Transitions of Care Medication Safety

Transitions of Care and Medication Safety

H. Edward Davidson, PharmD, MPH

Assistant Professor, Internal MedicineEastern Virginia Medical School

Partner, Insight Therapeutics, LLC

Current State of Healthcare

Care is complex Care is uncoordinated Information is often not available to

those who need it when they need it As a result patients often do not get

care they need or do get care they don’t need

IOM, Crossing the Quality Chasm

Transition of Care vs Transitional Care

The movement of patients from one practitioner or setting to another

Multiple levels• Within Settings

Primary care Specialty care

• Between Settings Hospital Home

• Across health states Curative care

Palliative care/Hospice

A set of actions ensuring the coordination and continuity of care as patients transfer between locations or levels of care

Includes:• Logistical arrangements• Education of the patient

and family• Coordination among the

health professionals involved in the transitionColeman E, et al. J Am Geriatr Soc 2003;51:556-7.

Ineffective Transitions Lead to Poor Outcomes

Wrong treatment Delay in diagnosis Severe adverse events Patient complaints Increased healthcare costs Increased length of stay

Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

Responsibilities of Health Professionals For Patients in

Transition •Stable

for transfer

•Patient/caregiver understand and are prepared

•Transfer information is complete

•Contact person’s name and number

Sending health care

team

•Review transfer information promptly and clarify

•Incorporate patient’s goals/preferences in care plan

•Document contact information

Receiving health care

team

(c) Eric A. Coleman, MD, MPH

Fundamental Disconnect…

Rehabilitation

HospiceHome

Ambulatory CareHospital

Nursing Facility

Patient

Outpatient Behavioral

Health Services

Transition Issues Dramatically Impact Patient

Care

PatientPatient

ERER ICUICU

In-PatientIn-Patient

PatientPatient

OUTPATIENT:• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver


SNFSNF ALFALF

Transition Issues Dramatically Impact Patient

Care

Patient

ER ICU

In-Patient

Patient


SNF ALF

NOMedication

Reconciliation

NOPersonal

Medicine List

NO Coordinated

Care Plan

NODischargeCare Plan

NO Care Plan

NO Medication Reconciliation

NO Personal Medicine List

NO Care Plan

NO Medication Reconciliation

NO Personal Medicine List

Barriers to Care Coordination

System level

barriers

Practitioner level barriers

Patient level

barriers


System Level Barriers

Practitioner Level Barriers

Practitioners often have not practiced in settings where they transfer patients

Sending practitioners may not communicate critical information to receiving practitioners

Practitioners may not know the patient and his or her preferences for care

Practitioners have no accountability(c) Eric A. Coleman, MD, MPH

Patient Level Barriers

Patients assume that someone is in charge of coordinating care

Patients (and caregivers) are often the only common thread weaving between care sites

Yet they navigate the system with few tools or training to manage in this role


The Epidemiology of Transitions of Care

Care Transitions Following Acute Care

Hospital

Home64%

77%13%

11%

Nursing

Facility

Hospital or TCU

16% 10%

74%

TCU = Transitional Care UnitColeman EA et al. Health Svcs Research 2004;37:1423-40

Predictors of Complicated Care Transitions

Heart disease Diabetes # of prior

hospitalizations Visual impairment Medicaid recipient Prior stroke

Coleman EA et al. Health Svcs Research 2004;37:1423-40.

Incr

easi

ng

Ris

k

Hospital Admission

On hospital admission, more than 50% of patients have at least one medication discrepancy*• Approximately 40% of those have

potential to cause harm

Cornish PL et al. Arch Intern Med 2005;165:424-9.

*Discrepancy defined as error between admission medication orders and patient interview of medication history.

Hospital Discharge

On discharge from the hospital

with possible or probable patient discomfort or clinical deterioration

* Most common discrepancy is incomplete prescription requiring clarification.

Wong JD, et al. Ann Pharmacother 2008;42:1373-9.

30% of patients have at least one medication discrepancy *

AHRQ Hospital Survey on Patient Safety Culture: 2007

Report

Hospital to Home

40% of patients experienced at least 1 medical error

Moore C et al. J Gen Intern Med 2003;18:646-51.

*Work-up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart).

Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 months

Medication Discrepancies: Hospital to SNFs Transitions

Tija et al. J Gen Intern Medicine 2009. Cross-sectional study of patients admitted

to SNF for subacute care (N=199, 2319 meds)

Results: • 21.3% of medication orders had a discrepancy• At least one discrepancy in 71.4% of patients• CV agents, opioid analgesics, neuropsychiatric

agents, hypoglycemics, antibiotics, and anticoagulants accounted for > 50% of all discrepancies

SNF=Skilled nursing facility

Hospital to PCP transfer

Meta-analysis Direct communication between hospital

physicians and primary care physicians occurred infrequently

Discharge summary • Availability at first postdischarge visit low (12%-

34%) • Remained poor at 4 weeks (51%-77%)• Affected quality of care in ~25% of follow-up

visits• Often lacked important information (e.g., lab

results, discharge medications, treatment, follow-up plan)Kripalani S et al. JAMA 2007;297:831-41.

