1. Pharmacist Directed Medication ReconciliationPlus in a LTC Facility Don H. Kuntz BSP Medication Reconciliation Project Manager, QI Unit Regina, Saskatchewan

2. Wascana Rehabilitation Centre • 50 Rehab • 250 LTC beds • veterans (66 beds) • restricted admits • specialized, high level care • advanced neuro • ventilator unit • peds to very elderly

3. Wascana Rehabilitation Centre • Seven attending family physicians • daily visits • 24hr on call • All therapies (PT, OT, Exercise, Rec, Music) • Lab & x-ray (Monday to Friday – days) • Pharmacy on site (hospital pharmacists & techs) • Team environment • Admission & annual patient conferences, physician attendance mandatory • Quarterly medication reviews

4. Med Rec Project “Medication Reconciliation on Admission to Long Term Care at Wascana Rehabilitation Centre” • HQC Innovation Fund Initiative 2004-5 • Commenced prior to Safer Healthcare NOW! Getting Started Kit

5. Project Overview • Impetus: 1997 RQHR CCHSA report suggested WRC residents on higher than average number of medications than benchmark institutions • Inherit & maintain is not reconciliation • Medication reconciliation • Appropriate & consciously continued, discontinued or modified

6. Primary Aim • Ensure WRC LTC pts receive only those medications deemed appropriate & necessary to reduce medication use, adverse events, drug interactions & drug misadventure • Develop a standardized method to reconcile prescribed medications • Develop process to optimize pharmacotherapy through improved documentation early on in the admission process

7. Observation • For LTC patients, information transfer is inconsistent, not standardized and in many admissions is sorely lacking • acute care > active rehab > LTC > PCH > Community (home)

8. PDSAs • Developed a LTC monitoring form for pharmacists • Standardized data collection & synthesis • Identified medication information sources at time of admission • Variation and reliability was dependent on where the patient was admitted from • Community (home, PCH) • LTC facility transfer • Acute care • Active rehabilitation unit

10. PDSAs • Developed a medication reconciliation form • Tested process & forms • 10 pt retrospective audit • 20 pt consecutive admissions audit • Developed tool to relay information in a systematic & standardized method into patient chart • Chart form development – not an order form • Acceptance from physicians & nursing • Forms committee & Health records approval

11. Medication Reconciliation Table

12. PDSAs • RQHR policy changed to allow complete acute care chart to remain at WRC for up to 7 days (previous 48hrs) • Revised pre-printed admission orders to include pharmacist consult for medication reconciliation, allergy verification & vaccination history

13. PDSAs • On request, HR provides the “WRC Package” to the pharmacist which includes two years of information (faxed or mailed): • Discharge summaries • Consults • Progress notes • Diagnostics (except lab which is on-line) • OR reports • Physician orders

14. PDSAs - • Developed standardized information for pharmacists to provide therapeutic goals for medications by disease state and drugs • Evidence based information, referenced • Guidelines (e.g. HTN, DM, Lipids, Stroke) • Indications, therapeutic targets, treatment options & monitoring

15. Therapeutic goals - sample Atrial Fibrillation (persistent & paroxysmal) Drugs for the Heart 6th ed; Chest; Therapeutic Choices 4th ed • Goal: stroke prevention • Warfarin – target INR 2.5; range 2-3 • ASA 325mg daily (for pts <65yo and no other risk factors) • Clopidogrel 75mg daily (ASA intolerance/allergy) • Rate Control (Beta-blockers, digoxin, verapamil, diltiazem) • Goals: - control heart rate (between 60-100 beats\min at rest; average 80 beats\min) • - control symptoms • Rhythm Control (sotalol, amiodarone, propafenone, etc) • Goal: restoration and maintenance of sinus rhythm

16. PDSAs • Satisfaction survey • Sent to physicians, nurses, pharmacists and nursing unit managers • High level of satisfaction 4.5/5 (25 respondents • Most difficult sell physician “Nice addition to the admission process” • Patients and families very satisfied (source patient team members)

17. Pharmacist Driven Med Rec Process • Admission generates pharmacist consult • Patient and/or family interview • Electronic Provincial Drug Plan data base information is reviewed • Info obtained & thoroughly reviewed • able to reconcile >95% of original home meds • Med rec info & therapeutic plan with recommendations placed on chart • Physician review and medication orders are written on standard RQHR order forms • Pertinent patient information placed on chart under history section

18. LTC vs Acute Care • Considerable differences in process • 2/3 of admissions to WRC generated through acute care stay, many of those are lengthy • Considerable changes to home meds during acute care stay (acute care med rec in spread stages) • Note: electronic provincial med rec form not trialed as this came into play in 2007

19. Outcomes • To date > 250 admissions completed • Physician acceptance – 100% • Recommendation acceptance > 90% • Many patients have fewer medications, some on more • lack of, or expiry of indication (e.g. DVT prophylaxis; symptom relief) • therapeutic duplications & double/triple plays

