NSG 523 Dissemination ProductAnthony Bernas, Hannah Fox, Airin Lam, Michelle Miller, Andrea Simonetti

Use medicines safely - NPSG.03.06.01:

“Record and pass along correct information about an individual’s medicines. Find out what medicines the individual served is taking. Compare those medicines to new medicines given to the individual served. Make sure the individual served knows which medicines to take when they are at home. Tell the individual served it is important to bring their up-to-date list of medicines every time they visit a doctor.” (JointCommission.org)

National Patient Safety Goal 2014

In patients with Type 2 Diabetes receiving care in an outpatient capacity (P), how does holistic education on medication (I) compared to standard medication education (C) affect patient adherence to and knowledge of safe medication practices (O) within a 90-day study period (T)

www.drugwatch.com

PICOT Question

Why Is Medication Management So Important?

• With the increasing prevalence of chronic diseases, the amount of medications consumed by American adults is rapidly increasing• 82% of American adults take at least one medication and 29% take five or more (Center

for Disease Control and Prevention, 2012)

• Each additional medication can pose the threat of drug interactions

• With each prescription medication there is a potential for side-effects to occur• A study of older adult outpatients who took five or more medications found that 35

percent experienced adverse drug events (Marek & Antle, 2008)

Problems with Medication Management

• The variety in medication timing/scheduling, dosage, and route of administration can be a challenge in medication management• In a study of medication compliance, the compliance rate was 87 percent for daily

dosing, 81 percent for twice a day, 77 percent for three times a day, and 39 percent for four times a day (Marek & Antle, 2008)

• Recognition of an individual’s abilities (e.g. physical and cognitive) are keys in managing their medication

The Importance of Medication ManagementAdverse Drug Events (ADEs) are preventable

• 700,000 emergency department visits and 120,000 hospitalizations are due to ADEs annually (Center for Disease Control and Prevention, 2012)

• $3.5 billion is spent on extra medical costs of ADEs annually (Center for Disease Control and Prevention, 2012)

• At least 40% of costs in ambulatory (non-hospital) settings related to ADEs are

estimated to be preventable (Center for Disease Control and Prevention, 2012)

In the United States, an estimated 3 million older adults are admitted to nursing homes due to drug-related problems at an estimated annual cost of more than $14 billion (Marek & Antle, 2008)

Older adults discharged from the hospital on more than five drugs are more likely to visit the emergency department (ED) and be rehospitalized during the first 6 months after discharge (Marek & Antle, 2008)

(Marek & Antle, 2008)

Evidence Addressing the Problem

Medication reconciliation• Multiple studies have demonstrated large discrepancies (between 30 and 66%) in

what medications were prescribed by the individual’s provider and the actual medications the older adult was taking (Marek & Antle, 2008)

Practice Guidelines:• Review with patient all prescribed medications that they are taking, as well

as any over-the-counter (OTC) medications, herbs, and vitamins. • Screen for ADEs• Provide patient or caregiver a current list of all medications the patient is

taking, including dose, frequency, and routes

Evidence Addressing the Problem

(Marek & Antle, 2008)

Medication Procurement• The act of obtaining medications

Practice guidelines• Assess the ability of patient or caregiver to pay for medication and obtain

any necessary refills• Assist patient or caregiver in setting up pharmacy delivery, refill reminders,

and scheduling family or friends to pick up medications• If the patient has financial problems, refer to a social worker or consult with

pharmacist regarding use of generic drugs

Evidence Addressing the Problem

(Marek & Antle, 2008)

Medication knowledge• Patient education is the key intervention to assist with medication management• Patient knowledge of his/her medication is positively correlated with medication

adherence

Practice Guidelines:• Assess patient’s or caregiver’s knowledge of the medication, including

dosage, frequency, special instructions (e.g take with food), route of administration, and side effects to monitor for

• Interventions related to medication knowledge• Written and visual instructions, medication schedules/charts, and

information on how to take the medications

Evidence Addressing the Problem

(Marek & Antle, 2008)

Physical ability• Low manual dexterity and poor vision are associated to poor medication

management

Practice guidelines• Assess manual dexterity or vision impairment and its influence on the

patient’s ability to open, prepare, and take the medication.• Observe the patient open medication containers, use inhalers, break tablets,

and use injections as needed.

