Exploring the implementation of Discharge Medicines Review referrals by hospital pharmacy professionals: A qualitative study using the consolidated framework for implementation research

BACKGROUND

The Discharge Medicines Review (DMR) is a community pharmacy service in Wales that aims to reduce medicines-related harm after care transitions, including hospital discharge. To undertake a DMR, the Community Pharmacist must receive a patient's discharge medicines information, either electronically, by fax or presented by the patient. Although the DMR has evidenced benefits for improving patient safety, its evaluation showed inconsistent uptake, which Community Pharmacists partially attributed to hospitals not providing the necessary information.

OBJECTIVE

Aiming to develop recommendations to improve hospital engagement to DMR referrals, this study explores hospital pharmacy professionals' views of the service.

METHODS

Qualitative focus groups, using hermeneutic phenomenology, were conducted in 16 hospitals across Wales, using a quota sampling method to include 61 Pharmacists and 31 Pharmacy Technicians. To understand the suboptimal engagement to DMR referrals, framework analysis was undertaken using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

The data were mapped onto all five CFIR domains, each containing barriers and facilitators to engagement with DMR referrals and suggestions for improvement. Only one hospital had successfully implemented DMR referrals, with many participants lacking any knowledge of the service or how to refer to it. Specific barriers included a clear absence of processes to implement referrals and engage hospital pharmacy professionals. A considerable barrier was many participants' perceptions that Community Pharmacist roles were less clinically orientated and patient-centred than their own, viewing them almost as a different profession. Participants believed that local champions for DMR referrals could promote engagement and integrate them into the workflow of hospital pharmacy professionals. Further recommendations to improve engagement was staff training for DMRs and regular feedback of its value.

CONCLUSION

Policymakers may use the findings and recommendations from this study to promote hospital pharmacy staff engagement to similar community pharmacy services like the Discharge Medicines Service in England.

Community Pharmacists' Views on the Early Stages of Implementation of a National Pilot Independent Prescribing Service in Wales: A Qualitative Study

Background

A pilot Independent Prescribers' Service (IPS) was introduced in 13 community pharmacies across Wales in June 2020. Independent Pharmacist Prescribers (IPPs) could prescribe in the areas of management of acute conditions, contraception, or opioid withdrawal, as agreed with local commissioners. Access to the patients' medical records was provided via Choose Pharmacy, the national community pharmacy IT platform.

Objective

To explore the experiences of IPPs delivering the service and commissioners responsible for financial resources regarding the IPS in Wales.

Methods

A qualitative methodology was employed, with purposive sampling, semi-structured interviews, and inductive thematic analysis.

Results

Five themes were constructed from 13 interviews (n=9 IPPs; n=4 commissioners): (i) patient experience and safety; (ii) professional enablement and rebalancing workload of GPs; (iii) role and limitations of remote consultations; (iv) funding and business model; (v) functionality on Choose Pharmacy to support patient care. The design of the service allowed pharmacists to determine how best to deliver the IPS, maximizing access for patients and promoting a sense of professional value amongst pharmacists.

Conclusion

This study builds on the body of evidence on enhanced patient experience with prescribing services in the community, reinforcing that IPPs have a key role in rebalancing management of common conditions from GP surgeries to community pharmacies. Several considerations need to be addressed to ensure future success of the service implementation, delivery and enhanced sustainability, such as formal referral pathways and access to medical records. These can be used by other commissioning bodies in the UK and internationally to build a network of suitably supported IPPs, confident to appropriately deal with uncomplicated acute and chronic conditions; and liaise with primary and/or secondary care when referrals are needed.

Views of independent prescribing pharmacists on the community pharmacy pilot independent prescribing service: a qualitative study

Introduction

Independent Prescribing Pharmacists (IPPs) can prescribe autonomously within their scope of practice. Their role is increasing within the community setting (1). The Welsh Pharmaceutical Committee has a vision to have at least one IPP in every community pharmacy by 2030 (1). In 2020, an Independent Prescribers’ Service (IPS) pilot was delivered in 13 pharmacies across six of the seven Health Boards in Wales (2), via Choose Pharmacy (CP), an IT platform that provides access to patients’ General Practitioner (GP) medical record. IPS allowed patients to access advice, and, where relevant, be treated in the community pharmacy setting, rather than the GP surgery. The consultation is recorded on CP and the patient’s GP informed of the outcome. As the IPS is a recent development there is little research on this service.

Aim

To explore the views of community IPPs delivering the IPS.

Methods

A qualitative methodology was utilised with semi-structured interviews, via telephone or MS Teams. Only thirteen pharmacies were commissioned to deliver the service. Purposive sampling was used to identify IPPs in these premises, who had completed at least one IPS consultation. Participants were informed of the study and written; informed consent obtained. An interview schedule utilised open questions to explore participants’ experiences of the service. Interviews were recorded, transcribed and analysed via deductive and inductive thematic analysis. Analysis was quality assured through discussion with the research team. All identifiable information in the transcripts were removed to ensure anonymity.

Results

Nine interviews were conducted, including participants from all Health Boards in the pilot. Interviewees had varied prescribing experience with some only prescribing since the roll out of the pilot. The IPPs’ scope of practice included acute minor ailments, contraception, urinary tract infections and asthma. Four themes were identified: 1.Impact of the IPS: Participants believed the service had impacted on the wider healthcare setting, patients and themselves. Patients had improved convenience and accessibility to a healthcare professional to manage their condition. Patient safety was of a high standard with access to patient notes ensuring informed, appropriate clinical decisions. 2.Relationship with GP: Positive relationships with local GPs was believed to be critical to the pilot’s success. 3.Future delivery: This will rely on support, funding, and ongoing review. A ‘blended approach’ whereby patients are seen with or without an appointment was believed to provide the flexibility that patients want. 4.Remote consultations: Can have an impact on patient safety, making non-verbal communication and language barriers more challenging. After nine interviews, no new information was gathered.

