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Transcript of Better Medication History Taking: The Way to Improve Medication Reconciliation Ed Tessier, Pharm.D.,...
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Better Medication History Taking: The Way to Improve Medication Reconciliation
Ed Tessier, Pharm.D., M.P.H., B.C.P.S.1, 2
Elizabeth A. Henneman, Ph.D., R.N.2, 3
Mark Heelon, Pharm.D.3
Karen Plotkin, Ph.D., R.N.2, 3
Brian Nathanson, Ph.D.4
Supported by a grant from the American Society of Health-System Pharmacists Foundation
1 Baystate Franklin Medical Center, Greenfield, MA2 University of Massachusetts Amherst School of Nursing
3 Baystate Medical Center, Springfield, MA4 OptiStatim, LLC, Longmeadow, MA
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Learning Objectives• Discuss the effect of a collaborative nurse-pharmacist intervention on obtaining accurate
medication and allergy histories.
• Identify drug categories frequently missed when obtaining a medication history.
• Identify factors which can improve the effectiveness of medication history taking by nurses.
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Outline• The Problem
– Medication History Taking Inadequate.
• What We Did
– Developed tool for nurses to improve medication history taking.
– Trialed tool in controlled environment.
– Trialed tool in clinical setting.
• What We Learned
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Medication Reconciliation – The Lived Experience
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Medication Reconciliation
process is highly
dependent on obtaining an
accurate medication
history
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Adapted from: Tam VC. Knowles SR. Cornish PL. Fine N. Marchesano R. Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Canadian Medical Association Journal. 173(5):510-5, 2005 Aug 30.
Extent of Inaccurate Medication Histories
Systematic Review of 22 Studies involving 3375 Patients% of Patients with One or More Errors in Medication History
0102030405060708090
100
> 1 error Rx > 1 error all Meds
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Our Charge
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Primary Study Objective
Evaluate the effectiveness of a collaborative nurse-pharmacist
intervention in decreasing medication errors in both
academic and acute care settings.
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Study Sites
• University of Massachusetts Amherst School of Nursing– Undergraduate and Graduate Programs
• Baystate Medical Center, Springfield MA– 653-bed academic teaching
hospital
• Baystate Franklin Medical Center, Greenfield MA– 93-bed acute care community
hospital.
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Nurse-Pharmacist Intervention Requirements
• Nurse Friendly
• Ability to Integrate into Nursing
Practice
• Resource Neutral
• Transferable Across Settings
• Ability to Integrate in Nursing
Education
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What We Did
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Tool Developme
nt• Peer
Reviewed by
Nurses and
Pharmacists
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Medication History Taking Template Version 3.0
1. GET THE BASICS: • Demographics - First/last name, date of birth • Allergies – Drugs/foods; nature of reaction• Diagnoses - Reason for admit/visit; other diagnoses • Prescribers – Primary and Specialists
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2. BUILD THE LISTDo you have your meds/list of meds
with you?
2A. LIST REVIEW• Last updated?• What other medications do you take?
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2B. SYSTEM REVIEW•Do you take any medicines for:
•Neuro: Seizures? Headache?•Psych: Sadness? Anxiety? Sleep?•EENT: Allergies? Your Eyes?•Pulm: Breathing? Inhalers?•CV: Your Heart? Blood Pressure?•Endo: Diabetes? Thyroid?•GI: Your Stomach? Bowels?•GU: Contraception? Your Bladder? Treatments for Erectile Dysfunction?•Skel/Musc: Your Bones? Joints?•Infection: Antibiotics?•Derm: Topicals?•Analgesics? Pain or Discomfort?
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3. WHAT’S MISSING?• Antibiotics: treatments for HIV, TB? Other infections?
• Cardiac Drugs: antidysrhythmics, antihypertensives, cholesterol lowering?
• Clots: anything to prevent clots? warfarin(Coumadin®), enoxaparin (Lovanox®), aspirin, clopidogrel (Plavix®)?
• Corticosteroids: prednisone, hydrocortisone?
• Diabetes Drugs: insulin? oral agents?
