Implementation of a Targeted Pharmacy
Discharge Medication Review Pilot
Kaitlyn Kastberg, PharmD | PGY1 Pharmacy Resident
Community Health Network | Indianapolis, IN
Project Preceptors:
Eileen Rohrbach, PharmD, BCPS | Clinical Pharmacy Specialist
Eric Lis, PharmD, BCPS | Senior Clinical Pharmacist
Sarah Lackey, PharmD, BCPS | Director of Clinical Pharmacy
Conflicts of Interest
• The speaker has no actual or potential conflict of interest in relation to this
presentation
• The project preceptors have no actual or potential conflict of interest in
relation to this presentation
Abbreviations
• CHNw = Community Health Network
• CHE = Community Hospital East
• CHRH = Community Howard Regional Hospital
• CHVH = Community Heart and Vascular Hospital
• AHRQ = Agency for Healthcare Resource and Quality
• ISMP = Institute for Safe Medication Practices
• EMR = Electronic Medical Record
• DMR = Discharge Medication Review
• ADR = Adverse Drug Reaction
• ACO = Accountable Care Organization
3
Background
Patient Safety
Medication Reconciliation is a 2022 Joint
Commission Patient Safety Goal
According to AHRQ, ~20% of patients experience
at least one ADR within 3 weeks of discharge
5
Literature
Michaelsen et al (2015)
• A systematic review that looked at 15 studies focused on discharge medication
reconciliation
• Discrepancy range was 20-87%
• Positive association between number of medications and the number of discrepancies
Rafferty et al (2016)
• Prospective study evaluating the effect of pharmacist-led admission and discharge
medication review on 30-day re-presentation rates
• Absolute reduction of 11% and a relative reduction of 50.2%
• A statistically significant reduction in re-presentations was sustained at day 60, 90, and
365
Michaelsen et al. Pharmacy (Basel). 2015;3(2):53-71. 6
Rafferty et al. Ann Pharmacother. 2016;50(8):649-655
ISMP High-Alert Medications
Acute Care Ambulatory Care Long-Term Care
• IV antiarrhythmics • Antithrombotic • Anti-Parkinson’s
• Adrenergic agonists agents** agents
and antagonists • Immunosuppressants • Antithrombotic
• Antithrombotic • Insulin** agents**
agents** • GABA analogs
• Teratogens
• IV inotropes
• Opioids** • Immunosuppressants
• Insulin**
• Lamotrigine • Insulin**
• Opioids**
• TPN • Opioids**
** on all 3 high-alert lists 7
Methods
Community Health Network
• 6 hospitals across central Indiana
• ~150 beds at CHRH
• ~200 beds at CHE
9
CHNw’s Current DMR State
DMRs are already
Medicare ACO patients
completed at CHRH
with CHF, COPD, and
and on select patients
DM admissions
at CHVH
10
Quality Improvement Process
11
Selecting the Five Areas for Targeted DMR
• Pilot #1 was started at CHRH in Fall 2020. Intervention data from January
2022 – May 2022 was reviewed.
Antibiotics Anticoagulants Insulin
CrCl < 30
Steroids
mL/min
12
Creating a Patient List
13
Inclusion and Exclusion Criteria
1. Discharging from 1. Transferring to
a hospitalist service another facility
2. Discharging
during clinical
pharmacy coverage
hours (0800-1600)
14
Process Overview
Pharmacist
Provider contacts
Pharmacist Document
completes discharging
reviews the intervention
discharge provider with
discharge (even if not
medication any
medication list accepted)
reconciliation recommendation
s
15
AIM Statement
To review 50% of patients who have a medication
that is at high-risk of being error-prone at discharge
Results
Patients Reviewed
37 patients with 42 total 38 interventions
interventions interventions accepted
195 patients
reviewed
158 reviewed
without
intervention
18
Interventions by DMR Category
33%
43%
2%
5%
17%
Antibiotics Anticoagulants Insulin
Steroids Other
19
Interventions by Type
2%
12%
36%
19%
5%
5%
21%
Duration Dosing Cost Duplicate Omission Therapeutic Choice Pharmacy
20
High Impact Interventions
Discontinued discharge antibiotics when the patient had
received adequate therapy
Discontinued tramadol and bupropion on discharge in a
patient with known seizure history
Ensured new start warfarin continued on discharge
21
Discharge Order Placed to Patient Discharge
6.6
4.1
22
AIM Statement Progress
0% 33% 100%
Goal = 50% reviewed
23
Discussion
Barriers to Implementation
Manually identifying DMR patients
Variable time between discharge orders entered and patient
discharge
Fitting this process into current workload
25
Future Opportunities
Utilizing the
Rollout Expand the Expand the
Epic in-basket
process to scope of hours that
for discharge
other CHNw patients this service is
med rec
facilities reviewed offered
notifications
26
Conclusion
Discharge medication reconciliation is a key aspect of transitions of care, and
pharmacists have the opportunity to further improve CHNw’s current process.
