1. The Scarborough Hospital Interdisciplinary Medication Reconciliation Angie Ganter: Patient Care Coordinator, Emergency Dept. Teresa Reardon, Nurse Educator, Emergency Dept. Dr. Maria Valois, MD, Medical Director, Pharmacy Grace Wong, Outpatient Pharmacist Gina Leung, Inpatient Pharmacist

2. The Scarborough Hospital Two sites: General Campus and Birchmount Campus –360-bed Acute Care/Community Hospital (General) –210-bed Acute Care/Community Hospital (Birchmount) Approximately 95 000 ED visits yearly between both sites –11 000 of these pts are admitted to the hospital annually Large geriatric community Regional dialysis site (General) Regional Mental Health site (Birchmount) Services 21 LTC homes between both sites Multicultural, Multilingual

3. Tools for Medication Reconciliation Meditech Magic System Paper base BPMH Computer generated transfer forms, discharge prescriptions and patient home medication schedule Planning to implement Iatric for discharge

4. Objectives Interdisciplinary medication reconciliation –Perspectives from nursing, physician, pharmacist Medication reconciliation from inpatient to outpatient and back again Key lessons learned Strategies for sustainability

5. Medication Reconciliation in the Emergency Department Since implementing Medication Reconciliation in Dec 2007 we have overcome many obstacles As of March 2009 we have performed audits in the ED to track our progress as we overcome these obstacles There has been improvement at times, but there have also been unforeseen circumstances that have hindered our improvement (refer to graph for audits in March/April/May)

6. Medication History Completed by RN’s in the Emergency Department

7. Medication Reconciliation in the Emergency Department CHALLENGES: Buy-in and compliance from ED staff (nurses and MDs) *Buy-in and compliance from specialists* Patient related issues: language, culture, cognitive impairment, lack of awareness of present meds, adverse events related to medications Staff resources and workload Perception of medication reconciliation process Change of practice Change of attitude

8. Medication Reconciliation in the Emergency Department FACILITATORS College of Nurses (CNO) Standards of Practice Registered Nurses Association of Ontario (RNAO) Ministry of Health and Long Term Care (MoHLTC) The Scarborough Hospital (TSH) Pharmacy Department ED staff ED Leadership Team Patients, Caregivers

9. Medication Reconciliation in the Emergency Department GOALS OF MED REC IN THE ED SHORT-TERM GOALS : ↓ number of medication errors, ↓ number of omitted medications, ↑ patient knowledge and patient satisfaction INTERMEDIATE GOALS: ↓ number of medication-related errors, ↑community awareness of medication reconciliation process, ↑ resource efficiency LONG-TERM GOALS: ↓ number/severity of adverse events (AE) from medication-related errors

10. Medication Reconciliation in the Emergency Department HOW WE GOT TO WHERE WE ARE: Education re. Safer Health Care Now! Education re. Accreditation ROP (Required Organizational Practice) Daily morning huddles Poster presentations/signage throughout the ED, pamphlets in waiting room Feedback from Pharmacy shared with staff Awareness of monthly medication reconciliation audits Dissemination of monthly medication reconciliation audit results with the ED staff

11. Medication Reconciliation in the Emergency Department MOVING FORWARD: Continue monthly medication reconciliation audits Continue providing feedback to ED staff Continue with education of all stakeholders Continue to engage pts and families with process Improve compliance

12. Physician Perspective: Introduction Med Reconciliation: fad  ROP Adverse drug reactions / polypharmacy: Vulnerable populations at risk: elderly pediatrics immunocompromised pregnant & lactating mothers Patients with chronic disease on multiple medications

13. Medication Reconciliation Challenges Difficulty for implementation due to –Ownership –Coverage –Bed Alerts (Extended patient stay in emerg) Admission History and Reconciliation: –Access to information in off hours –Off hours interdisciplinary collaboration

14. Admission Form

15. Transfer Form

16. Successes Proper space allocations on all forms for changes in med regimen continuity of careAllows quick & efficient comparisons with previous admissions : continuity of care Prescription format allows faxing to community pharmacy at the time of discharge

