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Primary care

Challenge or catalyst for change? How COVID made us think innovatively

Community nursing teams provide care to people in their own homes, allowing them to continue to live in their own community. They administer a wide range of medicines such as topical preparations, to medicines which require specialised training in administration, such as End of Life medicines, insulin injections and intravenous antibiotics. Referrals into these teams can come from both secondary and primary care.

Most community nursing teams will require documentation specifying clear directions for administration. The type of documentation required will depend on organisational policies. In our Trust, authorisation forms are completed and accompanied with community referrals for medicines administration to our community nursing teams.

Although it is not a legal authority to administer, the forms contain all the necessary information for safe administration for complex medicines (such as End of Life Care/syringe driver medicines and insulin), as often the full dosage directions for these types of medicines are not found on the label.

The challenge

At the height of the Covid-19 pandemic access to GP surgeries was severely limited. Surgeries were closed and many prescribers were reporting that they were working from home and the normal mechanism (ie seeking hard copies of authorisation forms) had become fraught with difficulties and was impractical. Our community teams spent a considerable amount of time trying to obtain written instructions or authorisations for the administration of high risk medicines such as insulin and End of Life medicines.

the pandemic was a catalyst for this project and suddenly there was an appetite to drive this forward and at pace

Until recently, our processes were very much paper based: signed, written authorisations physically moving from one place to another. For urgent authorisations, our staff would visit the surgery with the paper copy for the doctor to write up. The challenge was always trying to get hold of the authorisations correctly completed, signed and within a reasonable timeframe so that we didn’t compromise patient care, whilst keeping interactions with others as low as possible to prevent the spread of COVID. We had to find another way to work.

There was limited scope to look into alternative solutions like obtaining new software or installing new systems. This would take up valuable time and resource which was limited due to a reduced workforce. We needed a solution that would be quick to implement. Unfortunately, our electronic patient record system was not the same as the GP clinical systems and so we had limited access to patient records for medication, and Connected Care provided limited information.

What we did differently

It was one of those ideas that we had on the back burner pre-Covid – a good idea to implement when there was more time and more staff to pursue the initiative. But the pandemic was a catalyst for this project and suddenly there was an appetite to drive this forward and at pace. Our solution was very straightforward: we would enable our electronic templates of the authorisation forms to be shared with the GP practices within the clinical commissioning group (CCG).

The forms would be shared on the DXS Point of Care system (the clinical decision support system used by all GP practices within our local CCG patch) which provided an easy way of accessing documents and content in the clinician’s workflow. It contained a repository of local referral forms that could be auto-populated with relevant data from the clinical record, and the electronic templates of the authorisation forms would be stored on the system. We posted on community networks to find out if other organisations had done something similar or had used other approaches. This proved to be fruitful and a colleague reached out to us and shared their experience. 

We discussed this idea with a local GP and the CCG medicines optimisation team. Both were very supportive and helped put us in touch with key contacts within the organisation and DXS. With the help of the DXS Lead and our nursing and pharmacy teams we uploaded the authorisation template into the DXS Point of Care system.

Working with an electronic template offered a number of advantages: we were able to incorporate additional functions to make prescribing easier (such as drop down menus and prepopulated fields); clinicians could complete the forms remotely from any location; and it saved community nursing time and potential delays to medicines administration.

Were we successful?

To introduce the forms, the whole process had to be reviewed and mapped to ensure the electronic process could be incorporated safely into the current workflow. Potential issues were identified, mitigated and agreed with the relevant groups, clinical governance and stakeholders. This process took time.

There were also practical considerations to work through, such as whether the use of signatures was still required and how to obtain them remotely, how authorisations could be sent securely, how to verify the sender, whether the paper process was still required, how to monitor any problems, and cyber security issues.

We were able to run the forms as a pilot in three CCGs over a period of six months. The pilot was successful during the pandemic and it has now become standard process, embedded into the CCG localities.

We have tweaked our electronic paperwork following feedback during the pilot and are rolling out the process to the rest of the organisation. The neighbouring CCGs use a different clinical decision support system, so the current challenge is to ensure that the templates are as similar (in format and functionality) as possible to make this easier for our staff working across the Trust. We have shared our process with a neighbouring organisation and this had led to opportunities of collaborative work in another related area within the integrated care boards.

What did we learn?
  • We learnt that you don’t need to reinvent the wheel: through local networks we discovered what other organisations had done. We tapped into our existing contacts and posted on forums to find out who, what, why and – more importantly – how. Colleagues are happy to talk about their process.
  • We identified champions within our key stakeholders: those with an interest, enthusiasm and a willingness to help move things along and support with a top down and bottom up approach.
  • And we learnt that the governance process always takes time – usually longer than expected – and that we needed to manage those expectations.
  • Finally, we learnt to monitor all incidents closely, be flexible and responsive to changes, and be willing to tweak the process along the way.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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