another question for those in hospital pharm

[drhemi70]

How are you dealing with med reconciliation? Currently our nurses write down the med the patient or family member can recall or has on a med sheet. If we are lucky the patient came from a nursing home and we get a complete up to date med sheet.

They then send a pink sheet down to us and I an intern or a pharmacist(if they have the time) will go down and look at what the patient has going on. We calc IBW and CrCL and write it on the sheet. If CrCL is below 30 we check all meds for retention problems and things of that nature then if we find one(one thy're on in the hospital or on coming in before the hospital) we leave the doc a note about it. We then contact the patients retail pharmacy and get a complete med list for the last three months, and check it against what the patient has on their list. If there are descrepancies we go talk with the patient and make sure they are taking their meds as directed at home or if the doc changed dosage without telling the retail pharmacy. We then sign off on the med rec and keep a copy in the patients file.

Problem is this could be a full time job in a 70 bed hospital and it almost requires a pharmacist to do it because of the calcs and the drug interactions.
How are you guys handling it in 300 bed hospitals? What are your procedures? Who does what?

As you can tell from my last couple of posts I have been given some fun assignments this summer
DR

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[sdn1977]

How are you dealing with med reconciliation? Currently our nurses write down the med the patient or family member can recall or has on a med sheet. If we are luck the patient came from a nursing home and we get a complet up to date med sheet.

They then send a pink sheet down to us and I an intern or a pharmacist(if they have the time) will go down and look at what the patient has going on. We calc IBW and CrCL and write it on the sheet. If CrCL is below 30 we check all meds for retention problems and things of that nature then if we find one(one thy're on in the hospital or on coming in before the hospital) we leave the doc a note about it. We then contact the patients retail pharmacy and get a complete med list for the last three months, and check it against what the patient has on their list. If there are descrepancies we go talk with the patient and make sure they are taking their meds as directed at home or if the doc changed dosage without telling the retail pharmacy. We then sign off on the med rec and keep a copy in the patients file.

Problem is this could be a full time job in a 70 bed hospital and it almost requires a pharmacist to do it because of the calcs and the drug interactions.
How are you guys handling it in 300 bed hospitals? What are your procedures? Who does what?

As you can tell from my last couple of posts I have been given some fun assignments this summer
DR

Oh my gosh! What a lot of extra work! Are you an acute hospital or SNF?

If you are acute...some of the parameters you are looking at may be inconsequential - if they've been admitted for a cardiac problem, dehydration, renal failure, pulmonary edema, whatever....it doesn't matter what meds they were on for the past 3 months. It only matters right now!

The ER doc will evaluate medically what is going on & what needs to be done urgently & sometimes within the next 24 hours until the PMD will takeover. Then....the therapy may change completely, which makes your history meaningless - oh & the ER physician has already gotten this - that is their job!

The CrCl of a dehydrated pt in the ER at 1hr will be different from 3hr from 24hr & from 48h. Allow things to get to equilibrium before you try to contact the MD to get changes. The pt is changing - that is a given, otherwise they wouldn't be admitted to the hospital. If you have a stable pt admitted for a scheduled procedure...surgery, L&D, whatever - you still need to allow time for the surgically induced volume changes to equilibrate to make any recommendations for change.

Perhaps....if you have pts who never get admitted from the ER - just get evaluated, treated & discharged, then you could give a recommendation...but the ER physician is there to give a medical opinion & has already communicated with the PMD. So - why duplicate?

 

[ZpackSux]

Dr. Hemi,

Medication Reconciliation is a big part of the National Patient Safety Goals and also a big focus of JCAHO.

It's a simple process if done correctly. The goal of Med Rec is to provide a continuum of care from one provider to next by providing the medication information of a patient.

Simplified, admission nurse takes down the home medications of a patient during the admission process. The list is then reviewed by the primary physician within in the 12 hours of admission and determined which medication will be continued or discontinued.

The list is now an official medication order and is reconciled with the admission orders by pharmacy. When the patient is transferred from one level of care to another...ie ICU to Med Surg, there should be a list of medication which are continued and renewed...which is reconciled by the pharmacy.

At the discharge, the discharge medications are entered into the orginal reconciliation form... Then the form must be forwarded to the patient..and very importantly, it must also be forwarded to the next provider.. ie the primary physician of the patient.

The Medication Reconciliation process does not have to involve all that fancy crcl calculations... it is a process of reviewing home meds then reconciling with the new medication orders and then providing this info to the next provider.

JCAHO is hot on the trail with this process. I can give you tips for your director if you guys need some guidance. We just had our JCAHO...we passed with flying colors..on our Med Recon process. I can give u my # through PM if you would like.

