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Medication Reconciliation Strategies UMHS Experience

Medication Reconciliation Strategies UMHS Experience. Catherine Christen, PharmD Paul C. Walker, PharmD University of Michigan Health System and College of Pharmacy March 30, 2006 Michigan Health & Hospital Association Conference. JCAHO NPSG #8.

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Medication Reconciliation Strategies UMHS Experience

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  1. Medication Reconciliation StrategiesUMHS Experience Catherine Christen, PharmD Paul C. Walker, PharmD University of Michigan Health System and College of Pharmacy March 30, 2006 Michigan Health & Hospital Association Conference

  2. JCAHO NPSG #8 Goal: Accurately and completely reconcile medications across the continuum of care 8A Requirement: Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. 8B Requirement: A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization

  3. JCAHO Sentinel Alert #35 Recommendations • Place the medication list in a highly visible location in the patient's chart • Create a process for reconciling medications at all interfaces of care (admission, transfer, discharge) and determining reasonable time frames for reconciling medications • Provide the patient with a complete list of medications that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications, in addition to communicating an updated list to the next provider of care. Encourage the patient to carry the list with him or her and to share the list with any providers of care • Involve an authorized person(s) in the medication reconciliation process when the patient is unable to actively or fully participate

  4. Medication Reconciliation Errors • USP added 3 “causes of error" to its MEDMARX® program to capture errors involving medication reconciliation failures in 9/04 • 53% potential/intercepted error • 46% errors with no harm • 1% errors with harm • 0.1% errors caused death, which occurred at transition/transfer points 2,022 medication reconciliation errorsreports (9/04 to 7/05) USP Patient Safety CAPSLink™, October 2005, United States Pharmacopeia,http://www.usp.org/patientSafety/newsletters/capsLink/

  5. Medication Reconciliation:Patient Safety at Admission Source: Cornish PL, Knowles SR, Marchesano R et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-9

  6. Medication Reconciliation:Process Improvement • The use of a standardized form for reconciling patients’ medications is the heart of the medication reconciliation safety initiative • The form serves as a vehicle for consolidating information about a patient’s medications that is often dispersed throughout their medical record

  7. Multidisciplinary Team Approach • Led by OCA and Pharmacy • Nursing, Pharmacy, Risk Management, and Physicians from outpatient and inpatient settings • Staff from ED, OR, clinics, procedure areas • Charged with implementation of medication reconciliation • Consulted Programs and Operations Analysis for assessment of current systems for medication reconciliation at UMHS

  8. The Challenge of Medication Reconciliation at UMHS Discharge Navigator or Dictation AMBULATORYCARE INPATIENT Inpatient Admission Pharmacy Information System CareWeb PSL* Transfers in/ out ICUs & other units Procedure Areas Medicine & Surgery Clinics HomeMed MVNA ED *PSL = Problem Summary List for Current Medication Profile

  9. When a patient enters your unit who do you gather patient medication information from? Who gathers the information? Survey Findings Patient and nurse play key role in collecting med information Sample period: March – April 2005 Sample size: 32 Sample period: March – April 2005 Sample size: 32 Do you routinely ask about non-standard medications, i.e., herbals, vitamins, etc.? Do you ask the patient to verify information you obtained from various sources? Sample period: March – April 2005 Sample size: 32 Sample period: March – April 2005 Sample size: 32

  10. Which UMHS data system does your department use? Survey Findings CareWeb is widely used but some do not have access to update How often do you check the system for updates? Sample period: March – April 2005 Sample size: 32 Sample period: March – April 2005 Sample size: 32 Do you update your system or just view it? Do you have access to update your system? Sample period: March – April 2005 Sample size: 32 Sample period: March – April 2005 Sample size: 32

  11. No standardized way to transfer patient med information How do you forward medication information when a patient is transferred? Sample period: March – April 2005 Sample size: 32 WORx Medical Records Transfer Sheet Consult physicians Programs and Operations Analysis Consultants Feb 2005

  12. Medication Reconciliation • Problem Summary List is the medication reconciliation tool for all UMHHC outpatient care processes • Pharmacy WORx system (document is the Medication Administration Record or MAR) is the medication reconciliation tool for all UMHHC inpatient care processes

