Transcript Project Poster

Implementation and a Randomized Controlled Evaluation of
Pharmacist Medication Assessments in a Surgical Pre-Admission Clinic
Yvonne Kwan, BScPhm1; Olavo Fernandes, PharmD1,2; Jeff Nagge, PharmD1; Gary Wong, BScPhm1; Jin-Hyeun Huh, BScPhm1; Deborah Hurn, RN, MA1; Jana Bajcar, MScPhm, EdD, FCSHP2
1Department
Background
Figure 1. Key Vulnerable Moments for the Surgical In-Patient
PreAdmission
Clinic
Assessment
Surgical
Admission
Unit
OR
Phase 1: Development of Model
Results
Phase 1
Development of Model
1. Established the optimal practice model
Qualitative
Analysis of Expert
Interviews
Stakeholders
ICU = Intensive Care Unit
ER
OR = Operating Room
ER = Emergency Room
Table 3. Clinical Assessment of Post-Operative Medication
Discrepancies Related to Home Medications
Intervention
(N=154)
Baseline Characteristic
Mean ± SD, years
Standard Care
(N=156)
56.5 ± 14.5
Gender
Male
Female
2. Designed the following practice and research tools
Home
Phase 3
Randomized Evaluation
Age
Optimal
Model
In-Patient Unit
Phase 3: Randomized Evaluation
Figure 3. Components Used to Establish the Optimal Practice Model
Literature
Review
Results continued
Table 1. Baseline Characteristics
Vulnerable
Moment #3
Vulnerable
Moment #2
ICU
Dan Faculty of Pharmacy - University of Toronto
Methods continued
• Post-operative hospital admission is a key medicationrelated vulnerable moment where patients are at increased risk
of medication discrepancies that potentially can lead to adverse
drug events
Vulnerable
Moment #1
of Pharmacy - University Health Network,
2Leslie
• Preprinted Post-Operative Order Form for Pre-Operative Home
Medications
• Classification system for categorization of discrepancies
• Ranking system for clinical impact of discrepancies
• Worksheets and checklists outlining tasks at the PAC and on the unit
• Template for medical chart documentation
56.4 ± 14.3
75 (48.7%)
79 (51.3%)
Number of Home Medications*
Median
Range
Mean ± SD
87 (55.8%)
69 (44.2%)
4
0-17
5.1 ± 3.9
3
0-21
3.9 ± 3.7
Phase 2
Implementation of
Model
Phase 2: Implementation of Model
Primary Objective:
• Evaluate the impact of structured pharmacist medication
assessments in the surgical PAC and the use of a post-operative
order form on the incidence of patients with at least one postoperative medication discrepancy related to home medications
in patients undergoing planned elective surgeries
Secondary Objectives:
• Characterize the types of post-operative medication
discrepancies
• Determine the clinical impact of the post-operative medication
discrepancies by blinded measurements performed by clinical
experts
Patients with at least 1
post-operative
medication
discrepancy related to
home medications
• Strategies for conducting medication histories at the PAC
2. Designed and provided in-services for PAC nurses and
clerks, in-patient nurses, surgeons, and residents
• Approximately 140 in-patient nurses and 30 surgeons and residents
were in-serviced between April 11 to April 18, 2005
Intervention
(N=154)
Standard Care
(N=156)
p-value
30 (19.5%)
68 (43.6%)
<0.001
180
160
140
120
100
Post-Surgical Care Medications
80
Home Medications
Phase 3
Randomized Evaluation
21
44
Possible
18
35
Probable
8
46
• Our results confirm the benefit demonstrated in previous
investigations with respect to pharmacist involvement in the
PAC
• Fewer patients in the intervention arm had at least one postoperative medication discrepancy related to home medications
compared to the standard care arm
• Patients in the intervention arm had statistically higher mean
number of home medications, possibly suggesting that
pharmacists had identified more home medications at the PAC
through the structured medication assessments
• Limitations of this project include:
• Unblinding identification and reporting of medication
discrepancies
• Retrospective clinical assessment of discrepancies
40
20
Intervention
Conclusions
Standard Care
Design: Randomized, prospective, parallel study
Figure 6. Characteristics of Post-Operative Medication Discrepancies
Related to Home Medications
Number of Discrepancies
0
10
20
30
40
50
60
No indication
Exclusion Criteria
Patients scheduled for discharge the same day as their surgery
Failure to order drug
Therapeutic duplication
Drug interaction
Figure 2. Project Design
Unlikely
60
0
Phase 3: Randomized Evaluation
Standard Care
(N=125 discrepancies)
Discussion/Limitations
Figure 5. Total Number of Post-Operative Medication Discrepancies
1. Designed and provided education for surgical
pharmacists on:
Inclusion Criteria
All consecutive patients who had a PAC appointment at Toronto General
Hospital between April 19 to June 3, 2005 prior to undergoing surgical
procedures (ENT, Urology, Gynecology Oncology, Plastics, General Surgery,
and Thoracics)
Methods
Outcome
Number of Discrepancies
Objectives
3. Collected baseline data
• Data collected on post-operative medication discrepancies between
March 22 to April 14, 2005 in all patients who had a PAC visit and were
admitted to participating in-patient units
• A post-operative medication discrepancy was defined as any medication
clarification that was made by the pharmacist during the post-operative
period
Intervention
(N=47 discrepancies)
*p=0.039
Table 2. Incidence of Primary Endpoint
• Non-randomized investigations have suggested pharmacist
involvement in a surgical pre-admission clinic (PAC) may reduce
clarifications in the post-operative period
Potential to Cause
Patient Discomfort
and/or Clinical
Deterioration if
Discrepancy was
Unresolved
Misspelled drug name
Figure 4. Design of Evaluation Phase
Omission of drug name
Eligible Surgical Patients at PAC
Omission of formulation
70
• A pharmacy practice model that creates a combined
intervention of a structured pharmacist medication
assessment and a post-operative order form and supports
medication prescribing in surgical patients at the time of postoperative hospital admission can be successfully
implemented in the PAC
• The combined pharmacist intervention can reduce
significantly the incidence of post-operative medication
discrepancies related to a patient’s home medications
• Pharmacist involvement in the PAC may be beneficial at
improving patient safety
Incorrect dose
Phase 1
Development of Model
- Establish the optimal model
- Design of tools
- Baseline data collection
Phase 2
Implementation of
Model
Omission of dose
Phase 3
Randomized Evaluation
- Identification
- Characterization
- Clinical Assessment
Inappropriate route
Standard Care
Randomization
Intervention
Incorrect frequency
Standard Care
Slow to restart
Too soon to restart
(Structured pharmacist
medication assessment
and generation of a
post-operative
medication order form)
Intervention
(Nurse-conducted
histories and surgeongenerated orders)
Order w ritten for medication, but pharmacy to clarify
Pharmacy to clarify all medications
Illegible order
Miscellaneous
Acknowledgements
• Barbara Courtman, Jeffrey Doi, Nadia Gad, Gino Gizzarelli, Rosanna
Guidoccio, Anita Jakovcic, Patricia Kim, Valerie Marshall, Sonia Matos,
Kyung Ae Park, Elaine Rosenberg, Shun Wong, Clement Yuen
• Stephanie Ong, Bassem Hamandi, Gregory Pond
• TGH Pre-Admission Clinic Staff
**References available upon request