Hospital pharmacy delaying patient discharge

[Rillington]

I have recently had various relatives in hospital. Every time they are discharged they have to wait hours for their medication. This means they are taking up a hospital bed they don't really need.

The last relative was told at 8a.m. they could go home that day. The medication eventually arrived at 9.45p.m.

Is this normal or just a problem at our hospital?

HospitalPharmacist says:

"Wards also have what we called over-labelled medication so if for example all you need is lactulose or paracetamol the ward can just give you that."

Yes, we could not understand why a packet of normal strength non enteric aspirin could not have been provided by the ward.

@MintyMabel

At my hospital you've always been able to come back for them.

That’s a 3 hour round trip for us. It isn’t a solution.

No, it's not going to be possible for everyone, I realise that.

Our local hospital has now separated inpatient and outpatient prescriptions which has helped massively. Also means no waiting around after appointments for meds thankfully!

@Sirzy I guess the issue is so many discharges are done between 9 and 10ish so they have so many meds to sort

There are actually very few scripts done at this time as the junior doctors are mainly on ward rounds. It's usually later. On a medical ward 5+ patients can be going home. At my work a pharmacist can be covering two or three wards and will have to clinically screen all those prescriptions and usually check what they need as our technicians aren't ward-based. If we're lucky (we being pharmacy), the script will be on a day in advance. This is rare outwith Care of the Elderly.

@MintyMabel you can't always do the scripts days in advance. Probably okay in elective paeds but what if pain control requirements change? Your daughter may have needed Oramorph but the dose might have changed. Maybe she would have needed laxatives. In adults, maybe their blood pressure goes up or down and meds need adjusted, maybe their kidney function goes off and meds are no longer suitable. Things can change right up to the point of discharge. As PP said elective wards (and acute receiving) have pre-packs of common meds which nurses can give out, bypassing pharmacy. But it's not suitable in all cases. And more staff would be fantastic but we need to make cost-savings in every department. Pharmacy don't have a budget for anything other than staff so our cost-savings need to come from staffing. Posts are left unfilled/gapped for months to save money. People retire or leave and their posts aren't advertised or are down-banded. It's horrendous tbh and I don't know how we're supposed to function but there you go

And although pharmacy 'closes' at 5pm, there are usually staff employed later to finish off the day's work. We can't just go home, the work needs to be finished. At my hospital it's the on-call pharmacist who finishes off and locks up. They don't leave until everything is done.

we need to make cost-savings in every department

My mind’s boggling at what kind of state the NHS will be in if costs are cut even more then they have been already.

They tell you you can go home on the ward round, they then finish seeing all patients, then the most junior doctor writes all the discharges then they wait until someone from the ward has time to check what you need and send them to pharmacy. Thus the discharges all arrive in bulk. Often there are mistakes or queries which involve trying to get hold of the doctor. Or items aren’t in stock and need ordering. Then the meds wait for the porters to deliver them. Then they wait until a nurse has enough time to go through them with you and discharge you.

And this is a great example of the problem(s) and waste of time and effort involved.

A couple of summers ago I collapsed while on holiday in Austria, was admitted to hospital and required an emergency operation.

When the consultant did his rounds, he had access to a laptop and printer on a trolley in the ward. On the laptop he could see the patients' notes and obs and could immediately add his comments as he went.

On the morning of my discharge, he printed off the notes, the discharge letter and the drugs prescription, checked that I already had sufficient drugs for the next 24 hours and sent me on my way. (He checked that I was happy to collect the drugs from the local pharmacy - if that had not been possible, he would have sent the prescription electronically to the hospital pharmacy where it could have been collected - or sent to the ward if I had not been mobile enough to collect it in person).

As I needed a follow-up check-up and a second, minor operation had to be scheduled for 12 weeks later, this was also done at the same time.

Of course all of this requires an IT system that can facilitate this, but this is clearly possible.

It also needs enough doctors to be available in order for them to have the time to do this, but my observation is that what they did themselves took no longer than it would take to dictate their notes for someone else to write up and effectively saved "double work". The ability to schedule the follow-up appointments was an unexpected bonus - but since he could see his own diary and knew that I needed two follow-up appointments, why should he not book them there and then?

Finally, it needs a change of approach and attitudes. Why have a long chain and hierarchy of people involved - all of which delay things for the patient but which also clog up the system for the hospital - when technology allows many tasks to be automated?

you can't always do the scripts days in advance. Probably okay in elective paeds but what if pain control requirements change? Your daughter may have needed Oramorph but the dose might have changed.

We’ve just done surgery nr 4, same script each time. The last one we waited for was held up because of two bottles of paracetamol, which we always tell them not to bother with but for some reason they still do it.

And more staff would be fantastic but we need to make cost-savings in every department. Pharmacy don't have a budget for anything other than staff so our cost-savings need to come from staffing.

And by saving in your dept, millions are lost elsewhere in the NHS. False economy.

This has always been the way. I have a condition that means I have been a regular inpatient since birth, in a variety of hospitals, the reason you are left waiting is because you are the least sick person - not a priority.