  13. The Problem Summary List

  14. Medication Reconciliation Improvements • Enhanced availability of PSL to MVNA and HomeMed clinical staff – HomeMed now adding home IV meds to PSL • Pilot of automatic printing of PSL in the ED which is reviewed with the patient • Plan to print PSL in the PACU, based on ED pilot • Automatic printing of patient-friendly PSL in the outpatient clinics

  15. Medication Reconciliation Improvements • CareWeb Discharge Navigator as an automated method by which to reconcile inpatient WORx medications with outpatient PSL • Modified existing paper documents to support medication reconciliation • Inpatient nursing transfer summary • ED nursing transfer summary • PACU nursing transfer summary

  16. Nursing Perspective – Inpatient Inpatient Nursing Units (Macro) – Flowchart of Current State Patient not always aware of home meds; nurse not always asking about non-standard meds; inconsistent use of CareWeb Patient is admitted to unit Nurse obtains some source of med info – patient interview; CareWeb or other computer system, etc. Nurse fills out Health Assessment Form and possibly other forms) with new med info. Nurse looks at physician’s orders from previous unit; checks for consistency with up-to-date med list Meds look OK? No Consult physician regarding discrepancies Yes RNs to use PSL and MD admit note for med history, rather than re-do med history Physician prescribes medications in new unit J-1 Nurse/clerk sends strip orders to pharmacy Nurse creates temporary MAR with meds to administer New orders? Shift change? Time to administer? No No No Yes Yes Yes Patient DC’d/ transferred? No Administer meds Order new meds Transfer to next nurse Yes Carry out transfer procedure End process

  17. Nursing Perspective Inpatient Inpatient Nursing Units (Micro) – Flowchart of Current State (Blow up of key steps) Time to administer? (to next page) No Yes Administer meds Patient DC’d/ transferred? No Check MAR Carry out transfer procedure Yes Administer meds Patient transferred? No Give patient DC form Yes Note administration time on MAR Forward info. to next unit J-2 End process (from New Orders process) Have standardized all transfer from units to/from ICUs or other units, as well as procedure areas – and meds are all charted on the MAR, removing need to include med info on transfer form Inconsistent methods used to forward info (from MAR Rec process)

  18. Nursing Perspective – Inpatient Inpatient Nursing Units (Micro) – Flowchart of Current State (key steps) New orders? Shift change? (from previous page) No No Transfer to next nurse Yes Order New Meds Yes Nurse reconciles MAR with physician orders from shift Not done in all units Physician writes orders Physician flags chart MAR matches orders? No Take corrective action – usually re-order correct meds; update MAR Time delays Yes Nurse/clerk pulls strip & sends to pharmacy Transfer med info to next nurse – verbal or written Nurse manually writes orders on MAR J-3 Night nurse? No (to “Time to administer?”) Yes MAR reconciled when patient is transferred from another unit and at each shift with new orders Pharmacy sends new MAR at night Night nurse reconciles MAR with last 24 hrs. of physician orders Process not standardized MAR matches orders? No Take corrective action – usually re-order correct meds; update MAR Yes (to “Time to administer?”)

  19. Medication Reconciliation: Most Significant Challenges at UMHS • Who is responsible for updating the PSL med list, not just receiving information from it • Perceptions or “lack of confidence” in the accuracy of the PSL med list • Hospital discharge summaries not prepared through Discharge Navigator • Rely on Medical Information Staff updates to PSL from dictated CareWeb discharge summaries and dictated clinic visit summaries • Alternate on-line medical records systems (Centricity, Trace-Vue, Provation) not linked to PSL med list

  20. Medication Reconciliation Audit in Off-Site Clinics • 70 Outpatients: Internal Medicine and Family Practice at 4 Health Centers • Compared dictated CareWeb note and PSL med list • Meds listed/assessed in dictation? 94.3% compliance • Yes: 66 patient note dictations • No: 4 patient note dictations • PSL med list matches medications dictated in note? 72.9% compliance • Yes: 51 med lists • No: 19 med lists

