Introduction of a pharmacist prescriber to a heart failure service
Heart failure (HF) is a complex condition, with a poor prognosis and a considerable impact on quality of life. The condition affects around 900,000 people in the UK, and almost the same number of people have damaged hearts but no symptoms. HF accounts for around one million inpatient bed days, 2% of all NHS inpatient bed days and 5% of all emergency admissions.1
The annual cost of HF to the NHS is around 2% of the total NHS budget, with 70% attributable to hospital admission — readmissions are common.2–4 Of all patients diagnosed with HF, 30–40% die within a year and thereafter mortality is under 10% per year.1 Evidence suggests that the prognosis has improved in the past 10 years, with the six-month mortality rate reducing from 26% in 1995 to 14% in 2005.5
Enhancing the service
At the Countess of Chester Hospital NHS Foundation Trust (COCH), the HF service for inpatients has been developed to support the improvement of patient outcomes via advancing quality (AQ) targets. The AQ programme aims to improve standards of healthcare provided in NHS hospitals across the north west of England and reduce variation by defining quality standards to measure good clinical practice.6
The programme provides incentives for hospitals to reduce HF mortality by ensuring that patients are prescribed angiotensin-converting enzyme (ACE) inhibitors and beta-blockers, and are counselled on discharge regarding HF and smoking cessation (if applicable).6 In the past, a full-time HF specialist nurse provided this counselling and collected AQ data.
As the lead specialist pharmacist in cardiology with experience working in a multidisciplinary cardiology team, I was keen to develop the HF pharmacist role and was supported in this by the business manager for cardiology, the pharmacy clinical services manager, cardiologists and the heart failure specialist nurse.
It was hoped that the HF service could be redesigned to extend its scope beyond AQ targets and become more proactive, including clinical assessment and prescribing, and that it would be led by the HF specialist nurse and a newly created role — the HF specialist pharmacist.
Defining the role
The service was redesigned to include eight hours of pharmacist time (two hours a day, four days a week) to work alongside a specialist nurse. We both qualified as independent prescribers and, in addition, I completed a clinical examination course.
During this training I worked closely with the multidisciplinary team to build my own confidence, and to gain the confidence of the team in my clinical examination skills and prescribing decisions. I was mentored by a consultant cardiologist, who provided valuable support and guidance.
As the HF specialist pharmacist, my role is to review patients from across COCH with left-ventricular systolic dysfunction (ejection fraction £=40%) who are referred to the HF team; patients who do not meet this criterion are reviewed by my nurse colleague. Patients are referred from across the trust, not only from cardiology services. My review includes:
- Taking a full patient history, including review of information from case notes, and assessing all results, including echocardiogram, electrocardiogram, blood test results, chest X-rays, fluid balance and oxygen saturations
- Performing a cardiorespiratory clinical examination, including assessment of peripheral oedema, jugular venous pressure and heart sounds
- Developing an impression and plan, which can involve initiating and titrating HF medicines and advising on other medicines
- Discussing complex patients with medical staff
- Referring patients to other healthcare professionals, if needed
- Referring patients to the community HF team
- Completing AQ data collection
Facing the challenges
This role has taken me out of my comfort zone and, although I found it daunting at first, it has been a hugely rewarding experience now that some initial challenges have been overcome. My biggest challenges were:
- Fear of doing something new — examining patients and prescribing independently were skills I had to learn, and it took me a while to adjust to the responsibility that comes with these activities
- Patient examination — as a pharmacist I had little experience of physical contact with patients and performing clinical examinations, but this was quickly overcome with practice
- Interpreting clinical findings — these were new skills to acquire and ongoing learning alongside the team is essential
- Presenting cases — to get advice from consultant colleagues I must have a clear understanding of the facts of a particular case and be able to present them clearly, both of which I have improved with practice
- Time management — although hours were increased to accommodate the new role, juggling roles was inevitable and, at times, difficult
- Complicated patients — many patients referred to the service are complex and making sure that each patient is considered as a whole, rather than as someone with HF only, is crucial, particularly for those with multiple comorbidities
- Attitudes of clinicians — I have worked hard to build professional relationships and gain the trust of the healthcare professionals I am working alongside; from the beginning, the cardiologists were supportive of the development of this service and I focused on gaining the trust of other colleagues, some of whom were surprised that I was a pharmacist
Preliminary data were captured for the first nine months of the service, incorporating 252 patients with left-ventricular systolic dysfunction referred to the HF team in 2010–11 and 187 patients for 2011–12.
