Discharge Medication List Research Articles

Impact of a pharmacy student-driven medication delivery service at hospital discharge.

A pharmacy student-driven discharge service developed for patients to reduce the number of medication errors on after-visit summaries (AVSs) is discussed. An audit of AVS documents was conducted before the implementation period (September 3 to October 23, 2013) to identify medication errors. As part of the audit, a pharmacist review of the discharge medication list was completed to determine the number and types of errors that occurred. A student-driven discharge service with AVS review was developed in collaboration with nursing and medical residents. Students reviewed a patient's AVS, delivered the discharge prescriptions to bedside, and conducted medication reconciliation with the patient and family. The AVS audit was conducted after implementation of these services to assess the impact on medication errors. It was observed that 72% (108 of 150) of AVSs contained at least 1 error before discharge and AVS review. During the 2-month postimplementation period (September 3 to October 23, 2014), this decreased to 27% (34 of 127), resulting in a 52% absolute reduction in the number of AVSs with at least 1 medication error (p < 0.0001). The most common error was as-needed medication with no indication, which decreased from 55% in the preimplementation audit to 16% in the postimplementation audit. Prescribing to Nationwide Children's Hospital's outpatient pharmacy increased from 57% in the preimplementation period to 73% in the postimplementation period for the general pediatrics service. A pharmacy student-driven discharge and medication delivery service reduced the number of AVSs and increased access to medications for patients.

The effect of the TIM program (Transfer ICU Medication reconciliation) on medication transfer errors in two Dutch intensive care units: design of a prospective 8-month observational study with a before and after period

BackgroundThe transfer of patients to and from the Intensive Care Unit (ICU) is prone to medication errors. The aim of the present study is to determine whether the number of medication errors at ICU admission and discharge and the associated potential harm and costs are reduced by using the Transfer ICU and Medication reconciliation (TIM) program.MethodsThis prospective 8-month observational study with a pre- and post-design will assess the effects of the TIM program compared with usual care in two Dutch hospitals. Patients will be included if they are using at least one drug before hospital admission and will stay in the ICU for at least 24 h. They are excluded if they are transferred to another hospital, admitted and discharged in the same weekend or unable to communicate in Dutch or English.In the TIM program, a clinical pharmacist reconciles patient’s medication history within 24 h after ICU admission, resulting in a “best possible” medication history and presents it to the ICU doctor. At ICU discharge the clinical pharmacist reconciles the prescribed ICU medication and the medication history with the ICU doctor, resulting in an ICU discharge medication list with medication prescription recommendations for the general ward doctor. Primary outcome measures are the proportions of patients with one or more medication transfer errors 24 h after ICU admission and 24 h after ICU discharge. Secondary outcome measures are the proportion of patients with potential adverse drug events, the severity of potential adverse drug events and the associated costs.For the primary outcome relative risks and 95% confidence intervals will be calculated.DiscussionStrengths of this study are the tailor-made design of the TIM program and two participating hospitals. This study also has some limitations: A potential selection bias since this program is not performed during the weekends, collecting of potential rather than actual adverse drug events and finally a relatively short study period.Nevertheless, the findings of this study will provide valuable information on a crucial safety intervention in the ICU.Trial registrationDutch trial register: NTR4159, 5 September 2013

Prerequisites for patient self-management learning at hospital discharge – an observational multiple case study

