Transcript Dr Michal Boyd presentation

HealthCERT
Aged Residential Care
Medication Management Audit Data
Comparison 2009 and 2012
Dr Michal Boyd, RN, NP, ND
Sr Lecturer and Gerontology Nurse Practitioner
School of Nursing and Freemasons’ Department of Geriatric Medicine
University of Auckland
OPAL Results: Medications
Mean number of medications for all
residents in 1993, 1998 and 2008
Medications
8
2008 mean
numberTaken
of medications
Mean Number
of Medications
in the Last 24
by care
type
Hours for Each
Facility
Type
7.2
7
DEMENTIA CARE
6
PSYCHOGERIATRIC
6.5
RESPITE
6.5
5.4
5
5
4.4
4
PRIVATE HOSPITAL
7.2
3
PALLIATIVE
7.3
2
REST HOME
1
7.6
ALL FACILITIES
7.2
0
1993
1998
2008
0.0
1.0
2.0
3.0
4.0
5.0
Mean Number of Medications
6.0
7.0
8.0
Development of ARC Medication
Guidelines
• November 2009 HealthCERT analysed 320 audits
against the 2008 standards (introduced on 1 June
2009)
– 140 audits (44%) medicine management partial attainment
• MOH contracted Dr Michal Boyd to work with sector
representatives to develop a safe management of
medicines guide for residential aged care. Completed
in 2011.
HealthCERT Auditing Process Changes
Since 2009,
– increased accreditation of auditors
– HealthCERT spot audits
– publishing audit summaries online
– Increased medication management and compliance
training for auditors by HealthCERT
– Introduction of the Medication Care guides
Medicines Care Guides (MOH 2011)
• The aim of the Medicines Care Guides is to provide a
quick medicine management reference tool for all care
staff working in residential aged care in New Zealand.
• Guidance is provided for key medicine safety topics
relevant to the care of older adults.
• This guidance is based on current legislation, best
available evidence and published guidelines,
• “Ground up” development process
48 Medicines Care Guides
Two Main Functions
Goal is to improve compliance
and care quality:
• General medication safety
guides for residential aged
care
• Information about specific
high risk medications
Comparison of Medication Management Audit Data
• July 2009 and June 2010 (561 Facilities) and
January to December 2012 (516 Facilities)
– The data were in free text format within an Excel
spread sheet
– One column was used for each of the eight categories
of evidence contained in the auditor’s notes
– Each record was highlighted and numbered according
to the theme and the category that had been
developed from the baseline 2010 report.
Medication Management Categories
Category
Description
Medicines management system
A medicines management system is implemented to manage the safe and
appropriate prescribing, dispensing, administration, review, storage, disposal,
and medicine reconciliation in order to comply with legislation, protocols, and
guidelines.
Policies and procedures clearly document the service provider’s responsibilities
in relation to each stage of medicine management.
Service providers responsible for medicine management are competent to
perform the function for each stage they manage.
A process is implemented to identify, record, and communicate a consumer’s
medicine allergies or sensitivities and respond appropriately to adverse
reactions or errors.
The facilitation of safe self-administration of medicines by consumers where
appropriate.
Medicine management information is recorded to a level of detail, and
communicated to consumers at a frequency and detail to comply with
legislation and guidelines.
Policies and procedures
Staff competence
Allergies procedures
Self-administration procedures
Recording and communicating
medication management
information
2010 only: Accounting for
resident and others' views
Continuity of treatment and support is promoted by ensuring the views of the
consumer, their family/whānau of choice where appropriate and other
relevant service providers, for example GPs, are considered and documented
prior to administration of new medicines and any other medical interventions.
2012 only: Consumers receiving
medicines in a safe manner
Consumers receive medicines in a safe and timely manner that complies with
current legislative requirements and safe practice guidelines.
