EPMA in mental health: focus on prescribing and administering long acting injections

South West London and St George's Mental Health NHS Trust is the main provider of integrated mental health and social care services in south west London. The Trust serves 1.2m people of all ages across the London boroughs of Kingston, Merton, Richmond, Sutton and Wandsworth and employs more than 2,000 members of staff.

The Trust has 3 inpatient sites and 46 community sites. Services include inpatient mental health services, liaison psychiatry, community mental health services, psychological therapies in primary care (IAPT), addiction services, and specific learning disability and forensic services. The Trust also provides a range of specialist regional and national services, including mental health services for deaf children and adults, eating disorder services, and those for the treatment of obsessive-compulsive (OCD) and body-dysmorphic disorders (BDD).

The Trust’s pharmacy service plays a crucial role in individualising treatments for best outcomes for service users.

Situation

It is estimated that there are more than 47 million errors across the medication use process each year in England.

Key issues include:

• medication prescribing, discharge prescription errors and medication administration errors
• the number of inpatients experiencing an adverse drug reaction (ADR) - it is estimated that 14.7% of inpatients experience one or more ADRs, of which 6.4% were definitely avoidable and 46.9% were possibly avoidable
• avoidable increases in length of stays - 26.8% of patients experiencing an ADR had reported increase the length of stay of 4 days
• harm caused by prescribing errors - 16.9% have the potential to cause moderate harm whereas 1.9% have the potential to cause severe harm

(Data taken from Global Digital Exemplar Case Study)

The implementation of electronic prescribing and medicines administration (EPMA) in community mental health teams is known to be more difficult to achieve than implementation in inpatient settings. Factors influencing this include the cultural shift of staff to utilise mobile technology (such as laptops within patients’ homes), and flexibility needed around the administration date of injections (due to the nature of mental health illnesses which may result in erratic behaviour).

Alongside this, community mental health teams have very limited pharmacy staff establishment, compared to inpatient wards. This often causes lengthy delays between the point of prescribing to the point of prescription review by a member of the pharmacy team. This results in issues such as incorrect prescriptions and administrations outside of the frequency prescribed not being picked up immediately.

Aspiration

The aspiration was to introduce a robust community mental health EPMA solution that would help:

• minimise medication errors and ‘near-miss’ events
• improve eligibility and accuracy of prescriptions, instructions and patient identification
• integrate care by bringing essential data together, such as allergies, weight and medication history
• improve patient care through adherence to prescribing guidelines/regimens and formulary medicines
• improve patient experience
• reduce costs/legal actions related to the processing and resolution of medication errors
• provide robust data to support research, audit and investigations

Solution and impact

South West London and St George's Mental Health NHS Trust (SWLSTG) has successfully implemented EPMA in community mental health settings for both the prescribing and administration of long acting injections (LAIs). By doing this, prescriptions are always legible, reducing the risk of administration errors and thereby improving patient safety.

The EPMA solution clearly displays when the patient was last administered a dose, along with the next due date, reducing the likelihood of omitted doses. Prescriptions are also set up in such a way that they expire after 12 months, meaning that doses cannot be administered using an expired prescription - a practice that was previously happening.

The administration overview allows teams to easily identify when LAIs are due, reducing delayed and omitted medicines. It also allows overdue LAIs to be viewed on one screen allowing oversight and follow up. Reports are sent to prescribers when prescriptions have expired so that they can be reviewed, improving the governance process around medicines administration within community teams, while ensuring patients receive their medicines on time.

As all prescriptions are now electronic, all staff can access prescriptions remotely. Benefits of remote access of prescriptions through EPMA include:

• pharmacists are able to clinically verify prescriptions from any location, saving time travelling between multiple community teams
• reduced length of time between the point of prescribing and clinically screening of a prescription, with prescribing errors therefore being picked up in a timely manner
• doctors being able to review prescriptions at any location and nursing staff no longer needing to spend time locating prescription charts

Although these benefits of accessing prescriptions charts remotely have not resulted in cost savings, they have resulted in time savings, which can be reinvested into patient-facing care.

Functionality

The EPMA web-based solution was implemented across all community teams for the purpose of LAI prescription and administration and outpatient FP10 prescribing. This solution allows all staff to access EPMA through any Trust device with internet access.

