.........................................

back to top

• Leadership, accountability and governance
• Pharmacy's values, core beliefs and behaviors
• The new demand for strategic thinking
• Separating strategy from exhortation

.........................................

back to top

All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27^th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal.

To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented.

.........................................

back to top

Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home.

13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital.

Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit.

The OP costs were found to be approximately half of the IP costs.

We conclude that OP delivery of the deGramont regimen

is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance.

.........................................

back to top

Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care.

Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision.

The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders.

.........................................

back to top

The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex.

Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur.

The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas.

.........................................

back to top

Working with biotechnological products
Dr Cathleen Sass
Clinical Science Liaison
Gilead Sciences

Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing.

.........................................

back to top

Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available.

This workshop will focus on the following:

• What is an Intranet?
• Advantages of having an intranet?
• Intranet Vs Internet
• What content to publish
• Technologies involved
• Cost and time implications
• Maintenance of the data
• Electronic formularies (inc WeBNF)
• Future possibilities?

...................................

back to top

It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim.

Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other.

In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care.

Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance.

.........................................

back to top

NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally.

Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda.

The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support.

The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following:

• How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment?
• How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone?
• How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings?
• In what other areas might pharmacy wish to contribute?

.........................................

back to top

• To maintain the strong training component of the basic grade rotation
• To reduce the length of the working week to comply with WTR
• To address the length of each shift and ensure appropriate compensatory rest.

Changes to Practice
In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included:

• A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded
• Each shift would be reduced to 24 hours and followed by a whole day compensatory rest
• A continued commitment to the basic grade training programme.
• A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate.
• A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations

Consultation and Implementation
We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements.

Conclusion
The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future.

.........................................

back to top

1. To identify the career expectations and aspirations of pharmacy technicians in 5 years' time
2. To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time
3. To identify the level of support for a national register of technicians

Method
This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software³, which enables automatic data capture and analysis.

1. The career expectations and aspirations of pharmacy technicians in 5 years' time

	Expectation	Aspiration
Working as a technician	437 (81%)	339 (64%)
Training to be a pharmacist	5 (1%)	19 (4%)
Working in a non-pharmacy related job	43 (8%)	75 (14%)
Not working / career break / retired	30 (5%)	74 (14%)
Not answered	19 (4%)	27 (5%)

2. Managers' perceptions of the roles of pharmacy technicians in 2 years' time

1. Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13
2. Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732
3. http://www.formic.co.uk

.........................................

back to top

A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom
Taylor D, Mace S, & Mir S
Pharmacy Department,
Maudsley Hospital, London

Introduction
Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone.

Reasons to avoid the use of concurrent typical drugs:

• EPSE may emerge or worsen (and therefore worsen secondary negative symptoms)
• Symptoms of hyperprolactinaemia may emerge or worsen
• May increase incidence of TD

> 6 weeks therapy	Cloz	Risp		Sert	Olan		Quet	Amis
Number of patients	800	646		48	892		124	56
Mean dose (mg/day) Dose range (mg/day)	483.4 12.5 - 950	6.3 0.25 - 16.0		17.1 4.0 - 25.0	15.6 1.6* - 45.0		524.2 25 - 750	727.7 100 - 1200
N (%) patients on atypical alone(no regular or prn other antipsychotics)	450 (56.3)	178 (27.6)		13 (27.1)	169 (18.9)		12 (9.7)	4 (7.1)
N (%) patients on atypical and prn typical	233 (29.1)	256 (39.6)		23 (47.9)	377 (42.3)		64 (51.6)	31 (55.3)
N (%) patients on atypical and regular typical (+/- prn)	104 (13.0)	204 (31.6)		12 (25.0)	329 (36.9)		47 (37.9)	21 (37.5)
N (%) patients on atypical and another atypical	13 (1.6)	8 (1.2)		0	17 (1.9)		1 (0.8)	0
Use of anticholinergics
N (%) pts on reg. antich. and atypical alone	118/683 (17.3%)	101/434 (23.3%)		5/36 (13.9%)	53/546 (9.7%)		7/76 (9.2%)	9/34 (26.5%)
N (%) pts on reg. antich. & atypical& reg. typical	48/117 (41.0%)	122/212 (57.5%)		7/12 (58.3%)	155/346 (44.8%)		23/48 (47.9%)	13/22 59.1%)
Chi-squared test (df = 1) p	P< 0.0001	P< 0.0001		P=0.002	P<0.0001		P<0.0001	P=0.015
Note. Amis = Amisulpride			Olan = Olanzapine			Risp = Risperidone
Cloz = Clozapine			Quet = Quetiapine			Sert = Sertindole

Conclusions

• Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients
• The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)
Z
• The use of "PRN" typical antipsychotics is widespread despite being illogical
• Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers
• The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria

References
Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554.
Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109.
Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82.

.........................................

back to top

Table 1. Pharmacy Contribution to Patient Care on PTWR

Discussion
Whilst many of these interventions may have been made prior to the development of this service, the timeliness of care, which results from attendance of the PTWR, has improved the efficiency of treatment. Improvement in prescribing practice has also been noted, resulting in more evidence-based and cost-effective use of medicines.

Conclusions
Improvements have been demonstrated in quality of prescribing, timeliness of pharmacy intervention and efficiency of provision of pharmacy services to acute medical patients at St. Thomas' Hospital - pharmacist attendance of PTWR has made a difference to the standard of patient care.

.........................................

back to top

Impact of a high level clinical pharmacy service on prescribing costs.
Sue Bamford
Pharmacy Department, City General Hospital, Newcastle Rd, Stoke-on-Trent, ST4 6QG.

Background
There has been a dramatic rise in prescribing costs in the NHS over the last five years. Factors include the introduction of high cost drugs, the increase in the numbers of elderly patients, and the high expectations of the general public with regards to outcomes of therapy. This has not been matched by a similar rise in resources and there is therefore a need for prudent prescribing. In 1996 the Division of Medicine of North Staffordshire Hospital Trust was 30% overspent on a drug budget of £1 million. At this time there was a limited clinical pharmacy service to the Division with some wards not having a daily visit and there was no pharmacist regularly attending consultant ward rounds. It was hypothesised that the greatest impact on prescribing costs and quality would be achieved using an educational outreach model at ward level, delivered by an experienced clinical pharmacist. Therefore a pilot study was undertaken to assess the impact of a high-level clinical pharmacy service. This led to a successful business case and the appointment of two additional senior pharmacists to extend the clinical pharmacy service to the whole Division of Medicine.

Method
Each pharmacist was responsible for a clinical directorate within the Division of Medicine. Messages of good prescribing practice were issued to consultants and ward sisters which were reinforced by pharmacists at ward level. A pharmacist was present on all consultant ward rounds, attended directorate meetings with the clinical director, directorate manager and the divisional accountant, and contributed to the audit program. In addition a pharmacy action plan was agreed with the divisional general manager with set targets for savings in therapeutic areas. This was reviewed at quarterly meetings. Key messages were printed onto "post-it" notes¹. A prescribing link nurse was identified for each ward who received training in the background to the key messages and supported the directorate pharmacist. Cost comparison sheets were attached to all notes trolleys to be accessed by the doctors as they prescribed. Three of the key areas targeted were choice and route for antibiotics, nebuliser and inhaler costs, and appropriate use of nutritional supplements.

Results
By the end of 1998 the overspend on the drug budget had reduced to 12.6% and at the end of November 1999 the Division was underspent by 1.5%. Savings in the key areas targeted by the project are shown below.

Conclusion
The initial pilot study demonstrated the potential savings of a high-level clinical pharmacy service. This led to the development of a robust medicines management system involving doctors, nurses and pharmacists. The system operates at both ward level, with a review of individual patient's medication, and at divisional level with a divisional action plan and targeted messages. This has resulted in more rational prescribing without reducing the standard of patient care. Savings achieved over and above those identified in the cost-reduction plan have become available for re-investment in new therapies within each directorate. The benefits of the service could not have been achieved without the investment in additional staffing.

References
1. Bamford S.B. et al: Medicines Management at North Staffordshire NHS Trust - a review of macrolide antibiotics. Poster presentation, Guild of Healthcare Pharmacists Day Conference, Oxford, 26^th November 1999.

.........................................

back to top

Patients' representations of low dose aspirin and adherence to treatment post myocardial infarction (MI)
James D & Horne R
School of Pharmacy & Biomolecular Sciences, University of Brighton, Cockcroft Building, Lewes Road, Brighton, UK, BN2 4GJ

Background and aims
There is evidence that taking low dose aspirin post myocardial infarction (MI) causes a reduction in both overall mortality and reinfarction rates. However, this depends on patients adhering to a life-long daily regime where taking less than 95% is predictive of a higher risk of MI (Glynn et al., 1994). Patients' beliefs about their treatment influence how medicines are taken (Horne and Weinman in press). This study aims to investigate the role of patients' beliefs about medicines in adherence to aspirin during the first year following MI.

Method
A prospective, longitudinal study of 132 first time MI patients at four time-points (in hospital, 3, 6 and 12 months post MI) to investigate patients' representations of aspirin and other cardiac medicines (assessed using the standardised 'Beliefs about Medicines Questionnaire - Specific', Horne et al., 1999). Adherence was measured using a composite score of patients' self-reported adherence ('Reported Adherence to Medicines Scale'; Horne et al., 1999) plus a measure of prescription redemption from the GP or Pharmacy (available for aspirin in 50% of cases). High adherence was categorised as above 75% on both self-report and percentage supply measures. Differences in composite scores between aspirin and other cardiac medicines were explored using Chi-square test. Paired sample t-tests were used to investigate changes in beliefs about medicines over time and independent sample t-tests to assess differences in medication beliefs between high and low adherers.

