Electronic prescribing: how it can improve the delivery of time critical medications

Phase 2: daily reports (2015 onwards)

Nick: Phase 2 began with another conversation with Richard. I asked if we could use electronic prescribing to alert us when patients came into hospital, and we could! Now, at 7am every morning, 365 days a year, we get a report for the previous 24 hours that tells us the patient’s name, their Community Health Index (CHI) number or their unique NHS number, their hospital and ward.

It also provides their prescribed medication for Parkinson’s, the time it’s prescribed, the time it’s given by the nurse, and the discrepancy between those 2 numbers. The report is colour coded to show if medications are being given within 30 minutes of the prescribed time. That’s been the biggest benefit to the Parkinson’s nurse team as that lets us know when our patients are in hospital, we can support them better and also support the nurses on the ward.

Phase 3: Parkinson’s medicines ward prompts (2018 onwards)

Nick: Next, we wanted to do more to help the patients on a daily basis on the ward. Just because we have the report, that doesn’t mean that we have the time to check it every single day. So in phase 3, we developed the Parkinson’s medication prompts, known locally as “the tulip system”. Simply, this utilises an electronic whiteboard or television on the ward with the patients’ names and bed numbers.

A tulip icon appears automatically on the board when the patient is prescribed Parkinson’s medications, so that staff on the ward don’t have to identify the patient or their unique patient number to know that a Parkinson’s drug is due. 

This is what the tulip icons look like, and what the colours mean:

A grey tulip icon means a patient is not due any medication.

A green tulip icon means that a patient is due their medication within 30 minutes. The icon will flash until medication is administered.

A red tulip icon means that a patient's medication is overdue.

Phase 4: electronic dashboard

Nick: In 2023 we introduced an electronic dashboard. This is another system but the systems that we have: our patient management system, electronic prescribing and the whiteboard, all talk to each other. This has never been done before, as far as I am aware.

This program accesses the data held in the electronic prescribing system to produce a dashboard which shows details of every Parkinson’s medication administration in NHS Ayrshire & Arran in the last 12 months.

With the dashboard, we can analyse a single ward, all the wards, or even certain disciplines like care of the elderly. We can even analyse how good we are at administering medication at certain times of the day. This helps us to drill down and work with colleagues on wards to understand the challenges and find solutions.

In the future, we can go further and develop our reporting using this information.

Can you explain the pharmacy team’s role in this work?

Richard: Pharmacy continually works with nursing staff to optimise the supply and administration of medicines within our hospital sites. My role within the pharmacy HEPMA (ePrescribing) team enabled us to take a new approach to looking at administrations of medicines using the data collected within our HEPMA system.

Over the years I've been able to develop the ways in which we can use this information in Parkinson's patients. Auditing performance relating to the administration of medicines, the whiteboard prompts and dashboards are only a few of the many benefits that HEPMA (ePrescribing) has given us.

Can you explain the role which the IT team has played in this work?

Richard: At NHS Ayrshire & Arran HEPMA (ePrescribing) is managed by pharmacy. To display information on the ward whiteboards, support from digital services was required as they maintain the whiteboard system. Essentially it was a shared piece of work with my team developing the method of getting the information required from HEPMA (the query) and Michelle’s digital services team building the way of displaying this into the whiteboards.

Many hospitals that have ePrescribing will not have whiteboards on the wards. How essential is this?

Nick:The whiteboards have been a great help as a tool which alerts staff when medications are due but they aren't essential. If you don’t have whiteboards an alert can be sent to a ward computer, tablet, or even a ward mobile phone, so there are other ways of receiving an alert.

Some of our wards do not have the whiteboard system so instead they use pill timers. The ward team will print out the medication times on a sheet, put it up in the nurses’ station and set pill timers which we supply them with.

Robert: The key thing is to let staff know when it is time to administer medication.

How have your colleagues in different teams across the hospital worked collaboratively to implement this?

