Evaluation of disinfecting procedures for aseptic transfer in hospital pharmacy departments

Current practice in National Health Service (NHS) hospitals employs 70% Industrial Methylated Spirit spray for surface disinfection of components required in Grade A pharmaceutical environments. This study seeks to investigate other agents and procedures that may provide more effective sanitisation. Several methods are available to test the efficacy of disinfectants against vegetative organisms. However, no methods currently available test the efficacy of disinfectants against spores on the hard surfaces encountered in the pharmacy aseptic processing environment. Therefore, a method has been developed to test the efficacy of disinfectants against spores, modified from British Standard 13697 and Association of Analytical Chemists standards. The testing procedure was used to evaluate alternative biocides and disinfection methods for transferring components into hospital pharmacy cleanrooms, and to determine which combinations of biocide and application method have the greatest efficacy against spores of Bacillus subtilis subspecies subtilis 168, Bacillus subtilis American Type Culture Collection (ATCC) 6633, and Bacillus pumilis ATCC 27142. Stainless steel carrier test plates were used to represent the hard surfaces in hospital pharmacy cleanrooms. Plates were inoculated with 10(7)-10(8) colony-forming units per milliliter (CFU/mL) and treated with the various biocide formulations, using different disinfection methods. Sporicidal activity was calculated as log reduction in CFU. Of the biocides tested, 6% hydrogen peroxide and a quaternary ammonium compound/chlorine dioxide combination were most effective compared to a Quat/biguanide, amphoteric surfactant, 70% v/v ethanol in deionised water and isopropyl alcohol in water for injection. Of the different application methods tested, spraying followed by wiping was the most effective, followed closely by wiping alone. Spraying alone was least effective.

Medicines management across the primary-hospital healthcare interface: a study of paediatric patients

A comparison of medicines management documents in use by NHS organisations in the West Midlands confirms that there are important differences between the primary care and hospital sectors in respect to medicines management interface issues. Of these, two aspects important to paediatric patients have been studied. These are the transfer of information as a patient is admitted to hospital, and access to long-term medicines for home-patients. National guidance provided by NICE requires medication reconciliation to be undertaken on admission to hospital for adults. A study of paediatric admissions, reported in this thesis, demonstrates that the clinical importance of this process is at least as important for children as for adults, and challenges current UK guidance. The transfer of essential medication information on hospital admission is central to the medication reconciliation process. Two surveys of PCTs in 2007 and again in 2009 demonstrate that very few PCTs provide guidance to GPs to support this process. Provision of guidance is increasing slowly but remains the exception. The provision of long-term medicines for children at home is hindered by this patient population often needing unlicensed drugs. Further studies demonstrate that primary care processes regularly fail to maintain access to essential drugs and patients and their carers frequently turn to hospitals for help. Surveys of hospital medical staff (single site) and hospital nurses (six UK sites) demonstrates the activity these healthcare workers perform to help children get the medicines they need. A similar survey of why carers turn to a hospital pharmacy department for urgent supplies (usually termed rescue-medicines) adds to the understanding of these problems and supports identifying service changes. A large survey of community pharmacies demonstrates the difficulties they have when dispensing hospital prescriptions and identifies practical solutions. This programme concludes by recommending service changes to support medication management for children.

An evaluation of pharmacy education and pre-registration training

This thesis covers two major aspects of pharmacy education; undergraduate education and pre-registration training. A cohort of pharmacy graduates were surveyed over a period of four years, on issues related to undergraduate education, pre-registration training and continuing education. These graduates were the first-ever to sit the pre-registration examination. In addition, the opinions of pre-registration tutors were obtained on pre-registration training, during the year that competence-based assessment was introduced. It was concluded that although the undergraduate course provided a broad base of knowledge suitable for graduates in all branches of pharmacy, several issues were identified which would require attention in future developments of the course. These were: 1. the strong support for the expansion of clinical, social and practice-based teaching. 2. the strong support to retain the scientific content to the same extent as in the three-year course. 3. a greater use of problem-based learning methods. The graduates supported the provision of a pre-registration continuing education course to help prepare for the examination and in areas inadequately covered in the undergraduate course. There was also support for the introduction of some form of split branch training. There was no strong evidence to suggest that the training had been an application of undergraduate education. In general, competence-based training was well regarded by tutors as an appropriate and effective method of skill assessment. However, community tutors felt it was difficult to carry out effectively due to day-to-day time constraints. The assistant tutors in hospital pharmacy were found to have a very important role in provision of training, and should be adequately trained and supported. The study recommends the introduction of uniform training and a quality assurance mechanism for all tutors and assistants undertaking this role.

