Pharmacy needs
to consider how it
can target its
resources to work
efficiently and
prioritise activities
that provide the
greatest impact
to improve the
outcomes for
patients
Lord Carter’s report states, “In hospital pharmacy
we know that the more time pharmacists spend
on clinical services rather than infrastructure or
back-office services, the more likely medicines use
is optimised”. 4 Medicines optimisation is about
‘focusing the pharmacy workforce towards clinical
activities; working more closely with patients and
working alongside doctors and nursing staff in
clinical roles to optimise medicines and secure
better value and outcomes for patients’. 5 Pharmacy
needs to consider how it can target its resources to
work efficiently and prioritise activities that provide
the greatest impact to improve the outcomes for
patients. In other words, there is a need to prioritise
where pharmacy staff can have the greatest impact
and stop any non-value-added activities.
Transformation of services is required to
achieve quality, affordable and sustainable
clinical pharmacy services seven days a week. 6
A transformed seven days a week clinical pharmacy
service needs a greater focus on patient-facing
medicines optimisation, optimised use of staff
skill-mix, flexible workforce to practise as generalist
and specialist, implementation of technology,
identification of high-risk patients, rationalisation
of non-clinical infrastructure, collaboration between
healthcare organisations and pharmacy workforce
planning. 6 A common thread that runs through
this is the need for pharmacy teams to prioritise
their workloads and focus on activities that have
the greatest impact on patient care. To facilitate
prioritisation of clinical pharmacy activity, different
methodologies and tools have been developed.
Risk assessment approaches
Risk assessment forms the foundation of clinical
pharmacy resource prioritisation. The principle
is that specific patients have higher clinical
pharmaceutical need which can be identified
by the presence of specific risk factors. The key
element to ensure effective prioritisation is
accurate information; meaning prioritisation is
potentially better suited to focus resources postmedicines
reconciliation when an accurate list
of a patient’s usual medicines is available. Due
to the complexity of collating all the multiple
sources of information required to prioritise, many
of the more advanced prioritisation tools rely
on electronic prescribing technology and other
IT-based solutions. One such tool was developed
by NHS Ayrshire and Arran following a serious
incident on a ward that did not receive routine
clinical pharmacy services. 7 A screening tool was
developed to ensure that patients at the highest
clinical risk were targeted by the pharmacy team.
Patients were graded as low-, medium- or highrisk
using data such as absence of allergy status,
no prescribing activity, or the presence of specific
high risk medication. During development, the risk
scores were then independently validated to refine
the tool. Evaluation showed the tool effectively
screened both low and high risk patients but was
less sensitive to medium risk. The tool has proven
to reduce median time to clinical pharmacy activity
for high risk patients. The key element to ensure
uptake of the tool was automation of the system.
Further work is required to improve sensitivity by
including laboratory data and to help pharmacy staff
to interpret the results within the context of the
pharmaceutical service. The tool required significant
buy in and time commitment from pharmacy staff
to develop. 7,8
NHS Greater Glasgow and Clyde developed
a ‘Triage and Referral’ model; this included
a three-tier risk stratification tool supported by
a simultaneous referral system to allow medical
and nursing staff to refer back to pharmacy if the
patient’s status changed. 9 Triage is performed on
admission to hospital by an experienced clinical
pharmacist using a validated tool and their
professional judgement. Each level of risk then
corresponds to the frequency of pharmacy review.
The ‘Triage and Referral’ tool has been integrated
into the patient tracking software, allowing the
risk status to be electronically recorded to support
efficient workflow and handover. A dashboard has
been developed to visually display not only their
clinical pharmacy risk status but also other useful
factors to aid efficient delivery of pharmaceutical
care. This allows pharmacy teams to flexibly deliver
services dependent upon where the highest clinical
need lies. 9–11 The challenge for adoption within the
wider NHS is how to integrate into an existing IT
infrastructure.
A third approach was described by a large UK
teaching hospital. 12 Again a three-tier clinical risk
stratification tool, the ‘pharmaceutical assessment
screening tool’ (PAST), was implemented to help
clinical pharmacists prioritise frequency and
seniority of clinical pharmacy reviews. Evaluation of
the tool to confirm validity of scores demonstrated
57% (20/35) of patients were given an acuity level
that matched the PAST guidance. This meant that
in 43% of patients, the pharmacist risk stratification
TABLE 1
Pharmacy teams view on the importance of prioritising work load for
medicines reconciliation, clinical review/input and discharge activities
MR For clinical review For discharge
Essential for all patients 128 77 93
Something I try to do 59 73 65
whenever possible
Would be nice to do but 11 26 21
I don’t always get
round to it
Something I do 3 9 15
occasionally when I can
Of no use in my practice 6 14 10
18 | Issue 91 | 2019 | hospitalpharmacyeurope.com