Transcript Patient Safety Strategies Advanced Medication Reconciliation

Quality Improvement and
Medication Safety In Long Term
Care
Keith A. Swanson, Pharm.D., CGP
University of Oklahoma
College of Pharmacy
Learning Objectives
Upon completion of this presentation participants
will be able to:
 Identify types of medications associated with
medication misadventures in frail elders
 List one factor or behavior for each of the
following groups of individuals that increases risk
of inappropriate medication use in elders:
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physicians/prescribers
nursing staff
family/caregivers
residents
Identify key points in the medication use process
in post-acute and long term care systems that
increase the prevalence of medication
misadventures and identify directions for
corrective actions
Issues in Geriatric
Pharmacotherapy
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Elders are admitted to hospital three
times the rate of younger people as a
consequence of an ADR
Elders experience a disproportionate
number of deaths and hospital
admissions due to adverse drug reactions
28% of hospital admissions through the
emergency room by older people are due
to poor outcomes from drug therapy (16%
ADRs, 12% non-compliance)
Most common drugs causing admission
from ADRs
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Insulin, warfarin (anticoagulants), digoxin
Did You Know…
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Estimated cost of inappropriate medications
and their consequences in older people
approaches $200 billion/year
$32.8 billion associated with DRPs resulting in
LTC admissions
Estimated 50 to 75 thousand deaths annually
amongst older people in US due to ADRs or
non-compliance
Estimated 25% of all prescribed medications
for older people are inappropriately selected or
dosed in older people
Estimated 30% of all medications for older
people are considered unnecessary
Often referred to as:
“America’s Other Drug Problem”
Medication Misadventures in
Post-Acute and Long Term Care
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Medication discrepancies during transitions in
care
Prescribing ‘cascades’ and unnecessary
medications lead to polypharmacy
Unintended negative outcomes
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Falls
Cognition changes
Hypoglycemia
Excessive bleeding or thrombus formaton
Anticholinergic effects (dry mouth, constipation,
urinary retention, delirium)
Cardiovascular effects (hypotension,
dysrhythmias, thrombosis, sudden death)
Failure to reach therapeutic ‘targets’ (e.g.
untreated pain)
Mapping Medications through a
Recent Transition
Send to ER: Change in
Mental Status
Current Discharge
Medication List: Fall
Discharge Orders: Fall
“resume NH orders”
ASA 81 mg Daily
ASA 81 mg Daily
ASA 81 mg Daily
Divalproex 125 mg Daily
Divalproex 125 mg TID
Divalproex 125 mg Daily
Donepezil 10 mg Daily
Donepezil 10 mg Daily
Levothyroxine 50 mcg Daily
Levothyroxine 50 mcg Daily
Levothyroxine 50 mcg Daily
Lorazepam 0.5 mg BID
Lorazepam 1 mg q6H PRN
Lorazepam 0.5 mg BID
Metoprolol 25 mg Daily
Metoprolol 25 mg Daily
Metoprolol 25 mg Daily
Mesalamine 800mg TID
Mesalamine 1200 mg BID
Mesalamine 800mg TID
Calcium+D 500/400 Daily
Diphenhydramine 25mg HS
Ibuprofen 800 mg q8H prn
Quetiapine 50 mg BID
OC (86 y/o M) sent from ALF to ER for change in mental status.
Returned later same day.
Mapping Medications through a
Recent Transition
Send to ER: Change in
Mental Status
Current Discharge
Medication List: Fall
Discharge Orders: Fall
“resume NH orders”
ASA 81 mg Daily
ASA 81 mg Daily
ASA 81 mg Daily
Divalproex 125 mg Daily
Divalproex 125 mg TID
Divalproex 125 mg Daily
Donepezil 10 mg Daily
Donepezil 10 mg Daily
Levothyroxine 50 mcg Daily
Levothyroxine 50 mcg Daily
Levothyroxine 50 mcg Daily
Lorazepam 0.5 mg BID
Lorazepam 1 mg q6H PRN
Lorazepam 0.5 mg BID
Metoprolol 25 mg Daily
Metoprolol 25 mg Daily
Metoprolol 25 mg Daily
Mesalamine 800mg TID
Mesalamine 1200 mg BID
Mesalamine 800mg TID
Calcium+D 500/400 Daily
Diphenhydramine 25mg HS
Ibuprofen 800 mg q8H prn
Quetiapine 50 mg BID
OC (86 y/o M) sent to ER from ALF for change in mental status.
Returned later same day.