20. Med Rec Spread – Acute Care Sharing Experiences & Lessons Learned

21. RQHR Acute Care Facilities • Community Hospital • 210 beds • Eye centre • Cancer services • Ambulatory care • Palliative care Pasqua Hospital l

22. RQHR Acute Care Facilities • Major referral centre for southern Sask • 380 beds • Trauma, ICU, cardiosciences, neurosciences, neonatal, mental health, burn unit Regina General Hospital l

23. Med Rec History - RQHR • Provincial auto-populated form utilized for admissions • Pilot – family medicine Jun 07 – Jul 08 • 100% nurse utilization/bpmh creation • 5 months • 90% physician uptake • 8 months • Discrepancies being resolved

24. Team McMed – 4A Pasqua Hospital

27. The Process • Preadmission Medication List/Physician Order Form is printed from PIP program on admission (Regina - SWADD, rural - RNs) • Bedside nurse utilizes form when interviewing patient and creates the BPMH • Physician utilizes form and orders medications to continue, stop or change based on patient’s acute care status & documents rationale for changes and discontinuations

28. It is a fact…. • The patient interview is crucial to obtain the BPMH • 25-40% of PIP meds no longer taken by pt

29. Benefits of Med Rec • Patient safety enhanced • eliminates transcription errors • corrects/ prevents discrepancies • clearly identifies home meds including Rx, OTCs and herbals • Patient medication interview time reduced by 50% • Data base for home medications on chart • Physician medication ordering time reduced • Orders clearly legible (reduced calls for clarification) • Eliminate duplication of work (multiple lists)

30. Spread – communication & education Nursing managers & educators education days (29 x 1 hr presentations) = 800 + unit meetings Physicians one on one section & department meetings; clinical rds Direct mailing to 500 physicians cover letter one page role/instruction sheet sample completed med rec form Pharmacists – site staff meetings & e-mail updates

31. Spread – communication & education Board presentation SMT & ED Council Local cable television “Alive & Well” Newsletters Med rec E-Link (regional newsletter) The Physician DrugLine (pharmacy newsletter) RQHR Annual Report (community mailing) Posters Committees, Units & task forces pt safety task force; homecare nurses, client reps

32. Spread – acute care units • Two acute care facilities Regina General and Pasqua Hospitals • 27 nursing units • 2 ERs • 2 PACs • Go live date – September 2, 2008 • SWADD printing med rec form for all admissions • Rural hospitals (7) • 4/7 visits & training completed • 1 facility – 100% compliance • 16 beds; 4 physicians • Have spread to ER & clinic visits on their own

33. Measurement • First 4 weeks of audits (130 pts/wk) done by QI team • Ownership of process unit responsibility • Audit person identified for each unit • nurse, educator, manager, unit secretary • 5 pts/wk • Excel workbook • E-mail reporting to QI unit weekly

34. Reporting structure • QI collates information and reports to: • Each nursing unit manager • Executive Directors • Health Services VPs • Senior Management Team

35. Board: PSSC SMT: pt safety score card - % discrepancies resolved by site/service HS VP Sponsor – monthly report; % med discrepancies resolved by portfolio site/service HS VP – monthly report; % med discrepancies resolved by portfolio site/service Medical Dept Head Council: monthly report; % discrepancies resolved by acute care unit EDs: – monthly report; % med discrepancies resolved (by unit/site within portfolio CQI teams Unit/site managers Weekly date & progress info from key unit contact QI unit weekly date from unit key contact: generates monthly reports • Unit/Site Key Collaborative Contact: • Working with QI consultant: • in-service & mentor colleagues, champion process • mentor physicians • audit 5 patients/week

36. Accountability • Initiative is not owned by any one dept • Shared responsibility and accountability • patients, nursing, physicians, pharmacists, QI unit • Such a small piece • Such a simple thing

37. Spread barriers • ER • Lack of effective broad based communications • Physician acceptance • Incomplete bpmh/form completion • Unit culture variability • too busy, acuity is high, turn over is high

38. Lessons learned • Communicate immediately & frequently • Especially with physicians • Utilize dept/section secretaries to get on physician meeting agendas • Identify champions early • Physicians • Nursing units • Pharmacists • Nurse educators

39. Lessons learned • Use patient stories as often as possible • Barrier physicians – use stories of their own pts • Frequent nursing unit & site visits • Ongoing mentoring • Q & A • Visibility • Engage the doubters • Focus on regional/national patient safety initiative

40. National initiative needs… • Physician awareness • CMA & others • Process to be recognized • Core curriculum introduction • medicine, nursing, pharmacy • Branding • Logo • Discrepancies is still new terminology

41. Logo concept Patient Safety Physicians Nurses Medication Reconciliation Patients Pharmacists

42. Logo concept R M E D C