Bridging the Gap An audit of medication reconciliation at the primary/secondary care interface in medicine for the elderly admissions Natalie O GormanO Interface Pharmacist April 2011
Medicines Reconciliation the process of identifying the most accurate list of a patient s medicines including the name, dosage, frequency, and route comparing them to the current list in use, recognising any discrepancies, and documenting any changes, thus resulting in a complete list of medication, accurately communicated Institute of Healthcare Improvement, 2007
Background Problems with communication of medication information across the healthcare interfaces have long been recognised. Role of the Interface Pharmacist working at day hospital with elderly patients Individuals vs wider systems. NPSA and SPSP have identified improving the core processes involved in medicines reconciliation as a key target in their medication Medicines Management work streams. Improving medication reconciliation at discharge can help to reduce medication errors Patient Harm Readmission rates Confusion for patients and carers Time wasting for staff Medication waste
Aims To assess how accurately medication information is being communicated between primary and secondary care at discharge in a sample of medicine for the elderly admissions. To identify strengths and weaknesses in the current methods of communicating medication related information, if necessary implement changes in these systems and assess the benefit of these changes.
Methods Baseline Data Collection 50 patients IDD s followed up at discharge by the Interface Pharmacist Medication listed on IDD and GP system were compared and discrepancies recorded. Timeliness and compliance aid use also recorded. Discrepancies were investigated and brought to the attention of the patient s GP and, where appropriate, community pharmacist. Questionnaires Distributed by post to all 62 GPs and 19 Community Pharmacies in Inverclyde. Changes to system were piloted and assessed in 20 discharges. Post intervention data collection and feedback questionnaires.
Results Number of patients followed up post discharge. Mean average number of days for IDD to reach GP surgery. Baseline Data Collection 50 patients 4 days % of patients with one or more medication discrepancy. 60% Mean average number of old medications not been removed from a patient s medication record. Mean average number of new medications/doses not been added to a patients medication record. % of patients using a compliance aid. 62% (31) % of compliance aid patients with discrepancies. 61% (19) 2* 2** * 2 of the patients had 5 old medications not removed from their repeat medication list and one o patient had 7 old medications not removed. ** In one case a patient had 5 new medications not initiated at time of follow up.
Results Example new drugs/doses not added Example old drugs not removed Mirtazepine Aspirin Paracetamol Gabapentin Lantus Doxasosin Metformin Trimethoprim Gliclazide Co-codamol Cetirizine Traxam gel Furosemide Simvastatin Tramadol Omeprazole Clinutren Diazepam Fortisip Meptazinol Paracetamol Alendronate Furosemide Movicol Calcium Nicotine patch Gaviscon Lactulose Lisinopril Lansoprazole Quetiapine Omeprazole Tramadol Co-codamol Nicorandil Calcium Warfarin Cinnarazine Doxazosin Movicol Mixtard 30 Risedronate Ferrous Sulphate Amitriptylline Ramipril Meptazinol Temazepam Lactulose Ranitidine Paracetamol Senna Loperamide Quetiapine Alendronate Omeprazole Atenolol
GP Questionnaire 62 Questionnaires 42% Response Rate n=26 Does the IDD clearly indicate what changes have been made to preadmission medications? Does the IDD clearly indicate why new medications have been commenced? Does the IDD clearly indicate why pre- admission medications have been discontinued or doses changed? Is the copy of the IDD you receive from the MFTE department legible? Is the copy of the IDD you receive from the MFTE department timely? Is the copy of the IDD you receive from the MFTE department complete? Always Usually Occasionally Seldom Never 0% 65% 16% 19% 0% 0% 31% 23% 34.5% 11.5% 0% 19.5% 38% 19.5% 23% 0% 73% 23% 4% 0% 12% 57% 23% 8% 0% 4% 73% 11.5% 11.5% 0% GPs seemed less aware of problems faced by community pharmacies due to delays in system. 73% felt one week was sufficient time to furnish new prescriptions for compliance aid patient provided whole system made for efficient.
GP Questionnaire Sometimes unclear whether medications have been stopped or simply omitted Due to illegible hand writing poor quality of discharge letter means we have to contact the ward for clarity Fax us a copy directly don t rely on a patient to do it Patient s pharmacist should be informed of discharge If reasons for changes not clear I will not automatically add everything to repeat list until I receive a formal typed discharge letter 2 weeks post discharge meds issued by the hospital would help
Pharmacy Questionnaire 19 Questionnaires 53% Response Rate n=10 Are you notified when one of your patients is admitted to hospital? Always Usually Occasionally Seldom Never 0% 40% 60% 0% 0% Are you notified when one of your patients is discharged from hospital? Do you ever receive a copy of the Immediate Discharge Document? 0% 50% 50% 0% 0% 0% 30% 10% 60% 0% All would want to be routinely notified when their patients were admitted and discharged from hospital. Preferred methods of receiving this information were post and fax. 60% felt one week was sufficient time to furnish new prescriptions for compliance aid patient provided whole system made for efficient.
