Implementing a sustainable medication reconciliation process in Australian hospitals: The World Health Organization High 5s project.

BACKGROUND: Medication reconciliation (medrec) is a mandated patient safety strategy by national, including Australian, accreditation bodies. Yet there are no validated performance measures. OBJECTIVE: To determine the feasibility of implementing the World Health Organization (WHO) Medrec Standard Operating Protocol (SOP) in a range of Australian acute care facilities to achieve measurable and sustainable reductions in medication discrepancies occurring at admission. METHODS: A multicentre, prospective national study was conducted in ten academic, urban and regional hospitals to implement the SOP using WHO High 5s project and quality improvement methodology. Sites collected data on the rate of medrec performed within 24 h of admission in a random selection of 50 patients aged ≥65 years admitted via the emergency department, monthly for four years. Medrec quality was reviewed in a subset of 30 patients using three performance measures. Barriers, enablers and benefits of SOP implementation were collected using qualitative surveys. RESULTS: Ten health services reviewed 42,003 patient records. Of these, 20,162 (49.5%) had medicines reconciled within 24 h of admission. Four services increased, two decreased, and in four, medrec completion rates remained static. Mean number of unintentional and undocumented intentional medication discrepancies per patient decreased: 0.21 to 0.16 (p = 0.001) and 0.34 to 0.08 (p = 0.003), respectively. Unintentional discrepancies decreased from 15.2% to 11.1% (p = 0.001). Barriers to full implementation included: medrec not seen as a priority, limited resources and lack of electronic systems integration. Enablers included: use of medrec measures for feedback, educational resources, and 7-day week clinical pharmacy services. Benefits included improvements in medication safety culture and multidisciplinary teamwork. CONCLUSIONS: The WHO SOP was feasible, although challenging, to implement in a range of acute health services, and produced measureable and sustainable improvements in medicines information accuracy on admission. Sustaining the quantum of quality and timely medrec requires investment in pharmacist resources and electronic systems integration.

Standardization in patient safety: the WHO High 5s project.

QUALITY PROBLEM: Despite its success in other industries, process standardization in health care has been slow to gain traction or to demonstrate a positive impact on the safety of care. INTERVENTION: The High 5s project is a global patient safety initiative of the World Health Organization (WHO) to facilitate the development, implementation and evaluation of Standard Operating Protocols (SOPs) within a global learning community to achieve measurable, significant and sustainable reductions in challenging patient safety problems. GOALS: The project seeks to answer two questions: (i) Is it feasible to implement standardized health care processes in individual hospitals, among multiple hospitals within individual countries and across country boundaries? (ii) If so, what is the impact of standardization on the safety problems that the project is targeting? METHOD: The two key areas in which the High 5s project is innovative are its use of process standardization both in hospitals within a country and in multiple participating countries, and its carefully designed multi-pronged approach to evaluation. STATUS: Three SOPs-correct surgery, medication reconciliation, concentrated injectable medicines-have been developed and are being implemented and evaluated in multiple hospitals in seven participating countries. Nearly 5 years into the implementation, it is clear that this is just the beginning of what can be seen as an exercise in behavior management, asking whether health care workers can adapt their behaviors and environments to standardize care processes in widely varying hospital settings.

Safer use of antimicrobials in hospitals: the value of antimicrobial usage data.

The National Antimicrobial Utilisation Surveillance Program (NAUSP) collects aggregate data from hospitals in all Australian states and provides reports of monthly hospital inpatient antimicrobial usage to contributing hospitals. These data provide an Australian peer-group benchmark; hospitals can compare their usage with similar hospitals and identify areas of antimicrobial use that require more in-depth analysis. Overall high usage has been used by hospitals and area health services as a stimulus for initiation or expansion of antimicrobial stewardship programs. High use of particular classes of antimicrobials has triggered individual drug audits and been used to tailor interventions. Longitudinal antimicrobial usage data have been used by hospitals to measure the effects of antimicrobial stewardship strategies and provide feedback to prescribers.

