10/2/2017. Bozeman Health Deaconess Hospital Transition of Care Pharmacist Initiative. Problem. Problem

Transcription

1 Bozeman Health Deaconess Hospital Transition of Care Pharmacist Initiative KRISTAL BARKER, PHARMD EMILY STEED, PHARMD Problem Medical Error is the 3 rd leading cause of death in the United States Problem Resident 8 wk pilot project from 2015 demonstrated 52% of patients had pharmacist-identified medication discrepancies 13.7% of patients had medication errors with potential to cause harm (NNT 7.1 patients) A large percent of patients discharging from the hospital had medication discrepancies and a significant percentage had errors that could cause patient harm Patient education on discharge falling on nursing staff with minimal medication counseling provided 1

2 Initial Steps Cost justification of a full time transition of care pharmacist position (cost avoidance per resident project) Met with hospitalists and other disciplines including admit/discharge nurses and case management Barriers included new implementation of EPIC system-wide and user challenges of the new EMR Transitions of care to home and SNF/ALF and changes in culture and workflow Focusing on workflow and which patients to target Focus Area Only medical floor patients at BDH 30 beds + 8 progressive care unit beds = 38 total Initial focus was on high risk patients High LACE+ score High risk medications (ie insulin, anticoagulants, high cost medications, chemotherapy) CMS diagnoses included in the hospital readmissions reduction program Pneumonia, heart failure, COPD, acute myocardial infarction Final program included ALL patients discharging from the medical floor TOC Pharmacist Workflow Medical Floor TOC Pharmacist position is available Mon-Fri Attend discharge planning rounds at 0900 Review discharge orders on all patients Provide medication counseling on all patients who will managing their own medications Patients not going to another inpatient or skilled nursing facility Assist with cost/insurance issues as needed Offer med-to-bed service as needed 2

3 Outcomes: Summary Numbers Total Patients Reviewed and/or Counseled by TOC 2008 Total TOC Days 232 Ave Number of Patient s Reviewed per Day 8.7 Ave Number of Patient s Counseled per Day (patients discharging to facilities that administer their medications do not receive discharge education) 6.2 Ave Interventions Per Patient 1.1 Percentage of Interventions with Potential to Cause Harm 14%* N = 146 *56% of these (8% of the total interventions) were clinically considered a Great Catch Great Catch Examples Antimicrobial Stewardship Pyelonephritis patient discharged on both the sulfamethoxazole/trimethoprim prescribed in the ER and ciprofloxacin prescribed by the hospitalist No metronidazole prescribed for patient with C diff Antibiotic deescalated from piperacillin/tazobactam to amoxacillin/clavulanate for a Pseudomonal infection. Antibiotics not renally dose adjusted Anticoagulation/Anti-Platelet Incorrect Pradaxa dosing admitted for bleeding complications. Changed to correct Eliquis dose on discharge Patient on enoxaparin inpatient for PE, not reordered at discharge. NSTEMI patient with no aspirin prescribed on discharge. Incorrect NOAC dosing Heparin drip not initiated for acute MI prior to transfer for CABG Warfarin not ordered for new start, or not stopped after bleeding complications Other Common Errors on Discharge Diuretic, insulin, or blood pressure medication dose changed inpatient but not updated on discharge No hard scripts for controlled substances Issues with admit medication reconciliation Incorrect prednisone taper instructions Outcomes: Interventions Breakdown of Interventions 3% 3% 4% 6% 7% 9% 15% 22% 31% Corrected Dosing/Sig of Home Med(s) Coordination of Care Optimization of Therapy Clerical or # Prescribed Fix Insurance/Payment Assistance Missing Intended Therapy Added Missing Home Med(s) Anticoag Education 3

4 Intervention Categories Intervention Type Description Anticoag Education Warfarin, NOACs, enoxaparin Alert ACC of discharge, contacted PCP, re sent scripts to different pharmacy, Coordination of Care contacted pharmacy to determine product availability or cost, etc. Added Missing Home Med(s) Added home medication to home med list that was missed on admission Medications patient was on prior to admission were resumed without necessary Corrected Dosing/Sig of adjustments, adjusted home medication to correctly reflect how patient was taking Home Med(s) the medication or how they should be taking the medication. Clerical or # Prescribed Removed abbreviations, fix steroid taper, fixed drug quantity (not changing intent of Fix order) etc. Missing Intended Therapy MD meant to prescribe or should have prescribed (error of omission) Fixed a DDI, renally dose adjusted, started medication for an untreated condition, Optimization of Therapy recommended different antibiotics, stopped unneeded meds Duplicate Therapy Insurance/Payment Assistance Clarified and fixed duplicate medication orders Helped with prior authorization, provided coupon cards, contacted insurance company, etc. Lessons Learned All patients can benefit from TOC pharmacist services Best time to catch an error is before it occurs (before they discharge) Adds an extra layer of swiss cheese to the discharge process Importance and benefits of interdisciplinary collaboration between physicians, pharmacists, care managers, and nurses Importance of increased vigilance when implementing a new EMR Plan to Sustain Change Plan for expansion to surgical floor/icu Resident project initiated to evaluate outpatient pharmacist follow-up of high risk patients Potential for extending hours Development of an official med-to-bed program Work with our quality department to evaluate impact of TOC pharmacist interventions on 30 day readmission rates 4

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