Realising the benefits of clinical pharmacy in the bush: The efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote New South Wales health facilities

The VCPS will evaluate virtual clinical pharmacy support to inpatient care in facilities in WNSWLHD and FWLHD where there is no access to on site clinical pharmacy services. The aim of the project is not to evaluate the effectiveness of clinical pharmacy services which is well defined in the literature. The virtual clinical pharmacists will provide a telehealth service which is consistent with conventional face to face hospital pharmacy services. Depending on the patients’ medical history and reason for admission they may receive one or more of the pharmacy activities summarised below: • Patient prioritisation and recognition of high-risk patients • Medication reconciliation particularly during transitions of care • Patient education • Staff education • Health facility engagement • Medication review and addressing polypharmacy • Documentation and intervention recording • Antimicrobial stewardship The virtual pharmacists will utilise the eMR, eMeds and a “Wallie” wireless teleconferencing cart with two–way audio and visual (located in all WNSWLHD and FWLHD health facilities) to provide clinical pharmacy services to study sites. Frequency/duration - The virtual pharmacy intervention baseline data collection will begin February 2020 and intervention data from May 2020. Virtual pharmacy intervention data collection will continue for the stepped wedge analysis until December 2020. Post service implementation data collection and evaluation will then continue until June 2021. The Pharmacists will work during business hours, Monday-Friday of each week over the study period where it is anticipated they will see approximately 5-10 patients per pharmacist per day depending on the complexity of patients’ medication regimens for the period of time the hospital is in the intervention stage of the study. This will vary from site to site from 14 months to eight months depending on where they are in the randomised step of the study. Patients who are at the highest risk of medication related harm will be prioritised for review. Mode of delivery is determined by referral to the pharmacist from medical or nursing staff and prioritisation by the pharmacist. Prioritisation is based on the definition from the NSQHS Standard 4- medication safety and the Society of Hospital Pharmacists of Australia (SHPA) Standards of Practice. Medication reconciliation (Med Rec) is a formal process intended to prevent medication errors and medication related problems at transition points in patient care. Virtual clinical pharmacists will conduct Med Rec on admission, discharge or transfer and document the best possible medication history in eMeds. Interventions will be raised for issues that require prescriber or nursing management. Interventions of immediate clinical concern will be followed up with direct communication between pharmacist and site doctor or nurse. To ensure continuity of medication management on discharge back to the community, the pharmacist will provide an updated medication list on discharge. Where appropriate, the virtual clinical pharmacist will provide comprehensive information to the patient or carer to enable safe and effective use of the medications. This will be tailored to suit the patient’s individual circumstances and may be in the form of verbal instructions, demonstration, education, a medication list, written advice or a consumer medicines information sheet. Medication order review involves assessing all current and recent medication orders with the aim of optimising quality use of medicines, patient outcomes and minimise medication related problems. The virtual clinical pharmacist will take into account patient specific factors and provide advice on the most appropriate dose, dosage form, timing and duration of therapy so that risk of medication related problems are minimised. The virtual clinical pharmacist will do this by: • Reviewing all prescribed medication orders • Optimising chronic disease therapy • Identifying drug related causes of admission • Detecting medication interactions • Reviewing medications that may contribute to falls risk • Optimising venous thromboembolism (VTE) prophylaxis • Providing antimicrobial stewardship review • Providing monitoring for narrow therapeutic drugs The virtual clinical pharmacists will document identified actual and potential medication related problems, clinical decisions and suggested changes to medication therapy in the patient’s eMR. The virtual clinical pharmacists, project lead or other investigators will work on a coordinated communication, engage and change management process with study sites to ensure the new model of care in embedded into practice. This will involve providing education and training on the service with the aim of building rapport and ensure a successful implementation. This may involve activities such as site visits, telephone consults and videoconferencing. Adherence to the intervention is monitored via VCare (virtual care) routine monitoring and reporting of telehealth functionality.