Making a PDiF-ference Results of the PDiF Quality Improvement Initiative March 2014 www.saferhealthcarenow.ca
Bienvenue! Welcome also to our francophone attendees Bienvenue à nos participants francophones Hélène Riverin Conseillère en sécurité et en amélioration Safety Improvement Advisor www.saferhealthcarenow.ca
Objectives of today s call Colleen Cameron: Describe the PDiF initiative, its outcomes and key lessons learned. A few practical challenges to consider. Marg Colquhoun: The MedRec Journey from 2005 and onwards. 3 www.saferhealthcarenow.ca
Please input your Questions All questions will be addressed at the end of the webinar Ask questions or send feedback via the chat box Select All participants Type message Click Send All Participants www.saferhealthcarenow.ca
Where to find our webinars www.saferhealthcarenow.ca
Please complete our poll 6 www.saferhealthcarenow.ca
Making a PDiF-ference Results of the PDiF Quality Improvement Initiative Colleen Cameron, RPh, Pharm.D. PDiF Coordinator, Grand River Hospital ISMP Canada/Safer Healthcare Now! April 8, 2014
Objectives Describe the PDiF initiative, its outcomes and key lessons learned. A few practical challenges to consider.
Guelph General Hospital Grand River Hospital St. Mary s General Hospital Groves Memorial Hospital WW LHIN (775,000 people) Cambridge Memorial Hospital St. Joseph s Health Centre North Wellington Health Care
PDiF = Pharmacy Discharge Facilitator
Two stories - 63 year old male - 3 rd cardiac event. - Discharged post-stent insertion. $$$ $$$ $$$ PRE Metformin ASA Atorvastatin Ramipril Bisoprolol POST Metformin ASA Lipitor (Brand) Perindopril Bisoprolol Clopidogrel Lantus Rapid Ezetimibe Esomeprazole Docusate Senokot Nitro Patch
Two stories Losartan 100mg Irbesartan 300mg
Two stories Losartan 100mg 200 Irbesartan 300mg
The most unpredictable variables in the entire equation
Pharmacy Discharge Facilitator Project What is it? Quality Improvement Initiative Uniquely included 2 local CEOs in its development Possibly helped to keep the project s profile and momentum January-September 2013 Facilitate medication discharge for high-risk medicine patients with a goal of improving care and outcomes PDiF team = pharmacist + University of Waterloo pharmacy co-op student
Medication Care Map in Hospital Patient Pharmacy MD Discharge Pt Admitted To Hospital Discharge preparation and coordination BPMH Completed / AMR (Best Possible Medication History/ Admission Med Red) Medication Therapy In Hospital
Components of PDiF Patient Pharmacy MD Discharge Pt Admitted To Hospital PDiF 1 On admission Identify High-Risk Patients Discharge preparation and coordination BPMH Completed (Best Possible Medication History) Medication Therapy In Hospital
Components of PDiF Patient Pharmacy MD Discharge Pt Admitted To Hospital PDiF 2 During hospital stay Modify medications that will be practical and make sense for discharge Discharge preparation and coordination BPMH Completed (Best Possible Medication History) Medication Therapy In Hospital
Components of PDiF PDiF 3 At time of MD Patient Discharge preparation and coordination Discharge Pharmacy Pt Admitted To Hospital BPMH Completed (Best Possible Medication History) discharge 1. Communicate with involved health care providers about medication changes and rationale for those changes. 2. Talk to patient/ caregiver to ensure they understand directions. Medication Therapy In Hospital
Components of PDiF Patient Pharmacy MD Discharge Pt Admitted To Hospital PDiF 4 Post-discharge - Call patient 24-72 hours postdischarge to see if they are able to follow the instructions we gave them. Discharge preparation and coordination BPMH Completed (Best Possible Medication History) Medication Therapy In Hospital
Outcomes Qualitative Patient / caregiver satisfaction Primary Care Provider satisfaction Community Pharmacist satisfaction Hospitalist satisfaction Quantitative 7, 30 and 90 day ER visits 7, 30 and 90 day readmissions Conservable Bed Days unexpected
Demographics # of patients seen 148 (+) Average age 74.2 years 7 patients died during index hospital admission % 50 45 40 35 30 25 20 15 10 5 0 20-40 41-60 61-80 81-96 Age Ranges 79%
Age Range % of Patients 20-40 3.4% (N=5) 41-60 17.6% (N=26) 61-80 35.1% (N=52) 81-96 43.9% (N=65) Heart Failure (# of pts) Diabetes (# of pts) Warfarin (# of pts) 0 2 2 5 16 9 14 23 26 20 22 39 Total 148 pts 26% 43% 51%
Qualitative Outcomes Did we achieve Patient / Caregiver satisfaction? Did we achieve Primary Care Provider satisfaction? Did we achieve Community Pharmacist satisfaction? Did we achieve Hospitalist satisfaction?
