Presentation on theme: "Dr Treasure McGuire 19 November 2014 Medication reconciliation: Public vs. Private - is there are difference?"— Presentation transcript:
Dr Treasure McGuire 19 November 2014 Medication reconciliation: Public vs. Private - is there are difference?
You 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 2 nd 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. 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 morning Pharmacist conducted BPMH (within 24h) –Used > one source of Med Hx information Community pharmacy & patient’s psychiatrist Outcome 20x overdose (40x overdose prescribed)! Clinically – dizzy, drowsy, unsteady on feet Required 2 nights in hospital Dexamphetamine 10mg tdsCorrect (but may have contributed to tachycardia) Nortriptyline 100mg nocte NOT 80mgUnintentional 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 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 process & impact of implementing the Med Rec SOP Measure DefinitionTarget MR1Percent of Patients with Medications Reconciled within 24 hours of the decision to admit the patient 100% MR2Mean Number of Outstanding Undocumented Intentional Medication Discrepancies per Patient 0 -1 MR3Mean Number of Outstanding Unintentional Medication Discrepancies per Patient ≤ 0.3 MR4Percent of Patients with at Least One Outstanding Unintentional Discrepancy <40% MR0Mean 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 Sites Mater Health Services South 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 Rec – Public vs Private MR 0,1,2,3,4 Patient cohort HP conducting Med Rec Medical model Pharmacy model
1. 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 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 1 st 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 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 model Private 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 model PharmacyMater PublicMater PrivateAlternate Private model ServiceClinical service, with pharmacist in ward 85% of day* Supply on script or chart LocationOn site, dispensing from ward Remote Pharmacist to bed ratio SHPA guidelines based Script volume based PBSInpatient LAM Formulary Discharge only 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. MaterMHS “Public”MHS PrivateAlternate 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 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
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 tasks
So how did Mater perform on Medication Reconciliation during 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 patient identified 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 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 w rt: –CAMs –PRN unrelated to episode of care Sedatives Eye drops (non Rx) Topicals e.g. Creams If unrelated to episode of care
Conclusion Mater 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