Since March 2020 NHS resources have naturally been focussed on managing the COVID pandemic. However, as our attention and efforts have been seeing patients who are acutely ill, many patients with chronic conditions requiring surgical intervention have had to wait longer compared with pre-pandemic times.
NHS waiting lists for elective procedures are currently at an all-time high, with 6.1 million people waiting for surgeryand over 300,000 patients waiting over a year to start treatment.
So what can a pharmacist do to support waiting list reduction?
There are several considerations which can increase the efficiency and effectiveness of the pharmacy service for surgical patients which have an impact by:
- reducing the number of theatre cancellations, which in turn increases potential theatre utilisation as fewer theatre sessions are lost.
- improving patient flow through the system, which may result in increasing the number of patients that can be treated per session. This affects mainly day-case procedures.
- decreasing hospital stay, meaning more complex procedures requiring prolonged post-operative care can be undertaken.
- preventing re-admission, enabling teams to focus on treating new patients.
Work in pre-operative (pre-op) clinic:
Before planned surgery, patients will attend a pre-op clinic to assess their health status and suitability for surgery. Ensuring that medicines are taken correctly pre-operatively results in fewer on-the-day cancellations and reduces clinical risk. Better management of long term conditions also results in improved surgical outcomes, fewer complications and speedier discharges. The time between pre-assessment and surgery provides an opportunity to optimise long-term conditions such as diabetes, hypertension, atrial fibrillation, and anaemia.
Pharmacy pre-op reviews involve:
- Reviewing medicines to ensure that patients safely continue or withhold medicines preoperatively
- Considering dose adjustment of current medicines to optimise pre-existing medical conditions
- Considering if new medicines are needed perioperatively to manage pre-existing comorbidities.
There is a huge variance in the level of input by pharmacy departments into their Trust’s pre-op service, ranging from virtually no input at all to having full time prescribing pharmacists and Medicines Management Technicians (MMTs). Most department’s input is somewhere in the middle of these two extremes. Consequently, it is important that services are targeted, ensuring high risk patients are prioritised. A clear referral criterion from pre-op nurses to pharmacy is important to ensure that care is given to those who are likely to benefit from it. For example, patients taking medicines such as clopidogrel or DOACs would be a priority, as inappropriate use of these medicines can result in patient harm, or theatre cancellation.
Virtual consultations (speaking with patients directly via phone or video call) is a useful tool to ensure that patients understand, agree and adhere with the recommendations of which medicines to continue or omit prior to their procedure. The pharmacist should consider tailoring these recommendations to aid pre-operative COVID shielding rules. For example, for patients taking warfarin, ensuring that INR tests are done during the same visit as COVID swabs, prescribing and supplying low molecular weight heparins to bridge (if required) and counselling on its usage during the same visit all help.
For those departments that have significant staffing resource in their Trust’s pre-op model then the concept of ‘pre-optimisation’ becomes a possibility. This is where the patients’ medicines are actively managed prior to the procedure, ensuring that the patient is as medically fit as possible on the day of the procedure (for example optimising lung function observed via better peak flows or FEV1, or diabetes control via lower HbA1c measurements, or anaemia with the use of iron replacement therapy).
Get involved with waiting list initiatives
Extra theatre sessions are sometimes developed via ‘waiting list initiatives’ (WLIs) so that procedures can occur during the evening or at weekends. Pharmacy teams can support this, ensuring that sufficient stock medicines are in place to enable this extra demand to be met and that discharge prescriptions can be provided at times when pharmacy may not be open. Sometimes these WLI sessions are undertaken by external, private companies which may make this process more complex as governance, training and finance issues will need considering if the WLI is not being provided by staff employed directly by the Trust.
Optimising speed of discharge
Delays in patient discharge ultimately results in delays getting other patients into theatre. Nowhere in the NHS is this more apparent than on a theatre daycase list when each theatre may treat 10-15 patients in a day. Ensuring that your discharge process is as streamlined as possible ensures that patient flow is maintained by reducing waiting times for medicines supply.
Having an agreed formulary for discharge medicines enables the pharmacy team to either dispense discharge prescriptions early or in advance of the day of the patient’s procedure. Some Trusts support near patient dispensing via having ‘satellite’ pharmacies close to the clinical area, enabling the clinical pharmacy team to facilitate early dispensing. If your department supports the use of pre-labelled medicines in discharge packs, these can be used to supply discharge medicines.
The Getting It Right First Time programme recognises that ensuring tasks are completed to a high standard early in the patient journey results in the patient recovering faster and being less likely to require further intervention later in their journey. However, sometimes patients may be discharged without being fully medically optimised which can lead them to seek help for poorly managed known surgical complications such as post-operative nausea, vomiting, pain or constipation. These patients often present to general practice or back to the Trust via an emergency admission.
Ensuring that patients have good medicines counselling and sufficient supplies of medicines on discharge supports the patient to understand their recovery and post-operative management. This can empower them to self-manage minor complications and reduces the need to seek input from a healthcare professional. Surgical pharmacists can identify patients who are at higher risk of post-operative complications and therefore ensure that these patients are followed up either via a hospital outreach team, community pharmacist, or pharmacist working at the patient’s general practice.
This article was written whilst the author was in post as the Lead Divisional Pharmacist for Surgery at Wirral University Teaching Hospital.
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.