Pharmacy Issues in Care
Transitions
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Two-thirds of patients admitted have
unintended medication discrepancies*
Many are unresolved at discharge
 Potential harm with medication
discrepancy ranges from 11 to 59%
 40% to 80% of discrepancies considered
‘insignificant’
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13% Medicare readmission rate – most
considered preventable
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Two-thirds believed medication related
*Kwan et al. Medication reconciliation during transitions of care as a patient safety
strategy: a systematic review. Ann Intern Med 2013;158:397-403
Potential Causes
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Medications not ‘available’ to patients after
discharge
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“It’s quittin’ time” or “gettin’ ready for the
weekend” discharges
Short timelines create pressures on staff and put
resident at risk
Time delays after daily pharmacy deliveries
Hard to find and high intensity or expensive
therapies
Insufficient staff at both ends of the call to answer
questions or investigate inconsistencies
Reliance on existing data that hasn’t been
updated or reconciled against current
therapies
Potential Causes
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Medications not ‘necessary’ for patients
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Hospital ‘habits’ - stress ulcer prophylaxis,
DVT prophylaxis, appetite stimulants,
treatment for acute delirium
Unnecessary PRNS - Antiemetics, analgesics,
laxatives/antidiarrheals, hypnotics
Inpatient formulary changes
Consulting prescribers – specialty physicians,
dentists, podiatrists, alternative health
practitioners, family members
Impact of polypharmacy at ‘step-down’
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Risk of ADRs and non-adherence
‘Affordability’ to patients and post-acute care
facilities
Medication Issues Identified in a
Recent Transition
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70 Y/o male admitted to SNF following surgery
to repair torn muscles and ligaments in leg
Prior history of mechanical valve replacement
on warfarin
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Prior dosing 10 mg daily with extra 5 mg one day
a week (75mg weekly)
ER med history incorrectly listed dose as 20 mg
daily with an extra 5 mg dose (15mg total) one day
a week (135 mg weekly)
Discharge order was 5 mg daily (35mg weekly)
with enoxaparin bridge until therapeutic INR (2.5
to 3.5)
Also restarted previous antidepressant therapy
that was discontinued 9 months prior to
surgery due to adverse effects
Medication Issues Identified in a
Recent Transition
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Failure to reinitiate known pre-hospital
anticoagulant dose incurred following ‘costs’
Required 2 full weeks to achieve therapeutic
anticoagulation (enoxaparin stopped at day 4 & had
to be restarted when issues discovered)
 Enoxaparin ‘bridge’ cost (approximately $10 per
day)
 6+ INR lab tests (approximately $20 per test)
 Quality of life and satisfaction
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Issues related to reinitiating the
antidepressant
Resident admitted his ‘current’ med list still
included discontinued antidepressant
 Despite strong resistance from resident, hospital
and post-acute care staff insisted the potentially
harmful therapy was administered as ordered
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Lessons to be Learned
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How would staff at your facility handle
this situation?
What about the enoxaparin order ‘for 4
days or until warfarin therapeutic’?
Would your staff have concern about
this warfarin regimen?
How would your staff treat someone
who refuses to take an ordered
medication?
Would your staff step forward to
investigate the situation?
Patient Safety Strategies
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Medication Reconciliation
“Formal process for identifying and
correcting unintended medication
discrepancies across transitions of care”*
 Widely endorsed and mandated
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*World Health Organization (2006) & Institute for Healthcare Improvement (2006)
Patient Safety Strategies
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Best Possible Medication History
(BPMH)*
Cornerstone for medication reconciliation
 More comprehensive than routine
medication history
 Requires two steps:
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Systematic process obtaining thorough history
of ALL prescribed and nonprescribed
medications (structured patient interview)
 Verification of information against at least one
reliable source (database, vials, PMD or
pharmacy records, etc.),
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*World Health Organization (2006) & Fernandes (2012)
Patient Safety Strategies
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Advanced Medication Reconciliation
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Requires interprofessional collaboration
Team Approach: Prescriber – Nurse – Pharmacist
 Must include patient/caregivers in
discussions/decisions
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Requires integration into admission histories,
progress notes & discharge summaries
Requires effective patient education and
medication counseling
Integrated Components:
Discharge care plan counseling
 Coordinating follow-up appointments
 Postdischarge telephone calls and contacts
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*Kwan et al. Medication reconciliation during transitions of care as a patient safety
strategy: a systematic review. Ann Intern Med 2013;158:397-403
Patient Safety Strategies
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Potential Benefits of medication reconciliation
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Reduced risk of Preventable Adverse Drug Events
(pADEs) and Adverse Drug Events (ADE or ADR)
Reduced readmissions and emergency
department visits at 30 days
Reduced hospital visits at 12 months
Potential Harm
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Mistakes are ‘hard-wired’ into patient record
Practitioners rely on record and don’t confirm
accuracy with patient or other sources
Risk of process taking key personnel
(pharmacists) away from other patient safety
activities
*Kwan et al. Medication reconciliation during transitions of care as a patient safety
strategy: a systematic review. Ann Intern Med 2013;158:397-403
Patient Safety Strategies
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Factors affecting impact of medication
reconciliation
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Degree to which patients (and the ‘system’)
can provide current medication history
Health literacy and language
 EMR, prescription databases
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Clinical informatics milieu
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Integrated medication reconciliation into
computerized order entry, EMR
Costs and available personnel
Reconciliation of medication ‘list’ doesn’t
guarantee appropriateness of care
Patient Safety Strategies
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Medication Therapy Management
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Care provided by pharmacists with goal to
optimize drug therapy and improve
therapeutic outcomes
Thorough medication therapy review with
individualized action plan with follow-up and
documentation of action
Resources –
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Clinically focused pharmacist
Process provides for timely review of all
therapy
Communication pathways to prescribers
Systems for collecting, sharing, and
documenting information and interventions
Medication Therapy Management
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Return on Investment
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Health Partners MTM Cost Savings
Analysis (prepublication data)
706 MTM patients - over 1.5 years
 $331 PMPM savings = $2.8M
 TCOC reduced 18%; ROI = 11:1
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Clinical and Economic Outcomes of MTM
Services: Minnesota Experience (BCBS Mn
Analysis) (JAPhA 2008;48:203-11.)