Results Adherence scores for aspirin were significantly lower than for other cardiac medicines at each follow up phase (3 months, Chi=5.5, p<0.05; 6 months, Chi=11.8, p<0.01; 1 year, Chi=14.6, p<0.01) and decreased significantly between 6 months and 1 year (Chi=4.7, p<0.05), whereas adherence to other cardiac medicines remained stable over time. The perceived need ('necessity' scale scores) for aspirin at 3 months was significantly lower than for other cardiac medicines (t=-1.8, df=64, p<0.05) which was predictive of low aspirin adherence at 6 months (t=-2.3, df=64, p<0.05). However, the perceived need for aspirin increased significantly at 6 months (t=-2.1, df=78, p<0.05) and remained high at 1 year post MI. Patients' representations of the risks ('concerns' scale scores) of taking aspirin were significantly lower than for other cardiac medicines at each time-point (3 months, t=-6.3, df=64, p<0.01; 6 months, t=-3.0, df=84, p<0.01; 1 year, t=-2.6, df=90, p<0.01). Strong concerns about aspirin at 3 months and 6 months (t=2.6, df=64, p<0.01) were predictive of poor adherence to aspirin at 1 year.

Conclusions Following a first MI, patients may not be convinced of the necessity of taking low dose aspirin and perceive them as less important than other cardiac medicines leading to lower adherence. Misplaced concerns about aspirin (although infrequent) was another cause of sub-optimal secondary prevention of MI and death in this high-risk population.

References Glynn RJ, Burning JE, Manson JE, LaMotte F & Hennekens CH. Adherence to aspirin in the prevention of MI. Arch Intern Med 1994; 154:2649-2657.
Horne R & Weinman J (in press). Patients beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal Psychosomatic Research.
Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of anew method for assessing the cognitive representation of medication. Psychol & Health 1999; 14 (1): 1-24.

.........................................

back to top

Poster presentations

Pharmacists as Facilitators for Changing Prescribing Practice
McKenzie CA, Giles LJ. McRobbie DM
Pharmacy Department, Guy's and St.Thomas' Trust, St.Thomas' Hospital, London SE1 7EH

Introduction
In 1993 Guy's and St Thomas' Hospitals merged to create the Guy's and St Thomas' Trust. The newly formed Directorate of Intensive Care managed the two 15 bed general Intensive Care Units (ICU). These remained on separate sites until the ICU merged onto the St Thomas' site as part of the Trust's acute services transferred in October 1999. Prescribing was different for many therapeutic areas and it was anticipated that this might compromise patient and pharmaceutical care when the ICUs merged to become a single Unit. The two specialist clinical pharmacists (SCPs) providing the clinical pharmacy service to each unit were closely involved in the merger process. Their principal objective during the merger was to develop and implement joint prescribing policies in all areas that would allow consistent practice on the new 30 bed ICU. This process is described.

Method
Twelve months before the acute services were due to move to the St.Thomas' site; the SCPs identified the major prescribing areas where different practices occurred. Monthly meetings were arranged in order to debate these differences and these were attended by the six ICU consultants, the nursing director of ICU, and senior nursing representative from both sites. One or two major prescribing areas were presented by the SCPs who reviewed the subject, including the latest literature evidence to support best practice. This was compared to current clinical practice on the separate units. Meetings were not drawn to a close until consensus was achieved. After each meeting the SCP produced a policy which was ratified at the subsequent meeting. It was agreed that all policies would be subject to review three to six months after the merger.

Results
The following new prescribing and drug administration policies were produced and were implemented on both ICUs in advance of the merger:

• Antibiotic Selection and Prescribing
• Choice of Prescribing Unit (mcg/kg/min Vs mcg/min)
• Standard Drug Concentrations for continuous intravenous infusions
• Extended Duration Gentamicin Administration
• Guideline for the Safe Prescribing and Administration of Intravenous Insulin
• Guidelines for the use of Sedatives, Analgesics and Paralysis Agents
• Intravenous Phosphate Dosing and Administration Guidelines
• Prescribing Guidelines for Junior Medical Staff
• Stress Ulcer Prophylaxis
• Thromboembolic prophylaxis
• Criteria for the use of N-Acetylcysteine
• Prescribing and monitoring protocol for administration of Vancomycin by Continuous Infusion

Discussion
By managing the change in prescribing, the SCPs achieved full integration of different practices and this significantly contributed to the smooth transition of two separate ICUs to a single 30 bedded ICU. The evidence for drug usage in each area was reviewed and best practice assured. Where the evidence was equivocal, consensus practice was agreed between medical, pharmacy and nursing practitioners.

Conclusion
Clinical pharmacists are in a key position to take the lead in facilitating a change in prescribing practice and drug administration in any healthcare area which is undergoing the process of change.

.........................................

back to top

Guidelines for Drug administration via enteral feeding tubes
Helen Dhillon, Pharmacy Department, Derriford Hospital, Plymouth NHS Trust, Plymouth, PL6 8DH

Introduction:
Many patients who are fed by enteral tubes cannot swallow. As a result conventional dosage forms such as tablets and capsules are unsuitable. Although administration of medicines by these tubes is unlicenced and is fraught with uncertainty it is sometimes necessary.

Objective:
The aim of this project was to review current practice of enteral drug administration at Derriford hospital and to develop guidelines for administration via this route.

Methods:
A review of current practice was conducted by interviewing relevant nurses and by inspecting medication charts. A total of 70 enteral drug administration events were investigated.
Data relevant to drugs and formulations most commonly administered through enteral tubes at Derriford hospital was compiled to give guidance on methods of administration.

Results:
The snapshot review of seventy drug administration events via PEG or NG tubes carried out during 1999 showed that in 30% of cases the drug was either administered inappropriately (5 occasions) or inappropriate dosage form (16 occasions). Draft guidelines for enteral drug administration were drawn up, in the style of a decision making tree. Possible drug candidates were identified, together with their recommended dosage forms and comments about their administration. This information was then added to the algorithm to produce a quick reference source for ward staff.

Discussion:
There is scarcity of published guidelines. Few well-conducted studies have been done on medicines given by enteral feeding tubes (stability, absorption etc). Administration via the enteral tube route is generally unlicensed. Liaison within a multidisciplinary term can optimise the safety and effectiveness of drug administration. The draft guidelines should improve both clinical practice and risk management as they highlight factors involved in drug administration.

Acknowledgement:
We would like to thank all the staff at Derriford hospital, in particular Ms Jenny Lawrence, Miss C Chia and the entire pharmacy department along with the nursing and dietetic staff who gave support and encouragement throughout the project.

.........................................

back to top

The role of medication beliefs in angina patients' use of GTN spray
James D, Hawkins T and Horne R
School of Pharmacy & Biomolecular Sciences, University of Brighton, Brighton, UK

Background and Aims
A GTN spray is widely prescribed for patients diagnosed with angina. It is used by the patient as required for both symptom relief and prevention of angina symptoms. However, little is known about how patients use their GTN spray. This study aims to explore patients' willingness to use the spray and investigates the type of medication beliefs which may influence the way patients self-medicate.

Method
The validated 'Beliefs about Medication Questionnaire (BMQ), (Horne et al., 1999) was used to assess patients' beliefs about the GTN spray in 44 hospitalised angina patients admitted to the Royal Sussex County Hospital, Brighton, January to March, 1997. A single question was added to measure patients' willingness to use the spray and a three-item scale was constructed to assess how often patients carried the spray with them when they left their home.

Results
Results from the BMQ scores found that 89% believed that their GTN spray was both necessary and effective for the treatment of their angina, with most patients reporting that they carried it with them at all times (61%). However, 31% held strong concerns about the harmful effects of the spray, with 70% of subjects indicating that they tried to use as little as possible. Half of the subjects reported that they had avoided using their GTN spray in the past. Necessity beliefs correlated significantly with the likelihood of carrying the spray (rho=0.33, n=35, p<0.05). Willingness to use the spray correlated significantly with medication concerns (rho=0.36, n=39, p<0.05) in that those with higher scores on the 'concerns' scale had lower scores on the 'willingness to use' measure.

Conclusion
In this small sample of patients the GTN spray was mainly viewed to be necessary for the control of their angina. These views influenced whether or not the spray was carried, but not whether it was used. Patients were less likely to use the spray if they had strong concerns about its harmful effects or felt little control over their angina. Angina patients may not be achieving adequate control of their symptoms due to under use of their GTN spray. This may partly be due to patients' misconceptions regarding its harmful effects such as fears of dependence or worries about long-term effects.

Reference
Horne R , Weinman J A and Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol and Health 1999; 14 (1): 1-24.

.........................................

back to top

Health care professionals' views about medicines in general: a preliminary analysis
Roche M, James D, Horne R
School of Pharmacy & Biomolecular Sciences, University of Brighton, Cockcroft Building, Lewes Road, Brighton, UK, BN2 4GJ

Background
Patients encounter a range of different health care professionals (HCPs) as part of health care in the UK. The interaction between HCPs and patients during the clinical consultation may have an impact on medicine-taking behaviour. The type of advice which HCPs offer to patients about medicines may be influenced by their own attitudes to medication. A previous study found that pharmacy students had a significantly more positive view about medicines in general than students from other courses such as engineering, social policy and arts (Horne & Weinman, 1997). However, the degree to which the views of pharmacy students are shared by students of other HCPs is not known. Moreover, significant differences between HCPs views about medication identified during training may have an impact on subsequent practice in relation to medication (e.g. prescribing or the provision of advice to patients).

Aims
This study set out to compare the attitudes towards medicines in general among students of several health care professions.

Method
A total of 1416 students from 7 health and 2 non health-related undergraduate courses were studied. The former was a proxy measure of a group of HCPs and the latter represented a vocational and non-vocational course as the control group. The standardised 'Beliefs about Medicines in General Questionnaire' (BMQ-General, Horne et al., 1999) was used to assess views about medicines. ANOVA with Tukeys Honestly Significant Difference test was used for statistical analysis of variations within HCP groups and between HCPs and control groups.

Results
Pharmacy students (n=280) scored lowest on both the 'harm' (mean=8.6, SD=2.2) and 'overuse' (mean =12.8, SD=2.3) scales indicating that they perceived medicines in general to be less harmful and not to be over-prescribed. The perceived potential for causing harm was also low for students of medicine (n=313, mean=10.0, SD=2.3), physiotherapy (n=145, mean=10.1, SD=2.3), followed by dentistry (n=226, mean=10.2, SD=2.1), occupational therapy (n=56, mean=10.3, SD=2.0), environmental engineering (n=109, mean=10.6, SD=2.4), nursing (n=238, mean=10.7, SD=2.2), chiropody (n=22, mean=11.8, SD=2.4) and art (n=27, mean=12.4, SD=2.2) who viewed medicines as harmful substances. The view that medicines are overused was held strongest by students of art (mean=16.2, SD=2.6), followed by chiropody (mean=14.4, SD=1.9), occupational therapy (mean=14.3, SD=2.6), physiotherapy (mean=14.0, SD=2.1), nursing (mean=14.0, SD=2.6), dentistry (mean=13.4, SD=2.7), medicine (mean=12.9, SD=2.4) followed by pharmacy. Art students scored significantly higher on the 'overuse' scale than all other groups (F=12.9, df=8, p<0.01). Pharmacy students scored significantly less on the 'harm' scale than all other groups (F=25.3, df=8, p<0.01).

