Antibiotic prescribing for lower respiratory tract infections within secondary care

□ A systematic content analysis of the treatment guidelines for lower respiratory tract infection was performed on antibiotic formularies and policies obtained from hospital management units within the West Midlands and university hospitals from the rest of the United Kingdom □ Analysis of antibiotic formularies and policies demonstrated considerable variation between prescribing guidelines with regard both to the agents and dosages used □ A proportion of hospitals in the West Midlands and university hospitals from the rest of the UK gave no guidance regarding drug dosages, which may result in wide variations in therapy □ These findings have important consequences for quality of patient care, drug budget management and antibiotic resistance     

Does social environment affect arthritis patients' ability to remain on methotrexate treatment?

□ Drug toxicity is still a major limiting factor for methotrexate treatment continuation □ Treatment discontinuation within 12 months of start of methotrexate in this UK cohort was 20% (SE 2%) □ The monitoring of tolerance to methotrexate has implications for the dispensing of the drug in primary care □ Although social circumstances may have a role in arthritis patients' psychosocial health status, continuation rates of methotrexate in “affluent” and “deprived” patients were similar at the end of the first and second years of treatment □ The reasons for lower socio‐economic groups being discontinued on lower methotrexate doses warrant further study     

Implementing a system for tackling under‐eporting of adverse drug reactions within a district general hospital

□ The aim of the project was to produce a sustainable, stimulating ongoing programme to improve adverse drug reaction (ADR) reporting rates □ Baseline review revealed a serious shortfall in ADR reports within City Hospitals Sunderland Trust □ A variety of educational tools was employed to ensure retention of information by hospital staff □ Novel methods of promotion were implemented via short‐term, high impact awareness weeks together with continuous advertising     

Preliminary investigation of the problems associated with supply of palliative care medicines in primary care

□ Fax‐back was a cost effective method for administration of a self‐completion questionnaire which produced a high (76 per cent) response rate □ Problems with supply of palliative care medicines were reported by 58.5 per cent of health authorities responding to the survey □ Supply of medicines out of hours was the most common problem reported (93 per cent), with stock levels held in pharmacies and problems with specialist medicines also causing problems in over 50 per cent of respondents □ Some health authorities reported that protocols for supply of palliative medicines, or the existence of designated community pharmacies for their provision, reduced the problems reported □ Further research into effectiveness of protocols and designated palliative care pharmacies is indicated, and our study has identified those health authorities where such research could be targeted     

National and local guidance on services for drug misusers: do they influence current practice?— results of a survey of community pharmacists in South East England

Objective — To investigate levels of awareness of national and local guidance about services for drug misusers and their effect on pharmacy practice. Method — A postal survey in 1997 to collect data on current involvement in services for drug misusers, awareness of and receipt of key documents pertaining to drug misuse, effects of guidelines and protocols on practice, and influences on decisions to provide services. Setting — A random one in two sample (n=1,582) of community pharmacies in the South East of England (North and South Thames regions). Key findings — A 65.1 per cent response rate was achieved. Just over half (54.7 per cent) were dispensing Controlled Drugs for the management of dependence, 47.2 per cent were selling clean injecting equipment and 15.5 per cent were offering a needle exchange service. Most respondents were unaware of key government documents, with the exception of “Health of the nation,” and only a small minority had received copies. The most influential factors on current position on service provision were “personal experience,” “local need” and “Royal Pharmaceutical Society of Great Britain (RPSGB) policy.” New local guidelines and initiatives mainly related to supervised consumption of methadone in pharmacies and pharmacy needle exchange. Conclusion — Community pharmacies are substantially and increasingly involved in providing*** primary care services for drug misusers. However, there is a disturbing lack of awareness of key government initiatives, possibly due to the lack of dissemination of such documents. RPSGB policy as a key influencing factor points to an opportunity for the profession to take a more influential position.     

Variation in the management of PONV and pain in day case surgery: implications for evidence based practice

□ This study aimed to provide information on the variation in perioperative anaesthetic care for principal types of day case adult and paediatric procedures including the use of intraoperative analgesia and the treatment of post‐operative nausea and vomiting □ A structured postal survey comprising closed questions was sent to consultant anaesthetists involved in anaesthetising patients for day case surgery in United Kingdom National Health Service trusts □ This survey found wide variation in the selection of intraoperative analgesics and treatment anti‐emetics for the potential management of patients having three common day surgery procedures □ It is likely that the wide variation in practice seen in this, and previous studies, is due to uncertainty about effectiveness □ The lack of consensus about the preferred choice of analgesia and anti‐emetics provides a challenge to pharmacists and clinicians in the development of evidence based guidelines.     