The pharmacy prioritises dispensing medication for the sickest patients. Someone who is ready for discharge is the last priority.

Sometimes (oftentimes) the doctor is called to an emergency before being able to write up the prescription paperwork. That doctor will prioritise completing the paperwork for the most sick patients first.

Sometimes the pharmacy has to order in the medication and await delivery.

It is just one of those things. As the least sick person in the hospital you just have to wait your turn and be thankful you’re no longer top of their priority list!

Normal. We sent our prescriptions to pharmacy by 9am latest and we don’t get them back with the discharge meds until mid afternoon at the earliest. Which also means people can’t have lunch time analgesia because the prescription is at pharmacy.

The fault is more likely Drs than pharmacy and I say that as a Dr

The pharmacy have 100s of scripts flood in at the same time after morning ward rounds. junior Drs don't even get around to writing the scripts until after the ward round likely hours after the patient is told they will be discharged.

Drs need to plan better and decide to discharge patients and do the scripts the day before but everything is to the wire. They have to go the day anyone decides
they possibly can rather than wait he next day when everything is organised

So in a way the disorganised rush is actually saving a day which would be used to plan rather than wasting a day

@MintyMabel I agree it would be annoying to have to wait for two bottles of paracetamol. We would be annoyed if we had to dispense that when it can so easily be given over labelled by the ward.

@Havanananana I do agree that there needs to be a huge investment in IT in secondary care, it lags behind what is available in primary care considerably.
However in your scenario there is a missing second check of the consultant? Convenience is important but safety is also crucial. Perhaps they have some different mechanism, I don’t know. A community pharmacy has far less ability to check and act on something that is incorrect. Errors need to be picked up before they are sent down the line. It’s also more expensive to get medication dispensed that way. Interesting that the consultant prescribes as the majority here simply do not have time and it’s often doctors who are in their pre-reg year and are technically not fully qualified doctors but the hospital trust allows them to prescribe.
Hospitals have put lots of resource into this problem, nobody wants people to be delayed as it’s the staff on the ground taking needless grief for it ultimately. I could tell you several ways to improve matters- better IT, prescribing nurses and pharmacists, less responsibility for very junior staff, discharge co-ordinaries the list goes on. All comes down to cost and it’s probably ultimately cheaper to run more beds and a discharge lounge.

From my point of view we do actually spend time preparing for discharge in advance for many patients but these are usually the more complex patients who are not being discharged to home. You quite often get patients who a medically fit for discharge but waiting for a rehab bed, or care home, or Pysch input, or Occupational health. These patients we can plan for discharge in advance.

Work in the dispensary is not done in priority of who is sickest. It’s generally done in the order it arrived in the dispensary. With some exceptions.

[quote HospitalPharmacist]@MintyMabel I agree it would be annoying to have to wait for two bottles of paracetamol. We would be annoyed if we had to dispense that when it can so easily be given over labelled by the ward.[/quote]
Hospitals should be asking people to buy it, there’s no need to supply at all in the vast majority of cases

@BungleandGeorge agreed, that’s very true.

@MintyMabel And by saving in your dept, millions are lost elsewhere in the NHS. False economy.

Couldn't agree more but unfortunately I'm not the one making the decisions. Tell that to the ones in their ivory towers. One of my colleagues did a cost-saving initiative swapping patients on a specific med from branded to generic. She saved the health board £250k. They need to focus on how pharmacy can save money in other ways rather than reducing our staffing to bare bones.

@CovidCorvid Normal. We sent our prescriptions to pharmacy by 9am latest and we don’t get them back with the discharge meds until mid afternoon at the earliest. Which also means people can’t have lunch time analgesia because the prescription is at pharmacy.

What? This is mental. This is why health boards need to invest in ward-based pharmacy cover. All our scripts are screened near patients, kardexes are not removed from the ward.

@CovoidOfAllHumanity So in a way the disorganised rush is actually saving a day which would be used to plan rather than wasting a day

Very good point actually. We could tell you you're fit to go home tomorrow and meds would all be waiting for you at 9am the next day. It would look like a much more efficient process but in reality it's keeping someone in an extra day.

@CovidCorvid

Normal. We sent our prescriptions to pharmacy by 9am latest and we don’t get them back with the discharge meds until mid afternoon at the earliest. Which also means people can’t have lunch time analgesia because the prescription is at pharmacy.

This is an example of where better co-ordination and IT would help enormously. You can get administration records which run on a laptop or iPad, visible to all, no need to send anything. Just mark on there what is needed and you’ve cut out a huge amount of effort and time. Also shows exact time when given and by who, much better to prevent errors too

It is, unfortunately. Sometimes they will give you an FP10 to take elsewhere which is helpful.

The pharmacy have 100s of scripts flood in at the same time after morning ward rounds. junior Drs don't even get around to writing the scripts until after the ward round likely hours after the patient is told they will be discharged.

Why does any of this happen?