The infant was discharged to home with Mom in car seat

Independent Risk Factors for Having a Preventable ADE in

NFs

Risk FactorOdds Ratio 95% CI

Male 0.55 0.30 - 0.99No. regularly scheduled meds

0-45-67-8>=9

1.01.73.22.9

Referent0.83 - 3.51.4 - 6.91.3 - 6.8

New resident+ 2.9 1.5 -5.7

+within 60 days of admission

Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.

Adverse Events in Nursing Home Residents Transferred to the

Hospital

122 nursing home to hospital transfers

98% returned to the nursing home In 86% of transfers, at least one

medication order was altered (mean 1.4)• 65% - discontinued• 19% - dose changes• 10% - substitutions

20% of changes resulted in an adverse eventBoockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.

Post-hospital Medication Discrepancies

Post-hospital medication review Compare what hospital told patient to take

versus what patient was actually taking One MDE completed for each discrepancy Results• Of the 375 patients, 14.1% experienced one or

more medication discrepancies• Patients who experienced a discrepancy

averaged 9 medications compared to 7 for those without a discrepancy (p<.001)

Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.

Patient-Level Contributing Factors

Non-intentional nonadherence 34%

Money/financial barriers 6%

Intentional nonadherence 5%

Didn’t fill prescription 5%

Other 1%

Subtotal 51%


System-Level Contributing Factors

D/C instructions incomplete/illegible

16%

Conflicting info from different sources

15%

Duplicative prescribing 8%

Incorrect label 4%

Other 7%

Subtotal 49%


Examples of Duplicative Prescribing

Institute for Safe Medication Practices

Therapeutic duplication with the same drug• Enalapril 10 mg daily; Vasotec 5 mg daily• Lopressor 50 mg one tablet twice a day; Toprol XL 50 mg

one tablet twice a day • Adalat 10 mg three times a day; Procardia XL 30 mg daily

Therapeutic duplication within a drug class• Pravachol 10 mg daily; Lipitor 10 mg daily• Hytrin 1 mg orally at bedtime; Cardura 1 mg daily

Therapeutic duplication with components of combination products• Enalapril 5 mg daily; Vaseretic one tablet daily• Hydrochlorothiazide 50 mg daily; Maxzide one capsule

daily

Clinical Practice Guidelines, the Elderly, and Multiple Comorbid

Conditions

Hypothetical 79 yr old woman with COPD, Type 2 DM, osteoarthritis, hypertension, and osteoporosis

If followed published CPGs would• Be prescribed 12 routine medications• Cost of $406/month

Implications in pay-for-performance initiatives• Increase risk of medication related problems• Different settings, different goals• Potential for diminished quality of care

Boyd CM et al. JAMA 2005;295:716-24.

OIG Report – June ‘07 Consecutive Medicare stays involving

inpatient and skilled nursing facilities in CY 2004

Key findings …• 35% of consecutive stays were associated

with quality-of-care problems and/or fragmentation of services

• 11% of individual stays within consecutive stay sequences involved problems with quality-of-care, admission, treatments or discharges

DHHS; OIG, June 2007; OEI-07-05-00340

Medication Errors Involving Reconciliation Failure

September 2004 – July 2005 MEDMARX Data (N=2022)

Site of Error

Admission Transition Discharge

Total 23% 67% 12%

U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.

Medication Error Type by Transition Category

Transition Category

Error Type AdmissionTransitio

nDischarg

e

Improper Dose/Quantity

55% 73% 62%

Prescribing Error 49% 36% 27%

Omission Error 35% 36% 76%


Case Examples of Medication Errors on

Admission Patient’s home medication recorded as Coreg® 25

mg twice daily on admission• Patient taking 6.25 mg twice daily at home• Patient received 4 doses of excessive strength and

developed leg edema• Error not discovered until after leg ultrasound test to

rule out DVT Nursing home patient receiving propranolol 20

mg/5mL twice daily• Admitting orders written as propranolol 20 mg/mL

give 5 mL (which equates to 100 mg) twice daily• Patient received 5 doses of 100 mg strength before

error was discovered


Case Examples of Medication Errors on Transition/Transfer

Patient with prior history of several arterial stent placements• Receiving aspirin, enoxaparin, clopidogrel• Meds placed on hold prior to surgery for removal of

toe; Physician did not reorder after surgery• 2 of patient’s coronary arteries with stents became

100% occluded; patient died Patient transferred from ICU to step-down unit

• Prior to transfer, patient received morning doses of scheduled meds

• Administration of same meds repeated upon arrival to new unit due to unclear documentation and communication


Role of Pharmacist Counseling in Preventing ADEs After

Hospitalization

Does pharmacist counseling before discharge reduce the rate of preventable ADEs?

