Pharmacy Clinical Intervention

• Transitions of Care• May 12-15, 2014

Team Members

• Karyn Batdorf, HR, Team leader• Lisa Blaase, Pharmacy• Susan Hawes, Pharmacy• Geoff Lockwood, Pharmacy• Ryan ‘Wolverine’ Schell, Pharmacy• Chris Senn, Pharmacy• Jonna Whiteman, PCU• Amanda Mack, TVM facilitator

Reason for Action

Preventable heart failure patient readmissions is costly to the hospital. Medication therapy in HF patients play a huge role in this problem. An inaccurate admission medication list leads to inaccurate discharge medication lists. This process is essential to patient safety, helps patient adherence and satisfaction, and reduces potential errors.

Meds by History vs Med Rec

Meds by history:the list of patients’ home medications that is found in Cerner. This is to be completed within 24 hours of admit.

Medication Reconciliation:Pulls from the meds by history list. This is the actual physician order for the which meds to continue or discontinue.

Initial State• Patients do not present with up-to date med lists• Meds by history is rushed through – just trying to check it off the list• No method to identify HF patients in ED or as inpatient• There are multiple people in the med history process – nurse(s) in ED,

pharmacist in ED, floor nurse(s), floor pharmacist• Hard to get access to med information from outside pharmacies• No one knows what is being done and by who• Floor nurses do not trust the accuracy of meds by history from the

ED- so they do it over.• Patients are interrogated multiple times, being asked the same

questions• Patients may not be able to afford meds on discharge d/t new meds• Not all individuals involved in the patient care are aware of a

patient’s discharge• Med info on d/c is overwhelming

Steps involved in completing meds by history

Obtain list from patient (if lucky)

Verify with patient med, dose, last taken

Make call to outside pharmacy, ecf, or family for clarifications

Enter changes in Cerner

ED

Ask patient for home med list

Review with patient med, dose, last taken

Place call for clarifications

Enter any changes in Cerner

Pt to floor

Floor

Initial State - metrics

Metric

Qua

lity % of med errors discovered through

HF Clinic brown bag session 9.4%

Initial

Target State

• HF patients will have an accurate medication history obtained on admission

• HF patients to receive consistent medication education so they know how to manage their meds after discharge

Target State - metrics

Metric

Qua

lity % of med errors discovered through

HF Clinic brown bag session

Goal

4.7%

Patients who are at highest risk for medication errors (HF patients) are not easy to identify.

• If we create a tool that would help to identify these high risk HF patients, then services specific to their condition can be implemented appropriately and timely.

Gap Analysis Solution Approach

[somewhat of a] Rapid Experiment

Work with Darrel to develop a report, looking at active inpatients (and observations) who have had a BNP drawn with a result greater than 100.

If able to create this report, multiple departments would benefit from this – HF clinic, pharmacy, nursing units, core measures.

The responsibility of completing medications by history falls on multiple people with ill defined roles or expectations – resulting in duplication and errors. Those currently involved in completing meds by history are not able to focus 100% of their attention on ensuring accuracy or completeness.

• If we create a process where the role and duties of completing medications by history was clearly defined and performed by individuals specially trained in this role, then there would be less risk of errors occurring and floor nurses would not feel the need to rework the list.

Gap Analysis Solution Approach

Rapid ExperimentHave a pharmacy tech in ED to obtain home medication list from patient, enter medications correctly, and make any clarifying phone calls. The ED pharmacist will review and approve the list, enter an order stating “Medications by History completed by pharmacy” to show up in MAR x 24 hours, and sign meds by history as complete. Interventions will be documented by the ED pharmacist when further clarification is needed when patient transitions to floor. These interventions will be followed up by the unit pharmacist.

RESULTS:•ED nurses were very happy that they could focus their attention on caring for their patients•Floor nurses felt confident in the information that the pharmacy entered•Meds by history was accurate and complete

RESULTS:•ED nurses were very happy that they could focus their attention on caring for their patients•Floor nurses felt confident in the information that the pharmacy entered•Meds by history was accurate and complete

Patients often leave without fully understanding how to manage their medications or resources available.

• If we create a process where patients are able to receive education regarding medication and compliance, then patients will leave the hospital better prepared to manage their medications

Gap Analysis Solution Approach

Rapid Experiment

After getting the voice of our customers, we identified that while patients like the current discharge instructions, they were interested in attending a class while at the hospital.

We were unable to experiment with this, but did develop curriculum for a HF medication class for inpatients to attend. This class covers types of meds, compliance, side effects, drug interactions, and resources/tools available. This 1hour class would be led by a pharmacist, include patients and their family members, and occur every Tuesday and Thursday.

Solution:

Investigated ability to alert physician if completing a med rec prior to meds by history being complete.

Explore capability within Cerner to identify

medications that have not been verified or confirmed

on the Meds by History.

Investigated External Rx History module and ability

to utilize.

Discovered lots of

‘opportunities’

Other stuff we did:

Worked with HF clinic to identify

ways to enhance our current medication

review process

Worked with HF clinic to identify how pharmacy can help with

HF rounds

Parking lotThere were a few things that were identified as actionable root causes, but were outside the realm of this team to attempt to conquer.

Not all individuals involved in the patient’s care are aware of the plan for discharge

– Collaborative Rounds coming in June– recommend including floor pharmacist

Staff feel rushed to complete meds by history due to pressure from physicians so the med rec can be completed.

Report at handoff between ED RN and floor RN needs to include status of meds by history

Completion PlanFind location for trial class to take place in Jonna 6/13/14

Find ideal time for class to occur Jonna 6/13/14

Schedule/free up pharmacist to cover classWolverine &

Lisa 6/13/14

Train pharmacist to teach classWolverine &

Lisa 6/13/14

Get the word out to floors re: HF med class Jonna 6/13/14Follow up with Shona re: access for ED pharm tech Susan 5/23/14Continue trialing new ED pharmacy tech position and gathering further data

Chris, Nate, Geoff, & Susan ongoing

Follow up with Darrel re: HF identification reports Susan 5/23/14Follow up re: 3M 360 capabilities for identifying HF patients Susan 7/1/14Work with Helen look at other options for the brown bag process through the HF clinic

Pharmacy & Helen 6/20/14

Send letters to ECF/PCP re: providing patients with an updated medication list Lisa 5/23/14

Train pharmacists on motivational counseling Wolverine 7/1/14Ensure that all those making post-discharge follow up calls are inquiring about the ability to pay for their meds. (refer to Melanie if patient repsonds 'no') Susan 5/23/14

Further explore the gaps in the discharge med rec process

next pass team, facilitated by

Amanda

TBA post Core team meeting

Look at possiblity of giving patients going through brown bag session or HF med class a med box prior to discharge Susan 6/1/14

Action Who Date Due

Confirmed State

End of RIE

-

Metric

Qua

lity % of med errors discovered through

HF Clinic brown bag session 9.4%

Initial Goal

4.7%

Insanity:

doing the same thing

over and over again & expecting DIFFERENT results.

-Albert Einstein

Insights• Every patient we trialed had an error that was

able to be corrected that otherwise could have gone undetected

• Our voice of the customer results were shocking• Can we ‘TVM’ the government?• Support from ED and the floors was wonderful• When you go ask and see, you will find• Ryan likes his pasta al dente• Remember to wear clothes when Skyping• We should invest in an ultrafiltration Bentley• One of the TVM phases should be NAPTIME• Excuses to use to get out of a med rec event:

– I’m sick, my wife had a baby, I have an “emergency”

Thank you!!

our

Our Team Mascot Time to blow this process

up!!

Our Team