pharmacist directed medication reconciliation plus in a ltc facility don h. kuntz bsp medication...
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Pharmacist Directed Medication Reconciliation Plus in a LTC Facility
Don H. Kuntz BSPMedication Reconciliation Project
Manager, QI UnitRegina, Saskatchewan
Wascana Rehabilitation Centre 50 Rehab 250 LTC beds
veterans (66 beds) restricted admits specialized, high
level care advanced neuro ventilator unit peds to very
elderly
Wascana Rehabilitation Centre Seven attending family physicians
daily visits 24hr on call
All therapies (PT, OT, Exercise, Rec, Music) Lab & x-ray (Monday to Friday – days) Pharmacy on site (hospital pharmacists &
techs) Team environment
Admission & annual patient conferences, physician attendance mandatory
Quarterly medication reviews
Med Rec Project
“Medication Reconciliation on Admission to Long Term Care at Wascana Rehabilitation Centre”
HQC Innovation Fund Initiative 2004-5
Commenced prior to Safer Healthcare NOW! Getting Started Kit
Project Overview Impetus: 1997 RQHR CCHSA report
suggested WRC residents on higher than average number of medications than benchmark institutions
Inherit & maintain is not reconciliation
Medication reconciliation Appropriate & consciously continued,
discontinued or modified
Primary Aim Ensure WRC LTC pts receive only those
medications deemed appropriate & necessary to reduce medication use, adverse events, drug interactions & drug misadventure
Develop a standardized method to reconcile prescribed medications
Develop process to optimize pharmacotherapy through improved documentation early on in the admission process
Observation
For LTC patients, information transfer is inconsistent, not standardized and in many admissions is sorely lacking acute care > active rehab > LTC >
PCH > Community (home)
PDSAs Developed a LTC monitoring form for
pharmacists Standardized data collection & synthesis
Identified medication information sources at time of admission Variation and reliability was dependent on
where the patient was admitted from Community (home, PCH) LTC facility transfer Acute care Active rehabilitation unit
PDSAs Developed a medication reconciliation
form Tested process & forms
10 pt retrospective audit 20 pt consecutive admissions audit
Developed tool to relay information in a systematic & standardized method into patient chart Chart form development – not an order form Acceptance from physicians & nursing Forms committee & Health records approval
PDSAs
RQHR policy changed to allow complete acute care chart to remain at WRC for up to 7 days (previous 48hrs)
Revised pre-printed admission orders to include pharmacist consult for medication reconciliation, allergy verification & vaccination history
PDSAs On request, HR provides the “WRC
Package” to the pharmacist which includes two years of information (faxed or mailed): Discharge summaries Consults Progress notes Diagnostics (except lab which is on-line) OR reports Physician orders
PDSAs - Developed standardized information
for pharmacists to provide therapeutic goals for medications by disease state and drugs Evidence based information, referenced Guidelines (e.g. HTN, DM, Lipids, Stroke)
Indications, therapeutic targets, treatment options & monitoring
Therapeutic goals - sampleAtrial Fibrillation (persistent & paroxysmal) Drugs for the Heart 6th ed; Chest; Therapeutic Choices 4th
ed Goal: stroke prevention
Warfarin – target INR 2.5; range 2-3 ASA 325mg daily (for pts <65yo and no other risk factors) Clopidogrel 75mg daily (ASA intolerance/allergy)
Rate Control (Beta-blockers, digoxin, verapamil, diltiazem)
Goals: - control heart rate (between 60-100 beats\min at rest; average 80 beats\min)
- control symptoms Rhythm Control (sotalol, amiodarone, propafenone,
etc) Goal: restoration and maintenance of sinus rhythm
PDSAs Satisfaction survey
Sent to physicians, nurses, pharmacists and nursing unit managers
High level of satisfaction 4.5/5 (25 respondents
Most difficult sell physician “Nice addition to the admission process”
Patients and families very satisfied (source patient team members)
Pharmacist Driven Med Rec Process Admission generates pharmacist consult Patient and/or family interview Electronic Provincial Drug Plan data base
information is reviewed Info obtained & thoroughly reviewed
able to reconcile >95% of original home meds Med rec info & therapeutic plan with
recommendations placed on chart Physician review and medication orders are
written on standard RQHR order forms Pertinent patient information placed on chart
under history section
LTC vs Acute Care Considerable differences in process 2/3 of admissions to WRC generated
through acute care stay, many of those are lengthy
Considerable changes to home meds during acute care stay (acute care med rec in spread stages)
Note: electronic provincial med rec form not trialed as this came into play in 2007