Deliberate self-harm in alcohol and drug misusers: patient characteristics and patterns of clinical care

The aims of this study were to describe the characteristics of alcohol and drug misusers presenting to a general hospital following suicide attempts and to investigate the patterns of clinical care they received before and after the attempts. The Oxford Monitoring System for Attempted Suicide and patient case-notes were used to obtain information on alcohol and drug misusers assessed by the general hospital psychiatric services after deliberate self-harm in 1992. Of 724 patients, 200 (28%) were substance misusers (36% of males, 23% of females). Both alcoholics and drug misusers were more likely than other attempters to be male, have histories of personality disorder and criminal offences and to make repeat attempts, and the drug misusers were more likely to be living alone and unemployed. These are characteristics associated with particularly high risk of suicide. A large proportion of the substance misusers had received specific treatment for their misuse before their attempts and the majority were offered this afterwards. Over a quarter did not accept the care they were offered. The general hospital management of attempted suicide patients must include systematic assessment for evidence of alcohol and drug misuse and maintain close links with substance misuse services. Patients identified as having problems in the use of alcohol without having developed dependence and/or physical symptoms are a group that warrants specific attention. Audits should be conducted in general hospitals to ensure that sufficient attention is being paid to the detection and management of suicide attempters with substance misuse.     

A patient‐held medication record and a patient medication profile to support the continuity of acute cancer care

□ The sharing of care of patients receiving medical oncology care is vulnerable to errors in their documented drug history □ A patient‐held medication record identified over 90 per cent of patients' medications but was ‘forgotten’ by the patient in a third of contacts with a pharmacist □ Discrepancies between the medication records of GPs, community pharmacists and the medical oncology clinic were highly prevalent □ A posted patient medication profile issued by the hospital pharmacist to both the patient's GP and their community pharmacist was associated with a significant convergence in their records (discrepancies reduced from 17 to 6 % P<0.001) □ The patient‐held record had little impact on the accuracy of practitioners' records and its value lies more in facilitating patient education than rectifying errors in documentation     

Addressing pharmaceutical and medicines management issues within the cancer network structure

□ The presentation focuses on the contribution that oncology pharmacists make to the work of the cancer networks □ The current contribution varies between networks but includes development of evidence‐based treatment guidelines, the setting up of network oncology pharmacist groups, audit, drug procurement, and research and development □ The recent establishment of the NHS Cancer Research Network will build upon the current contribution made to research and development by oncology pharmacists by their support of clinical trials and other activities □ The presentation reflects on the barriers and facilitators that exist for these roles and invites discussion on the potential for the future role of the pharmacist within the network structure     

Risk assessment of intravenous dose presentation in secondary care

□ The Breckenridge report highlighted that intravenous drug additions were aseptic procedures and should be conducted under the direct control of a pharmacist □ This study attempts to determine the extent of intravenous drug preparation at ward level and apply a risk assessment model □ Observation and risk assessment of intravenous drug preparation was carried out in two clinical areas within a large hospital □ Two thirds of the intravenous drug administration events were graded as high risk □ In the absence of a centralised intravenous additive service, the use of ready to administer forms or novel reconstitution systems may significantly reduce the risks associated with intravenous administration events     

Identification of the pharmaceutical needs of patients with heart failure

□ An extensive evidence‐base exists to support the treatment of heart failure □ A systematic identification of the pharmaceutical care of heart failure patients is needed to develop a model of pharmaceutical care □ Pharmaceutical care issues may be identified from a number of sources □ Care issues may be based on evidence or accepted “best practice”     

Patients' perspectives on medicines and pharmacy: views of patients with Type 2 diabetes

□ The study was conducted to inform the design of pharmaceutical care support to patients with Type 2 diabetes – a recognised health care priority and a target for new pharmacy initiatives □ Interviews in an outpatient clinic revealed an apparent lack of patient‐pharmacist communication and low patient expectations □ Some patients felt a lack of feedback about the results of clinic checks and what they meant for disease control □ Patient information leaflets were not consistently seen as meeting patients' needs for information and advice □ Patients' experiences can be used to develop the role of community pharmacy services within the health care team effort     