  21. Medication Reconciliation Audit on Inpatient Unit • 8 Inpatients: Internal Medicine and Pediatrics using Discharge Navigator • Admission Reconciliation 48/58 meds (83%) • Meds not reconciled • Low risk: 8 meds • Med risk: 2 meds • High risk: 0 • Discharge Reconciliation 53/62 meds (85%) • Meds not reconciled • Low risk: 7 meds • Med risk: 2 meds • High risk: 0

  22. Medication-Related Problems Following Discharge • Up to 19% of patients experience adverse events within 5 weeks following discharge • Approximately 66% are adverse drug events (ADEs) ranging in severity from laboratory abnormalities that need correcting to permanent disability.1 • 25 to 30% of these ADEs are preventable • 30-35% can be ameliorated appropriate monitoring/intervention.2 1Forster AJ et al. Ann Intern Med. 2003;138:161-167. 2Forster AJ et al. J Gen Intern Med. 2005; 20:317-323.

  23. Factors Contributing to ADEs After Discharge • Recent changes in health status • New medications at discharge • Dose changes at discharge • Discontinuity of care during transitions • Common reasons for ADEs • Post-hospital medication discrepancies • ~ 50% due to system-associated factors • Lack of patient understanding of treatment plans • Failure to evaluate for (and act on) predictable medication related side effects. • Failure to implement appropriate drug monitoring Forster AJ et al. J Gen Intern Med. 2005; 20:317-323. Coleman EA et al. Arch Intern Med. 2005; 165:1842-1847.

  24. Understanding of Treatment Plans and Diagnosis at Discharge Makaryus AN, Friedman EA. Mayo Clin Proc. 2005; 80:991-994.

  25. Benefit of the Pharmacist in Medication Reconciliation • Pharmacist Transition Coordinator1 • Reduced ED visits and hospital readmissions in elderly patients discharged to LTCF • No difference in reported ADEs • Pharmacist discharge counseling2 with a follow-up phone call 2 days after discharge helped to • Identify and resolve medication-related problems • Reduce hospital readmissions and ED visits • Improved patient satisfaction • The intervention did not include medication reconciliation at discharge and planning of follow-up medication monitoring. 1Crotty M, et al. Am J Geriatr Pharmacother. 2004;2:257-64. 2Dudas V et al. Am J Med. 2001; 111(9B):26S-30S

  26. Pharmacy Intervention Pharmacy-Assisted Care Coordination Discharge Navigator or Dictation AMBULATORY CARE INPATIENT Inpatient Admission Pharmacy Information System CareWeb PSL* Transfers in/out of ICU and other units Procedure Areas Medicine & Surgery Clinics HomeMed MVNA ED *PSL = Problem Summary List

  27. The Importance of Discharge Navigator

  28. The Importance of Discharge Navigator

  29. Pharmacist-Facilitated Discharge • Works with Discharge Planner to identify patients scheduled for discharge • Criteria for Pharmacist-Facilitated Discharge (PFD) • 5 or more chronic medications on discharge • Targeted medications • digoxin, diuretics, anticoagulants, sedatives, opioids, asthma/COPD medications, ACE/ARB • Other medications requiring therapeutic monitoring (e.g., electrolyte supplements, anticonvulsants) • 2 or more medications changed, stopped or started during admission • Patients confused (excluding those with delirium), unable to handle own medications • Discharged to home, caregiver or assisted living

  30. Demographics of Patients Requiring Pharmacist-Coordinated Discharge • N = 18 • Average age: 65 years (range 32-91 years) • Met criteria: 67% (12) • Specific criteria met: • 11/12 received meds that required monitoring • 12/12 had 2 or more medications changed, stopped or started during admission • 10/12 had more than 5 chronic meds • Mean: 9.8 meds/patient • 3/12 were confused or unable to manage meds

  31. Pharmacist Responsibilities • Assess discharge medications • Reconcile pre-admission and discharge medications • Ensure a follow-up plan for medication monitoring • Verify medications are covered by patient’s insurance • Counsel on discharge prescriptions • Verify patient comprehension • Identify and address potential adherence concerns • Communicate medication list to f/u provider • Update PSL or letter • Post-discharge follow-up phone calls (48 hours, 30 days)