As some DMR categories had few interventions related to them, the scope of
patients reviewed should be re-evaluated.
Further pharmacist resources are necessary to fully implement pharmacy
discharge medication review services.
27
Assessment Question #1
Which of the following is a potential outcome of implementing a pharmacy
discharge medication review?
A. Increased medication discrepancies at discharge
B. Decreased preventable medication adverse events
C. Increased hospital length of stay
D. Decreased communication between providers and pharmacists
28
Assessment Question #1
Which of the following is a potential outcome of implementing a pharmacy
discharge medication review?
A. Increased medication discrepancies at discharge
B. Decreased preventable medication adverse events
C. Increased hospital length of stay
D. Decreased communication between providers and pharmacists
29
Assessment Question #2
Which of the following medication classes is considered a high-alert
medication in acute care, ambulatory, and long-term care settings by ISMP?
A. Oral antiarrhythmics
B. Inhaled corticosteroids
C. Anticoagulants
D. Antidepressants
30
Assessment Question #2
Which of the following medication classes is considered a high-alert
medication in acute care, ambulatory, and long-term care settings by ISMP?
A. Oral antiarrhythmics
B. Inhaled corticosteroids
C. Anticoagulants
D. Antidepressants
31
References
1. National Patient Safety Goals Effective January 2022 for the Hospital Program. The Joint Commission. October 2021.
Accessed October 6, 2022.
https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_
hap_jan2022.pdf
.
2. Readmissions and Adverse Events After Discharge. AHRQ. September 7, 2019. Accessed October 6, 2022.
https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge#
3. Michaelsen MH, McCague P, Bradley CP, et al. Medication reconciliation at discharge from hospital: a systematic review
of the quantitative literature. Pharmacy (Basel). 2015;3(2):53-71. doi: 10.3390/pharmacy3020053
4. Rafferty A, Denslow S, Michalets EL. Pharmacist-Provided Medication Management in Interdisciplinary Transitions in a
Community Hospital (PMIT). Ann Pharmacother. 2016;50(8):649-655. doi: 10.1177/1060028016653139
5. High-Alert Medications in Acute Care Settings. Institute for Safe Medication Practices. August 23, 2018. Accessed January
17, 2023. https://www.ismp.org/recommendations/high-alert-medications-acute-list
6. High-Alert Medications in Community/Ambulatory Care Settings. Institute for Safe Medication Practices. September 30,
2021. Accessed January 17, 2023. https://
www.ismp.org/recommendations/high-alert-medications-community-ambulatory-list
7. High-Alert Medications in Long-Term Care (LTC) Settings. Institute for Safe Medication Practices. May 20, 2021. Accessed
January 17, 2023. https://www.ismp.org/recommendations/high-alert-medications-long-term-care-list
32
Implementation of a Targeted Pharmacy
Discharge Medication Review Pilot
Kaitlyn Kastberg, PharmD
[email protected]
Project Preceptors:
Eileen Rohrbach, PharmD, BCPS | Clinical Pharmacy Specialist
Eric Lis, PharmD, BCPS | Senior Clinical Pharmacist
Sarah Lackey, PharmD, BCPS | Director of Clinical Pharmacy