Conclusion

Participants were supportive of the service which will potentially benefit IPPs, patients and GPs, and improve patient care. Pharmacists, by providing a high quality, accessible service, ensures that forward thinking healthcare is delivered in a manner which makes use of the skills of those working in the community. The study, albeit small scale, explored the thoughts of the majority of IPPs conducting the IPS service at that time. More information is needed to understand the impact of the service and effect on practice, from the practitioner and patient perspective.

References

(1) Walsh A. All Welsh pharmacies to have independent prescribers. Wales; 2019 [accessed 5 February 2021]. Available from: http://www.pharmacymagazine.co.uk/all-welsh-pharmacies-to-have-independent-prescribers

(2) NHS Wales Informatics Service. Choose Pharmacy. Wales; 2021 [accessed 5 Feb 2021]. Available from: http://www.nwis.nhs.wales/systems-and-services/in-the-community/choose-pharmacy/

Medicines prescribed by non-medical independent prescribers in primary care in Wales: a 10-year longitudinal study April 2011-March 2021

OBJECTIVES

The therapeutic classes of medicines prescribed by non-medical independent prescribers (NMIPs) working in primary care in Wales has not been studied in detail. The aim of this study was to conduct a 10-year longitudinal analysis of NMIP prescribing in Wales from April 2011 to March 2021. The study examined the British National Formulary (BNF) chapters from which medicines were prescribed by NMIPs, whether this changed over time, and whether there was variation in prescribing across the geographic regions of Wales.

DESIGN

Retrospective secondary data analysis of primary care prescribing data. Monthly prescribing data for the 10 National Health Service financial years (April to March) from April 2011 to March 2021 were obtained from the Comparative Analysis System for Prescribing Audit software. Data were analysed according to BNF chapter, to identify in which therapeutic areas NMIPs were prescribing, and whether this changed over the study period.

RESULTS

The number of items prescribed by NMIPs increased during the study period. From April 2011 to March 2021 prescribing in seven BNF chapters equated to approximately 80% of total items, with cardiovascular system medicines most prescribed. In the financial year 2011-2012 the BNF chapters with the greatest proportion of items prescribed were infection (18%) and respiratory system (13%), while in 2020-2021, these had changed to cardiovascular (23%) and nervous system (19%). The number of items prescribed in each health board in Wales varied, however, the BNF chapters contributing the largest percentages of items to the health board totals were broadly comparable.

CONCLUSIONS

The BNF chapter with the most prescribed items changed from infection to cardiovascular during the study period, suggesting an increase in chronic disease management by NMIPs. The impact of this on the delivery of primary care services and patient outcomes is a focus for future work.

Exploring the independent prescribing role of the community pharmacists in Wales

Introduction

Since 2019, the role of independent pharmacist prescribers (IPPs) in primary care has extended to community pharmacies in Wales [1]. This was in response to a Welsh Pharmaceutical Committee report in 2019 that outlined a plan to include an IPP in each community pharmacy in Wales by 2030. This aimed to relieve pressure on general practices, enhance patient care and reduce referral and admission rates to secondary care [2]. As funding was provided by the Government, the number of community pharmacists completing the independent prescribing course increased and many have implemented their prescribing role.

Aim

To explore the views of community IPPs regarding their prescribing role within community pharmacies in Wales.

Methods

Semi-structured face-to-face and telephone interviews were conducted with community IPPs from all seven health boards (HBs) in Wales. Ethical approval was obtained from the School of Pharmacy and Pharmaceutical Sciences at Cardiff University and the School of Pharmacy and Bioengineering at Keele University. Purposive sampling was used to identify potential participants. Gatekeepers (HB community pharmacy leads and directors of IPP courses in Wales) sent invitation emails, participant information sheet and consent form to potential participants. Written consent was obtained. Interviews were audio-recorded and transcribed ad verbatim. Thematic analysis was used to analyse the data.

Results

Thirteen community IPPs across Wales participated. Six themes were identified, including the utilisation of their role as community IPPs, their experiences with their independent prescribing training, motivation to obtain their prescribing qualification and utilise it, the impact, barriers and facilitators to implement and utilise their role. Participants practised as IPPs in the management of minor ailments and some other conditions, such as respiratory and sexual health. The course and training for community IPPs was helpful, but there was a need to focus more on therapeutic and clinical examination skills. The main impact of the role was that it helped to improve communication between community pharmacies and general practices and relieved some pressure on general practices. The main barriers were the lack of appropriate funding by the Government to develop the role, lack of access to patients’ medical records, lack of support and high workload.

“One of the areas identified as high risk is for pharmacy prescribers is the lack of access to clinical records. How can you [as community IPPs] make any sensible decisions with half the information?” IPP6

Facilitators included that some services were already in place and the drive from the 2030 vision.

Conclusion

This is the first study that explored the views of community IPPs regarding their prescribing role in community pharmacies in Wales. It provided an insight into this new role that can be considered by the Welsh Government to achieve the 2030 vision for this role. A limitation to this study was that the role is still new in community pharmacies, which may affect the views of the community IPPs. Many of them have obtained their prescribing qualification but have not started to utilise it yet. Further work is needed to explore a wider population of community IPPs’ experiences as the role develops.

References

1. Wickware, C. 2019. All community pharmacies in Wales to have an independent prescriber as part of long-term plan for Welsh pharmacy. Available at: https://www.pharmaceutical-journal.com/news-and-analysis/news/all-community-pharmacies.

