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Piloting Self-Administration in the Acute Care Setting. Clare Holley RGN, BSc (Hons). Kathryn Holt, MRPharmS BSc (Hons). Abstract: This article focuses on the introduction of self-administration of medicines in the acute care setting. Cotton ward, a busy General and Emergency Medicine ward, at the Royal London Hospital has been piloting self-administration for approximately six months. In this article we outline the planning and implementation for self-administration and our progress so far. Contents. Figure 1: Assessment form Return to Nursing Progress contents list The concept of patients administering their own drugs is not a new one; the United Kingdom first investigated the idea in the 1970's (1) and to date self-administration has been primarily aimed at elderly patients. Accordingly the majority of the research and nursing articles, concerning self-administration, focus on its effect in elderly care. The Royal Hospitals Trust has also been involved with drug self-administration for many years notably in the renal directorate. However drug self-administration in the acute care setting provides a challenge for all health care workers. This article outlines the progress of self-administration on Cotton ward during the last six months. We discuss the benefits and cautions surrounding self-administration and look at the relevant nursing research. We describe the changes that the ward made prior to implementation of self-administration and how we prepared the staff. The pilot has so far run for six months and we discuss the reactions we have encountered so far. Self-administration is believed to benefit the patient by attempting to maintain normal life patterns; this is especially enhanced if the patients own drugs are used which the patient can recognise. However Patients Own Drugs (PODs), at present can only be used on Cotton ward where there is a pharmacist to check the quality of the drugs, (this is under review and a new policy may expand this to other wards). Self-administration enables the patient to take control over a part of their treatment and increased education about their medication may help the patient to make informed choices in liaison with health care workers (2). Other authors have suggested that self-administration leads to an improved nurse-patient relationship (3) and improved communication (4). Thomas demonstrated that although self-administration appears to have many benefits, patients may not always be in favour stating reasons such as 'I would not trust myself to take the correct tablet'.(5) Education and support from the nurses and pharmacy staff may help patients with these feelings. Another area where self-administration can aid the patient is on discharge. As a result of the pressures on nursing staff, patients may be handed their TTAs (tablets to take away) with minimal instruction or observation, it may only become apparent at home that the patient is unable to open the tablet bottles or is unable to read the text on the bottles. Self-administration allows the patient to practice taking their own medication under nurse supervision. In November 1996 Cotton ward was chosen as the pilot unit for General and Emergency Medicine for drug self-administration. Cotton ward is a very busy acute medical ward specialising in respiratory medicine. Due to the complex medical history of many medical patients their drug prescriptions may be vast and complicated. There are a large number of patients who are readmitted to the medical wards and, although no research has been completed on the many reasons for this, it has been noted by all health care staff that patients who are readmitted are often unaware how or why they need to take their medication. A research study by Parkin et al in 1976 noted that 66 patients out of 130 deviated from the prescribed regimen.' 46 because they did not understand the instructions regarding their medication.(6) It was believed by the health care teams that if self-administration could be successfully introduced to Cotton ward then it should be possible to implement it to most other wards in the hospital, using Cotton ward's experiences to aid this process. The first process in commencing self-administration was to hold multi-disciplinary meetings which allowed all members of the health care team to air their views and beliefs. The members included experienced pharmacists and senior nurses in the General and Emergency directorate and from Cotton ward. All members were enthusiastic and excited about the possibilities of self-administration. A full-time pharmacist was appointed to the ward in February 1997 to co-ordinate the program; it was arranged that she would work full time on the ward. Primarily her role consisted of preparation for self-administration, she compiled a procedure for Cotton ward based on the Trust Guidelines for Self-administration. Permission was obtained from the ward's four consultants to include their patients on the pilot. There were some concerns about the legal situation if a medication error was made; but after discussion with pharmacy and the Trust's Medicines Committee all patients were allowed to be included on the pilot if they met the criteria. Discussion was held on the selection of patients and who should be excluded from the trial. It was agreed that patients must be assessed for suitability for self-administration by the pharmacist, nursing and medical staff. The patients who would not be considered for self-administration are outlined in figure 1, section A. Due to the complexities of ensuring consultant-based care it was predicted that occasionally patients from other medical teams would be cared for on the ward, it was decided not to include these patients at present. There was also debate on which drugs would not be suitable for self-administration, these were chosen to help protect patients and were listed as:
It was essential for all patients to have a secure place to keep their medication and for this purpose locks were fitted to the main drawer on the patients locker. The nursing staff hold a master key that opens all the drawers and the individual keys are locked away securely on the ward. The lockers and keys were numbered to enable the staff to find the correct key easily. An intensive training program was set up for all qualified staff to ensure their understanding and competence. At this stage it was decided that bank or agency staff would not be able to administer or observe administration of drugs for patients on the self-administration protocol. A documentation package was produced, figures 1 to 5, this was printed in a bright colour to ensure that it was outstanding. The initial assessment was to be completed by the admitting nurse or a pharmacist , see The ward staff were encouraged to discuss any concerns in ward meetings, there were initial worries regarding a change to an established part of the nursing routine, however the proposed benefits to the patients were outlined to the nursing staff; and they felt reassured that a pharmacist would be on the ward during the day to answer any queries. A starting date was decided on and the pilot commenced in March. The patient's medication is supplied and kept in their drawer. Ideally patients' own drugs (PODs) are used, if