Technical prerequisites

Infrastructure requirements included:

• efficient and reliable Wi-Fi access available at all Trust sites
• single sign-on implemented for use with EPMA solution to ensure quick login process
• web-based learning platform to share training materials and e-learning packages

Hardware requirements included:

• staff having access to a PC or laptop in order to access EPMA within the Trust
• staff accessing EPMA outside of the Trust, such as nurses administering injections in patients’ homes, requiring a 4G laptop along with secure VPN access to record administration in real time

For the reporting solution:

• a separate server was configured for use with the reporting tool to enable automated reporting to end users
• access to the server was granted to the Pharmacy EPMA team in order to both create reports and update the distribution list of recipients for automated reports

Interoperability, data and standards considerations:

• all allergy reactions have been built into EPMA using structured clinical terminology aligned to SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms)
• the version of EPMA used by the Trust uses the First Databank drugs dictionary which is updated monthly. This dictionary is compliant with dm+d (dictionary of descriptions and codes for medicines and devices in use across the NHS) and all medicines have been mapped to the correct dm+d code

Data quality considerations:

• prescription changes are made in real time due to the ability to access prescriptions charts remotely
• prescription fields relating to patient demographics are automatically completed from an automated feed from the Electronic Care Record (ECR)
• EPMA eliminates the need for transcribing, thereby eliminating transcribing errors

Capabilities

Records, assessments, and plans

• Charts are available from any Trust device at any location
• Multiple users can access a patient record at once
• Patient demographics can be carried over from ECR to EPMA, which means the risk of errors within this dataset is fully eliminated. Previous practice was to manually enter patient demographic information onto paper charts
• The transfer of demographics from ECR to EPMA also ensures prescription charts contain all required information, which was not always completed previously

Medicines management and optimisation

• The process of audit is easier and quicker due to the accessibility of data and ability to run reports easily
• There is improved governance around medicines, as all prescriptions are easily accessible at all times
• Expected reduction in incorrect administrations due to illegible prescriptions
• Greater visibility of due doses, thereby reducing the likelihood of omitted medicines
• Eliminated need for transcribing from paper to paper, as medicine orders are completed electronically, thereby reducing risk of transcribing errors

Decision Support

• Decision support around medicines, including conflict checks around interactions and contraindicated medicines due to recorded allergies or intolerances

Scope

For use in the mental health inpatient setting.

Digital capture of records, assessments and plans

This has been the primary improvement realised by the implementation of the physical observation application.

Decision support

SWLSTG has successfully implemented EPMA in community mental health settings for both the prescribing and administration of LAIs.

Key learning points

Identify correct stakeholders

It is very important to select the correct stakeholders at the beginning of the project. Ensure you have a mix of professions along with a mix of staff with enough power and influence in order for the project to be delivered on time.

In the early stages a nurse was not included within the project board. This was noted in the lessons learned. Dedicated nursing support within the project team for phase 2 was invaluable.

Service user involvement in the design

During the decision of what method to use input from key staff groups was sought. This included the pharmacy team, nursing staff and medics. The project did not include a service user or carer representative at this stage, which in hindsight would have been useful, and also would have been in line with the Trust values. Service users and carers can help evaluate options by sharing their experiences and views of how services can be improved.

Training and development

Create e-learning and publish before roll out. E-Learning would have been useful to have at the beginning of the roll out to aid training for those who could not attend planned training sessions and also as an additional resource for those who had completed face-to-face training.

Creation of e-learning packages requires lots of time and resources. Multiple edits will likely be needed before the final approved version is completed.

It is important to include the training department. There were delays in uploading the packages to the Trust e-learning platform as the Trust policy had changed regarding the time taken for review for e-learning packages. This was recently changed from immediate upload to a 6-week time period. This delay could have been avoided if the Training department were involved earlier on in the process as the timeline of approval could have then been factored into the project plan.

Allow time for reflection

If possible, factor in some weeks with no activity into your roll out plan to allow for some flexibility should anything not go to plan.

Be flexible

Some teams may have planned activities, such as team away days, which may mean the original go-live date needs to be changed. Where possible, this can be accommodated within the roll out plan.

Key figures/quotes

The completion of allergy status of patients prescribed an LAI was 90% prior to the introduction of EPMA. Completion of an allergy status is now mandatory and therefore the risk of patients being prescribed or administered an LAI to which they are allergic is reduced.

Key contact

Michele Sie, chief pharmacist, South West London and St George's Mental Health NHS Trust

Michele.sie@swlstg.nhs.uk