2. Welsh Pharmaceutical Committee. 2019. Pharmacy: Delivering a Healthier Wales. Available at: https://www.rpharms.com/Portals/0/RPS%2.

Using Technology-Supported Transfer of Care Systems: Informing Good Practice Recommendations

The Discharge Medicines Review (DMR) referral system, Refer-to-Pharmacy (RTP), PharmOutcomes and Help for Harry are UK transfer of care systems that aim to reduce the risks associated with hospital discharge. These systems use technology to facilitate the transmission of discharge information to community pharmacy, allowing community pharmacists to provide an adherence-support service. Despite the evidence that these systems benefit patient safety, there is a paucity of literature on their use. This study aimed to describe, compare and contrast these systems to highlight areas that could inform good practice recommendations. A rapid literature review was completed, and from the twenty-six sources of literature that were synthesised, three themes were identified for further exploration in semi-structured interviews with key informants: implementation, system attributes and stakeholder engagement. The key informants were purposively sampled for their role in the development and/or strategic implementation of each transfer of care system (n = 4). Audio recordings were transcribed ad verbatim and analysed both deductively and inductively. One interview was undertaken for each of the DMR, RTP and PharmOutcomes systems. Although all systems shared the same aim, differences were identified such as automated feedback for referrals, marketing strategies and practitioner accountability. Good practice recommendations suggested in this study could be applied to the future development of such systems.

Prescribing trends over time by non-medical independent prescribers in primary care settings across Wales (2011-2018): a secondary database analysis

INTRODUCTION

As of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary care to train as independent prescribers (IPs).

OBJECTIVES

This research aimed to identify the number of NMIPs in primary care in Wales and describe their prescribing trend of items between 2011 and 2018, in order to compare their prescribing pattern before and after the implementation of primary care clusters for Wales.

DESIGN

Retrospective secondary data analysis and interrupted time series analysis in order to compare prescribing by non-medical independent prescribers (NMIPs) preimplementation and postimplementation of primary care clusters across Wales.

RESULTS

Over the study period, 600 NMIPs (nurses n=474 and pharmacists n=104) had prescribed at least one item. The number of nurse IPs increased by 108% and pharmacists by 325% (pharmacists had the largest increase between July 2015 and March 2018). The number of items prescribed by NMIPs increased over time by an average of 1380 per month (95% CI 904 to 1855, p<0.001) after the implementation of primary care clusters compared with 496 (95% CI 445 to 548, p<0.001) prior its implementation. Approximately one-third of the items prescribed by NMIPs was within Betsi Cadwaladr University Health Board (HB) with only 4% in Powys Teaching HB.

CONCLUSION

The number of NMIPs and their volume of prescribing in primary care in Wales has increased following the implementation of primary care clusters in 2015. This suggests that the Government's recommendations of using NMIPs in primary care have been implemented. Future studies should focus on efficiency and quality of prescribing by NMIPs in primary care.

Learning from Practice: How East Lancashire Hospitals' Pharmacy Service Has Embraced Information Technology

The ethos of the pharmacy service at East Lancashire Hospitals NHS Trust (ELHT) could be described as 'let's make things better'. We have a history of innovation involving technology and people; one without the other does not work but together they are synergistic. The Trust currently does not have an electronic patient record (ePR) or electronic prescribing and medicines administration (ePMA), although we do have electronic prescribing for chemotherapy. However, like all Trusts, we have many electronic systems which offer interoperability, or can support making it easier for the pharmacy team to do a good job. This article describes the many fronts we have worked on over the last ten plus years. Taken individually, the elements cannot be considered as revolutionary; together, they have helped us develop and deliver the safe, personal and effective pharmacy service that we call dedicated ward pharmacy.

Theory-based electronic learning intervention to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers: an acceptability and feasibility experimental study using mixed methods

OBJECTIVES

To assess the acceptability and feasibility of using a theory-based electronic learning intervention designed to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers for patients presenting with common, acute, uncomplicated self-limiting respiratory tract infections (RTIs).

DESIGN

Experimental with mixed methods; preintervention and postintervention online surveys and semistructured interviews.

SETTING

Primary care settings across the UK.

PARTICIPANTS

11 nurse and 4 pharmacist prescribers.

INTERVENTION

A theory-based brief interactive animation electronic learning activity comprised a consultation scenario by a prescriber with an adult presenting with a common, acute, uncomplicated self-limiting RTI to support a 'no antibiotic prescribing strategy'.

OUTCOME MEASURES

Recruitment, response and attrition rates were assessed. The overall usefulness of the intervention was assessed by analysing prescribers' self-reported confidence and knowledge in treating patients with RTIs before and after undertaking the intervention, and views on the relevance of the intervention to their work. Acceptability of the intervention was assessed in semistructured interviews. The feasibility of data collection methods was assessed by recording the number of study components completed by prescribers.

RESULTS

15 prescribers (maximum sample size) consented and completed all four stages of the study. Prescribers reported high to very high levels of confidence and knowledge preintervention and postintervention, with slight postintervention increases in communicating with patients and a slight reduction in building rapport. Qualitative findings supported quantitative findings; prescribers were reassured of their own practice which in turn increased their confidence and knowledge in consultations. The information in the intervention was not new to prescribers but was applicable and useful to consolidate learning and enable self-reflection. Completing the e-learning intervention was acceptable to prescribers.

CONCLUSIONS

It was feasible to conduct the study. The intervention was acceptable and useful to prescribers. Future work will add complex clinical content in the intervention before conducting a full trial.

Exploring the association of the discharge medicines review with patient hospital readmissions through national routine data linkage in Wales: a retrospective cohort study

OBJECTIVE

To evaluate the association of the discharge medicines review (DMR) community pharmacy service with hospital readmissions through linking National Health Service data sets.

