Western Node Collaborative

1. Western Node Collaborative Capital Health MEDICATION RECONCILIATION Edmonton, Alberta Suburban / Rural Communities & Sturgeon Community Hospital

2. Edmonton and area www.capitalhealth.ca

3. Background WestView Health Centre • 20 bed primary care centre staffed by GP’s serving a population of approximately 60,000 with 36,000 emergency visits annually. • Integrated site with Rehab, Pharmacy, LTC, PHN, Community Care, Shared Care Maternity, Ambulatory clinics, Out-patient surgeries, Laboratory, and DI services. Edmonton and area www.capitalhealth.ca

4. Background (cont’d) Sturgeon Community Hospital • 116 bed hospital located in St. Albert serving a population of approximately 85,000 with 47,000 emergency visits annually. • Services on site are Surgery, CCU, ICU, Medicine, Pediatrics, ED, L&D, Ambulatory Clinics, Adult Day Program. • On Site Services include DI, Laboratory, Pharmacy, Social Work, Respiratory and Rehabilitation. Edmonton and area www.capitalhealth.ca

5. Background (cont’d) Capital Health’s Commitment to Medication Reconciliation • Started November 2005, projected end November 2006. • Regional Support and Dedicated FTE’s: • Project Coordinator- 0.5 • Nursing - 1.0 • Pharmacy - 0.9 • Admin Support - 0.2 • Data entry - 0.2 • Quality Consultant - as required Edmonton and area www.capitalhealth.ca

6. Aim • To improve patient care and safety in the pilot sites through the reduction of adverse drug events and the promotion of seamless care between settings. This is based on the assumption that a reduction in medication discrepancies will reduce adverse drug events. Edmonton and area www.capitalhealth.ca

7. Aim Statements • To decrease the number of unintentional medication discrepancies in the targeted areas by 75% by Oct. 2006 on an incremental basis. • To decrease the number of undocumented intentional discrepancies in the targeted areas by 75% by Oct. 2006 on an incremental basis. • Establishment of BPMH on 100% of all inpatient charts by Oct. 2006. Edmonton and area www.capitalhealth.ca

8. Aim Statements (cont’d) • To develop and evaluate a BPMH tool, accompanying processes and related procedures to support implementation and use. • On the basis of measurements of success, recommend implementation of the BPMH tool and processes for consideration of implementation at interfaces of patient care throughout Capital Health. Edmonton and area www.capitalhealth.ca

9. Team Members • Team Lead - Mary James, Senior Operating Officer Suburban / Rural Communities • Project Coordinator - Esther Nelles • Pharmacists • Kim Spiers, Sturgeon Community Hospital • Shelly Proft, WestView Health Centre • Nurse Clinician - Linda Cawthorn, Suburban / Rural Communities • Nurse Clinician - Recruiting, SCH • Clinical Quality Consultant - Marilyn Dumkee • Administrative Support - Karen Nickerson • Pharmacy Technician - Isabella Voju • Ad Hoc Physician Edmonton and area www.capitalhealth.ca

10. Changes Tested • Completed 50 PDSA cycles since beginning of the project. • Format for Medication Reconciliation in Community Care (home care) is in process, with standards for use implemented. Edmonton and area www.capitalhealth.ca

11. Learning's from Run Charts • Extreme data fluctuations are dependent on small sample size (every medication counts). • Fluctuation in results is a reflection of staffing challenges, summer vacations and the inclusion of new professions in the process. (Site 2) • Changes in undocumented intentional’s increased due to the expectation that reasons for med changes be provided at Site 2. (Assumptions are no longer acceptable for reasons meds are changed) • Auditing is very subjective. • Multiple physicians make education as a group challenging. Education is better received from same profession. • Inter-rater reliability can be a factor. Edmonton and area www.capitalhealth.ca

12. Mean Number Undocumented Intentional Discrepancies (Site 1) Sample Size Range 14-18 pts. Summer Interruption in Staffing* Baseline Physician variability (results vary with style of Admission orders) • *Over summer • Lost 9 senior nurses • Worked with casual staff while recruiting occurred Edmonton and area www.capitalhealth.ca

