In 2013, this quality improvement project was started for the Quality Improvement Fellowship, Faculty of Medicine, University of Toronto. It assesses the medication reconciliation process for inpatients in a large adult cystic fibrosis centre and looks to improve this process.
In 2013, this quality improvement project was started for the Quality Improvement Fellowship, Faculty of Medicine, University of Toronto. It assesses the medication reconciliation process for inpatients in a large adult cystic fibrosis centre and looks to improve this process.
In 2013, this quality improvement project was started for the Quality Improvement Fellowship, Faculty of Medicine, University of Toronto. It assesses the medication reconciliation process for inpatients in a large adult cystic fibrosis centre and looks to improve this process.
Assessing and improving medication reconciliation in adult cystic fibrosis care
Daniel Cortes, RPh BScPhm
Adult Cystic Fibrosis Program, Division of Respirology and the Pharmacy Department, St. Michaels Hospital INTRODUCTION "At St. Michaels Hospital, obtaining a paper-based BPMH is a responsibility shared amongst doctors (MDs), nurse practitioners (NPs), nurses (RNs), and pharmacists (RPhs) and is to be initiated by the clinician who is first point of contact "Reconciliation is done by the MD or RPh "Med Rec compliance is measured by the completion of a BPMH that is documented on a Pre-admission (Home) Medication List and Reconciliation Form (PMLRF) CURRENT STATE Figure 2: CF Med Rec Process Map AIM STATEMENT CHANGE CONCEPT Figure 5: RPh-provided Inpatient CF Med Rec Sustainability score Inpatient CF Med Rec Pilot (March 8 - April 5) PMLRF completed (out of 24 patients) % Med Rec Avg. # medication discrepancies / patient 24 100 3.33 (0-14) LESSONS LEARNED NEXT STEPS Contact Information "Share ongoing progress with CF team at already established monthly CF-Quality Improvement meetings "Monitor sustainability periodically and explore new change concepts to address low scoring sustainability dimensions "Spread initiative to all inpatient respirology patients "Continue prioritizing RPh administrative, operational, and clinical duties and explore pharmacy student integration "Document medication discrepancies and clinical significance electronically (Siemens Pharmacy database) to enable ongoing outcome measurement "Promote Med Rec as a component of medication therapy management (MTM) Daniel Cortes E-mail: cortesd@smh.ca Figure 1: Inpatient Respirology Med Rec compliance, St. Michaels "Inpatient respirology (6B) Med Rec - ~21% compliance "Any and all CF team members communicate medication di screpanci es to MDs di rectl y (urgent) and/or duri ng interprofessional Kardex rounds (non-urgent) References Acknowledgements Accreditation Canada, the Canadian Institute for Health Information, the Canadian Safety Institute, and the Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation in Canada: Raising the Bar - Progress to date and the course ahead. Ottawa, ON: Accrediation Canada. Sawicki GS, Tiddens H. Managing treatment complexity in cystic fibrosis: challenges and opportunities. Pediatric Pulmonology 2012 June; 47(6): 523-33. Special thanks to Sabrina Chan, Charmaine Mothersill, Joyce Fenuta, and Janice Wells for their guidance and assistance in this project. Thank you to the St. Michaels Hospital Foundation and their support through the Quality Innovation Fund. BACKGROUND "To achieve >60% Med Rec for hospitalized CF patients between March 8th to April 5th, 2013
"Medi cati on Reconci l i ati on (Med Rec) i s a f ormal , interprofessional process requiring a systematic, comprehensive review of a patients medications to ensure accurate and comprehensive information is provided across transitions in care "The process begins with a Best Possible Medication History (BPMH) obtained by a systematic process, reviewing at least two sources of information (i.e., patient and community pharmacy) "Unintentional medication discrepancies / errors during transitions in care are common and have the potential to cause harm "Adult cystic fibrosis (CF) care can involve high treatment burden, complex medication regimens, and frequent transitions between ambulatory and hospital care "Medication reconciliation in adult CF care is challenging "Ambulatory and inpatient CF Med Rec with 100% compliance "CF Med Rec is a standardized process minimizing medication discrepancies "Med Rec process integrated with identification and documentation of medication discrepancies PROBLEM & BARRIER IDENTIFICATION "Locally developed quality improvement approach can lead to Med Rec adherence "Bundling medication discrepancy documentation and Med Rec provides immediate feedback regarding clinical importance "Literature search, observations, patient/clinician feedback identified: Numerous CF medications, time-consuming medication histories It is unknown if admission medication discrepancies occur in the adult CF population and if they are clinically significant CF ambulatory Med Rec process uses a paper form intended for the CF clinic and the Toronto CF Database, and is not integrated into an the current inpatient Med Rec process Other CF team members play a role (i.e., dietitian, respiratory therapist, physiotherapy, etc.) Quality of BPMH / Med Rec more important than compliance
"Process mapping: February 2013 Ambulatory CF Med Rec process provides list for the admitting MD to reconcile, assuming no changes since last clinic visit PMLRF not routinely completed by MD or RPh due to transcription redundancy RN, RPh and other team members have an existing process to relay medication discrepancies to the MD "CF RPh will be responsible for inpatient CF Med Rec process "Standardized CF Med Rec process: PMLRF initiated ideally within 48 hours of admission, but must be completed before hospital discharge accept input from all CF team members utilize at least 3 sources of BPMH information: ambulatory medication list, previous hospital admission, eHealth drug profile viewer, patient, community pharmacy, etc. identify and calculate number of medication discrepancies notify MD of medication discrepancies or refer MD to PMLRF TESTING CHANGE & PRELIMINARY RESULTS "Implementation: March 8th to April 5th, 2013 26 CF admissions (24 to 6Bond, excluding 2 to MSICU) 4/24 (16.7%) PMLRF initiated by MD, 20/24 (83.3%) by RPh 3/24 (12.5%) pts with no medication discrepancies "Retrospective chart review: January 2012-2013 20 randomly-selected CF admissions to 6Bond 4/20 (20%) PMLRF completed 1/4 (25%) MD-initiated PMLRF; 3/4 (75%) RPh-initiated
"Ambulatory CF Med Rec quality review: March 4-28, 2013 20 randomly-selected CF patients Medication list documented by clinic RN - 100% compliance Med Rec performed by RPh - 100% compliance 19/20 (95%) patients - RPh-identified medication discrepancies Figure 4: Inpatient CF Med Rec adherence and quality (March 8 - April 5) IDEAL STATE Process Measure Outcome Measure % Med Rec = # of completed PMLRF / # of CF admissions # of medication discrepancies Figure 3: Process and Outcome Measures