TABLE 1: COMPARISON OF AUDIT CATEGORY PARTIAL ATTAINMENT PERCENTAGES: 2010 AND 2012
Category
2010
2012
% Partial attainments % Partial attainments
p value
Medication Management Systems
25.7%
45.0%
< .001
Policies and Procedures
2.9%
0.8%
.01
Staff Competence
12.7%
11.2%
.48
Allergies Procedures
4.1%
5.2%
.38
Self-administration
5.5%
8.1%
.09
Recording and communicating
medication management information
19.4%
21.3%
.45
0%
-
-
3.5%
Listening to residents’ and others’ views
Consumers receiving medicines
In a safe and timely manner
Medication Management
Medication management systems
category partial attainments
2010
2012
25.7%
(144 of 561 audits)
45.0%*
(232 of 516 audits)
*p< .001
T ABLE 1: MEDICATION MANAGEMENT SYSTEMS RISK LEVEL CATEGORIES: 2010 AND 2012
Level of Risk
2010 PA risk category % (count)
2012 PA risk category % (count)
Negligible
0.4% (1)
0
Low Risk
11.6% (65)
14.0% (72)
Moderate Risk
10.3% (58)
26.0% (134)*
High Risk
3.7% (21)
5.0% (26)
0
0
Critical
*p< .001
Medication Management
• Only one sub-category improved significantly in
2012 compared to 2010. This category was:
– Staff competency updating and recording PAs
decreased significantly in 2012 (0.4%) compared to
2010 (2.1%).
– Unused medications not returned to pharmacy
category showed slight improvement in 2012
compared to 2010 but it was not statistically
significant.
Medication Management
Signing documentation and records: Pas 8.4% in 2010 and 17.8% in 2012, p<.001, Examples:
– Failure to sign medication charts
– Controlled drugs checking
– Fridge temperatures
Administration of medications: PAs 3.2% 2010 and 16.9% 2012 (p<.001), Examples:
– medications not being administered at the right time of day
– not being administered when prescribed,
– medication being left out.
Labelling of medications absent/unclear: 0.9% 2010 and 11.6% 2012 (p<.001), Examples
– eye-drops that had been opened with no date recorded of the opening date.
Controlled drugs checking and record keeping: 7.5% 2010 and 10.1% 2012 (p<.001),
– carrying out the weekly controlled drug checks.
Transcribing medications and prescription onto charts: 1.2% 2010 and 7.0% 2012 (p<.001)
Medication Management (Cont)
Three monthly medication reviews not completed by GP: 1.6% 2010
and 4.1% 2012 (p<.001)
Standing orders procedures inadequate or not followed: 1.2% 2010
and 2.9 % 2012 (p<.05)
No resident photo identification : 1.1% 2010 and 2.7% 2012 (p<.05)
Documenting and record keeping 5.7% 2010 and 8.3% 2012 (ns)
– failure to document processes following medication lapses
– failure to administer warfarin
– lack of evidence showing doctor’s signatures.
Medication reconciliation and Medication errors were not significantly
different between 2010 and 2012.
