Transcript 09 Sep 9 National Call Transfer Discharge Principles

Passing the Baton:
Medication Reconciliation
at Internal Transfer and Discharge
Olavo Fernandes PharmD, FCSHP
ISMP Canada
Safer Healthcare Now! National Call
Sept 10, 2009
LCD Version
© Institute for Safe Medication Practices Canada 2009®
Objectives
At the end of this session, participants will be able to:
1. Outline the key elements and general principles of
an interdisciplinary internal transfer and discharge
practice process.
2. Highlight strategies for overcoming common
challenges to successfully implement medication
reconciliation at discharge and transfer.
Open Discussion Forum:
3. To provide participants with an open forum for
sharing current challenges, successes, lessons
learned and controversies with medication
reconciliation implementation at transfer and
discharge.
© Institute for Safe Medication Practices Canada 2009®
Slide 2
Moving On From Admission….
• Feedback from teams:
• many have started and moved toward
sustaining admission med rec and are now
earnestly focused on internal transfer and
discharge
• Requests to represent and revisit key
principles of effective reconciliation at internal
transfer and discharge
© Institute for Safe Medication Practices Canada 2009®
Slide 3
Unintentional Discrepancy Rates
• Admission*
• 5/10 patients
(Cornish P, Arch Int Med 2005;165:424)
• Transfer*
• 6/10 patients
(Lee J, 2007; manuscript submission)
• Discharge*
• 4/10 patients
(Wong J. Ann Pharmacother 2008;42:1373-9)
*~Many of these discrepancies are clinically significant
J Harrison TGH
© Institute for Safe Medication Practices Canada 2009®
Slide 4
Practical
Overview of
Medication
Reconciliation in
Acute Care
Summary of the Medication Reconciliation Process
at Admission
Summary of the Medication Reconciliation Process
at Internal Transfer and Discharge
Medication Reconciliation
at Internal Transfer
Internal transfer is an interface of care associated with a
change in patient status where medications are assessed
and medication orders should be reviewed and updated
Internal transfer may include:
• Change in responsible medical service
• Change in level of care (critical care unit to hospital ward)
• Post-operative transfer and/or
• Internal Transfer between units
© Institute for Safe Medication Practices Canada 2009®
Slide 8
Medication Reconciliation
at Internal Transfer
The goal of internal transfer is to ensure
all medications are appropriate for the
patient’s new status of care.
The Best Possible Medication Transfer
Plan (BPMTP) is the most appropriate
and accurate list of medications the
patient should be taking after the
transfer.
© Institute for Safe Medication Practices Canada 2009®
Slide 9
Summary of the Medication Reconciliation Process
at Internal Transfer and Discharge
Medication Reconciliation
at Internal Transfer
Internal transfer medication reconciliation involves assessing and
accounting for:
•
the medications the patient is taking prior to admission (BPMH)
•
the medications from the transferring unit (medication
administration record (MAR)
•
the new post-transfer medication orders (includes new,
discontinued and changed medications upon internal transfer).
© Institute for Safe Medication Practices Canada 2009®
Slide 11
What Is The Optimal Strategy For
Internal Transfer?
Wong C et al. UHN/ ISMP
Subset - National Survey
© Institute for Safe Medication Practices Canada 2009®
Slide 12
National Transfer Medication
Reconciliation Team Descriptions
Wong C et al. UHN/ ISMP
© Institute for Safe Medication Practices Canada 2009®
Slide 13
Key Elements of Interdisciplinary Practice Model for
Medication Reconciliation at Internal Transfer
(from national survey and clinician interviews)
Wong C et al. UHN/ ISMP
1.
Best Possible Medication History on admission
2.
Clear assignment of responsibilities
3.
Clear expectation of timeframe
4.
Standardized tool / process
5.
Comprehensive communication to all team members
6.
Auditing and sharing results with staff
7.
Standardized interdisciplinary clinician training
8.
Support from leadership/ stakeholders
© Institute for Safe Medication Practices Canada 2009®
Slide 14
National Snapshot Of Transfer
Medication Reconciliation
Wong C et al. UHN/ ISMP
© Institute for Safe Medication Practices Canada 2009®
Slide 15
Transfer: Clinicians Primarily
Responsible
Wong C et al. UHN/ ISMP
© Institute for Safe Medication Practices Canada 2009®
Slide 16
Sample Process:
computer
generated paperbased transfer
orders form
community
hospital
Used with permission from
Markham Stouffville Hospital
Medication Reconciliation at Discharge
Should result in clear and comprehensive information for the patient and
other care providers
The Best Possible Medication Discharge Plan (BPMDP) is the most
appropriate and accurate list of medications the patient should be
taking after discharge. Should account for:
1.
