Changing the script


Can pharmacists transform prescribing through protocol change and prescriber education?

A US study has looked at the role pharmacists can play in impacting prescribing habits for patients discharged from hospital emergency departments (ED).

Researchers from the Duquesne University School of Pharmacy and the University of Pittsburgh Medical Center – Mercy Hospital, US, analysed prescribing for 741 patients discharged from an ED with a diagnosis of community-acquired pneumonia.

They compared a cohort from 2012-13 (55.5% of participants) with one from 2014-15 (44.5% of participants), following a pharmacist-led protocol change with prescriber education that occurred during January 2014.

Protocol change related to the choice of therapy for community-acquired pneumonia: while macrolide monotherapy was historically the primary therapy chosen for patients with CAP at the researchers’ institution, data on resistance rates suggested the need for enhanced coverage with a macrolide/β-lactam combination.

Changes were therefore implemented to better align ED treatment practices with clinical practice guidelines.

Prescriber education comprised of a presentation by the ED pharmacist, including discussion of increasing resistance rates and accompanying guidelines recommendations.

The study results, recently published in the International Journal of Pharmacy Practice, found that prescribing of macrolide monotherapy regimens decreased significantly following the protocol change and prescriber education (from 70.1% down to 42.7%, a drop of 27.4%).

There was also a reciprocal increase in macrolide/β-lactam combination prescribing (from 6.3% to 21.8%, an increase of 15.5%).

Data revealed that patients discharged from the ED who were prescribed a macrolide alone had no statistical difference in 30-day revisits compared to those prescribed either macrolide/β-lactam combination or fluoroquinolone monotherapy.

With an almost 30% absolute reduction in macrolide prescribing, this “demonstrated considerable success of the protocol and the utility of pharmacist presence in the ED environment,” say the researchers.

“Pharmacist-led interventions have demonstrated success in optimisation of community-acquired pneumonia treatment in other studies, including assuring appropriate duration of therapy at discharge, bundled interventions including medication reconciliation, recommendations and counselling, and use of motivational interviewing to increase adherence.”

Pharmacists are in a “unique position to impact prescribing habits for patients discharged from the ED as well as patients subsequently admitted to the hospital,” say the authors.

Additional prospective studies are needed to further address the optimal treatment of community-acquired pneumonia in the ED setting across various geographical regions, they say.

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1 Comment

  1. John Wilks
    16/01/2019

    This article highlights (again) the urgent need for pharmacists with suitable training to have access to certain prescribing capacities.

    Within my scope of practice as a clinical hospital pharmacist and as an accredited pharmacist (HMR/DMMR) I regularly encounter circumstances appropriate for a pharmacist to prescribe and/or make correcting changes to a prescription.

    1. Make appropriate adjustments to errors on scripts:

    My regular experience within the hospital milieu indicates that much of the hospital doctor’s time and work is needlessly interrupted by requested for correction to discharge scripts written by another doctor. Both yesterday and today I have had to phone the CMO, requesting that he visit the nurse’s desk to add a quantity to a discharge antibiotic script. This requires that the CMO either interrupt his interaction with a patient, or if he cannot, the patient has to wait until the CMO is free to make the necessary script change so that the patient can have the script dispensed at a community pharmacy (CP).

    Prudent haste is required on this vital clinical issue. The years of delay should be swiftly consiged

    If the CMO is busy eg cannulating, attending to a code blue, dressing a wound etc, the patient is delayed in leaving, the room is occupied needlessly and upstream there is bed-block.

    Other script related delays for patients include a script containing an S8 and a S4. This cannot be dispensed at a CP. Given that it is clear what the patient is to receive, it is a waste of the CMO’s time to call him/her to re-write the S4 and S8 on two separate scripts.

    2. Write scripts for patients awaiting discharge:

    Another cause of patient discharge delays is if the CMO has failed to write a discharge script though the progress notes written by the specialist clearly indicates what is to be prescribed, why and for how long. Again, if a prescribing pharmacist had prescribing rights, these problems could be efficaciously resolved with no disturbance to the CMOs activities, delays in patient discharge and bed-block problems.

    3. Write scripts for patients during the HMR process:

    I have been accredited for HMRs for 21 years and in that time there have been many hundreds of times where a patient has ceased taking a medication because it is too difficult for them to see a GP in a timely manner. This is particularly the case for patients who live 30-40 minutes from their GP. It is clearly in the patient’s best clinical interests if an approved pharmacist could prescribe within the context of therapy continuation eg ongoing statin use, a long term antibiotic for UTI prophylaxis, maintenance of HTN therapy, or inhalers for asthma, to list but a few circumstances I have encountered.

    Prudent haste is now required on this important clinical matter.

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