Realization of medication history in the emergency departement

Transcription

1 Realization of medication history in the emergency departement Evaluation the impact of a hospital pharmacist on the medication history of patients admitted to emergency departments: a prospective interventional study Rosart Laurence Clinicamp may 2017 GRAND HÔPITAL de CHARLEROI

2 Table of contents 1. Background 2. Method 3. Results 4. Discussion 5. Bibliography

3 Who has already carried out medication history in the emergencies?

4 1. Background Getting a reliable and complete medication history is a real challenge in the emergency department. Acquiring the medication history has an impact during the patient s stay in the emergencies and during the rest of the hospitalization. Discrepancy: Differences between the medication history of the physician and that of the pharmacist

5 1. Objective Primary objective: Compare the medication history performed by the pharmacist with the medication history conducted by the emergency physician and identify any discrepancies Primary outcome: Percentage of patients with at least one divergence Secondary Outcome: Evaluation of the clinical impact of the identification of divergences

6 1. Objective Secondary objective: Measurement of the completeness, exhaustiviness, availability and accessibility of its main sources of information

7 2. Method Context Population Period Tools Process Prospective interventional study Mono-centric Grand Hôpital de Charleroi Emergencies of Notre-Dame and Saint-Joseph Organization: 1 pharmacist in the last year of a complementary master in hospital pharmacy Training at the Centre Hospitalier de Lunéville for 6 weeks and 6 weeks CHU UCL Namur

8 2. Method Context Population Period Tools Process Exclusion criterion: <18 years Incapacity or refusal to give consent Language barrier No drug prior to admission Presence of the patient outside the presence of the pharmacist in the emergency room Gynecology, psychiatry, traumatology

9 2. Method Context Population Period Tools Process January 9 to February 24, weeks of collect Presence of the pharmacist from 8 to 18h from Monday to Friday

10 2. Method Context Population Period Tools Process Form to compare the pharmacist's drug history with the drug history of the emergency physician Medication discrepancy tool Scale: To assign the clinical impact of identification of divergences by two pharmacists and 2 emergency physicians

11 2. Method Context Population Period Tools Process 1. Patient selection according to inclusion criteria 2. Medication history of the emergency physician 3. Analysis of the patient's computerized medical record by the pharmacist 4. Patient interview by pharmacist 5. Collection of information about treatments by the pharmacist 6. Comparison with the medication history by the emergency physician 7. Meeting with the emergency physician and proposed change in case of divergence(s) 8. Update of files by the pharmacist and the emergency physician

12 2. Method Context Population Period Tools Process

13 2. Method Context Population Period Tools Process Systematic for obtaining medication history by pharmacist: oanalysis of the patient's previous medical record opatient interview (and family) ocollection of informations from other sources: community pharmacy and primary care provider

14 2. Method Context Population Period Tools Process Discrepancies: oomission oaddition omissing: moment, frequency, dosage odifferent: moment, frequency, dosage oconfusion drug name oconfusion generic name and drug name

15 2. Method 2 pharmacists and 2 physicians assigned the clinical impact of identification of divergences according to the scale inspired by Hatoum scale. Score Context Population Period Tools Process Signification 0 No clinical impact for the patient: the intervention is either a financial or informative objective or has been proposed after the event; It is of no consequence to the patient 1 Significant impact: the intervention increases the effectiveness of the treatment and/or the safety of the patient and/or the quality of life of the patient 2 Very significant impact: the intervention prevents an organic dysfunction, it avoids an intensive medical supervision or an irreversible sequel 3 Vital impact: intervention avoids potentially fatal accident

16 2. Method Context Population Period Tools Process Measurement of the accessibility, availability, completeness and exhaustiveness oaccessibility: likely to give information oavailability: provides information during its consultation oexhaustiveness: the list include all drugs ocompleteness: the list include for each drug: the name, the dosage, the frequency and the moment of setting

17 2. Method Exercises

18 Situation: 11/05/17 : Mr Dupont A 45-year-old man arrives at the emergency room for rectorrhagia for 1 week. What is the first thing you do? Sources?

