Introduction

The COVID-19 pandemic has led to a significant reduction in the volume for all elective surgical procedures across the NHS. NHS Scotland has seen an estimated 50% reduction in total hip replacement (THR) and total knee replacement (TKR) elective procedures, which has adversely affected patient waiting times for surgery.1 Traditionally, arthroplasty surgery would require an inpatient stay but COVID-19 recovery planning has presented an opportunity to restructure and streamline elective arthroplasty surgery pathways by involving the wider multidisciplinary team to optimise care.2 The British Association of Day Surgery (BADS) and the Centre for Perioperative Care have identified the current post-pandemic period as an opportunity to push the boundaries of day surgery to aid the recovery of elective surgery in the NHS.3 Total joint arthroplasty surgeries (THR/TKR) as well as unicompartmental knee replacements (UKR) are ideal candidates for day surgery, given their low complication rates and excellent outcomes.4 It has been shown that enhanced recovery and day surgery protocols can be successfully implemented in arthroplasty patients to reduce length of stay (LoS) without increased rates of complications or reducing functional outcomes, while also providing cost savings compared with inpatient models.5 6

NHS Scotland has rapidly expanded its day case and short-stay pathways in the wake of the COVID-19 pandemic, with arthroplasty surgeries (THR/TKR/UKR) being conducted as days cases at ambulatory care hospitals. A requirement for rapid access to discharge medicines along with a drive for greater patient preoperative education regarding medicines necessitates preoperative clinical pharmacist input in this service. This presents an opportunity for new ways of working for traditionally ward-based, reactive clinical pharmacy services to shift to a proactive, preoperative service supporting the day surgery model, which reduces LoS, to be sustained and rolled out across the UK.

Preoperative patient education should be a multidisciplinary team endeavour, using the medicines specialisation of pharmacists.7 Evidence shows that there is both reduced LoS and overall cost of admission, as well as improved care and safety, for patients who attend a preoperative education session before hip and knee arthroplasty (which are ideally run by the preoperative multidisciplinary team including pharmacists).8 Pharmacists (specifically those with independent prescribing qualifications) being involved in the pre-assessment process also frees up valuable multidisciplinary team clinical time both preoperatively and postoperatively, as well as reducing waiting times for discharge prescriptions.9

Remote consultations and electronic prescribing have been key to overcoming the challenges which have arisen as a result of the COVID-19 pandemic. Remote patient consultations are a cost-effective and efficient way of enabling access to care, while electronic prescribing is known to reduce medication error rates compared with traditional approaches.10 11

This project aims to evaluate the preoperative involvement of a prescribing pharmacist in day case arthroplasty patients, focusing on ensuring safety within the day case model. We aim to investigate the significance of pharmacist input, the impact on reducing prescribing errors, postoperative patient outcomes and patient and staff satisfaction with the service.

Methods

The preoperative arthroplasty pharmacy service was funded through an NHS programme to remodel planned care post-pandemic in 2021. Contact was made with the local health board ethics committee who confirmed that no approval was required for this service improvement project. All data were held on secure NHS networks.

Evidence-based guidance was produced in collaboration with the arthroplasty day surgery multidisciplinary team for medications to be prescribed at discharge. Health board guidance on postoperative venous thromboembolism (VTE) risk assessment and standard operating procedures for completion of electronic prescribing forms were followed.

Day case arthroplasty (THR/TKR/UKR) began at an ambulatory care hospital with 60 short-stay surgical beds in October 2020, with the arthroplasty preoperative pharmacy service commencing in April 2021 and continuing at the time of publication. All patients who underwent arthroplasty surgery before the start of the pharmacy service (September 2020 to April 2021) were identified using historic surgery lists (pre-intervention group, n=80). The data collection period was 20 weeks from April to early September 2021. All patients undergoing THR, TKR or UKR procedures as a day case at this hospital site during this period were eligible for, and received, preoperative pharmacist review (intervention group, n=129). Additional demographic data were sought from the Arthroplasty Rehabilitation in Scotland Endeavour (ARISE) dataset. ARISE is a national programme aimed at improving evidence-based pathways and quality of recovery for patients after arthroplasty surgery. This programme has a significant dataset of patient demographics and follow-up information.

Patients were identified using ‘To Come In’ (TCI) lists generated using orthopaedic surgery listing software (Bluespier). Patients were contacted by telephone by a prescribing clinical pharmacist 1–2 weeks before admission, for remote consultation. The consultation consisted of:

Remote review of all electronic notes using NHS Virtual Private Network (VPN).

Phone call with patient to confirm medication history, give perioperative medicines advice, answer questions and involve patient in shared decision making about their discharge prescription. Relevant details of the consultation were recorded on the patient’s electronic medical record, accessible to the multidisciplinary team.