Interventions• Pill box or easy-open container• Medication calendar• Blister packs

Evidence Addressing the Problem

(Marek & Antle, 2008)

Cognitive capacity• The degree to which the patient can understand and retain information

Practice guidelines• Assess patient or caregiver’s capacity to organize and remember to

administer medication• Including understanding and recall of proper dosage, frequency, and

route of administration • Teach about memory cues such as clock time or meal time• Provide memory-enhancing methods such as medication calendar or chart,

electronic reminder, or pill box

Credibility of the Evidence

• Evidence was obtained from Patient Safety and Quality: An Evidence-Based Handbook for Nurses, which looked at several studies to develop guidelines to improve medication management

• Guidelines were produced with expert assistance of a colleague in the nursing research field (Marek & Antle, 2008)

• This review of studies was published by the Agency for Healthcare Research and Quality (AHRQ)

• AHRQ’s mission statement is:• “to produce evidence to make healthcare safer, higher quality, more accessible,

equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that evidence is understood and used.” (AHRQ, 2010)

Reliability of the Evidence

• The authors of Patient Safety and Quality: An Evidence-Based Handbook for Nurses conducted a review of many research studies to determine risk factors that impact non-adherence and medication mismanagement in older adults.

• After looking at the evidence of risk factors provided in the studies, the authors developed guidelines to assist nurses in improving medication management.

• Many of the studies that were analyzed were Level 1 designation. • Level 1 studies are accepted as the most reliable and highest quality evidence in

randomized controlled trials (Devries & Berlet, 2010).• Multiple studies yielded similar results and were consistent through replication• Reputable organizations conducted the studies that provided the evidence for review

Applicability of the Evidence

This evidence is applicable across a variety of medical settings:• Inpatient settings, outpatient clinics, home-health, skilled-nursing and long-term

care facilities, etc

• Including and reinforcing these teachings during each patient encounter is simple and quick

• Practicing and reinforcing these guidelines in a clinical setting will:• Increase patient adherence to proper medications • Decrease adverse reactions • Decrease annual healthcare costs • Decrease hospital readmissions for drug related problems • Increase the patient’s quality of life.

Translation into the Clinical Setting:

Stetler’s Model

Plans for Translation into Clinical Setting

Stetler’s Model• Consists of five phases, used for planning and implementing holistic medication

education into clinical practice

Phase I: Preparation• Define and determine the purpose and potential outcome of the change• We have defined the need for improved medication education to produce better

outcomes for the client’s health related medication safety

Phase II: Validation• Studies linked to the topic of medication safety would need to be critically appraised for

their strength, validity, and reliability

Plans for Translation into Clinical Setting

Phase III: Comparative evaluation/decision making • Study results need to be consistent through replication (reliable)• Evaluate how the evidence will fit into healthcare systems

• Evidence could be either inhibited or facilitated by policy and protocols • Test feasibility regarding associated risk and resources needed, such as medication

education materials and readiness of personnel to enact the change• Our practice change is the need to train healthcare professionals regarding

holistic medication education• Readiness to change will be assessed through evaluation and mock trial

• Finally, it must be established that the change will positively impact current practice• In our case it will be at the outpatient clinic at Rush University Medical Center

Plans for Translation into Clinical Setting

Phase IV: Translation/Application• The plan developed during the previous phases will be applied in the clinical setting• Healthcare professionals will provide holistic medication education to the clients in the

outpatient clinic • Baseline HbA1c levels will be drawn and a pre-intervention survey on medication

knowledge will be given to obtain baseline data • Holistic medication education begins with a patient interview to assess their current

knowledge of the medications, and to determine individual factors that impact the client’s ability to adhere to safe medication management

Plans for Translation into Clinical Setting

Phase IV: Translation/Application (continued)• Medication reconciliation, financial support for healthcare, physical ability, and

cognitive capacity will also be assessed • Interventions that the health care professionals will provide with their teaching include

• Written and visual instructions• Medication schedules/charts, pill boxes, and blister packs • Side effect teaching and symptom management • Who to call in case of an emergency • What to do in case of a missed dose• Address any other questions the client may have

Plans for Translation into Clinical Setting

Phase V: Evaluation• The medication education intervention is evaluated and the impact will be assessed • We will provide clients with a post-intervention survey to assess medication knowledge

as well as draw HbA1c levels• Ideally, we want to see an improvement in medication knowledge and a

decreased HbA1c • The impact of this intervention will improve client self-efficacy, their ability to manage

chronic illnesses, decrease ADEs, decrease the financial burden of medication mismanagement, improve health outcomes, and improve their quality of life!

Agency for Healthcare Research and Quality (AHRQ). (2010). About AHRQ. Retrieved from: http://www.ahrq.gov/cpi/about/index.html

Burns, N. & Grove, S. K. (2011). Understanding Nursing Research: Building an Evidence-Based Practice, 5th Edition. Maryland Heights, MO: Elsevier Saunders

DeVries, J.G., & Berlet, G.C. (2010). Understanding levels of evidence for scientific communication. Foot and Ankle Specialist, volume 3, 206. doi: 10.1177/1938640010375184

Marek, K. D. & Antle, L. (2008). Medication Management of the Community-Dwelling Older Adult. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and

Quality. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2670/

Melnyk B.M. & Fineout-Overholt E. (2011). Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Wolters Kluwer, Philadelphia, PA.

References