Conclusion
Significant differences were found between the extent to which HCPs and the control groups felt that medicines in general are harmful and overused. Whilst pharmacists and medical students hold the most positive views about medicines, other HCPs were significantly less positive about medicines in general. Furthermore, HCPs need to recognise that lay people may not have such a 'pro-medicine' outlook as themselves.

References
1. Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of anew method for assessing the cognitive representation of medication. Psychol & Health 1999; 14 (1): 1-24.
2. Horne R & Weinman J. Cultural variation in beliefs about medicines. British Psychological Society Annual Conference of Health Psychology. University of Southampton, 13, 1997

.........................................

back to top

Improving quality of prescribing through therapeutic substitution
Mark Tomlin, Caroline Taylor & Caron Weeks
Pharmacy Department, Southampton General Hospital, SO16 6YD

Medicines Management
Medicines management is an important aspect of Clinical Governance. Clinical pharmacists visit hospital wards and offer constructive comments and advise doctors about evidenced based prescribing. Around a third of prescriptions result in an intervention. 95% of the pharmacists' contributions are accepted positively.

Guideline Compliance
Most clinical pharmacy contributions to patient care were made after prescribing had taken place. Tradition required the pharmacist to find the doctor and persuade them to alter their prescription. Consultants see the pharmacists' role as assurance that prescribing follows their locally approved guidelines.

Multidisciplinary Continuous Professional Development
Multidisciplinary team working allows experienced pharmacists and nurses to enhance patient care by applying evidenced-based medicine. Therapeutic substitution extends this process by empowering the pharmacist to make changes according to a consultant approved local protocol, consistent with the principles of the Crown reports.

Risk Management
Clinical pharmacists encourage evidence based best practice and can be seen as medication error avoidance in action. It. Health economic concepts of 'best value' apply. Maximising resource use for the many whilst maintaining the quality of care for individual patients.

Results
An audit of this pilot showed that 349 therapeutic substitutions were conducted in a 6-month period. 212 improved quality, 137 reduced costs. Cost reductions where made from a broad perspective, cognisant of any impact on primary care.

Conclusions
Therapeutic substitution has proven that clinical governance principles can be embedded into clinical practice. It is still evolving but forms an important part of the hospital's medicines management system.

.........................................

back to top

Identification of factors affecting job and career satisfaction in hospital pharmacists
G.S. Fleming, *J.G. Davies, **V. Bewick & *A. Bhudia
South Thames NHSE Pharmacy Education & Training, Worthing & Southlands Hospitals NHS Trust, Shoreham by sea,
*School of Pharmacy, University of Brighton, Brighton, &
**Dept of Computing & Mathematical Sciences, University of Brighton, Brighton,

Purpose
The recruitment and retention crisis within British pharmacy services is recognised and is expected to worsen during the next 5 years. As retention is related to job satisfaction, a survey of job and career satisfaction was undertaken in hospital pharmacists employed within the South Thames region of the UK.

Method
A questionnaire which had been previously validated to quantify job and career satisfaction was circulated to 608 pharmacists ¹. Responses were assessed using a 5 point Likert scale with "1" indicating most dissatisfaction. Scoring was reversed for negatively worded statements so that a high score denoted greater satisfaction.

Results
Responses were received from 232 pharmacists (38%) of whom 174 were female. The median age range was 31-40 years and most (46%) were employed at a middle management grade. Sixty eight percent of pharmacists were satisfied with their current job and 65% with their career. Highly significant relationships were identified between job satisfaction and company policies, job role and supervision at work (p<0.0001). Career satisfaction was related to company policies, compensation practices, job role and education and training (p<0.001).

Conclusions
The results of this study highlight the need for employers to ensure that pharmacists are maintained in challenging roles which optimise use of their knowledge and skills. These findings will be used to inform the design of a recruitment strategy for hospital pharmacists.

Reference
Barnett C.W. & Kimberlin C.L. Development and validation of an instrument to measure pharmacist's satisfaction with their j jobs and careers. Am J Pharm Educ 1986; 50: 5-14

.........................................

back to top

Validation of an instrument to measure pharmacist's job and career satisfaction in british hospital pharmacists
GS Fleming*, JG Davies, V Bewick, A Bhudia
South Thames NHSE Pharmacy Education & Training, Worthing & Southlands NHS Trust, Shoreham by sea, West Sussex * & University of Brighton, Brighton, UK

The recruitment and retention crisis within UK pharmacy services is well recognised and it has previously been shown that turnover is affected by job satisfaction¹. An existing job satisfaction questionnaire was validated with the aim of utilising it to determine which factors are most strongly associated with job and career satisfaction in hospital pharmacists in 1998².

The questionnaire used a Likert scale to quantify job and career satisfaction overall and with 11 independent variables. The original questionnaire was revised to include demographic data and a subscale on education and training and piloted on 15 pharmacists. A revised questionnaire was circulated to all pharmacists employed by hospitals within the South Thames region of the U.K. (n=600). The internal consistency reliability for dependent and independent variable subscales was assessed using co-efficient alpha. A co-efficient alpha value of 0.65 or greater indicated internal consistency.

Questionnaires were returned by 232 pharmacists (30%). Eight of fourteen subscales demonstrated internal consistency (Table 1). Of those that were shown to be unreliable, three contained only 2 variables and therefore were open to statistical misinterpretation. The remaining three, pharmacist-patient relationship, pharmacist - doctor/ nurse relationship and work schedule subscales were considered to contain statements that were not representative of current hospital pharmacy practice.

Eight dependent and independent variables were shown to be valid and reliable for use in a job and career satisfaction survey of hospital pharmacists employed by UK hospitals. The reduction in the number of subscales should abbreviate the questionnaire and hence improve response rates.

Table 1 - Co-efficient alpha values for subscales used in a job and career satisfaction survey

Subscale	Alpha value - Barnett & Kimberlin 1986	Alpha value when tested in UK hospital pharmacists, 1996
Compensation practices	0.81	0.85
Recognition from supervisors	0.77	0.77
Supervision	0.83	0.81
Education and training	-	0.76
Communication	0.63	0.61
Clinical encounter	0.70	0.54
Work schedule	0.68	0.62
Company policy	0.73	0.69
Job role	0.76	0.69
Co-workers	0.72	0.60
Workload	0.69	0.57
Autonomy	0.73	0.61
Job satisfaction	0.83	0.70
Career satisfaction	0.87	0.75

References
1. Ortmeier B.G. & Wolgang A.P, American Pharmacy 1991; 31: 27-31 2. Barnett C.W. & Kimberlin C.L, Am J Pharm Educ 1986; 50: 5-14

.........................................

back to top

Development of Information Management Systems
Stephen Wood, North Thames Drug Information Service (NTDIS), Northwick Park & St.Mark's Hospitals, Harrow HA1 3UJ

The ability to input, retrieve and disseminate information in a fast and user friendly way has been the motivating force for the development of new information technology systems. The use of IT systems to address the need for up-to-date information has helped to streamline both clinical pharmacy and drug information processes. Outlined below are the systems developed by NTDIS in the past 12 months:

The System.	The Purpose.	The Future.
CINDERS Database	Drug Information Enquiry system for logging enquiries. Enables searching and retrieval of past enquiries and production of workload reports.	Move towards paper-less office Integration of scanned archives Incorporation of intranet technologies Centralisation of Drug Information data
CIID Database	Clinical intervention system. Enables documentation of pharmacy interventions, reporting of workload figures, and search and retrieval of previous interventions.	Integration of hand-held devices Personal and departmental auditing
Drug & Therapeutics Committee Decisions Database	Collection of Drug & Therapeutic Committee decisions made by Trusts in North Thames. Fully searcheable.	Incorporation of intranet technologies Incorporation of Area Prescribing Committee decisions in collaboration with South Thames DI Service and extend to cover Eastern, London and South East Regions
New Drugs Database	National database of drugs in development including indications, expected launch, etc. Fully searcheable.	Incorporation of intranet technologies
The Fridge Database	Collection of stability data for products inadvertently left out of the refrigerator. Fully searcheable.
Weekly Information "Packs"	Weekly electronic dissemination of drug information material on the Internet. Contains an archive of previous mailings and is fully searchable.	Streamlining of mailing systems using web technologies

The further development of information technology systems represents an exciting future for improving pharmacy practice.

Ackowledgements: Systems designed by: Anita Balestrini, Judith Cope, Sarla Drayan, Stuart Driver, Caroline Edwards, David Erskine, Roy Gillman, Peter Golightly, Richard Goodman, Shapour Hariri, Julia Horwood, Rita Jones, Anne Maher, Andrea Patel and Jane Sharp

.........................................

back to top

An Audit of Tinzaparin in the Treatment of Deep Vein Thrombosis and Pulmonary Embolism
Kris Dighton* & Uttam Chouhan**
*Preregistration Pharmacist, **Principal Pharmacist-Clinical Services
Glan Clwyd Hospital, Rhyl, North Wales

Introduction
Over the last four years guidelines for treating deep vein thrombosis (DVT) and pulmonary embolism (PE) have been amended to take advantage of new low molecular weight heparins (LMWHs). The original guidelines involved the use of warfarin to anticoagulate the patient whilst giving a continuous unfractionated heparin infusion. Once the patients INR was stabilised, the heparin infusion was stopped and the patient discharged on warfarin. If it was known that the patient had suffered a recent PE, streptokinase could be used to dissolve the clot before starting heparin and warfarin.