Outcomes To date > 250 admissions completed Physician acceptance – 100% Recommendation acceptance > 90% Many patients have fewer medications,
some on more lack of, or expiry of indication (e.g. DVT
prophylaxis; symptom relief) therapeutic duplications & double/triple
plays
RQHR Acute Care Facilities Community
Hospital 210 beds
Eye centre Cancer services Ambulatory care Palliative care
Pasqua Hospital l
RQHR Acute Care Facilities Major referral
centre for southern Sask 380 beds
Trauma, ICU, cardiosciences, neurosciences, neonatal, mental health, burn unit Regina General
Hospital l
Med Rec History - RQHR
Provincial auto-populated form utilized for admissions
Pilot – family medicine Jun 07 – Jul 08 100% nurse utilization/bpmh creation
5 months 90% physician uptake
8 months Discrepancies being resolved
The Process1. Preadmission Medication List/Physician
Order Form is printed from PIP program on admission (Regina - SWADD, rural - RNs)
2. Bedside nurse utilizes form when interviewing patient and creates the BPMH
3. Physician utilizes form and orders medications to continue, stop or change based on patient’s acute care status & documents rationale for changes and discontinuations
It is a fact…. The patient
interview is crucial to obtain the BPMH
25-40% of PIP meds no longer taken by pt
Benefits of Med Rec
Patient safety enhanced eliminates transcription errors
corrects/ prevents discrepancies
clearly identifies home meds including Rx, OTCs and herbals
Patient medication interview time reduced by 50%
Data base for home medications on chart
Physician medication ordering time reduced
Orders clearly legible (reduced calls for clarification)
Eliminate duplication of work (multiple lists)
Spread – communication & education Nursing
managers & educators education days (29 x 1 hr presentations) = 800 + unit meetings
Physicians one on one section & department meetings; clinical rds Direct mailing to 500 physicians
cover letter one page role/instruction sheet sample completed med rec form
Pharmacists – site staff meetings & e-mail updates
Spread – communication & education Board presentation SMT & ED Council Local cable television
“Alive & Well” Newsletters
Med rec E-Link (regional newsletter) The Physician DrugLine (pharmacy newsletter) RQHR Annual Report (community mailing)
Posters Committees, Units & task forces
pt safety task force; homecare nurses, client reps
Spread – acute care units Two acute care facilities Regina General and
Pasqua Hospitals 27 nursing units 2 ERs 2 PACs
Go live date – September 2, 2008 SWADD printing med rec form for all admissions
Rural hospitals (7) 4/7 visits & training completed 1 facility – 100% compliance
16 beds; 4 physicians Have spread to ER & clinic visits on their own
Measurement First 4 weeks of audits (130
pts/wk) done by QI team Ownership of process unit
responsibility Audit person identified for each unit
nurse, educator, manager, unit secretary 5 pts/wk Excel workbook E-mail reporting to QI unit weekly
Reporting structure
QI collates information and reports to: Each nursing unit manager Executive Directors Health Services VPs Senior Management Team
Board: PSSC
SMT: pt safety score card - % discrepancies resolved by site/service
HS VP – monthly report;% med discrepanciesresolved by portfolio site/service
HS VP Sponsor – monthly report;% med discrepancies resolvedby portfolio site/serviceEDs: – monthly report;
% med discrepancies resolved (by unit/site within portfolio
CQIteams
Medical Dept Head Council:monthly report; % discrepanciesresolved by acute care unit
Unit/site managersWeekly date & progress infofrom key unit contact
QI unitweekly date from unit keycontact: generates monthly reports
Unit/Site Key Collaborative Contact:Working with QI consultant:
•in-service & mentor colleagues, champion process • mentor physicians
• audit 5 patients/week
Accountability
Initiative is not owned by any one dept
Shared responsibility and accountability patients, nursing, physicians,
pharmacists, QI unit Such a small piece Such a simple thing
Spread barriers
ER Lack of effective broad based
communications Physician acceptance Incomplete bpmh/form completion Unit culture variability
too busy, acuity is high, turn over is high
Lessons learned Communicate immediately & frequently
Especially with physicians Utilize dept/section secretaries to get on
physician meeting agendas Identify champions early
Physicians Nursing units Pharmacists Nurse educators
Lessons learned Use patient stories as often as possible
Barrier physicians – use stories of their own pts
Frequent nursing unit & site visits Ongoing mentoring Q & A Visibility
Engage the doubters Focus on regional/national patient
safety initiative
National initiative needs… Physician awareness
CMA & others Process to be recognized
Core curriculum introduction medicine, nursing, pharmacy
Branding Logo Discrepancies is still new terminology
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