Discussion with surgical team/anaesthetist to highlight or resolve perioperative medicines issues.

Individualised electronic discharge prescription written, emailed, dispensed and supplied to the ward before patient admission.

All interventions made during the pharmacist’s reviews were collected and categorised using a six-point scoring system produced by Eadon12 for assessing the quality and clinical impact of pharmacist’s interventions (table 1). Scoring was conducted by two senior surgical clinical pharmacists independently, before being compared, discussed and agreed on.

Table 1

Scoring system produced by Eadon for pharmacist interventions

A retrospective review of all perioperative medical notes and discharge prescriptions was conducted for all patients who underwent day case arthroplasty surgery before the introduction of the pharmacy service, and a mock review was conducted by a clinical pharmacist for these patients based on the information available, to identify difference in advice and prescribing between the pre-intervention and intervention populations.

A patient satisfaction questionnaire for the pharmacy service was produced. A subset of 15 patients from the intervention group was contacted via telephone by another member of the multidisciplinary team during a 3-week period in September 2021, 7–10 days after discharge. Staff feedback was gathered through an online questionnaire using Microsoft Forms.

Logistic regression analysis was carried out using R to determine the significance of the results.13 Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guidelines were followed for this quality improvement in healthcare report.14

Results

Patient demographics were collected with additional information sought from the ARISE dataset, which included the patients’ American Society of Anesthesiologists (ASA) score, a system used to convey a patient’s pre-anaesthesia comorbidites (table 2). Demographic data for the intervention population obtained from the ARISE dataset were only available for 103 of 129 patients, owing to changes in the ARISE data collection method during the data collection period.

Table 2

Demographic data for pre-intervention (n=80) and post-intervention (n=129) patient populations

Pre-intervention reviews

Prescriptions were reviewed for the 80 patients before introduction of the pharmacy service. It was found that a pharmacist would have produced a prescription with ≥1 prescribing difference for 38.8% of these patients. A different prescription for postoperative thromboprophylaxis would have been written for 22.5% of patients. The main difference found was before the introduction of the pharmacy service, 18.75% of patients were given aspirin as thromboprophylaxis despite a body mass index (BMI) >30, above which patients are classified as at increased thrombosis risk and should be prescribed alternative thromboprophylaxis (eg, low molecular weight heparin).15 16 In the pre-intervention group, 15% of patients were prescribed a non-steroidal anti-inflammatory drug (NSAID) despite a caution, contraindication or existing NSAID prescription, and 6.3% were prescribed a potentially QT-prolonging medication despite a borderline or prolonged QTc on preoperative electrocardiogram.

Intervention group

A total of 115 interventions were undertaken by the pharmacist in 129 patients reviewed preoperatively during the data collection period. It was found that 93.0% of interventions were given a grading of ≥3 (7% were graded 2), the threshold for clinical significance, and 77.4% of interventions were graded ≥4, indicating that they would be expected to produce an improvement in patient care (table 3).

Table 3

Categorised interventions undertaken by pharmacist at preoperative review graded using Eadon scoring tool

Post-discharge outcomes

Information on post-discharge outcomes was gathered from the ARISE dataset (table 4)

Table 4

Post-discharge outcomes from ARISE dataset

No significant difference in LoS was found between the pre-intervention and intervention groups. A significant reduction was found in the incidence of any healthcare encounters post-discharge at the time of telephone follow-up at day 9 in the preoperative pharmacist review intervention group. A reduction was seen in the percentage of patients who were still requiring oxycodone as pain relief by telephone follow-up at day 9, but this was not found to be significant.

Logistic regression analysis was used to identify variables which may have had an impact on the finding of reduction in healthcare encounters post-discharge in the intervention group, but no variable could be found in the data collected. Similar analysis was able to show an increase in number of interventions which took place at pharmacist preoperative review with increasing patient age (incidence rate ratio (IRR) 1.04, 95% confidence interval (CI) 1.01 to 1.06) and increasing ASA score (IRR 1.81, 95% CI 1.04 to 3.21).

Staff and patient feedback

Seven to 10 days following discharge, a subset of 15 patients from the intervention group was contacted via telephone over a 3-week period to ask their opinions on the preoperative pharmacist review service. Staff opinion was also sought via electronic questionnaire. There were 19 respondents: 11 anaesthetists, four nursing staff, three surgeons and one physiotherapist (figure 1).

Figure 1

Staff (n=19) and patient (n=15) feedback on the pharmacy service.

It was also found that 100% of patients felt that the pharmacist helped them understand the need for blood thinners and understand what tablets should be withheld before surgery.