Support for paediatric prescribers:what is discussed at hospital board level?

Prescribing support tools range from traditional printed texts to state-of-the-art computerised decision support systems. Comparison between available literature is difficult due to country-specific resources often being the focus of the research. In the UK, it is widely accepted that hospitals take their own individualised approaches to reducing prescribing errors. Objective - This study focused on specialist paediatric hospitals. It aimed to identify the localised approaches taken by paediatric hospitals to reduce prescribing errors. Method - Applied thematic analysis was used to explore the publically published board meeting minutes from the four specialist stand-alone paediatric hospitals in England. Three years of data was collected from each hospital. Codes were collected into groups to identify themes from the data. Results - The main themes identified were clinician involvement in prescribing support is important; credit card-sized reminder tools are used to provide prescribing guidance; electronic prescribing is considered important for reducing prescribing errors; feedback from clinical pharmacists on prescribing errors is widely used; junior doctors require extra support when prescribing; medical records may be incomplete and specific prescribing support (eg, antibiotic prescribing support) is widely in use. Conclusions - There is no single collaborative approach taken to paediatric prescribing support in English paediatric hospitals. Success of electronic prescribing in English paediatric hospitals is considerably behind leaders such as the USA. Use of clinical pharmacists to support prescribers is important as supported by previous studies in Spain and the USA.

Primary care pharmacists: a profile

A survey was carried out in 1998 in 43 English health authorities of primary care pharmacists (employed to provide prescribing advice to GPs at medical practice level). 119 responses were received (66%). Most combined working as a PCP with another occupation, usually community pharmacy (57%), hospital pharmacy (13%) or as an academic (7%). 53% of respondents worked 8 hours or less per week as a PCP. Only 18 respondents were employed full-time as a PCP. The most common activities were drug information (91%), PACT analysis (90%), drug cost containment (90%) and review of individual patient medication (88%). (7 refs.)

Support tools for paediatric inpatient prescribers:a review

Prescribing support for paediatrics is diverse and includes both standard texts and electronic tools. Evidence concerning who should be supported and by what method is limited. This review aims to collate the current information available on prescribing support in paediatrics. Many tools designed to support prescribers are technology based. For example, electronic prescribing and smart phone applications. There is a focus on prescriber education both at undergraduate and postgraduate level. In the UK, the majority of inpatient prescribing is done by junior medical staff. It is important to ensure they are competent on qualification and supported in this role. A UK national prescribing assessment is being trialled to test for competence on graduation and there are also tools available to test paediatric prescribing after qualification. No information is available on the tools and resources UK prescribers currently use to support their decision making. One US study reported a decrease in the availability of paediatric prescribing information in a popular reference text. There is limited evidence to show that decisionsupport tools improve patient outcomes, however, there is growing confirmation that electronic prescribing reduces medication errors. There have been reports of new error types, such as selection errors, occurring with the use of electronic prescribing. Another concern with computerised decision-support systems is deciding what alerts should be presented to the prescriber and when/how often in order to avoid alert fatigue. There is little published concerning paediatric alerts perhaps as a consequence of commercial systems often not including paediatric specific support.

CP-036 evaluation of outpatient clinic letters for medication errors

Background - It is well recognised that errors are more likely to occur during transitions of care, especially medicines errors. Clinic letters are used as a communication tool during a transition from hospital (outpatient clinics) to primary care (general practitioners). Little is known about medicines errors in clinic letters, as previous studies in this area have focused on medicines errors in inpatient or outpatient prescriptions. Published studies concerning clinic letters largely focus on perceptions of patients or general practitioners in respect to overall quality. Purpose - To investigate medicines errors contained in outpatient clinic letters generated by prescribers within the Neurology Department of a specialist paediatric hospital in the UK.Materials and methods - Single site, retrospective, cross-sectional review of 100 clinic letters generated during March–July 2013 in response to an outpatient consultation. Clinic letters were conveniently selected from the most recent visit of each patient. An evaluation tool with a 10-point scale, where 10 was no error and 0 was significant error, was developed and refined throughout the study to facilitate identification and characterisation of medicines errors. The tool was tested for a relationship between scores and number of medicines errors using a regression analysis.Results - Of 315 items related to neurology mentioned within the letters, 212 items were associated with 602 errors. Common missing information was allergy (97%, n = 97), formulation (60.3%, n = 190), strength/concentration (59%, n = 186) and weight (53%, n = 53). Ninety-nine letters were associated with at least one error. Scores were in range of 4–10 with 42% of letters scored as 7. Statistically significant relationships were observed between scores and number of medicines errors (R2 = 0.4168, p < 0.05) as well as between number of medicines and number of drug-related errors (R2 = 0.9719, p < 0.05). Conclusions - Nearly all clinic letters were associated with medicines errors. The 10-point evaluation tool may be a useful device to categorise clinic letter errors.