• Electrolytes: potassium, calcium supplements
• Immunosuppressant Drugs: to prevent organ rejection or treat MS, arthritis, psoriasis, Crohn’s?
• Less Than Daily: drugs given irregularly (patches, injections at MD office)?
• MAOI’s: monoamine oxidase inhibitors? (Nardil®, Parnate®, linezolid - Zyvox®)
• Natural: herbal/vitamins, over the counter?
• Opioids: morphine (MS Contin®), methadone, fentanyl
(Duragesic®), oxycodone (Percocet®, Oxycontin®)? • Recreational Drugs: any “street drugs”, use drugs recreationally, smoking, alcohol?
• Seizures: drugs to prevent seizures
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4. PROBE FOR MORE
•For medications/conditions with
incomplete information consider one or
more of the following:
• Who ordered the medication?
• What dose?
• When did you last take it?
• Where do you get your medications?
• Why do you take it?
• Tell me about missed doses in the past
week.
• What problems do you have with your
medications?
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5. FINAL CHECK
Is there anything else you would like
to tell me about your medications
that I have not asked?
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6. ADDRESS ASAP:•Allergy Conflicts•Antibiotics: HIV, TB, other•Anticoagulants: heparins, warfarin•Anticonvulsants: phenytoin, carbamazepine
•Antidiabetics: insulin, oral agents•Antidysrhythmics: amiodarone, procainamide
•Corticosteroids: prednisone, dexamethasone
•Duplicate Medications:• orders for lisinopril and enalapril• total acetaminophen dose/24hrs not over 4000mg
•Immunosuppressant/Transplant Drugs:• cyclosporin, mycophenalate
•MAOI’s: Nardil®, Parnate®, Zyvox® •Opioids: morphine, methadone, street drugs
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Trial in Controlled Environme
nt• 16 RN students
• 4 trained actors/
faculty played
scripted standardized
roles as mock
patients each with
medication list
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Trial in Controlled Environment16 Senior RN Students
Informed ConsentINTERVENTION
7 StudentsCONTROL
9 Students Randomization
Training+Tool
Med HistoryWith Mock
Patient
AssessmentOf AccuracyTraining+Tool
Med HistoryWith Mock
Patient
AssessmentOf Accuracy
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Results of Trial in Controlled Environment
% of Medications Accurately Identified
73%
89%
67%73% 74%
100%
81%
95%
73%
87%
Case 1 Case 2 Case 3 Case 4 Overall
Control Tool
* p < 0.01 using a two sample t-test for proportions
*
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Trial in Clinical Setting
• The tool and educational plan implemented on 4 nursing units:– 2 at a community hospital– 2 at a large tertiary care
center • Education:
– Unit poster campaign– One on one sessions with nurses– Nurse “Kit”:
•Laminated Tool with Top 100 drugs Brand/Generic on back.
•Slides/Handouts
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Outcome # 1: Medication Events METHODS
• Review of all spontaneously reported medication events on each unit for:
• Initial review by clinical pharmacist, secondary independent review by clinical nurse and by second clinical pharmacist.– Subset 1: All events.– Subset 2: All events related to med history taking.– Subset 3: All allergy events related to med history
taking.