Introduction : In recent years much attention has been given to care transitions between healthcare settings and to re-hospitalizations. This is not without reason. Errors in medication, therapy, and in follow-up of tests and procedures following hospitalization are not uncommon and the associated costs are profound. Putting effort on increasing patients’ knowledge on disease control and symptom management has shown an effect on decreased re-hospitalization rates. Yet, little is known about how the information aimed to prepare patients are given to patients during hospital discharge, and how the information make sense to the patients. This study aims to explore how the hospital discharge process provides a learning environment for patients’ understanding of their self-management. Theory/Methods : This study uses observational multiple-case study design. The cases – three wards of internal medicine from different hospital types: one regional, one general and one university hospital, all located in the county council of Stockholm, Sweden – were selected to allow inclusion of patients with varying diagnoses and backgrounds. The observations primarily focused on the discharge encounters but included other events where patient self-management learning was considered to either take place or be discussed: medical distribution, bedside rounds, formal/informal meetings between patients and healthcare professionals. After the observed discharge encounters, patients and their present next-of-kin who agreed to participate in the study, and thereafter the discharging healthcare professional were interviewed. Semi-structured interview guides were used. Data was analysed using cross-case synthesis in which the case under study at each units first were analysed separately, using content analysis, where after the analyses were compared and cross-case conclusions drawn. Results : The wards were overall similar in the prerequisites for patient understanding of self-management in the hospital discharge process. Patient understanding of self-management were supported or constrained during the medical distribution by the registered nurses, the bedside rounds and the discharge encounters. Each of these encounters provided opportunities for the patients to learn about self-management, and for the healthcare professionals to gain and provide information to support the patients’ self-management. Patients were not involved in the decisions preceding discharge. The bed-side rounds overall focused on giving informations to patients and not on involving patients in the communication. The short hospital stays were considered as barriers for patient self-management learning; the patients were too stressed at the discharge encounters to grasp the information and the healthcare professionals lacked time to grasp the patients’ situation and needs. The healthcare professionals used several pedagogical efforts to facilitate patient understanding. The efforts were however not a conscious thought-through strategy and the professionals expressed uncertainty whether the patients had understood the information or not. Upon discharge, patients received a plain language written discharge note and medication list. The oral information followed the structure of the discharge letter, omitting self-management activities. Patients’ made several efforts to facilitate their understanding, they checked that they had understood the healthcare professional, asked for clarification and confirmed when they had understood. Discussion : The discharge letter constituted the base of the discharge information, as both the oral and written information given by the physician sprung out of the letter. As we found that the discharge letter overall had a retrospective focus it only gives patients limited understanding of self-management activities post-discharge. Much time and effort was put into providing patients with accurate information and to facilitate the practical details of the discharge. However, only a small amount of effort was given to involve patients in the decisions, to ensure that patients had understood the information and had the skills to manage the self-management needed. Evidence suggests that information alone does not promote patient adherence to medications. A targeted, person-centred communication, in order to reach common ground for decision-making, is far from realized in healthcare. In contrast we found that patients were not actively involved in the planning of their discharge, and that sensemaking rarely came through in the discharge encounters. Conclusion : The information given at discharge was driven by the needs of the staff of communicating information, rather than patients´ needs or level of understanding. Simple use of pedagogical teaching and patients’ involvement in the decisions preceding discharges with the aim of ensuring patient understanding has the potential to enhance patient self-management knowledge, whereas a system accountability overlapping the gaps could provide patients with comfort to put knowledge into action.

Reduction of 30-Day Hospital Readmissions After Patient-centric Telephonic Medication Therapy Management Services.

Background: Transitional care programs are a growing topic in health care systems across the country, with a focus on achieving a reduction in hospital readmissions and improving patient and medication safety. Numerous strategies have been employed and studied to determine successful approaches to patient transition from the hospital setting to the home setting. Pharmacist-mediated postdischarge telephonic outreach has demonstrated decreased hospital readmission rates in multiple hospital systems. Objective: To evaluate the effectiveness of pharmacist-facilitated telephonic medication therapy management (MTM) services on reducing hospital readmissions. Methods: A retrospective chart analysis (n = 314) was performed for patients who received MTM services following hospital discharge between February 23, 2014 and July 4, 2014. The primary outcome was 30-day all-cause readmission. The secondary outcomes were identification of pharmacist interventions for and recommendations about medication-related problems and discrepancies found between the patients' reported medication list and the hospital discharge medication list. Results: The data revealed no statistically significant difference in hospital readmission rates between the intervention and control groups (odds ratio,1.04; 95% CI, 0.68-1.60). Pharmacists intervened on 189 medication-related problems via facsimile to the prescriber (35.7% of charts), contacted prescribers by phone for 23 medication-related or health-related issues, and identified 823 medication list discrepancies (78.34% of charts). Conclusion: Although the provision of telephonic MTM services by pharmacists did not result in an improvement in the readmission rate during this study period, pharmacists were able to intervene on numerous medication-related problems and medication list discrepancies.

