A special dispensation

The traditional system of drug administration in hospital aims to ensure the patient is accurately given medicines in accordance with the inpatient prescription but it allows little time for patient education. On discharge patients are presented with their drugs, and receive a short burst of instructions from the pharmacist, doctor or nurse on how to take them. At home, many do not remember how to take their drugs, let alone what they are for or what the side effects are and what to do if they occur.

A system of self-medication gives patients some responsibility. By self- medication we mean selected patients or carers being responsible for storing and administering their own medicines, with the nurse and pharmacist acting as educators and supervisors of the process. This provides a good platform for education and counselling, and has been shown to improve compliance.1

The self-medication scheme fits in well with current nursing practices. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting recommends that self-medication schemes are established during the hospital stay as a way of giving patients the knowledge and confidence to maintain compliance on discharge.2

It has also proved to be a good platform from which to introduce new pharmacy practices.

The self-medication scheme introduces a one-tier dispensing system. Traditionally, patients are supplied drugs on several occasions during their stay, and then again at discharge. A more efficient way of supplying medication is once only, on admission. If enough medication is given and it is labelled with directions, the amount of medication supplied and the number of prescriptions dispensed on discharge are reduced.

Using drugs brought into hospital by the patient allows an accurate drug history to be obtained on admission. In these days of formulary pharmacy, patients who bring in their own medication may continue to use non-formulary medication without the need to change therapy. Use of patients' own drugs may produce large savings for the trust.3,4

A self-medication scheme has been set up on three wards at the Royal Free Hampstead trust. It is based on the scheme at the Queen's Medical Centre, Nottingham.5 The project, which started in 1996, now covers the renal transplant unit (12 beds), the HIV/general medical ward (20 beds) and an orthopaedic ward (28 beds).

All classes of drugs are included, except those used for the treatment of opiate and alcohol addiction. Controlled drugs are included and patients using opiates for pain control benefit greatly from being able to take their drugs when they need, rather than waiting for the nurse. We ensure controlled drugs are not abused by counting tablets regularly and supplying a small amount at a time.

All medication is dispensed to the patient on admission. They are given enough to last throughout their stay and to cover two weeks after discharge. All medication is labelled with directions. Patients are asked to bring in medication from home when seen in preadmission and outpatient clinics. Any medication brought in is assessed by pharmacy staff to ensure that it is of a good enough quality and safe for the patient to use on the ward.

Drugs are stored in individual patient medicine cabinets attached to the bedside lockers. Each has a key, with a master key kept by the nurses.

On admission, each patient is assessed by their nurse to ascertain whether they are mentally and physically capable of self-medication. We soon came to realise that the success of the self-medication scheme hinged on the assessment tool.

We also find out if the patient is able to open bottles and blister-packaging, and to read and understand labels. They are asked what they know about their drugs, and any educational needs are assessed at this time. Each patient is then assigned to one of three levels of responsibility.

Patients on level one either do not want to self-medicate, or are assessed as not capable. They have no access to medication on the ward, and the nurses administer drugs in the traditional way. Patients on level three are assessed as competent to take their own medication and have full responsibility for the key to their medicine cupboard.

Level two is a halfway situation. The patient has no access to their medicines, but has a responsibility to alert nurses when they are due for medication. This may highlight patients who need some advice. All patients are informally reassessed daily, to ensure they remain capable of self-medication. The scheme is fairly flexible; patients may move between levels as their clinical condition dictates throughout their stay. One objective is that patients attain level three by the time they are discharged.

A patient admitted for a non-emergency operation may be on level three, with full responsibility, for one or two days before the operation. Immediately after the operation, they may be on level one until fit enough for level three again.

So far, about 20-25 per cent of patients have chosen to take part. In practice, patients who are responsible for their medication are informally assessed every day, and at the time of each drug round, that is four times a day, nurses usually ask them if they have taken their drugs.

Each patient is given a card with details of their medication. This tells the patient what drug they are taking, what it is for and how to take it. Special instructions are written on the card ('take before meals', for example), and whether drug therapy is for a long or short course. Patients are also given a short summary of the aims and objectives of the self-medication scheme.

On discharge, a take-home prescription is written by the doctor. The patient is given their drugs from their medicine cabinet, instead of a whole new supply. A member of the pharmacy staff is available via a bleep, and visits the ward to check these supplies against the prescription. If new items have been added, or any bottles have insufficient supplies or incorrect instructions, these items are redispensed. This is a good moment for final counselling about the patient's drug therapy. The medicines card is updated at this stage.

The scheme is being extended to obstetric, neurosurgery, and medium and long-stay surgical wards, and there are plans to extend it to neurology, oncology, care of the elderly and paediatric wards. Eventually, 20 wards, representing about half the hospital, may be included. The scheme is not appropriate for short-stay patients and those whose drug therapy is continuously changing.

We collected data on the 20-bed HIV and general medical unit before and during the pilot phase. This ward was selected because it had sufficient turnover of patients and a varied case-mix.

The pharmacy department supplies 25 per cent less medication to patients on the ward following implementation of the scheme. The ward drug budget has decreased. Drug supplies from the dispensary to the pilot ward have increased by 50 per cent, showing that more medication is sent up as individual patient supplies.

The average time patients wait for take-home prescriptions has decreased by about one third since the introduction of the scheme. More significantly, the amount of medication dispensed at discharge has been reduced by two thirds. Cost savings made by using patients' own drugs have totalled approximately pounds13,000 over a 22-week period (equivalent to pounds31,000 a year).

We tested patient and nurse satisfaction with the scheme. About 20 patients and 20 nurses replied to questionnaires asking about levels of information and whether the scheme was easy to operate and take part in. The nurses rated the scheme 7.4 out of ten, and the patients 8.6. Patients said they had received more information on their drugs than during previous hospital admissions.

A further step is the initiative of pharmacist prescribing. The delay in discharge in many hospitals is largely caused by patients waiting for prescriptions to take home. The major problem is often not slow turnaround of prescriptions by pharmacy but in getting the doctor to write the prescription.6 Pharmacists are legally entitled to write the discharge prescription and we are setting up this service.

The cost savings made by asking patients to bring in their own drugs on our pilot ward were substantial. This is due to the high cost of therapy in the HIV patient group and is not indicative of savings which might be made on a standard ward. But previous research has suggested that significant savings can be made, and it is predicted that these will be sufficient to fund the self-medication scheme. 3,4

The pilot phase was run by a pharmacist in conjunction with nursing personnel. Now a senior pharmacy technician has taken over the day-to-day running of one of the wards. This entails ordering patient supplies, assessment of the drugs patients bring with them to hospital, counselling patients on their drug therapy, writing medication cards, aiding nurses in patient assessment and facilitating drug supplies for discharge. A pharmacist still visits the ward to perform a clinical role, but has minimal input into the scheme. This is seen as a large step towards the use of pharmacy technicians to a greater extent in the future.5

The self-medication scheme has proved a worthwhile initiative, well received both by patients and staff.