Pre-Intervention3 Month Period
Intervention1 Month Period
Post-Intervention3 Month Period
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Outcome # 1: Spontaneously Reported
Medication Events
Rates All Spontaneously Reported Medication Events:
• Community Hospital – Lower POST over PRE: p = 0.181
• Large Teaching Hospital – Similar POST over PRE: p = 0.826
Rates Events Related to Med History Taking:
• Community Hospital - Lower POST over PRE: p = 0.204
• Large Teaching Hospital - Similar POST over PRE: p = 1.00
Rates Events Involving Allergies and Med Histories:
• Community Hospital - PRE vs. POST: no documented events
• Large Teaching Hospital - PRE vs. POST: no documented events
All tests were either Chi Square or Fisher's Exact (Fisher's Exact were used when a count was < 3)
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Outcome # 2: Medication Discrepancies
PATIENT SELECTION
Pre-Intervention15 Days
Immediately PriorIntervention
Intervention1 Month Period
Post-Intervention
15 Days Immediately
PostIntervention
50 Consecutive Admissions
Randomized to 25 to ensure a greater variety of caregivers
50 Consecutive Admissions
For Each of the Four Intervention Units:
Randomized to 25 to ensure a greater variety of caregivers
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Outcome # 2: Medication DiscrepanciesAlignment of Medication Orders at 3
Points of the Electronic Medical Record
ElectronicHistory
AndPhysical
ComputerizedMedication OrdersDuring Admission
ElectronicDischargeSummary
ElementsCollected:
• Medications• Allergies• Date/Time• Clinical Status• MD
• Medications• Allergies• Date/Time
• Medications• Allergies• Date/Time• Clinical Status
Other Elements Collected: • Demographics• Site of Patient Prior to Admission
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Categorization of Discrepancies
MINOR DELAY (BEYOND 48HRS)
Time between admission and POE or first dose exceeded 48 hours – likely benign implications (e.g. multivitamin delay )
IMPORTANT DELAY
(BEYOND 48 HRS)
Time between admission and POE or first dose exceeded 48 hours – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid delay)
MINOR OMIT FOR HOSP. STAY
Drug omitted during hospitalization – likely benign implications (e.g. multivitamin omit)
IMPORTANT OMIT FOR HOSPITAL
STAY
Drug omitted during hospitalization – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid omit)
MINOR OMIT IN DISCH. SUMMARY
Drug omitted in discharge summary – likely benign implications (e.g. multivitamin omit)
IMPORTANT OMIT IN DISCHARGE
SUMMARY
Drug omitted in discharge summary – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid omit)
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Outcome # 2: Medication Discrepancies
IMPLEMENTATION
ElectronicHistory
AndPhysical
ComputerizedMedication OrdersDuring Admission
ElectronicDischargeSummary
For Small Community Hospital: • All Data Elements Available Electronically
ElectronicHistory
AndPhysical
ComputerizedMedication OrdersDuring Admission
ElectronicDischargeSummary
For Large Academic Teaching Hospital: • H&P Not Available Electronically
.
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Outcome # 2: Medication Discrepancies
RESULTS - Community Hospital Demographics of Pre vs. Post Intervention Similar
Gender did not differ:
• PRE Female = 46.2%
• POST Female = 53.9%
• P-value = 0.423Provider PRE POSTHospitalist 35 (71.4%) 33 (66.0%)General Medical (Non- Hospitalist) 8 (16.3%) 8 (16.0%)
Surgeon 5 (10.2%) 9 (18.0%)Obstetric 1 (2.0%) 0 (0%)
Age did not differ:• PRE: Mean(SD) = 68.1
(18.9)
• POST: Mean(SD) = 69.3 (18.4)
• P-value = 0.756Providers did not differ:
Fisher’s Exact P-value = 0.623, 1 missing value in the Pre-Intervention group
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Outcome # 2: Medication Discrepancies
RESULTS - Community Hospital Prior Location did
not differ
statistically
• Observation:
– Trend toward
more complex
patients in PRE vs
POST?
