Utilization of pharmacy technicians for accurate and timely medication histories. Brenda Asplund, PharmD, CPPS March 11, 2018

Transcription

1 Utilization of pharmacy technicians for accurate and timely medication histories Brenda Asplund, PharmD, CPPS March 11, 2018

2 Disclosure The content of this presentation does not relate to any product of a commercial interest. Therefore there are no relevant financial relationships to disclose. Dr. Asplund is the site lead at Mission Hospital for the MARQUIS2 trial: (Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety)

3 Mission Hospital Mission Hospital is a 730 bed tertiary care, community hospital. It is the primary regional referral center and flagship of a 5 hospital system in a 17 county region of Western North Carolina. Mission has 5 ASHP accredited pharmacy residency programs and affiliations with University of North Carolina (UNC) School of Pharmacy and School of Medicine.

4 Mission Hospital Stats In fiscal year 2017, the Emergency Department (ED) saw 102,130 patients 11,627 were pediatric patients Behavioral health patients have increased 25.79% of all ED patients are admitted 3 rd busiest ED in NC Current technician staff complete histories for: 78% all patients admitted through the ED 87% of high risk patients, 57% general risk patients 24% of patients discharged from the ED 39% complex risk, 9% general risk

5 Learning Objectives Describe barriers for nurse gathered histories Discuss comparative accuracy of pharmacy gathered and nurse gathered medication histories E plai o pletio of a good faith effort Develop a business plan for program development

6 Self-Assessment True or false: RNs are the most accurate staff when gathering and documenting a medication history. pharmacy technicians are not as competent as pharmacists or nurses in gathering an accurate medication history. A good faith effort a e a hie ed a patient interview.

7 The Journey of Reconciliation Literature going back as early as 1981 evaluates clinical significance of an accurate medication history. 1 Evidence suggested that more than 40% of medication errors can be attributed to inadequate medication reconciliation : The Joint Commission (TJC) added medication reconciliation as a National Patient Safety Goal 2006: TJC pu lished a se ti el e e t alert titled Using Medication Reconciliation to Prevent Errors 3

8 The Journey of Reconciliation Documenting a list of medications seems easy, ho e er 4 Variation in process causes confusion Who s role is it? A d ho has ti e? Lack of standard documentation location and type of information create unresolved discrepancies Patient acuity may skew prioritization

9 The Journey of Reconciliation Documenting a list of medications seems easy, ho e er 4 Patient lack of knowledge or confusion regarding medications/ poor historians Limited access to external pharmacy records Up to 25% of prescription medications were not recorded in the hospital admission record, according to Lau and colleagues. 5

10 Medication History: Nurse Chevalier et al. studied nurse perceptions about medication history documentation. 6 Identified barriers: time and staffing resources Histories taken in ED resulted in discrepancies for 37-87% of patients 7,8 With standardization, training, and resource devotion, nurses are accurate with histories 9,10,11

11 Assessment True or False: RNs are the most accurate staff when gathering and documenting a medication history.

12 Medication History: Pharmacist More accurate then physicians in the ED 12 More accurate on an internal medicine service 13,14 More expensive than nurses or pharmacy technicians.

13 Medication History: Technician When compared to physicians in the preoperative setting, a significant reduction in medication discrepancies resulted from technician involvement. 15 Technicians improved history accuracy from 45.8% to 95% over nurse-collected, according to Smith and Mango. 16 This accuracy of technician histories has been demonstrated in multiple other studies as well, at greater than 90% accuracy. 17,18,19

14 Technicians in the ED Technicians have been shown to have comparable accuracy to pharmacists in the ED setting. 20 ED Pharmacy technicians have fewer errors than nurses. 21,22,23 Overall, a meta analysis determined that interventions reliant on pharmacy staff is supported for medication reconciliation with a focus on high risk patients. 24

15 Assessment True or False: Pharmacy technicians are superior to nurses when documenting medication histories, but inferior to pharmacists.

16 Building a Business Case Assess the problem Observations Retrospective chart review Gather literature support Talk to the other process owners! Physicians Nurses Accreditation department

17 Building a Business Case Try a small pilot Important to select the right people 26 Important to train staff well 15,25 Standardize process and documentation Collect data points Time of completion Comparison of defects to pre-intervention chart audit High risk defects Do t forget a out staff satisfa tio!

18 Building a Business Case Utilize savings information Saved RN time Projected medication error savings Most importantly, physicians demanded the service to facilitate safer admission from the ED. Obtaining the physician champion sealed the deal.

19 Building a Business Case Do t e pe t a full staff odel at first Plan to prioritize high risk patients 27,28,29 Some cited risk factors include: Age Polypharmacy High risk medications Multiple, frequent hospital admissions MARQUIS (Multi-Centered Medication Reconciliation Quality Improvement Study) developed a quality tool post-study, available online free of charge (including a cost ROI excel document). 30

20 Building a Business Case Mission Hospital example: Pharmacy students (trained by faculty) reinterviewed patients with a completed medication history. Technicians: average 2 clarifications needed/history Nurses: 5 Well trained technician can average 3 histories per hour

21 Assessment What are the first steps to building a business case? True or false: 1. Gather data on current problem 2. Go straight to pharmacy VP for money 3. Start a pilot with your PRN IV room technician

22 Good Faith Effort Struggle to balance time constraints with accuracy Nursing staff have multiple tasks at admission that must take priority. TJC allows us to define this term

23 Good Faith Effort List all the places medication information can be located Work with nursing to determine what is reasonable for a bedside nurse Develop policy and pharmacy consult guidelines for complicated patients Leverage the EMR to help with follow-up when necessary

24 Good Faith Effort Mission Hospital example: If a patient arrives to the unit without a pharmacy-documented history, the RN completes a good faith effort defi ed as: Interview patient or family/caregiver Utilize available written records from patient, outside facility, nursing home, or assisted living facility Review historic list in EMR and utilize online centralized prescription database After those steps, a pharmacy consult can be utilized for assistance.

