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Medicines management

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Ensuring prescribed medication is taken involves developing partnerships with patients and the right systems. Kaye McIntosh discovers how nurses are key to the process

As many as half of all patients who are prescribed medication never actually take it.

Wasted medicines cost the NHS more than £100m annually, according to NICE statistics. Yet if patients don’t take the right drug in the right dose at the right time, their health and well-being suffers.

Until now, the blame has usually been put on patients for not taking health professionals’ advice. But that view is changing. ‘It is increasingly recognised that medicines taking is a complex behaviour and it’s not as simple as non-compliance
by patients,’ says nurse consultant Bunis Packham, of Barnet and Chase Farm Hospitals NHS Trust in London.

So what is really happening when patients fail to take the drugs they need? And what role can nurses play in ensuring patients truly benefit from their medicine?

Ms Packham, a nurse consultant in thrombosis and anticoagulation, is advising NICE on a guideline on medicines concordance, due to be published in January. Nurses and doctors used to talk about patient ‘compliance’ but the
guidance will put more of an onus on health professionals supporting patients and reaching shared decisions about medicine.

It will apply to all staff who are involved in prescribing, dispensing and reviewing medicine, from nurse consultants and prescribers to ward staff, pharmacists, doctors and allied health professionals such as physiotherapists.

‘It will help to standardise practice and emphasise the importance of working with patients,’ says Ms Packham.

It will suggest simple measures to support patients and help professionals identify when they need more training.

She points out that it is easy to neglect communication about medicines when you have only a few minutes with each patient, so attitudes need to change to recognise that taking the time to discuss medicines now will help to prevent errors and worsening health – saving more time in the long run. ‘There needs to be a cultural change across the healthcare professions to raise awareness,’ she says.

And it is not always patients who are responsible for missed doses – often it is the system that fails.

Research by charity Diabetes UK, due to be published this month in the report Improving inpatient diabetes care – what care adults should expect when in hospital, reveals that many patients experience major problems when admitted to hospital. Care adviser Caroline Butler, a diabetes specialist nurse, says: ‘People don’t always get their medicine and it wasn’t always given at an appropriate time, coordinated with mealtimes, which was interfering with their glycaemic control.’

Poor communication about drug changes was another key issue.

As many as 10% of all hospital beds at any one time will be occupied by patients with diabetes, says Ms Butler, but they are often cared for by nurses who are not specialists in this condition, for example on cardiac wards.

‘We want appropriate training in place so people have all the competencies and skills and have the ability to deliver a high standard of care for patients with diabetes – that is not the case at the moment,’ she adds. Ms Butler also believes nurses should be working closely with pharmacists to ensure drug regimens are appropriate and delivered on time.

Nurses say that many of the issues identified in the Diabetes UK report are a symptom of more widespread difficulties.

At Calderdale and Huddersfield NHS Foundation Trust, for example, an audit found 18% of prescribed doses were not administered to patients and that this was for a variety of reasons.

‘When doses are not being administered it is generally for legitimate reasons,’ explains Karen Guy, pictured, who is one of only two medicines management nurse specialists in the UK and works at the trust. ‘The patient was away from the ward, or could not take the medicine, for example had difficulty in swallowing, or refused the medicine or the dose has not been available.’ On occasions the pharmacy had not dispensed the drug, or a nurse or doctor requested an omission.

Ms Guy has been working with pharmacy colleagues at the trust to cut waste and improve patient care. They have developed a new drugs chart that shows why medicines were not administered.

Data from the charts is combined with that from annual audits examining all doses prescribed in a 24-hour period. This is shared with ward managers and matrons, allowing staff to identify problems. One audit found that only 5,865 of 7,160 doses prescribed were actually given to patients.

Ms Guy and the pharmacist leading on clinical governance have developed a training package for all nurses, doctors, pharmacists and pharmacy technicians across the trust, which has 55 nurse prescribers, four pharmacy and six allied health professional prescribers. Newsletters and posters keep staff informed about the trust’s medicines code.

‘Making sure patients are on the right medicines and communicating with them in a way they can understand is very empowering for nurses,’ she says. What nurses want, most of all, is better patient care – and ensuring patients receive the drugs they need when they need them is crucial to achieving that.

Ms Guy and pharmacy colleagues have also developed a ‘When to take your medicines’ leaflet, which can be used to inform patients. Written in consultation with patients, it lists official drug names and colloquial terms – spironolactone is described as a water tablet, for example. It also tells patients when and how to take their drugs, and gives health professionals the opportunity to talk to them and explore fears or misconceptions about medicines.

The latest audit took place last month and will be used as a benchmark. Changes at the trust mean it cannot be compared with previous years as some wards have merged.

Medicines reconciliation is a major part of the initiative, ensuring there is an accurate, up to date list of what the patient was taking before admission, including over-the-counter drugs and herbal remedies, and documenting any adjustments. ‘The aim
is for 95% of medicines to be reconciled within 24 hours of admission,’ says Ms Guy. ‘It was 85% at the last audit so we are on our way. What we are trying to do is to improve concordance on discharge. [So that] patients know about their medicines, why they are taking them.’

