Barry Jubraj

A pilot survey of junior doctors’ attitudes and awareness around medication review: time to change our educational approach?

Objectives Our aim was to explore junior doctors’ attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. Method An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. Results Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacists duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. Conclusions Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a ‘bottom-up’ educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists.

Deprescribing medicines in the acute setting to reduce the risk of falls

Background Falls are a common cause of morbidity and hospitalisation in older people. Inappropriate prescribing and polypharmacy contribute to falls risk in elderly patients. This studys aim was to quantify the problem and find out if medication review in the hospital setting led to deprescribing of medicines associated with falls risk. Methods Admissions records for elderly patients were examined to identify those whose presenting complaint included a fall. Inpatient medication charts, pharmaceutical care notes, medical notes and discharge summaries were examined to identify any falls-risk medicines from admission histories and to determine if any medication review took place, and whether or not changes were made as a result. In particular deprescribing and dose reduction details were analysed. Results 100 patients over 70 years old were admitted following a fall during the 2 months study period. The mean number of medicines on admission was 6.8 per patient with polypharmacy found in 62/100 (62%). One or more falls-risk medicine was found in 65/100 (65%) patients. Medicines review was carried out in 86/100 (86%) of patients, and 59/697 (8.5%) medicines were deprescribed. Pharmacist involvement in medication review led to a significant reduction in the number of falls-risk medicines per patient (p=0.002). Conclusions Inappropriate prescribing and polypharmacy are found frequently in elderly patients at admission following a fall. Comprehensive medicines reviews should be carried out in all such patients with the objective of deprescribing or reducing doses to minimise risk of harm. Involvement of a pharmacist improves the rate of reduction of falls-risk medicines.

Why we should understand the patient experience: clinical empathy and medicines optimisation

To critically discuss the need for pharmacists to underpin their consultations with appropriate ‘clinical empathy’ as part of effective medicines optimisation.

Improving Pharmacists’ Targeting of Patients for Medication Review and Deprescription

Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults’ medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily “hold” medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital.

Use of a medication passport in a disabled child seen across many care settings

Written information for patients about their medicines has demonstrable benefits for their understanding and adherence. In the UK, no single, complete record of medications for individual patients can be guaranteed. Therefore, patients and carers are often relied on to recall the complete medication list, which can be a challenge given multiple and potentially stressful appointments. Wide-ranging feedback suggests that a medication ‘passport’ developed by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North West London (NIHR CLAHRC NWL) has benefited elderly patients, who often attend many appointments where the current medication list may not be available. We describe the use of this passport (known as ‘My Medication Passport’—MMP) in a child with multiple disabilities. The practical advantages are explored, including the potential for a paediatric version to facilitate discussions around the administration of medicines. MMP is an early example of a useful tool to help children and young people, parents and carers to manage medicines more effectively.

Use of a Multisource Feedback Tool to Develop Pharmacists in a Postgraduate Training Program

Objectives. To evaluate use of a peer-assessment tool as a performance indicator for junior pharmacists in a formal postgraduate training program in London. Methods. A 4-year retrospective analysis of data gathered using the pharmacy mini-PAT (peer-assessment tool) was undertaken. Assessments, including junior pharmacist self-evaluations, were conducted every 6 months. Overall performance and performance for clustered items were analyzed to determine changes. Assessments by healthcare professionals were then compared between professional groupings, which included pharmacists, physicians, and nurses. Results. There was a significant improvement over time in both self-assessment scores and scores on assessments conducted by others using the mini-PAT. Junior pharmacists rated themselves significantly lower than did their assessors (p<0.001); pharmacist assessors rated the performance of junior pharmacists significantly lower than did other healthcare professionals (p<0.001). Validity, ease of use, and relevance of the pharmacy mini-PAT were demonstrated. Conclusions. As part of a range of formative evaluations involving assessors from across various health professions, the mini-PAT is a valuable instrument for developing junior pharmacists. A cohort’s mini-PAT result provides a snapshot of his/her performance that can be used to identify key areas requiring further training.

The Acute Care Assessment Tool: 'Pharmacy ACAT'.

The Acute Care Assessment Tool (ACAT) was developed as a workplace‐based assessment (WPBA) for trainee performance whilst working in acute medicine. Here, we discuss the multi‐professional potential of ACAT through a pilot with foundation and senior hospital pharmacists.

Education around deprescribing: ‘spread and embed’ the story so far

In the editorial of this deprescribing themed issue, we began by recognising that deprescribing is not easy. For many clinicians, the decision to deprescribe is hampered by the lack of evidence for safe methods of deprescribing. We identified the need for education to support clinicians in their deprescribing endeavours. Here, we describe our strategy to educate around deprescribing, which emerged from the medicines optimisation work stream at the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Northwest London (CLAHRC NWL). CLAHRC NWL is a research and implementation programme1 ,2 that uses the model for improvement3 as a central component of quality improvement (QI) initiatives. We contend that education about deprescribing should adopt both a ‘top down’ to include senior clinicians, and ‘bottom up’ to include junior staff and students. This is supported by a patient safety initiative that was found to be best facilitated by such a combination approach to change.4 We will focus on the latter (hereafter bottom-up approach): educating junior and undergraduate clinicians, so that they enter the workplace with the confidence and skill to at least consider the need for deprescribing both at the point of initial prescribing and when undertaking medication review. We are conscious that the term bottom-up approach can have a number of meanings, here we use it to refer to the capacity to lead to grass-roots changes that will grow and pervade practice, rather than ‘command and control’ regulations on actions. The theory and practice of education are, at this level, andragogy (the education of adults), thus the principles of adult learning should be used;5 yet the evaluation techniques used for child education may prove useful for long-term assessments of change, for instance, those studies seeking to address differentials in earnings. …