This treatment has several disadvantages. Patients on heparin infusions require daily monitoring of their activated partial thromboplastin time (APTT) and consequent adjustment of the rate of heparin administration. Previous audit had also demonstrated that an APTT within the desired range was not achieved in a significant proportion of patients, with the consequent risk of either a further clot or a bleed. If streptokinase was used, further PEs cannot be treated with the same regimen as antibodies raised to streptokinase rapidly render it ineffective on subsequent administration.

LMWHs are a better treatment option. They do not require APTT monitoring, are simpler for nursing staff and more acceptable to patients with a once a day injection rather than continuous infusion. Tinzaparin is licensed to treat both DVT and PE.

Aim of the Audit and Method
New guidelines were introduced in the 1999 edition of the Trust Medicines Guide to increase the probability that patients diagnosed with DVT or PE received optimal treatment; i.e. to improve outcomes. The aim was to assess compliance with the guidelines by medical and nursing staff.

• The audit was a retrospective review of in-patients who received at least one therapeutic dose of tinzaparin between September and November 1999.
• Pharmacy records identified 173 patients in this category and the casenotes of 117 (72%) were retrieved.
• A data collection form was designed to collect specific information from the casenotes.
• Data have been collated and are currently being analysed and compared with the guidelines.
• Discrepancies between casenote records and the guidelines should help to identify specific problem areas.
• These areas can then be addressed to increase compliance with, or amend, the guidelines to improve outcomes.

Preliminary Results
The main problem areas appear to be as follows:

• Incorrect tinzaparin dose prescribed (calculated on the patient's weight).
• Delay in radiological confirmation of the diagnosis.
• Delay in starting warfarin after a positive D-dimer test (an indicator of the presence of a clot).
• Tinzaparin not being continued until the patient's INR stabilised in the correct range.
• Patients being discharged on warfarin before their INR stabilised.

.........................................

back to top

Which statin for a hospital formulary? economic considerations
Dr. Clare Conroy MRPharmS, PhD Pharmacy Department, Bristol Royal Infirmary

Background
Within the United Bristol Healthcare Trust (UBHT) pravastatin and simvastatin are currently recommended as first line lipid-lowering drugs (LLDs) in the management of mild-moderate and moderate-severe hyperlipidaemia, respectively. Their inclusion in the hospital formulary is based on the positive results from four clinical event trials, which demonstrated a reduction in total mortality.

Methods
A cost-effectiveness analysis was used to compare the differential costs and outcomes of simvastatin and pravastatin based on the results from four pivotal studies. Review of published clinical trials and meta-analyses, report that simvastatin represents a more efficacious LLD in comparison to pravastatin (Illingworth and Tobert, 1994; Conroy, 1996; Kong et al., 1997). Projected cost-savings to both UBHT and the local Health Authority were hence established by replacing pravastatin 20mg with simvastatin 10mg.

Results
Some 29 post-Myocardial infarction (MI) or angina patients would need to be treated according to the Scandanavian Simvastatin Survival Study (4S) protocol for 5.4 years in order for coronary mortality to be reduced by one. The incremental cost-effectiveness ratio was £58,482. On comparison with the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial, the cost of secondary prevention with pravastatin in post-MI or angina patients proved to be over two times that of simvastatin. Over the last year, the equivalent of 5715 pravastatin 20mg tablets were issued within the Trust. Since simvastatin represents a more potent and cost-effective LLD, replacing pravastatin 20mg with low dose simvastatin would save UBHT £1554 per annum, assuming that pravastatin was indicated for secondary prevention. In addition, if patients were to be discharged on simvastatin 10mg rather than pravastatin 20mg, the annual cost saving for the local Health Authority would be in the region of £114,057.

Conclusion
Cost-effectiveness analysis demonstrates simvastatin to be more cost-effective than pravastatin in secondary prevention. By considering respective LLD potency, substitution of pravastatin 20mg with simvastatin 10mg would result not only in an evidence-based improvement in outcome, but significant savings to both UBHT and the health authority.

Acknowledgement
I would like to thank Dr Eileen Scott, The Queens University of Belfast, and Professor Alain Li Wan Po, Aston University for their invaluable assistance with my thesis.

.........................................

back to top

An audit of antibiotic prescribing in renal impairment
Paul Buckley, Pharmacy Department, North Staffordshire Hospital NHS Trust

Background
Renally eliminated drugs exhibit extended half lives and prolonged serum drug concentrations as a result of decreased drug excretion in patients with renal impairment. Dosage adjustments are therefore needed to avoid accumulation and potential toxicity¹. An audit of antibiotic prescribing in renal impairment was undertaken as part of the Pharmacy department DUE / audit programme.

Aim
To investigate the appropriateness of antibiotic prescribing with respect to renal function on the nephrology ward at the North Staffordshire NHS Trust.

Methods
The audit was a retrospective analysis of prescribed antibiotics in patients with renal impairment from June 1999 to October 1999 inclusive. A data collection proforma was produced and included basic patient demographic details, indication for antibiotic, dose, frequency and duration of therapy. Antibiotic doses were audited against recommended doses specified in The Renal Drug Handbook (Bunn R & Ashley C) and locally adopted guidelines for the treatment of CAPD peritonitis and line infections.

Results
Fifty eight patient episodes were collected (male 32, female 26) with an age range of 30-81 years (mean = 56.9 years). All patients required renal replacement therapy (haemodialysis= 29, CAPD =29). Indications for antibiotic therapy included exit site infection (n=12), line sepsis (n=10), chest infection (n=8), CAPD peritonitis (n=5), sepsis (n=5), wound infection (n=7), UTI (n= 6), endocarditis (n=1), abscess (n=1) and abdominal pain (n=1). The total number of antibiotics prescribed was 101 and are shown as follows

Twenty two antibiotics were prescribed outside recommended guidelines and included erythromycin (9), cefuroxime (2), ciprofloxacin (3), Co-amoxiclav (3), ceftazidime (2), metronidazole (1), ofloxacin (2).

Discussion
The main limitation of this audit was the difficulty in obtaining patients notes on the unit and therefore the sample obtained may not be truly representative for all patients presenting with infection. However, the results revealed that prescribing of antibiotics on the renal ward was generally good with 77% of antibiotics prescribed within the recommendations specified. The main antibiotic prescribed outside of the recommended dosage guidelines was erythromycin, a concern given the potential risk of ototoxicity associated with macrolides in renal failure. The results of this audit were presented at a renal unit audit meeting to provide positive feedback to junior medical staff and as a means of education with respect to specific antibiotics.

References
1. Preston SL et al Dosing adjustment of 10 antimicrobials for patients with renal impairment. Annals Pharmacother 1995: 29: 1202-7

.........................................

back to top

Presentation of drug doses for use in paediatric emergencies
Kit M Lai MRPharmS and Gillian Hinson, MRPharmS, Pharmacy Department, University Hospital Lewisham, London SE 13 6LH

Introduction
Like most hospitals, University Hospital Lewisham (UHL), has paediatric 'crash' boxes with fixed dose prefilled syringes and ampoules yet a variety of dosages are required for resuscitation due to the age range of the children involved. The dosage information available within current boxes is in the form of a table based on weights. However, feedback from users suggested that doses were out-of-date and inadequate. It was identified that a user friendly reference guide to determine doses in paediatric emergencies would be of considerable use. Ideally such a guide should be comprehensive, simple to understand, and easily accessible to users. This study was set up to determine the preferred format and content of such a guide.

Method.
Twenty UK hospitals were surveyed by telephone to review formats currently in use. A short structured interview of either a senior pharmacist or resuscitation officer was carried out by a single researcher (KML). Using the information from the telephone survey, a postal questionnaire was sent out to 30 clinical staff at UHL who attend paediatric emergencies to determine the preferred format. This questionnaire also addressed a number of other associated issues. The information was analysed using an Excel spreadsheet.

Results
Four reference guides were found to be in use at the UK hospitals surveyed. These included Broselow tape (1), Flipchart (1), table based on age and weight (8), and the Oakley chart (7). There was a 60% response rate to the postal questionnaire atr University Hospital Lewisham. A majority of staff; 15/18 (83%) did not use the current reference guide available. A number of reasons were given: never seen the guide (8/15), committed the doses to memory (4/15), while some did not state a reason (3/15). The preferred option chosen by UHL users was the flipchart based on weight (8/18), with a table based on age and weight being second popular (5/18), followed by the Oakley chart (3/18), with the Broselow tape being least popular (2/18). A range of reasons included ease and simplicity of use.

Conclusion
This work shows that a flipchart based on weight is preferred reference guide by users within UHL. A copy of such a guide will be incorporated into the new paediatric crash boxes.

.........................................

back to top

A review of the appropriateness of the prescribing of HMG Co-A Reductase Inhibitors prior to and post coronary artery bypass grafting.
Duncan McRobbie, ^* MSc. MRPharms & Audrey O' Reilly, ^** MRPharmS
^* Principal Clinical Pharmacist, Guy's and St Thomas' Hospital, London SE1 7EH
^** Resident Pharmacist, Guy's and St Thomas' Hospital

Introduction
A number of recent studies evaluated the effect of lipid-lowering therapy on late clinical and angiographic outcomes in patients undergoing CABG1,2,3. These studies demonstrated that aggressive lipid lowering with a range of statins improved clinical and angiographic outcomes in this group of patients.

Methodology
Patients who underwent CABG at St. Thomas' hospital's Cardiac Centre during June, July and August 1998 were identified. One hundred patients' notes were retrieved on the basis of ease of access. A satisfactory data collection form was designed and piloted and the notes were reviewed. A postal questionnaire was designed (Appendix 2) and posted with a covering letter to the GPs.

When total cholesterol levels were <= 4.1mmol/l appropriate prescribing was considered to be a daily dose of statin equivalent to 20mg of Simvastatin. When total cholesterol levels were > 4.1 mmol/l appropriate prescribing was considered to be a daily dose of statin equivalent to 40mg of Simvastatin.

Results
100 subjects were included in the study. 76% were male and 24% were female. The mean age was 63.2 years for males and 66.8 years for females. 100% of the subjects were diagnosed as having CAD and had undergone coronary artery bypass grafting during the specified time period. Only 2% of the subjects had undergone CABG previously. There was a 49% response rate from the GPs.