Fisher’s Exact: P-value =
0.083
Location
PRE POST
Home37 (74%)
45 (90%)
Nursing Home
9 (18%) 4 (8%)
Group Home
1 (2%) 0 (0%)
Hospital
2 (4%) 0 (0%)
Rest Home
0 (0%) 1 (1%)
Other 1 (2%) 0 (0%)
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0
5
10
15
20
25
Pre Total # of Drugs per H & P Post Total # of Drugs per H&P
Pre Total # of Drugs in CIS Post Total # of Drugs in CIS
Pre Total per Discharge Summary Post Total Per Discharge Summary
Similar but Statistically Smaller Post Intervention (p<0.05)
Outcome # 2: Number of Drugs/Patient
RESULTS – Community Hospital
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Outcome # 2: Rates of Discrepancies per Patient
PRE Mean (SD)
[No Discrepancies]
POSTMean (SD)
[No Discrepancies]
P-value
MINOR DELAY (BEYOND 48HRS)
0.14 (0.5) [45/50]
0.14 (0.64) [47/50]
0.461
IMPORTANT DELAY (BEYOND 48 HRS)
0.22 (0.62)[43/50]
0.20 (0.57)[43/50]
1.000
MINOR OMIT FOR HOSP. STAY
1.10 (1.25)[20/50]
0.60 (1.25)[35/50]
0.003
IMPORTANT OMIT FOR HOSPITAL STAY
0.63 (1.24)[33/49]
0.58 (1.36)[38/50]
0.339
MINOR OMIT IN DISCH. SUMMARY
0.28 (0.83)[42/50]
0.06 (0.24)[47/50]
0.110
IMPORTANT OMIT IN DISCHARGE SUMMARY
0.43 (0.71)[33/49]
0.18 (0.44)[42/50]
0.053
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What the Intervention Did NOT Affect:
• Length of Stay:
• Allergy Discrepancies:
Variable PRE POST P-value
LOS (Days) 4.20 (5.09)
4.02 (2.86)
0.826
Variable PRE POST P-value
Allergy Discrepancy Rate
0.14 (0.35)
0.10 (0.3)
0.541
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Top 10 Drug Discrepancies
These drugs represent 54.3% of all observed discrepancies
0 10 20 30
# of Discrepancies
CARDIOVASCULAR: DIURETICS
MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY
CARDIOVASCULAR: BETA ADRENERGIC BLOCKER
BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS
GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION
RESPIRATORY TRACT: BRONCHODILATORS
HORMONES: ANTIDIABETIC AGENTS
CNS:PSYCHOTROPICS:ANTIDEPRESSANTS
GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES
VITAMINS/MINERALS
0 10 20 30
# of Discrepancies
CARDIOVASCULAR: DIURETICS
MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY
CARDIOVASCULAR: BETA ADRENERGIC BLOCKER
BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS
GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION
RESPIRATORY TRACT: BRONCHODILATORS
HORMONES: ANTIDIABETIC AGENTS
CNS:PSYCHOTROPICS:ANTIDEPRESSANTS
GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES
VITAMINS/MINERALS
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Goal: No medication discrepancies
% Patients With NO
Discrepancies:
• PRE: 20% (10/50)
• POST: 42% (21/50)
p = 0.027
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What We Learned
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Lesson 1: Systematic Approach May Help
• Systematic approach for nurses in
conducting medication histories
associated with modest, but
measurable improvement:
– in controlled setting
– in small community hospital setting
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Lesson 2: Alignment of Goals and Responsibilities
• Success in controlled and smaller
settings may be related to:
– Motivated nurses who see medication
history taking as important part of their
job.
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Lesson 3: Continuing/Ongoing Reinforcement
• Success in controlled and smaller
settings may be related to:
– Strong and positive one-on-one
pharmacist/nurse relationships.
– Process integrated into workflow.
– Ongoing support for nurses.
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Lesson 4: Missed Drugs Include Critical Agents
• Among top drugs in discrepancies:
– Antidepressants
– Drugs for Diabetes Mellitis
– Bronchodilators
– Antiplatelets
– Bronchodilators
– GI Cytoprotectants
– Diuretics
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Lesson 5: Catching Discrepancy Early May Reduce
Risk at Discharge
• Intervention early was associated with trend
toward fewer omissions at discharge.
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Lesson 6: When in Doubt, Laminate It!
• Intrinsic “value” of tool appeared to improve when
tool was:
– Simplified
– Logical
– Visually Appealing
– Provided Useful Information
• (including the top 100 brand/generic list)
– Durable
– Integrated into Workflow
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Half of the modern drugs could well
be thrown out of the window, except
that the birds might eat them.
Dr. Martin Henry Fischer
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Now it’s your turn!
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State of Med Rec in Rural New England• What is your biggest obstacle?
• Who are the key players at your facility?– MD
– Nurse
– Pharmacist
– Pharmacy Tech
– Other
• What works? Any best practice to share?
• What doesn’t work?
• Anything else to share?