We also have a good process for anesthesia audits... we busted an anesthesiologist 2 weeks ago for diversion.

 

[sdn1977]

The rate limiting step here is the primary provider.....he/she always had this info in the discharge summary.

The ambulatory pharmacy never (NEVER) gets this info (unless you are the only provider)! This - IMO, is JCAHO paperwork & is one of the worst examples of the JCAHO interference in a system which has already been implemented & has worked well in many places. The difference here is the name of the paperwork. The one thing this does not resolve & is still an issue is providing information to all providers of service, which I think is what they wanted to do, but what is not done.

Anytime a pt transferred to a different level of service - ICU to transitional care to med/surg to SNF - the orders were always rewritten. The pharmacy makes sure to update (reconcile????) the current orders with what is being transferred. What is different here? On admission, the admitting physician has already done an H&P which includes a summary of current medications. Repeating them to a nurse is just duplicate paperwork (& by my experience, not as complete!)

The PMD always got the discharge summary - mostly recently we've implemented it by secured email. In addition, the discharge medication sheet is given to the pt &/or caregiver, one sent to the PMD (if it was written by the hospitalist). The part that is lacking is the update of all providers of service. If the pt is admitted for atrial fibrillation....the PMD may have admitted...perhaps made a referral to a cardiologist, perhaps not. The updated discharge info gets to the PMD, but still is not sent on to the pts rhematologist, because of past history of RA who is being treated with hydroxycholoroquine & mtx, for ex...or the gyn who sees the pt for ongoing menopausal sx, or the radiologist who follows the pt for the PMH of a breast bx for a suspect lesion - still big holes in provider care! Most importantly, the info is not sent on to the pharmacy! So...we don't know that the pt has been put on atenolol & warfarin for atrial fib. We still rely on pt interaction.

Having pharmacists do inpt drug histories on an acute pt, IMO, is superfluous. You'll have much more impact if you intervene within 36 hrs of the pts admission. By then...the pt has become stabilized, is being evaluated as a surgical candidate &/or is being treated medically. The absolute most impact a pharmacist can have on a pt being discharged is to do a discharge summary.

My facility stopped this because, in their view, it is currently done by the dispensing pharmacy.....well.....keep reading here & see how few folks actually do any pt counseling! So....this is another huge hole in provider care....but...you have the form that says you've done JCAHO Med Reconcilliation & you can say you passed - but in reality, there is still a huge hole in provider care (& I see this from both sides)!

 

[ZpackSux]

I disagree.

Medication Reconciliation mandate by JCAHO is a good thing and the step in the right direction. You're not going to tell me that your charts will have 100 percent compliance of Medication Reconciliation on all of your patients if it's not enforced.

With the process in place, the benchmark is 100% compliance of home medication reconciliation. Yes, we were already doing the reconcilication when patient transfers from one level of care to the next. But we were not 100% compliant with providing the medication information to the Primary Physician on discharge.

The reason for the mandate is because it wasn't done on all patients...

But the benchmark has been set at 100 percent and if JCAHO tracer process discovers noncompliance, then it's a likely RFI.

Your hospital can choose not to comply if you're not JCAHO accredited and many CA hospitals aren't.

It's a simple process. It's good for the patients. And if JCAHO accredidation means anything, you shouldn't ban the process.

Some JCAHO processes are ludicrous... like unapproved abbreviation of QD... we can either challenge it or comply.

Medication Reconciliation is a good process.

 

[sdn1977]

I disagree.

Medication Reconciliation mandate by JCAHO is a good thing and the step in the right direction. You're not going to tell me that your charts will have 100 percent compliance of Medication Reconciliation on all of your patients if it's not enforced.

With the process in place, the benchmark is 100% compliance of home medication reconciliation. Yes, we were already doing the reconcilication when patient transfers from one level of care to the next. But we were not 100% compliant with providing the medication information to the Primary Physician on discharge.

The reason for the mandate is because it wasn't done on all patients...

But the benchmark has been set at 100 percent and if JCAHO tracer process discovers noncompliance, then it's a likely RFI.

Your hospital can choose not to comply if you're not JCAHO accredited and many CA hospitals aren't.

It's a simple process. It's good for the patients. And if JCAHO accredidation means anything, you shouldn't ban the process.

Some JCAHO processes are ludicrous... like unapproved abbreviation of QD... we can either challenge it or comply.

Medication Reconciliation is a good process.

We are JACHO accredited & do this redundant paper processing.

