Table 2 Planned vs. actual activities and results

Patient selection

Selection of stable patients

Selection of patients who are not clinically stable because strict guideline application proved difficult within a context of:

(a) multi-morbidities

(b) high prevalence of patients with sub-optimal outcomes

(c) changing outcomes and

(d) patients’ needs perceived to be beyond clinical care.

In addition, non-medical factors such as service pressures, enrolment targets by management, intention to save on the facility’s financial budget for medicines by putting more patients on the CDU’s budget.

Prescription quality

Clinicians issue prescriptions in accordance with legislation and policies

Overall rate of prescription rejection was an estimated 4–5% (of approximately 14,000 prescriptions each day). Errors were attributed to:

(a) cumbersome administrative processes attached to the intervention

(b) misunderstanding of processes between healthcare practitioners and the service provider.

Pharmacists check all new prescriptions for compliance with legislation and policies

Pharmacists did not always check prescriptions before submitting them to the CDU because they felt it was time consuming.

Dispensing and dispatch of patient medicine parcels (PMP)

Prescription verification, dispensing and delivery to the facility three working days before the collection date

Except when a prescription had been rejected for reasons earlier stated, PMP were delivered on time.

Medicines distribution

Pharmacist checks all parcels and fulfils the prescription requirements using pharmacy stock in case of stock-outs. Distribution of PMP follows at the facility or in the community.

Pharmacists did not check all parcels – the process was deemed to be time consuming and consequently to reduce the benefits of the intervention. Pharmacists recommended the use of transparent instead of opaque packaging and inclusion of prescriptions in the PMP to facilitate easier checking. That said, when there were stock-outs, the facility was provided with a list of outstanding prescriptions needs and these were fulfilled unless the facility was also stocked-out.

Health system causes for non-collected medicines

Patients are given 5 working days should they miss their scheduled appointment. Thereafter, PMP are returned to the CDU within 10 working days from the date of collection or the medication is absorbed into the facility’s pharmacy.

Challenges resulted from:

(a) clinicians who were resistant to changing their ways of working to adapt to CDU requirements

(b) locum doctors who were not familiar with processes

(c) patients who reported for acute care prior to their CDU appointment often led to establishment of new appointment systems.

Clinicians recommended marking CDU patient files differently from other patient files for easier identification.

Management of non-collected medicines

If a patient misses 2 appointments consecutively, the prescription is stopped and the patient must consult the clinician for counselling and assessment.

Reports on non-collected PMP should be submitted to the CDU.

Some pharmacy staff returned non-collected PMP while others opened PMP that were not collected. The reasons given for the latter were:

(a) shortage of space to keep the parcels until the patient comes or until the parcel is returned to the CDU 

(b) to discourage patients from missing appointments [coercion]

Pharmacy staff who opened PMP believed that the same patients would come to the facility even if late so they could re-dispense medicines and save on their facility's financial budget for medicines.

Unstable patients who missed appointments were not removed from the system as per protocol for similar reasons earlier mentioned (saving on facility budget and high prevalence of unstable patients).

Monitoring and Evaluation

Data on all activities

Mid-level managers found it difficult to comprehend routine data and in some cases doubted its accuracy. Statistics on collection of PMP were still under reported because healthcare practitioners considered reporting a time-consuming task and feared negative views.