Transcript Safer Health Care Now Med Rec Presentation Jul 15 finalcomplete

The Scarborough Hospital
Interdisciplinary Medication
Reconciliation
• Angie Ganter: Patient Care Coordinator,
Emergency Dept.
• Teresa Reardon, Nurse Educator, Emergency Dept.
• Dr. Maria Valois, MD, Medical Director, Pharmacy
• Grace Wong, Outpatient Pharmacist
• Gina Leung, Inpatient Pharmacist
The Scarborough Hospital
• Two sites: General Campus and Birchmount Campus
– 360-bed Acute Care/Community Hospital (General)
– 210-bed Acute Care/Community Hospital (Birchmount)
• Approximately 95 000 ED visits yearly between both sites
– 11 000 of these pts are admitted to the hospital annually
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Large geriatric community
Regional dialysis site (General)
Regional Mental Health site (Birchmount)
Services 21 LTC homes between both sites
Multicultural, Multilingual
Tools for Medication Reconciliation
• Meditech Magic System
• Paper base BPMH
• Computer generated transfer forms, discharge
prescriptions and patient home medication
schedule
• Planning to implement Iatric for discharge
Objectives
• Interdisciplinary medication reconciliation
– Perspectives from nursing, physician,
pharmacist
• Medication reconciliation from inpatient to
outpatient and back again
• Key lessons learned
• Strategies for sustainability
Medication Reconciliation in the
Emergency Department
• Since implementing Medication Reconciliation in Dec 2007
we have overcome many obstacles
• As of March 2009 we have performed audits in the ED to
track our progress as we overcome these obstacles
• There has been improvement at times, but there have also
been unforeseen circumstances that have hindered our
improvement (refer to graph for audits in March/April/May)
Medication History Completed by
RN’s in the Emergency Department
80%
70%
60%
50%
General
40%
Birchmount
30%
20%
10%
0%
March
April
May
Medication Reconciliation in the
Emergency Department
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CHALLENGES:
Buy-in and compliance from ED staff (nurses and MDs)
*Buy-in and compliance from specialists*
Patient related issues: language, culture, cognitive
impairment, lack of awareness of present meds, adverse
events related to medications
Staff resources and workload
Perception of medication reconciliation process
Change of practice
Change of attitude
Medication Reconciliation in the
Emergency Department
FACILITATORS
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College of Nurses (CNO) Standards of Practice
Registered Nurses Association of Ontario (RNAO)
Ministry of Health and Long Term Care (MoHLTC)
The Scarborough Hospital (TSH) Pharmacy Department
ED staff
ED Leadership Team
Patients, Caregivers
Medication Reconciliation in the
Emergency Department
GOALS OF MED REC IN THE ED
• SHORT-TERM GOALS: ↓ number of medication errors, ↓
number of omitted medications, ↑ patient knowledge and patient
satisfaction
• INTERMEDIATE GOALS: ↓ number of medication-related errors,
↑community awareness of medication reconciliation process, ↑
resource efficiency
• LONG-TERM GOALS: ↓ number/severity of adverse events (AE)
from medication-related errors
Medication Reconciliation in the
Emergency Department
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HOW WE GOT TO WHERE WE ARE:
Education re. Safer Health Care Now!
Education re. Accreditation ROP (Required Organizational
Practice)
Daily morning huddles
Poster presentations/signage throughout the ED, pamphlets
in waiting room
Feedback from Pharmacy shared with staff
Awareness of monthly medication reconciliation audits
Dissemination of monthly medication reconciliation audit
results with the ED staff
Medication Reconciliation in the
Emergency Department
MOVING FORWARD:
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Continue monthly medication reconciliation audits
Continue providing feedback to ED staff
Continue with education of all stakeholders
Continue to engage pts and families with process
Improve compliance
Physician Perspective:
Introduction
• Med Reconciliation: fad  ROP
• Adverse drug reactions / polypharmacy:
• Vulnerable populations at risk:
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elderly
pediatrics
immunocompromised
pregnant & lactating mothers
Patients with chronic disease on multiple medications
Medication Reconciliation
Challenges
• Difficulty for implementation due to
– Ownership
– Coverage
– Bed Alerts (Extended patient stay in emerg)
• Admission History and Reconciliation:
– Access to information in off hours
– Off hours interdisciplinary collaboration
Admission Form
Transfer Form
Successes
• Proper space allocations on all forms for
changes in med regimen
• Allows quick & efficient comparisons with
previous admissions : continuity of care
• Prescription format allows faxing to
community pharmacy at the time of
discharge
Challenges
• Timelines: get the job done within 24 hrs
– Special considerations for insulin, systemic
steroids, PD medications, Antibiotics, etc
• Format not practical for tapering regimens
• Format does not allow electronic editing by
prescriber
• When pharmacists become the fallback to
complete medication history – not good use
of pharmacist skills  ownership
Conclusions
Good MedRec program
1. Costs $$$, but also saves $$$ (decrease rate of
re-admissions, decrease length of stay)
2. Improves communication with community
health care professional (family MD,
pharmacist)
3. Efficient regional programs need harmonization
among different hospitals; ideally this would
include medication prescription forms
Medication Reconciliation in the
Complex Outpatient Patient: Outline
• MedsCheck® program in Ontario
• Process of MedsCheck/med reconciliation
• Clinical Importance
• Benefits and Challenges
MedsCheck® Program in Ontario
• Unique program paid for by the Ministry of Health in Ontario
• Eligibility: Any Ontarian taking more than 3 prescription
medications
• Initial medication history reimbursement is $50 per patient.