My point was - its not good for the pts. It doesn't add to the pts care. The PMD already got the information before & the other care provders do not get it now that the process has changed so it has added nothing.

I don't ban the process - I disagree with the way the process has been implemented - it is short sighted & places a paperwork burden on hospital staff who already generates too much paperwork which is not looked at.

I will respectfully have to request that we agree to disagree

 

[ZpackSux]

The rate limiting step here is the primary provider.....he/she always had this info in the discharge summary.

The ambulatory pharmacy never (NEVER) gets this info (unless you are the only provider)! This - IMO, is JCAHO paperwork & is one of the worst examples of the JCAHO interference in a system which has already been implemented & has worked well in many places. The difference here is the name of the paperwork. The one thing this does not resolve & is still an issue is providing information to all providers of service, which I think is what they wanted to do, but what is not done.

Anytime a pt transferred to a different level of service - ICU to transitional care to med/surg to SNF - the orders were always rewritten. The pharmacy makes sure to update (reconcile????) the current orders with what is being transferred. What is different here? On admission, the admitting physician has already done an H&P which includes a summary of current medications. Repeating them to a nurse is just duplicate paperwork (& by my experience, not as complete!)

The PMD always got the discharge summary - mostly recently we've implemented it by secured email. In addition, the discharge medication sheet is given to the pt &/or caregiver, one sent to the PMD (if it was written by the hospitalist). The part that is lacking is the update of all providers of service. If the pt is admitted for atrial fibrillation....the PMD may have admitted...perhaps made a referral to a cardiologist, perhaps not. The updated discharge info gets to the PMD, but still is not sent on to the pts rhematologist, because of past history of RA who is being treated with hydroxycholoroquine & mtx, for ex...or the gyn who sees the pt for ongoing menopausal sx, or the radiologist who follows the pt for the PMH of a breast bx for a suspect lesion - still big holes in provider care! Most importantly, the info is not sent on to the pharmacy! So...we don't know that the pt has been put on atenolol & warfarin for atrial fib. We still rely on pt interaction.

Having pharmacists do inpt drug histories on an acute pt, IMO, is superfluous. You'll have much more impact if you intervene within 36 hrs of the pts admission. By then...the pt has become stabilized, is being evaluated as a surgical candidate &/or is being treated medically. The absolute most impact a pharmacist can have on a pt being discharged is to do a discharge summary.

My facility stopped this because, in their view, it is currently done by the dispensing pharmacy.....well.....keep reading here & see how few folks actually do any pt counseling! So....this is another huge hole in provider care....but...you have the form that says you've done JCAHO Med Reconcilliation & you can say you passed - but in reality, there is still a huge hole in provider care (& I see this from both sides)!

Now now... you know better than that... HPI at the admission and the Discharge Summary take a long time to get completed...even weeks after the patient has been discharged. How does that help the patient while the patient is inpatient?? I know what you're saying... but the JCAHO has made the Medication Recon a priority.. and it's working well.

 

[ZpackSux]

We are JACHO accredited & do this redundant paper processing.

My point was - its not good for the pts. It doesn't add to the pts care. The PMD already got the information before & the other care provders do not get it now that the process has changed so it has added nothing.

I don't ban the process - I disagree with the way the process has been implemented - it is short sighted & places a paperwork burden on hospital staff who already generates too much paperwork which is not looked at.

I will respectfully have to request that we agree to disagree

Then you have a kink in your system. The Med Rec form stays in the chart and is the first page on the physician's order form. So every physician consulted on the case is aware of the home meds and which are continued. The current meds are on the MAR. And I highly doubt that every PMD received the medication info from the hospital as the patient is discharged..I do believe some have. With the growing number of hospitalists, many PMDs don't see the patients in the hospital. Having the Med Rec form forwarded to PMD at the discharge has a significant value.... because it wasn't 100% compliant before.

 

[sdn1977]

However....I will add...that any way Z-pack or any other poster can provide to help the OP simplify this process is good!

Don't worry about IBW & CrCl on admission - if it is accompished within the JCAHO time framework, whether it is used or not is adequate.

Does your pharmacy computer system have the capability to interface with demographics & lab? If so - that satisfies. In fact....we only do hand IBW calculations on pts who are receiving drugs which use that as a dosing requirement. Otherwise, the computer demographics take care of the paperwork stipulations.

 

[ZpackSux]

And this does not have to be an added paperwork if your institution has it in place already. If not, then of course it's extra work.

The reason for the mandate is because it is believed that 45% of ADRs occur during a patient transfer from one service to next. The goal is to reduce the ADRs. How is that a bad thing.

Only thing that's changed is that the practice of Med Reconcilation is now a requirement instead of being a just "good Practice."