Pharmacy Questionnaire Communication in current system is very little with little or no info passed on A lot of time wasted chasing up discharge notes Sometimes it is not explained enough to relatives/carers what to do with discharge sheets which can slow down the supply chain When pharmacies receive a copy of the discharge letter the whole process is more efficient GPs don t always up date dose changes so we often get scripts for preadmission doses and it can take numerous calls to find correct doses
Changes Implemented 1) A typed Medication Management Form for GP s. 2) A Discharge Medication Communication Form for Compliance Aid Patients sent to GP s and Community Pharmacists. 3) Formalised communication with Community Pharmacists. 4) A standardised mode of communication used for the transfer of medication related information at discharge. 5) A patient Information Leaflet.
Results Number of patients followed up post discharge Mean average number of days for IDD to reach GP surgery. % of patients with one or more medication discrepancy. Mean average number of old medications not been removed from a patient s medication record. Mean average number of new medications/doses not been added to a patients medication record. Baseline Data Post intervention 50 patients 20 patients 4 days 2.8 days 60% 10% 2 1 2 0 % of patients using a compliance aid 62% (31) 65% (13) % of compliance aid patients with discrepancies 61% (19) 15% (2)
GP s 80% Response Rate Feedback 87.5% found the Medication Management Form Very Helpful 75% found the Medication communication form for compliance aid patients very helpful. Positive comments around amount of information given on med changes. Community Pharmacists 45% Response Rate 77.7% found the Medication Communication form for compliance aid patients Very Helpful Comments around internal mail being too slow, too many forms, possibility of 2 week supply from hospital, GPs taking too long to generate prescriptions.
Conclusions Elderly patients discharged from the MFTE department are exposed to potential medication errors as a result of poor communication between primary and secondary care. Results from the pilot study showed that improvements can be achieved in this area. The improved content of the medication information sent to GPs and the inclusion of the Community Pharmacists in the discharge process are likely to be the biggest influences. Recognise that this was a labour intensive process and that to be made widely reproducible integration into everyday ward routines is required.
Recommendations 1) Provide primary care with an accurate IDD based on use of a medication reconciliation/management process reflecting all medication changes generated from admission. 2) Include Community Pharmacists in the discharge process by providing them with written confirmation of discharge medications. 3) Explore the possibilities of safer and quicker modes of communication between primary and secondary care with the current IT available. 4) Remove the responsibility from patients and their carers to transfer the IDD and provide them with written information on how to obtain a further supply of medication following discharge from hospital. 5) Explore the option of the Hospital pharmacy issuing a 2 week supply of compliance aid medication at discharge.
What are we doing now? Education of junior medical staff about the medication reconciliation/ management process and the documentation used. Clinical Ward Pharmacists working to together with medical staff to achieve above and with the Interface Pharmacists to follow out patients at discharge. Re-auditing.
References Institute of Healthcare Improvement 2007 www.ihi.org Bateson C, Duggan C, Bates I (2002) Pharmaceutical care across the health care interface: an evidence based approach to developing and evaluating documentation on in Practice. Int J PHarm Pract :10(suppl): R15 Morrison P, Abu-Arafeh Arafeh I, Davison J, Chapman S. (2004) Optimum prescribing of discharge medicines: roles of hospital and community pharmacists. The Pharmaceutical Journal (Vol( 272) 21 Morcos S, Francis S, Duggan C.(2002) Where are the weakest links? Adescriptive study of discrepancies in prescribing between primary and secondary care sectors of mental health service provision. Psychiatric Bulletin, 26, 371-374 374 Wong JD, Bajcar J, Wong GG et al. (2009) Medication Reconcilliation at Hospital Discharge: Evaluating Discrepanices.. The Annals of Pharmacotherpay SIGN guidance on minimum dataset for discharge summary RPSGB, GHP, PSNC, PCPA Moving patients, moving medicines, moving g safely. Guidance on Discharge and Transfer Planning 2005 NICE /NPSA Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. December 2007 Bellingham C.(2004) How to improve medicines management at the primary/secondary p care interface. The Pharmaceutical Journal (Vol( 272) 21 Milton JC, Hill-Smith I, Jackson S. (2008) Prescribing for older people. BMJ 336;606 ;606-609609 Norris C, Thomas V, Calvert P. (2001) An audit to evaluate the acceptability a of a pharmacist electronically prescribing discharge medication and providing information to GPs. The Pharmaceutical Journal (Vol( 267) NSF for older people