Optimizing the Use of Discharge Medication Lists in Nursing Facilities.

To highlight the need to optimize the use of discharge medication lists in nursing facilities. In January 2014, the care transitions (CT) pharmacists at Frederick Memorial Hospital, Frederick, Maryland, began a pilot project in which they identified and followed high-risk patients transitioning from hospital to nursing facility and from nursing facility to home. This pilot project served as a needs assessment to identify opportunities to improve patients' transition from nursing facility to home with the goal of reducing hospital readmissions. One of the enormous opportunities that were immediately recognized was the nursing facility discharge medication list. The CT pharmacists found that patients had difficulty deciphering and understanding the medication lists. By reviewing the elements of existing medication lists, the CT pharmacists identified 11 components of a nursing facility discharge medication list that would increase patient safety and potentially reduce medication-related hospital readmissions. These elements include the capability of electronically generating a medication list that includes both brand and generic medication names with accurate indications in layperson terms. The ideal discharge medication list would also be patient-specific and remove irrelevant information and take into consideration patients' age, vision, and health literacy. With the upcoming implementation of the nursing facility value-based purchasing program, nursing facilities may soon receive incentives to improve their medication management systems at discharge.

Incorporating a Pharmacist Into the Discharge Process: A Unit-Based Transitions of Care Pilot.

Objective: To evaluate the impact of a multifaceted, pharmacy-driven, unit-based transitions of care (TOC) program on all-cause 30-day readmission rates and to assess readmission rates in predefined subgroup patient populations. Methods: This prospective study included adult patients who were discharged from the pilot unit from January 5 to January 30, 2015. Patients who expired during hospitalization, left the hospital against medical advice, or transferred to another unit or nonaffiliated hospital were excluded. Possible pharmacist interventions included daily medication profile review, delivery of discharge medications to the bedside, counseling, and communication of a discharge medication list to follow-up providers. Patients had a 30-day follow-up period from the date of discharge to assess for readmission. Results: A total of 131 patients were screened and 94 patients were included. The primary outcome evaluating 30-day readmission rates occurred in 12.8% of patients in the pilot group versus 18.8% of patients in the historical control group (p = .26). None of the patients who received all possible pharmacist interventions were readmitted. Secondary outcomes assessing readmission rates in predefined subgroup populations as well as length of stay were comparable between the 2 groups. All identified medication discrepancies were resolved prior to discharge. Conclusion: Readmission rates during the pilot were numerically lower but not statistically significant when compared with historical data. Enhancement of the pharmacy-driven TOC services through allocation of additional resources is in progress. Further investigation is warranted to determine the impact of a TOC pharmacist after the service is sustained.

Prevalence of Beers Criteria Medications Among Elderly Patients in a Military Hospital.

Objective: This study aims to examine potentially inappropriate medication (PIM) prevalence and factors that affect the use of PIMs in a military treatment facility. Method: Admission and discharge medication lists of 60 patients aged ≥65 years were retrospectively reviewed by a clinical pharmacist and a member of the study team for the presence of PIM using the 2012 Beers Criteria. Patients included were those discharged between December 2012 and September 2013 from the Womack Army Medical Center, Internal Medicine unit. Results: Among the 60 patients evaluated, 44 (73%) were on at least one PIM at admission, whereas the prevalence of PIM at discharge (30 patients) was 50% (p < .001). The top three classes of PIM at admission were antihistamines (11, 15.3%), nonsteroidal anti-inflammatory drugs (10, 13.9%), and benzodiazepines (6, 8.3%). Patients on >10 medications at admission (37, 62%) were 4 times more likely to have a PIM (p < .001). Conclusion: Data showed a high and a previously unknown PIM prevalence among older adults in a U.S. military treatment facility.