DESIGN

Retrospective cohort study.

SETTING

All hospitals and 703 community pharmacies across Wales.

PARTICIPANTS

Inpatients meeting the referral criteria for a community pharmacy DMR.

INTERVENTIONS

Information related to the patient's medication and hospital stay is provided to the community pharmacists on discharge from hospital, who undertake a two-part service involving medicines reconciliation and a medicine use review. To investigate the association of this DMR service with hospital readmission, a data linking process was undertaken across six national databases.

PRIMARY OUTCOME

Rate of hospital readmission within 90 days for patients with and without a DMR part 1 started.

SECONDARY OUTCOME

Strength of association of age decile, sex, deprivation decile, diagnostic grouping and DMR type (started or not started) with reduction in readmission within 90 days.

RESULTS

1923 patients were referred for a DMR over a 13-month period (February 2017-April 2018). Provision of DMR was found to be the most significant attributing factor to reducing likelihood of 90-day readmission using χ² testing and classification methods. Cox regression survival analysis demonstrated that those receiving the intervention had a lower hospital readmission rate at 40 days (p<0.000, HR: 0.59739, CI 0.5043 to 0.7076).

CONCLUSIONS

DMR after a hospital discharge is associated with a reduction in risk of hospital readmission within 40 days. Linking data across disparate national data records is feasible but requires a complex processual architecture. There is a significant value for integrated informatics to improve continuity and coherency of care, and also to facilitate service optimisation, evaluation and evidenced-based practice.

Theory-based electronic learning intervention to support appropriate antibiotic prescribing by nurses and pharmacists: intervention development and feasibility study protocol

INTRODUCTION

Nurse and pharmacist independent prescribers manage patients with respiratory tract infections and are responsible for around 8% of all primary care antibiotic prescriptions. A range of factors influence the prescribing behaviour of these professionals, however, there are no interventions available specifically to support appropriate antibiotic prescribing behaviour by these groups. The aims of this paper are to describe (1) the development of an intervention to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers and (2) an acceptability and feasibility study designed to test its implementation with these prescribers. METHOD AND ANALYSIS: Development of intervention: a three-stage, eight-step method was used to identify relevant determinants of behaviour change and intervention components based on the Behaviour Change Wheel. The intervention is an online resource comprising underpinning knowledge and an interactive animation with a variety of open and closed questions to assess understanding. Acceptability and feasibility of intervention: nurse and pharmacist prescribers (n=12-15) will use the intervention. Evaluation includes semi-structured interviews to capture information about how the user reacts to the design, delivery and content of the intervention and influences on understanding and engagement, and a pre-post survey to assess participants' perceptions of the impact of the intervention on knowledge, confidence and usefulness in terms of application to practice. Taking an initial inductive approach, data from interview transcripts will be coded and then analysed to derive themes. These themes will then be deductively mapped to the Capability, Opportunity, Motivation-Behaviour model. Descriptive statistics will be used to analyse the survey data, and trends identified.

ETHICS AND DISSEMINATION

Ethical approval for the study has been provided by the School of Healthcare Sciences Research Governance and Ethics Committee, Cardiff University. The findings will be disseminated via publication in peer-reviewed journals and through conference presentations.

A 5-year evaluation of the emergency contraception enhanced community pharmacy service provided in Wales

BACKGROUND

Access to emergency contraception (EC) has been a core component of attempts to address high teenage pregnancy rates in Wales. A national service was commissioned in 2011, allowing supply of EC free of charge from community pharmacies (CPs). This study investigated 5 years of the EC service, to describe its use and investigate changes in the pattern of use over time.

METHODS

Secondary analyses of data from all National Health Service funded CP EC consultations in Wales between 1 August 2012 and 31 July 2017 (n=181 359). Data comprised standardised clinical and demographic information, in the form of predefined service user responses, submitted for reimbursement by CPs.

RESULTS

Overall service provision remained relatively consistent over the study period, with women aged between 13 and 59 years accessing the service. An association was observed between the time since unprotected sexual intercourse and the day on which the service was accessed (Χ2(18)=16 292.327, p<0.001). Almost half (47.9%) of requests were because no contraception had been used, with a strong and positive association for teenagers and women aged 40+ years. A statistically significant and increasing percentage of consultations were accompanied by further sexual health advice (r=0.7, p<0.01).

CONCLUSIONS

Access to EC through CPs is contributing to reducing teenage conceptions and termination rates. However, action is needed to increase contraception use in all age groups. Reduced availability of CP services on Sundays is a barrier to timely EC access. Findings support an expanded role for community pharmacists in provision of regular contraception.

Community pharmacists at the heart of public health: A longitudinal evaluation of the community pharmacy influenza vaccination service

BACKGROUND

Influenza ("flu") is a contagious viral infection causing approximately 600 deaths/year in the United Kingdom. Annual vaccination is the most effective prevention strategy with a target of 75% uptake in 'at-risk' patient groups. Before 2012, immunisation was conducted in General Practice (GP), but uptake was below target. NHS Wales therefore introduced a programme allowing community pharmacists to administer the vaccine to certain patient groups^. OBJECTIVES: This study aimed to evaluate the community pharmacy (CP) flu Vaccination Programme in Wales.

METHODS

A longitudinal study was undertaken by secondary data analysis on data related to all NHS funded flu vaccinations administered in CP between 2012 and 2018 (n = 103941). Data were analysed using IBM SPSS® and Excel®. Pearson's correlation and independent sample t-test were conducted to compare the number of vaccines administered in CP vs overall numbers and those under 65 years and in the 'at risk' category in CP and GP respectively. Ethical approval was not required.