That requires an open and non-judgemental conversation with patients on admission, she emphasises. ‘We make sure they feel OK to say to us, “actually I haven’t been taking that”.’ It includes explaining the possible effects of a drug, such as mild nausea or diarrhoea, so they are not alarmed if they occur and don’t stop taking it.

Improving medicines management is very satisfying for nurses, says Ms Guy. ‘It makes your job easier in a way. We are putting a lot of time in with patients talking about medicines but we are having an impact at the time of discharge, and throughput and patient flow have improved. We have the knowledge that patients who are self-administering know what they are doing.’

Ms Guy and the pharmacy team are now working with neighbouring trusts to develop a drug chart for use across several hospitals, and hope to take it Yorkshire-wide.

The Calderdale project is supported by the Health Foundation’s Safer Patient’s Initiative. The foundation is working with 24 trusts, and medicines reconciliation is a key issue – making sure a thorough history is taken on admission and nurses work closely with ward pharmacists throughout a patient’s stay and as they are prepared for discharge.

Why patients are not taking their drugs

  1. Most common reasons for missed doses:

  2. Patient away from ward

  3. Patient could not take

  4. Patient refused

  5. Dose not available

  6. Omitted at nurse’s discretion

  7. Doctor requested omission

  8. Patient self-administered (not missed)

  9. Administered late

Source: Karen Guy, nurse specialist, medicines management, using data from the Calderdale and Huddersfield NHS Foundation Trust audit

Gillian Hastings, assistant director at the foundation, says a key development was to introduce safety briefings at the start of shifts, where ward managers look at the staff available on call and patients’ risk profiles.

‘With same-name patients you have a potential error in waiting,’ she points out. Introducing a system where you identify those patients, or those who have allergies, or are confused or at risk of developing DVT, means you can ‘prepare for and mitigate against [risk] rather than waiting for something to happen,’ she explains.

Medicines management is not just an issue for hospitals. Many older people in care homes are on complex regimens. ‘If you are trying to care for elderly people, quality of life is synonymous with good medication,’ explains Tony Heywood, chief executive of home operator Four Seasons Healthcare.

Internal audits and reports from the Commission for Social Care Inspection showed the company could improve. ‘It was clear drug delivery wasn’t consistent around the country. We weren’t happy, the regulator wasn’t happy, sometimes patients had the wrong medication, and sometimes weren’t getting the drugs as quickly as we would like in the home,’ says Mr Heywood.

Four Seasons launched an audit across all its homes, involving local pharmacies and conducting site visits. It found staff often had little information about residents’ medicines history, and there was a risk that oral liquids were being given inappropriately.
Mr Heywood says: ‘Everyone has their own bottle of liquid medicine – sometimes there is a temptation [when you have] five patients to do it out of one bottle – it’s quicker. As an operator we have got to be sure our systems can’t be got around.’

The homes introduced shrink-wrapped individual trays, containing separate sealed pods for each medicine, supplied direct from the pharmacy, to limit the risk that patients would get someone else’s medicine.

Mr Heywood says the system gives nurses more ‘protection’ when they are pressed for time and could be working alone. ‘People have got to get it right – anything that helps them do that safely is welcome. Nurses say it is making their drugs round much easier.’ It is also helping patients take control of their own medicines where possible, as well as reducing the chance of errors, he adds.

The audit has also helped homes talk to pharmacies about the level of service they need and how to improve the quality of care, rather than simply continuing to do what has always been done.

Community nurses, too, have accepted the need to embrace medicines management. Kay Kane, a consultant community nurse, says district nurses at the South and East Belfast trust (now Belfast Health and Social Care Trust) who identified a need for better support for older patients living in their own homes. A pilot, now translated into standard practice, saw nurses assess which patients would benefit from community pharmacists dispensing drugs in medi-boxes, which have sealed and clearly labelled compartments stating which medicine to take at what time. This freed up nurses who had been called out regularly by relatives or other carers to administer drugs. Now all carers have to do is prompt patients to take their medicine.

‘It had a huge impact, making the difference between remaining in your own home or having to go into residential care,’ Ms Kane says.

Recognising that medicines have to be managed, not just administered, is clearly the way forward. Ms Hastings says: ‘Every patient, every time, the right drug, the right process’ is the goal.

Medicines management in mental health care

Department of Health guidance issued earlier this year, Medicines Management: Everybody’s Business, says health professionals should take a ‘person-centred approach’, supporting service users and addressing their concerns.

Stephen Hemingway, a nurse and senior lecturer in mental health at the University of Huddersfield, is a member of the advisory group working on the NICE guideline on medicines concordance.

‘Safety is the big issue, not just concordance,’ he says.

‘What we are trying to do locally and nationally from a pre-registration and post-registration point of view is highlighting that medicines management is not just knowledge about medicines, it is how to make sure that the person gets the right medicine at the right time.’

Nurses need to work with pharmacists to understand what drugs patients are taking, he explains. ‘We need to embrace medicines management, rather than just calling it administration of medicines – this is not just a pharmacy issue. Nurses need to be playing a role in the process and be aware of their own responsibilities.’

They should be having a conversation with patients, offering support and checking at every stage, from when a medicine is prescribed, through to administration, any changes in medicine, and ensuring a consistent approach during admissions and in the community. More training, information and guidance from employers in NHS trusts is required, Mr Hemingway adds.

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