A24/B24: A High Quality Safe Medicines Management System for Patients

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1 A24/B24: A High Quality Safe Medicines Management System for Patients Michael Scott Head of Pharmacy and Medicines Management Northern Health and Social Care Trust Northern Ireland IHI 25 th Annual National Forum on Quality Improvement in Health Care December 2013 Disclosures The software developed as enabling technologies during the course of this work has been undertaken under an innovation programme in conjunction with two commercial companies 1

2 Session Objectives Describe how an integrated medicines management process can reduce harm and costs for acute care patients Discuss how to establish such a system in their organisation Identify two ways in which patients can be engaged in this process in their organisation Belfast Trust 2

3 Medicines Management Medicines management in hospital encompasses the entire way that medicines are selected, procured, delivered, presented, administered and reviewed, to optimise the contributions that medicines make to producing informed and desired outcomes of patient care Audit Commission (2001) What is Clinical Procurement? No formal definition The procurement of pharmaceutical(s) within a distinct clinical area where there is sufficient competition that selection of products may be rationalised Utilises STEPSelect methodology to select the most appropriate products through determination, in strict order, of: 1 st step - Clinical Evaluation 2 nd step - Safety Evaluation 3 rd step - Budgetary Impact Assessment Results in the recommendation of suitable first-line agents for treatment of common therapeutic indications For 70% of prescribing ie representative of majority Remaining 30% may require alternative eg complex patients 3

4 What is STEPSelect? S T E P S Stages of STEPSelect Process 1 Clinical Evaluation 3 Budget Impact Analysis 2 Safety & Risk Assessment 4 Final Selection of Product Lines 4

5 Significant challenges Patient safety, efficiency, cost Suboptimal prescribing Poor patient adherence ADRs / interactions / side-effects Errors Inadequate communication across interface (intra & inter sector) Scale of Medicines Related Problems in Northern Ireland 10% of all admissions are due to adverse drug reactions 16,500 patients; 7.8 bed days = 30million 5% of inpatients suffer an adverse incidents with 20% being due to medicines 6,600 patients; 7.8 bed days = 12.25million 5

6 Target Population 65 years or older and / or a previous hospital admission within the last 6 months Taking at least 4 or more regular medications Taking high risk drugs Received IV antibiotics on day 1 of admission (Morrissey et al Clin. Drug Invest ) TASKS UNDERTAKEN Communication with primary care on admission Accurate medical history Management of patients own drugs Inpatient management including counselling Pharmacist discharge and counselling Communication with primary care on discharge 6

7 Standard Operating Procedures Admission In patient monitoring Counselling Discharge Data collection/recording proformas INTEGRATED MEDICINES MANAGEMENT (IMM) IN NORTHERN IRELAND Drug history at admission reduction of 4.2 errors per patient Length of stay reduced by 2 days Increased time to readmission (20 days) Kardex monitoring (inpatient) 5.5 interventions per patient 7

8 INTEGRATED MEDICINES MANAGEMENT (IMM) IN NORTHERN IRELAND Faster medication rounds > 25 minutes per day saved Faster discharge > 90 minutes quicker More accurate discharge < 1% error rate compared to 25% by medical staff (Scullin,Scott, Hogg,McElnay.Journal of Evaluation in Clinical Practice 13(5), ,2007) IMPROVED MEDICINE USE There was a significant improvement in the medication appropriateness index. Admission Discharge Control Intervention (Burnett,Scott,Fleming et al.am.j Health System Pharm. 66; ) 8

9 IMM Roll-out (Spread) Reduced length of stay 1.43 days (P<0.02) Reduced length of stay on readmission 5.8 days (P<0.013) (60% of IMM and non-imm patients readmitted within 12 months) Trend to have longer time to and reduced number of readmissions For every 100 patients receiving IMM the opportunity cost is 135k (Scullin et al. Journal of Evaluation in Clinical Practice 18(4) ) Risk adjusted mortality index 9

10 Medicines Administration Error Rate (MAE) An MAE is a dose administered,or omitted that deviates from that prescribed The effectiveness and quality of a medicine administration system can be successfully measured by determining the incidence of MAEs Do Patient bedside lockers result in a safer and faster medicines administration round MAE rate fell from 8.3% to 1.3% (P<0.001) Medicines administration time per patient decreased from 6.80 minutes to 3.03 minutes (P<0.01) Hogg et al European Journal of Hospital Pharmacy Practice

11 Medicines Reconciliation SAFER PATIENT INITIATIVE 2 Medicines Reconciliation IHI definition: Reconciliation is a process of identifying the most accurate list of all medications a patient is taking, including name, dosage, frequency and route and using this list to provide correct medications for patients in hospital. Reconciliation involves comparing this list against the doctors prescribing on admission, transfer or discharge with reasons for any omissions or dose changes being documented. It is more than a simple drug history 11

12 MEDICINES RECONCILIATION (WHSCT) Gp list accuracy 54% to 83% Accurate admission record 29%- 70%(p<0.001) Significant increase in accuracy when the MOA form used (p<0.001) Significant increase in accurate discharge medication information 58%-82%(p<0.01) Enabling Technology Bespoke locker Electronic pharmacist intervention clinical system (EPICS) Medicines reconciliation software Intelligent alerts Clinical rules Safe therapeutic economic pharmaceutical selection(stepselect) Antimicrobial surveillance system(lamps) 12

13 E P I C S Electronic Pharmacist Intervention Clinical System a software tool to enable patient safety EADON GRADING SYSTEM Intervention Grade Analysis: 1 Dec 05 to 31 Aug 06 Intervention Grade Definition Number of Interventions Percentage of Total 1 Detrimental to patient care % 2 Of no significance to patient care 3 Significant but does not improve patient care 4 Significant and improves the standard of care 5 Very significant; prevents major organ failure or similar % 9, % 17, % % 6 Potentially life-saving % Ungraded TOTAL 27, % 13

14 NEXT STEPS 14

15 System re-engineering current - small scale tests of change Consultant prescribing pharmacist in nursing homes advanced care planning Consultant prescribing pharmacist in intermediate care settings Prescribing pharmacist in medicines adherence support service System re-engineering currentsmall scale tests of change Community services pharmacist in domiciliary training for patients and carers Hospital and community pharmacist in care home setting concordance service Medicine Management clinic run by prescribing pharmacist for patients with medicines problems (referral by medical staff ) 15

16 TASK How would you establish such a system in your organisation? PATIENT ENGAGEMENT 16

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