Prior to admission, 67% of patients were prescribed steroids, although only 9% were prescribed statins appropriately. This figure included 44 patients for whom no cholesterol level was known. On discharge 88% of patients were prescribed a statin, but again only 10% were prescribed correctly according to a known serum cholesterol. Nine to 12 months after discharge 40/49 (92%) of patients were prescribed a statin, 20/49 (42%) were appropriate according to their cholesterol levels and only 10% of patients had unknown cholesterol level.

Discussion
Prior to admission approximately a third of patients with substantial CAD were not prescribed a statin and in 44% cholesterol, a significant risk factor was not known. After CABG at St. Thomas' the number of patients discharged on a statin markedly increased. While the cholesterol level of these patients was not recorded in the medical notes in 44% of occasions, a pragmatic approach to prescribing ensured that the vast majority of these patients with unknown cholesterol received a statin.

In the follow-up with GPs, it would appear that cholesterol levels were reduced compared to the pre and post surgical cohort. This may reflect the increasing awareness of the benefits of lipid-lowering medication in high risk groups amongst GPs. It was not possible to assess the dose titration of the statin to cholesterol level. As with all retrospective reviews, the data was reliant upon that documented in the patient notes. Clerking, inpatient notes, GP and consultant letters were reviewed for documented cholesterol levels.

Conclusion
This study demonstrated that, while statins are frequently prescribed to patients with CAD, this is not always in relation to a known cholesterol level, either prior to surgery, immediately post-surgery or in general practices.

References
1. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383-1389.
2. Post-CABG Trial Investigators. The effect of aggressive lowering of low density lipoprotein cholesterol levels and low dose anticoagulation on obstructive changes in saphenous-vein coronary artery bypass grafts. N Engl J Med, 1997:18;336(3), 153-162.
3. Lansky AJ et al. Lipid-lowering therapy after coronary revascularisation: the interventional cardiologist's perspective. Am J Cardiol 1998; 81: 55E-62E.

.........................................

back to top

Treatment of hypophosphataemia in critically ill patients with a two day regimen.
Giles LJ, Jennings A, Ng B, Creed G, Gallard L, Pierre D, Beale R, McLuckie A.
Departments of Pharmacy and Intensive Care, Guy's and St. Thomas' Hospital Trust, St. Thomas' Hospital, London, SE1 7EH.

Introduction
Standard phosphate replacement regimens (1,2) are only 21-30% effective at correcting serum concentrations in severely hypophosphataemic critically ill patients, with 60-85% of patients redeveloping hypophosphataemia. We evaluated a two day regimen employing a relatively rapid infusion rate.

Method
52 intensive care patients developing hypophosphataemia (< 0.8 mmol/L) were evaluated. Intravenous phosphate doses on days 1 and 2 were based on the morning serum phosphate concentration: 0.8-0.6 mmol/L: 20 mmol and 20 mmol, 0.6-0.4 mmol/L: 40 mmol and 20 mmol, < 0.4 mmol/L: 50 mmol and 20 mmol. Sodium phosphate (0.1 mmol/mL) was infused centrally or peripherally at a rate of 10 mmol/hr. Serum phosphate and ionised calcium concentrations and calcium phosphate product were determined pre-, immediately post- and 6 hours post-infusion for each dose and after 24 hours. 22 patients were receiving continuous renal replacement therapy.

Results

Serum PO4 mmol/L	Dose	N	Efficacy					Safety
			Mean (SD) serum PO4 (mmol/L)		Patients % successfully corrected (³     0.8 mmol/L):			Mean (SD) change in ionised Ca (mmol/L) from pre-treatment value
			dose 1 +24h	dose 2 +24h	dose 1 +24h	dose 2 +24h	dose 2 +48h	dose 1 +24h	dose 2 +24h
0.8-0.6	20:20	35	0.9(0.2)	1.1(0.4)	66%	71%	74%	-0.06(0.11)	-0.07(0.17)
0.6-0.4	40:20	13	0.8(0.2)	0.8(0.2)	46%	53%	69%	+0.03(0.16)	-0.04(0.12)
<0.4	50:20	4	0.8(0.2)	0.9(0.3)	25%	75%	75%	-0.02(0.03)	+0.01(0.05)

Only seven calcium phosphate product values were slighty raised (range: 4.9-5.7 mmol²/L²). 22 patients had ionised calcium concentrations of £   1.05 mmol/L on occasions during the regimen but the extent of the hypocalcaemia was mild (mean (SD) ionised Ca: 0.99 (0.07) range: 0.68-1.05 mmol/L (n=50)) and usually transient. Furthermore the degree of change in ionised calcium concentrations from pre-treatment values for all patients was not significant (see table). No clinical evidence of hypocalcaemia was noted.

Conclusion
The two day intravenous phosphate regimen described is safe and highly effective at correcting hypophosphataemia in critically ill patients.

References
1. Perreault MM, Ostrop NJ, Tierney MG. Ann Pharmacother 1997; 31: 683-688
2. Clark CL, Sacks GS, Dickerson RN et al. Crit Care Med 1995; 23: 1504-1511

.........................................

back to top

Prescribing in schizophrenia - evaluating the effect of introducing a new treatment protocol
Shameem Mir BPharm MRPharmS*, David Taylor MSc MRPharmS**, & Robert Kerwin DSc FRCPsych
* Principal Liaison Pharmacist, **Chief Pharmacist, *** Professor of Clinical Neuropharmacology, Institute of Psychiatry. Maudsley Hospital London SE5 8AZ

Introduction
The introduction of the atypical antipsychotics has brought with it systematic programmes of valid research and a corresponding increase in demand for evidence-based prescribing. In our own unit, evidence-based prescribing protocols had been in force since October 1994. Nevertheless, two published studies which incorporated some of our patients (Taylor et al, 1997; Taylor et al, 1998) had shown clear deficits in prescribing practice. In particular, the co-prescription of atypical and typical antipsychotics seemed disturbingly prevalent.

As part of an agreed protocol-development programme with our Health Authority, we undertook an evaluation of prescribing practices before and after the introduction of a new prescribing protocol and examined rates of co-prescription and the relative need for anticholinergics in patients treated with different drug combinations.

The Study
Audit 1 was carried out in one week in January 1998. Pharmacists of the Trust collected data from all prescriptions for antipsychotics. Data were collated and analysed using the SPSS software system. In September 1998 a prescribing protocol was circulated to all medical staff in the Trust.. A second prescribing audit (Audit 2), was conducted in one week in February 1999.

Findings
In Audit 1, prescribing data were collected for 1676 patients prescribed antipsychotics. Audit 2 reviewed 1218 prescriptions. A break down is shown in Table 1.

Table 1 - Overview of prescribing

	Audit 1 (N = 1676)	Audit 2 (N = 1218)
Typical antipsychotics
Typical alone	941 (56.1%)	557 (45.7%)
Typical and regular typical	277 (16.5%)	180 (14.8%)
Typical and prn typical only	56 (3.3%)	55 (4.5%)
Atypical antipsychotics
Atypical alone	278 (16.6%)	310 (25.5%)
Atypical plus regular typical	55 (3.3%)	47 (3.7%)
Atypical plus prn typical only	38 (2.3%)	61 (5.1%)
Atypical plus regular atypical	32 (1.9%)	8 (0.7%)

Table 2 - Atypical antipsychotic prescribing

	Audit 1	Audit 2
Total	403 (100%)	426 (100%)
Alone	278 (69.0%)	310 (72.8%)
Plus regular typical	55 (13.7%)	47 (11.0%)
Plus prn typical	38 (9.4%)	61 (14.3%)
Plus regular atypical	32 (7.9%)	8 (1.9%)

Table 3 - Prescribing of anticholinergic medication

	Audit 1		Audit 2
	Reg. antichol.	No reg. antichol.	Reg. antichol.	No reg. antichol.
Atypical alone	30 (10.8%)	248 (89.2%)	36 (11.6%)	274 (88.4%)
Atypical + reg. typ	16 (29.1%)	39 (70.9%)	12 (25.5%)	35 (74.5%)

Comment

• The proportion of patients prescribed atypical drugs increased from 16.6% of the total to 25.5%.
• Co-prescription of atypical and typical antipsychotics was uncommon and did not change markedly.
• Co-prescription was significantly associated with prescribing of regular anticholinergic medication.

The increased use of atypical antipsychotics in our study cannot definitively be linked to the publication of our prescribing protocol. Common sense would predict that new drugs with a reputation for improved efficacy and tolerability would, over time, be used more often. However, our new protocol was the first Trust-produced document to recommend the use of atypicals as first line and our impression was that this had an important impact on prescribing practice.

References
1. Taylor, D., Holmes, R., Hilton, T., et al. (1997) Evaluating and improving the quality of risperidone prescribing. Psychiatric Bulletin, 21, 680-683.
2. Taylor, D., Drummond, S., Pendlebury, J. (1998) Olanzapine in practice. Psychiatric Bulletin, 22, 552-554.

.........................................

back to top

Aim
To determine whether clopidogrel is being used within Wirral Hospitals according to the drug and therapeutic committee's (D&TC) recommendations: Clopidogrel should only be used within Wirral Hospital NHS Trust for its licensed indications in patients who have a true allergy (rash, angioedema or difficulty in breathing with aspirin).

Objectives
1. To audit clopidogrel prescribing against the Wirral Hospitals drug and therapeutic committee's recommendations for a two month period (26/5/99-25/7/99) 2. To use the results of the audit to re-educate prescribers in the correct use of clopidogrel

Results
The audit took place over two months. 17 of 19 patients started on clopidogrel were audited, either at the time of prescribing or retrospectively from their case notes.

Summary of results (Patient numbers)

Indication for clopidogrel	Peripheral vascular disease Ischaemic stroke Myocardial infarction Atrial fibrillation Ischaemic heart disease Cardiomyopathy	1 7 3 2 3 1
Reason for clopidogrel against other agents	Gastric problems Bleed with warfarin Breathing problems with aspirin Anaphylaxis / Rash with aspirin To try clopidogrel	10 2 2 2 1

Discussion
11 of the 17 patients in the audit were started on clopidogrel for licensed indications. Six patients were started on clopidogrel for unlicensed indications with no clinical trial support.