Balancing risk versus benefit: the elderly patient’s perspective on warfarin therapy / Sopesando riesgo y beneficio: perspectiva del paciente anciano a tratamiento con warfarina

Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored. Objective: To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy. Method: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers. Results: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision. Conclusions: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin (AU)

El tratamiento con warfarina se sub-utiliza en los ancianos de alto riesgo. Los clínicos perciben que los ancianos son reacios a este tratamiento, sin embargo la perspectiva de los pacientes y de sus cuidadores aún no ha sido estudiada. Objetivo: Explorar en profundidad las perspectivas de los pacientes ancianos y/o sus cuidadores sobre el uso de tratamiento con warfarina. Método: Se realizó un estudio cualitativo, utilizando entrevista semi-estructurada en grupos. Las discusiones grabadas se transcribieron a papel, y se analizaron temáticamente para identificar los temas emergentes. Las discusiones en grupos se realizaron en un gran hospital universitario de Sydney durante un periodo de dos meses. Mediante respuesta voluntaria a folletos, se reclutó a individuos de 65 o más años (y/0 sus cuidadores) que estaban utilizando crónicamente (6 o más meses) tratamiento con warfarina. Resultados: 17 pacientes y cuidadores (edad media 77,2 DE=7,5 años) participaron en uno de los dos grupos focales. Emergieron 5 temas principales en relación al tratamiento con warfarina: conocimiento y entendimiento inadecuado, experiencia variable de pacientes/cuidadores de la información proporcionada, ciclo de reacciones de estar bajo esto, problemas de manejo práctico, y espectro de experiencias con el tratamiento. Generalmente los participantes aceptaban bien el tratamiento, describiendo altos niveles de cumplimiento, a pesar de sus miedos y ansiedades inicial, y la relativa falta de conocimiento. Los pacientes se sentían algo abandonados en su manejo del tratamiento con warfarina debido a la falta de servicios de apoyo continuo en la comunidad y de la inadecuada provisión de información. Conclusión: Los pacientes ancianos y sus cuidadores parecen estar tranquilos aceptando el tratamiento con warfarina, en contraste con la percepción de los profesionales de la salud. Sin embargo se necesita un mayor esfuerzo en relación a la provisión de información, especialmente en los servicios comunitarios, para ayudar a los pacientes en el manejo de la warfarina a largo plazo (AU)

Balancing risk versus benefit: the elderly patient's perspective on warfarin therapy.

UNLABELLED: Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored. OBJECTIVE: To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy. METHOD: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers. RESULTS: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision. CONCLUSIONS: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.

Management of warfarin in atrial fibrillation: views of health professionals, older patients and their carers.

OBJECTIVE: To identify the views of health professionals, patients and their carers on strategies to improve the use and management of warfarin in older patients with atrial fibrillation. DESIGN: Qualitative study based on analysis of group interviews. SETTING: A major metropolitan teaching hospital, from 1 March to 30 April 2003. PARTICIPANTS: 14 patients (>/= 65 years) with established atrial fibrillation and taking warfarin, three carers, 12 specialists, eight general practitioners, six community pharmacists, nine hospital pharmacists, and 11 nurses volunteered in response to flyers promoting the study. RESULTS: Suggested strategies to improve warfarin management targeted support services for GPs and patients. Hospital-based clinicians felt that dissemination of trial evidence to GPs to support treatment recommendations is required, and that GPs need to enlist allied health professionals in the management of patients taking warfarin. GPs preferred access to practical advice from expert colleagues on the day-to-day management. Patients requested more information about warfarin therapy, as access to information is inadequate, particularly from primary sources (GPs, community pharmacists). Verbal and written information are equally important, but a single counselling session or supply of a booklet was viewed as inadequate. Participants identified various interventions for all levels of warfarin management; from the collective input, a framework for management strategies was developed. CONCLUSIONS: Health professionals and patients require more customised information to support warfarin use and management.

Warfarin use in the elderly: the nurses' perspective.

