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Discussion

Reducing admissions with patient group directions

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Using patient group directions helped a COPD community service to reduce unnecessary hospital admissions, improve patient experience and reduce costs

Abstract

In times of financial restrictions and reform impediments, health services need to invest in resources that provide value for money and reduce hospital admissions. Improving disease management in the community is a primary target for those trying to reduce costs. The second most common cause of emergency admissions to hospital is chronic obstructive pulmonary disease and it has been suggested that more effective treatments and better management of the condition would likely result in an estimated 5% fewer admissions to hospital, saving around £15.5m each year. This article discusses how savings could be made by improving care provided in the community.

Citation: Wat D et al (2014) Reducing admissions with patient group directions. Nursing Times; 110: 16, 18-20.

Authors: Dennis Wat is consultant chest physician; Elaine Glossage is lead nurse, Knowsley Community Services; Onnor Hampson is team lead, COPD nurse specialist; Sarah Sibley is consultant chest physician; all at Liverpool Chest Hospital.

Introduction 

Chronic obstructive pulmonary disease (COPD) is the second most common cause of emergency admissions to hospital, with one in eight admissions resulting from an acute exacerbation of the condition (National Institute for Health and Care Excellence, 2011).

The Knowsley Community COPD Service was developed to help address health inequalities in the borough, where the prevalence of COPD is twice the national average (3.2%) and emergency admission rates are 1.75 times higher. The main aims of the service are to reduce the number of premature deaths and unnecessary emergency admissions caused by COPD, while empowering patients to self-manage their condition. The service prioritises seamless care coordination to improve quality of life for service users and carers, and to reduce the financial burden of avoidable admissions to hospital.

We developed a patient-centred pathway to provide a link between primary and secondary care via a rapid-response team. The team is available at all times, enabling our COPD service users who have exacerbating conditions to call specialist COPD nurses. These nurses offer advice and are able to triage service users with visits within two hours, assessing and managing them in their own homes where clinically and socially applicable.

In the past, treatment recommendations were faxed to the GP to prescribe medications after home visits by the team. However, this led to delays in treatment starting, often due to prescriptions being issued after local pharmacies had closed or service users being unable to access a pharmacy. This system resulted in unnecessary anxiety for service users so we consulted a patient expert and friends-and-family group to find out how it could be improved. The group members said they would welcome the idea of being able to receive treatment immediately after being assessed, without having to pick up a prescription from their GP and attend their local pharmacy.

After this feedback, we obtained a patient group direction (PGD) to allow the nurses who were operating the at-home service to supply and administer appropriate medications without having to refer to a doctor.

Patient group directions

PGDs are written instructions for medicines to be supplied or administered to groups of patients, who may not be individually identified, before presentation for treatment (Statutory Instrument, 2000). A PGD, signed by a doctor and agreed by a pharmacist, can allow registered nurses to supply or administer prescription-only medicines (POMs) to patients using their own assessment of patient need, without necessarily referring back to a doctor for an individual prescription (NHS Executive, 2000).

In the past, PGDs were used to supply or administer POMs to homogeneous patient groups, who consistently presented with certain characteristics and requirements, such as:

  • Infants and children needing immunisation as part of a national programme;
  • Adults needing immunisation as part of a national programme;
  • Those needing immunisation for foreign travel;
  • Those needing contraceptive services, including the use of emergency hormonal contraception;
  • Those needing analgesia before minor surgery or treatment of injury.

Many COPD services around the country use PGDS but little has been reported on the experiences of the providers and users.

Before implementing the PGD, we held a number of service-user engagement events to gain patients’ perspectives on hospital-at-home care. Stakeholders involved in the development of the project included doctors, nurses, primary care team, patient expert group, pharmacists, a clinical commissioning group, the service manager and the Drug and Therapeutics Committee.

We considered the following options:

  • All senior nurses to gain a non-medical prescribing qualification to allow independent prescribing;
  • Providing standby antibiotics to patients at risk of exacerbations or those who have frequent exacerbations;
  • Setting up PGDs.

Obtaining a non-medical prescribing qualification was ruled out due to being too costly (approximately £1,000 per nurse) and taking up to six months. Having standby antibiotics may not cater for all at-risk individuals with COPD, particularly those with physical or mental disabilities, or those who may not have the capacity to decide when to take the antibiotics. We therefore concluded that PGD would be the best option as it would allow treatment to be started without delay (particularly out of hours) and would help patients who are not well enough to pick up medications from pharmacies. It would also make the community COPD team the main point of contact for all COPD exacerbations, which is particularly relevant for clinical governance and audit purposes.

PGD gives nurses the authority to practise autonomously with the support of respiratory consultants, who are available at all times. This practice also potentially saves money by avoiding unnecessary clinic consultations and accident and emergency attendances.

During a six-month consultation period the list of PGD medications was drawn up and policies and standard operating procedures were approved by the local Drug and Therapeutic Committee. COPD nurse specialists were trained to use PGD and their competencies were assessed.

