THE STATE HOSPITALS BOARD FOR SCOTLAND ANNUAL REPORT. Medicines Committee. Reference Number

Transcription

1 THE STATE HOSPITALS BOARD FOR SCOTLAND ANNUAL REPORT Medicines Committee Reference Number Lead Author Contributing Authors Morag Wright Jill Kerr, Clinical Effectiveness Issue: Approval Group Medicines Committee Effective Date November 2016 Review Date November 201 Responsible Officer Professor Lindsay Thomson (e.g. SMT lead) Medicines Committee Report

2 Table of Contents Page 1. Chairperson s Foreword 3 2. Governance Arrangements 3 3. Key Pieces of Work 4 4. Key Performance Indicators Comparison with Last Annual Report Areas of Good Practice 12. The Patients Voice Future Areas of Work 13. Next review date 13 Appendix 1 Medicines Committee Report

3 1 Chairperson s Foreword It has been a productive year for the committee with the Pharmacy department continuing to work efficiently both in making savings from the medicines budget and in making more effective use of staff time. I would highlight the initiative to have pharmacy staff at the GP clinic. This has been well received by our GP colleagues and has led to a dramatic decrease in prescription sheets needing correction by psychiatrists on the ward. The Medication Incident Bulletin for staff was well received, making good use of practical examples of where medication errors have occurred and how to avoid such perils. Patients have welcomed the implementation of Medicines: A Patient Profile Summary (MaPPs). This contains individualised medicine information in a format that patients can read and understand. Guidance has been produced for the safe use of medication in the treatment of erectile dysfunction which is now being taken forward at Forensic Network level. Dr Natasha Billcliff Please note this annual report covers extended data (>12 months) to the end of September where possible to ensure Clinical Governance have up to date information at the time of approval of this report. 2 Governance Arrangements 2.1 Committee membership Dr P Apurva, Consultant Psychiatrist Dr N Billcliff, Consultant Psychiatrist (Chair) Dr J Murie, General Practitioner Dr B Prasad, Speciality Doctor Mr I Rodger, Practice Development Mrs S Smith, Clinical Effectiveness Mrs C Topping, Practice Nurse Mrs J McWilliam, Clinical Pharmacist Mrs M Wright, Lead Pharmacist Minute Secretary: Mrs Avril Adamson, Medical Secretary Dr P Myatt, Consultant Psychiatrist, stepped down from the Committee in December 2015 due to his pending retirement. Dr N Billcliff has taken over as Chair and Dr P Apurva has been welcomed as a new member. 2.2 Role of the committee The role of the committee is to help improve the quality and cost effectiveness of prescribing. This along with the objectives below is in line with the 14 Health Board Area Drug and Therapeutic Committees (ADTCs). In relation to formulary choices and for new medicine guidance the State Hospital as a Special Health Board (out with ADTC network) links in with NHS Lothian ADTC decisions. The Medicines Committee has now better links to the ADTC Consortium with regards Scottish Government workplan and priority developments. Medicines Committee Report