RESULTS

In total, pharmacists administered 103941 vaccinations. Vaccination numbers increased each season from 1568 in 2012/13 to 36238 in 2017/18. The main risk group was those aged 65 and over (59.9% of vaccinations). The proportion of those vaccinated who were aged <65 years and in an 'at risk' category was significantly higher in CP than GP (p < 0.01). There was a shift in balance between vaccinations administered by GPs and CPs in which CPs increased their share of all vaccinations in the flu programme from 0.3% in 2012-13 to 5.7% in 2017-18. A strong positive correlation was observed between increasing CP vaccinations and total vaccination numbers (R = 0.9316, p < 0.01).

CONCLUSIONS

Community pharmacists are providing increasing numbers of flu vaccinations in Wales, benefitting patients in all at-risk groups and reinforcing the valuable role of pharmacists at the heart of their communities, in terms of public choice and accessibility.

Views, experience and adherence among pregnant women with gestational diabetes participating in a weight loss study (WELLBABE)

AIMS

To investigate the views and experience of pregnant women newly diagnosed with gestational diabetes mellitus participating in a 1200 kcal/day diet to achieve moderate weight loss (the WELLBABE study), and to explore barriers to and facilitators of adherence.

METHODS

Twelve participants engaged in semi-structured interviews after completion of the 4-week diet. An interview schedule was devised using open-ended questions guided by the Theoretical Domains Framework. Transcript responses were analysed thematically.

RESULTS

Participants were anxious about their diagnosis of gestational diabetes, but concerns related to dieting in pregnancy were allayed by reassurance from the research team. Participants expected health benefits, improved knowledge and support from enrolling on the study. The participants' primary motivator to diet adherence was their baby's wellbeing. Other facilitatory factors included improving their own health and reducing any future risk of diabetes. Trying to provide reliable results and receiving extra care also facilitated adherence. Partners, friends and family were an important source of social support and no barrier caused by concern about weight loss in pregnancy was encountered. Observed and experienced physical changes and feedback from the research team positively reinforced adherence. The main barrier was that learning new skills was initially time-consuming.

CONCLUSIONS

Weight loss was acceptable to women with gestational diabetes provided with clear information about likely benefit. A randomized controlled trial of this intervention is now required, employing clear information and feedback of glycaemic benefit to facilitate efficacy.

Classic e-Delphi survey to provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services in Wales

OBJECTIVE

To provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services.

DESIGN

Classic e-Delphi survey.

SETTING

National study in Wales.

PARTICIPANTS

Pharmacists, nurses and allied health professionals with the independent/supplementary prescribing qualification.

RESULTS

A total of 55 non-medical prescribers agreed to become members of the expert panel of whom 42 (76%) completed the round 1 questionnaire, 40/42 (95%) completed round 2 and 34/40 (85%) responded to round 3. Twenty-one statements were developed, and consensus was achieved on nine factors representing those necessary for the successful implementation of non-medical prescribing and five representing actions required for its continued development. Strategic fit between non-medical prescribing and existing service provision, organisation preparedness, visible benefits, good managerial and team support, and a clear differentiation of roles were each important influences.

CONCLUSION

Given the high degree of consensus, this list of factors and actions should provide guidance to managers and commissioners of services wishing to initiate or extend non-medical prescribing. This information should be considered internationally by other countries outside of the UK wishing to implement prescribing by non-medical healthcare professionals.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education

BACKGROUND

Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities.

AIM

To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education.

METHODS

A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017.

FINDINGS

A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals.

CONCLUSION

Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Defining antimicrobial stewardship competencies for undergraduate health professional education in the United Kingdom: A study protocol

Multi-drug resistant infections have been identified as one of the greatest threats to human health. Healthcare professionals are involved in an array of patient care activities for which an understanding of antimicrobial stewardship is important. Although antimicrobial prescribing and stewardship competencies have been developed for healthcare professionals who adopt the role of a prescriber, competencies do not exist for other medicine-related stewardship activities. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities. This report presents a protocol for a study designed to provide national consensus on antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education. A modified Delphi process will be used in which a panel of Experts, comprising members from across the United Kingdom, with expertise in prescribing and medicines management with regard to the education and practice of healthcare professionals, and antimicrobial prescribing and stewardship, will be invited to take part in two survey rounds. The competencies developed will be applicable to all undergraduate healthcare professional education programmes. They will help to standardise curricula content and enhance the impact of antimicrobial stewardship education.

Community pharmacists' opinions on skill-mix and delegation in England

OBJECTIVES

Following the 2005 contractual framework amendment, the expanding role of community pharmacy team members required a shift in entrenched views on roles and duties. This study aimed to report on community pharmacists' opinions on skill mix and explore how they can be addressed so that skill mix may be optimised.

METHODS

An invitation to complete an online questionnaire was distributed via email, marked for the attention of the lead pharmacist. Following a low response, a paper-based questionnaire was sent to all community pharmacies in England (n = 11,816). Questions elicited data about the respondent, the pharmacy (including staffing profile) and opinions on skill mix.

KEY FINDINGS

A total of 1154 returns were received, representing a 10% response rate. Of these, most were pharmacy chains (76%; n = 877), with 5-9 staff (54%; n = 600); commonly open 40-49 hours (42%; n = 487), dispensing <6000 prescriptions per week (41%, n = 533). From 26 statements on skill mix, three factors were identified by principal-components factor analysis: 'working well', 'feeling the pressure' and 'open to development'. Characteristics associated with 'working well': pharmacy owners, single businesses, with pharmacy technician(s), dispensing fewer prescriptions and open shorter hours. Characteristics associated with 'feeling the pressure': pharmacy chains, open longer hours, large numbers of prescriptions and relief pharmacists. Characteristics associated with 'open to development': recently qualified, second pharmacists, working longer hours, chains and dispensing lower numbers of prescriptions.

