Implementation and a Randomized Controlled Evaluation of

1. Background Methods continued Results Results continued Optimal Model Stakeholders Literature Review Qualitative Analysis of Expert Interviews Phase 2: Implementation of Model • 1. Designed and provided education for surgical • pharmacists on: • • Strategies for conducting medication histories at the PAC • Designed and provided in-services for PAC nurses and clerks, in-patient nurses, surgeons, and residents • • Approximately 140 in-patient nurses and 30 surgeons and residents were in-serviced between April 11 to April 18, 2005 Phase 3 Randomized Evaluation Phase 3 Randomized Evaluation Phase 2 Implementation of Model Phase 2 Implementation of Model Eligible Surgical Patients at PAC • Phase 1 • Development of Model • Establish the optimal model • Design of tools • Baseline data collection Phase 3 Randomized Evaluation Randomization - Identification - Characterization - Clinical Assessment Intervention (Structured pharmacist medication assessment and generation of a post-operative medication order form) Standard Care (Nurse-conducted histories and surgeon-generated orders) Implementation and a Randomized Controlled Evaluation of Pharmacist Medication Assessments in a Surgical Pre-Admission Clinic Yvonne Kwan, BScPhm1; Olavo Fernandes, PharmD1,2; Jeff Nagge, PharmD1; Gary Wong, BScPhm1; Jin-Hyeun Huh, BScPhm1; Deborah Hurn, RN, MA1; Jana Bajcar, MScPhm, EdD, FCSHP2 1Department of Pharmacy - University Health Network, 2Leslie Dan Faculty of Pharmacy - University of Toronto Phase 1: Development of Model Phase 3: Randomized Evaluation • Post-operative hospital admission is a key medication- related vulnerable moment where patients are at increased risk of medication discrepancies that potentially can lead to adverse drug events Phase 1 Development of Model Table 3. Clinical Assessment of Post-Operative Medication Discrepancies Related to Home Medications 1. Established the optimal practice model Table 1. Baseline Characteristics Figure 3. Components Used to Establish the Optimal Practice Model Figure 1. Key Vulnerable Moments for the Surgical In-Patient Vulnerable Moment #3 Vulnerable Moment #1 Vulnerable Moment #2 ICU • 2. Designed the following practice and research tools • Preprinted Post-Operative Order Form for Pre-Operative Home Medications • Classification system for categorization of discrepancies • Ranking system for clinical impact of discrepancies • Worksheets and checklists outlining tasks at the PAC and on the unit • Template for medical chart documentation • 3. Collected baseline data • Data collected on post-operative medication discrepancies between March 22 to April 14, 2005 in all patients who had a PAC visit and were admitted to participating in-patient units • A post-operative medication discrepancy was defined as any medication clarification that was made by the pharmacist during the post-operative period Pre-Admission Clinic Assessment OR Surgical Admission Unit In-Patient Unit Home ICU = Intensive Care Unit OR = Operating Room ER = Emergency Room ER *p=0.039 Table 2. Incidence of Primary Endpoint Discussion/Limitations • Non-randomized investigations have suggested pharmacist involvement in a surgical pre-admission clinic (PAC) may reduce clarifications in the post-operative period • Our results confirm the benefit demonstrated in previous investigations with respect to pharmacist involvement in the PAC • Fewer patients in the intervention arm had at least one post- operative medication discrepancy related to home medications compared to the standard care arm • Patients in the intervention arm had statistically higher mean number of home medications, possibly suggesting that pharmacists had identified more home medications at the PAC through the structured medication assessments • Limitations of this project include: • • Unblinding identification and reporting of medication discrepancies • • Retrospective clinical assessment of discrepancies Objectives • Primary Objective: • Evaluate the impact of structured pharmacist medication assessments in the surgical PAC and the use of a post-operative order form on the incidence of patients with at least one post-operative medication discrepancy related to home medications in patients undergoing planned elective surgeries • Secondary Objectives: • Characterize the types of post-operative medication discrepancies • Determine the clinical impact of the post-operative medication discrepancies by blinded measurements performed by clinical experts Figure 5. Total Number of Post-Operative Medication Discrepancies Conclusions Phase 3: Randomized Evaluation Design: Randomized, prospective, parallel study • A pharmacy practice model that creates a combined intervention of a structured pharmacist medication assessment and a post-operative order form and supports medication prescribing in surgical patients at the time of post- operative hospital admission can be successfully implemented in the PAC • The combined pharmacist intervention can reduce significantly the incidence of post-operative medication discrepancies related to a patient’s home medications • Pharmacist involvement in the PAC may be beneficial at improving patient safety Inclusion Criteria All consecutive patients who had a PAC appointment at Toronto General Hospital between April 19 to June 3, 2005 prior to undergoing surgical procedures (ENT, Urology, Gynecology Oncology, Plastics, General Surgery, and Thoracics) Exclusion Criteria Patients scheduled for discharge the same day as their surgery Figure 6. Characteristics of Post-Operative Medication Discrepancies Related to Home Medications Methods Figure 2. Project Design Figure 4. Design of Evaluation Phase • Acknowledgements • Barbara Courtman, Jeffrey Doi, Nadia Gad, Gino Gizzarelli, Rosanna Guidoccio, Anita Jakovcic, Patricia Kim, Valerie Marshall, Sonia Matos, Kyung Ae Park, Elaine Rosenberg, Shun Wong, Clement Yuen • Stephanie Ong, Bassem Hamandi, Gregory Pond • TGH Pre-Admission Clinic Staff **References available upon request