Pharmacy best practice in Scotland – written case studies

Pharmacist prescribing of antivirals during COVID

NHS Greater Glasgow and Clyde

During the COVID-19 pandemic, there was an urgent need to safely prescribe antivirals for patients with COVID-19 in the community who were at highest risk of progression to severe disease.

NHS Greater Glasgow and Clyde’s pharmacy team innovated at pace to introduce the antiviral prescribing service.

When a patient on the high risk list for COVID tested positive, they received a text message asking them to contact an Advanced Nurse Practitioner (ANP) for clinical assessment.

The ANP then assessed eligibility before passing the patient to a pharmacist prescriber.

The pharmacist then assessed the patient’s suitability for antivirals or monoclonal antibody to treat coronavirus (either Paxlovid, Sotrovimab or Molnupiravir).

“Pharmacists are uniquely skilled in assessing and managing drug interactions.”

Following assessment and consultation with the patient, the pharmacist, if appropriate, would prescribe the antiviral, which would then be dispensed from one of 15 community pharmacies in the region for collection or delivery.

More than 160 pharmacists have been involved in the service, treating more than 3,000 patients. At the height of the pandemic, pharmacists were reviewing and prescribing for up to 70 patients a day.

The feedback from patient who were often anxious about their high-risk status and positive test result was excellent. Pharmacists are uniquely skilled in assessing and managing drug interactions, making them ideal professionals to lead on this work.

Audrey Thompson, Lead Pharmacist, Prescribing, NHS Greater Glasgow and Clyde

Email: [email protected]

Implementing pharmacogenomics in the stroke service

NHS Tayside

The NHS Tayside stroke service is using pharmacogenomics to deliver person-centred, and more effective, care to patients.

Clopidogrel is recommended for treatment in UK clinical guidelines following an (non-cardioembolic) ischaemic stroke. It stops platelets sticking to each other so reduces the risk of blood clots. It only works if it is metabolised by the body into an active drug that has a clinical effect.

“The patient receives personalised medicine and therefore more effective care.”

When a patient is admitted to the stroke ward, an investigation and assessment is carried out. The clinical pharmacist on the stroke ward orders a genomic test for enzyme CYP2C19 (which is the most important enzyme to support metabolisation of Clopidogrel).

The pharmacists then reviews the result. If the patient’s clopidogrel metabolism is not impaired then treatment is continued as normal. If impaired, the pharmacist reviews the patient and typically switches the patient to an alternative antiplatelet treatement lowering their risk of having a further stroke.

The pharmacist will explain the result and subsequent treatment to the patient and provide information to the patient’s GP for ongoing prescribing.

The result is that the patient receives personalised medicine and therefore more effective care.

Alex Matos, Specialist Clinical Pharmacist – Stroke

Email: [email protected]

Pharmacy led mindfulness for pain

NHS Dumphries and Galloway

A pharmacist and trained mindfulness teacher is using a mindfulness led approach to support people living with chronic pain in NHS Dumfries and Galloway. Chronic pain is pain that carries on for more than 12 weeks despite medication or treatment. This can have a profound effect on people’s quality of life.

The purpose of the course is to explore and assist participants’ understanding of self-management of pain, providing options beyond medication.

One participant stated, ‘I feel I am in better control of my pain…I have nothing but praise for the course’.

Information regarding the mindfulness for pain course is circulated throughout the Health Board. Referrals are accepted via email from health care professionals such as GPs, pharmacists (primary care and community), rheumatology professionals and community link workers. Self-referrals from patients are also accepted.

The course lasts for 8 weeks, with online attendance at a teacher-led weekly class for 1.5 hours. After each session, participants put mindfulness into practice at home for about 30 minutes per day.

Mindfulness techniques are taught as a way of managing chronic pain, not eradicating pain. One participant stated: ‘I feel I am in better control of my pain….I have nothing but praise for the course. It was excellent.’ Another participant said, ‘I definitely feel more generally settled and I am keeping up with the exercises’. Regarding medication use, one participant stated: ‘I am not having to take as much’.

All participants reported benefit to their management of pain.

Dr Emily Kennedy, Lead Cluster Pharmacist, Dumfries and Galloway

Email: [email protected] 

Pharmacists supporting frailty prevention

NHS Lanarkshire

Pharmacists in North Lanarkshire were key in supporting the development of a multidisciplinary preventative approach for older adults at high risk of deterioration. Three General Practices with a population of around 16,000 are benefiting from access to this service.