A Medical Resident–Pharmacist Collaboration Improves the Rate of Medication Reconciliation Verification at Discharge

At the Hospital of the University of Pennsylvania (Philadelphia), it is standard practice to perform medication reconciliation at patient discharge. Although pharmacists historically were available to assist resident physicians in the discharge medication reconciliation process, the process was never standardized. An internal review showed a 60%-70% rate of pharmacist review of discharge medication lists, potentially enabling medication errors to go unnoticed during transitions of care. In response, a medical resident- and pharmacist-led collaboration was designed, and a pre-post-intervention study was conducted to assess its effectiveness. A new work flow was established in which house staff notified pharmacists when a preliminary discharge medication list was ready for reconciliation and provided access for pharmacists to correct medication errors in the electronic discharge document with physician approval. Length of stay, average time of day of patient discharge, and readmission data were compared in the pre- and post-intervention periods. There were 981 discharges in the preintervention period and 1,207 in the postintervention period. The rate of pharmacist reconciliation increased from 64.0% to 82.4% after the intervention (p<.0001). The average number of errors identified and corrected by pharmacists decreased from 0.979 to 0.862 per discharge (p<.0001). There was no significant change in readmission rates or time of discharge after the intervention. Redesigning the discharge medication reconciliation process in a teaching hospital to include a review of medical resident discharge medication lists by pharmacists provided more opportunities for discharge medication error identification and correction.

Medication Discrepancies and Associated Risk Factors Identified in Home Health patients.

Medication discrepancies can place patients at increased risk for adverse drug events. We sought to determine the frequency, type, and reason for medication discrepancies in patients receiving home healthcare following hospital discharge. We conducted a retrospective, observational study of adults discharged from an academic medical center who received home healthcare following hospital discharge from one affiliated home healthcare agency. Medication discrepancies were identified by comparing the hospital discharge medication list to what the patient was taking at the first home healthcare visit. Almost all patients (66/70, 94%) had at least one medication discrepancy. The median number of discrepancies per patient was 5. Nearly half of the discrepancies were omissions (46%), in which the patient was not taking a medication on the discharge medication list. Increased age was significantly associated with fewer medication discrepancies overall (IRR = 0.99, p < 0.05). Higher health literacy was associated with more omissions (IRR = 1.85, p < 0.05).

Medication discrepancies and associated risk factors identified among elderly patients discharged from a tertiary hospital in Singapore.

Medication discrepancies and poor documentation of medication changes (e.g. lack of justification for medication change) in physician discharge summaries can lead to preventable medication errors and adverse outcomes. This study aimed to identify and characterise discrepancies between preadmission and discharge medication lists, to identify associated risk factors, and in cases of intentional medication discrepancies, to determine the adequacy of the physician discharge summaries in documenting reasons for the changes. A retrospective clinical record review of 150 consecutive elderly patients was done to estimate the number of medication discrepancies between preadmission and discharge medication lists. The two lists were compared for discrepancies (addition, omission or duplication of medications, and/or a change in dosage, frequency or formulation of medication). The patients' clinical records and physician discharge summaries were reviewed to determine whether the discrepancies found were intentional or unintentional. Physician discharge summaries were reviewed to determine if the physicians endorsed and documented reasons for all intentional medication changes. A total of 279 medication discrepancies were identified, of which 42 were unintentional medication discrepancies (35 were related to omission/addition of a medication and seven were related to a change in medication dosage/frequency) and 237 were documented intentional discrepancies. Omission of the baseline medication was the most common unintentional discrepancy. No reasons were provided in the physician discharge summaries for 54 (22.8%) of the intentional discrepancies. Unintentional medication discrepancies are a common occurrence at hospital discharge. Physician discharge summaries often do not have adequate information on the reasons for medication changes.

Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle.

