Pharmacist Directed Medication
Reconciliation Plus in a LTC
Facility
Don H. Kuntz BSP
Medication Reconciliation Project
Manager, QI Unit
Regina, Saskatchewan
Wascana Rehabilitation Centre
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50 Rehab
250 LTC beds
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veterans (66 beds)
restricted admits
specialized, high
level care
advanced neuro
ventilator unit
peds to very elderly
Wascana Rehabilitation Centre
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Seven attending family physicians
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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
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Admission & annual patient conferences, physician
attendance mandatory
Quarterly medication reviews
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
Project Overview
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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
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Appropriate & consciously continued,
discontinued or modified
Primary Aim
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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
Observation
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For LTC patients, information transfer is
inconsistent, not standardized and in
many admissions is sorely lacking
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acute care > active rehab > LTC > PCH
> Community (home)
PDSAs
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Developed a LTC monitoring form for
pharmacists
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Standardized data collection & synthesis
Identified medication information sources at
time of admission
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Variation and reliability was dependent on where
the patient was admitted from
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Community (home, PCH)
LTC facility transfer
Acute care
Active rehabilitation unit
PDSAs
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Developed a medication reconciliation form
Tested process & forms
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10 pt retrospective audit
20 pt consecutive admissions audit
Developed tool to relay information in a
systematic & standardized method into
patient chart
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Chart form development – not an order form
Acceptance from physicians & nursing
Forms committee & Health records approval
Medication Reconciliation Table
Medication/Dose
Indication
Therapeutic Goal
Goal
Achieved
(Y/N/?)
PDSAs
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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
PDSAs
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On request, HR provides the “WRC Package”
to the pharmacist which includes two years of
information (faxed or mailed):
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Discharge summaries
Consults
Progress notes
Diagnostics (except lab which is on-line)
OR reports
Physician orders
PDSAs 
Developed standardized information for
pharmacists to provide therapeutic
goals for medications by disease state
and drugs
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Evidence based information, referenced
Guidelines (e.g. HTN, DM, Lipids, Stroke)
Indications, therapeutic targets,
treatment options & monitoring
Therapeutic goals - sample
Atrial Fibrillation (persistent & paroxysmal)
Drugs for the Heart 6th ed; Chest; Therapeutic Choices 4th ed
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Goal: stroke prevention
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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
PDSAs
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Satisfaction survey
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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)
Pharmacist Driven Med Rec
Process
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Admission generates pharmacist consult
Patient and/or family interview
Electronic Provincial Drug Plan data base information
is reviewed
Info obtained & thoroughly reviewed
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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
LTC vs Acute Care
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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
Outcomes
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To date > 250 admissions completed
Physician acceptance – 100%
Recommendation acceptance > 90%
Many patients have fewer medications, some
on more
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lack of, or expiry of indication (e.g. DVT
prophylaxis; symptom relief)
therapeutic duplications & double/triple plays
Med Rec Spread – Acute Care
Sharing Experiences & Lessons
Learned
RQHR Acute Care Facilities
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Community Hospital
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210 beds
Eye centre
Cancer services
Ambulatory care
Palliative care
Pasqua Hospital
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RQHR Acute Care Facilities
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Major referral centre
for southern Sask
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380 beds
Trauma, ICU,
cardiosciences,
neurosciences,
neonatal, mental
health, burn unit
Regina General Hospital
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Med Rec History - RQHR
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Provincial auto-populated form utilized
for admissions
Pilot – family medicine Jun 07 – Jul 08
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100% nurse utilization/bpmh creation
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90% physician uptake
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5 months
8 months
Discrepancies being resolved
Team McMed – 4A Pasqua Hospital
The Process
1.
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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
It is a fact….
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The patient
interview is crucial
to obtain the BPMH
25-40% of PIP
meds no longer
taken by pt
Benefits of Med Rec
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Patient safety enhanced
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eliminates transcription errors
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corrects/ prevents discrepancies
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clearly identifies home meds including Rx, OTCs and herbals
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Patient medication interview time reduced by 50%
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Data base for home medications on chart
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Physician medication ordering time reduced
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Orders clearly legible (reduced calls for clarification)
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Eliminate duplication of work (multiple lists)
Spread – communication &
education
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Nursing
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managers & educators
education days (29 x 1 hr presentations) = 800 +
unit meetings
Physicians
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one on one
section & department meetings; clinical rds
Direct mailing to 500 physicians
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cover letter
one page role/instruction sheet
sample completed med rec form
Pharmacists – site staff meetings & e-mail updates
Spread – communication &
education
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Board presentation
SMT & ED Council
Local cable television
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Newsletters
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“Alive & Well”
Med rec
E-Link (regional newsletter)
The Physician
DrugLine (pharmacy newsletter)
RQHR Annual Report (community mailing)
Posters
Committees, Units & task forces
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pt safety task force; homecare nurses, client reps
Spread – acute care units
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Two acute care facilities Regina General and Pasqua
Hospitals
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Go live date – September 2, 2008
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27 nursing units
2 ERs
2 PACs
SWADD printing med rec form for all admissions
Rural hospitals (7)
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4/7 visits & training completed
1 facility – 100% compliance
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16 beds; 4 physicians
Have spread to ER & clinic visits on their own
Measurement
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First 4 weeks of audits (130 pts/wk)
done by QI team
Ownership of process unit responsibility
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Audit person identified for each unit
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nurse, educator, manager, unit secretary
5 pts/wk
Excel workbook
E-mail reporting to QI unit weekly
Reporting structure
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QI collates information and reports to:
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Each nursing unit manager
Executive Directors
Health Services VPs
Senior Management Team
Board: PSSC
SMT: pt safety score card - %
discrepancies resolved by site/service
CQI
teams
HS VP – monthly report;
% med discrepancies
resolved by portfolio site/service
HS VP Sponsor – monthly report;
% med discrepancies resolved
by portfolio site/service
EDs: – monthly report;
% med discrepancies resolved
(by unit/site within portfolio
Medical Dept Head Council:
monthly report; % discrepancies
resolved by acute care unit
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
Accountability
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Initiative is not owned by any one dept
Shared responsibility and accountability
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patients, nursing, physicians, pharmacists,
QI unit
Such a small piece
Such a simple thing
Spread barriers
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ER
Lack of effective broad based
communications
Physician acceptance
Incomplete bpmh/form completion
Unit culture variability
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too busy, acuity is high, turn over is high
Lessons learned
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Communicate immediately & frequently
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Especially with physicians
Utilize dept/section secretaries to get on physician
meeting agendas
Identify champions early
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Physicians
Nursing units
Pharmacists
Nurse educators
Lessons learned
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Use patient stories as often as possible
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Frequent nursing unit & site visits
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Barrier physicians – use stories of their own pts
Ongoing mentoring
Q&A
Visibility
Engage the doubters
Focus on regional/national patient safety
initiative
National initiative needs…
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Physician awareness
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Core curriculum introduction
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CMA & others
Process to be recognized
medicine, nursing, pharmacy
Branding
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Logo
Discrepancies is still new terminology
Logo concept
Patient
Safety
Physicians
Medication
Reconciliation
Pharmacists
Nurses
Patients
Logo concept
R
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