Better Medication History Taking: The Way to Improve Medication Reconciliation

1. Supported by a grant from the American Society of Health-System Pharmacists Foundation Better Medication History Taking: The Way to Improve Medication Reconciliation Ed Tessier, Pharm.D., M.P.H., B.C.P.S.1, 2 Elizabeth A. Henneman, Ph.D., R.N.2, 3 Mark Heelon, Pharm.D.3 Karen Plotkin, Ph.D., R.N.2, 3 Brian Nathanson, Ph.D.4 1 Baystate Franklin Medical Center, Greenfield, MA 2 University of Massachusetts Amherst School of Nursing 3 Baystate Medical Center, Springfield, MA 4 OptiStatim, LLC, Longmeadow, MA

2. Learning Objectives • Discuss the effect of a collaborative nurse-pharmacist intervention on obtaining accurate medication and allergy histories. • Identify drug categories frequently missed when obtaining a medication history. • Identify factors which can improve the effectiveness of medication history taking by nurses. 

3. Outline • The Problem • Medication History Taking Inadequate. • What We Did • Developed tool for nurses to improve medication history taking. • Trialed tool in controlled environment. • Trialed tool in clinical setting. • What We Learned

4. Medication Reconciliation – The Lived Experience

6. Medication Reconciliation process is highly dependent on obtaining an accurate medication history

7. Extent of Inaccurate Medication Histories Adapted from: Tam VC. Knowles SR. Cornish PL. Fine N. Marchesano R. Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Canadian Medical Association Journal. 173(5):510-5, 2005 Aug 30.

8. Our Charge

9. Primary Study Objective Evaluate the effectiveness of a collaborative nurse-pharmacist intervention in decreasing medication errors in both academic and acute care settings.

10. Study Sites • University of Massachusetts Amherst School of Nursing • Undergraduate and Graduate Programs • Baystate Medical Center, Springfield MA • 653-bed academic teaching hospital • Baystate Franklin Medical Center, Greenfield MA • 93-bed acute care community hospital.

11. Nurse-Pharmacist Intervention Requirements • Nurse Friendly • Ability to Integrate into Nursing Practice • Resource Neutral • Transferable Across Settings • Ability to Integrate in Nursing Education

12. What We Did

13. Tool Development • Peer Reviewed by Nurses and Pharmacists

14. Medication History Taking Template Version 3.0 • GET THE BASICS: • Demographics - First/last name, date of birth • Allergies – Drugs/foods; nature of reaction • Diagnoses - Reason for admit/visit; other diagnoses • Prescribers – Primary and Specialists

15. 2. BUILD THE LIST Do you have your meds/list of meds with you? • 2A. LIST REVIEW • Last updated? • What other medications do you take?

16. 2B. SYSTEM REVIEW • Do you take any medicines for: • Neuro: Seizures? Headache? • Psych: Sadness? Anxiety? Sleep? • EENT: Allergies? Your Eyes? • Pulm: Breathing? Inhalers? • CV: Your Heart? Blood Pressure? • Endo: Diabetes? Thyroid? • GI: Your Stomach? Bowels? • GU: Contraception? Your Bladder? • Treatments for Erectile Dysfunction? • Skel/Musc: Your Bones? Joints? • Infection: Antibiotics? • Derm: Topicals? • Analgesics? Pain or Discomfort?

17. 3. WHAT’S MISSING? • Antibiotics: treatments for HIV, TB? Other infections? • Cardiac Drugs: antidysrhythmics, antihypertensives, cholesterol lowering? • Clots: anything to prevent clots? warfarin(Coumadin®), enoxaparin (Lovanox®), aspirin, clopidogrel (Plavix®)? • Corticosteroids: prednisone, hydrocortisone? • Diabetes Drugs: insulin? oral agents? • Electrolytes: potassium, calcium supplements • Immunosuppressant Drugs: to prevent organ rejection or treat MS, arthritis, psoriasis, Crohn’s? • Less Than Daily: drugs given irregularly (patches, injections at MD office)? • MAOI’s: monoamine oxidase inhibitors? (Nardil®, Parnate®, linezolid - Zyvox®) • Natural: herbal/vitamins, over the counter? • Opioids: morphine (MS Contin®), methadone, fentanyl (Duragesic®), oxycodone (Percocet®, Oxycontin®)? • Recreational Drugs: any “street drugs”, use drugs recreationally, smoking, alcohol? • Seizures: drugs to prevent seizures

18. 4. PROBE FOR MORE • For medications/conditions with incomplete information consider one or more of the following: • Who ordered the medication? • What dose? • When did you last take it? • Where do you get your medications? • Why do you take it? • Tell me about missed doses in the past week. • What problems do you have with your medications?