Nick: We started this project by creating a focus group. You have to build relationships with colleagues in other disciplines.

The Communications team were vital because they kept colleagues across all hospitals informed about the project and how to get involved. 

How important has communication been to this work?

Nick: I’ve learned a lot about how to approach this over the years! We need to remember that these are busy wards and lots of colleagues still don’t know that Parkinson’s medications are time critical. You have to take people with you.

Now I phone the ward and say that I can see there is a difficulty with medications and ask how we can help them to deliver that a little bit better. The daily report is not used by us to police or castigate the wards. It is an aide to identify wards or specific times of the day within a ward that need attention.

We run Parkinson’s education days and offer training on the wards because you have to go to the people. Don’t expect them to be able to come off the ward. Education on the wards should be short, 5 or 10 minute sessions, at lunchtime.

As Parkinson’s nurses, we go to the wards to review patients. When we do that we talk to the nurse that’s looking after the patient and ask if they understand what the icon means. Do they understand that Parkinson’s medications are timely because of the way that medications are delivered and the half life of medications? It doesn't take long to remind someone of that because they probably never had training on this through their nursing career.

If you explain to a nurse that if they give medications on time their job will be easier because that patient can take themselves to the toilet, that is improving things for patients but also improving things for nurses!

Robert: We educated each group with the reasons why we were doing this and how beneficial it could be to our patients, who are central in this. When people understood that I would say we had almost complete acceptance.

Nick: Yes, when 1 or 2 people buy into the idea and start to improve their practice, then the numbers go up and they see that they are improving something. And that is when you start to see other people going along with it as well.

Do you have any advice for other hospital teams on how to gain support for ePrescribing to be used in their organisation?

Nick: Use our data as an evidence base. It shows that there can be a change. In our case, it wasn’t a fast change because we had to create the systems but hopefully, that will be different with you and it can be implemented more quickly, in a controlled manner.

Electronic prescribing will be everywhere eventually. You can use this evidence to show why electronic prescribing should come earlier.

Explain that this did not cost the NHS any money. There is no ongoing cost to the NHS because this system is running in the background and the whiteboards were already there.

Robert: It's a great way of improving patient care and it’s free. It’s not so much when you’re doing it, why are you not already doing it? Ask the folk who are the most important: the patients.

What can teams that don’t have ePrescribing yet do to improve the delivery of time critical Parkinson’s medications?

Nick: Go back to basics, as part of your ward handover meetings at the end and beginning of a shift discuss that the person’s medications are due in a timely manner. Make the timings clear in your ward handover or your SBAR communication sheet.

Improve access to Parkinson’s medications, especially out of hours. We improved the emergency cupboards and created emergency stores on wards in smaller hospitals. Now we don’t have every drug but we do have smaller versions of drugs such as ropinirole 2mg. This means that we have medication available on the wards if someone comes into hospital and doesn’t have their medication with them.  

We also worked on the local intranet. Now staff can go into the pharmacy on the intranet, type in a drug and it will tell them which ward has it. This means that they can go to that ward and get a small supply if the emergency cupboard does not have the drug that the patient needs. 

What have you learned through doing this work?

Nick: Don’t panic every time you look at the daily report and a patient got their medication late. Be realistic that you can’t fix everything.

I hope I’ve learned to be constructive when I’m talking to people and support the wards. There are so many people that have come along with us, ward staff, ward managers, nurses, pharmacy staff, digital services, patients, and relatives. They are very busy but we have proved that we can make a difference, even on our busiest wards.

Robert: The system isn’t a panacea for poor care. Good care is enhanced by it and it will show up bad care because statistically, you cannot hide from it. But that is not necessarily a bad thing if you then use it to improve patient care.

The patients on the ward know how important it is to get their medications on time. Knowing that there is a system in place gives them the reassurance that they are going to get their medications on time. This increases patient trust and helps their patient journey.