Length of stay and readmission There was no difference in length of stay after the new service was introduced but readmissions of patients with HF were reduced from 15.5% to 11% overall (see Figure 1).
|Figure 1: Readmission to hospital of patients with heart failure after discharge |
Medicines on discharge Each patient with HF should be discharged taking a beta-blocker and an ACE inhibitor, unless contraindicated or omitted for clinical reasons. After the service redesign, the number of patients inappropriately discharged without these medicines was reduced (see Figure 2).
|Figure 2: Percentage of patients inappropriately discharged without the recommended medicines|
Pharmaceutical care As a pharmacist, my general and specialist knowledge of medicines is of huge benefit in this role. Rather than looking at HF in isolation, I am able to consider comorbidities and concomitant medicines and help individualise treatment. Many HF patients have renal impairment, and providing advice on how to manage these patients is a key part of ensuring optimisation of treatment.
Being a pharmacist lends itself to prescribing — over the first nine months of the redesigned service, I prescribed more often than my nurse colleague — 69% (81 prescriptions) compared with 31% (37 prescriptions) — despite having fewer hours dedicated to the service.
My nurse colleague spent a large proportion of her allocated 30 hours per week managing referrals to the service, counselling and reviewing patients who did not meet the criterion for pharmacist review.
In these first nine months, 57 pharmaceutical interventions were recorded in addition to the usual pharmacy service. These interventions included providing specialist advice around cardiac medicines and conditions, managing interactions and contraindications, and managing complex patients.
Patients were identified with new atrial fibrillation, acute coronary syndromes, valvular problems and severe congestive HF. These patients were referred for cardiology review or transferred to a cardiology ward for specialised care.
Working as part of a team makes it difficult to isolate clearly and quantify the impact of the HF pharmacist role; we have also found it difficult to analyse data from patients referred to the service due to problems with coding that are currently being addressed.
The key learning point for me has been around continual development of examination skills and clinical knowledge. As undergraduates and postgraduates, pharmacists have a good understanding of physiology and this made my transition to a role that required clinical examination skills relatively straightforward, despite my early discomfort.
Knowledge gleaned from clinical examination also helps greatly when discussing cases with medical staff, which helps them gain confidence in the skills of prescribing pharmacists.
Funding has been provided to increase the pharmacist time from eight to 15 hours per week, and audit and research will continue. Plans to include the HF specialist pharmacist role in outpatient clinics, to identify new patients with HF from primary care, are in place. I am also involved in developing the HF service in ambulatory care.
ACKNOWLEDGEMENT Thanks to Chris Green, director of pharmacy at Countess of Chester Hospital NHS Foundation Trust.
Joanne Bateman is lead pharmacist for cardiology at Countess of Chester Hospital NHS Foundation Trust.
1 National Institute for Health and Care Excellence. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. August 2010. www.nice.org.uk/cg108 (accessed 8 February 2013).
2 Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long term implications on readmission and survival. Circulation 2002;105:2861–6.
3 Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation; 2002.
4 Cleland JG, Swedberg K, Follath F, et al. The EuroHeart Failure survey programme — a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. European Heart Journal 2003;24:442–63.
5 Mehta PA, Dubrey SW, McIntyre HF, et al. Improving survival in the 6 months after diagnosis of heart failure in the past decade: population-based data from the UK. Heart 2009;95:1851–6.
6 North West NHS. Advancing quality targets. www.advancingqualitynw.nhs.uk (accessed 8 February 2013).
Citation: Clinical Pharmacist DOI: 10.1211/CP.2013.11127254
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