19. 5. FINAL CHECK Is there anything else you would like to tell me about your medications that I have not asked?

20. 6. ADDRESS ASAP: • Allergy Conflicts • Antibiotics: HIV, TB, other • Anticoagulants: heparins, warfarin • Anticonvulsants: phenytoin, carbamazepine • Antidiabetics: insulin, oral agents • Antidysrhythmics: amiodarone, procainamide • Corticosteroids: prednisone, dexamethasone • Duplicate Medications: • orders for lisinopril and enalapril • total acetaminophen dose/24hrs not over 4000mg • Immunosuppressant/Transplant Drugs: • cyclosporin, mycophenalate • MAOI’s: Nardil®, Parnate®, Zyvox® • Opioids: morphine, methadone, street drugs

21. Trial in Controlled Environment • 16 RN students • 4 trained actors/ faculty played scripted standardized roles as mock patients each with medication list

22. Trial in Controlled Environment 16 Senior RN Students Informed Consent CONTROL 9 Students INTERVENTION 7 Students Randomization Med History With Mock Patient Training+Tool Med History With Mock Patient Assessment Of Accuracy Assessment Of Accuracy Training+Tool

23. Results of Trial in Controlled Environment * * p < 0.01 using a two sample t-test for proportions

24. Trial in Clinical Setting • The tool and educational plan implemented on 4 nursing units: • 2 at a community hospital • 2 at a large tertiary care center • Education: • Unit poster campaign • One on one sessions with nurses • Nurse “Kit”: • Laminated Tool with Top 100 drugs Brand/Generic on back. • Slides/Handouts

25. Pre-Intervention 3 Month Period Intervention 1 Month Period Post-Intervention 3 Month Period Outcome # 1: Medication Events METHODS • Review of all spontaneously reported medication events on each unit for: • Initial review by clinical pharmacist, secondary independent review by clinical nurse and by second clinical pharmacist. • Subset 1: All events. • Subset 2: All events related to med history taking. • Subset 3: All allergy events related to med history taking.

26. Outcome # 1: Spontaneously Reported Medication Events • Rates All Spontaneously Reported Medication Events: • Community Hospital – Lower POST over PRE: p = 0.181 • Large Teaching Hospital – Similar POST over PRE: p = 0.826 • Rates Events Related to Med History Taking: • Community Hospital - Lower POST over PRE: p = 0.204 • Large Teaching Hospital - Similar POST over PRE: p = 1.00 • Rates Events Involving Allergies and Med Histories: • Community Hospital - PRE vs. POST: no documented events • Large Teaching Hospital - PRE vs. POST: no documented events All tests were either Chi Square or Fisher's Exact (Fisher's Exact were used when a count was < 3)

27. Outcome # 2: Medication DiscrepanciesPATIENT SELECTION For Each of the Four Intervention Units: Post-Intervention 15 Days Immediately Post Intervention Pre-Intervention 15 Days Immediately Prior Intervention Intervention 1 Month Period 50 Consecutive Admissions 50 Consecutive Admissions • Randomized to 25 to ensure a greater variety of caregivers • Randomized to 25 to ensure a greater variety of caregivers

28. Outcome # 2: Medication Discrepancies Alignment of Medication Orders at 3 Points of the Electronic Medical Record Electronic History And Physical Electronic Discharge Summary Computerized Medication Orders During Admission • Medications • Allergies • Date/Time • Clinical Status • MD • Medications • Allergies • Date/Time • Medications • Allergies • Date/Time • Clinical Status Elements Collected: Other Elements Collected: • Demographics • Site of Patient Prior to Admission