Dosage form preference consultation study in children and young adults:paving the way for patient-centred and patient-informed dosage form development

Objectives: The current study aims to evaluate dosage form preferences in children and young adults together with identifying the key pragmatic dosage form characteristics that would enable appropriate formulation of orally disintegrating tablets (ODTs). Methods: International, multisite, cross-sectional questionnaire of children and young adults aged from 6 to 18 years. Eligibility was based on age, ability to communicate and previous experience in taking medications. The study was carried out at three locations: the UK, Saudi Arabia and Jordan. The questionnaire instrument was designed for participant self-completion under supervision of the study team.Results 104 questionnaires were completed by the study cohort (n=120, response rate 87%). Results: showed that ODTs were the most preferred oral dosage forms (58%) followed by liquids (20%), tablets (12%) and capsules (11%). The preferred colours were pink or white while the preferred size was small (<8 mm) with a round shape. With regard to flavour, strawberry was the most preferred (30.8%), while orange was the least preferred (5.8%). The results also showed that the most important physical characteristics of ODTs were disintegration time followed by taste, size and flavour, respectively. Conclusions: The results of our study support the WHO's claim for a shift of paradigm from liquid towards ODTs dosage forms for drug administration to young children older than 6 years. Data from this study will also equip formulators to prioritise development of key physical/performance attributes within the delivery system.

A telephone survey to determine the experiences of children and their parents/carers, following the initiation of a new medicine

Objective: To determine what issues are experienced during the first few weeks of therapy by patients, and their parents/carers, when a child/young person has been prescribed a new medicine. Method: One hundred patients aged ≤18 years of age prescribed a new medicine for ≥6 weeks were recruited from a single UK National Health Service specialist paediatric hospital outpatient pharmacy. Six weeks after the first dispensing of their new medicine the patient or their parent/carer received telephone follow-up by a researcher and verbally completed a questionnaire containing both open and closed questions. Patient or parent/carer experiences were identified and analysed using thematic analysis and descriptive statistics. Results: Eighty-six participants were available for telephone follow-up. Six (7%) had not started their medicine. Paediatric patients and their parents/carers experienced a range of issues during the first few weeks after starting a new medicine. These included additional concerns/questions (24/80, 30%), administration issues (21/80, 26.3%), adverse effects (29/80, 36.3%) and obtaining repeat supplies (12/80, 15%). The Morisky Medication Adherence Scale indicated that 34/78 (43.6%) participants had a high adherence rating, 35/78 (44.9%) medium and 9/78 (11.5%) a low rating. Conclusions: Paediatric patients and their parents/carers experience a range of issues during the first few weeks after starting a new medicine. Further research is required to determine the type of interventions that may further support medicines use in this group of patients.

The role of pharmacists in caring for young people with chronic illness

Purpose - To explore the perceived and potential roles of pharmacists in the care of young people aged 10-24 years with chronic illness, through the exemplar of juvenile arthritis, from the perspectives of UK community and hospital pharmacists, health service commissioners, rheumatology health professionals and lay advocates. Methods - A sequential mixed methods study design comprising: focus groups with community and hospital pharmacists; telephone interviews with pharmacy and rheumatology stakeholders and commissioners, and multidisciplinary group discussions to prioritize roles generated by the first two qualitative phases. Results - The high priority roles for pharmacists, identified by pharmacists and rheumatology staff, were: developing generic healthcare skills among young people; transferring information effectively across care interfaces; building trusting relationships with young people; helping young people to find credible online health information, and the need to develop specialist expertise. Participants identified associated challenges for pharmacists in supporting young people with chronic illness. These challenges included parents collecting prescription refills alone, thus reducing opportunities to engage, and pharmacist isolation from the wider healthcare team. Conclusions - This study has led to the identification of specific enhancements to pharmacy services for young people which have received the endorsement of a wide range of stakeholders. These suggestions could inform the next steps in developing the contribution of community and hospital pharmacy to support young people with chronic illness in the optimal use of their medication.