I'm with JCAHO on this one.

 

[ZpackSux]

However....I will add...that any way Z-pack or any other poster can provide to help the OP simplify this process is good!

Don't worry about IBW & CrCl on admission - if it is accompished within the JCAHO time framework, whether it is used or not is adequate.

Does your pharmacy computer system have the capability to interface with demographics & lab? If so - that satisfies. In fact....we only do hand IBW calculations on pts who are receiving drugs which use that as a dosing requirement. Otherwise, the computer demographics take care of the paperwork stipulations.

Our system is nifty. When Epogen is processed, it pops up H&H, when Vanco is processed, it automatically pulls vanc labs..crcl etc. When Neupogen is entered, it pulls up ANC, and WBC count. I may be a cost pinching nice guy director...but I'm all about making everyone of my pharmacists as clinical as they can be.

 

[sdn1977]

Then you have a kink in your system. The Med Rec form stays in the chart and is the first page on the physician's order form. So every physician consulted on the case is aware of the home meds and which are continued. The current meds are on the MAR. And I highly doubt that every PMD received the medication info from the hospital as the patient is discharged..I do believe some have. With the growing number of hospitalists, many PMDs don't see the patients in the hospital. Having the Med Rec form forwarded to PMD at the discharge has a significant value.... because it wasn't 100% compliant before.

Yes - I can say absolutely that every PMD had a copy of the discharge summary because they were named in the admission note:

XYZ, 82 yo f, pt of Dr QRS....

If a physician is named in the admission note, they get the discharge summary - always!

Also...if the specialists are not aware of the admission - & why would the gyn be informed if the A fib had nothing to do with the pts occasional vaginal menopausal dryness thus why would that physician ever visit the pt in the hospital to see the sheet which has so neatly been placed as the first sheet in your chart?

See my point? The disconnect of care of patients who see multiple providers is still the issue. This does nothing to help that. So...the pt goes along for 9 months being treated with atenolol & warfarin for her A fib, has a flare in her arthritis or a particular strain in her groin & a provider tells her to take ibuprofen. Altho they ask her if she has had any change in her condition since the last visit...she says....like lots of 82 yo's will - "just a mild heart problem, but its all fine now - my Dr says I'm fit as a fiddle" Any new medicine? No...just a heart pill, she says....

Now....in 2 weeks...she's back in your hospital because she fell down while feeding the cat & now has a hematoma over her hip which looks suspicious.

Your statement was "every physician who was consulted".....what about those who weren't - because they were not primary nor needed for the actual admission. What about consultants like my husband - her dentist? He never knows about any of this - yet he'll prescribe antiinflammatants too.

I'm not arguing the validity of the paperwork in house - its fine. But you are wrong if you think it goes to all the providers of a pts care - it does not! It only satisfies the folks who would like to make the excuse that they didn't see something when in fact, the orders were completely rewritten each and every time the pt transferred to a different level of care.

It is just another easy piece of paper for inspectors to look at rather than read the chart!

Again.....I'm happy to accept your opinion, mine just differs. Altho we do similar paperwork here, we don't give it that much credence because it is not considered very vital nor of any particular improvement in pt care.

 

[sdn1977]

So I'm not viewed as just a complainer of the current paper morass of JCAHO...this is my view of what is required - which is currently being discussed in pharmacy & medical information management.

Each pt has a medical information card - could be their medicare card, their insurance card, their driver's license...whatever....

Now...when the pt is admitted...to the ER or directly from surgery, mh or any other unit - the card is scanned. All the past medical history is on it including the most recent medications.

When a pt is discharged...the card is scanned again. Now...all providers who scan the card can see what the pt takes - is it Avapro or Avelide - no need for the pt to try to remember the name.

As pharmacists, we see the warfarin was stopped 3 months previously...so I don't have to call on that drug interaction - saves me time!

For the ER - the physician can see the pt got ibuprofen 600mg from my husband last week, so doesn't have to try to get the info out of a distraught spouse whose wife cannot speak...

This is way out there, but is currently being trialed in the military - but this requires tremendous effort of interface between acute providers (JCAHO being the standard bearers who just love paper) & ambulatory providers & IT people. It also requires trust & encryption on the part of patients & IT.

But...that, I believe, ultimately, is where medication reconcilliation needs to go. Otherwise...it is as limited to the institution & they eyes which view it.

 

[drhemi70]

The ER doc will evaluate medically what is going on & what needs to be done urgently & sometimes within the next 24 hours until the PMD will takeover. Then....the therapy may change completely, which makes your history meaningless - oh & the ER physician has already gotten this - that is their job!

