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Monday 11 December 2017
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Experiences and insights

Meeting report
The provision of information to patients about unlicensed medicines (ULMs) was inconsistent according to the EMULSION (Exploring Multidisciplinary use of Unlicensed Medicines across Primary and Secondary Care) study, although patients were keen to have information. Gemma Donovan and Lindsay Parkin (Department of Pharmacy, Health and Wellbeing, University of Sunderland) described how the study was designed to explore the views of prescribers, dispensers and users of ULMs. Unlicensed medicines, ‘specials’, investigational products and off-label usage of licensed medicines were all included in the scope of the investigation. 
 
Health care professionals’ awareness of ULMs varied widely – junior staff in all professions were unable to define ULMs or describe the implications of using ULMs, but senior staff and specialists were better informed. ULMs were perceived to be as safe as licensed products. Little information was given to the patient about ULMs, partly because there is little written material and partly because health care professionals believed patients did not want information. Some also said that the term ‘unlicensed medicine’ might be alarming and imply “that patients are being used as guinea pigs”. Some pharmacists were also reluctant to provide more information because they did not know what patients had already been told.
 
The research team concluded that there was a lack of information resources for ULMs. Moreover, there appeared to be no formal education about ULMs for either pharmacists or doctors and knowledge was usually “picked up on the job”. Ms Donovan added that additional information about the ongoing progress of this project is now available on the EMULSION website at http://wp.sunderland.ac.uk/emulsionstudy. The EMULSION study was supported by a research grant from UKCPA and Practice Research UK in 2014. 
 
EPMA and magnesium safety
An incident in which a patient with hypomagnesaemia received an overdose of intravenous magnesium1 had prompted the introduction of standardised magnesium injections throughout the organisation, according to a poster presented by Gillian Cavell and Caroline Anderson. An oral dose of 12mmol magnesium was prescribed but, as the patient had diarrhoea, the route of administration was changed to intravenous, although the dose remained the same. The patient received an infusion, became unwell and was found to be hypermagnesaemic. He later made an uneventful recovery. Both 10% and 50% magnesium sulphate injections were available on the ward and it appeared that an error had been made in calculating the amount required to provide 12mmol.
 
After a careful review of the products in use and the treatment guidelines, alternative methods of preparation and administration with lower risk scores were identified. In addition, new order sets were written for the electronic prescribing and medicines administration (EPMA) system. For example, when magnesium is entered in the EPMA system, the prescriber is prompted to choose from a list of indications and is then the guided to the most appropriate treatment option. Furthermore, the order set tells the nurse exactly how to make the dose, for example, for a magnesium infusion of 20mmol in 100ml sodium chloride, it says, “Add 10ml magnesium chloride 50% to 100ml of normal saline”. Magnesium sulphate 50% ampoules have now been removed from ward stock but are supplied when needed, explained Ms Cavell.
 
Magnesium injections are frequently required in critical care areas and in the bone marrow transplant unit – “amphotericin commonly causes hypomagnesaemia and hypokalaemia”, she added. “What we really need is a licensed product containing 20mmol magnesium in 100ml saline; a licensed product containing 20mmol magnesium in 50ml saline for obstetrics would also be very useful”, concluded Ms Cavell. 
 
Carter insights
“Lord Carter will do more for pharmacy than anyone else in the past 20 years”, declared Ann Jacklin (formerly Professional Lead for Pharmacy at the Department of Health‘s NHS productivity and efficiency programme). Describing her insights into the recent review of productivity in the National Health Service (NHS) (www.gov.uk/government/publications/productivity-in-nhs-hospitals) she added that “there is currently much duplication of effort, pharmacists are too busy and are spread too thinly” and the review represents “a charter for pharmacy”. 
 
At present there are wide variations in performance and costs across the health service and this is chaotic – only “appropriate variation” should be expected. Lord Carter’s review has described the elements of a good pharmacy service and identified areas of unmet need in the NHS. Improving the quality of prescribing and medicines’ usage is an example of unmet needs where pharmacists could ensure that there is adequate follow up and review, she said. This is an escalating problem because patients are now prescribed greater numbers of medicines than in the past, she added. However, taking on this function would involve giving up other tasks. Another important step would be to adopt the use of biosimilar infliximab and etanercept as soon as possible to liberate funds for other things. If all hospitals had switched eligible patients to the biosimilar products immediately then the NHS could have saved £2.2 million per month on these products alone, she said.
 
