Role of hospital pharmacists in transitions of care

Rosalynn L. PanganPublic Relations OfficerThe Philippine Society of Hospital PharmacistsSt. Luke’s Medical Center – Global City

WHAT IS TRANSITION OF CARE?

“care transitions" refers to the movement patients make between health care practitioners

http://www.caretransitions.org/definitions.asp

WHAT IS TRANSITION OF CARE?

Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.

Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities.

Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.)

MEDICATION ERRORS IN TRANSITIONS OF CARE


Study Design: Prospective Results:

After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria

81patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy.

Most common error (46.4%) was omission of a regularly used medication.

61.4% of the discrepancies were judged to have no potential to cause serious harm.

38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration.

Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med2005;165(4):424-9.


Study Design: Population-based cohort study using admin records from 2007 to 2009 of hospitalizations and outpatient prescriptions

Results: Patients admitted to the hospital (n = 187,912) were more

likely to experience potentially unintentional discontinuation of medications than controls (n = 208,468) across all medication groups examined.

Admission to an ICU was associated with an additional risk of medication discontinuation in 4 of 5 medication groups vs hospitalizations without an ICU admission.

One-year follow-up of patients who discontinued medications showed an elevated AOR for the secondary composite outcome of death, emergency department visit, or emergent hospitalization of 1.07 (95% CI, 1.03-1.11) in the statins group and of 1.10 (95% CI, 1.03-1.16) in the antiplatelet/anticoagulant agents group.

Patients prescribed chronic medications were at higher risk for unintentional discontinuation following hospital discharge, and ICU stay during hospitalization increased the risk of medication discontinuation even further

. Bell CM, Brener SS, Gunrai N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA 2011;306(8):840-7.


Study Design: Prospective Method:

60 randomly selected patients at a Canadian Community hospital

At admission, compared patients’ medication ordesr with pre-admission medication use based on med vials and interviews with patients, caregivers and/or outpatient healthcare providers

At discharge, pre-admission and in-patient medications were compared with discharge orders and written instruction

Variances were discussed with prescriber and classified either as intended or unintended

Vira T., Colquhoun, M., Etchells, E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006 April; 15(2): 122–126.


Results: Overall, 60% (95% CI 48 to 72) of patients had at

least one unintended variance and 18% (95% CI 9 to 28) had at least one clinically important unintended variance.

None of the variances had been detected by usual clinical practice before reconciliation was conducted.

Of the 20 clinically important variances, 75% (95% CI 56 to 94) were intercepted by medication reconciliation before patients were harmed.


MEDICATION ERRORS IN TRANSITIONS OF CARE Study Design: Prospective Method: studied patients who were consecutively

discharged home or to a seniors' residence from the general internal medicine service during a 14-week interval in 2002; phone interview and chart review to identify outcomes; 2 physicians conducted an independent review the outcomes to determine occurrence of AE

Results: outcomes were determined for 328 of the 361 eligible patients,

who averaged 71 years of age After discharge, 76 of the 328 patients experienced at least 1 AE

(overall incidence 23%, 95% confidence interval [CI] 19%–28%). AE severity ranged from symptoms only (68% of the AEs) or AE severity ranged from symptoms only (68% of the AEs) or

symptoms associated with a nonpermanent disability (25%) to symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). permanent disability (3%) or death (3%).

Most common AEs were adverse drug events (72%), therapeutic Most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%–16%).ameliorable (overall incidence 12%, 95% CI 9%–16%).

Forster A J, Clark H D, Menard A. et al Adverse events among medical patients after discharge from hospital. Can Med Assoc J 2004. 170345–349.349.

WHAT IS THE KEY ROLE OF HOSPITAL PHARMACISTS IN TRANSITIONS OF CARE?

WHAT IS MEDICATION RECONCILIATION

“the process of creating the most the most accurate list accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medication to the patient at all transition points within the hospital.”

- IHI’s 100,000 Lives Campaign

IMPACT OF HOSPITAL PHARMACISTS IN TRANSITIONS OF CARE

IMPACT OF MEDICATION RECONCILIATION DURING ADMISSION

Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010;25(5):441-7.

Study Method: Study pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications

Results: 35.9% experienced 309 order errors 85% of patients had errors originate in medication

histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%).

If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful.

In logistic regression analysis, patient's age > or = 65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09-4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14-1.29) were significantly associated with errors potentially requiring monitoring or causing harm.

Presenting a medication list (OR, 0.35; 95% CI, 0.19-0.63) or bottles (OR, 0.55; 95% CI, 0.27-1.10) at admission was beneficial.

PHARMACIST FACILITATED DISCHARGE

Study Design: Descriptive Report Methods:

Clinical pharmacist participated in multidisciplinary discharge rounds in selected medicine services

Patient selection: (1) discharge to home, (2) with >5 medications with at least 1 high risk medicine; (3) English speaking; (4) active telephone service

CP activities: (1) reconciled with clinicians discharge medication discrepancies; (2) counseled patients and families; (3) provided reconciled medication list to subsequent providers; (4) contacted patients within 72 hours after discharge and at 30 days to identify and address post-discharge medication problems.