4 2.3 Main objectives of the Committee To promote safe, effective and economic use of medicines To advise, monitor and coordinate the production of policies and procedures relating to drug prescribing and safe administration of medicines. To determine and operate a system to ensure full evaluation of new medicines before introduction to the hospital. To monitor drug expenditure within the hospital and provide information on good practice for the optimal use of medicines. To advise the Clinical Forum on ethical issues relating to medicine use. 2.4 Meeting frequency and dates met Meetings are held every 2 months and over the last year this target had been met. 2.5 Strategy and workplan The workplan of the committee is largely based around four key areas which emanate from strands of the Local Delivery Plan. These are: Medicines Management expenditure, formulary developments, Scottish Medicine Consortium guidance, unlicensed medicine usage, Individual Patient Treatment Requests (IPTR), product supply problems Safe Use of Medicines policy updates, treatment guidelines, medication incidents, drug safety data, patient group directions (PGDs) Clinical Effectiveness local and national clinical audits, gap analysis of national guidelines (SIGN, NICE) Patient Safety liaising with local Patient Safety Group and also national Scottish Patient Safety Programme (SPSP), medicine management workstream on priority topics e.g. medicines reconciliation, high risk medicines 2.6 Management arrangements The committee reports directly to the Clinical Governance Committee 3 Key pieces of work undertaken during the year 3.1 Medicines: A Patient Profile Summary (MaPPs) MaPPs is a webbased Medicines Management Service which aims to support organisations, improve medicine taking and understanding of all mental and physical health medicines. It contains clear, consistent, up to date, high quality medicine information in a format that patients can read and understand. The Senior Management Team agreed for the hospital to fund MaPPs in Since then patients have received individualised summary information for their case reviews (84%) and are able to access adhoc information if appropriate when a new medicine is due to start. 3.2 Guidance for Use of IM Medication for Acute Behavioural Disturbance Following guidance from NICE on rapid tranquilisation the hospital, as well as other areas in Scotland, have reviewed use of IM medication for acute behavioural disturbance. The main changes include: patients must have an individualised treatment strategy for such events that is logged in their CPA document and only one medication type should be administered each time (combined therapy was suggested previously). An audit into adherence will be taken forward during 201. Medicines Committee Report

5 3.3 Medicines Management Support to GP Clinic In order to help support the GPs at the Health Centre clinic Pharmacy staff are now present to be able to advise on formulary/product choice and contribute to advising on prescription writing in line with Safe Use of Medicines Policy. An agreed framework for this initiative was produced via the Medicines Committee in February Since it has been introduced it has received a positive response from GPs and there has been a reduction in the number of psychiatrist prescription changes required at ward level around physical health medicines. 66 corrections were made at pharmacy staff s request within the GP clinic in the first 6 months 3.4 Pharmacist Independent Prescribing The hospital supported registration of the first Pharmacist Independent Prescriber who finished the qualification course in May Implementation is now underway in Iona Hub. From a Clinical Governance perspective a prescribing framework has been agreed through the Medicines Committee of which areas within competency the Pharmacist is able to prescribe in. These primarily include initiation/change of psychotropic therapy as agreed with Responsible Medical Officer (RMO) and medicines to treat psychotropic medicine side effects 3.5 Clinical Effectiveness Clinical Audit Projects National Prescribing Observatory in Mental Health (POMH) Projects These are national benchmarking projects that The State Hospital now participates in as part of the Forensic Network (code 5). The funding, coordination and data input of the projects sits with The State Hospital. Primarily these are facilitated by the Clinical Effectiveness Department. Junior medical staff are often involved with the data collection. One project has been completed this year (Monitoring Patients on Lithium reaudit). The report is due in November. The other project (Rapid Tranquilisation) is currently underway with data collection Clinical Audit Projects Local Adherence to Antimicrobial Formulary 16 patients were prescribed antimicrobials during the audit period (02/03/2015 to 26/04/2015). There were, in total, 20 treatment episodes as 3 patients were given more than one antimicrobial during the audit period. Results show a high level of compliance with NHSL empirical policy and formulary with clear documentation in relation to treatment agent choice and duration. The most common indications continue to be for skin and respiratory complaints. Consent to Treatment Reaudit This continued to show improved adherence to Mental Welfare Commission standards. No major concerns. As required Psychotropic Reaudit The final report showed that 101 out of 123 patients (82%) were written up for psychotropic (antipsychotic or benzodiazepine) PRN medication and 23 were administered it during the 4 week audit period (23%). Only 3 patients received an IM preparation. There has been a significant reduction of prescribing of PRN IM antipsychotic medication from previous years. A contributory factor is that IM emergency medication is no longer allowed on a T2 Consent to Treatment form so in appropriate cases it has been discontinued from prescription sheets. There is also general veering away from unnecessary routine PRN prescribing in line with practice across the country. Post injection observation and physical health monitoring recording however was highlighted as an area of improvement and this has been incorporated into the new guidance in 3.2 Medicine Trolley ReAudit A reaudit looking at the systematic layout of medicines in the ward trolley to help prevent administration errors (2015) showed improvement in most wards. The 2016 reaudit results are Medicines Committee Report

