Gerontological Nursing: Promoting Evidence Based Quality Care

Presenter: Fiona Dunne MSc Advanced Leadership in Nursing,

ADoN Nurse Practice Development email: fionam.dunne@hse.ie

Outline of presentation

• Title of systematic review

• Medication reconciliation explained

• Background for study

• Reasons for choosing a systematic review

• Aim

• Methods used

• Results

• MedRec interventions carried out by nurses

• Findings

• Secondary outcomes

• Challenges for healthcare professionals

• Conclusion & recommendations

Systematic review title

• “The impact of nurse-led medication reconciliation on medication discrepancy detection at older adult care transitions.”

Medication reconciliation?• The process of creating & maintaining the most accurate list possible of all medications a person is taking in order

to identify any discrepancies & to ensure any changes are documented and communicated 1

• Ensures that the person has a complete list of accurate medication

• Aim: to provide service users with the correct medications at all care transitions. It can be considered effective when all medication that a person has been consuming has been purposely continued, stopped , temporarily held or amended at each point of transfer & importantly when this has been communicated effectively to the next providers of care 2

Medrec… not med wreck!

Background

• Safe healthcare is a national & international priority with one of the most worrying aspect of care being medication safety 17

• Increased challenges: an ageing population + associated increase in chronic conditions = people consuming more medications

• Medication errors have been reported as the most common type of error & can have detrimental outcomes for patients yet are often preventable

• Hospital transition is a stressful, complex and potentially dangerous process for patients. 3,4,5,6

• Particularly vulnerable times for older adults who often have co-morbidities with consequent complex medication regimens, frequently amended by many different healthcare providers 18

• 71.2% of hospital discharges had at least one type of MedRec problem 8• 40% medication errors due to inadequate MedRec at transition 9

• Although transition is complex, accurate and complete medication reconciliation plays an integral role in securing safe transitions 3

•

Global ageing population.

Background

• In 2004, The Joint Commission recommended that organisations must carefully reconcile medications to avoid adverse drug events.

• Consequently, many organisations developed strategies for achieving a complete patient medication list at admission & conveying this list accurately to the next care provider.

International & national documents advocating all healthcare providers should ensure MR policies are instigated at admission

There is an urgent need for evidence-based research regarding

nurses’ role in medication reconciliation (MedRec).

Medication reconciliation

• Despite the focus on MedRec, the most effective process of conducting MedRec remains unclear 10

• Literature review shows variation of standards of MedRec

• Questions have been posed such as who is responsible for MedRec?

• Irish report highlighted lack of policies & clarity around MedRec and requested all services to review MedRec practices 1

• Nurses should have a key role in MedRec but majority of literature refers to pharmacists and doctors.

Why a systematic review?

>The question of ‘what works’ in international development policy & practice is becoming ever more important against a backdrop of accountability and austerity 11

>Enormous volume of research evidence for

clinicians to keep abreast of 12

>A method of identifying & synthesising

all the available high quality research

that has evidence on a particular topic

using transparent and specified in advance

explicit methods 13, 14

>Gold standard for comparison & synthesis

of evidence in healthcare due to the rigorous

methodology 15

Aim of this review

• To systematically review & evaluate research studies which analysed medication reconciliation interventions performed by nurses in older patients at care transitions, in order to assess the impact of the nursing role in detecting medication discrepancies (MDs), determine the validity and transferability of the results.

Outcomes

• Primary outcome of interest: the rate of medication discrepancies detected by nurses when performing MedRec.

• Secondary outcome of interest: factors which contribute to MedRec and a comparison of nurse-led MedRec with other healthcare professionals.