Walker, P.C. et. al. Pharmacist facilitated discharge: a prospective study of medication reconciliation and telephone . 2007

PHARMACIST FACILITATED DISCHARGE Results (10-month period):

958 out 1122 patients (85%) were screened 721 (75%) patients met the inclusion criteria 477 (66.2%) patients were interviewed to assess

current medication use 248 (34%) patients were counseled at discharge 486 discrepancies identified and resolved in 63% of

patients counseled with an average of 3 discrepancies per patient Missing Meds (41.2%) Failure to Discontinue unnecessary or inactive meds

(23.7%) Wrong dose/frequency (16.3%) Discrepancy occurred most frequently in the following

therapeutic classes: CV, analgesic, endocrine, antimicrobial and gastric acid suppression

Follow-up phone call within 72 hrs. and at 30 days are completed in 24% (59) and 8.5%(21), respectively. 123 post-discharge problems were identified and resolved

Walker, P.C. et. al. Pharmacist facilitated discharge: a prospective study of medication reconciliation and telephone . 2007

KEY ELEMENTS TO SUCCESSFUL MEDICATION RECONCILIATION

“ONE SOURCE OF TRUTH”

Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. http://www.ahrq.gov/qual/match/match1.htm

Develop a single medication list, shared by all disciplines for documenting the patient's current medications.

http://www.ashp.org/s_ashp/docs/files/MedRec_3414AHome.pdf

DEFINE ROLES


Clearly define roles and responsibilities for each discipline involved in medication reconciliation. To help determine roles and responsibilities, map out the various admission points in your organization

SAMPLE WORKSHEET


INTEGRATE MEDICATION RECONCILITATION INTO EXISTING WORKFLOW

Standardize and simplify the medication reconciliation process

Eliminate unnecessary redundancies Make the right thing to do the easiest thing to do within

the patterns of normal practice. Ensure process design meets all pertinent local laws or

regulatory requirements. Linking medication reconciliation to other strategic

goals (e.g., heart failure publicly reported process of care measures related to discharge instructions on medications) and/or other initiatives (e.g., a hospital project working on improving patient satisfaction related to pain management or patient communication regarding medications) when appropriate can also strengthen the importance of this process.


SAMPLE WORKSHEET

http://www.ashp.org/s_ashp/docs/files/PS_Flowcharts%20of%20MedRec%20for%20Ambulatory%20Settings.pdf

EDUCATE PATIENTS

Educate patients and their families or caregivers on medication reconciliation and the important role they play in the process.


WHERE CAN MEDICATION RECONCILIATION HAPPEN?


Admission Medication History Verification is an important step, as patients often forget to

mention medications or OTC medications/herbal supplements during the initial medication collection. Any new information regarding the patient's home medication list should be discussed with the physician and resulting changes documented

provides an educational opportunity to teach patients about the medications ordered for them in the hospital in relation to their home medications, and comment on any differences.

Reconciling home medications with current inpatient orders.

Clarifying unintended discrepancies (i.e., discrepancies that are not explained by the current care plan, by the patient's clinical status, or formulary substitution) with the physician for resolution.

Completing a discipline-specific form with radio buttons and comment sections to document interactions and clarifications with patients, other sources, and the prescriber to trace follow-through on discrepancies and resulting clarifications and modifications, if neededSource: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for

Medication Reconciliation. http://www.ahrq.gov/qual/match/match1.htm


Intra-hospital Transfer Assess current medication orders

and make any changes or modifications in preparation for the new level of care.

Review the patient's pre-admission medication list. Home medications initially held may now be appropriate to restart upon transfer.



Discharge Contact the physician if the patient's discharge

medication list is not updated and/or complete (note: when establishing roles and responsibilities for preparing patients' discharge medication lists, a blanket statement such as "resume home medications" is not acceptable).

Contact the physician to clarify patient questions encountered during the patient counseling session prior to discharge.



External TransfersPatient's list of medications prior to their hospitalization.

Medications that are being administered to the patient at the outside hospital prior to transfer.

Medications ordered at your hospital.

TAKE HOME MESSAGE

DOWNLOADABLE RESOURCES/TOOLS

1. http://www.ahrq.gov/qual/match/2. http://www.ashp.org/menu/PracticePolicy/

ResourceCenters/PatientSafety/ASHPMedicationReconciliationToolkit_1/MedicationReconciliationBasics.aspx

3. http://www.ihi.org/offerings/MembershipsNetworks/MentorHospitalRegistry/Pages/MedicationReconciliationADE.aspx

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Rosalynn L. Pangan

Public Relations Officer

The Philippine Society of Hospital Pharmacists

St. Luke’s Medical Center – Global City

Role of hospital pharmacists in transitions of care

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