OBJECTIVE: To explore the barriers to warfarin use from the perspective of nurses working in aged care. DESIGN: A qualitative study, involving a semi-structured group interview, during March-April 2001. SETTING AND SUBJECTS: Eleven nurses, employed within the catchment of the Northern Sydney Area Health Service, who were involved in the care of elderly warfarinised patients. MAIN OUTCOME MEASURE: Identification, via thematic analysis, of the main themes underpinning the nursing perspective on warfarin use in this setting, with regard to their perceived role/s, experiences with patients, and potential strategies for managing the therapy. RESULTS: Five main themes were identified: perceived patient attitude toward warfarin; barriers to the use of warfarin; expressed lack of confidence in the processes involved; nurses' role in warfarin use; and strategies to improve warfarin use. Nurses were concerned about warfarin use in the elderly, but felt they had a limited capacity to intervene. CONCLUSION: Nurses are potentially underutilised as a resource and support for both patients and prescribers, in the management of warfarin therapy.

Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.

OBJECTIVES: To develop, implement, and evaluate a pharmacist-led multidisciplinary intervention in a hospital setting that would optimize antithrombotic use in elderly atrial fibrillation patients. The hypothesis that there would be an increase in the proportion of patients receiving antithrombotic therapy at discharge was tested. DESIGN: Evidence-based algorithms were developed to define the criteria (stroke risk vs contraindications) by which an elderly patient's requirement for antithrombotic therapy was assessed. SETTING: A major Sydney teaching hospital. PARTICIPANTS: Two hundred eighteen consecutively admitted elderly patients (mean age 85.2) were recruited over a 6-month period. INTERVENTION: A pharmacist-coordinated multidisciplinary review process was implemented to coordinate risk assessments and subsequently recommend appropriate antithrombotic therapy, as per the algorithms. MEASUREMENTS: The proportion of patients receiving antithrombotic therapy was assessed on admission (preintervention), at discharge (postintervention), and postdischarge (follow-up at 3 and 6 months). RESULTS: As a result of the intervention, 78 patients (35.8%) required changes to their existing antithrombotic therapy. Of these changes, 60 (76.9%) were "upgrades" to more-effective treatment options (e.g., from no therapy to any agent or from aspirin to warfarin). The remaining 18 (23.1%) changes were "downgrades" to less-effective, albeit safer, options. Despite a significant increase in anti thrombotic use overall (59.6% vs 81.2%, P<.001), fewer patients received warfarin postintervention, after having been assessed as inappropriate candidates (20.7% vs 17.4%, P=.39). CONCLUSION: A pharmacist-led multidisciplinary process was successfully developed and implemented within the hospital setting to increase overall antithrombotic use. Having addressed some of the known barriers and limitations to warfarin use, these algorithms may allow allied health workers, patients, and clinicians to work collaboratively to achieve optimal and, importantly, appropriate (i.e., safe and effective) antithrombotic use in at-risk elderly patients.

Health professionals rarely record history of complementary and alternative medicines.

AIMS: To identify the completeness of documentation of Complementary And Alternative Medicine (CAM) use in hospital medical records of patients before and after an education programme. METHODS: Documentation of CAM in all parts of the medical records was compared to patients' self-reported use. Data were collected for one month before and one month after an education programme for hospital staff. RESULTS: At baseline: 59 (58%) of 101 patients used 129 CAM in the month prior to admission; only 36 (28%) of the CAM were documented in the medical record. After education: 51 (54%) of 94 patients used 91 CAM in the month prior to admission; 40 (44%) of the CAM were documented in the medical record. After education, recording rates increased by 16% (95% CI: 3% to 29%) due to improvements by pharmacists (18%, 95% CI: 5% to 31%). 32 (54%) of CAM users at baseline and 29 (57%) of CAM users after education informed a health professional. The recording rates were only 23 (39%) and 28 (55%) respectively for patients in these two sub-groups, being an improvement of 16% (95% CI: -2% to 34%). CONCLUSIONS: Prevalence of CAM use among patients admitted to hospital is high, but documentation of usage is low. Strategies need to be designed to improve health professionals' knowledge about the need to record history of CAM use.