In 2008, Kaiser Permanente Northwest identified the transition from hospital to home as a pivotal quality improvement opportunity and used multiple patient-centered data collection methods to identify unmet needs contributing to preventable readmissions. A transitional care bundle that crosses care settings and organizational functions was developed to meet needs expressed by patients. It comprises 5 elements: risk stratification, a specialized phone number for discharged patients, timely postdischarge follow-up, standardized patient discharge instructions and same-day discharge summaries, and pharmacist-supported medication reconciliation. The transitional care bundle has been in place for 6 years. Readmission rates decreased from 12.1% to 10.6%, Hospital Consumer Assessment of Healthcare Providers and Systems scores for the discharge instruction composite moved from below the 50(th) to above the 90(th) national percentile, average time to the first postdischarge appointment decreased from 9.7 days to 5.3 days, and error rates on the discharge medication list decreased from 57% to 21% (P<.0001 for all). The program, which continues to evolve to address sustainability challenges and organizational initiatives, suggests the potential of a multicomponent, patient-centered care bundle to address the complex, interrelated drivers of preventable readmissions.

Pharmacist-managed inpatient discharge medication reconciliation: A combined onsite and telepharmacy model

The development, implementation, and pilot testing of a discharge medication reconciliation service managed by pharmacists with offsite telepharmacy support are described. Hospitals' efforts to prepare legible, complete, and accurate medication lists to patients prior to discharge continue to be complicated by staffing and time constraints and suboptimal information technology. To address these challenges, the pharmacy department at a 324-bed community hospital initiated a quality-improvement project to optimize patients' discharge medication lists while addressing problems that often resulted in confusing, incomplete, or inaccurate lists. A subcommittee of the hospital's pharmacy and therapeutics committee led the development of a revised medication reconciliation process designed to streamline and improve the accuracy and utility of discharge medication documents, with subsequent implementation of a new service model encompassing both onsite and remote pharmacists. The new process and service were evaluated on selected patient care units in a 19-month pilot project requiring collaboration by physicians, nurses, case managers, pharmacists, and an outpatient prescription drug database vendor. During the pilot testing period, 6402 comprehensive reconciled discharge medication lists were prepared; 634 documented discrepancies or medication errors were detected. The majority of identified problems were in three categories: unreconciled medication orders (31%), order clarification (25%), and duplicate orders (12%). The most problematic medications were the opioids, cardiovascular agents, and anticoagulants. A pharmacist-managed medication reconciliation service including onsite pharmacists and telepharmacy support was successful in improving the final discharge lists and documentation received by patients.

Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity.

To determine whether medication regimen complexity (MRC) could predict likelihood for occurrence of potential adverse drug events (ADEs), unplanned 30-day hospital readmission, or 30-day emergency department use in patients transitioning from hospital to home care. Hospital discharge medication lists and medication lists constructed during visits to patients' homes were analyzed for 213 participants. MRC was quantified with the Medication Regimen Complexity Index (MRCI). The potential for ADEs was based on medication discrepancies detected between the discharge and patient reported home medication lists. Unplanned acute care utilization in the 30 days after index hospitalization was tracked. Logistic regression analyses were used to approximate the odds for an ADE and postdischarge acute care utilization from MRCI scores. Home medication lists were less complex than hospital discharge medication lists. High home medication list MRCI scores increased the odds more than 4-fold for a potential ADE (P < 0.001). High discharge medication list MRCI scores increased the odds more than 5-fold for an unplanned 30-day hospital readmission (P = 0.026). High regimen complexity did not significantly elevate odds for emergency department use. MRC was predictive of patients' potential for ADEs and unplanned hospital readmission. MRC may be useful in identifying patients that would benefit from additional transitional care interventions. Results indicate that simplifying medication regimens may favorably impact postdischarge outcomes.

Effect of a care transition intervention by pharmacists: an RCT.