The most frequent reason for choosing clopidogrel against other agents is concern over patient's gastric problems. In the caprie trial¹ clopidogrel 75mg was shown to have less GI side effects than aspirin 325mg non soluble 0.49% Vs 0.71% (serious bleeds). A lower dose of aspirin may prevent side effects in patients unable to tolerate higher doses and is effective for the secondary prevention of stroke, MI and death². Dipyridamole M/R 200mg bd is a suitable alternative for patients with ischaemic stroke³.

Conclusions / recommendations
1. Only two patients received clopidogrel fully complied with the recommendations of the D&TC
2. Clopidogrel is mainly used by patients with GI problems
3. Prescribers must be reeducated towards the evidence based use of clopidogrel

References
1. Caprie steering committee. A randomized blinded trial of Clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). The Lancet 1996;348:1329-1339
2. Antiplatelet trialist collaboration: Collaborative overview of randomized trials of antiplatelet therapy I. Prevention of death, myocardial infarction an stroke by prolonged antiplatelet therapy in various categories of patients. British Medical Journal 1994:308:81-106
3. Diener HC et al European Stroke prevention study 2. Dipyridamole and acetycylic acid in the prevention of stroke. J Neurol sci 1996;143:1-13

.........................................

back to top

A clinical accuracy checking test for pharmacists
Alison G Eggleton Box 104, Inpatient Pharmacy,
Addenbrooke's NHS Trust, Cambridge CB2 2QQ

Aims and Objectives

• To develop a structured assessment of clinical competence of pharmacists carrying out pharmaceutical assessment of prescriptions in a large teaching hospital.
• To define the appropriate level of competence as the minimum accepted standard.

Method
A panel of four clinical pharmacists reviewed 10 prescriptions and identified major medical and pharmaceutical care issues and a priority intervention for each. Where agreement could not be reached, two priority interventions were selected. These evaluated prescriptions formed a structured clinical accuracy assessment validated by a trial on eleven pharmacists, who attempted the test over 90 minutes with access to defined reference texts and a calculator. Competence was defined as an overall score of 70% (in line with the RPSGB examination¹). Two assessment methods were tried:

Assessment Method 1
Correctly identify major medical problems, minimum 50% pharmaceutical problems, the correct priority intervention(s) and action required and not harm the patient.

Assessment Method 2
Correctly identify the priority intervention(s) and action required and not harm the patient.

Results
Eleven candidates, mean registration experience 11 years, completed the clinical accuracy checking test. Using assessment method 1, the scores achieved ranged from 0% to 80%, mean 55% and three candidates (27.8%) were deemed competent. Using assessment method 2 (Table 2), the scores ranged from 50% to 90%, mean 68% and five candidates (46%) were deemed competent. Five candidates failed to complete the test in the time allowed and one failed completely to understand the test.

Discussion
Setting a standard for clinical accuracy checking should ensure a minimum competence that can be audited. This clinical accuracy checking assessment, similar to an OSCE^2,3,4,5, provided an objective measure of this clinical skill. Using the first assessment method, eight of the eleven candidates (73%) failed to reach the defined level of competence. In a busy dispensary, however, the essential skill is to identify clinically significant interventions whilst not harming the patient. The second assessment method, which may therefore more accurately reflect the required minimum standard, enabled 46% of candidates to achieve competence set at 70% and 91% of candidates to achieve competence set at 60%. This may be the practical target to aim for. The test could also include a portfolio of actual checking work in the dispensary and an oral examination for borderline candidates. Performance feedback to candidates clarified individual learning points and broader training needs were immediately highlighted enabling resources to be directed effectively, an important consideration in the current financial climate⁶. Pharmacists found participation in the review panel improved their own clinical knowledge.

Conclusion
Clinical accuracy checking in the dispensary forms an integral part of the pharmaceutical care process, since it targets identification of potential and actual drug related problems to produce an optimum outcome for the patient. This programme improved the quality of pharmaceutical care by:

• Defining a minimum standard for clinical accuracy checking pharmacists
• Providing a means of audit to ensure the standard is maintained
• Highlighting a wide range of pharmaceutical care issues
• Providing individual feedback to facilitate reflective practice
• Identifying pharmacist's individual training needs and targeting limited resources

Bibliography
1. Royal pharmaceutical Society. Preregistration training manual 1999. London: The Society 1999.
2. McRobbie D, Davies G, Pharm J (1996), 256, 908-910. 'Assessing clinical competence - a new method of evaluating hospital preregistration trainees'.
3. McPherson G, Davies G, McRobbie D, Pharm J (1999), 263, 168-170. 'Preregistration trainee clinical competence: a baseline assessment'.
4. Roberts J, Norman G. Med Educ (1990), 24, 219 - 223. Reliability and learning from the objective structured clinical examination'.
5. Harden R, Stevenson M, Wilson Downie W, Wilson G. BMJ (1975), I, 447 - 451. 'Assessment of Clinical Competence using Objective Structured Examination'.
6. Cairns C. Hospital Pharmacist (2000), 7 (1), 24 - 26. 'Study leave and the pharmacist'.

Acknowledgements
I would like to acknowledge the contribution of all pharmacists who took the test or participated in the review panel.

.........................................

back to top

IV Drug use in Cardiac Intensive Care
Chris Cairns* M.Sc. FRPharmS, Director of Pharmacy Academic Practice Unit St. George's Hospital & Kwadwo Amankwa **, PharmD, Albany College of Pharmacy, New York, USA.
* Now Director of Pharmacy & Dietetics at University Hospital Lewisham, London
** Now Pharmacy Resident at Cooperstown Hospital, Cooperstown, New York.

Introduction
Centralised intravenous additive services (CIVAS) are far from universal. [1] In critical care the IV route is routinely used for drug administration for a number of reasons. which means significant nurse time is used in preparing IV doses in CIVAS is not provided. Errors in preparation leading to patient harm may also occur. Published work on the likely size and nature of the work that a CIVAS would be required to carry out for a busy critical care area is limited to work that is now 10 years old. Our study was therefore carried out to identify the volume and nature of drugs given by IV infusion on a Cardiothoracic Intensive Therapy Unit (CITU), to inform the process of introducing CIVAS.

Method
The study was carried out in a 9 bed teaching hospital CITU with a comprehensive clinical pharmacy service and preparative service for TPN and cytotoxics only. Data were collected on drug, dose, amount and nature of diluent, administration method and device from the CITU flow chart, prescription and administration record, and daily medication orders chart over a 14 day period. Records were cross checked to ensure no doses were missed or 'double counted'. Data were collected daily by the same individual (KA). Epi Info was used for analysis. Bolus or intermittent antibiotics doses were specifically excluded.

Results and Discussion
During the study 22 different drugs were given by infusion, a total of 386 doses. Potassium Chloride was most frequently administered, 89 doses, (23%) followed by Propofol, 48 (12%), Morphine Sulphate, 42 (11%) and Insulin, 41 (11%). Frusemide, (24), Heparin (30) Cyclosporin (25) and Noradrenaline were also commonly prepared and administered. Sodium Chloride 0.9% (50ml) was the commonest diluent, (29%), Glucose 5% (50ml) was used for 19% of doses and 12% of infusions were given neat. There was considerable consistency in the doses employed with the exception of Frusemide and Heparin. Administration was by a 50ml syringe pump for 71% of doses. A quarter (23%) were administered by burette, the great majority of which were Potassium Chloride and 6% in a large volume IV solution. Continuous infusion accounted for 78% of doses.

83% of IV doses given on CITU were accounted for by 8 agents, and one, Propofol, is presently available in a prefilled syringe presentation, means that that provision of a substantial proportion of doses with CIVAS is feasible, subject to appropriate resource allocation. The consistency of doses employed for most drugs aids this process. Rationalisation of Frusemide and Heparin doses would further assist this process.

The work load of 800 admixtures a month is considerable for nursing staff on the CITU. Transfer to pharmacy would release a significant number of nursing hours. Australian work [3], found on average 13 minutes of nursing time were used to prepare an IV dose. Australian and UK practice are very similar, so it is likely that timing would be similar. Recent UK work using their method [3] in paediatrics [4] confirmed this. Thus up to 170 hours of nursing time per month could be released for other activities. Benefit could also accrue from potential reduction in errors, etc., adding to the overall value of an admixture service.

Conclusion
This study has demonstrated that providing CIVAS for CITU is a feasible proposition as the range of drugs required is limited and consistent.

References
1. Needle R. A survey of hospital centralised additive services. Pharm J. 1995; 255: 326-7. 2. Cannon P, Bertch K, Cousins D. The introduction of a satellite pharmacy service for the intensive care and coronary care units at a district general hospital. Pharm J. 1990; 244: HS36-9.
3. Plumridge R, Maher M. Justification of a pharmacy admixture service in an Australian hospital. Am J Hosp Pharm. 1993; 50: 463-6
4. Armour D, Cairns C, Costello I, Riley S, Davies E. The economics of a pharmacy-based central intravenous additive service for paediatric patients. Pharmacoceconomics. 1996; 10: 386-94.

.........................................

back to top

An investigation into the use of unlicensed drugs in paediatric patients of a District General Hospital and the impact in primary care.
Nevett S, Binyon D, Millership JS.
Pharmacy Department, Eastbourne District General, Eastbourne, East Sussex, BN21 2UD

Introduction
The use of drugs outside their product license requires that the prescriber takes full responsibility for the effects and adverse effects of the drug and that no blame is attached to the manufacturer of the product. Paediatric patients are often thought to be the largest cohort of patients where unlicensed medications are used. Studies have looked at this issue within specialist centres ^(1,2) and neonatal intensive care units. Consequently it has been highlighted in the literature that well constructed randomised clinical trials are needed to establish the safety of drugs in paediatrics. The 1997 E.U. guidelines have been produced in response to these concerns, they aim to encourage the pharmaceutical companies to obtain product licenses for use in this patient group.

Objective
The present study was undertaken to assess the extent of unlicensed prescribing in the paediatric patients of Eastbourne District General Hospital (EDGH) and the impact this was likely to have on the local General Practitioner (GP) population.

