Medication Reconciliation Strategies UMHS Experience

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 patients
  current medications upon the patients 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 patients
  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 errors reports
(9/04 to 7/05)
USP Patient Safety CAPSLink, October 2005,
United States Pharmacopeia, http//www.usp.org/pat
ientSafety/newsletters/capsLink/
5
Medication ReconciliationPatient Safety at
Admission
Source Cornish PL, Knowles SR, Marchesano R et
al. Unintended medication discrepancies at the
time of hospital admission. Arch Intern Med.
2005165424-9
6
Medication ReconciliationProcess 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 patients 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
AMBULATORY CARE
INPATIENT
Pharmacy Information System
Inpatient Admission
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
Patient and nurse play key role in collecting med
information
Survey Findings

• When a patient enters your unit who do you gather
  patient medication information from?

• Who gathers the 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
CareWeb is widely used but some do not have
access to update
Survey Findings

• Which UMHS data system does your department use?

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 have access to update your system?
Do you update your system or just view it?
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
(No Transcript)
16
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

17
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 physicians 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 DCd/ transferred?
No
Administer meds
Order new meds
Transfer to next nurse
Yes
Carry out transfer procedure
End process
18
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 DCd/ 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)
19
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
Yes
Order New Meds
Nurse reconciles MAR with physician orders from
shift
Not done in all units
Physician writes orders
Physician flags chart
MAR matches orders?
Take corrective action usually re-order
correct meds update MAR
No
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?)
20
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

21
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

22
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

23
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.
2003138161-167. 2Forster AJ et al. J Gen
Intern Med. 2005 20317-323.
24
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
20317-323. Coleman EA et al. Arch Intern Med.
2005 1651842-1847.
25
Understanding of Treatment Plans and Diagnosis
at Discharge
Patient Awareness of the Discharge Treatment Plan Patient Awareness of the Discharge Treatment Plan Patient Awareness of the Discharge Treatment Plan
Patients (N 43) No () 95 CI
Who knew the names of all their medications 12 (27.9) 15.3 43.7
Who knew the purpose of all their medications 16 (37.2) 23.0 53.3
Who knew common side effects 6 (14.0) 5.3 28.0
Who knew their diagnosis or all their diagnoses 18 (41.9) 27.0 57.9
Mean number of medications prescribed 3.89
Makaryus AN, Friedman EA. Mayo Clin Proc. 2005
80991-994.
26
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.
20042257-64. 2Dudas V et al. Am J Med. 2001
111(9B)26S-30S
27
Pharmacy-Assisted Care Coordination
Discharge Navigator or Dictation
AMBULATORY CARE
INPATIENT
Pharmacy Information System
Inpatient Admission
CareWeb PSL
Transfers in/out of ICU and other units
Procedure Areas
Medicine Surgery Clinics
MVNA
ED
HomeMed
PSL Problem Summary List
28
The Importance of Discharge Navigator
29
The Importance of Discharge Navigator
30
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

31
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

32
Pharmacist Responsibilities

• Assess discharge medications
• Reconcile pre-admission and discharge medications
• Ensure a follow-up plan for medication monitoring
  
• Verify medications are covered by patients
  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)

33
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

34
Example Distribution of Interventions January 1
February 10, 2006
No. Patients 77 Total Interventions 214
Ave 2.8 interventions/patient
35
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

36
Documentation of Discharge Medication Counseling

• 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.

37
Documentation of Discharge Medication Counseling

• Known Allergies/Sensitivities No Known Allergies
• Identified Barriers to Medication Adherence
• gt2 meds stopped, started, or changed at discharge
  
• gt5 chronic medications
• Action Taken Reviewed each of the patient's
  medications, emphasizing new medications and
  changes in current medication therapy. Important
  changes in this patients 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

38
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.)

39
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

40
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 ODell, RN
• Elizabeth Nolan, MSN, RN
• Cheryl Grostic

41
(No Transcript)