Pharmacy department
The pharmacy team provide ward-based pharmacy services to the Centre.
The pharmacists form an integral part of the consultant intensivist led MDT ward rounds. Each drug chart is clinically screened, providing medicines management and optimisation related interventions for all patients attending SWLEOC for elective procedures.
The pharmacy team is involved in conducting medicines reconciliation for inpatients at the Centre, ensuring that medications are optimised post-operatively and that patients’ own medication is accurately restarted as clinically appropriate.
The pharmacy team clinically screen and often produce To Take Out (TTO) discharge prescriptions on behalf of the consultant intensivists to enable efficient discharging of patients.
The team manages the medicine stock levels and ensures safe storage, management and security of medicines at the Centre. The team regularly participates with and leads clinical audits relating to medicines (both routine & as required audits).
Finally, they work with the wider department to examine and influence financial control of medicine spends, governance and safety issues concerning medicines as well as overall patient safety and experience of the service from pre-admission to post-operative recovery.
The service was part of the original set-up of the SWLEOC unit. The pharmacists and technician are the daily constant from Monday to Friday on the wards; as the nurses, consultant intensivists, and other support staff change shifts daily, but pharmacists provide continuity of care between these changes.
The pharmacists are usually the same people covering each clinical ward area Monday to Friday. However, the staffing group and their respective contributions has evolved over the years as our service has changed, as IT systems and the pharmacy profession have developed (including the various workforces involved e.g., pharmacy technicians, pharmacy assistants, pharmacists, specialist pharmacists, prescribing pharmacists etc.).
Consultant Anaesthetists, Consultant Intensivists, Nurses, Health-care Assistants, Physiotherapists, Clinical Nurse Specialists, Senior Management, Administration Clerks, Main Pharmacy Dispensary and a range of wider specialists both within and external to the Trust including GPs and community pharmacies in primary care.
All these interactions are usually face to face on the unit or via electronic methods, to improve and optimise patients’ experience and care through SWLEOC and beyond during their perioperative journey and recovery.
Ward-based at the Centre, meaning much of the activity is clinical and patient-centred.
Clinical manager, care-flow vitals, Lifebox, patient summary care records, and Bluespier.
Supply of medicines to the patient before discharge
This major bottleneck has been managed by redesigning the pathway so that discharge prescriptions are produced immediately after an operation by the Anaesthetist. However, there are still many patients that require adjustment, amendment, and optimisation to both their pre-admission and post-operative medicines during their visit to hospital. This means that a significant proportion of discharge prescriptions are processed on behalf of the consultant intensivists/anaesthetists by the ward-based pharmacists to account for changes required to optimise and deliver personalised pharmaceutical care.
Medicines that are not pre-packed or cannot be pre-packed
The team are currently exploring a variety of options to resolve this issue.
Controlled drugs
Pharmacy wait for signed copies of controlled drugs prescriptions to be given to a pharmacist (either on the ward(s) [Monday to Friday], or to the dispensary pharmacist [Saturday to Sunday]) before the screening process can be undertaken.
Saturday surgical procedures
There is no form of pharmacy ward-based service to support SWLEOC at weekends. This can cause both clinical and operational issues during the weekend as there is a marked change in the way the pharmacy service is delivered. Of the various options under consideration, the team are exploring the trial a Saturday ward-based pharmacist at the Centre.
By being involved at the point of prescribing as part of the consultant led ward rounds, the pharmacists can work in tandem with the MDT to help the right prescribing decision to be made first time as well as integrating plans for discharge planning and monitoring into the patients longer-term/future care.
This means that discharge processes are usually smoother as medicines administration, safety, and follow-up issues are identified, discussed, escalated or disseminated in a timely manner with all stakeholders keeping the patient at the centre of care. Being ward-based and working closely with the MDT helps address issues as they present throughout the day.
My predecessor was involved in setting up the service to facilitate the day-zero pathways. He was very anxious about the need to switch to oxycodone as the primary choice of escalation opioid offered for major arthroplasty. He was wary that this would mean a substantial change in clinical effect (both positive and negative – in terms of side-effects) that may be passed on to the patient. He was also wary about the significant operational challenges that would be presented to pharmacy dispensary due to this change to oxycodone. It means that the pharmacy dispensary has effectively had to individually cut down full packs of controlled drug medicines into appropriate course lengths for each patient, as the appropriate sized containers are not available directly from the manufacturer.