CONCLUSIONS

Although limited by a low response, results suggest being in a position to influence (more experienced, business owners) may be associated with more positive opinions. Further training (including about legalities and leadership) could contribute to optimising skill mix in community pharmacies.

Overview of the uptake and implementation of non-medical prescribing in Wales: a national survey

OBJECTIVES

To identify (1) the non-medical healthcare professionals in Wales qualified to prescribe medicines (including job title, employer, where the prescribing qualification is used, care setting and service provided); (2) the mode of prescribing used by these healthcare professionals, the frequency with which medicines are prescribed and the different ways in which the prescribing qualification is used; and (3) the safety and clinical governance systems within which these healthcare professionals practise.

DESIGN

National questionnaire survey.

SETTING

All three National Health Service (NHS) Trusts and seven Health Boards (HB) in Wales.

PARTICIPANTS

Non-medical prescribers.

RESULTS

379 (63%) participants responded to the survey. Most of these prescribers (41.1%) were specialist nurses who work in a variety of healthcare settings (primarily in secondary care) within each HB/NHS Trust, and regularly use independent prescribing to prescribe for a broad range of conditions. Nearly a quarter of the sample (22%) reported that prior to undertaking the prescribing programme, they had completed master's level specialist training and 65.5% had 5 years qualified experience. Over half (55.8%) reported that there were plans to increase non-medical prescriber numbers within the team in which they worked. Only 7.1% reported they did not prescribe and the median number of items prescribed per week was between 21 and 30. Nearly all (87.8%) of the sample reported that they perceived prescribing to have ensured better use of their skills and 91.5% indicated that they believed it had improved the quality of care they were able to provide.

CONCLUSION

Non-medical prescribing has been implemented across the whole of Wales; however, its uptake within HBs and NHS Trusts has been inconsistent, and it has not been considered across all services, particularly those in primary care. Opportunities therefore exist to share learning across organisations.

The public's perception of the role of community pharmacists in Wales

OBJECTIVE

To investigate the general public's perceptions of the community pharmacist's (CP) role in Wales by exploring understanding, awareness of services provided and potential interventions for promoting the role of CPs.

METHODS

Qualitative methodology using focus group (FG) discussions exploring opinions, facilitated by a moderator (pharmacist) and an assistant. Topics discussed included the following: what a CP does; reasons for visiting; from whom they seek advice on medicines or lifestyle issues; use of traditional and newer services and promotion of services. The groups, totalling 32 participants, represented non-users and users of pharmacy services, that is pupils from a local secondary school (x1 group), people from the local community (x3) and patients plus carers from a Parkinson's disease group (x1). FG discussions were recorded and transcribed verbatim, and analysis was undertaken to identify themes.

KEY FINDINGS

Traditional dispensing and supply of medicines roles were clearly recognised, but poor awareness of the newer services emerged, particularly in public health roles. CP's professionalism was acknowledged, but there was confusion over where they 'fit' within the National Health Service or with General Practitioners, with concerns or misconceptions raised over the impact of commercialism on professionalism.

CONCLUSIONS

Based on these findings, the public is accepting of the extended role of CPs and would engage with CPs for a wider range of services. However, there is a lack of awareness of what public health services are available. Considerable work is needed to increase public awareness, during the strategic development of these services in Wales.

Antibiotics for acute respiratory tract infections: a mixed-methods study of patient experiences of non-medical prescriber management

OBJECTIVE

To (1) explore patients' expectations and experiences of nurse and pharmacist non-medical prescriber-led management of respiratory tract infections (RTIs), (2) examine whether patient expectations for antibiotics affect the likelihood of receiving them and (3) understand factors influencing patient satisfaction with RTI consultations.

DESIGN

Mixed methods.

SETTING

Primary care.

PARTICIPANTS

Questionnaires from 120 patients and follow-up interviews with 22 patients and 16 nurse and pharmacist non-medical prescribers (NMPs).

RESULTS

Patients had multiple expectations of their consultation with 43% expecting to be prescribed an antibiotic. There was alignment between self-reported patient expectations and those perceived by NMPs. Patient expectations for non-antibiotic strategies, such as education to promote self-management, were associated with receipt of those strategies, whereas patient expectations for an antibiotic were not associated with receipt of these medications. 'Patient-centred' management strategies (including reassurance and providing information) were received by 86.7% of patients. Regardless of patients' expectations or the management strategy employed, high levels of satisfaction were reported for all aspects of the consultation. Taking concerns seriously, conducting a physical examination, communicating the treatment plan, explaining treatment decisions and lack of time restrictions were each reported to contribute to patient satisfaction.

CONCLUSIONS

NMPs demonstrate an understanding of patient expectations of RTI consultations and use a range of non-antibiotic management strategies, particularly those resembling a patient-centred approach. Overall, patients' expectations were met and prescribers were not unduly influenced by patient expectations for an antibiotic. Patients were satisfied with the consultation, indicating that strategies used by NMPs were acceptable. However, the lower levels of satisfaction among patients who expected but did not receive an antibiotic indicates that although NMPs appear to have strategies for managing RTI consultations, there is still scope for improvement and these prescribers are therefore an important group to involve in antimicrobial stewardship.

Lesbian and bisexual women's likelihood of becoming pregnant: a systematic review and meta-analysis

BACKGROUND

Few data exist regarding pregnancy in lesbian and bisexual (LB) women.

OBJECTIVES

To determine the likelihood of LB women becoming pregnant, naturally or assisted, in comparison with heterosexual women SEARCH STRATEGY: Systematic review of papers published 1 January 2000 to 23 June 2015.