they are not available, medication is dispensed in Patient Packs labeled with full instructions. Where possible original packs supplied by pharmaceutical companies are used to speed up the dispensing process and aid patient identification of different medications. The quantity of drugs supplied for the patient is designed to cover the estimated length of stay on the ward plus 14 days for the TTAs (tablets to take away). These are the actual TTAs that the patient will take home. Child resistant containers and standard print labels can be replaced by easy open lids and large print labels where necessary. Some patients benefit from the use of a Dosette box, a container with divisions that clearly separates tablets into day and time to be taken. The nurse or pharmacist explains the scheme to the patient and obtains their consent figure 3. Once the patient has been assessed as suitable for self-administration the drug chart is marked accordingly to ensure that any changes to the chart are communicated to the nursing staff. The nurse or pharmacist then explains the medications to the patient detailing the doses and times; highlighting any warnings such as 'take after food' and provides any other information on side-effects, health education as the patient requires or desires. This information is tailored to each individual patient. If required the patient can have a tablet card which shows the exact tablets to be taken. Stage 1 can now be commenced: At the appropriate time the patients medication drawer is unlocked. All the patients' containers of medication are given to the patient and they are asked to select which tablets are due at this time. the nurse supervises this procedure and only intervenes if absolutely necessary. The nurse signs the usual drug chart and then locks the drugs away in the drawer. PRN (as required ) medication may be given from stock as required. Once the patient has made no mistakes for more than 48 hours and if the pharmacist and nursing staff are agreed then the patient may move onto stage two. This stage is unsupervised drug self-administration. The patient has stage 2 explained to them and they are given their own key to their drawer. The patient is instructed to ensure that their medication is kept in the drawer at all times and that if they leave the ward for example for an x-ray or on discharge they must hand their key to the nursing staff. The patient now takes their own medication at the appropriate time independently of the nursing staff; the nurse checks on each drug round what the patient has taken. The patient does not have to stick to traditional medication times and so can take their medication when it suits them, for example before or after food. As the nurse is no onger supervising the patient they do not need to sign the drug chart but they must tick the drug chart for the doses the patient has taken and sign the administration record, figure 4. Tablet counts are performed by the pharmacist or the nursing staff initially on a daily basis, and then once a week if the patient has made no mistakes, this information is recorded in the documentation, see figure 5. The patient is told that they must inform the nursing or pharmacy staff if they miss a dose or believe they have taken any tablets incorrectly, or if they drop tablets on the floor, as this will alter the tablet count. It should be stressed to the patient that if the tablet count is incorrect the patient would not be reprimanded but that the pharmacy and nursing staff would investigate to find out the cause. Patients may be moved back to stage 1 if they are not competent at self-administration and reassessment should also take place if the patients' condition deteriorates or if they are suspected of non-adherence. Any changes to the patients' medication should be instructed to the patient to ensure they take the right medicines. Stage 2 may continue indefinitely, if no mistakes are made, until discharge. The patient will then be able to take their tablets home, remembering to hand in their key to the nursing staff. The Extended Role of the Pharmacist The ward pharmacist is not only responsible for coordinating self-administration. The ward based service enables the pharmacist to take greater responsibility for the management of patients' drug therapy compared to the traditional style service. Other responsibilities include drug history taking, proactive contributions to appropriate prescribing via physician ward rounds, pharmaceutical advice to nursing staff, patient counselling and discharge medication planning. The pilot has so far been running for six months and has been predominantly successful. The nursing staff have found it easy to adjust to self-administration and have been encouraged by the reports from the patients. Medical patients have continued to be readmitted, and although we have no statistics we have not noticed any patients who have previously been on the trial who are taking their medication incorrectly. The patients have given us positive feedback about the pilot and we have only had a couple of patients who have not been willing to take part. Patients who have previously self-administered on the ward have requested to do so again if they are readmitted. The pilot is being continuously analysed to look at the benefits for the pharmacy department, and the patients' and nurses' experiences surrounding self-administration; so far we have no results to present. We have noticed that although Stage 1 appears to be time consuming as patients require education and reassurance, Stage 2 is time saving and the increased nurse-patient interaction in Stage 1 can only be regarded as beneficial to all. This article has outlined the introduction of self-administration to Cotton ward, a busy acute care medical ward. We have displayed the documentation used and discussed the relevant processes required prior to implementation of self-administration and hope that this would assist other directorates and wards who may be interested in this area. Self-administration appears to have been successful on Cotton ward and has proved popular with the patients. The success, we believe is due mainly to the hard work of all the staff and their willingness to work together as a multidisciplinary team. Self-administration will become more widespread in the Trust, already a pharmacist has been appointed to the Rheumatology directorate to introduce a similar ward based service. We hope that other wards will find self-administration as exciting and beneficial as we have. 1. Davidson J. Trial of self-medication in the elderly. Nursing Times 1974. 70:11; 391-2. 2. Bird C. Taking their own medicine. Nursing Times Nov. 9 1988: 84(45),28-32. 3. Hassall J. Mutual benefits. Nursing Times 1991. 87.18; 49-50. 4. Wade B, Bowling A. Appropriate use of drugs by elderly people. Journal of Advanced Nursing 1986: 11.1; 47-55. 5. Thomas E. Self-medication. Nursing 1992: 15.2; 26-7. 6. Parkin DM, Henney CR, Quirk J, Crooks J. Deviation from prescribed treatment after discharge from hospital. British Medical Journal 1976:2; 686-8. Nursing Progress: Issue 3: January 1998. Copyright: Nursing Progress, Royal Hospitals NHS Trust. Return to Nursing Progress contents list Page last updated by DEB on 14/10/02 |
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