Controlled Drugs are also not currently allowed to be part-packed, packed-down, or come as pre-packs from either specialist suppliers or pre-packing units. This has necessarily has significantly increased the length of time required to dispense discharge prescriptions from SWLEOC, increased the complexity of the task of dispensing, and increased the risks and consequences of potential errors. Setting appropriate mitigating factors and managing expectations regarding this change with all stakeholders involved was incredibly challenging for my predecessor. These issues are still present and have both crystalized and come further into focus as the volume of operations has dramatically increased after increasing our services post COVID-19.
- Staffing our SWLEOC pharmacy team. Recruitment remains a significant challenge.
- Managing expectations across departments (SWLEOC/Pharmacy Dispensary)
- The impact caused when differing staffing levels both within the unit and ancillary departments affect the ability to process the work for the Centre.
- Establishing a consistent and quality service that accounts for all the days the Centre is operational (managing a seven-day service)
- Education and training and implementing SOPs/Guidelines. It is vitally important that all of these are accessible, up-to-date, formulated and delivered in the most effective way to allow up-take and implementation.
- Setting-up measurement apparatus that can consistently enable the capture of accurate empirical data relating to key performance indicators (KPIs), so that pertinent information can be recorded with ease and presented to stakeholders to both audit performance and drive service development/improvement.
- Keeping the patient at the centre of care and all decisions analysed to review their efficacy in improving patient outcomes.
- You need great collaboration with all stakeholders.
- You need great communication channels and follow-up pathways.
- Protected time to spend on education and training within pharmacy team and wider teams is essential.
- Consistently measuring, recording and analysing empirical data concerning KPIs and patient safety to develop the service and ensure high quality levels are achieved and maintained.
The day zero pathway service has been great for the patient. It really has focused resources and teams to provide a consistently high-quality service, keeping patients at the Centre of treatment.
Varying supply chain issues (Medicines Procurement). For example, when pre-packs are not available this can create a significant impact on both dispensary workload and delays to discharging patients efficiently.
Ring-fencing staff specifically for the unit is a crucial element required to consistently deliver a quality, standardised service. When you must rely on staff from other departments or “lend” members of your team to other departments due to staff shortages or system-wide challenges, it has a dramatic impact on your ability to deliver excellence. Consider setting up an appropriate team to start with, but also consider succession planning in the set-up. Creating a leadership chain and an internal divisional structure helps ensure that future leaders can be trained and developed internally within that specialist team. Consider the strengths and weakness of the using rotational staff from other departments Vs fixed positional roles within the unit.
Staff
Staff Member: Principal Pharmacist (Band 8A x 1WTE)
Role:
Band 8a is responsible as the pharmacy clinical and managerial lead for the department.
Staff Member: Senior Rotational Pharmacist (Band 7 x 1 WTE)
Role:
The role is to manage the routine day-to-day delivery of pharmacy services to the Centre. They participate in routine audits, service development, quality improvement and cost-improvement measures as well as research.
Staff Member: Rotational Pharmacist (Band 6 x 1 WTE)
Role:
This is fundamentally a training positon. The pharmacists here aim to develop their knowledge and understanding around perioperative pharmaceutical care. It is also important and junior pharmacist are exposed the centre so that they can picture future careers or training pathways into specialising as a surgical pharmacist. The role is also to learn to manage the routine day-to-day delivery of pharmacy services to the department. They may also participate in audits, service development, quality improvement and cost-improvement measures/research & development.
Staff Member: Senior Clinical Pharmacy Technician (Band 5 x 1 WTE)
Role:
Their role is to manage the routine day-to-day delivery of pharmacy services to the department. They also participate in audits, service development, quality improvement and cost-improvement measures/research & development.
Staff Member: Pharmacy Assistant (part-time)
Role:
The Pharmacy Assistant is responsible for ordering and maintaining good stock levels of medicines and fluids routinely used at the Centre. They also dispense all of our TTOs (which require the need pharmacy dispensing activity) in the pharmacy dispensary.