  32. Outcomes to Be Measured • Descriptive statistics of the patient population • Number and type of regimen changes recommended/made by the pharmacist • Percentage of patients experiencing transition-related ADEs, unscheduled ED or physician visits, hospital readmissions, and the associated costs

  33. Example: Distribution of Interventions January 1 – February 10, 2006 No. Patients: 77 Total Interventions: 214 Ave: 2.8 interventions/patient

  34. Example BB is a 45 yo pt with asthma and hypertension admitted for glaucoma and elevated creatinine. Initial Patient Assessment • Patient Would Benefit From PFD • Patient is responsible for med administration - no caregiver. • Patient has no recollection of the names of his medication. • # Meds PTA: unknown • Additional OTC/Herbal Products Not Listed on PSL: Motrin, Aleve for headaches; Alka-Seltzer Plus for Colds • Intolerable Side Effects Reported by Patient: none reported • Medication Issues/Barriers to Medication Adherence: none reported • Compliance: 50-79% • Payment Issues: none reported - has Medicaid • Pharmacy of Choice: Sesame Street Pharmacy in Neighborhood, MI

  35. Discharge Medications: Furosemide 80mg Po Daily Metoprolol 75mg Po BID Salmeterol/Fluticasone 1 Puff Inhalation BID Hydrocodone/Acetaminophen 1-2 Tab Po Q4-6h prn Albuterol 2 Puff Inhalation Q4-6h prn Amlodipine Besylate 10mg Po Daily (New) Dorzolamide 2% 1 Drop in Eye BID (New) Brimonidine P 0.15% 1 Drops In Eye BID (New) Renagel 800mg Po TID with Meals (New) Erythromycin Base 1 Apply in Eye QID (New) Latanoprost 0.005% 1 Drops in Eye QHS OTC/Herbal Medications: Motrin, Aleve, Alka-Seltzer Plus Provided written information: Yes. Documentation of Discharge Medication Counseling

  36. Known Allergies/Sensitivities: No Known Allergies Identified Barriers to Medication Adherence: >2 meds stopped, started, or changed at discharge >5 chronic medications Action Taken: Reviewed each of the patient's medications, emphasizing new medications and changes in current medication therapy. Important changes in this patient’s regimen are indicated above **Special Counseling** Reviewed proper technique for eye drop administration Recommended BP monitoring post-d/c – Recommended to patient that he not take NSAIDs at home for headache, as he has impaired renal function and elevated BP Documentation of Discharge Medication Counseling

  37. Documentation of Discharge Medication Counseling • Outcome Assessment: • Patient verbalized understanding of medication regimen. Patient agreed to have a pharmacist call home for post-discharge follow-up. • Additional Pharmacy Interventions/ Recommendations: • Clarified final medication list with attending prior to discharge. • Informed MD that Aranesp was omitted from final med list. (Nephrology recommended initiating Aranesp 40mcg q week to be continued after discharge for anemia of chronic renal failure.)

  38. Post-Discharge Phone Follow-up • Spoke to: Patient • Medical Issues: No new or worsening symptoms reported by patient. Patient states that he is "doing fine.“ • Medication Issues: Patient reports that he was able to attain all discharge medications from the pharmacy and understands administration instructions. Patient is able to verbalize correct dose and schedule of Renagel and Xalatan eye drops, both newly prescribed at discharge. • Medical Follow-up Issues: Patient has appointment with PCP for tomorrow, and will be seen at Kellogg Eye Institute on Thursday. • Patient Questions: None Action Taken Following Phone Call: None needed

  39. Acknowledgements for Discharge Project Randolph R. Regal, PharmD James G. Stevenson, PharmD Scott Flanders, MD Caroline S. Blaum, MD, MS Steven Bernstein, MD Jasmine Tucker, PharmD Madhavi Dandu, MD Vikas I. Parekh, MD Jean Schlafer, MSA, RN Kathy O’Dell, RN Elizabeth Nolan, MSN, RN Cheryl Grostic

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