Can virtual pharmacist-led prescribing help improve medication safety among hospital inpatients?

The intervention is based on the PPMC model developed in Victoria, however, pharmacy services will be delivered virtually. The virtual clinical pharmacy service utilises a range of modalities including the electronic health records, teleconferencing and videoconferencing using designated telehealth equipment such as portable wireless videoconferencing cart with two-way audio and visual including a tilt, pan and zoom camera lens to conduct patient reviews and discuss patient care with medical officers and nursing staff. Primary communication with patients is via videoconference, and teleconference and electronic documentation with medical officers, nurses and allied health. However this may change depending on need and particular circumstances e.g. multidisciplinary meetings are via videoconference. The intervention will have a credentialed pharmacist take a best possible medication history and review venous thromboembolism (VTE) risk on all eligible patients, as soon as possible as part of admission to hospital. Patients will be prioritised for review based on clinical judgement and pharmacist workload, and medication history-taking is dependent on various factors including awaiting correspondence from other health care providers. Therefore, no specific timeframe has been set for the intervention. After medication history-taking and review, the pharmacist will then create a medication management plan in collaboration with the medical officer. Once agreed upon, the pharmacist will electronically document the medication management plan and chart the patient's regular medication and VTE prophylaxis, co-signed by the medical officer. Relevant information is then communicated to the nurse. VTE risk assessment is based on a standardised electronic form for medical officers to complete which helps identify risk factors for VTE and contraindications to VTE chemoprophylaxis. Clinical pharmacists can make recommendations and prescribe VTE prophylaxis as part of partnered charting but will not formally assess VTE risk using this electronic form. A documentation template for PPMC will be developed, and will contain (per the draft local procedure): - Reason for admission - Current clinical issues - Current Home Medications - Changes to admission medications in consultation with the partnering medical officer - VTE Risk Assessment (if completed) and prophylaxis considerations and dose - Name of the partnering medical officer - Pharmacist contact details - Authorisation statement (“Nursing staff are authorised to administer medications approved by the medical practitioner signatory and charted by the pharmacist as documented on this inpatient progress note”) The research team will ensure ongoing training and engagement with clinical staff for the duration of the study to ensure uptake of the intervention. However, it will not be possible or appropriate for all patients to receive VPPMC at the intervention sites, for example it will be quicker for a doctor to chart medications if a patient takes only one cholesterol tablet. Informational training materials will be supplied by New South Wales Health and the Society of Hospital Pharmacists of Australia, who will provide training for accreditation of virtual pharmacists. Pharmacist accreditation is planned within the three months before intervention commencement. A one-off PPMC training and credentialling program will be completed prior to the commencement of the intervention. The training is a combination of online and face-to-face learning with an oral assessment: 1. PPMC online learning module (45mins) 2. My Health Learning Online Modules -- eMeds: Pharmacist Pathway (Documenting Allergies 15-20 mins, Home Medications 15-30 mins, Admission Reconciliation 15-30 mins, Medication Orders 15-30 mins, Medication Order Actions 20-40 mins, Medication Complex Orders 15-30 mins, Clinical Pharmacy Review 15-30 mins, PowerPlan 10-20 mins, Discharge Reconciliation 15-30 mins -- eMeds: Fluid infusions – Prescribing (course code 327248785) (60-70 mins) -- Safely prescribing and administering insulin (Course Code 194502204) (30 mins) 3. Supervised PPMC cases using an Entrustable Professional Activity (EPA) assessment tool until pharmacist reaches EPA Level 4 for independent credentialing (“Perform with minimal supervision, available if needed, essentially independent performance”), and Level 5 to credential others (“Supervise more junior colleagues” - per Australian Pharmacy Council) 4. OSCE facilitated by a senior pharmacist and a senior doctor (registrar or above) nominated by the medical unit.