We introduced PGDs in June 2012. Medications included in the PGDs include:

  • Amoxicillin;
  • Doxycycline;
  • Prednisolone;
  • Salbutamol inhaler;
  • Nebulised salbutamol;
  • Nebulised ipratropium bromide.

Table 1 shows the cost of each medication. Standard operating procedures were drawn up for transporting medications from hospital to community clinics for storage, and from community clinics to patients’ homes. Regular audits were carried out to ensure the list of medications was still appropriate and would address patients’ needs.

After the PGDs were introduced we reviewed their use over the first 12 months, using data from our COPD database and feedback from the stakeholders.

Results

The use of PGD between June 2012 and May 2013 is shown in Fig 1. The total amount spent on PGD medication during this period was £2,299.94 and the hospital admission rate was reduced by 27%. It is not possible to attribute this reduction in admissions to the inception of PGDs alone as other elements may have contributed to this, such as the year-round rapid-response team, daily consultant-led multidisciplinary team community clinics, daily community-based pulmonary rehabilitation and the specialist psychological support service. However, Box 1 shows the major benefits of incorporating PGDs into the community COPD service, as obtained from the stakeholders.

Box 1. Major benefits of incorporating patient group directions

  • Improved patient satisfaction – this was measured by a patient satisfaction survey and positive feedback was received from service users and carers
  • Gives patients the opportunity to be managed in their home environment
  • 39% reduction in emergency admissions and COPD spells from baseline, in line with supplied trajectories
  • Gives nurses the authority to practise autonomously with the continuing support of the respiratory consultants, who are available at all times
  • Reduces pressure on nurses having to rely on consultants and GPs to provide rescue medications in the event of an exacerbation
  • Nurses no longer have to send faxes to GPs for prescriptions once they return to the office, saving valuable time so more patients can be reviewed
  • Significant cost-saving implications by reducing emergency outpatient consultations and accident and emergency attendances
  • Regular review of the use of patient group directions, together with feedback from staff and service users to ensure new medications can be added to the list of medications if necessary 

Discussion

PGDs allow service users to be managed at home during exacerbations, improving their experience and that of their families. We have found this innovation maximises service uptake and reduces the burden on secondary care by transferring service users’ care to a more cost-effective community setting. This in turn prevents unnecessary hospital admissions.

The PGDs have given nurses the autonomy to start appropriate treatment and allows treatment response to be monitored in the home setting. The steady increase in the use of PGD medication could be due to the COPD nurse specialists becoming more confident and competent with the PGD policies. Service users and relatives soon became aware of the PGD service and began contacting the COPD team more rather than using other acute services such as GPs, walk-in centres and A&E departments.

The convenience of being given immediate medical treatment reduces the stress of having to go to the GP for a prescription or to the pharmacy; reducing the delay in starting treatment is crucial in preventing an exacerbation from getting worse. In addition consultants can be contacted at all times if there is uncertainty or if the team needs an agreement for a treatment plan. This is reassuring for the nurses as they feel they are supported and it provides them with on-the-job teaching.

This initiative has played a major role in cost savings by contributing to a reduction in non-elective COPD admissions by 27% over 12 months. It is not possible to attribute the significant savings of £589,000 solely to the PGD scheme as other components have played a part in this achievement, but the introduction of PGDs was the only change in service provision compared with previous years. The total amount spent on PGD medications was £2,300 over 12 months, representing excellent value for money - the cost of a single COPD admission is £2,442 (Department of Health, 2013).

The major challenge was collecting prescription charges, as the Royal College of Nursing does not recommend nurses handle payment during home visits. This was overcome by providing payment slips and stamped addressed envelopes to patients liable for prescription charges and advising them to send payment to the trust.

The initial consultation phase was difficult due to many disciplines being involved, all of whom had different ideas and expectations and worked at different paces; this led to delays in the development of the project. However, appointing a project lead to oversee the project helped reduce these problems.

Box 2. Key learning points

  • Appoint a leader to take ownership of the project, be responsible for it and maintain its momentum
  • Involve all disciplines from the start to avoid any delays in development of the project
  • Identify practical obstacles – who should pay prescription charges and how these could be collected – early
  • Decide and agree what medications to include in patient group directions
  • Promote continuous involvement from all disciplines to help manage fears and concerns
  • Resolve challenges of integrated working 

Conclusion

The majority of clinical care should be provided on an individual, patient-specific basis. However, as patients with COPD usually have multiple comorbidities and take numerous medications, giving medications under PGD should only be done when it offers an advantage for them without compromising their safety. It should also be consistent with appropriate professional relationships and accountability. The potential cost savings and convenience of use serves an integral part of a community COPD service.

Key points

  • Chronic obstructive pulmonary disease is the second most common cause of hospital emergency admissions
  • Starting treatment is often delayed because service users cannot collect prescriptions and medications out of hours
  • Patient group directions (PGDs) are written instructions for medicines to be supplied or administered to groups of patients without a doctor’s signature
  • Using PGDs in community services has been shown to result in fewer hospital admissions
  • Most clinical care should be provided on an individual, patient-specific basis
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