25 Assessment True or False: The Joint Commission defi es a Good Faith Effort i the Natio al Patient Safety Goals. -diversity-in-the-demographics/

26 Assessment True or False: A good faith effort a be accomplished by a patient interview. -diversity-in-the-demographics/

27 Key Takeaways Nurses, pharmacists, and pharmacy technicians are all capable of taking an accurate medication history with appropriate training and task time Pharmacy technicians are equal to or better than pharmacists and nurses respectively at documentation of an accurate medication history A good faith effort can be defined by an institution and may mean different things to different staff team members Building a business case requires careful planning, engagement and support of physician and nursing staffs, and proof of effectiveness.

28 . References 1. Dawson P, Gray, S. Clinical significance of pharmacist-obtained drug histories. Pharm J. 1981;227: Rozich JD, Howard RJ, Justeson JM, et al. Patient safety standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf. 2004;30(1): The Joint Commission. Medication reconciliation. sentinel event alert /SentinelEventAlert/sea_35.htm 4. Bayley KB, Savitz LA, Rodiquez G, et al. in patient safety: from research to implementation. 3. Rockville, MD: Agency for Healthcare Research and Quality; Barriers associated with medication information handoffs. AHRQ Publication No Lau HS, Florax C, Porsius AJ, et al. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. Br J Clin Pharmacol. 2000;49(6): Che alier BA, Parker DD, Ma Ki o NJ, et al. Nurses per eptio s of edi atio safet a d edi atio reconciliation practices. Nurs Leadersh. 2006;19(1): Mazer, M., DeRoos, F., Hollander, J. E., McCusker, C., Peacock, N. and Perrone, J. (2011), Medication History Taking in Emergency Department Triage Is Inaccurate and Incomplete. Academic Emergency Medicine, 18: Caglar s, Henneman PL, Blank FS, et al. Elergency medication lists are not accurate. J Emerg Med. 2011;40: Rozich JD, Resar RK. Medi atio safet : o e orga izatio s approa h to the halle ge. J Clin Outcomes Manag. 2001;8(10):27 34.

29 . References 10. Stover P, Somers P. An approach to medication reconciliation. Am J Med Qual. 2006;21: Henneman EA, Terrier EG, Nathanson BH, Plotkin K. An evaluation of a collaborative, safety focused, nursepharmacist intervention for improving the accuracy of the medication history. Journal Patient Safety, 2014;10(2): De Winter S, Spriet I, Indevuyst C, Wilmer A, et al. Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department. Qual Saf Health Care. 2010; 19: Reeder TA, Mutnick A. Pharmacist-versus physician-obtained medication histories. Am J Health-Syst Pharm. 2008; 65: Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy. 2006; 26: Van den Bemt P, van den Broek S, van Nunen AK, et al. Medication reconciliation performed by pharmacy technicians at the time of preoperative screening. The Annals of Pharmacotherapy. 2009; 43: Smith SB, Mango MD. Pharmacy-based medication reconciliation program utilizing pharmacists and technicians: a process improvement initiative. Hosp Pharm. 2013; 48(2): Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm Oct 1; 60(19): Cooper JB, Lilliston M, Brooks D, Swords B. Experience with a pharmacy technician medication history program. Am J Health-Syst Pharm. 2014; 71: Leung M, Jung J, Lau W, Kiaii M, Jung B. Best possible medication history for hemodialysis patients obtained by a pharmacy technician. Can J Hosp Pharm. 2009; 62(5): Johnston R, Saulnier L, Gould O. Best possible medication history in the emergency department: comparing pharmacy technicians and pharmacists. Can J Hosp Pharm Sep; 63(5):

30 . References 21. Hart C, Price C, Graziose G, Grey J. A program using pharmacy technicians to collect medication histories in the emergency department. P&T Jan; 40(1): Gard Ella JE, Cardwell TB, Nnadi M. Improving medication safety with accurate preadmission medication lists and post discharge education. Jt Comm J Qual Patient Saf Oct; 38(10): van den Bemt PM, van der Schrieck-de Loos EM, van der Linden C, Theeuwes AM, Pol AG, Dutch CBO WHO High 5s Study Group. Effect of medication reconciliation on unintentional medication discrepancies in acute hospital admissions of elderly adults: a multicenter study. J Am Geriatr Soc Aug; 61(8): Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices, a systematic review. Arch Intern Med, 2012; 172(14): Knight H, Edgerton L, Foster R. Pharmacy technicians obtaining medication histories within the emergency department. Am J Health Syst Pharm Apr 1; 67(7): Remtulla S, Brown G, Frighetto L. Best possible medication history by a pharmacy technician at a tertiary care hospital. CJHP 2009; 62(5): Gleason KM, McDaniel MR, Feinglass J, et al. results of the Medications At transitions and Clinical Handoffs (MATCH) Study: an analysis of medication reconciliation errors and risk factors at hospital admission. J of Gen Intern Med. 2010; 25(5): Unroe KT, Pfeiffenberger T, Riegelhaupt S, et al. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J of Geriatric Pharm. 2010; 8(2): Pippins JR, Gandhi TK, Hamann C, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008; 23(9): Innovation/Implementation_Toolkit/MARQUIS/Med_R ec_resources_medication_reconciliation.aspx