6 currently being evaluated. Initial results show there may have been some slippage. This will be addressed. Prescription Sheet ReAudit A final report will be going to the Medicines Committee in November but the initial results show good adherence to standards in the Safe Administration of Medicines Policy. This year it also incorporated in reasons for missed doses to help inform the patient safety work. As thought these tend to be related to topical preparations and laxatives Implementation of National Clinical Guidelines & Standards Over the last 12 months (1 October 2015 to 30 September 2016), there were 2 guidelines reviewed by the Medicines Committee. One of these was a guideline from the National Institute for Health and Clinical Excellence (NICE) which was covered by a similar Scottish guideline. There was a recommendation review carried out for the remaining guideline (see details below). Body Title Current Situation NICE 46 Controlled drugs: safe use and management 5% compliance achieved with 2 outstanding recommendations. One recommendation regarding commissioning an audit into standard operating procedures has been completed. The remaining recommendation covers communication with patients and is being added into the Safe Administration of Medicines policy In addition, 58 NICE Medication Technology Appraisals (MTA s) were reviewed. These 58 MTA s were deemed to be either not relevant or were covered by a similar Scottish guideline. As these 58 MTA s were released by NICE, that are English based, both Clinical Effectiveness and Pharmacy are involved in the process of reviewing these against medications released by the Scottish Medicines Consortium. The Physical Health Steering Group also sought the Medicine Committee s input in the recommendation review process of a guideline entitled The management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. As this guidance was released by the British Association for Psychopharmacology it would not normally have been automatically reviewed however given that the topic was considered extremely relevant a gap analysis was completed. Medicine considerations are being taken forward via the Supporting Healthy Choices Implementation Group. Pharmacy staff are also members of other professional groups that review guidelines/standards and can complete the medication components of these. 3.6 Scottish Patient Safety programme (SPSP) There is now a specific Medicines programme focusing on Medicines Reconciliation and high risk medicines. The Hospital has a robust medicines reconciliation process at both admission and discharge plus a recent gap analysis of medicines topics suggests the hospital covers many of the areas identified. Error free prescribing and looking at omitted doses are two areas where progress has been made in the last year 3. Electronic Prescribing SMT accepted the recommendation that the hospital should not go alone with an electronic prescribing module (linked to RiO) that had not been recognised for use in NHS Scotland by the Scottish Government. The alternative was to be included with the national business case. Work is now underway at a national level to deliver this. Medicines Committee Report