Methods
Data were collected on the prescribing of all medicines on our paediatric ward over an 8 week period from January to March 1999. Patients were admitted for both medical management and surgical management. Changes to medication were noted on admission and discharge and compared to the pre-admission prescription. The medicines were split into licensed and unlicensed groups and on discharge an assessment was made as to whether the prescribed drugs would be taken long-term. At the same time a postal questionnaire was issued to all GP's in the locality. The questionnaire investigated the perceived extent of unlicensed prescribing in primary care, the attitudes of the GP's to prescribing unlicensed drugs and how they felt the situation could be improved. The questionnaire was sent to 93 GP's with a follow-up to non-responders after 3 weeks. All questionnaires were anonymous.

Results
One hundred and twenty seven patients were followed up through their admission and on to discharge. Most children were in the 1 - 3 years age range. Only 17% of patients were receiving drugs on admission. The percentage of medicines prescribed that were unlicensed was 23%. During admission the 127 patients received 418 medicines where 17% of drugs were unlicensed. On discharge 276 drugs were prescribed for the 127 patients and again 17% of drugs were unlicensed. Looking at the number of long-term unlicensed drugs prescribed there were 19 on admission and 23 on discharge.

Forty six replies were received from the 93 GP's contacted after the follow-up questionnaire. The GP's highlighted that they felt patients under 1 year of age were most likely to be at risk from unlicensed drugs being prescribed. Thirty five percent of GP's knew that they had paediatric patients who were receiving regular unlicensed medicines within their practices and 43% percent were unsure. The GP's were asked if there were any circumstances in which they felt starting treatment with an unlicensed drug was acceptable. All but one GP felt that the child's carer should be informed that an unlicensed drug has been prescribed. Sixty five percent of GP's felt they should tell the carer and 22% felt this was a role for the community pharmacist. There was no consensus as to which drug groups should have priority for conducting clinical trials to gain a product license with 67% of respondents having no preference.

Fig 1 Circumstances under which unlicensed treatment may be started.

Discussion
It is seen from the results of the in-patient study that there were relatively few new long-term prescriptions written by the prescribers at EDGH. In an 8 week period there were 4 cases where an unlicensed drug was prescribed for continued treatment in the study patients. This represents 26 new long-term unlicensed drugs written by the paediatric department each year.

The GP questionnaire showed that over a third of respondents knew of paediatric patients receiving long-term unlicensed drugs. Encouragingly the chart shows that GP's felt that prescribing unlicensed drugs was a potential problem and that even when no licensed product exists over half still felt that this was not a sufficient enough case to prescribe unlicensed medicines. The circumstances in which it was acceptable to start treatment with an unlicensed product was on the advice of a specialist centre and when the child was almost at the age of the drug being licensed. Almost all GP's felt that the carer should be warned that the child was receiving an unlicensed product and almost a quarter felt that the community pharmacist was in an ideal situation to provide this information.

Even though this study showed that the number of new long-term unlicensed medicines prescribed by the paediatric department at EDGH is low, there is still a concern amongst GP's that unlicensed prescribing in children is still a problem. They feel that patients' carers should be informed of the unlicensed nature of their child's prescription and that community pharmacists may be in a suitable position to do this.

References
1. Turner S. et al. "Unlicensed and off label drugs in paediatric wards: a prospective study". BMJ 1998: 316; 343 - 345
2. Conroy S. " Developments in relation to unlicensed and off label drug use". Paediatric and Perinatal Drug Therapy 1998; 23 - 26

.........................................

back to top

To identify the use of topical mupirocin 2% (Bactrobanâ  ) in treating superficial skin infection in 100 patients at St John's Dermatology Centre
Paritosh Solanki, Preregistration Pharmacist and Samuel Bundu-Kamara, Principal Pharmacist
Guys & St. Thomas' Hospital NHS Trust, Pharmacy Department, London, SE1 7EH

Introduction
Mupirocin exerts a bactericidal action against most strains of Staphylococcal aureus, Streptococcus pyogenes, Staphylococcus epidermidis and Staphylococcus saprophyticus,¹ and Gram-negative organisms such as Escherichia coli and Haemophilus influenzae. Bactrobanâ    (topical mupirocin 2% ointment) is indicated for skin infections, such as impetigo, folliculitis, furunculosis.

Since 1990, reports state that overall mupirocin resistance world-wide have increased.² Recent data suggest that high- and low-level mupirocin resistance is widespread in the UK and mainly associated with the various strains of MRSA epidemic in hospitals.³ The high usage is of great concern as it can certainly lead to the emergence of mupirocin resistance in multiresistant Staphylococcus aureus. Locally mupirocin 2% is used in many areas; one of the largest usage areas is in dermatology where it is applied routinely after biopsies.

Aims
1) To determine the high usage of topical mupirocin 2% used to treat superficial skin infections in the outpatient clinic at St John's Institute of Dermatology Centre.

2) To recommend alternative therapy to topical mupirocin 2%

Method
A report of topical mupirocin 2% issues over a 12 month period was obtained from the pharmacy JAC system. Records of 100 randomly selected patients were collected and analysed.

Results
Of the 100 patients selected, the distribution of mupirocin 2% usage is shown in the table below. Recommendations of alternative therapy were concluded after using Medline, Micromedex and Pharmline.

No of pts	% of pts	Diagnosis
81	81	Biopsy & Excision mole, wart, intradermal naevus, cyst, carcinoma, etc
10	10	Boils / Cyst / Folliculitis
4	4	CO2 laser treatment for acne scarring and excision of keloid
3	3	Atopic Eczema
2	2	Impetigo

Discussion
Dermatology surgical procedures are regarded as clean operations thus eliminating the need for using topical antibiotics post surgery.⁴ 85% of the patients received topical mupirocin 2% for the prevention of post surgical infection. Emergence of mupirocin resistance and the potential loss of one of the major weapon in MRSA control emphasise the importance of using this drug judiciously. Literature search showed that if a topical antibiotic is required for the treatment of superficial skin infections, then fusidic acid/ sodium fucidate is equally effective as mupirocin⁵. Resistance of Staphylococcus aureus to fusidic acid has been relatively constant over the years of not exceeding 1%- 2%⁶. For widespread skin infection systemic flucloxacillin or erythromycin is recommended, whilst fusidic acid should be reserved for localised skin lesions.

Conclusion
This study has highlighted the fact that the use of topical antibiotics post dermatology surgery requires re-evaluation since there is no definite indication for its use in such situations. In the light of the emergence of mupirocin resistance, it may be prudent to limit the use of mupirocin to decolonizing patients with documented Methicillin-resistant Staphylococcus aureus (MRSA) infections, as these strains are frequently resistant to multiple antibiotics, antiseptics and disinfectants. I recommend that there be close liaison between the dermatology unit and the microbiology department inorder to review periodically the appropriate drug usage in order to prevent resistance. Also, reaudit the usage of topical mupirocin 2% in the future.

References
1. Sutherland R, Boon R. J, Griffin K. E et al: Antibacterial activity of mupirocin (pseudomonic acid): a new antibiotic for topical use. Antimicob Agents Chemother 1985; 27: 495-498 2. Franz-Josef Schmitz, Elke Lindenlauf, Basia Hofmann, Ad C. Fluit, Jan Verhoef, Hans-Peter Heinz and Mark E. Jones: The prevalence of low- and high-level mupirocin resistance in staphylococci from 19 European hospitals. Journal of Antimicrobial Chemotherapy 1998; 42, 489-495 3. Marples R. R., Speller D.C. & Cookson B.D. Prevalence of mupirocin resistance in Staphylococcus aureus. Journal of Hospital Infection 1995. 29, 153-5 4. Gyssens I. C. Preventing postoperative infections. Current treatment recommendations. Drugs 1999 Feb; 57(2): 175-185 5. Sutton J.B. Efficacy and acceptability of fusidic acid cream and mupirocin ointment in facial impetigo. Curr Ther Res 1992; 51: 673-678 6. Simon C., Stille W. (Hrsg) Antibiotika-Therapie in Klinik and Praxis. 9. Aufl. New York. Stuttgart: Schattauer, 1997

.........................................

back to top

Investigation of patient satisfaction with pharmacist consultation in a pharmacist-led anticoagulation clinic.
Elma J Still, B. Pharm., PG Dip, MRPSGB,
Gail McPherson, M. S., Marie O'Brien, B.S., Robert Horne., M.S., Ph.D., MRPSGB; University of Brighton, Elm Grove, Brighton, United Kingdom; Worthing and Southlands National Health Service Trust Hospitals.

Purpose
An important aspect of the delivery of pharmaceutical care is to meet the patients' requirements for information about medicines. This study set out to evaluate patient satisfaction with both the information received and the consultation process adopted by the pharmacist.

Method
Patients attending a pharmacist-led anticoagulation clinic were interviewed over a 5-week period. The consultation was assessed on the Indian Heath Service communication model¹and the IDEAL health communication model². Patient satisfaction with information received during the consultation was evaluated using the Satisfaction with Information about Medication Scale³. Data were analyzed using Statistical Packages for Social Sciences.

Results
Forty patients were enrolled into the study. Levels of satisfaction with information received on medication ranged from 52-98%. Patient were less satisfied with information on length of treatment and the meaning of the international normalized ratio. During the consultation, patients varied in the method in which they liked information to be provided. Thirty-nine percent of patients preferred to receive information by asking questions. 32% found it hard to ask questions, and 85% of patients wanted to receive written information.

Conclusion
Patient consultation needs to be individualised to ensure information is provided in an appropriate and systematic manner. This study has provided information about a training program for pharmacists working in pharmacist-led clinics and will be developed for assessing competence of the pharmacists consultation in the future.

References
1. Svarstad BL. Patient-practitioner relationships and compliance with prescribed medical regimen. In Aiken LH, Mechanic D, eds. Applications of social science to clinical medicine and health policy. New Brunswick, NJ:Rutgers University Press; 1986: 438-59 2. Fallowfield L. The ideal consultation. British Journal of Hospital Medicine 1992; 47: 364-367.
3. Horne R. Satisfaction with Information about Medication Scale (SIMS). Psychometric properties and validity testing. Manuscript admitted for publication.