SDN1977,
I disagree here. First let me tell you we're are just a normal small town hospital. The reason I disagree with the above statement is because of t1/2. I might be being a first year geek here, but I think sometimes depending on what the patient is on it really does matter what the patient has been on. One big one is warfarin, say patient has dementia and got a dog bite it would be nice to know for the ER doc and the rest of the docs in the hospital that the patient was on warfarin got a big dose of vit k and once in the hospital for the left over infection needs to have INR and warfarin therapy restarted. Here all we get is basic info from ER-primary care provider. Let me know what you think.

ZPACK,
How do you get complience in my instance. When Jcaho made this manditory we sat down and talked with the docs about how they would like to bring it about. We came up with a med rec form, but the docs didn't want them as orders. So now we don't know if they are looking at them or not, I think most are, because some of the meds from the sheet are on the MAR. But out of 15-20 docs here at this hospital, only 1-2 actually signs the form. Question here is if the med rec sheet is not going to be orders to continue meds how do we get doc complience?

Nursing is pissed about it, they see it as another project that has been thrown on top of them(and I feel for them, they are getting the blunt end of the deal I think) and we just started a DVT prophylaxis program too. I have a hard enough time getting nursing staff to enter height and weight on the computer. Every morning I come in I have probably 10-15% of the patients admitted from the previous day that don't have height and weight in the computer. Do you think I am going to trust what they have written on the sheet? Hell no. I see crap like thyroid med (levothyroxin) on the sheet with out any dosage info, I see dosing instructions on the sheet they are completely different from how the pharmacy downtown say the patient should be taking the meds and they are different from how the patient says they are taking the meds. How am I supposed to trust what they have on the sheet when I see that kind of stuff? Some times I get the pink sheet we are supposed to be getting within 2-3 hours of patient admit on the day the patient is being discharged, and they have been here for ten days. How do you get nursing to buy into another sheet of paper they have to fill in?

And yes, I would love to give you a holler and talk with you about this and diversion.
DR

 

[ZpackSux]

Yes - I can say absolutely that every PMD had a copy of the discharge summary because they were named in the admission note:

XYZ, 82 yo f, pt of Dr QRS....

If a physician is named in the admission note, they get the discharge summary - always!

Also...if the specialists are not aware of the admission - & why would the gyn be informed if the A fib had nothing to do with the pts occasional vaginal menopausal dryness thus why would that physician ever visit the pt in the hospital to see the sheet which has so neatly been placed as the first sheet in your chart?

See my point? The disconnect of care of patients who see multiple providers is still the issue. This does nothing to help that. So...the pt goes along for 9 months being treated with atenolol & warfarin for her A fib, has a flare in her arthritis or a particular strain in her groin & a provider tells her to take ibuprofen. Altho they ask her if she has had any change in her condition since the last visit...she says....like lots of 82 yo's will - "just a mild heart problem, but its all fine now - my Dr says I'm fit as a fiddle" Any new medicine? No...just a heart pill, she says....

Now....in 2 weeks...she's back in your hospital because she fell down while feeding the cat & now has a hematoma over her hip which looks suspicious.

Your statement was "every physician who was consulted".....what about those who weren't - because they were not primary nor needed for the actual admission. What about consultants like my husband - her dentist? He never knows about any of this - yet he'll prescribe antiinflammatants too.

I'm not arguing the validity of the paperwork in house - its fine. But you are wrong if you think it goes to all the providers of a pts care - it does not! It only satisfies the folks who would like to make the excuse that they didn't see something when in fact, the orders were completely rewritten each and every time the pt transferred to a different level of care.

It is just another easy piece of paper for inspectors to look at rather than read the chart!

Again.....I'm happy to accept your opinion, mine just differs. Altho we do similar paperwork here, we don't give it that much credence because it is not considered very vital nor of any particular improvement in pt care.

This is the exact reason why Medication Reconciliation is important. JCAHO requirement mandates forwarding of Medication Reconciliation to the Patient and the patient's primary physician. So if your husband the dentist need the info, he can simply contact the primary physician for the info. It would be ideal for every physician consulted to receive that info but that is not the requirement at this time. Medication Reconciliation is a process headed in the right direction for improved care. It's not perfect but it's a start.

And every consulted physician will know what home meds patient was on. Because the form is the 1st page of the physician's orders throughout the entire stay. You can't convince me that the H&P is in the chart as the patient is admitted and you won't convince me that the discharge summary is in the chart as the patient is being discharged. That's why the medication reconciliation form provides immediate info to the consulted physician.