NSG 523 Dissemination Product

1. NSG 523 Dissemination Product Anthony Bernas, Hannah Fox, Airin Lam, Michelle Miller, Andrea Simonetti

2. National Patient Safety Goal 2014 Use medicines safely - NPSG.03.06.01: “Record and pass along correct information about an individual’s medicines. Find out what medicines the individual served is taking. Compare those medicines to new medicines given to the individual served. Make sure the individual served knows which medicines to take when they are at home. Tell the individual served it is important to bring their up-to-date list of medicines every time they visit a doctor.” (JointCommission.org)

3. PICOT Question In patients with Type 2 Diabetes receivingcare in an outpatient capacity (P), how does holistic education on medication (I) compared to standard medication education (C) affect patient adherence to and knowledge of safe medication practices (O) within a 90-day study period (T) www.drugwatch.com

4. Why Is Medication Management So Important? • With the increasing prevalence of chronic diseases, the amount of medications consumed by American adults is rapidly increasing • 82% of American adults take at least one medication and 29% take five or more (Center for Disease Control and Prevention, 2012) • Each additional medication can pose the threat of drug interactions • With each prescription medication there is a potential for side-effects to occur • A study of older adult outpatients who took five or more medications found that 35 percent experienced adverse drug events (Marek & Antle, 2008)

5. Problems with Medication Management • The variety in medication timing/scheduling, dosage, and route of administration can be a challenge in medication management • In a study of medication compliance, the compliance rate was 87 percent for daily dosing, 81 percent for twice a day, 77 percent for three times a day, and 39 percent for four times a day (Marek & Antle, 2008) • Recognition of an individual’s abilities (e.g. physical and cognitive) are keys in managing their medication

6. The Importance of Medication Management Adverse Drug Events (ADEs) are preventable • 700,000 emergency department visits and 120,000 hospitalizations are due to ADEs annually (Center for Disease Control and Prevention, 2012) • $3.5 billion is spent on extra medical costs of ADEs annually(Center for Disease Control and Prevention, 2012) • At least 40% of costs in ambulatory (non-hospital) settings related to ADEs are estimated to be preventable(Center for Disease Control and Prevention, 2012) In the United States, an estimated 3 million older adults are admitted to nursing homes due to drug-related problems at an estimated annual cost of more than $14 billion (Marek & Antle, 2008) Older adults discharged from the hospital on more than five drugs are more likely to visit the emergency department (ED) and be rehospitalized during the first 6 months after discharge (Marek & Antle, 2008)

7. Evidence Addressing the Problem Medication reconciliation • Multiple studies have demonstrated large discrepancies (between 30 and 66%) in what medications were prescribed by the individual’s provider and the actual medications the older adult was taking (Marek & Antle, 2008) Practice Guidelines: • Review with patient all prescribed medications that they are taking, as well as any over-the-counter (OTC) medications, herbs, and vitamins. • Screen for ADEs • Provide patient or caregiver a current list of all medications the patient is taking, including dose, frequency, and routes (Marek & Antle, 2008)

8. Evidence Addressing the Problem Medication Procurement • The act of obtaining medications Practice guidelines • Assess the ability of patient or caregiver to pay for medication and obtain any necessary refills • Assist patient or caregiver in setting up pharmacy delivery, refill reminders, and scheduling family or friends to pick up medications • If the patient has financial problems, refer to a social worker or consult with pharmacist regarding use of generic drugs (Marek & Antle, 2008)

9. Evidence Addressing the Problem Medication knowledge • Patient education is the key intervention to assist with medication management • Patient knowledge of his/her medication is positively correlated with medication adherence Practice Guidelines: • Assess patient’s or caregiver’s knowledge of the medication, including dosage, frequency, special instructions (e.g take with food), route of administration, and side effects to monitor for • Interventions related to medication knowledge • Written and visual instructions, medication schedules/charts, and information on how to take the medications (Marek & Antle, 2008)

10. Evidence Addressing the Problem Physical ability • Low manual dexterity and poor vision are associated to poor medication management Practice guidelines • Assess manual dexterity or vision impairment and its influence on the patient’s ability to open, prepare, and take the medication. • Observe the patient open medication containers, use inhalers, break tablets, and use injections as needed. Interventions • Pill box or easy-open container • Medication calendar • Blister packs (Marek & Antle, 2008)

11. Evidence Addressing the Problem Cognitive capacity • The degree to which the patient can understand and retain information Practice guidelines • Assess patient or caregiver’s capacity to organize and remember to administer medication • Including understanding and recall of proper dosage, frequency, and route of administration • Teach about memory cues such as clock time or meal time • Provide memory-enhancing methods such as medication calendar or chart, electronic reminder, or pill box (Marek & Antle, 2008)