.........................................

back to top

Patient's Own Drugs Scheme - is it financially viable?
Debbie Campbell MSc MRPharmS * & Clare Conroy PhD MRPharmS **
* Medical Directorate Pharmacist,** R & D Pharmacist, Department of Pharmacy, Bristol Royal Infirmary, BS2 8HW

Background
Evidence describes the success of patient's own drugs (PODs) schemes throughout many United Kingdom hospitals. The main outcome measure associated with PODs, has focused on the economic impact, particularly that of the cost saving to the hospital, at discharge^1,2. Expenditure on discharge medication within the medical directorate at the Bristol Royal Infirmary (BRI) has been calculated at £100,000 per annum (1998-1999). The aim of this study was to assess the financial impact of implementing a PODs scheme on the drug expenditure in both primary and secondary care.

Method
From April 1999, consecutive recruitment commenced of patients admitted onto four wards within the medical directorate. Accurate documentation of medication type and quantity, together with suitability of items for re-use were documented by the ward pharmacist. The PODs remained on the ward until the discharge decision was made. PODs were brought to pharmacy together with the discharge prescription, and medication re-issued to the patient if considered appropriate. Cost savings to the trust were identified as those PODs re-issued against prescribed items on the discharge prescription. Cost-avoidance to Avon Health Authority were calculated on the basis that PODs were not destroyed, and that the patient had sufficient medication remaining beyond one week from hospital discharge.

Results
The data from 200 fully evaluated patients is presented.

Of the 1006 drugs taken from patients on hospital admission, 778 (77%) were considered suitable for re-use. On receipt of the discharge prescription, 438 (56%) of the 778 PODs were re-issued, 311 (40%) of the 778 PODs were unsuitable for re-use because the medication had been discontinued. The total cost saving to the United Bristol Healthcare Trust (UBHT) was on average £4.58 per patient. Since there are approximately 10,000 discharges each year, implementation of the PODs scheme would save the trust, £45,800 per annum. With regard to savings to the local Health Authority, £15.21 of PODs per patient were re-issued, representing an annual £152,100 reduction in drug wastage.

Discussion
It is evident that PODs schemes save money. This study endorses and adds to previous work illustrating the financial benefit to the hospital. It is now evident from this work that the saving to primary care is some three times more than that to the hospital. Importantly from a risk management issue, by ensuring that the drugs that are no longer prescribed are discarded should lead to improved compliance, less confusion and reduce readmission rates to hospital for compliance related problems. Based on these results the medical directorate has invested in this scheme and the Health Authority should follow this lead.

References
1. PharmJ. 1993; 251: 356-357
2. PharmJ. 1993; HS53-HS56.

.........................................

back to top

Communicating patient drug therapy between secondary care and general practitioners
Sharon Pritchard, Pharmacy, Wordsley Hospital, Wordsley, Stourbridge DY8 5QX

Introduction
Poor communication between hospital and GP practices has been demonstrated for many years. It is important there is good communication between secondary and primary care to ensure seamless care. The objective of this audit was to identify how often GP's received drug therapy details following discharge and outpatient attendance. The audit also looked at the quality of the information received.

Method
The TTO's in our trust consist of three copies, one which is kept in pharmacy, one for the patient notes and one that is hand delivered to the GP via the patient. A retrospective study of one hundred TTO's from two GP practices were audited to determine the percentage of TTO's delivered and the time taken for them to be received by the GP practices. A tick box questionnaire was also designed to establish GP's views on the communication between the trust and practices regarding the information received following outpatient attendance or hospital discharge.

Results
46 patient's TTO's from Stepping Stones surgery and 54 from Wordsley Green surgery were investigated. Of the 27 questionnaires sent to local practices 15 were returned. 92% of TTO's were received via the patient at Stepping Stones and 67% were received at Wordsley Green. 94% of GP's supported these findings by replying in the questionnaire that they always or often received the TTO copy. The number of days taken for TTO's to arrive at Wordsley Green and Stepping Stones surgeries are aggregated in the graph below:

From the questionnaire 85% of doctors replied that it took at least 15 days to receive the consultant letters detailing outpatient treatment and 67% of GP's requested information about outpatient medication prescribed in clinic, before they received the outpatient letter from the hospital.

Conclusions
Hand delivery of TTO's via the patient is an acceptable method of delivery to the surgeries. Other trusts use faxing and posting but these methods have important time and cost implications. There was a noticeable difference in the number of TTO's received by the two surgeries, this could be due to social class of the area or the reason for admission into hospital. GP's commented on the poor handwriting and lack of clinical information on the TTO. As it takes the majority of outpatient letters at least 15 days to arrive at the surgery and the pharmacy are contracted to dispense 14 days supply, patients are often visiting their GP's for continuation of supply before the GP has received the outpatient letter. In the questionnaire it was noted that surgeries always or often required information about patient medication before the communication from the hospital arrives.

Ways in which pharmacy could improve communication regarding drug therapy were investigated. One option was to produced double labels when dispensing outpatient prescriptions, these second labels could be attached to a simple proforma, which could then be hand delivered by the patient to the surgery. This method is in the process of been audited in the trust. If this proves to be an effective and successful way of improving the communication concerning drug treatment to GP's, we could implement a similar system for TTO's as a way of addressing the problem of poor doctor handwriting.

.........................................

back to top

Can prescription redemption rates be used in practice as an indicator of adherence and a predictor of future treatment failure in people with HIV?
H Leake^*, K Chinchen^*, M Fisher¹, R Horne^**.
*Brighton Health Care NHS Trust, ** University of Brighton.

Background
The mortality and morbidity rates for people with Human Immunodeficiency Virus (HIV) infection have declined dramatically in developed nations since the widespread introduction in 1996 of highly active antiretroviral therapy (HAART). However, low adherence to HAART is a significant predictor of negative treatment outcomes, with >95% adherence reported to be necessary to achieve a sustained reduction in HIV RNA viral load (VL).¹ HIV specialist pharmacists play a key role within the multidisciplinary team in facilitating adherence to HAART, to maximise the clinical and economic benefits of these therapies. Unfortunately, there is no simple, validated, non-invasive measure which can easily be used to detect poor adherence at an early stage prior to treatment failure. This study investigated the potential utility of prescription redemption rate (PRR) as an indirect predictor of adherence and outcome.

Methods
Antiretroviral (ARV) prescriptions were retrieved for 200 patients from January to December 1998 and the PRR calculated for each of their ARV combinations. Statistical analysis was carried out to determine if there was a correlation between PRR and virologic outcome (controlling for ARV history).

Results
Data are presented on 50 subjects (90% male), receiving 66 ARV combinations during the study period, with a median PRR of 96% (range 56-100%). At the start of the study, 18% were on dual, 74% were on triple, and 8% were on quadruple therapy. At study close the figures were 12%, 63% and 18% respectively, with 6% on 5 or more ARVs. 41% maintained viral suppression <200 copies/ml (BLQ) throughout the combination; 28% never achieved viral load (VL) <200 and 30% had at least one VL BLQ. 70% of patients remained on one ARV regimen for the study duration.

There was a highly significant association between a PRR ³   94% and achieving and sustaining VL BLQ and between a PRR £   85% and VL never reaching BLQ (t=1.9, df=28, p=0.03, 1-tailed).

Using multiple regression analysis, the most significant predictors of virologic response were duration on current combination prior to study (b =0.39, p=0.013) and number of ARVs in the regimen (b   =-0.32, p=0.04). The variables of baseline VL, time on current combination, number of prior ARV regimens and number of ARVs in the combination were found to account for 35% of the variation in VL outcome scores (p<0.005).

A similar analysis of immunologic response was performed, with baseline CD₄ entered instead of baseline viral load. In this analysis, the only significant predictor of CD₄ response was found to be baseline CD₄, (b   = 0.56). When potentially confounding variables were controlled for, PRR was not found to provide any additional explanation for the VL or CD₄ response to treatment.

Conclusions
The most significant predictors of a successful virologic response were: PRR (when other variables were not controlled for) and baseline VL, duration on an ARV combination and number of ARVs in the regimen (controlling for potentially confounding variables). This indicates that, although PRR alone is not predictive of outcome, it may be useful as a tool to identify those patients most at risk of failing HAART. Although there are logistical and resource implications, it could be calculated by the pharmacy team without them needing to know other patient-related data (e.g. VL and CD₄). These data support the assertion that low adherence can be broadly categorised as 'primary' (failure to collect drugs at the expected times, manifested by a low PRR) and 'secondary' (appropriate script collection [high PRR] but low adherence to the actual ARV regimen). This may facilitate the practical use of PRR to highlight potential adherence problems, which may enable appropriately targeted interventions to reduce the likelihood of treatment failure in patients with primary low adherence. Further work is ongoing to validate the use of PRR and to establish its role as part of a comprehensive and holistic strategy to optimise adherence.

Reference
Paterson D, Swindells S, Mohr J, et al. How much adherence is enough? A preparative study of adherence to protease inhibitor therapy using MEMSCaps. 6th Conference on Retroviruses and Opportunistic Infections, Chicago, USA, 1999. Abstract 92.

.........................................

back to top

Development of a gas sterilisable pump for aseptic filling
Christina Lowe, Quality Assurance and Control, and Richard Wastnage, Pharmacy Technical Services. Pharmacy, Singleton Hospital, Swansea NHS Trust, Swansea, Wales

Background
Automation of aseptic filling is desirable to increase productivity and reduce contamination risks. Potential benefits include reductions in operator fatigue and volume error rates and an increased filling rate.

There are practical obstacles to using pumps within an isolator particularly where gas sterilisation is employed. Corrosion is a problem and although gas sterilisable units for TPN compounding are available the available pumps for batch filling multiple units at set volumes are less satisfactory.

The Baxa Repeater pump delivers the required functionality and is available as a standard single unit or a special two unit version. The latter was designed to be compatible with gas sterilisation processes, it comprises a stainless steel clad pump unit and a separate electronic control unit. The design of the pump unit was found to be sub-optimal in practice being difficult to handle particularly during sterilisation. For use at Singleton with peracetic acid sterilisation, until a more suitable alternative could be sourced, a standard version was silicone sealed under the casing to confer some degree of gas protection.

Project
The ideal pump was defined; essentially comprising three sections:

• a pump head to be located within the isolator and required to be gas resistant
• the mechanics to be located externally
• a control unit to be mounted at the front of the isolator for ease of operator access.

In the current application the pump can be docked onto any one of four production isolators. This mobility allows increased and more efficient pump and isolator use while reducing the risks of cross contamination between batches of differing nature through improved product segregation.

back to top