13. Mean Number Unintentional Discrepancies (Site 1) Sample Size Range 14-18 pts. Lack of nursing compliance completing the BPMH (13 / 22 intentional discrepancies were due to incorrect BPMH) Baseline One Patient with ## Meds had incomplete BPMH and therefore had ## unintentionals Departure of full time nurse in ER Edmonton and area www.capitalhealth.ca

14. Success Index (Site 1) Sample Size Range 14-18 pts. Baseline Decreased visibility of team member in ER and confusion among staff about which patients’ to complete BPMH Implementation of BPMH in ER Full time nurse and 0.5 pharmacist available to teach / mentor and help complete BPMH Edmonton and area www.capitalhealth.ca

15. Mean Number of Undocumented Intentional Discrepancies (Site 2) Sample Size Range 14-20 pts. Inconsistent use by all ER physicians Vacation taken by team member = decreased visibility in ER Implementation of form for Physician medication order. One on one physician teaching. Baseline Edmonton and area www.capitalhealth.ca

16. Mean Number of Unintentional Discrepancies(Site 2) Sample Size Range 14-20 pts. 1. Increased awareness of project in facility 2. Education of nursing Inconsistent MD use Baseline MD Using as order form Edmonton and area www.capitalhealth.ca

17. Medication Reconciliation Success Index (Site 2) Sample Size = 14-20 pts. 1. Rollout to MD’s as order form 2. High team visibility Form Revisions & Acute Compliance Baseline Not all physicians using form and / or incorrect usage. Implementation of BPMH in ED Form Testing (PDSA #1-8) Edmonton and area www.capitalhealth.ca

18. Nursing Progression • Audit information only addresses the prescriber success in decreasing ADE. Also important to the process is the successful integration of collecting a BPMH into existing nursing processes. • The following graphs show the progression of nursing improvement in obtaining BPMH for the WestView site. Edmonton and area www.capitalhealth.ca

19. Average # ER Visits vs. Average Number of Patients with 4 or more meds Edmonton and area www.capitalhealth.ca

20. Average % Pts Requiring BPMH vs. % BPMH Completed Edmonton and area www.capitalhealth.ca

21. Keys to Success and Lessons Learned • Site Leadership support and reinforcement of the process is essential. • PATIENCE: change is slower than the team expects. • Form development is very time consuming. • Formal education for staff. Edmonton and area www.capitalhealth.ca

22. Keys to Success and Lessons Learned • There are 3 levels of reconciliation. • Inter-disciplinary approach including pharmacists, nursing and physicians requiring clear role definitions to maximize potential. • Medication Reconciliation is essential to chronic disease management. Edmonton and area www.capitalhealth.ca

23. Next Steps • Continue to change the culture. • Plan for sustainability and spread within pilot sites. • Processes required to ensure reconciliation occurs at discharge. • Public campaign for patient education and creating the ‘smart patient’. • Define where pharmacists can have the greatest impact. Edmonton and area www.capitalhealth.ca

24. Next Steps • Recommendations for spread to region. • I.S. involvement for electronic solutions. • Policy development to meet accreditation standards. • Determine who the most effective provider is at the any given point in the process. (Roles and responsibility of each provider in the entire process) Edmonton and area www.capitalhealth.ca

25. Contact Information • Esther Nelles: WestView Health Centre (780) 968-3770 esthernelles@cha.ab.ca • Linda Cawthorn: WestView Health Centre (780) 968-3770 lindacawthorn@cha.ab.ca • Kim Spiers: Sturgeon Community Hospital (780) 418-8214 kimspiers@cha.ab.ca • Marilyn Dumkee: Regional Quality Office (780) 735-8072 mdumkee@cha.ab.ca • Shelly Proft:WestView Health Centre (780) 968-3770 shellyproft@cha.ab.ca Edmonton and area www.capitalhealth.ca