Subsequent consultations within a 12 month interval - $25.
• No compensation for non Ontarians and refugee claimants.
• For more information, see www.MedsCheck.ca
Population Studied – Outpatient
Dialysis
• Corporate Drive
120 Patients
• Yee Hong Centre
20 Patients
Patient Profile
• Receive dialysis on
an outpatient basis
3x/week.
• Average age: 61.8
• Average number of
medications: 13.2
More on the Patients with Chronic
Conditions…
• Taking many medications
• Have multiple co-morbidities
• Under the care of multiple Doctors
• May have many changes to medications due to
nature of disease.
Process
• Identify potential DRPs through a profile review
• Education of patients to ensure proper utilization of
medications.
• Reinforcement of compliance and awareness.
• Clarification and respond to patient questions and
concerns
• Check lab results
Goals and Process
• Reconciliation of medication records.
• Communication with attending physician
regarding needs for adjustment or
clarification of therapy
Next Steps
• Prepare and provide the patient with their
Personal Medication Record.
• Bring attention to the inpatient Pharmacist
for ongoing issues that require follow-up
Clinical Importance
Types of Discrepancies Found
Taking drug improperly
Discontinued medications still on
med chart
Taking prescribed drug not
documented
Dosage discrepency
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20
40
60
% of patients
80
100
Number of Discrepancies Found:
5%
25%
None
1 to 3
4 to 6
7 or More
35%
35%
Significant Interventions
• Clarification of drug therapy and dosages
• Request physician to reassess drug dose after
identification of abnormal lab results.
Benefits and Challenges
Benefits
• Improve patient compliance.
• Improve patient safety.
• Improve patient understanding of medications.
• Decrease Med Chart discrepancies, resulting
in reduced adverse events.
Challenges for Community
Pharmacists
• Time consuming due to many medication changes
for this patient population.
• The usual MedsCheck® program is self-funding
for most patient populations, however only 60 %
of the Pharmacist salary is compensated by this
program due to the complexity of the outpatient
dialysis patient group.
Challenges Cont’d
• Most retail pharmacies do not have the resources to
access the patient’s lab results and med charts, unlike the
Scarborough Grace Drugstore, which is affiliated with
the hospital.
• Accessibility to another health care professional for
consultation is limited.
• Not all community pharmacists feel comfortable in
taking on this expanded role for this complex patient
group. More than 90% of this patient group has never had
a MedsCheck® done by their community pharmacists.
Conclusion
• This patient population group benefits a
great deal from this program.
• Medication Reconciliation is achieved with
the coordination of Physicians and Nurses.
• More resources are required for successful
implementation of this expanded program.
Where are we at now?
Keys to Success ….
Nursing
Pharmacist
Clerk
Pharmacist
Pharmacist
MD
Keys to Success
• Increase awareness, give ownership and
accountability by having each nursing unit
conduct their own audit on medication
reconciliation on admission and discharge
• Accreditation ROP
• Since then results improved from ~10% to
50% on admission
Keys to Success …
Meeting with each team…..
• Cardiology
physician support
grouping of cardiac meds on discharge form
• Mental Health
bringing awareness
physician buy in
• ICU
physician support on transfer form
awareness of medication history form
Challenges
• Quality of medication history
• Pharmacist vs. interdisciplinary approach
• Need to photocopy forms until equipment updated
Surgery…….
• Pharmacist focus on patients with changes to their
medications during their hospital stay
• Calling consulting physician for related Rx
• Counseling patient from gathered information
• Physician buy-in, compliance at post-op and
discharge
Contact Information
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Patricia Macgregor
Angie Ganter
Teresa Reardon
Grace Wong
Dr. Maria Valois
Gina Leung
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]