The impact of hospital antimicrobial policy on the incidence of Clostridium difficile infection

□ An antibiotic policy specifically targeting high risk drugs for Clostridium difficile‐associated diarrhoea (CDAD) development was introduced in the study site hospital □ Despite an increased usage of antibiotics (calculated in defined daily doses) within the hospital, the policy led to a 19.7 per cent decreased incidence of CDAD □ Further improvements are predicted with improved adherence of hospital staff to the hospital antibiotic policy     

Implementation of statin prescribing guidelines: a cost effectiveness analysis

□ The evidence that statins reduce coronary heart disease mortality and morbidity is strong yet these drugs are under‐utilised in the UK □ Statin prescribing guidelines were implemented in five general medical practices using academic detailing, audit, feedback and written materials □ Statin prescribing increased following introduction of the guidelines, to a greater extent than predicted by regression analysis in the absence of intervention, with an additional 102 patients being treated 12 months after intervention □ Assuming benefits in this patient group are equivalent to those seen in the major trials, this equates to an additional 3.6 major coronary events and 1.5 coronary deaths prevented □ Including both the cost of guideline introduction and the additional statin drug costs, the cost per event prevented was 28,063 for major coronary events and £67,351 for coronary deaths.     

The Consultancy Liaison Addiction Service - the first 5 years of an integrated,primary care-based community drug and alcohol team

Government policy, running through the 10-Year Drug Strategy, Tackling Drugs to Build a Better Britain (The Stationery Office, 1998) and the New Drug Misuse Clinical Guidelines (Department of Health, The Scottish Office, 1999) highlights the need for health authorities and now PCGs to invest in shared care mechanisms to support primary care in its task of caring for drug misusers. Primary Care Trusts, as freestanding NHS organizations, will in time be able to commission, purchase and provide these services themselves, using primary care expertise alongside specialists. This paper describes a model of primary care-based shared care service, the Consultancy Liaison Addiction Service, that has been in operation for 5 years in South London, that predates these changes in the NHS yet could be considered by PCGs or PCTs when planning services for drug misusers. The service comprises a team of drug and alcohol community psychiatric nurses, supported and managed by a principal in general practice. Together they have worked with 72 neighbouring general practices, supporting the treatment of alcohol-misusing and drug-misusing patients. The team has a separate identity from, but is closely integrated into the secondary specialist addiction service producing effective continuum of care.     

The Consultancy Liaison Addiction Service - the first 5 years of an integrated, primary care-based community drug and alcohol team

Government policy, running through the 10-Year Drug Strategy, Tackling Drugs to Build a Better Britain (The Stationery Office, 1998) and the New Drug Misuse Clinical Guidelines (Department of Health, The Scottish Office, 1999) highlights the need for health authorities and now PCGs to invest in shared care mechanisms to support primary care in its task of caring for drug misusers. Primary Care Trusts, as freestanding NHS organizations, will in time be able to commission, purchase and provide these services themselves, using primary care expertise alongside specialists. This paper describes a model of primary care-based shared care service, the Consultancy Liaison Addiction Service, that has been in operation for 5 years in South London, that predates these changes in the NHS yet could be considered by PCGs or PCTs when planning services for drug misusers. The service comprises a team of drug and alcohol community psychiatric nurses, supported and managed by a principal in general practice. Together they have worked with 72 neighbouring general practices, supporting the treatment of alcohol-misusing and drug-misusing patients. The team has a separate identity from, but is closely integrated into the secondary specialist addiction service producing effective continuum of care.     

Compliance,concordance and the revolving door of care: caring for elderly people with mental health problems

□ The project involved community pharmacists receiving specialised training, becoming integrated into the community mental health teams and providing pharmaceutical care when making joint domiciliary visits with the key workers. □ Community pharmacists, psychiatrists and key workers all wanted the project to develop into a service and had similar views about the general benefits of the study. However, they had contrasting expectations of the project, based on their own perspectives on compliance, concordance and models of care □ The key workers valued the provision of monitored dosage systems for patients with confusion or memory problems. But the pharmacists felt that they were being expected to organise compliance aids; they recognised that it was their role to assess complaince and that other measures could be taken before organising an MDS □ The psychiatrists stated that involuntary non‐compliance with medication, arising from confusion, memory and physical problems, was a major issue and the project had made improvements in this area; they wanted to keep patients in the community and particularly valued reductions in morbidity, relapses and the “revolving door of care”