29. Categorization of Discrepancies

30. Outcome # 2: Medication DiscrepanciesIMPLEMENTATION • For Small Community Hospital: • All Data Elements Available Electronically Electronic History And Physical Electronic Discharge Summary Computerized Medication Orders During Admission • For Large Academic Teaching Hospital: • H&P Not Available Electronically • . Electronic History And Physical Electronic Discharge Summary Computerized Medication Orders During Admission

31. Outcome # 2: Medication DiscrepanciesRESULTS - Community Hospital Demographics of Pre vs. Post Intervention Similar • Age did not differ: • PRE: Mean(SD) = 68.1 (18.9) • POST: Mean(SD) = 69.3 (18.4) • P-value = 0.756 • Gender did not differ: • PRE Female = 46.2% • POST Female = 53.9% • P-value = 0.423 Providers did not differ: Fisher’s Exact P-value = 0.623, 1 missing value in the Pre-Intervention group

32. Outcome # 2: Medication DiscrepanciesRESULTS - Community Hospital • Prior Location did not differ statistically • Observation: • Trend toward more complex patients in PRE vs POST? • Fisher’s Exact: P-value = 0.083

33. Outcome # 2: Number of Drugs/Patient RESULTS – Community Hospital Similar but Statistically Smaller Post Intervention (p<0.05)

34. Outcome # 2: Rates of Discrepancies per Patient

35. What the Intervention Did NOT Affect: • Length of Stay: • Allergy Discrepancies:

36. VITAMINS/MINERALS VITAMINS/MINERALS GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES CNS:PSYCHOTROPICS:ANTIDEPRESSANTS CNS:PSYCHOTROPICS:ANTIDEPRESSANTS HORMONES: ANTIDIABETIC AGENTS HORMONES: ANTIDIABETIC AGENTS RESPIRATORY TRACT: BRONCHODILATORS RESPIRATORY TRACT: BRONCHODILATORS GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS CARDIOVASCULAR: BETA ADRENERGIC BLOCKER CARDIOVASCULAR: BETA ADRENERGIC BLOCKER MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY CARDIOVASCULAR: DIURETICS CARDIOVASCULAR: DIURETICS 0 0 10 10 20 20 30 30 # of Discrepancies # of Discrepancies Top 10 Drug Discrepancies These drugs represent 54.3% of all observed discrepancies

37. Goal: No medication discrepancies • % Patients With NO Discrepancies: • PRE: 20% (10/50) • POST: 42% (21/50) • p = 0.027

38. What We Learned

39. Lesson 1: Systematic Approach May Help • Systematic approach for nurses in conducting medication histories associated with modest, but measurable improvement: • in controlled setting • in small community hospital setting

40. Lesson 2: Alignment of Goals and Responsibilities • Success in controlled and smaller settings may be related to: • Motivated nurses who see medication history taking as important part of their job.

41. Lesson 3: Continuing/Ongoing Reinforcement • Success in controlled and smaller settings may be related to: • Strong and positive one-on-one pharmacist/nurse relationships. • Process integrated into workflow. • Ongoing support for nurses.

42. Lesson 4: Missed Drugs Include Critical Agents • Among top drugs in discrepancies: • Antidepressants • Drugs for Diabetes Mellitis • Bronchodilators • Antiplatelets • Bronchodilators • GI Cytoprotectants • Diuretics

43. Lesson 5: Catching Discrepancy Early May Reduce Risk at Discharge • Intervention early was associated with trend toward fewer omissions at discharge.

44. Lesson 6: When in Doubt, Laminate It! • Intrinsic “value” of tool appeared to improve when tool was: • Simplified • Logical • Visually Appealing • Provided Useful Information • (including the top 100 brand/generic list) • Durable • Integrated into Workflow

45. Half of the modern drugs could well be thrown out of the window, except that the birds might eat them. Dr. Martin Henry Fischer

46. Now it’s your turn!

47. State of Med Rec in Rural New England • What is your biggest obstacle? • Who are the key players at your facility? • MD • Nurse • Pharmacist • Pharmacy Tech • Other • What works? Any best practice to share? • What doesn’t work? • Anything else to share?