7 3.8 Glasgow Antipsychotic Side Effect Rating Scale (GASS) After testing on Mull this scale is to replace LUNSERS that was currently used to rate the level of side effects patients experience from their antipsychotics. Roll out is currently underway. 3. Safe Use of Medicines Policy and Procedure An update of this policy is due to go to SMT for approval shortly. The changes are either due to service development or in response to medication incidents Diabetes Work continues to ensure the diabetic population in the hospital receive appropriate treatment and monitoring regimes Vitamin D The committee has endorsed continuing with the current vitamin D dosing regime in place in order to get patients into the adequate target range as demonstrated through the local vitamin D study Erectile Dysfunction The use of medication to treat the sexual side effects of antipsychotic medication has been discussed and is now being taken forward as a Forensic Network issue Adrenaline for Anaphylaxis Prefilled automated devices are now available in the correct strength to treat anaphylaxis in the hospital environment. For ease of administration they have replaced the ampoules in the medical emergency drug bags. 4. Key Performance Indicators 4.1 Medicines Expenditure Monthly invoices continue to be checked and authorised by Pharmacy against Royal Edinburgh Hospital Medicines Management reports. A live electronic link to NHS Lothian streamlines the medicine ordering process. 1 st and 2 nd quarter totals 6 months 16/1 (Baseline budget 115,50) Total Apr 15 Mar 16 (Baseline budget 231,500 reduced by 5,000 recurring) Stores 6,30 158,24 Dispensary,662 20,10 Clozapine Dispensing 6,30 13,85 TOTAL 85,82 12,26 Budget target 101,50 202,1 Savings to target 15,68,41 Savings from baseline 2,68 38,4 For the year 2015/16 the medicines budget contributed 38,4 nonrecurring and 5,000 recurring to hospital savings. For 2016/1 so far the medicines budget has met the full year s savings ( 28,000) at 6 months. Potential future financial pressures on the medicines budget are highlighted to SMT through regular quarterly meetings with finance. Current pressures lie with an increased use of the newer long acting antipsychotic injections, a rapidly growing range of new antidiabetic medications and other specialist physical health medicines. Continuous savings are therefore becoming more challenging. Medicines Committee Report 2016

8 The top monthly expenditure remains with the long acting atypical antipsychotic injection paliperidone. Other items in the top 20 include further atypical antipsychotics, vitamin D, antidiabetic medications and testing strips, nicotine replacement therapy, procyclidine. Some individual patient physical health items are also present. The committee has actively reviewed these products and made local changes as appropriate to reduce costs where possible. In 2004/05 there were approximately 22 patients in the hospital. This was an average spend of 222 per patient per month. The average now is 120 per patient per month. Primarily this is due to availability of generic products although tight formulary management has also impacted. Some patients receive specialist treatment via Infection Control services in Lanarkshire for hepatitis C. The hospital is able to cross charge patients home health board for these high cost medicines as they are very effective and prevent serious liver disease further down the line. Each year an annual stock take is performed to calculate the cost holding of medicines in the hospital. At the end of March 2016 this was totalled at 15,088, down 5,000 from March (Information from procurement) 4.2 Prescribing reports Six monthly prescribing reports on antipsychotic medication are reported to the Consultant group. These are used to identify patient outliers who may be receiving unusual antipsychotic regimes. Peer review discussion then takes place on these more complex medication combinations. A selection of reports is available with a summary table as shown below: Average daily doses of oral atypical antipsychotics per patient for each consultant Number of patients per consultant on each oral atypical antipsychotic Number of patients on high dose antipsychotics per consultant Number of patients on multiple antipsychotics per consultant Medicines Committee Report

9 e.g. No. Patients on oral atypical antipsychotics and average daily doses Amisulpride Aripiprazole Clozapine Olanzapine Quetiapine Risperidone Lurasidone Jan 2012 (134) Jul 2012 (134) Jan 2013 (13) Jul 2013 (133) Jan 2014 (12) Jul 2014 (126) Jan 2015 (122) Jul 2015 (123) Jan 2016 (126) Jul 2016 (11) ( ) number in brackets = total number of patients in the hospital The average daily dose of clozapine has decreased over the years due to introduction of more frequent plasma monitoring and awareness of side effects at higher levels. The smoke free programme contributed to this closer monitoring of plasma levels to prevent toxicity from altered metabolism. Awareness of the risk of relapse when clozapine patients maybe start smoking again in a smoking environment is highlighted at transfer CPA meetings. There is still some use of the older antipsychotics often as part of a combination regime in patients with complex regimes. Number of Patients on Regular Oral Typical (older) Antipsychotics Chlorpromazine 5 (2 in a combination regime) Haloperidol 4 (1 in a combination regime) Sulpiride 2 (1 in a combination regime) Trifluoperazine 1 (combination) Zuclopenthixol 2 (1 in a combination regime) Medicines Committee Report 2016