The area has significant urban deprivation and has the lowest GPs to patient ratio in Scotland, meaning access for vulnerable people can sometimes be harder. This approach was developed to try and ensure equity of access for those who need it.

’90 medications were stopped…and 52 doses reduced with an overall cost saving of £100 per patient per year.’

Communities with older adults at high risk of deterioration were identified, and pharmacy teams assessed patients to prioritise home visits, remote consultations or in person appointments.

Advanced pharmacists carried out comprehensive geriatric assessments in patients’ homes.

Pharmacy teams also undertook polypharmacy reviews with patients who were identified as needing support. In total, 72 patients were reviewed with a median age of 85 years. They were assessed and a Clinical Frailty Score was determined for each patient to give an indication of their level of risk.

As a result of the polypharmacy reviews undertaken, 90 medications were stopped, 40 started, 5 increased and 52 doses reduced; with an overall cost saving of over £100 per patient per year.

Medication reviews also resulted in a 31% reduction of the overall anticholinergic burden, , reducing the risk of unintended impairment in patients affected.

Positive feedback was received from patients and the model has now been adopted by other GP practices in Lanarkshire.

Rizwan Din, Advanced Clinical Pharmacist, NHS Lanarkshire

Email: [email protected]

Pharmacists enhancing surgical capacity

NHS Greater Glasgow and Clyde

Pharmacists in Glasgow are leading a pre-surgical review service to expedite the discharge process following day case hip and knee replacement surgery and to improve post-operation outcomes for patients. The service was set up in March 2021, stimulated by the need to increase surgical capacity due to the backlog caused by the pandemic.

Prescribing pharmacists initiate a remote consultation with patients on the surgical waiting list to discuss plans for their medication whilst in hospital, and to formulate a person-centred discharge prescription plan in collaboration with the patient.

“This novel pharmacy led service has contributed to a dramatically reduced length of hospital stay.”

An electronic discharge prescription is written, dispensed and delivered in advance of admission, to minimise time the patient spends in hospital following surgery.

Both staff and patient feedback is extremely positive. All patients with previous experience of surgery in the health board reported an improved experience. Patients also reported being more confident in their understanding of what medicines to take post-discharge and why. Staff reported that the service improved prescribing standards and freed them up to focus on their clinical duties.

This service also resulted in a statistically significant reduction in the incidence of post-discharge healthcare encounters (such as GP visits or presentation at a hospital site) in the group reviewed by a pharmacist compared to the pre-implementation group.

This novel pharmacist-led service has proved to be an invaluable part of a multidisciplinary effort which dramatically reduced the length of stay for arthroplasty patients in Glasgow. The pharmacy review has improved prescribing standards and patient safety, enhanced the patients’ surgical experience and reduced the surgical burden on healthcare systems.

Keith Addie, Clinical Pharmacist and Kieran Fitzpatrick, Clinical Pharmacist, NHS Greater Glasgow and Clyde

Email: [email protected] | [email protected] 

Saving life through emergency administration of naloxone

Community pharmacy, Glasgow

JF, a pharmacist who works in a busy community pharmacy, was leaving work when they were called frantically by their colleague to come to a stairwell. Upon approaching, JF found a man lying unconscious. JF quickly assessed the patient who had a very faint pulse. He was breathing but completely unresponsive. JF suspected that the patient was suffering from an opioid overdose.

One member of the pharmacy team returned to the pharmacy to obtain naloxone (prenoxad) while another phoned for an ambulance. Two police officers who were in the vicinity came to assist.

“The whole pharmacy team were praised for their quick thinking which saved this patient’s life.”

JF asked the police officer to keep the patient on his side and his airways open whilst they administered naloxone to the patient’s upper thigh. JF’s colleague supported the process by timing dosing intervals. JF had to administer three 0.4mls doses of naloxone before the patient began to move and talk. They had been preparing to perform CPR and resuscitation if there had been no response.

JF introduced themselves and explained what had happened. They informed the patient that naloxone had to be administered because he had been unconscious for a long time. JF encouraged the patient to go to hospital when the paramedics arrived.

JF relayed to the paramedics what had happened, that naloxone had been used, the number of doses provided, and their colleague could provide the time of when the last dose was given. The whole pharmacy team were praised for their quick thinking which saved this patient’s life.

JF was able to act quickly due to having had full naloxone training four years previously and they had kept that training up to date. This case really demonstrates the importance of every pharmacist being trained in administering naloxone, and of every pharmacy having access to naloxone, ready to use if required.

Jessica Fung, Community Pharmacist, Glasgow

Email: [email protected]