Discussion

A patientcentred pharmacist virtual consultation produced significant interventions in the majority of patients and improved prescribing standards when compared with patients whose surgery predated the service. Patients reviewed by a pharmacist preoperatively were less likely to have post-discharge contact with healthcare in either primary or secondary care. Patients found that the service improved their experience of surgery and made them more confident to follow plans to manage their postoperative symptoms. Staff found that the service improved efficiency and feasibility for the overall arthroplasty day surgery service.

Prescribing standards

Pharmacist prescribers have been shown to have very low rates of both minor and significant prescribing errors, which compares favourably to that of other prescribers.17 18 The pharmacist intervention group was compared with the pre-intervention group, who were reviewed by medical staff in the months before this project commencing. Analysis showed that a different discharge prescription would have been generated for 38.8% of patients in the pre-intervention group if a prescribing pharmacist had reviewed the patient before surgery. Two key prescribing themes were identified: VTE prophylaxis and NSAID. The interventions undertaken by the pharmacist at the preoperative consultation in the intervention group (table 3), such as amending discharge medications based on preoperative status or owing to patients’ chronic medications, would be expected to significantly reduce the medications errors which were found to have occurred in the pre-intervention group.

VTE is a major clinical and economic burden to the global healthcare system, and patients undergoing joint arthroplasty surgery are at high risk of VTE postoperatively.19 The estimated cost for just one NHS Scotland health board for hospital admissions owing to VTE in 2011–2017 was greater than £23 million, in addition to more than 3000 deaths caused by VTE being recorded from 2008–2017.20 The project demonstrated via retrospective review of prescriptions generated before the pharmacy service intervention that 22.5% of patients had VTE prophylaxis, which was not policy and may have led to adverse outcomes. Of pre-intervention patients, 18.5% were prescribed aspirin despite a BMI >30. As well as evidence that shows an increased occurrence of pulmonary embolism and deep vein thrombosis postoperatively in primary hip and knee replacement patients with a BMI >30, there is evidence that aspirin once daily is insufficient to produce an adequate antiplatelet response in obese patients.15 16

NSAIDS are associated with more emergency hospital admissions due to adverse drug reactions (ADRs) than any other class of medication.21 In primary care, 6% of patients prescribed NSAIDs reconsulted their GP with an ADR in the next 2 months.22 Retrospective review of the pre-intervention group showed 15% would not have been prescribed an NSAID had a pharmacist reviewed them preoperatively. Given the relatively small number needed to harm for common NSAIDs (82 for ibuprofen),23 reducing inappropriate prescribing will lead to avoidance of patient harm and reduced burden on both primary and secondary care as a result.

All prescribing decision made by the pharmacist within the intervention group were aligned with current evidence-based guidelines for all medicines, including VTE prophylaxis and NSAIDs, and the intervention group could therefore be determined to be at lower risk of postoperative VTE-associated and NSAID-associated patient harm in comparison with the pre-intervention population.

Patient opinion

Following discussion with the pharmacist, patients reported more confidence in taking pain killers. Levels of satisfaction with how pain is managed may be improved by providing patient-tailored analgesic regimens, in addition to ensuring patients are empowered to use optimal analgesia with an understanding of side effect and their management.24 The pharmacist intervention focused on safer use of opioids including advice on self-administration, weaning analgesia postoperatively and follow-up if required.

It has been shown that patient refusal is a significant reason for poor adherence to thromboprophylaxis and that patient education can address this by clarifying the purpose of their therapy.25 Of the patients questioned, 100% reported that they felt they understood the need for blood thinners postoperatively after pharmacist review. Feedback from patients demonstrated that they clearly understood therapy explained by the pharmacist, and concerns regarding administration of injections were also addressed.

Remote consultations are an increasingly used and widely available method of patient consultation, which have demonstrated consistently high satisfaction scores from patients. Remote telephone consultations also reduce the logistical and geographical barriers which may prevent patients from accessing services.26 As the preoperative pharmacist review did not require any direct patient examination, this service was ideally placed to use the benefits of remote consultations. Our results demonstrate that patients found this method of pharmacist consultation useful and convenient, and that it improved their overall experience of care.

Staff opinion

Staff opinion was sought, as this was a new service being provided by a pharmacist prescriber fulfilling a role traditionally performed by a medical practitioner. Staff opinion on the service was extremely positive. In particular, all staff questioned thought that the pharmacist intervention improved prescribing standards and efficiency of medicines supply.

It was found that 79% of staff felt that the pharmacist intervention released time for them to focus on clinical duties. A comment of interest from the staff group noted that the pharmacist prescriber was a valuable link between primary and secondary care, with specific reference to the opioid prescribing crisis. Patients are often discharged home with opioid analgesia postoperatively, with patient education ensuring that appropriate follow-up is in place are essential to prevent a worsening of the situation in primary care.