New medications started in hospital
2.
Discontinued medications (from BPMH)
3.
Adjusted medications (from BPMH)
4.
Unchanged medications that are to be continued (from BPMH)
5.
Medications held in hospital
6.
Non-formulary/formulary adjustments made in hospital
7.
New medications started upon discharge
8.
Additional comments as appropriate - e.g. status of herbal
medications/ supplements or medications to be taken at the
patient’s discretion
FOR WHOM? : Discharge Reconciliation
Safer Health Care Now! GSK: Med Rec 2007
• Best Possible Medication Discharge Plan (BPMDP) should
be communicated to :
• Patient
• Community Physician / Primary Care Physician
• Community Pharmacist
• Other Community health care providers
• Alternative Care Facility or Service
• Clearly Communicate Medication Status:
• New, Discontinued, Adjusted or Unchanged
• Suggested/ preferred reference point for community
clinicians: changes since admission to hospital
Synchronization Challenge of Discharge
Tools
Patient Care
System
Patient
schedule
Discharge
Prescription
Manual
Dear
Dr
Letter
Electronic
EMITT
Letter
Patient
Wallet card
Electronic
J. Wong BScPhm
Wong J. [Abstract] Pharmacotherapy 2006 ;26: 106
Medications may be altered:
new, adjusted, discontinued
Ward
Decision to discharge
patient
Best Possible
Medication
BPMDP
Discharge
Plan
Discharge
Reconciliation
Home
Electronically
Generated
Prescriptions
2
Synchronized
Outputs
Medication
Information
Transfer Letter
3
Patient
Medication
Grid
4
Patient
Medication
Wallet Card
5
Physician
Discharge
Summary
6
Vertical : Patient Medication Grid
Patient Friendly
Discharge Medication List
Used with permission from Markham Stouffville Hospital
DOCTOR:
LOCATION:
PATIENT:
Medication Reconciliation at
Dryden Regional Health
Centre
Transfer & Discharge
WOW what a journey!!
Lorie-Anne Blair
Director of Patient Safety & Clinical
Education
DRHC
Dryden Regional Health Centre
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Dryden is centrally located in the most
western portion of North western Ontario,
approximately 360 km from Thunder Bay
and 320 km from Winnipeg
41 beds - 31 acute care and 10 chronic care
Approximately 20,000 Emergency room visits per
year.
Average about 100 births per year.
33% of all hospital patients are over 65 years of
age and 15% are children.
We have three operating theatres.
And a variety of outpatient departments.
Medication Reconciliation
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Senior Management at DRHC made Medication
Reconciliation a priority in February 2008.
A committee was formed which included:
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Senior VP
Director of the In-patient unit
Physician
Nursing Supervisor
Pharmacist
RN
RPN
Director of Patient Safety
CCAC
2 Community Pharmacists
Transfer & Discharge Medication
Reconciliation
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Admission Med Rec. implemented in
January 2008
Transfer & Discharge implemented
in January 2009
Form changed significantly due to
feedback from staff over time and
the desire to include all three
processes on one sheet.
Transfer Medication Reconciliation –
The process
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The only internal point of transfer
was from East Unit to OR and back.
The paper form was placed with an
in hospital med list for review by
the MRP post operatively.
Med Rec. was completed by the
Recovery Room nurse and the
patient was returned to the floor.
Discharge Medication Reconciliation –
The other process
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Upon discharge the Physician
reviews the Med. Rec. form and in
hospital medications and
incorporates the home meds. into
their discharge orders.
The Discharging Nurse reviews the
BPMH and compares them to the
discharge orders and rectifies any
discrepancies.
Auditing the Processes
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In Jan 2009, audit process was
changed to reflect all three
processes.
We had fully implemented Admission
Med Rec. and no longer found the
discrepancy rate valuable – now we
needed to focus on completion rates.
I collect all Med Rec’s from Clinical
Records and analyze data
Medication Reconciliation Completion Rates
2009
100
80
New audi t pr ocess
star ted A pr i l '09
60
data col l ecti on - l i mi ted data
avai l abl e
% of Admission Med.
Rec. Completed
40
% of Discharge Med.
Rec. Completed
20
0
Ja
n
Fe
Ma b
rc
h
Ap
Ma r
Ju y
ne
Ju
ly
Au
Se g
pt
Oc
No t
De v
c
%
M ay 2009: E r r or occur r ed i n
Month
120
M ay 2009: Error occurred in data collection - limited data
available
100
% of Adm. Med. Rec.
