Working with a background as a pharmacist in the NHS Emergency Care Improvement Programme (ECIP) has given me quite a unique perspective and I think pharmacy has a lot to offer in terms of patient flow. One of the principles of the SAFER care bundle which has been shown to improve patient flow is to carry out todays work today (or yesterday when it comes to TTOs / TTAs) and to do it as early as possible.
While pharmacy can’t address this alone (there is a need for a joined up system wide approach to improving flow) – there is a lot that pharmacy can do to move work to earlier in the day and improve flow. I have seen these principles used in some of the Trusts I have worked with and they have been shown to improve TTO processing times.
Principal 1) Frontload work to reduce the need for pharmacy involvement in TTO at the end of the process
• Reconcile medicines and dispense for discharge as soon as possible following admission.
• Use the summary care record.
• Match pharmacist & technicians working hours on acute medical units to work demand & patient flow into & out of the unit.
• Use advanced level clinical pharmacists on admissions units.
• Supply – Use Patients Own Drugs (PODs), one stop dispensing from admission & pre-packs.
• Provide weekend clinical pharmacy services to high admission areas to reduce delays to discharges.
Principle 2) Reduce TTO processing time (from decision to discharge to the patient leaving)
• Supply new TTO medicines as soon as discharge decision is made. Think minutes, not hours, on short stay and acute wards.
• Match pharmacy staff hours to discharge decision making – if a board round starts at 8am – ward pharmacy staff should too!
• Encourage the use of robust Estimated Discharge Dates (EDD) and work to them. If a patient doesn’t have one – ask for one!!
• Pharmacy staff must be easily contactable if there are changes to TTOs.
• Pharmacy staff must also communicate clearly with ward staff. Consider internal professional standards.
• Embed pharmacy technicians in ward teams to improve communication, counselling and supply.
• Use pharmacists to write TTOs – on one stop ward rounds. Drs often batch this to afternoons- this is a way around it.
• Embrace technology. Use integrated inpatient & discharge electronic prescribing (ePMA) – reduce errors & speed up process.
• Use near patient dispensing in high flow/high discharge areas (hubs, satellites, discharge trollies – pharmacy must be mobile!)
• Advise patients at pre-op clinic to have a supply of their own medicines prior to admission so no supply at discharge needed.
Principle 3) Stream the urgent work separately
• Do NOT batch TTOs (batching work is a great way of building in delays into a process).
• Consider a discharge bleep held by pharmacy staff that can respond quickly.
• Porters are great for non-urgent work – but if TTOs are going back to a ward with the porters then there’s a delay.
Principle 4) Just do it! (& measure it).
• Try things and see how they work. Often they don’t need extra resources (but need a leap of faith and some strong leadership)
• Use rapid cycle PDSA testing to assess. You should know within a couple of weeks if something is worth continuing with.
• Don’t just measure the pharmacy aspect – pharmacy is just the filling in the sandwich!
• Measure the whole process as the patient experiences it – from decision to discharge to the patient going home with medicines.
• Influence ALL aspects – not just the pharmacy part.