Randomized controlled trial of pharmacist intervention (n=92) vs usual care (n=84)

Intervention on day of discharge• Medication reconciliation• Screening for nonadherence, previous drug-

related problems, lack of drug efficacy, and side effects

• Review of indications, directions for use, and potential side effects with patient Schnipper JL et al. Arch Intern Med 2006;166:565-71.

Study Outcomes: Pharmacist Intervention vs Usual Care

Outcome*

Pharmacist Intervention

(n=92)

Usual Care

(n=84) P ValueAdverse drug events, No. (%)

All 14/79 (18) 12/73 (16) >.99

Preventable 1/79 (1) 8/73 (11) .01

Health Care Utilization, No. (%)

ED visit or readmission 28/92 (30) 25/84 (30) >.99

Medication-related 4/92 (4) 8/84 (8) .36

Preventable medication-related

1/92 (1) 7/84 (8) .03

*Outcomes 30 days postdischarge

Schnipper JL et al. Arch Intern Med 2006;166:565-71.

Health Information Technology

Health Information Technology for Economic and Clinical Health Act (HITECH)• Part of the American Recovery and

Reinvestment Act of 2009 Electronic Health Record (EHR) and

Meaningful Use Criteria Health Information Exchange (HIE) Continuity of Care Document (CCD)

NTOCC: Barriers and Gaps in Supporting Transitions of Care

Lack of Connectivity

Lack of Shared Goals

Misaligned Incentives

Consumer Knowledge

Issues of Trust

The Leapfrog Group Study: CPOE

Hospital Type

# of medication

orders processed

% of medication orders that did not

receive an appropriate warning

Adult Hospitals (n=187) 8,716 52%

Pediatric Hospitals (n=37) 1,731 42.1%

Survey Period: June 2008-January 2010

http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf

The Leapfrog Group (cont.)

Hospital Type

# of potentially fatal errors processed

% of potentially fatal orders that did not

receive an appropriate warning

Adult Hospitals (n=187) 311 32.8%

Pediatric Hospitals (n=37) 62 33.9

Survey Period: June 2008-January 2010

http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf

Snow V et al. J Gen Intern Med 2009;24:971-6.

“Ideal Transition Record”(ACP, SGIM, SHM, AGS, ACEP, and

SAEM)

1. Primary, secondary diagnoses and problems list2. Medication list (reconciliation) including

OTC/other 3. Treatment and diagnostic plan 4. Clearly identifiable medical home/coordinating

and transferring MD/institution and contact information

5. Prognosis and outcome goals 6. Test results (available and pending)7. Patient cognitive status8. Advance directives, power of attorney, consent9. Planned interventions, med equipment, wound

care10. Emergency plan, contact information 11. Assessment of caregiver status

National Efforts

A Report from the HMO Care Management Workgroup

Supported by the Robert Wood Johnson Foundation

One Patient, Many Places:Managing Health Care

Transitions

Medication List Toolkit

CMS 9th Scope of Work

Care Coordination (3 measures)1) Global re-hospitalization rate2) Patient assessment of hospital discharge

performance (H-CAHPS items 17, 19, 20)3) Physician visit postdischarge, before re-

admission (within 30 days)

The Care Transitions Theme focuses on improving coordination across the continuum of care.

The Joint Commission National Patient Safety

Goals Goal 8: Accurately and completely reconcile

medications across the continuum of care• 8A: There is a process for comparing the

patient/resident’s current medications with those ordered for the patient/resident while under the care of the organization

• 8B: A complete list of the resident’s medications is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient/resident on discharge from the facility

The Joint Commission National Patient Safety Goals. Available at htt://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm

Working to Address the Issues

www.ntocc.org

Transition of Care Evaluation:Identifying Process Nodes

Case study: In a nursing home to hospital bi-directional transfer, you may consider that there are six exchanges• Exchange 1: Preparation in nursing home to

transfer patient to hospital (nursing home handover)

• Exchange 2: EMS/Ambulance transport• Exchange 3: Hospital receipt of patient• Exchange 4: Preparation in hospital to transfer

patient back to nursing home (hospital handover )• Exchange 5: EMS/Ambulance transport• Exchange 6: Nursing home receipt of patient

www.ntocc.org

Other Organizations at Work

Society of Hospital Medicine (Boost)

Boston Medical Center (Project

RED)

Centers for Medicare & Medicaid Services

American Medical

Directors Association

American College of Physicians

RAND – ACOVE measures

Role of the Pharmacist Play a key leadership role in medication

reconciliation Be involved in the design and

implementation of emerging medication safety technologies

Assist in evaluating your practice• Can it be improved with regard to transitions of

care issues? Pay special attention to patients in

transition – this is a vulnerable population

Transitions of Care Medication Safety

Documents

Transcript of Transitions of Care Medication Safety