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

Medication Reconciliation Table

Medication/Dose

Indication Therapeutic Goal

Goal

Achieved

(Y/N/?)

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

Med Rec Spread – Acute Care

Sharing Experiences & Lessons Learned

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

Team McMed – 4A Pasqua Hospital

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

Logo concept

Medication Reconciliation

PatientsPharmacists

Physicians

Nurses

PatientSafety

Logo concept

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