Dr Treasure McGuireDr Treasure McGuire19 November 201419 November 2014

Medication reconciliation: Medication reconciliation: Public vs. Private - is there Public vs. Private - is there are difference?are difference?

You have already met DanielYou have already met Daniel

• 60 y.o male presented for day surgery in our Private hospital

• Not eligible for High 5s– < 65 y.o.

– Not admitted through the ED to inpatient services

– Intention was a hospital stay of < 24 hrs

• When he needed to be admitted– Medication Hx - No 2nd source used

• Minimal information from VMO or GP

• Patient didn’t bring own medications

• Only knew names of his medicines

• “Best guess” for doses

Case study cont.Case study cont.

Medications charted by cardiologist

Dexamphetamine 10mg po tds (withheld)

Allegron® (nortriptyline) 80mg nocte

Paxam® (clonazepam) 20mg nocte•Only one source: patient recall

•Nurse contacted Surgeon for Phone order for evening meds

• Patient no dose recall (20mg vs10mg)

• VMO – reduced to 10mg

Next morningNext morning

Pharmacist conducted BPMH (within 24h)– Used > one source of Med Hx information

• Community pharmacy & patient’s psychiatrist

Outcome20x overdose (40x overdose prescribed)!

Clinically – dizzy, drowsy, unsteady on feet

Required 2 nights in hospital

Dexamphetamine 10mg tds Correct (but may have contributed to tachycardia)

Nortriptyline 100mg nocte NOT 80mg Unintentional discrepancy

Clonazepam 0.5mg nocte NOT 20mg prescribed & 10mg administered

Unintentional discrepancy

Would this misadventure have occurred:

Across the road in our public hospital?

If a BPMH had been taken?

High 5s Medication Reconciliation High 5s Medication Reconciliation project project

“Assuring medication accuracy at transitions of care”Evidence-based patient safety solution sponsored by WHO

Lead technical agency - Australian Commission on Safety and Quality in Health Care (ACSQHC)

10 participating hospitals over the 4-5 year period (2010-14) Most were public hospitals

High 5s Standard Operating Protocol (SOP) Consistent with Australian practice Aligns with APAC Guiding principles to achieve

continuity in medication management.

4 Quality Improvement Measures used to evaluate the 4 Quality Improvement Measures used to evaluate the process & impact of implementing the Med Rec SOPprocess & impact of implementing the Med Rec SOP

Measure Definition Target

MR1 Percent of Patients with Medications Reconciled within 24 hours of the decision to admit the patient

100%

MR2 Mean Number of Outstanding Undocumented Intentional Medication Discrepancies per Patient

0 -1

MR3 Mean Number of Outstanding Unintentional Medication Discrepancies per Patient

≤ 0.3

MR4 Percent of Patients with at Least One Outstanding Unintentional Discrepancy

<40%

MR0 Mean Number of Medication Discrepancies (Intentional + Unintentional) per patient, identified at admission (i.e. prior to BPMH)

-

To use these Measures to answer the question Public vs Private Med Rec: is there a difference

• Need to understand the variables that underpin Med Rec in both settings

Australian High 5 SitesAustralian High 5 Sites

Mater Health ServicesSouth Brisbane

Tertiary hospital with public & private beds (total approx 1000 beds) consisting of: •Mater Adult Hospital (Public)•Mater Children’s Hospital (Public & Private)•Mater Mothers’ Hospital (Public & Private)•Mater Private Hospital

Variables impacting on the quality of Med Variables impacting on the quality of Med Rec – Public vs PrivateRec – Public vs Private

MR0,1,2,3,4

Patient cohort

HP conducting Med Rec

Medical model

Pharmacy model

1. Patient cohort1. Patient cohort

Public vs. Private

•Patient cohort – same High 5s criteria

– However

• More social issues in Public setting• Potential differences in SES, education levels• Higher use of CAMs

2. HP conducting BPMH2. HP conducting BPMH In the Private system – HP may receive minimal

information from VMO or GP

Cost-effective BPMH depends on HPs’ Medication skill base & Willingness to obtain >1 source of Med Hx Communication skills

In Daniel’s case, – Nursing staff recorded 1st Med. Hx – relied on only 1 source (patient

recall)

– Neither Prescriber nor Nurse who administered overdose of clonazepam were familiar with the usual dose range & did not check

an information source.

3. Medical model3. Medical model

At Mater Private

- General reluctance for nursing & medical staff involvement in conducting a BPMH: •In-house survey

– “perceived insufficient time” to invest on this activity

Nurses•Medication Hx on admission 2-5 mins vs BPMH (15-30min up to an hour for complex patients)

3. Medical model3. Medical modelPrivate VMOs

– Less time for writing scripts &/or documenting care plan – vs JMO in Public

– Increased reliance on Phone orders• Rely on memory when giving ward staff medn orders

– Appreciated Pharmacist BPMH• Stated couldn’t justify time implications

• Wanted Pharmacists to complete BPMH before they write up chart (& some would like pharmacists to do that for them too!)