Nurse Practitioners in
Aged Residential Care
• National contract included Nurse Practitioners
– Can do admission and quarterly assessments
• Nurse Practitioner Intern Positions have been
created in ARC
• NP in aged care evaluation - >20% fewer
hospitalisations
(Peri, Boyd, Stillwell & Foster, 2013, Health Workforce New Zealand)
Medication Management (Cont)
Expired Medications in Use 1.2% 2010 and 6.8% 2012 (p< .001)
Storage of medications: 6.4% 2010 and 9.3% 2012 ( (p = 0.07)
• security of storage,
• maintenance of the fridge temperature
• storage of medications within the main fridge used for foods
Maintaining and using medication charts: 1.2% 2010 and 4.8% 2012
(p<.001)
Block signing document: 1.2% 2010 and 3.9% 2012 (p<.001)
Three monthly medication reviews not completed by GP 1.6% 2010
and 4.1% 2012 (p<.001)
Medicines Care Guides:
Medication Storage
Policies and Procedures
Policy and procedures
category partial attainments
2010
2012
2.9%
(16 of 561 audits)
0.8%*
(4 of 516 audits)
*p= .02
T ABLE 1: POLICY AND PROCEDURES RISK LEVEL CATEGORIES : 2010 AND 2012
2010
2012
Level of Risk
PA risk category % (count)
PA risk category % (count)
_________________________________________________________________________________
Negligible
0
0
Low Risk
1.6% (9)
0.2% (1)*
Moderate Risk
1.2% (7)
0.6% (3)
High Risk
0
0
Critical
0
0
*p= .04
Policies and Procedures (NS)
Staff Competence
Staff competence
category partial attainments
2010
2012
12.7%
(71 of 261 audits)
11.2%
(58 of 516 audits)
All changes non-significant
T ABLE 1: S TAFF COMPETENCE RISK LEVEL CATEGORIES : 2010 AND 2012
Level of Risk
2010 PA risk category % (count)
2012 PA risk category % (count)
_________________________________________________________________________________
Negligible
0% (0)
0.2%(1)
Low Risk
5.0% (28)
5.1% (26)
Moderate Risk
6.4% (36)
5.8% (30)
High Risk
1.2% (7)
0.2% (1)
0
0
Critical
All changes non-significant
Medication Administration
Registered nurses can:
Check and administer all prescribed
medicines
Assess and monitor for effect or
reaction
Health care assistants/caregivers
can:
Enrolled nurses can:
Check and administer oral, topical and
rectal medicines and under the
direction
and delegation of a registered nurse
(eg,oral from a unit dose pack
[blister pack] topical medicines,
suppositories)
Check and administer oral, topical and
rectal medicines and intramuscular and
subcutaneous injections under the
direction
and delegation of a registered nurse.
Insulin
Administration specific competence is
required for administering
subcutaneous
insulin.
Staff Competence
Allergies Procedures
Allergies procedures
category partial attainments
2010
2012
4.1%
(23 of 561 audits)
5.2%
(27 of 516 audits)
T ABLE 1: A LLERGIES PROCEDURES RISK LEVEL CATEGORIES: 2010 AND 2012
2010
2012
Level of Risk
PA risk category % (count)
PA risk category % (count)
______________________________________________________________________________
Not applicable
6.2% (35)
Negligible
0
0
Low Risk
1.8% (10)
1.7% (9)
Moderate or High Risk
2.3% (13)
3.5% (18)
Allergies Procedures
Self Administration
Self-Administration
Total Partial Attainments
Not applicable
2010
2012
5.5%
(31 of 561 audits)
8.1%*
(42 of 516 audits)
1.4% (8)
0
*p= .01
T ABLE 1: SELF ADMINISTRATION RISK LEVEL CATEGORIES : 2010-2012
Level of Risk
Negligible
2012
PA risk category % (count)
0
Low Risk
4.5% (23)
Moderate Risk
3.5% (18)
High Risk
0.2% (1)
Medicines Care Guides: Self Medication
Self Administration
Recording and Communicating
Medicines Management Information
Recording and communicating
medicines management information
category partial attainments
2010
2012
19.4%
(109 of 561 audits)
21.3%
(110 of 516 audits)
No significant differences
T ABLE 1: RECORDING AND COMMUNICATING MEDICINES MANAGEMENT INFORMATION RISK LEVEL : 2010-2012
Level of Risk
2012 PA risk category % (count)
_____________________________________________________
Negligible
0
Low Risk
5.0 % (26)
Moderate Risk
14.9% (77)
High Risk
Critical
No significant differences
1.4% (7)
0
Recording and Communicating Medicines
Management Information
Documentation
Documents/records not signed or
unclearly signed
Recording of GP 3 monthly reviews
Evidence of controlled drugs checking
absent
Records relating to allergies or
medications absent or unclear
Documentation illegible or unclear
*2010-2012
2010
2012
% of total
Audits
% of total
audits
8.4%
9.9%
3.9%
7.5%
2.1%
3.1%
3.3%*
(p= .004)
3.9%
1.8%
1.7%
difference significant to p=0.05 or less; increased PAs between in 2010 to 2012 in bold.