Methods

• Adhered strictly to PRISMA• Protocol designed• Well-framed question• PICO framework• Inclusion and exclusion criteria

(older adults over 50 years at care transitions)

• Search strategy• Data extraction• Quality appraisal• Data analysis and synthesis• Results• Conclusions• Recommendations

Results

• Search identified 457 citations

• Additional records identified from study references totalled 2

• Full text of 53 articles was retrieved and 8 met the inclusion criteria

PRISMA 2009 Flow Diagram

Records identified through database searching: Embase (132) Pubmed (50) Cochrane (4) Cinahl

(189) Web of Science (82) (n= 457)

(n =369 )

Studies included in quantitative synthesis

(meta-analysis) (n = 8)

Studies included in qualitative synthesis

(n = 0)

Full-text articles assessed for eligibility

(n = 53)

Records screened (n = 360)

Records after duplicates removed (n = 360)

Additional records identified through other sources

(n = 2)

Iden

tifi

cati

on

El

igib

ility

In

clu

ded

Sc

reen

ing

Records excluded (n = 307)

See appendix 8 for rationale

Full-text articles excluded, with reasons (n=45)

Age criteria <50 (n=21) No nurse detected MR (n= 20) Thesis (n=1) Pharmacy focus (n= 1) Case study (n=1) Protocol (n= 1) See appendix 9

Location of studies

Quality of studies

Nurse-led interventions

• Specialist diabetes nurse.

• Carried out structured nurse-patient interviews in OPD (referred from GPs) with a strong focus on medication reviews

Nurse-led interventions

• Nurses performing home visits post hospital discharge

• Interviews patients in their home and checks medications

Nurse-led interventions

• Specially trained transitional nurse.

• Identifies medication discrepancies during telephone calls made within 2-3 days of discharge

• Community hospital nurses

• Used a structured assessment tool to obtain an accurate medication history

Nurse-led interventions

• Advanced Nurse Practitioner working in the Emergency Department.

• Assumed complete responsibility for the management of MedRec

Nurse-led interventions

Findings

• In all of the studies medication reconciliation carried out by nurses improved the rates of medication detection discrepancy

Some interesting findings

• Over 80% GP letters contained 1 or more discrepancy.

• Nurses detected 58.9% omissions in GP letters.

Some interesting findings

• Nurses detected medication discrepancies in 45-53% patients at the

home visit within the first week post hospitalisation.

• Nurses detected medication discrepancies in 22% patients during a first follow up phone call post discharge.

• Improved history taking by nurses led to a decrease in drug omissions in the discharge summary (pre 0.43 (0.71) versus post 0.18 (0,44) p=0.053

Some interesting findings

Electronic assessment tool versus no tool

• Nurses’ use of a structured assessment tool produced an improvement in the accuracy of history taking at admission & less odds of having a medication discrepancy when an electronic assessment tool is used (p=0.004).

• Percentage of patients with at least 1 discrepancy decreased from 94% to 81% where an ANP carried out Medrec.

• ANP intervention led to a decrease of almost 50% in medication discrepancies compared with nurses working in the ED.

Secondary outcomesPatient contributing factors leading to inaccurate medication lists

System-level contributory factors leading to inaccurate medication lists

Patient-level contributory factors to inaccurate medication lists

• Patients unaware of the importance of having a clear understanding of their own medication & the MedRec process.

• Levels of patient acuity (if unwell poor patient recall)

• Acute admission (medications left at home)

• Increased age

• Unrecognised cognitive deficits

• Polypharmacy (sometimes but not always)

• Increased patient anxiety - poor history giving

• Patients with limited English, low education level

• Financial burden of medication

• Poor tolerance of medication

• Failure to fill a prescription

System-level contributory factors to inaccurate medication lists

• More system level discrepancies than patient level discrepancies

• Incomplete or inaccurate communication and/or documentation

• Incomplete discharge instructions

• Changes in formularies of medications (medication substitutions can lead to MDs)

• Handwritten GP letters increased errors

• Lack of standardised processes to enable nurse to collect accurate medication information from patients

KEY POINT: Information technology is a central component to support the process of MedRec

• Positive impact of electronic assessments were proven

Challenges for other healthcare professionals

Importance of interviewing patients to elucidate actual medication use.

Difficulties busy clinicians face

Need for interpreters with increasedglobalisation

Mean time of telephone calls was 80 minutes

Staff workloads

Not all nurses have the benefit of ANP service

Conclusion

• Despite extensive searching…. limited number of studies evaluating nurse-led MedRec & lack of available high quality quantitative research.