Quantitative Outcomes (#, $) ER/Readmission Rates 7, 30 and 90 day ER visits 7, 30 and 90 day hospital readmission rates Data disclaimer Historical = All comers young patients, DKA, pneumonias, acute ingestions, dialysis PDiF patients
GRH Readmission Rates - Historical 16 14 CIHI 13.3% % 12 10 8 6 4 2 FY 09-10 FY 10-11 FY 11-12 FY 12-13 0 7 day 30 day 90 day
GRH Readmission Rates 16 14 CIHI 13.3% % 12 10 8 6 4 2 FY 09-10 FY 10-11 FY 11-12 FY 12-13 PDiF 0 7 day 30 day 90 day
ER Visit Rates - Baseline 30 25 % 20 15 10 5 FY 09-10 FY 10-11 FY 11-12 FY 12-13 0 7 day 30 day 90 day
ER Visit Rates 30 25 % 20 15 10 5 FY 09-10 FY 10-11 FY 11-12 FY 12-13 PDiF 0 7 day 30 day 90 day
What do these numbers have the statistical power to prove? Anything? probably not Causality? certainly not Benchmarking? - maybe Is that the only information that matters? What if patients subsequently go elsewhere for care?
Quantitative Outcomes (#, $) Hospital Readmissions and ED Visits At first glance, our PDiF numbers look great
Quantitative Outcomes (#, $) Hospital Readmissions and ED Visits At first glance, our PDiF numbers look great BUT
This is bigger than GRH
Quantitative Outcomes (#, $) Conservable Bed Days Definition relevance Over 9 months, PDiF realized 8 weeks of conservable bed days Medications involved Warfarin, Methadone Unexpected, but fascinating Consequently have started targeting patients on medications that are more likely to delay discharge Warfarin / NOACs Insulin
Top 5 lessons learned 1. Dare to look at your patients experience post-discharge. Are they seeing their family doctor postdischarge? Are they getting their prescriptions filled as expected? Are they going to other local hospitals for subsequent visits? Follow-up phone calls are quick, and incredibly valuable!
Top 5 lessons learned 2. Drugs delay discharge Warfarin, LMWHs, insulins, methadone We now assess 100% of patients on warfarin for timely and safe discharge from Medicine program Assist with LMWH coordination post-discharge Educate injection technique while in hospital Phone call follow ups Anticoagulation summary of INRs & warfarin doses, Ensure patient has appt with PCP as well as plans to go to lab
Top 5 lessons learned 2 ½. Where there is warfarin (or NOACs) there are other medication misadventures looming Warfarin and NOACs are predictors of other highrisk medications (insulin, digoxin, spironolactone, amiodarone etc) Most computer systems can search for certain medications. This is the best place to start!