Recording and Communicating Medicines
Management Information
Documentation
Stock taking of medications
Recording medications expiry dates
Block signing of documents
GP 3 monthly reviews out of date
Documenting allergies information
No photo ID for all residents for recognition when
administering medications
Recording times and dates of medications
Transcribing medications and prescriptions onto
charts
*2010-2012
2010
2012
1.6%
0.9%
1.2%
2.5%
0.4%
4.3%*
(p= .001)
1.2%
0.0%
1.0%
1.6%
0.5%
1.1%
0.5%
1.2%
4.1%*
(p< .001)
4.5%*
(p= .003)
difference significant to p=0.05 or less; increased PAs between in 2010 to 2012 in bold.
Recording and Communicating
Medicines Management Information
• 2012 - 110 providers PAs
– 70% moderate risk
– 23% regarded as low risk
– 7% facilities were considered high risk in this field.
• Main issues:
– documents and medication records being signed
– block signing of medications by GPs.
– Transcribing of medications by the RN
Recording and Communicating
Medicines
Management Information
T ABLE 1: C ONSUMERS RECEIVE MEDICATION IN A SAFE AND TIMELY M
2012 (only)
Level of Risk
PA risk category % (count)
______________________________________________
Negligible
0.4% (2)
Low Risk
1.6% (8)
Moderate Risk
1.4% (7)
High Risk
0.2% (1)
Critical
Total Category PAs
0
3.5% (18)
Listening to resident and others’ views
• Category not in the 2012 database
• In 2010, no issues were identified
• 555 of 561 records were reported not applicable
• The remaining 6 achieved full attainment
• This standard pertains more to mental health
residential care rather than aged residential care
What is not measured?
Subjective clinical indications, e.g.
• If the correct type medications are used in the
correct situation
• Side effects and adverse effects
BUPA Anti-Psychotic Initiative
Bupa Dr Maree Todd
ANZSGM June 2013
34
Where to from here?
• National Medication Chart
– developed by Health Quality and Safety Commission
– standardise medication records to reduce potential errors
due to clinician unfamiliarity with medication documentation
– Introduced into public hospitals
– Will be rolled out to ARC facilities in the near future
– has the potential to decrease issues identified in this report
such as:
• maintaining and using medication charts
• block signing documents
• three monthly medication reviews not completed by the General
Practitioner.
Electronic Medicines Management System
• Software to manage the charting of medication in aged
care facilities
• Prescribers can manage individual patient medicines
charting from any location through a secure access
• Reduces the time spent by prescribers, facilities and
pharmacists managing the charts
• Ensures an up to date current chart is continuously
available, to all users (GP, Community Pharmacy, Aged
Care Facility, Hospital Specialists and Nurse
Practitioners), at the same time
Electronic Medicines Management System will:
• Record administration of all medicines by staff
• Record medicines that haven’t been given and reason/s why
• Allow reporting by patient, unit or facility to allow prescriber's to make
better informed clinical decisions
• Provide reporting on individual medicines, a therapeutic group etc.
• Provide robust authentication for charting and updating when a prescriber
saves the new item/change, and notification of a change is directed to the
care facility and the pharmacy for supply.
• Track medicine supply quantities. This will to reduce medicine wastage
and ensure prescriptions exactly match the supply required within a
medication cycle.
Recommendations
• Ministry of Health will continue to raise medication management by
working closely with the sector
• Road Shows regarding identified themes and trends such as:
– GP and RN documentation management
• Encourage DHB and ARC provides to enable education about
medication management
• Continue to work with auditors regarding medication management
• Standardised sub-category classifications for audit report
Thank You!
Questions?