Assessing and improving medication reconciliation in adult cystic fibrosis care Daniel Cortes, RPh BScPhmAdult 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.caFigure 1: Inpatient Respirology Med Rec compliance, St. Michaels

Inpatient respirology (6B) Med Rec - ~21% compliance Any and all CF team members communicate medication discrepancies to MDs directly (urgent) and/or during 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

!Medication Reconcil iation (Med Rec) is a formal, 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 IDENTIFICATIONLocally 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 discrepanciesRetrospective 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

discrepanciesFigure 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