12. Credibility of the Evidence • Evidence was obtained from Patient Safety and Quality: An Evidence-Based Handbook for Nurses, which looked at several studies to develop guidelines to improve medication management • Guidelines were produced with expert assistance ofa colleague in the nursing research field (Marek & Antle, 2008) • This review of studies was published by the Agency for Healthcare Research and Quality (AHRQ) • AHRQ’s mission statement is: • “to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that evidence is understood and used.” (AHRQ, 2010)

13. Reliability of the Evidence • The authors of Patient Safety and Quality: An Evidence-Based Handbook for Nurses conducted a review of many research studies to determine risk factors that impact non-adherence and medication mismanagement in older adults. • After looking at the evidence of risk factors provided in the studies, the authors developed guidelines to assist nurses in improving medication management. • Many of the studies that were analyzed were Level 1 designation. • Level 1 studies are accepted as the most reliable and highest quality evidence in randomized controlled trials (Devries & Berlet, 2010). • Multiple studies yielded similar results and were consistent through replication • Reputable organizations conducted the studies that provided the evidence for review

14. Applicability of the Evidence This evidence is applicable across a variety of medical settings: • Inpatient settings, outpatient clinics, home-health, skilled-nursing and long-term care facilities, etc • Including and reinforcing these teachings during each patient encounter is simple and quick • Practicing and reinforcing these guidelines in a clinical setting will: • Increase patient adherence to proper medications • Decrease adverse reactions • Decrease annual healthcare costs • Decrease hospital readmissions for drug related problems • Increase the patient’s quality of life.

15. Translation into the Clinical Setting: Stetler’s Model

16. Plans for Translation into Clinical Setting Stetler’s Model • Consists of five phases, used for planning and implementing holistic medication education into clinical practice Phase I: Preparation • Define and determine the purpose and potential outcome of the change • We have defined the need for improved medication education to produce better outcomes for the client’s health related medication safety Phase II: Validation • Studies linked to the topic of medication safety would need to be critically appraised for their strength, validity, and reliability

17. Plans for Translation into Clinical Setting Phase III: Comparative evaluation/decision making • Study results need to be consistent through replication (reliable) • Evaluate how the evidence will fit into healthcare systems • Evidence could be either inhibited or facilitated by policy and protocols • Test feasibility regarding associated risk and resources needed, such as medication education materials and readiness of personnel to enact the change • Our practice change is the need to train healthcare professionals regarding holistic medication education • Readiness to change will be assessed through evaluation and mock trial • Finally, it must be established that the change will positively impact current practice • In our case it will be at the outpatient clinic at Rush University Medical Center

18. Plans for Translation into Clinical Setting Phase IV: Translation/Application • The plan developed during the previous phases will be applied in the clinical setting • Healthcare professionals will provide holistic medication education to the clients in the outpatient clinic • Baseline HbA1c levels will be drawn and a pre-intervention survey on medication knowledge will be given to obtain baseline data • Holistic medication education begins with a patient interview to assess their current knowledge of the medications, and to determine individual factors that impact the client’s ability to adhere to safe medication management

19. Plans for Translation into Clinical Setting Phase IV: Translation/Application (continued) • Medication reconciliation, financial support for healthcare, physical ability, and cognitive capacity will also be assessed • Interventions that the health care professionals will provide with their teaching include • Written and visual instructions • Medication schedules/charts, pill boxes, and blister packs • Side effect teaching and symptom management • Who to call in case of an emergency • What to do in case of a missed dose • Address any other questions the client may have

20. Plans for Translation into Clinical Setting Phase V: Evaluation • The medication education intervention is evaluated and the impact will be assessed • We will provide clients with a post-intervention survey to assess medication knowledge as well as draw HbA1c levels • Ideally, we want to see an improvement in medication knowledge and a decreased HbA1c • The impact of this intervention will improve client self-efficacy, their ability to manage chronic illnesses, decrease ADEs, decrease the financial burden of medication mismanagement, improve health outcomes, and improve their quality of life!

21. References Agency for Healthcare Research and Quality (AHRQ). (2010). About AHRQ. Retrieved from: http://www.ahrq.gov/cpi/about/index.html Burns, N. & Grove, S. K. (2011). Understanding Nursing Research: Building an Evidence-Based Practice, 5th Edition. Maryland Heights, MO: Elsevier Saunders DeVries, J.G., & Berlet, G.C. (2010). Understanding levels of evidence for scientific communication. Foot and Ankle Specialist, volume 3, 206. doi: 10.1177/1938640010375184 Marek, K. D. & Antle, L. (2008). Medication Management of the Community-Dwelling Older Adult. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2670/ Melnyk B.M. & Fineout-Overholt E. (2011). Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Wolters Kluwer, Philadelphia, PA.