285 MTM patients over 1 year (2007)
 TCOC reduced 31% ($3750 PMPY); ROI = 12:1
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*PMPM = Per Member Per Month; TCOC = Total Cost of Care; ROI = Return on Investment
Potential Solutions
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Post-discharge pharmacist medication
reconciliation
Decreased readmission rates at 7*, 14*, &
30 day
 Financial savings of $35,000 per 100
patient discharges
 80% of discharged patients in this
integrated group practice and health plan
had at least medication discrepancy on
discharge
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Kilcup M, et al. Post discharge pharmacist medication reconciliation: Impact on
readmission rates and financial savings. J Am Pharm Assoc 2013;53:78-84.
Potential
Solutions
Medication
Reconciliation
Toolkit
(104 pages)
Medication Reconciliation Toolkit
Guiding Principles for Reconciliation Programs
“Define Roles and “One Source of Truth”
Responsibilities”
“Standardize
and
“Make Simplify”
the right thing to do
the easiest
thingPrompts
to do”
“Effective
or
Reminders”
“Patients
and
“Laws or Regulatory
Caregivers”
“Link to other goals or
Requirements”
initiatives”
Transitions - Pharmacy “Pearls”
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Advanced Medication Reconciliation is only
one piece of an integrated plan
CURRENT and ACCURATE information is
key; Goal is ‘One Source of Truth’
Resources ($$$, time, personnel, technology)
are required
Patient health literacy and beliefs must be
assessed and addressed
Attention to detail and assuming ‘no one else
noticed this’
Summary
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Transitions in care put patients at risk due to
poor communication and inadvertent
information loss
Unintended medication discrepancies are
common, but often with limited harm (acutely)
Significant discrepancies have high risk and
high cost to patients and systems
Medication reconciliation is just one tool that
can be implemented
Medication reconciliation must be ‘teamed’
with early comprehensive therapeutic review
An integrated approach is necessary to
maximize benefit from decisions and
interventions to reduce risk across the care
continuum
Exercise –
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Identify one specific issue you would like
to address to optimize medication
outcomes and transitions
Create a vision – what would the top of
the mountain look like
Outline a plan – what would it take to get
there
Devise a process you’d like to see at your
facility Develop a timeline – what would it
take to get started
Assuming adequate resources (not
unlimited)
Exercise Example
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Your facility has entered into an agreement with a
local acute care hospital to provide post acute
care for elders after elective hip and knee
replacements
A post-care survey indicates 18% of the residents
surveyed indicate inadequate pain control on the
first day of admission.
Review of the current residents admitted reveals
the following information:
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Number of residents arriving after 4 pm: 6/20 (30%)
Number of residents arriving without ‘paperwork’ or
‘hard’ copies of prescriptions for controlled
substances: 3/20 (15%)
Number of residents ordered only PRN pain
medicines: 7/20 (35%)
Identify the Issue
Create a Vision
Outline a Plan
Devise a Process
Develop a Timeline
Exercise Example
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72 year old man with Type 2 Diabetes
Mellitus and history of renal insufficiency
Currently prescribed glyburide in addition
to metformin
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Glyburide is considered potentially
inappropriate in elderly (BEERs List) due to
very long duration of action especially with
renal insufficiency
Metformin contraindicated with renal
insufficiency
FSBS values this week – 2 values below
70 mg/dL (requiring nursing intervention)
with no values above 115 mg/dL
Identify the Issue
Create a Vision
Outline a Plan
Devise a Process
Develop a Timeline
Summary (repeated)
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Transitions in care put patients at risk due to
poor communication and inadvertent
information loss
Unintended medication discrepancies are
common, but often with limited harm (acutely)
Significant discrepancies have high risk and
high cost to patients and systems
Medication reconciliation is just one tool that
can be implemented
Medication reconciliation must be ‘teamed’
with early comprehensive therapeutic review
An integrated approach is necessary to
maximize benefit from decisions and
interventions to reduce risk across the care
continuum
QUESTIONS AND
COMMENTS?