benefit is
appropriate and processes for this should be in place.