BackgroundPharmacists may improve medication-related outcomes during transitions of care. The aim of the Iowa Continuity of Care Study was to determine if a pharmacist case manager (PCM) providing a faxed discharge medication care plan from a tertiary care institution to primary care could improve medication appropriateness and reduce adverse events, rehospitalization and emergency department visits.MethodsDesign. Randomized, controlled trial of 945 participants assigned to enhanced, minimal and usual care groups conducted 2007 to 2012. Subjects. Participants with cardiovascular-related conditions and/or asthma or chronic obstructive pulmonary disease were recruited from the University of Iowa Hospital and Clinics following admission to general medicine, family medicine, cardiology or orthopedics. Intervention. The minimal group received admission history, medication reconciliation, patient education, discharge medication list and medication recommendations to inpatient team. The enhanced group also received a faxed medication care plan to their community physician and pharmacy and telephone call 3–5 days post-discharge. Participants were followed for 90 days post-discharge. Main Outcomes and Measures. Medication appropriateness index (MAI), adverse events, adverse drug events and post-discharge healthcare utilization were compared by study group using linear and logistic regression, as models accommodating random effects due to pharmacists indicated little clustering.ResultsStudy groups were similar at baseline and the intervention fidelity was high. There were no statistically significant differences by study group in medication appropriateness, adverse events or adverse drug events at discharge, 30-day and 90-day post-discharge. The average MAI per medication as 0.53 at discharge and increased to 0.75 at 90 days, and this was true across all study groups. Post-discharge, about 16% of all participants experienced an adverse event, and this did not differ by study group (p > 0.05). Almost one-third of all participants had any type of healthcare utilization within 30 days post-discharge, where 15% of all participants had a 30-day readmission. Healthcare utilization post-discharge was not statistically significant different at 30 or 90 days by study group.ConclusionThe pharmacist case manager did not affect medication use outcomes post-discharge perhaps because quality of care measures were high in all study groups.Trial registrationClinicaltrials.gov registration: NCT00513903, August 7, 2007.

P18.03 * PATIENT FEEDBACK INTERVIEWS FOR DEVELOPMENT OF DISCHARGE PROCEDURES

BACKGROUND: Discharging patients from the hospital is a complex process. A survey revealed that about one-third of dismissed neurosurgical patients did not have a concluding consultation (32 %), an accurate discharge medication list (28 %), or an updated information on relevant symptoms requiring a follow-up (28 %). Improving the quality of hospital discharges may prevent re-hospitalization and has the potential to improve the quality-of-life for patients. PURPOSE: To highlight the priorities and experiences of patients and next of kin at discharge after intracranial neurosurgery in order to improve discharge procedures with incorporation of major key elements. METHODS: Direct staff-to-patient feedback discussions were based on a semi-structured interview template presented to patient discharged within two month after intracranial neurosurgery. Patients and next of kin were grouped with independent interviewers and instructed to elaborate lists of priorities regarding 1) good-experience events, 2) things that went wrong, 3) experience of discharge process, 4) reconciliation with discharge, 5) quality of post-discharge care. RESULTS: The response of patients and next of kin could be categorized into three main themes: 1) in-hospital information and patient involvement in the process of discharge, 2) post-discharge support and plans, 3) reconciliation with discharge. Typical discontent focused on not to be informed of test results (i.e. simple blood pressure measurements), being asked the same questions over again, and lack of advise concerning treatment opportunities. Also more involvement of next of kin and a follow-up consultation at about two weeks after discharge was warranted. In addition, patients felt that provisions for follow-up care were often inadequate. PERSPECTIVES: Responses from the interviews suggest that development of discharge checklists may favorably focus on 1) univocal in-hospital information about procedures, tests and medication, 2) involvement of patient and next of kin in individualized discharge plans, 3) determination of the need and site of post-discharge care. Development of personalized discharge checklists may improve patient outcome and diminish rate of re-hospitalization.