The value of pharmacy services has recently been recognised and understood by some in the Department of Health. Professor Jacklin described her surprise and delight when a “man in a suit” (non-pharmacist) explained to others that patient flow in Accident and Emergency departments could be solved by employing pharmacists to work routinely in those areas.
 
Lessons learned
Reflecting on his experiences as a Chief Operating Officer in a hospital, Richard Catell (Clinical Director of Pharmacy and Associate Director of Medicines Optimisation, Worcestershire Acute Hospitals NHS Trust, previously Chief Operating Officer, Walsall Healthcare Trust, UK) said that one of the things he had learned was that if there is not a way of measuring the impact of a change then it is not possible to manage it effectively. This had become clear to him when he decided to ensure that ‘board rounds’ (reviewing the list of patients on the ward and agreeing the next step in care with the ward team) took place on each ward in order to reduce the length of stay for all patients. Although the concept is generally well-supported, board rounds often work poorly in practice, he commented. 
 
At a meeting, senior managers agreed to implement board rounds within one month and to report to him on progress. Clinical commissioning groups (CCGs) and other outside bodies were told about the plan. After one month senior managers reported that board rounds had been implemented but the information department reported that the average length of stay had increased. Feedback from the pharmacy also suggested that board rounds were not happening in all departments. The next morning Mr Cattell set out at 8.30 a.m. to see how the board rounds were working in practice. It rapidly became apparent that board rounds were only taking place in 17% of departments. Using another method – the length of stay information – to check on progress and letting people know that he was doing this was an important step in dealing with the problem, he said. 
 
In brief
Posters covered a wide range of topics. Some of thehighlights were:
  • A multidisciplinary team from Kings College Hospital revised the EPMA order set for hyperkalaemia treatment to ensure that glucose was always administered together with insulin when treating hyperkalaemia. As a result the incidence of unintended, treatment-induced hypoglycaemia fell from 30% to 7%.
  • An automated electronic locker system (PILBOX) at SingHealth Polyclinics in Singapore allows patients to collect regular medication without standing in long queues and contributing to congestion in the pharmacy. After the patient or caregiver has made the required payment and verified his or her identity, the designated locker opens to allow collection of the dispensed medicines. Patients save about 25 minutes by not having to queue for their medicines. 
  • Community pharmacists need more time and more training to improve the effectiveness of their contribution to delivery of the five-year antimicrobial resistance strategy, researchers in West Yorkshire found. Including the indication for the antibiotic on the prescription form is one measure that could help pharmacists to have a more meaningful dialogue with patients about prescribed antibiotics.
  • Antibiotic usage for dairy mastitis – the largest dairy health problem in the UK – is often poorly understood and sub-optimally delivered, researchers from Cardiff University found. Veterinary pharmacists should work pro-actively with veterinarians and farmers and focus on appropriate antibiotic targeting, advice and treatment to help tackle antimicrobial resistance. 
  • About 80% of insulin-dependent diabetic patients had not been offered an Insulin Passport (IP), according to a study at Royal Stoke University Hospital. The IP was recommended in 2011 by the National Patient Safety Agency to reduce the risks associated with insulin therapy. Future collaborative work with CCGs could empower patients to become more engaged with their insulin treatment and improve safety, suggest the investigators. 
  • Multidisciplinary Connecting Care Teams based at Mid-Yorkshire Hospitals NHS Trust, Wakefield had a major impact on medication adherence in adult patients who were believed to be at risk of admission or readmission to hospital. Between April 2015 and March 2016, 410 patients were referred to the CCT pharmacists; in addition to other services, medicines education and advice was provided on 370 occasions. The outcomes demonstrated sufficient benefit to secure continued funding for the CCT pharmacists. 
 
Reference
1 Cavell GF et al. Iatrogenic magnesium toxicity following intravenous infusion of magnesium sulfate: risks and strategies for prevention. BMJ Case Rep 2015; doi:10.1136/bcr-2015-209499.

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