10 Number of Patients on Depot/Long Acting Injections Product No.Patients 2016 No.Patients 2015 No.Patients 2014 No.Patients 2013 Flupentixol Fluphenazine Haloperidol Olanzapine Risperidone Paliperidone Zuclopenthixol TOTAL 16 (14%) 21 (1%) 23 (1%) 2 (21%) There has been a decrease in the number of patients on long acting antipsychotic injections from the last three years, mostly around zuclopenthixol depot. The second generation long acting injection paliperidone has now levelled out. This product tops the monthly list of high cost items. Consultant Peer Review Prescribing Reports Regular Antipsychotics Local Delivery Plan Target no more than 20 patients to receive regular high dose antipsychotic regimes Please note patients can fall into both categories if they are on 2 or more antipsychotics and are receiving these in high dose Consultant High Dose (HD) Antipsychotics 16 Multiple Antipsychotics 1 A 1 patient olanzapine + amisulpride B 1 patient olanzapine monotherapy 3 patients clozapine + amisulpride haloperidol depot + aripiprazole * C 1 patient 1 patient (HD) clozapine + olanzapine D 1 patient 1 patient (HD) olanzapine + aripiprazole E 1 patient clozapine + sulpiride F 5 patients quetiapine monotherapy olanzapine + chlorpromazine * olanzapine monotherapy paliperidone LA injection + 3 patients (HD) Medicines Committee Report

11 G H I J risperidone * zuclopenthixol tabs + chlorpromazine* 2 patients quetiapine + aripiprazole * olanzapine + amisulpride 1 patient paliperidone LA injection + risperidone * 3 patients olanzapine max + prn s clozapine + aripiprazole zuclopenthixol depot + aripiprazole (for physical side effects) 2 patients olanzapine monotherapy clozapine + amisulpride 4 patients (2 HD) aripiprazole + haloperidol + trifluoperazine)* clozapine + aripiprazole 2 patients (1 HD) clozapine + aripiprazole 2 patients (HD) 1 patient (HD) *Regimes not listed in refractory schizophrenia The Maudsley Prescribing Guidelines 12 th Edition 4.3 Non Formulary Medicines Use Reports from the pharmacy medication database allows monitoring of all regular non formulary items prescribed. Overall, as a percentage of total prescribed regular medicines, nonformulary items account for less than 5% of all regular prescribed medication. The pharmacy department continues to monitor adherence to formulary in the GP prescribing for both short and longer term medicines with ongoing excellent adherence. Antibiotic prescribing adherence to the Lanarkshire antimicrobial formulary continues to be monitored and reviewed (see section 4.6). An IPTR process is available for non SMC approved medication requests (see section 4.5) 4.4 Unlicensed/Off Label Prescribing The list of unlicensed and off label medicines accepted for use within the hospital is available on the intranet. The medicines committee reviews requests for unlicensed or off label medicines (as per hospital policy). Our main use of an unlicensed medicine continues to be pirenzepine for the treatment of clozapine induced hypersalivation. 4.5 Individual Patient Treatment Request (IPTR) Applications No IPTR applications have been submitted for review by the Medicines Committee and Senior Management Team this year although there is continuous review of those previously authorised. IPTR is to be replaced by the Scottish Government to a new national system to be applied locally which will be clinically led. There will be standard application forms for NHSScotland. 4.6 Antimicrobial prescribing The State Hospital has a Service Level Agreement with NHS Lanarkshire for the provision of sessional input from an Antimicrobial Pharmacist who is also a member of The State Hospital Infection Control Committee. There is also close liaison with the onsite pharmacy team and Medicines Committee. Three monthly usage reports continue to be produced for the Infection Control and Medicines Committee. Adherence to the antimicrobial formulary has been shown to be excellent Prescribers have embraced the policy which minimises use of cephalosporans, quinilones, coamoxiclav and clindamycin (antibiotics more associated with Clostridium difficile infection) into daily clinical practice and this is evidenced through annual audit. 4. Controlled Drugs All controlled drug supplies continue to be monitored and any anomalies recorded through the DATIX system. The Associate Medical Director is the named Accountable Officer for the Board Medicines Committee Report