Characteristics Associated With Postdischarge Medication Errors

ObjectiveTo examine the association of patient- and medication-related factors with postdischarge medication errors. Patients and MethodsThe Vanderbilt Inpatient Cohort Study includes adults hospitalized with acute coronary syndromes and/or acute decompensated heart failure. We measured health literacy, subjective numeracy, marital status, cognition, social support, educational attainment, income, depression, global health status, and medication adherence in patients enrolled from October 1, 2011, through August 31, 2012. We used binomial logistic regression to determine predictors of discordance between the discharge medication list and the patient-reported list during postdischarge medication review. ResultsAmong 471 patients (mean age, 59 years), the mean total number of medications reported was 12, and 79 patients (16.8%) had inadequate or marginal health literacy. A total of 242 patients (51.4%) were taking 1 or more discordant medication (ie, appeared on either the discharge list or patient-reported list but not both), 129 (27.4%) failed to report a medication on their discharge list, and 168 (35.7%) reported a medication not on their discharge list. In addition, 279 participants (59.2%) had a misunderstanding in indication, dose, or frequency in a cardiac medication. In multivariable analyses, higher subjective numeracy (odds ratio [OR], 0.81; 95% CI, 0.67-0.98) was associated with lower odds of having discordant medications. For cardiac medications, participants with higher health literacy (OR, 0.84; 95% CI, 0.74-0.95), with higher subjective numeracy (OR, 0.77; 95% CI, 0.63-0.95), and who were female (OR, 0.60; 95% CI, 0.46-0.78) had lower odds of misunderstandings in indication, dose, or frequency. ConclusionMedication errors are present in approximately half of patients after hospital discharge and are more common among patients with lower numeracy or health literacy.

Multidisciplinary team puts the ‘home’ in hospital-to-home

Kim Thrasher, PharmD, BCPS, CPP, recently received a call from a care manager at Community Care of the Lower Cape Fear (CCLCF) about a medically fragile 2-year-old patient. The child had had numerous hospitalizations and was on multiple chronic medications. Most recently, the child had been discharged from the hospital after being on a ventilator and receiving narcotics for several weeks. She was discharged with a 36-hour supply of compounded methadone solution to combat withdrawal symptoms.

Change in Readmissions and Follow-up Visits as Part of a Heart Failure Readmission Quality Improvement Initiative

ObjectivesThe study objectives were to quantify the change in 7-day follow-up visits and 30-day readmissions as part of a hospital quality improvement initiative and to characterize events at 7-day follow-up visits. Some data suggest that outpatient assessments of patients with heart failure within 7 days of hospital discharge may prevent readmissions, although little is known about patient needs at 7-day follow-up visits. MethodsWe performed a single-center, retrospective chart review of all heart failure discharges at the University of Connecticut Health Center (398 patients) the year before (2008) and the year after (2011) a quality improvement initiative that included mandatory 7-day follow-up visits. We quantified the change in 30-day readmission rate after the initiative, frequency of 7-day follow-up visits, and events at follow-up visits. ResultsThe average age of patients with heart failure was 79.9 years in 2011, with 45.9% having systolic heart failure. Thirty-day all-cause readmissions decreased from 27.5% to 19.1% after our quality improvement initiative (P = .024). Frequency of 7-day follow-up visits increased from 19.6% to 46.9% (P < .01). Eighty-one percent of 7-day visits occurred in the University of Connecticut Heart Failure Center with a cardiologist or heart failure nurse practitioner. Fifty-one percent of patients had blood work drawn, and 26% had a medication dose changed. Only 13% of patients had no discrepancy between the discharge and follow-up medication lists. ConclusionsOur hospital's 30-day readmission rate for patients with heart failure decreased in parallel with an increase in 7-day follow-up visits. Patients with heart failure were complex and often had diagnostic testing and medication changes at follow-up visits.