Completed by Nursing
80
% of Adm. Med Rec.
completed by MD
60
40
% of Discharge Med. Rec.
completed by Nursing
20
% of Discharge Med. Rec.
completed by MD
0
Ja
n
Fe
M b
ar
ch
Ap
r
M
ay
Ju
ne
Ju
ly
Au
g
Se
pt
Oc
t
No
v
De
c
Percentage completed
Med. Rec. Completion Rates by Discipline
2009
Month
Vi
he
M rj o
az k
ur i
Lo ski
D u tt
ah it
C me
W ort r
hi en
tta s
D ke
ah r
m
Po er
G rte
ag r
n
Ke on
hl
Sh er
Fa ah
irl i
e
D y
o
M ve
ut
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ut
ka
% Completion
Physician Completion of Admission
Med Rec.
120.00
100.00
80.00
60.00
40.00
20.00
0.00
No peaking!!
Physicians
Extremely powerful data!!
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Vi
h
M erj
az ok
ur i
Lo ski
Da utt
hm it
Co e
W rte r
hi ns
tta
Da ke
hm r
Po e r
G rt e
ag r
n
Ke on
hl
Sh er
Fa a h
irl i
e
Do y
M ve
ut
Ru rie
tk
a
% Complete
% of Physician completion of
Discharge Med. Rec.
The graph of shame!
Physician
Ahhhhhh!!! Transfer Med. Rec.
Transfer Medication Reconciliation Completion Rates
% Completed
100
80
% Total completion
60
33.33333333
40
% RN completion
% MD completion
20
0
0
July
Aug
2009
One lonely
signature!!
Successes
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Admission Medication Reconciliation is
standard procedure and Physicians are
completing greater than 95% of
Admission Medication Reconciliation’s.
Much better collaboration between
Physician, Nurse and Pharmacist on
Admission.
We have seen a 50% decrease in the
number of medication incidents.
There have been other interventions implemented during this time to
decrease Medication Errors – not all the decrease can be attributed to
Med. Rec., but a significant portion can be.
#1 Incident report
generator
Less than 50%
of last years #’s
Challenges
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Buy in from the MRP and visiting
Specialists.
Buy in from the staff.
Nurses forgetting where to sign.
Form changes: should have used
small PDSA cycles rather than edits
and trials with all staff – even
though we were small
Plans
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1:1 meetings with Nurses &
Physicians to review process
No further changes to forms
Development of a tracking method
for staff to identify good catches of
unintentional discrepancies.
OPEN FORUM
© Institute for Safe Medication Practices Canada 2009®
Slide 46
Common Challenges and Strategies in Internal Transfer
Challenge
Strategy
Electronically generated transfer form
does not capture BPMH information
from admission
•Ensure a process in place to review
medications on BPMH that were ‘held’
or discontinued by prescriber.
•In some facilities, hold is not an
acceptable order, and meds are
discontinued and may fall off the
radar.
Electronically generated transfer
order form may not capture recently
written orders
•Designate a person whose
responsibility is to check that the
most recent orders have been
transcribed and added to the
electronically printed transfer form
Prescriber receiving the patient not
comfortable with re-ordering/reassessing medications not related to
their area of practice
•Assign responsibility of who is going
to order the medications. Whether it
be the prescriber who is receiving or
transferring the patient, or both.
© Institute for Safe Medication Practices Canada 2009®
Slide 47
Common Challenges and
Strategies in Discharge
Used with permission by : EHR and Medication Reconciliation US Panel
Challenge
Strategy
Discharge Reconciliation is tedious
especially if reconciliation was not
done upon admission
• ED initiated process improves
reconciliation rates
• System generates prescriptions and
pre-populates discharge plans and
instructions in patient friendly terms
Creating Patient friendly discharge
instructions
•Automate discharge instructions from
information pulled from electronic
health system in patient friendly terms
instead of clinical terminology
Reconciliation in surgery units must be
as streamlined as possible, as
surgeons often do not feel qualified to
address home medications
•Some hospitals now allow surgeons
to delegate some of this responsibility
to the pharmacist.
•Hospitals can emphasize that
discharge instructions are not orders.
© Institute for Safe Medication Practices Canada 2009®
Slide 48
Medication Reconciliation in the Community
ISMP Canada / O. Fernandes UHN
Framework: Ambulatory Medication Reconciliation Model
Creating the most “up to date” medication record (BPMH)
(UHN/ SHN Home Care Pilot)
Compare:
Medication
Information from all
other sources
Patient and
Family Interview
Examples:
•Medication vial inspection
•Referral record
“medication
discrepancies that
•Community pharmacy
•Hospital Discharge
Summary
require clarification”
document
Review and follow
up where indicated
“up to date”
medication
record (BPMH)
© Institute for Safe Medication Practices Canada 2009®
Slide 51