If Daniel was in our public system Pre-admission clinic & BPMH avail during & post surgery (whether intention is to admit or not)

•Missing for Private Surgical Day Patients

4. Pharmacy model4. Pharmacy model

Pharmacy Mater Public Mater Private Alternate Private model

Service Clinical service, with pharmacist in ward 85% of day*

Clinical service, with pharmacist in ward 85% of day*

Supply on script or chart

Location On site, dispensing from ward

On site, dispensing from ward

Remote

Pharmacist to bed ratio

SHPA guidelines based

SHPA guidelines based

Script volume based

PBS Inpatient LAM FormularyDischarge only

Inpatient & Discharge

Inpatient & Discharge

Our Pharmacy Model is same for Public and Private:Ward based clinical service M-F 8am til 4:30pm* and ED in public from 7am til 11am Sat/ Sun & public holidays. Central pharmacy until 7:30pm M-F and 5:30pm Sat/Sun

We would still have ‘missed’ Daniel’s first Med Hx!

4. Pharmacy model contd.4. Pharmacy model contd.Mater MHS “Public” MHS Private Alternate Private

model

Communication methods (of discrepancies)

Phone, pager, in person as discrepancy found. Less use of clinical notes

Depends on seriousness /level of urgency. More use of clinical notes. Phone for more urgent

Phone, pager

Transfer of Med Hx (in hospital to community)

e-PCP transposed to Med List for discharge

e-PCP transposed to Med List for discharge

Variable

Detail of documentation

Variable – moderate to excellent

Variable – minimal to excellent

May not be accessible by pharmacist

ePCP: Mater’s equivalent of an eMAP•In use for almost a decade•Electronic, real time data collection & reports

Admissions ListAdmissions List

Patient Demographics & Admission InformationPatient Demographics & Admission Information

‘‘Drugs on Admission’Drugs on Admission’

Drugs on Admission SummaryDrugs on Admission Summary

Patient-specific tasksPatient-specific tasks

• Series of automatic tasks which appear for all newly admitted patients

• BPMH– Completed within 24 hours of admission. – NOT completed within 24 hours of admission– Differs from other documented medication history (Delete if no

difference)

Patient-specific tasksPatient-specific tasks

Discharge Drugs - PreparationDischarge Drugs - Preparation

Drug Profile – Drug Profile – Log of ALL Med-related events Admission to D/CLog of ALL Med-related events Admission to D/C

ePCPs – ePCPs – EElectronic lectronic PPharmaceutical harmaceutical CCare are PPlanslans

So how did Mater perform on So how did Mater perform on Medication Reconciliation during Medication Reconciliation during High 5 – Public vs Private?High 5 – Public vs Private?

MR0 Mean Number of Medication Discrepancies (Intentional + Unintentional) per patient, identified at admission (i.e. prior to BPMH)

Mean Number of Medication Discrepancies per patientidentified at admission

MR1 MR1: Percent of Patients with Medications Reconciled within 24 hours of the decision to admit the patient

%

Target = 100%

MR2 (Target <1)

Target <1

MR2: Mean Number of Outstanding Undocumented Intentional Medication Discrepancies per Patient

MR3 (Target = 0.3)

MR3: Mean Number of Outstanding Unintentional Medication Discrepancies per Patient

Target = 0.3

MR4 (Target = < 30%)

MR4: Percent of Patients with at Least One Outstanding Unintentional Discrepancy

Target = < 30%

Limitations – High 5s SOPLimitations – High 5s SOP

Focus was on admissions via ED:Omitted surgical day care patients admitted with complications

Lack of initial consensus (or individual hospital perspective) on the potential for clinical impact from discrepancies wrt:

– CAMs– PRN unrelated to episode of care

• Sedatives • Eye drops (non Rx)• Topicals e.g. Creams

If unrelated to episode of care

ConclusionConclusionMater High 5 statistics MR1 slightly higher in Public vs Private (% Med Recs within 24 hrs of adm)

But MR2,3,4 & 0 comparable Public vs Private

Med Rec is a feasible model to improve patient safety / QUM, with comparable outcomes in a Private vs Public setting IF 3 CRITERIA SATISFIED:•Model & staff support BPMH•Staff take time to access resources for double check•HP conducting the BPMH in any transition of care has a good working knowledge of not just medication available but their dose forms, strengths & usual doses