Top 5 lessons learned 3. Use the hospital admission to optimize chronic medications Clinical inertia Look for adherence issues!!! ODB DPV has picked up on MANY misadventures Incorporate practical medication discharge assessment upstream
Top 5 lessons learned 4. Medication knowledge transfer contributes to efficient and safe patient care GRH has an electronic discharge prescription but. PCPs and Community Pharmacists need information about medications, including rationale and plans of care. What is your ehealth system? Fusion software (transcription software) Clinical Connect (LHIN EHR) Medication-Focused Discharge Summaries
Medication-Focused Discharge Summary One of the most valuable interventions from the PDiF project!
Medication-Focused Discharge Summaries Standardized document including Date of Admission/Discharge Adherence Issues Identified** Drug Cost Issues Identified Numerical List of medications comment if same, increased, decreased or new Medications discontinued or held Additional information Commentary including plan of care, monitoring plans, concerns My name and telephone extension
Top 5 lessons learned 5. Discharge medication reconciliation is time consuming! Track outcomes/stories to strengthen your argument for more funding Go to your program director with proposal Develop a business case? Dr. Schnipper s data Be creative in staffing Pharmacist : patient ratio Pharmacy students Pharmacy Technicians Financially: 1 pharmacist 2 technicians 4 co-op students
Summary Was the PDiF project successful? Did we improve outcomes? Unequivocally Are there simple strategies every hospital can implement to help these patients? Absolutely Medication misadventures We don t even know the magnitude of the problem yet
colleen.cameron@grhosp.on.ca
The MedRec Journey Margaret Colquhoun, B.Sc.Phm., FCSHP, R.Ph., Project Lead, ISMP Canada http://www.ismp-canada.org/medrec/ 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Objectives To talk about the MedRec from 2005 2014 Highlight SHN tools and resources Highlight your accomplishments To announce changes in 2014-2015 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Thanks to Canadian Patient Safety Institute 2005 MedRec Intervention 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
MedRec 2005 Unknown did not know what we did not know Systems not in place Measures not in place Studies not driving practice change
Things I am Proud of!!! Creation of new language and knowledge Being used around the world Whole country worked together and learned together as a team Tools and Resources Webinars, kits, questions Unbelievable sharing though our network of MedRec teams across Canada 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Action for Safer Medical Care Medication Reconciliation, CMPA/ACPM, 2103 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
www.saferhealthcarenow.ca www.ismp-canada.org/medrec 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
www.saferhealthcarenow.ca www.ismp-canada.org/medrec 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
National Team Sharing through Webinars 200-400 lines for each webinar Showcase the Success of our Teams Well received by attendees Relevant and Timely 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
The Stepping Stones to MedRec Success London Health Sciences Centre describes: The challenging elements of MedRec implementation in one of Canada's largest, acute care teaching hospitals 1. How LHSC overcame these challenges by focusing on interdisciplinary collaboration 2. How LHSC is evaluating and sustaining the process 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Square Peg in a Round Hole: MedRec in Ambulatory Clinics Requires a Different Model Vancouver Health Authority and University Health Network, Toronto Describe how ambulatory clinic patients require a different system to enable medication reconciliation & review. Understand the longitudinal team approach to improve accuracy & error reduction through regular review. Describe two approaches to medication reconciliation in the ambulatory clinic setting. Identify opportunities of a patient registry as it relates to patient care (medication reconciliation), the organization (drug usage review) and outcomes research. To share the findings of medication discrepancies and drug therapy problems identified in a post discharge medication reconciliation pilot study. 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Different Strokes: Engaging Pharmacy Technicians in MedRec The Moncton Hospital, The Ottawa Hospital, Trillium Health Centre, Peterborough Regional Health Centre Describe the medication reconciliation model developed for pharmacy technicians Review the training process involved for pharmacy technicians in medication reconciliation Highlight the role of the pharmacy technician in the Emergency Department and/or the pre-admission clinic 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Dr. Jeffrey Schnipper Results of a funded research study into what works and what is the impact of MedRec All past and future webinars available from: SHN website: http://www.saferhealthcarenow.ca/en/events/nationalcalls/pages/default.aspx ISMP Canada website: http://www.ismp-canada.org/medrec/ (Education & Training) 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Slide Courtesy of Dr.Jeff Schnipper Safer Healthcare Now! Webinar Jan, 2014 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