19 Tools

20 Tools

21 Medication history Are there any discrepancies? Which? How would you classify the impact of identification of discrepancies? Zocor? Paracétamol? Collargol?

22 Sources Are there enough sources? What is the most complete source? What is the most exhaustive source? What is the most available source? What is the most accessible source?

23 3. Results 163 patients included All patients admitted to the ER from Monday to Friday (100%, n= 2797) Patients admitted during pharmacist presence (67,93 %, n= 1900) Patients admitted outside pharmacist presence (32,07%, n= 897) Excluded: <18 years (33.05%, n = 628) No consent (1%, n = 19) Linguistic barrier (0.26%, n = 5) No drug (5.47%, n = 104) Lack of time (21.53%, n = 409) Ortho, psy, gynecologist (30.10%, n = 572) Included (8,58%, n=163)

24 3. Results 98.88% of patients have at least one drug discrepancy The most frequent were missing moment and omission Types of discrepancies n (%) (n total=163) Missing moment 627 (32,63 %) Omission 548 (28,78 %) Missing frequency 326 (17,26 %) Missing dosage 255 (13,47 %) Addition 49 (2,51 %) Different dosage 44 (2,25 %) Different frequency 27 (1,39 %) Confusion drug name 14 (0,72 %) Different moment 12 (0,62 %) Confusion generic name and drug name 8 (0,40 %)

25 3. Results The most commonly encountered ATC class is that of the digestive tract and metabolism. A group of physicians and pharmacists assessed that the most frequent discrepancy were score 1 (91,11%). Score Signification 0 : no impact <1% 1 : significant impact 91,11% 2 : very significant impact 8,57% 3 : vital impact 0%

26 3. Results The previous medical record and patient are 100% accessible. The patient and community pharmacy are the best source. The attending primary care provider shows the worst results. Sources Exhaustiveness Completeness (%) Accessibility (%) Availability (%) (%) Patient, family 91,07% 77,46% 100 % 98,15% Community 78,06 % 38,45 % 99,25 % 94,48 % pharmacy Previous medical 53,87 % 33,06 % 100 % 84,66 % record Primary care providers 34,94 % 18,97 % 64,44 % 50,30 %

27 3. Results Have you performed clinical pharmacy interventions in department emergency?

28 3. Results Check interventions for 109 patients (67%) 166 interventions At least one intervention for 50 patients (moy: 3,32/patient min:1 and max:17 interventions/patient) 72% of intervention have been accepted and implemented

29 3. Results

30 4. Discussion Limitations: Gold standard Recall bias Not thorough analysis of all sources No follow-up on the floor Advantages: - Preventing errors - Evaluation of impact of identification discrepancy

31 4. Discussion Horizon: - Assistant to carry out the medication history? - Réseau de Santé Wallon?

32 5. Bibliography Becerra-Camargo, J., et al. (2013). «A multicentre, double-blind, randomised, controlled, parallel-group study of the effectiveness of a pharmacist-acquired medication history in an emergency department.» BMC Health Serv Res 13: 337. Becerra-Camargo, J., et al. (2015). «The effect on potential adverse drug events of a pharmacist-acquired medication history in an emergency department: a multicentre, double-blind, randomised, controlled, parallel-group study.» BMC Health Serv Res 15: 33 Bonhomme, J., et al. (2013). «La juste liste des médicaments à l admission du patient hospitalisé : De la fiabilité des sources d information.» Risques & qualité en milieu de soins (4) : Caglar, S., et al. (2011). «Emergency department medication lists are not accurate.» J Emerg Med 40(6) : Contreras Rey, M. B., et al. (2016). «Analysis of the medication reconciliation process conducted at hospital admission.» Farm Hosp 40(4) : Cornish, P. L., et al. (2005). «Unintended medication discrepancies at the time of hospital admission.» Arch Intern Med 165(4) : De Winter, S., et al. (2010). «Pharmacist-versus physician-acquired medication history: a prospective study at the emergency department.» Quality and Safety in Health Care 19(5) : De Winter, S., et al. (2011). «A simple tool to improve medication reconciliation at the emergency department.» Eur J Intern Med 22(4) : Doerper, S., et al. (2015). «Development and multi-centre evaluation of a method for assessing the severity of potential harm of medication reconciliation errors at hospital admission in elderly.» Eur J Intern Med 26(7) : Dufay, E., et al. (2011). «Conciliation des traitements médicamenteux : détecter, intercepter et corriger les erreurs médicamenteuses à l admission des patients hospitalisés.» Risques & qualité en milieu de soins (2) : Fitzsimons, M., et al. (2011). «Sources of pre-admission medication information : observational study of accuracy and availability.» International Journal of Pharmacy Practice 19(6) : Geurts, M. M., et al. (2012). «Medication review and reconciliation with cooperation between pharmacist and general practitioner and the benefit for the patient: a systematic review.» Br J Clin Pharmacol 74(1) :

