A ward manager in the Cancer and Associated Specialties Division at the Nottingham University Hospital NHS Trust led change by introducing a nurse supplied medication programme on the ward. A review of processes, led by the nursing leadership team identified unwarranted variation in the practice of drug collection upon discharge from services which led to concerns regarding patient outcomes, experience and also the cost implications of unused medications. The programme demonstrated better outcomes, better experience and better use of resources.
Where to look
Nursing staff conducting a process review observing that many antibiotic drugs were not effectively dispensed at a patient’s discharge using the existing patient pathway. The unwarranted variation in the collection procedure, including whether they were collected or not, had subsequent patient outcome implications both in terms of well-being but also extending their need for hospital care, following initial discharge.
What to change
The Cancer and Associated Specialties Division admitted approximately 40 to 50 emergency cases per week, with an average length of stay of 1.5 days. With this high level of patient turnover, a safe, timely, efficient and effective patient discharge process is paramount. The nurse ward manager identified the need for change. Under existing processes, the on call pharmacy would dispense medication from another site in the Trust, making the out of hours dispensing of medication less efficient and impacting on patient experience. The ward manager and other nursing staff noted that this led to:
- patients frequently returned home and then needed to return to the hospital to collect their medication
- a proportion of patients never returned for the medication
- some patients were readmitted
- some patients were kept overnight to ensure they were discharged with their medication
In order to improve performance for discharge drugs the team developed a timely out of hours pathway for the Trust.
How to change
The introduction of a nurse supplied medication programme was agreed and a joint venture between the ward manager and the head of pharmacy to create a local agreement, risk assessment and training packages, alongside ensuring an effective medication pathway was undertaken.
A training package was created to enable nurses to supply and check a specified list of medication for specific conditions and as per prescribing guidelines. The aim was to enable patients to receive the correct medication within an hour to facilitate discharge home and prevent unnecessary prolonged hospital stay and prevent readmission. In addition, a further benefit was improved patient flow and an increased bed capacity to facilitate admission of emergency patients.
- Better outcomes – The change has been implemented for more than one year, with waiting times reducing from on average 489 minutes to 23 minutes, from the decision to discharge the patient to actual discharge time. There was also a trend towards a reduction in those with emergency admissions that were discharged out of hours with their medication to prevent readmission. In the pilot, this was not measured, but when addressed in May 2018, only 4 patients did not go home with the correct medication which anecdotally was a significant improvement.
- Better experience – Because the patients were often inpatients for less than 24 hours, the nursing team were unable to collect family and friends feedback information. However, informal feedback from patients has been very positive and anecdotally suggests a trend towards streamlining a patient pathway all the way through to smooth discharge with the appropriate medication and resources necessary to continue to recover closer to home.
- Better use of resources – During a one month pre-programme pilot review (November 2016), a total of 29 uncollected medication items valued at £720.51 were noted. This was reassessed in May 2018 post programme implementation and this had reduced to a total of 10 uncollected medications (from only 5 patients), valued at £132.18, a clear indication of better use of resources following the change.
Challenges and lessons learnt for implementation
The ward manager learnt that cross speciality working was a key factor. Engagement with both the nurses on the ward as well as the pharmacy team to motivate them to make a change to improve care was key.
Seeking timely consensus agreement for the project was important. Agreement was needed on regulations, adequate training and assessment and the hospital’s medicine management committee were meeting only once a month with many things to discuss. A further challenge was training staff and adapting the training materials for the project to make sure they were fit for purpose and met the needs of the staff.
This work is being written up for publication to share the work nationally to support further quality improvement work.
As a marker for success, the nurse team on the ward are exploring disseminating this project to other areas within the Trust to address unwarranted variation in patient outcomes and experience specifically related to discharge medication.
Find out more
For more information contact:
Ward manager; Cancer & Associated Specialities Division
Nottingham University Hospitals NHS Trust