17. Challenges Timelines: get the job done within 24 hrs –Special considerations for insulin, systemic steroids, PD medications, Antibiotics, etc Format not practical for tapering regimens Format does not allow electronic editing by prescriber When pharmacists become the fallback to complete medication history – not good use of pharmacist skills  ownership

18. Conclusions Good MedRec program 1.Costs $$$, but also saves $$$ (decrease rate of re-admissions, decrease length of stay) 2.Improves communication with community health care professional (family MD, pharmacist) 3.Efficient regional programs need harmonization among different hospitals; ideally this would include medication prescription forms

19. Medication Reconciliation in the Complex Outpatient Patient: Outline MedsCheck® program in Ontario Process of MedsCheck/med reconciliation Clinical Importance Benefits and Challenges

20. MedsCheck® Program in Ontario Unique program paid for by the Ministry of Health in Ontario Eligibility: Any Ontarian taking more than 3 prescription medications Initial medication history reimbursement is $50 per patient. Subsequent consultations within a 12 month interval - $25. No compensation for non Ontarians and refugee claimants. For more information, see www.MedsCheck.ca

21. Population Studied – Outpatient Dialysis Corporate Drive Yee Hong Centre 20 Patients 120 Patients

22. Patient Profile Receive dialysis on an outpatient basis 3x/week. Average age: 61.8 Average number of medications: 13.2

24. More on the Patients with Chronic Conditions… Taking many medications Have multiple co-morbidities Under the care of multiple Doctors May have many changes to medications due to nature of disease.

25. Process Identify potential DRPs through a profile review Education of patients to ensure proper utilization of medications. Reinforcement of compliance and awareness. Clarification and respond to patient questions and concerns Check lab results

26. Goals and Process Reconciliation of medication records. Communication with attending physician regarding needs for adjustment or clarification of therapy

28. Next Steps Prepare and provide the patient with their Personal Medication Record. Bring attention to the inpatient Pharmacist for ongoing issues that require follow-up

30. Clinical Importance

31. Types of Discrepancies Found

32. Number of Discrepancies Found:

33. Significant Interventions Clarification of drug therapy and dosages Request physician to reassess drug dose after identification of abnormal lab results.

34. Benefits and Challenges

35. Benefits Improve patient compliance. Improve patient safety. Improve patient understanding of medications. Decrease Med Chart discrepancies, resulting in reduced adverse events.

36. Challenges for Community Pharmacists Time consuming due to many medication changes for this patient population. The usual MedsCheck® program is self-funding for most patient populations, however only 60 % of the Pharmacist salary is compensated by this program due to the complexity of the outpatient dialysis patient group.

37. Challenges Cont’d Most retail pharmacies do not have the resources to access the patient’s lab results and med charts, unlike the Scarborough Grace Drugstore, which is affiliated with the hospital. Accessibility to another health care professional for consultation is limited. Not all community pharmacists feel comfortable in taking on this expanded role for this complex patient group. More than 90% of this patient group has never had a MedsCheck® done by their community pharmacists.

38. Conclusion This patient population group benefits a great deal from this program. Medication Reconciliation is achieved with the coordination of Physicians and Nurses. More resources are required for successful implementation of this expanded program.

40. Where are we at now?

44. Keys to Success …. Pharmacist Clerk Pharmacist MD Nursing

45. Keys to Success Increase awareness, give ownership and accountability by having each nursing unit conduct their own audit on medication reconciliation on admission and discharge Accreditation ROP Since then results improved from ~10% to 50% on admission

46. Keys to Success … Meeting with each team ….. Cardiology physician support grouping of cardiac meds on discharge form Mental Health bringing awareness physician buy in ICU physician support on transfer form awareness of medication history form

47. Challenges Quality of medication history Pharmacist vs. interdisciplinary approach Need to photocopy forms until equipment updated Surgery……. Pharmacist focus on patients with changes to their medications during their hospital stay Calling consulting physician for related Rx Counseling patient from gathered information Physician buy-in, compliance at post-op and discharge

49. Contact Information Patricia Macgregor pmacgregor@tsh.to Angie Ganteraganter@tsh.to Teresa Reardontreardon@tsh.to Grace Wonggrawong@tsh.to Dr. Maria Valoismvalois@tsh.to Gina Leunggleung@tsh.to