dr treasure mcguire 19 november 2014 medication reconciliation: public vs. private - is there are...
TRANSCRIPT
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