1. Safer Medicine Admissions Review Team (SMART) Carl Eagleton and Hannah O’Malley on behalf of the SMART Working Group

2. The Need… Increasing General Medicine patient volumes Volume EC arrival year

3. The Need… Increasing patient wait times in Emergency Care (EC) LOS (Hours) EC arrival year

4. The Innovation Streamline the admission process Improve patient and medication safety Meet national Medication Reconciliation (MR) targets ThedaCare’s ‘Admission Trio’ mapping the way

5. ‘MAP’ Model of Care Team-based admitting pharmacists Pharmacist at the front of the hospital Collaborative patient review with admitting doctor Medication history and reconciliation in EC Continuity of care

6. Adapting the ‘Admissions Team’ IHI Model for Improvement TRIO to PAIR = MAP model 5 week pilot study

7. Aim The SMART model (a doctor and pharmacist working together) will be applied to 90% of triage category 2-5 patients presenting to EC who are referred to GM between the hours of 8am and 10pm, Monday to Friday.

8. Objectives and Measures Safer Reduce unintended medication errors to zero Complete MR ≤ 6 hours of GM referral Faster 80% of patients referred to GM will be seen by SMART within 60 minutes of referral With 95% seen within 90 minutes Patient-focused Improve patient experience Systematic Improve Medication History documentation to 100% Reduce length of stay by 0.25 days per patient

9. Process Improvement – PDSA’s Change TestedOutcome 1 Evening shift PDSAs 1 pharmacist  2 pharmacists  3 pharmacists 2 Shared model of care – tested whether two pharmacists sharing 3 teams provides sufficient cover PDSA confirmed adequate cover using this model of care. Clinician concern regarding possible fragmented care – to monitor subspecialty cover 3 Alerting staff to unsigned medications chart Tested green cards inserted into medication charts (Fell out)  Stickers on medication chart

10. Process Improvement - Data Electronic Reports With help from statistician a daily report was developed capturing the # of patients SMARTed versus total # in target group, time to be seen, time to MR, and LOS Manual Data Collection Manual data collection is needed to record interventions and contributions by pharmacists – an electronic data collection form is being developed to streamline this process Dashboard A dashboard has been developed to track progress on measures which are updated weekly or monthly

11. SMART Collaborative Dashboard – End October 2013 1 2 3 4 5 6 1

12. Percent of patients seen increasing as SMART tests new combinations and rolls out new teams

13. Safety Data Clinical input by pharmacist occurs sooner and is proactive rather than reactive More convenient communication and collaboration allowing errors to be prevented or rectified faster 747 patients seen by SMART since August 2013 302 contributions recorded and 65 interventions Examples: “Patient had run out of epoetin injections and didn't know to continue them. Hb = 80g/L (anaemic), recommended to prescriber to restart” “HbA1c 79mmol/mol advised increase glipizide dose” “Citalopram 10mg charted but patient normally on escitalopram 10mg. Medication corrected.”

14. Key Successes Improved working relationship between pharmacists, doctors and nursing staff Rolling out eight general medical teams with the shared model of care covering 8am-10pm Significant reduction in time to MR from >2 days to <6 hours and increased # of patients receiving MR Earlier contribution by pharmacist has led to fewer medication errors Winning medication safety and innovation award and best paper award at NZHPA

15. Buy In Various stakeholders including pharmacy, nursing, medical staff and allied health union Meetings held with Key EC nursing staff and presentations at EC nursing handovers Presentations at medical RMO/SMO handovers to educate doctors about SMART Email and poster communications Weekly SMART updates at Medical Pharmacist meetings SMART themed week involving all clinical pharmacists aimed to educate, engage and identify potential issues

16. Challenges Several measures require multiple methods of data collection Quality of historical data such as number and type of interventions and contributions has not been reliable – needed to investigate more reliable ways of collecting Risk of medicines charted by pharmacist being administered before being signed Changing work hours of pharmacists – ensuring issues identified and addressed is important

17. SMART Staff Feedback

19. THE SMART PHARMACISTS