SELECTION CRITERIA

Studies contained details of pregnancy rates among LB women compared with heterosexual women. No restriction on study design.

DATA COLLECTION AND ANALYSIS

Inclusion decisions, data extraction and quality assessment were conducted in duplicate. Meta-analyses were carried out, with subgroups as appropriate.

MAIN RESULTS

Of 6859 papers identified, 104 full-text articles were requested, 30 papers (28 studies) were included. The odds ratio (OR) of ever being pregnant was 0.19 (95% CI 0.18-0.21) in lesbian women and 1.22 (95% CI 1.15-1.29) in bisexual women compared with heterosexual women. In the general population, the odds ratio for pregnancy was nine-fold lower among lesbian women and over two-fold lower among bisexual women (0.12 [95% CI 0.12-0.13] and 0.50 [95% CI 0.45-0.55], respectively). Odds ratios for pregnancy were higher for both LB adolescents (1.37 [95% CI 1.18-1.59] and 1.98 [95% CI 1.85, 2.13], respectively). There were inconsistent results regarding abortion rates. Lower rates of previous pregnancies were found in lesbian women undergoing artificial insemination (OR 0.17 [95% CI 0.11-0.26]) but there were higher assisted reproduction success rates compared with heterosexual women (OR 1.56 [95% CI 1.24-1.96]).

CONCLUSIONS

Heterosexuality must not be assumed in adolescents, as LB adolescents are at greater risk of unwanted pregnancies and terminations. Clinicians should provide appropriate information to all women, without assumptions about LB patients' desire for, or rejection of, fertility and childbearing.

TWEETABLE ABSTRACT

Review of likelihood of LB women becoming pregnant: LB teenagers at greater risk of unwanted pregnancies.

Antibiotic intravenous-to-oral switch guidelines: barriers to adherence and possible solutions

Objectives

To identify reasons for poor adherence to antibiotic intravenous-to-oral switch guidelines and to explore the possible solutions. To rate the importance of the barriers and solutions identified, as perceived by a multidisciplinary expert panel.

Methods

Three-round Delphi study in an expert panel comprising doctors, nurses and pharmacists, with concurrent semi-structured interviews.

Key findings

The three rounds of the Delphi were completed by 13 out of the 30 healthcare professionals invited to participate. No nurses were included in the final round. Consensus was achieved for 28 out of 35 statements, with the most important barrier being that of inappropriate antibiotic review at the weekend, and the most important solution being to raise guideline awareness. The findings from the seven interviews (three doctors, two pharmacists and two nurses) complemented those from the Delphi study, although they provided more specific suggestions on how to improve the adherence to guidelines.

Conclusion

This study, using a combination of quantitative and qualitative methods, has identified several barriers to explore further and offered many practical solutions to improve practice. The importance of a multidisciplinary approach to address guideline non-adherence was emphasised. Clinical guidelines must be well publicised and well written to prevent a feeling of guideline saturation in the healthcare populous. Novel approaches may have to be investigated in order to further encourage adherence with antibiotic intravenous-to-oral switch guidelines.

Mechanism of insulin resistance in normal pregnancy

Normal pregnancy is associated with insulin resistance although the mechanism is not understood. Increased intramyocellular lipid is closely associated with the insulin resistance of type 2 diabetes and obesity, and the aim of this study was to determine whether this was so for the physiological insulin resistance of pregnancy. Eleven primiparous healthy pregnant women (age: 27-39 years, body mass index 24.0±3.1 kg/m2) and no personal or family history of diabetes underwent magnetic resonance studies to quantify intramyocellular lipid, plasma lipid fractions, and insulin sensitivity. The meal-related insulin sensitivity index was considerably lower in pregnancy (45.6±9.9 vs. 193.0±26.1; 10(-4) dl/kg/min per pmol/l, p=0.0002). Fasting plasma triglyceride levels were elevated 3-fold during pregnancy (2.3±0.2 vs. 0.8±0.1 mmol/l, p<0.01) and the low-density density lipoprotein fraction, responsible for fatty acid delivery to muscle and other tissues, was 6-fold elevated (0.75±0.43 vs. 0.12±0.09 mmol/l; p=0.001). However, mean intramyocellular lipid concentrations of the soleus muscle were not different during pregnancy (20.0±2.3 vs. 19.1±3.2 mmol/l, p=0.64). The pregnancy effect on muscle insulin resistance is distinct from that underlying type 2 diabetes.

Are coagulation studies on blood sampled from arterial lines valid?

Coagulation tests were performed on two venous blood samples and two blood samples from arterial lines taken from 79 patients on an intensive care unit. For the first arterial sample the discard volume was 4.5 ml and for the second arterial sample the discard volume was 16 ml. From each pair of venous samples a mean venous coagulation value was calculated. There were statistically significant differences between arterial and venous results and between the two arterial samples for activated partial thromboplastin time and thrombin time assays but not for prothrombin time, reptilase time and fibrinogen assays. However, these differences were sufficiently small to be of little clinical significance. The bias for the difference in activated partial thromboplastin time values between the first arterial sample and the venous sample was +1.24 s (limits of agreement: -4.39 to +6.87 s) and between the second arterial sample and the venous sample the bias was +0.89 s (limits of agreement: -3.25 to +5.03 s). Only 3.8% of first arterial samples and 1.3% of second arterial samples produced activated partial thromboplastin time values that were more than 10% longer than the corresponding venous values. No heparin was detectable in these arterial samples using a heparin assay (< 0.02 iu.ml-1). The differences between arterial and venous activated partial thromboplastin times were slightly but not significantly greater in subgroups of patients with moderately or severely deranged coagulation compared with a group with normal coagulation. We conclude that samples from arterial lines provide valid activated partial thromboplastin time results using a discard volume of either 4.5 ml or 16 ml.