Why can the junior doctors not write the prescriptions on the spot as the rounds are done (and why can't the consultants write their own scripts instead of dictating them to someone else to do?)? A laptop or app on an i-Pad would enable this to be done in real time, so there is less delay for the patients and the pharmacy doesn't get flooded with prescriptions all arriving at once.

If the patient is happy and able to collect the prescription themselves at their local pharmacy, it could be printed out and signed there and then on the ward and the patient discharged.

Most of the delay is our fault as doctors.

Ward rounds typically start at 8/8.30 and go on until 12/1ish (although until 3 in some areas is pretty common!). During that time the juniors will take it in turns to prep notes (look at what's keeping someone in, recent bloods/ imaging, obs, meds etc) and then see the patient with the consultant and write that up. If you use electronic notes and have a laptop it's easy and can write as you go and do discharge meds as you go. If it's all paper based then you need to wait for a computer to do it. If the team is understaffed then you have to wait to do it at the end or delay ward round. An acute ward can have 6-7 discharges per day. Some meds are quick to do but other take time, especially if the have a loading/ tapering regime to sort out. Likewise letters can take some time to write if someone has had a complicated admission.

We try to plan ahead and use any free time to start discharges in advance but it's not always possible. We can't send meds straight to pharmacy on admission becuase we don't know how they're going to change. All discharge meds have to be checked by a pharmacist who is often covering multiple wards and also trying to look at new admissions too.

Sometimes things are out of stock or there's a mistake on the meds so that has to be changed. This involves pharmacy calling the doctor who may not be able to answer at that point or may not have access to a computer to check and change things.

Sometimes the porters are too busy to collect things as soon as they're ready and bring them to the ward.

Some prescriptions need a signature from the doctor before the drug can be issued. If the doctor is with a patient/ attending an emergency then this can take time.

Unfortunately it's not a quick and easy process, but a lot of the delay is because we don't want to rush things and because everything is double/ triple checked.

I work on a ward and it does take time ,a job has been created for enhanced pharmacists to write discharge summaries and order freeing up doctors time.a big hospital has a lot of orders a day they need picking,checking and double checking and third time check for controlled drugs.my hospital has a discharge lounge to free beds up but this shut during covid.

Yep completely normal and a pain in the ass. The only time it speeds up is if you get it yourself or in my case the prescription goes to your local doctors. I’ve waited hours before and I always feel bad as they need the beds so now as soon as I know I’m getting discharged I get my meds to go to my doctors surgery .

Getting and switching to an integrated IT system including notes and prescribing for a big acute hospital is a huge huge disruption and expense and not without risk. The short term pain is not a small thing.

Our local acute trust did it a few years back and it's now acknowledged by most it was a very good thing to do. At the time it nearly bankrupted them cost wise and there were a number of clinical errors which I would think almost unavoidable with that scale of change all at once. They were trashed by CQC for the first time in their prestigious history. The chief executive had to resign.

Many hospitals still have paper charts and paper notes. Or 2 or 3 separate systems for clinical notes, investigations and prescribing. These systems largely do not talk to the GP systems. Even if they have the potential to there are huge IT governance issues. It's a big mess.
It's not an easy issue to solve in any way

@Havanananana

The pharmacy have 100s of scripts flood in at the same time after morning ward rounds. junior Drs don't even get around to writing the scripts until after the ward round likely hours after the patient is told they will be discharged.

Why does any of this happen?

Why can the junior doctors not write the prescriptions on the spot as the rounds are done (and why can't the consultants write their own scripts instead of dictating them to someone else to do?)? A laptop or app on an i-Pad would enable this to be done in real time, so there is less delay for the patients and the pharmacy doesn't get flooded with prescriptions all arriving at once.

If the patient is happy and able to collect the prescription themselves at their local pharmacy, it could be printed out and signed there and then on the ward and the patient discharged.

Sometimes on ward round there isn't time or a free computer. We have iPads for round round but can't prescribe from them. We have one laptop but that's needed for prepping notes. Where prescriptions are quick they will be done but if more complicated then time is needed to sit down and work out the correct number of days at doses etc. Some consultants don't allow us to do them on ward round as it slows them down and they are trying to get through a 30 patient ward round before their clinic/ theatre list. Sometimes it also isn't possible to do on ward round- if we want to check bloods/ HR/ BP/ scans during that day before we're sure it's ok to discharge that could all mean a change to medication.

when it can so easily be given over labelled by the ward.

Not at any of the hospitals we’ve been to, apparently.

Couldn't agree more but unfortunately I'm not the one making the decisions. Tell that to the ones in their ivory towers.

“Not my job, mate” Except, change will only come when those affected by it stand up for it. And of course, it isn’t affecting you so you’ll just plod along, doing what you do.

Hospitals should be asking people to buy it, there’s no need to supply at all in the vast majority of cases

Yep. The amount of paracetamol we’ve been encouraged to take from hospitals over the years is depressing. It’s never “do you need it” it’s “we’ll get you some” Probably some misguided attempt to make sure people who can’t afford it aren’t going without, but the solution of providing it for all is very wasteful. Especially as we can’t use it anyway as it makes DD puke.