• There is an alarmingly high rate of medication discrepancies at care transitions.•

• Timely follow-up post discharge very significant.

• Need for improvements in care that will potentiate effective communication regarding medications throughout hospitalisation in addition to hospital to home discharge.

• Nurses can contribute to a substantial reduction in medications discrepancies in care settings for older persons by performing MedRec.

• Nurses can deliver improved outcomes by reducing potential medication errors.

• Outcomes of this review have global relevance.

Recommendations

• Strategies that facilitate the prevention of medication errors at care transitions need urgent consideration.

• Further research needed to investigate how nurse-instigated MedRec can reduce medication discrepancies.

• Focus on developing randomised designs to accurately evaluate MedRec during care transitions.

• Include larger number of patients to determine significance.

How to ensure good MedRec

• Use of a checklist to facilitate MR at transition points is advisable, such as at the point of transfer from a nursing home/social care setting to an acute hospital, or at the time of discharge from an acute hospital to a nursing home/social care setting.

• The availability of pre-printed service or ward-specific forms may facilitate the MR process.

Don’t nurses have enough to do already?

https://www.youtube.com/watch?v=U3qiZGB9yUg&t=124s

References1.Health Information & Quality Authority (2014) Principles of good practice in medication reconciliation

2. Institute for Healthcare Improvement (2011) How to guide: Prevent adverse drug events by implementing medication reconciliation. Cambridge: MA: Institute for Healthcare Improvement.

3. Ruggiero J., Smith, J., Copeland J. & Boxer B. (2015) Discharge time out: an innovative nurse-driven protocol for medication reconciliation. Medsurg Nursing. 24(3), 165-172

4. Coleman, E. A, Smith, J. D., Raha, D., & Min, S. J. (2005). Posthospital medication discrepancies: prevalence and contributing factors. Archives of Internal Medicine, 165(16), 1842–1847.

5. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K. L., & Zuckerman, I. H.

(2012). Medication reconciliation during the transition to and from long-term care settings: a

systematic review. Res Social Adm Pharm, 8(1), 60-75. doi:10.1016/j.sapharm.2010.12.002

7. Alper E. Greenwald JL. & O’ Malley (2015) Hospital discharge and readmission. http://www.uptodate.com/contents/hospital-discharge-and-readmission#H10

8. Foust J., Naylor M., Bixby B., & Ratcliffe S. (2012) Medication problems occurring at hopital discharge among older adults with heart failure. Journal of gerontological Nursing. 5(1), 25-33

9. Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/nurseshdbk.pdf (accessed 12th October 2015)

References

10. Redmond P, Grimes TC, McDonnell R, Boland F, Hughes C, Fahey T. (2013) Interventions for improving medication reconciliation across transitions of care (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD010791. DOI: 10.1002/14651858.CD010791.

11. Mallett, R. , Hagen-Zanker, J., Slater, J & Duvendack, M. (2012) The benefits and challenges of using systematic reviews in international development research, Journal of Development Effectiveness, 4:3, 445-455, DOI: 10.1080/19439342.2012.711342

12. Gugiu, P.C. (2015). Hierarchy of evidence and appraisal of limitations. Evaluation and Program Planning. 48, 149-159.

13. Oxman, A. D., & Guyatt, G. H. (1993). The science of reviewing research. Annals of the New York Academy of Sciences, 703, 125-133.

14. Gough, D., Oliver, S. & Thomas J. (2012) An Introduction to Systematic Reviews. Sage p. 4

15. Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle P. & Stewart L. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews 4(1).

16. National Institute for Clinical Excellence (2015). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Retrieved November 13, 2015, from https://www.nice.org.uk/guidance/ng5

17. Godfrey, C.M., Harrison, M.B., Lang, A., Macdonald, M., Leung, T., & Swab M. (2013). Homecare safety and medication management with older adults: A scoping review of the quantitative and qualitative evidence. JBI Database of Systematic Reviews and Implementation Reports, 11(7), 82-110.

18. Wang, T., & Biederman, S. (2012). Enhance the accuracy of medication histories for the elderly by using an electronic medication checklist. Perspectives in Health Information Management. 9(Fall), 1-15.