Safer Medicine Admissions Review Team (SMART)
Carl Eagleton and Hannah O’Malley
on behalf of the SMART Working Group
Volume
The Need…
Increasing General Medicine patient volumes
EC arrival year
LOS (Hours)
The Need…
Increasing patient wait times in Emergency
Care (EC)
EC arrival year
The Innovation
•
•
•
•
Streamline the admission process
Improve patient and medication safety
Meet national Medication Reconciliation (MR)
targets
ThedaCare’s ‘Admission Trio’ mapping the way
‘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
Adapting the ‘Admissions Team’
• IHI Model for Improvement
• TRIO to PAIR = MAP model
• 5 week pilot study
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.
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
Process Improvement – PDSA’s
Change Tested
Outcome
1 Evening shift PDSAs


1 pharmacist
2 pharmacists
3 pharmacists
2 Shared model of care – tested PDSA confirmed adequate cover
whether two pharmacists
sharing 3 teams provides
sufficient cover
3 Alerting staff to unsigned
medications chart
using this model of care. Clinician
concern regarding possible
fragmented care – to monitor
subspecialty cover
Tested green cards inserted into
medication charts (Fell out)
Stickers on medication chart
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
SMART Collaborative Dashboard – End October 2013
1
1
4
Percent of Patients Presenting to EC Between 8am and 10pm Mon-Fri who
were SMARTed each week
40%
General Medicine eMedication Reconciliation Forms
Completed on Admission (P Chart)
100%
90%
A dditio nal teams
ro lled o ut
35%
80%
30%
70%
25%
P harmacy staff absences
60%
20%
50%
15%
40%
30%
10%
20%
SMART starts
5%
10%
0%
2
Average time from Gen Med Referral to Gen Med Seen By for SMARTed patients
compared with historical baseline
(I chart)
3
3
13
-O
ct 1
3
11
-O
ct 1
3
09
-O
ct 1
3
07
-O
ct 1
3
05
-O
ct 1
3
-O
ct 1
03
p- 1
3
-O
ct 1
-S
e
5
4.5
4
UCL
Hours
1.4
1.2
1.0
LCL
0.8
UCL
3.5
3
2.5
2
6
Average Time from Gen Med Referral to Gen Med Seen By for SMARTed Patients
(X-bar Chart)
Jun-2014
May-2014
Apr-2014
Mar-2014
Average LOS for Inpatients who were SMARTed compared with historical averages
(I chart)
8.0
SMARTed patients only 
7.0
1.6
Feb-2014
Jan-2014
Dec-2013
Nov-2013
Oct-2013
Sep-2013
Aug-2013
LCL
Jul-2013
Jun-2014
May-2014
Apr-2014
Mar-2014
Feb-2014
Jan-2014
Dec-2013
Nov-2013
Oct-2013
Sep-2013
Jul-2013
Aug-2013
Jun-2013
May-2013
Apr-2013
Mar-2013
Aug-2012
Feb-2013
0
Jan-2013
0.5
0.0
Dec-2012
0.2
Oct-2012
1
Nov-2012
0.4
Sep-2012
1.5
Jul-2012
0.6
1.8
UCL
6.0
1.4
1.2
UCL
1
0.8
Days
5.0
Mean = 0.970 (58 mins)
4.0
LCL
3.0
0.6
LCL
0.4
2.0
0.2
1.0
Week beginning
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Nov-13
Dec-13
Oct-13
Sep-13
Jul-13
Aug-13
Jun-13
Apr-13
May-13
Mar-13
Jan-13
Feb-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
0.0
Jul-12
11/18/13
11/11/13
11/4/13
10/28/13
10/21/13
10/14/13
10/7/13
9/30/13
9/23/13
9/16/13
9/9/13
9/2/13
8/26/13
8/19/13
8/12/13
8/5/13
0
7/29/13
Hours
01
23
5.5
1.6
Hours
Average time from Gen Med Referral to Medicines Reconciliation
(I chart)
56
SMARTed patients only 
1.8
2
p- 1
3
Week beginning
2.0
3
-S
e
3
Week beginning
09
3
-A
ug
-1
26
l-1
3
-A
ug
-1
12
l-1
3
-Ju
29
15
-Ju
l-1
3
n- 1
3
-Ju
01
17
-Ju
-13
n- 1
3
03
-Ju
-M
ay
20
06
-M
ay
-13
12/30/13
12/23/13
12/9/13
12/16/13
12/2/13
11/25/13
11/18/13
11/4/13
11/11/13
10/28/13
10/21/13
10/7/13
10/14/13
9/30/13
9/23/13
9/9/13
9/16/13
9/2/13
8/26/13
8/19/13
8/5/13
8/12/13
7/29/13
0%
Percent of Patients Presenting to EC Between 8am and 10pm Mon-Fri who
were SMARTed each week
40%
A dditio nal teams
ro lled o ut
35%
30%
25%
P harmacy staff absences
20%
15%
10%
Week beginning
12/30/13
12/23/13
12/16/13
12/9/13
12/2/13
11/18/13
11/11/13
11/4/13
10/28/13
10/21/13
10/14/13
10/7/13
9/30/13
9/23/13
9/16/13
9/9/13
9/2/13
8/26/13
8/19/13
8/12/13
8/5/13
7/29/13
0%
Percent of patients
seen increasing as
SMART tests new
combinations and
rolls out new teams
11/25/13
5%
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.”
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
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
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
SMART Staff Feedback
SMART Staff Feedback
THE SMART PHARMACISTS