Background

Western Avenue Medical Centre in Chester, with a patient population of just under 4,000, was keen to increase patient safety by conducting face-to-face medication reviews with patients.

Action

Our Medicines Management and Optimisation (MMO) Team deployed a clinical pharmacist (non-prescribing as requested) to work for a total of 25 four-hour sessions. The pharmacist conducted 30-minute face-to-face medication reviews targeting patients with 10 or more medications on their record who had not attended for an annual review within the last six months. Patients were asked to bring along all their medications to the review appointment.

The review process involved:

• educating patients about what each medication was for
• assessing current compliance and concordance with dosage instructions
• aligning medication
• reviewing necessary monitoring requirements
• assessing other medication purchased over-the-counter (OTC)
• counselling patients about possible medication changes (for example dose reductions)
• referring patients to other services (for example counsellors or smoking cessation).

The pharmacist worked closely with the GPs, offering prescribing advice to ensure patients’ medication was optimised. Trends observed were discussed with the practice as areas for further audit to either implement procedures or raise awareness with all clinicians.

Impact 

The medication reviews carried out by our pharmacist enabled the practice to make optimum use of clinician time, improved patient experience of healthcare and improved the quality and safety of prescribing.

From 80 face-to-face reviews there were a total of 241 separate quality interventions and an additional 33 cost-saving interventions saving £802.45.

Several practice medication audits were developed as a result of the pharmacist interventions, including:

• review of rheumatoid arthritis patients and QRISK
• eGFR<30ml/min and dose of simvastatin
• denosumab monitoring requirements for prescribing
• clopidogrel and aspirin co-prescribing
• consideration about how best to inform patients prescribed DAMN drugs (diuretics/ACEI/ARBSs/Metformin/NSAIDs) about sick day rules and risks of acute kidney injury
• targeting and assessing all patients for a QRISK2 assessment following updated NICE guidance for lipid modification.

The individual patient reviews raised awareness amongst the GPs of the need to consider dose reduction of long term PPIs and also opiates when patients present for an appointment, and to consider drug monitoring if OTC medication, for example NSAIDs and U&Es, is taken regularly. 

Clinically significant individual interventions included:

• a breast feeding mother prescribed fluoxetine
• mirabegron in an undiagnosed hypertensive patient
• follow-up blood tests for a bariatric surgery patient who hadn’t had one
• nicorandil in a patient with several severe mouth ulcers
• dose of citalopram/escitalopram in the elderly
• metoclopramide restrictions for the number of days of treatment.

[The CSU pharmacist] quickly integrated with the team and worked closely with the GP Partner to establish aims and develop the role.  Feedback from patients was extremely positive.  [She] always made appropriate changes to medication and prioritised patient safety.  [She] also took into consideration the wider health needs of the patient, and often encouraged and arranged for patients to attend for blood tests and annual health reviews for chronic disease.  [She] showed great attention to detail and was extremely professional at all times.”

Jamie Ducker | Practice Manager, Western Avenue Medical Centre, Chester