Prophylactic immunization against experimental leishmaniasis. VI. Comparison of protective and disease-promoting T cells

In previous studies, we reported that mice immunized i.v. with lethally irradiated Leishmania major promastigotes developed substantial resistance to a subsequent L. major infection. However, such protection could be totally suppressed by prior s.c. injection with the same antigens. Both the protective immunity and the inhibition of its induction could be adoptively transferred with specific Lyt-2- T cells. Here, we present evidence showing that protection and disease promotion resulting from i.v. or s.c. immunization, respectively, are mediated by functionally distinct subsets of T cells. In a series of titration experiments, it was found that freshly isolated T cells derived from prophylactically i.v. immunized BALB/c mice were either protective (greater than 10(7) cells/recipient) or ineffective (less than 10(7) cells/recipient). No exacerbation of disease was observed at any dose. Conversely, T cells from mice immunized s.c. either accelerated disease development and inhibited protective immunization (greater than 10(7) cells/recipient) or had no effect (less than 10(7) cells/recipient). No protection was observed at any dose tested. In mixed transfer experiments, increasing numbers of T cells from s.c. immunized donors progressively inhibited the protective effect of T cells from i.v. immunized donors. Supernatant of T cell cultures from protectively immunized donors contained substantial macrophage-activating factor whereas such activity was not detectable in the supernatant of T cell culture from s.c. immunized donors. Analysis by flow cytometry showed that the spleen and lymph nodes of normal, i.v., or s.c. immunized BALB/c mice contained similar ratios of L3T4+ cells and Lyt-2+ cells.

Prophylactic immunization against experimental leishmaniasis. VI. Comparison of protective and disease-promoting T cells

In previous studies, we reported that mice immunized i.v. with lethally irradiated Leishmania major promastigotes developed substantial resistance to a subsequent L. major infection. However, such protection could be totally suppressed by prior s.c. injection with the same antigens. Both the protective immunity and the inhibition of its induction could be adoptively transferred with specific Lyt-2- T cells. Here, we present evidence showing that protection and disease promotion resulting from i.v. or s.c. immunization, respectively, are mediated by functionally distinct subsets of T cells. In a series of titration experiments, it was found that freshly isolated T cells derived from prophylactically i.v. immunized BALB/c mice were either protective (greater than 10(7) cells/recipient) or ineffective (less than 10(7) cells/recipient). No exacerbation of disease was observed at any dose. Conversely, T cells from mice immunized s.c. either accelerated disease development and inhibited protective immunization (greater than 10(7) cells/recipient) or had no effect (less than 10(7) cells/recipient). No protection was observed at any dose tested. In mixed transfer experiments, increasing numbers of T cells from s.c. immunized donors progressively inhibited the protective effect of T cells from i.v. immunized donors. Supernatant of T cell cultures from protectively immunized donors contained substantial macrophage-activating factor whereas such activity was not detectable in the supernatant of T cell culture from s.c. immunized donors. Analysis by flow cytometry showed that the spleen and lymph nodes of normal, i.v., or s.c. immunized BALB/c mice contained similar ratios of L3T4+ cells and Lyt-2+ cells.

Is there an interleukin 2 inhibitor in human serum?

Normal mouse serum has been shown to contain an inhibitor of interleukin 2 (IL-2). Here we report that a molecule with similar activity cannot be found in normal human serum (NHS). Although NHS inhibited the IL-2-dependent proliferation of mouse CTLL cells, as expected of an IL-2 inhibitor, it also had inhibitory activity on IL-3-dependent cells and was cytolytic to IL-2-independent mouse cells as measured by a 51Cr release assay, indicating a nonspecific effect. In addition, NHS had no effect on the IL-2-dependent proliferation of human peripheral blood T-cell blasts. Fractionation of NHS by size exclusion HPLC failed to separate cytolytic activity from any putative true IL-2 inhibitor activity. The cytolytic component was not related to immunoglobulin since it had a molecular weight of 50,000 to 60,000 and was not bound by protein-A-Sepharose. However, its molecular weight, heat lability, and trypsin sensitivity suggest it to be a protein.

The ultrastructure of the liver of the rainbow trout: normal structure and modifications after chronic administration of a polychlorinated biphenyl Aroclor 1254

Rainbow trout (Salmo gairdneri) were fed dietary levels of 0-, 1-, 10-, and 100-ppm Aroclor 1254 for 229 to 330 days. The ultrastructural features of control livers were similar to those of other animals, but rainbow trout liver differed from mammalian liver in an apparent absence of Kupffer cells. Also small dense duct-type cells were present that formed a transition zone, combining with hepatocytes to form canaliculi; alone they formed preductules and in combination with cells of lower density they formed ductules. Microtubules were found in the vicinity of canaliculi and less frequently adjacent to the plasma membrane of other cell surfaces. They were not seen at the sinusoidal border as they are in mammalian liver. Peroxisomes lacked nucleoids. There were no ultrastructural liver changes in the 1-ppm group. The most frequently encountered alterations in both the 10- and 100-ppm groups were those involving the nucleus. These included irregular and bizarre nuclear outlines, separation of nucleolar components, and large nuclear pseudoinclusions. Other frequently encountered changes were slight increases in smooth endoplasmic reticulum, altered rough endoplasmic reticulum, increased lysosomes, reduced and altered glycogen, increased lipid, and hypoxic vacuoles. Seen also were concentric membrane arrays, myelin figures in intercellular spaces and Golgi cisternae, and bundles of fine tubules throughout the cytoplasm.