Pharmacist-led medication reviews on a virtual frailty ward led to reduced inappropriate polypharmacy. The pharmacist completed medication reviews for 100% of patients, identifying opportunities to optimize medications. This resulted in stopping, adjusting, or changing medications, especially those related to cardiovascular systems. Deprescribing unnecessary medications reduced pill burden and costs. Involving pharmacists in medication management improved outcomes for vulnerable older patients.

1. Impact of Pharmacist Led Medication Reviews
on the Virtual Frailty Ward (South West Essex)
Aziza Qureshi, Lead Pharmacist Frailty and Older People, aziza.qureshi@nelft.nhs.uk
Introduction
Virtual Wards are designed to facilitate the provision of acute care to patients in their own home. Patients over the age of 65 and identified as moderate or severely frail requiring acute
care are referred to the Virtual Frailty ward in South West Essex (VFW). This provides a safe alternative to hospital for this vulnerable patient population. The benefits of the VFW result
in avoiding hospital admission and facilitating early discharge.
Frailty is a health state such that patients are more vulnerable to sudden changes in health triggered by ‘small events’ such as infection, medication changes and environmental changes.
Frailty increases the risk of adverse outcomes such as falls, disability, admission to hospital, or the need for long-term care. Frailty and polypharmacy are closely linked; an individual
with frailty is six times more likely to be on 10 or more medicines. This increases the risk of adverse effects, hospital admissions and dependence. Furthermore those with frailty are
more susceptible to the side effects of medicines. Patients with multiple conditions will have multiple medicines and patients are often treated in a single disease centred approach po-
tentially causing a prescribing cascade. The evidence base for medicines predominantly excludes the older population and those identified as moderately and severely frail. As such,
medicines optimisation is of particular importance in this patient population to help patients with frailty get the best out of their medicines and reduce inappropriate polypharmacy.
The VFW does not consist of a pharmacist and currently medication reviews are not occurring consistently. Medication reviews are reactive and are not routinely used in a holistic
manner by encompassing patient views, previous history and comorbidities due to lack of expertise and capacity within the team.
The AHSN national polypharmacy programme provided tools and principles to facilitate holistic medication reviews, focussing on factors important to the patient. Applying this in pa-
tients with moderate and severe frailty will have significant benefits with respect to quality of life, healthcare outcomes and economic savings.
Aim: To reduce inappropriate polypharmacy through completion of medication re-
views for 100% of the patients admitted on the virtual frailty ward identified as
polypharmacy or referred due to medication needs between November 1st 2022
and January 6th 2023.
Stakeholder Engagement:
Therapists: Regularly involved in post
falls review and would benefit from
pharmacist input with respect to
medicines.
Doctors: Identified this is a key con-
cern for this patient group.
Patients: Moderate/severely frail pa-
tients are at high risk of adverse
effects. Patient engagement shows
that many are concerned about the
‘number of medications’ prescribed.
Pharmacy team: Allows integration
with the multidisciplinary team
(MDT) and application of expertise.
Change Idea Testing
Based on discussions with stakeholders and reviewing the driver diagram, the prima-
ry idea to test was to include a pharmacist within the MDT to facilitate medication
reviews. The pharmacist is an expert in medicines and therefore can also support
colleagues and provide education. In addition, the pharmacist can develop a medica-
tion review tool applying the learning from the AHSN polypharmacy national pro-
gramme to include prompts and tools to facilitate shared decision making.
Testing
Outcome Measure: Number of pharmacist led medication reviews completed.
Process Measure: Implementation of the medicines review tool.
Process Measure: Specific classes of medications changed.
Balance Measure: Time required from the pharmacist to complete medications re-
views.
Outcomes and Impact
0
20
40
60
80
100
120
140
Medication
reviews
Medication
Changes
Adherence Medicines
management
Patient
Education
Patient Assessments Completed
Complete Incomplete
0
10
20
30
40
50
60
Number
of
medications
BNF chapters
Pharmacist led medicines interventions
0
10
20
30
40
50
60
70
80
Medication
Stopped
Dose Adjusted Medication
Started
Medication held Formulation
changes
Number
of
medications
Medication changes following pharmacist led
medication reviews
Impact:
Medication reviews had a direct correla-
tion with medication changes. Medica-
tion reviews enabled discussions regard-
ing adherence, patient education and
medicines management. This enabled
shared decision making.
Impact:
Overall, the greatest interventions were in
relation to the cardiovascular system. This
was due to reviewing preventative medica-
tions. Applying the learning from the AHSN
polypharmacy national programme to focus
on individual parameters and to not evi-
dence base in isolation, enabled this. This
will have economic savings and reduce inap-
propriate polypharmacy.
Impact:
Deprescribing was the most significant
outcome of medication reviews. This re-
duces inappropriate polypharmacy and
encourages adherence due to reduced
pill burden. Furthermore, impact was
found in financial savings in relation to
medication cost, resources required for
prescribing, dispensing and administer-
ing.
Next Steps:
• Patients are identified for a medication review due to polypharmacy or through
referral. The next phase would be to conduct medication reviews for all patients
admitted on to the virtual frailty ward.
• The current process involves pharmacist review and discussion with MDT first,
whereas the next phase would include patient engagement in the first steps.
This will engage the patient and facilitate further Shared Decision Making.
• Continue to apply the principles of reviewing medication in the context of indi-
vidual patient factors and patient views alongside the evidence base.
Current Process Change Idea
Driver Diagram