12 and the Lead Nurses have been newly appointed as responsible persons to witness any controlled drug destructions necessary on site. 4.8 Medication incidents Type of Incident Apr 15 Mar 16 Apr 16 Sep 16 Dispensing/supply problem, including 2 Supply not on ward Clozapine labelling error Administration, including 11 Medicine continued to be administered after it had been stopped Wrong dose given Wrong route recorded as being given Prescribing, including 6 2 Transcribing errors Prescription not signed No administration time Patient Noncompliance 3 Other 2 TOTAL 3 14 There were 32 incidents in With regard to selecting the correct medicines from the medicine trolley there was a piece of work done through the patient safety group to ensure medicines are placed in alphabetical order and from lowest strength to highest. A new prescription sheet is being implemented following a response to an incident around the prescribing of ONCE only medicines. A Medicine Incident Bulletin was created to improve feedback to staff see appendix 5. Comparison with last annual report Update from the future areas identified last year please refer to key areas and key performance indicators. Medicine Expenditure This continued to deliver savings although reduced patient numbers have assisted this year. The committee needs to keep abreast of developments and new treatments especially for physical health issues (4.1) Medicines: A Patient Profile Summary (MaPPs) Use of this information source has been delivered to patients (3.1) Electronic Prescribing The hospital agreed the way forward was via the national business case. Papers have recently been issued from the Scottish Government to aid Health Boards progress (3.). Rapid Tranquilisation Review This has been completed and implemented with new guidance (3.2) Pharmacist prescribing First candidate has been successful on this qualification. Implementation is underway (3.4) Patient Safety Programme The Medicine Committee continue to work with the hospital Patient Safety Group on the national medicines management workstream (3.6). GASS implementation Switch from LUNSERS currently in progress (3.8) Medicines Committee Report

13 Change of medicine supplier Due to legislative changes around wholesale dealer licenses there will require to be a change of where the hospital receives its medicine from. The hospital agreed with the proposal that supplies should stay from NHS Lothian but transfer to St John s hospital who hold the necessary wholedealer license. This transfer work continues to be delayed due to upgrade building work, Home Office Licence application and other workload pressures at St Johns. 6. Areas of good practice Overall the hospital can be assured that processes continue to be in place for the safe and effective use of medicines. These are evidenced with regular monitoring, review and audit. The new initiative with the GP clinic has certainly been welcomed by all.. The Patients Voice Patients have greater access to information on their medicines via the new MaPPs documentation and Choice and Medication leaflets. In addition there has been a continued increase in the percentage of patients discussing their medicines with a pharmacist as part of the multidisciplinary team. This is evidenced via monthly VAT data. There continues to be feedback to clinical teams on issues raised by patients at the clozapine clinic on side effects of their medication as well as direct access to a dietician at the clinic. All medicine policies are referred through the Patient Partnership Group for comment if appropriate. 8. Future areas of work As well as the regular workplan the following areas are to be addressed: Policies for Update and Approval The Safe Use of Medicines Policy and Procedures, Unlicensed/off label Medicines Policy and Individual Patient Treatment Request (IPTR) policies are all up for review. Healthy Choices Implementation To contribute to guidance on the use of medicines that consider best options for individual patients around metabolic syndrome and weight gain. Electronic Prescribing The Committee will engage as necessary with progressing towards this national ehealth target. Clozapine via Nasogastic tube The Committee is developing a policy for administration of nasogastric clozapine in the rare event that this option may be considered as a way forward for a patient. It would require Mental Welfare Commission approval. Change of medicine supplier will also continue to move forward. Next review date The next review date for Clinical Governance is November 201 Medicines Committee Report