Hospital pharmacists' awareness of a new antibiotic guideline in the UK:implications for practice

Objectives: Pharmacists play an important role in the review of local hospital guidelines. British Thoracic Society (BTS) guidelines for the management of patients with community-acquired pneumonia (CAP) were updated in 2001, and it is important that individual hospital recommendations are based upon this national guidance. The aim of this study was to identify UK Chief Pharmacists' awareness of these updated guidelines one year after their publication. Secondary aims were to identify whether pharmacists had subsequently initiated revision of institutional CAP guidelines, and what roles different professional staff had performed in this process. Method: A self-completion postal questionnaire was sent to the Chief Pharmacist (or their nominated staff) in 253 UK NHS hospitals in November 2002. This aimed to identify issues relating to their awareness of the 2001 BTS guidelines and subsequent revision of their hospital's guidelines. Results:188 questionnaires were returned (a response rate of 74%), of which 164 hospitals had local antibiotic prescribing guidelines. Respondents in 29% of these hospitals were unaware of the 2001 BTS publication and institutional guidelines had been revised in only 51% of hospitals where the Chief Pharmacist was purportedly aware of the new BTS guidance. Generally, more staff types were involved in revising guidelines than initiating revision. Conclusions:Variability existed in both Chief Pharmacists' awareness of new national guidance and subsequent review processes operating in individual hospitals. A lack of proactive reaction to new national guidance was identified in some hospitals, and it is hoped that the establishment of specialist "infectious diseases pharmacists" will facilitate the review of institutional antibiotic prescribing guidelines in the future. © Springer 2005.

Influences on general practitioner prescribing with particular reference to community pharmacy

Influences on general practitioner prescribing of drugs continue to be of interest and importance as cost containment becomes central to Government health policy. This thesis employs a plurality of research methods including quantitative and qualitative survey techniques for example, questionnaires, interviews and prescription analyses to investigate some of the factors which may influence GP prescribing such as information sources, hospital consultants and in particular the community pharmacist. When the use and influence of drug information sources by GPs was examined, the community pharmacist was given a relatively low rating as a source but a high rating, similar to that of the consultant, for helpfulness. Influences are needed to improve prescribing and reduce the incidence of iatrogenic disease for the benefit of the patient. The education and expertise of pharmacists and their familiarity with local prescribing habits places them in a unique position to meet the needs of local GPs. As 96.5% of the public always or nearly always take their prescriptions to the same pharmacy, patient medication records, now kept by 77.5% of pharmacies, provide a valuable check on the appropriateness and safety of patients' medication. The barriers to the pharmacist's greater involvement were shown to be suspicion by GPs of pharmacists' motivation, isolation of many community pharmacists, difficulties in leaving the pharmacy for domiciliary visits, residential home care and GP practice meetings. These barriers must be lowered if the pharmacist is to have a greater influence and involvement. It was concluded that changes are necessary in pharmaceutical education, staff training, organisation and remuneration. Some changes in the targeting of remuneration to the pharmaceutical care services provided and registration of patients with pharmacies would contribute greatly to these aims.

Physicians' perceptions, attitudes and expectations regarding the role of hospital-based pharmacists in the West Bank, Palestine

Objective - To evaluate the perceptions, expectations and experiences of physicians with regard to hospital-based pharmacists in the West Bank, Palestine. Methods - A self-administered questionnaire was distributed to 250 physicians practising in four general hospitals in the West Bank, Palestine. The main sections of the questionnaire comprised a series of statements pertaining to physicians' perceptions, expectations and experiences with pharmacists. Key findings - One hundred and fifty seven questionnaires were completed and returned (response rate, 62.8%). The majority of respondents were most comfortable with pharmacists detecting and preventing prescription errors (76.4%; 95% confidence interval (CI) 69.5–81.2%) and patient education (57.9%; CI 51.2–63.4%) but they were not comfortable with pharmacists suggesting the use of prescription medications to patients (56.7%; CI 49.8–62.4%). Most physicians (62.4%; CI 56.8–69.1%) expected the pharmacist to educate their patients about the safe and appropriate use of their medication. However, approximately one-third (31.7%; CI 26.0–39.6%) did not expect pharmacists to be available for consultation during rounds. Physicians' experiences with pharmacists were less favourable; whereas 77% (CI 70.2–81.5%) of the physicians agreed that pharmacists were always a reliable source of information, only 11.5% (CI 6.2–16.4%) agreed that pharmacists appeared to be willing to take responsibility for solving any drug-related problems. Conclusion -The present study showed that hospital physicians are more likely to accept traditional pharmacy services than newer clinical services for hospital-based pharmacists in the West Bank, Palestine. Pharmacists should therefore interact more positively and more frequently with physicians. This will close the gap between the physicians' commonly held perceptions of what they expect pharmacists to do and what pharmacists can actually do, and gain support for an extended role of hospital-based pharmacists in future patient therapy management.