Med Rec in Rural NSW hospitals –

the High 5s study and

accreditation

• 8 hospitals in southern NSW collected data from July 2010 till September 2011 – all had on site clinical pharmacists

• 5 days/wk in 5 (7 days/wk for some time in 1) 4 days/wk in 3

• 3 hospitals employed junior medical staff, the remainder were VMO only

• We added a measure: discrepancies on discharge• We discontinued involvement due to

• requirement to only measure those reconciled within 24 hours significantly increased the sample size

• workload associated with independent observer verification

OUR HIGH 5 EXPERIENCE

Our data showed.. consistently high coverage of patients in target group received clinical pharmacy services including med rec

Jul-10

Sep-10

Nov-10

Jan-11

Mar-11

May-11

Jul-11

Sep-11

0102030405060708090

100medication reconciliation rates

percentage of patients rec-onciled

percentage of patients with medications reconciled within 24 hours of admission

percentage of patients with at least one unintentional dis-crepancy

month

per

cen

tag

e

.. no great change in discrepancies over time

.. as expected, discharge was more of a problem than on admission

Jul-1

0

Sep-1

0

Nov-1

0

Jan-

11

Mar

-11

May

-11

Jul-1

1

Sep-1

10.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60medication reconciliation discrepancies

no. of undocumented intentional medication discrepancies per pa-tient

no. of unexpected discrepancies per patient on discharge

number of unintentional medica-tion discrepancies per patient

month

nu

mb

er p

er p

atie

nt

Our data showed (2)

how medication hx verified

• Front of drug chart (red box) was common• At the time 2 sites using paper MMP• Electronic solution (GP prescribing software) in 3 hospitals• Definition of verification – 2nd source

• traditional pharmacist approach or• could also be eg admitting doctor using medicines list / webster

pack / nursing home charts provided evidence in clinical record that it had been checked /annotated

what is different in small hospitals

• Less steps between GP and inpatient stay: often same doctor or same practice sends patient to hospital -> better information

• Good liaison with community pharmacy in small towns• Group GP practices have routine processes for transmitting

information to and from hospital out of GP prescribing software (but these lists are not always up to date, verification still needed)

• GP VMOs may access surgery software from in hospital and transmit data back on discharge

• RACF charts and DAA packs are highly reliable sources of information

standard 4 – what we did in 2013

• Extended the high 5 approach, incorporating key questions into routine medication chart audits done post discharge, LOS > 24hrs; pharmacist + 1 does the audit

• Included all hospitals, subacute, MPS’s, mental health• Since high 5, electronic medical record used in more

facilities -> forcing function if electronic discharge summaries are used

Clinical pharmacy service

med rec indicator

discharge is where it’s at.. we were previously poor at documenting actions taken on discharge.. now if it’s not in the clinical record it didn’t happen.. med rec on discharge is incorporated into generation of pt “medilist”

electronic MMP / discharge plan eg

hard coded look up lists- Pharmacies- GP surgeries- Hospital pharmacists

can be written to emr copy and paste

medilist, medication chartscan be generated

Conclusion• Participation in High5 forced us to be more accountable in the way we

documented histories and particularly actions taken at discharge• Electronic MMP’s are either fully implemented or being implemented

in all hospitals – if emr being used for discharge summaries pharmacist med rec is not optional – “forcing function”

• We continue to measure key outcome measures (% clinical pharmacy review, med rec on admission, med rec within 24 hours, discharge information given)