33 5. Bibliography Hart, C., et al. (2015). «A program using pharmacy technicians to collect medication histories in the emergency department.» P t 40(1) : Hatoum AT, et al. (1988). «Evaluation of the contribution of clinical pharmacist: Inpatient care and cost reducation.» Drug Intelligence and clinical Pharmacy 22 (3): Haynes, K. T., et al. (2012). «Pharmacists' recommendations to improve care transitions.» Ann Pharmacother 46(9) : Hellström, L. M., et al. (2012). «Errors in medication history at hospital admission: prevalence and predicting factors.» BMC Clin Pharmacol 12: 9. Johnston, R., et al. (2010). «Best possible medication history in the emergency department: comparing pharmacy technicians and pharmacists.» Can J Hosp Pharm 63(5) : Kramer, J. S., et al. (2014). «A quantitative evaluation of medication histories and reconciliation by discipline.» Hosp Pharm 49(9) : Kwan, J. L., et al. (2013). «Medication reconciliation during transitions of care as a patient safety strategy: a systematic review.» Ann Intern Med 158(5 Pt 2) : Leguelinel-Blache, G., et al. (2014). «Impact of admission medication reconciliation performed by clinical pharmacists on medication safety.» Eur J Intern Med 25(9) : Mekonnen, A. B., et al. (2016). «Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.» BMJ Open 6(2) : e Mekonnen, A. B., et al. (2016). «Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.» J Clin Pharm Ther 41(2) : Monteil B. et al. (1985). «Les outils de cercles et de l amélioration de la qualité» Edition d Organisation. 401 p. Mueller, S. K., et al. (2012). «Hospital-based medication reconciliation practices: a systematic review.» Arch Intern Med 172(14) :

34 5. Bibliography Okere, A. N., et al. (2015). «Evaluation of the influence of a pharmacist-led patient-centered medication therapy management and reconciliation service in collaboration with emergency department physicians.» J Manag Care Spec Pharm 21(4) : Ramjaun, A., et al. (2015). «Educating medical trainees on medication reconciliation: a systematic review.» BMC Med Educ 15: 33. Roulet, L., et al. (2014). «Establishing a pharmacy presence in the emergency department: opportunities and challenges in the French setting.» Int J Clin Pharm 36(3) : Salanitro, A. H., et al. (2013). «Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS).» BMC Health Serv Res 13: 230. Schiettecatte, S., et al. (2015). «Medication reconciliation in an emergency department.» Annales françaises de médecine d urgence 5(4) : Steurbaut, S., et al. (2010). «Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home.» Annals of Pharmacotherapy 44(10) : Tulner, L. R., et al. (2009). «Discrepancies in reported drug use in geriatric outpatients: relevance to adverse events and drug-drug interactions.» Am J Geriatr Pharmacother 7(2) : Unroe, K. T., et al. (2010). «Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies.» Am J Geriatr Pharmacother 8(2) : Van Den Bemt, P. M., et al. (2013). «Effect of medication reconciliation on unintentional medication discrepancies in acute hospital admissions of elderly adults: a multicenter study.» Journal of the American Geriatrics Society 61(8) :

35 Thank you for your attention and participation