Robust patient review processes are crucial to ensuring the safety and efficacy of IBD medications, including immunomodulators. However, the workload required from such reviews can put significant strain on staff.
The IBD UK Standards recommends clear protocols should be in place for the supply, monitoring and review of medication - which can help not only with patient outcomes, but also with ensuring that existing processes are time-efficient and cost-effective.
Statement 7.3
Clear protocols should be in place for the supply, monitoring and review of medication across primary and secondary care settings.
Who’s doing it well?
At University Hospitals Sussex (UHS), immunomodulator reviews are completed by a multi-disciplinary team (MDT), with specialised pharmacists and nurses leading on autonomous blood monitoring and symptom review. This work was led by Fiona Rees, Lead Pharmacist for Gastroenterology at Royal Sussex County Hospital.
What wasn't working?
The workload of the review process was increasing and putting considerable strain on the team - particularly pertinent in the Covid pandemic, which resulted in staff shortages. There was also short availability of experienced gastroenterology staff to employ into specialist roles, with training and recruitment not matching demand. Business cases for improved IT systems at UHS to aid with monitoring had been denied.
The idea
Upskilling and task shifting is recognised as legitimate strategy for service enhancement, care access, cost effectiveness and sustainability, plus ensures team flexibility, boosted morale and career progression. The UHS IBD team includes a highly motivated pharmacy technician (PT). In the UK, pharmacy technicians are registered non-prescribing healthcare professionals, but training does not include autonomous blood monitoring and symptom review.
We wanted to determine if with appropriate training and support, pharmacy technicians can become competent in immunomodulator blood monitoring and symptom review to aid MDT capacity and PT development.
To ensure competency of autonomous blood monitoring and symptom review, a training package was developed and was approved by UHS Medicines Governance Committee.
The pharmacy technician completed the training in 10 weeks. Once accredited, the pharmacy technician prospectively recorded blood monitoring and symptom review activity over 24-weeks plus referrals completed via a single-centre study.
Results
Over 24 weeks, the pharmacy technician completed 2047 distinct monitoring activities, with 178 (9%) needing referral to a specialised pharmacist. All referrals to the specialised pharmacist were appropriate as they needed action by a prescribing professional. The highest proportion of autonomous workload was observed in the IBD infusion clinic (801, 39%), followed by thiopurine monitoring (697, 34%) and then ‘others’ (323, 16%).
‘Others’ were essential activities including faecal calprotectin levels (FCPL), pre-initiation tests (e.g.thiopurine methyltransferase levels (TPMT), viral screening, t-spots) and medication levels to optimise therapy. In addition, PT contributed substantially to data collection for virtual biologic clinic (VBIC) reviews; 48 patients.
Since joining the team nearly 7 years ago I have been fortunate to work with a well-established multidisciplinary team that have encouraged me and pushed me out of my comfort zone. When I first joined the team, I had no experience of reviewing and interpreting blood results. By helping to develop and subsequently completing the in-house Autonomous Blood Monitoring training package, I have been able to expand my knowledge and work autonomously to help improve the team capacity. I enjoy talking to patients about their blood results and symptoms and as necessary can then provide advice. My role as a specialist pharmacy technician is unique and I look forward to coming to work as no two days are the same.
Having the pharmacy technician as part of our team has enhanced the whole service. We have previously shown that having skilled pharmacists in clinic freed up doctor's time and clinic capacity, whilst improving safety and efficiency. Up-skilling and empowering our pharmacy technicians to take over part of this role has had the same knock-on positive effect on the whole service. Involving a broader group of multi-disciplinary colleagues in patient-facing activities also enhances the holistic nature of the care our patients receive.
With the upskilling off our pharmacy technician this has provided care to our patients that is based on a mutual understanding of their physical, psychological and emotional needs. In turn this has allowed the extended team to prioritise and enhance nursing care to the same level.
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