Underutilization of cardiovascular medications: Effect of a continuity-of-care program

The effect of hospital pharmacists' enhanced communication with patients and community providers on the underutilization of key cardiovascular medications was studied. Patients enrolled in the Iowa Continuity of Care study were eligible for inclusion in this study if they had a diagnosis of hypertension, hyperlipidemia, heart failure, coronary artery disease, or a combination of these diagnoses. Eligible patients also had to be admitted to the internal medicine, family medicine, cardiology, or orthopedics services and receive their usual medical care in the community and their prescriptions from a community pharmacy. Patients were randomized to receive minimal intervention, enhanced intervention, or usual care. For the minimal- and enhanced-intervention groups, pharmacy case managers (PCMs) performed comprehensive medication reconciliations and identified drug-related problems within 24 hours of admission. The PCMs made recommendations to the inpatient care team and to patients' community physicians. For patients in the enhanced-intervention group, the PCM developed a discharge care plan containing the patient's discharge medication list. PCMs made specific recommendations to optimize regimens that did not meet current guidelines or medications that were underutilized. Medication underutilization was assessed at admission, discharge, 30 days after discharge, and 90 days after discharge. A total of 732 patients were enrolled in this study. There were no significant differences among the three study groups. Overall, the rate of underutilization remained constant among all three groups, despite enhanced pharmacist involvement in both intervention groups. Enhanced interventions by PCMs had no effect on the underutilization of key cardiovascular drugs during hospitalization or after hospital discharge.

Potentially Inappropriate Prescribing in Patients on Admission and Discharge from an Older Peoples’ Unit of an Acute UK Hospital

The Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) classifies 65 common drug issues found to contribute to inappropriate prescribing in the elderly. International studies using STOPP criteria indicate high potentially inappropriate medication (PIM) prevalence rates; however, no studies have been conducted in older patients in UK hospitals. Published literature has not assessed whether prescribers attempt to minimise the potential risk of PIMs by putting in place follow-up or review plans. The objectives of this study were (1) to determine prevalence and types of PIMs in older people admitted to and discharged from a UK hospital; and (2) to determine how often PIMs prescribed on discharge are accompanied by a plan for follow-up. This was a retrospective, non-randomised study conducted in the Specialist Health and Ageing Unit (HAU) of a 950-bed acute hospital trust in England, UK. The subjects were patients aged ≥65 years admitted to the HAU in June and July 2011. Data were obtained by applying STOPP criteria to electronic admission and discharge medication lists. Parametric and non-parametric tests were performed to assess variables and to detect differences between groups. A PIM index was calculated by dividing the total number of PIMs by the total number of medications. Medication lists for 195 patients were assessed. Median age was 85.5 years. The median number of admission medicines was nine. A total of 66 patients (34 %) were prescribed more than ten medications. The median number of discharge medicines was ten, with 80 patients (41 %) prescribed more than ten medicines. Admission PIM prevalence was 26.7 % (95 % CI 20.5-32.9; 52 patients, 74 PIMs). The most common PIM categories on admission were central nervous system (CNS) and psychotropic drugs, drugs adversely affecting patients at risk of falls and drugs acting on the urogenital system. The likelihood of having a PIM on admission was doubled in patients receiving more than ten medications compared with those taking fewer (odds ratio 2.3 [95 % CI 1.2-4.4]; p = 0.01). Discharge PIM prevalence was 22.6 % (95 % CI 16.7-28.5; 44 patients, 51 PIMs). PIMs reduced significantly on discharge (p = 0.005). The most common discharge PIMs were drugs adversely affecting patients at risk of falls, CNS and psychotropics, urogenital drugs and cardiovascular agents. Advice for general practitioners to monitor medication was documented on the discharge summary of three patients. An index was developed, based on the ratio of PIMs to medication totals. The PIM index complements the assessment of PIM prevalence and allows comparison of prescribing appropriateness between populations and between studies by taking into account the total amount of prescribed medication. Despite an increase in medication prescribed, the PIM index (rate) decreased from 0.043 on admission to 0.027 at discharge. Admission to a specialist HAU was associated with a significant reduction in PIMS. Very few patients discharged with a PIM had a documented follow-up plan. PIM prevalence was lower than published rates found internationally. Similar studies in settings of varying types across the UK are needed.