MedRec Webinars 2009-2014 Available online All past and future webinars available from: SHN website: http://www.saferhealthcarenow.ca/en/events/nationalcalls/pages/default.aspx ISMP Canada website: http://www.ismp-canada.org/medrec/ (under Education & Training) 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2010- National MedRec Summit To accelerate a system-wide strategy to implement medication reconciliation (MedRec) Healthcare CEOs, senior leaders, representatives from national organizations, provincial quality councils, physicians, nurses and pharmacists identified themes that would accelerate and optimize MedRec across the continuum of care 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Senior leadership commitment is critical to ensuring MedRec is implemented successfully across an organization. Accountability must rest with the CEO with clear reporting expectations at the board level. REF: Optimizing Medication Safety at Care Transitions: A National Challenge, 2011 http://www.ismp-canada.org/download/medrec/medrec_national_summitreport_feb_2011_en.pdf 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Consumer Awareness and Tools PR Campaign from North Bay Regional Health Centre (ON) 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Interactive Map Relatively few self-identified MedRec All-Stars who have MedRec in place across admission, transfer and discharge 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Paper to Electronic Tools/Checklists Organizational Readiness Steps to support the safe transition to emedrec Ideal features of emedrec, Evaluation of emedrec 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
October 2013 was National MedRec Quality Audit Month 103 Organizations 2340 patients 29% (acute care) 55% (Long Term Care) 1906 Acute Care 329 Long Term Care Met all 5 quality criteria Met all 5 quality criteria 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
National Quality Audit Results Summary Comments MUST critically evaluate admission to ensure quality at discharge Canadian audit tool results demonstrate need for ongoing and specific improvements People believe they are doing MedRec but they may not be doing it well The foundation of the process the BPMH needs work 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
In 2014 we have NOT reliably implemented MedRec!!! 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Outstanding Issues in MedRec! Getting to where we want to be Leadership Measuring and Monitoring Quality Role and use of technology Embedding roles and processes into system Consumer Engagement Primary care 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Light. at the end of a lot of hard work The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire. 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Changes in 2014-2015 2014 Institute for Safe Medication Practices Canada (ISMP Canada)
2014 Institute for Safe Medication Practices Canada (ISMP Canada)
Questions 80 www.saferhealthcarenow.ca
Questions 1. Raise your hand and we may be able to open your phone line 2. Send feedback via the chat box Select All participants Type message Click Send All Participants www.saferhealthcarenow.ca
Please complete our poll 82 www.saferhealthcarenow.ca
Upcoming MedRec Webinars Thank you for attending Join us on May 6, 2014 at 12 noon ET for our next MedRec webinar Safety, Sleuthing and Students: A Novel Collaborative MedRec Event at the University of British Columbia 83 www.saferhealthcarenow.ca
We encourage you to report medication incidents Practitioner Reporting https://www.ismp-canada.org/err_report.htm Consumer Reporting www.safemedicationuse.ca/ www.ismp-canada.org www.saferhealthcarenow.ca 84
Medication Safety Self-Assessment Hospitals (acute care)(2006) free for Ontario* Long-term care (2012) free for Ontario* Complex Continuing Care and Rehabilitation (2008) free for Ontario* Community and Ambulatory Pharmacy (2007) free for Ontario* Operating Room Medication Safety Checklist (2009) free for Ontario* Oncology (2012) Anticoagulant Safety (VTE) free for Ontario* HYDROmorphone Safety Self-Assessment (2014) - $50 * Supported by the Ontario MOHLTC For more information visit www.ismp-canada.org/mssa or email mssa@ismp-canada.org www.ismp-canada.org www.saferhealthcarenow.ca
Thank you for attending www.saferhealthcarenow.ca