Post-discharge outcomes

A significant reduction in post-discharge healthcare encounters was seen in the intervention group in comparison with the pre-intervention group. Within the intervention population, logistic regression analysis was not able to identify any specific variable (such as a particular intervention or patient type) which influenced the likelihood of a post-discharge healthcare encounter within the data collected. It was not possible to characterise the exact reason for the post-discharge healthcare encounters which took place in either group. This being said, the pharmacist review preoperatively focuses on patient education regarding pain management, thromboprophylaxis, control of nausea and constipation. As such, it could be hypothesised that patients required less contact with primary care for the management of these issues.

It was found that the number of interventions enacted during the pharmacist’s preoperative review increased with patient’s age and ASA score. As a measure of overall health it would be anticipated that those with a higher ASA score would require more interventions during review owing to higher burden of comorbidities and medicines. Similarly, with increasing age, patient morbidity and medication burden will increase, therefore potentially requiring more pharmacist input. As surgical services recover and refocus after the COVID-19 pandemic there is a drive towards expanding day surgery capacity and maximising patient eligibility for day surgery. As the pharmacist service in question focuses on delivering preoperative interventions for patients preparing for day surgery, the finding that more interventions can be made in older and more comorbid patients strengthens the case that pharmacist-led services such as this can help support day surgery expansion.

Context and sustainability

Many health boards across the NHS are pushing to facilitate the delivery of complex orthopaedic procedures as day case surgery in appropriate patients. BADS targets detail that between 25–40% of hip and knee arthroplasty surgery should be aimed to be performed as day case.27 New approaches are needed to tackle this issue and restore and improve surgical capacity. This is only possible with co-ordinated initiatives utilising the skills of the whole surgical multidisciplinary team. This links to the key principles of the NHS Day Surgery Delivery Pack which emphasises multidisciplinary team working and bespoke day surgery protocols, including those for discharge medicines.3

The Royal Pharmaceutical Society’s publication28 recommends that pharmacy teams take a person-centred approach to care, and that pharmacists change focus from checking the work of other healthcare professionals towards their own prescribing role in optimising therapeutic outcomes for individual patients.28 Our initiative is an example of pharmacists taking responsibility for prescribing in a specific patient group undergoing major surgery in a day case setting. Furthermore, the use of digital solutions, and remote consultation to access patient information and provide bespoke patient prescriptions provides an example of pharmacists pushing the boundaries of the traditional checking role in order to deliver a proactive high standard of patient-centred care.

The introduction of the day case arthroplasty model in our health board has led to a reduction in length of stay when compared with the traditional inpatient model (mean LoS: THR 2.8 days, TKR 3.3 days, UKR 1.19 days) versus the day case model (mean LoS: THR 1.06 days, TKR 1.10 days, UKR 0.87 days).29 The pharmacist consultation within the day case population did not significantly reduce the LoS any further (table 4).

Limitations

Although it has been shown that preoperative education can reduce the overall costs and improve outcomes for TKR and THR procedures,8 analysing the costs savings associated with the pharmacist intervention was outside the scope of this project given the complexities associated with such costings.

The introduction of a pharmacy service into the day surgery multidisciplinary team is in line with the recommendations of the NHS Day Surgery Delivery Pack. Although the large day surgery multidisciplinary team efforts have improved outcomes, the involvement of many specialities also makes it difficult to isolate the effectiveness of individual professional contributions such as pharmacist preoperative consultations.

Owing to the retrospective nature of the data collection in the pre-intervention group, we were able to compare prescribing standards with guidelines, but we were unable to perform a full review and collect data on all the medication-related problems in this population.

Owing to the scope of the follow-up dataset we had access to we were unable to quantify the number or nature of any post-discharge ADRs which occurred in either the pre-intervention or intervention populations.

We were able to demonstrate from our data an increase in prescribing standards; however, it is difficult to link these improvements in prescribing practice to specific outcomes such as a lower incidence of VTE postoperatively, owing to our small sample size. Lack of effective IT interface between primary and secondary care also makes follow-up of patient postoperative outcomes challenging. For these reasons, long-term clinical follow-up of patients, such as identifying rates of VTE postoperatively between pre-intervention and intervention groups, was beyond the scope of this work.

Further work

Increasing the scope of the post-discharge follow-up dataset going forward would be useful to ascertain the nature of any ADRs and their severity. These data could be used to compare the impact on medication safety of any future service developments within this patient population.

Further data collection is warranted to establish the specific feature of the pharmacy service attributable to a reduction in post-discharge healthcare encounters, as we were unable to define this through logistic regression analysis. Identifying the patients who may benefit most from preoperative pharmacist review may allow for a more targeted and efficient service in the future.