Partnered pharmacist medication charting: evaluation of a process change

<p dir="ltr">Acute care provided in the hospital’s emergency department (ED) is a key component of the healthcare system that serves as an essential bridge between outpatient and inpatient care. However, due to the emergency-driven nature of presenting problems and the urgency of care required, the ED is more prone to unintended medication regimen changes than other departments. Ensuring quality use of medicines (QUM), defined as “choosing suitable medicines and using them safely and effectively”, remains a challenge in the ED and hence requires special attention.<br>An area that has received considerable attention is obtaining a patient’s complete and accurate medication history, known as ‘best possible medication history’ (BPMH), as early as feasible on hospital attendance. This may form the basis for initial and subsequent care plans, if a patient is admitted, following presentation to ED. Another important consideration is having a clinical conversation between a pharmacist and a medical officer to optimise treatment plans and intercept any medication management issues early in the ED. In line with these cornerstones, the Tasmanian Department of Health approved a 12-month partnered pharmacist medication charting (PPMC) project in the Royal Hobart Hospital ED in 2020. A multidisciplinary working group developed the PPMC care model. The program was delivered by more than 20 PPMC-credentialled pharmacists. Within this thesis, an independent University of Tasmania research team evaluated it.<br>The objectives of this thesis were to <br>• synthesise evidence from previous studies examining the impact of ED-based pharmacist interventions on QUM, • evaluate the impact of PPMC on medication-, health- and economic-related outcomes, and <br>• explore ward pharmacists’ awareness, perceptions, and experiences of PPMC. <br>The thesis employed a mixed-methods pragmatic evaluation design and was structured in three phases. In the first phase, a systematic review with meta-analysis was conducted in MEDLINE, EMBASE and CINAHL. Studies that compared the impact of pharmacists’ interventions with usual care in the ED and reported medication-related primary outcomes were included (N = 31). The interventions reduced the mean number of medication errors per patient by 0.33 and the proportion of patients with at least one error by 73%.<br>In the second phase, four controlled concurrent pragmatic evaluations investigated PPMC’s impact on medication-, health- and economic-related outcomes. This part of the thesis compared PPMC (process ‘redesign’) to early BPMH (process ‘tweak’) or usual care (traditional ‘standard of care’). The PPMC arm included a pharmacist-documented BPMH at the earliest possible point, followed by a partnered charting approach (i.e., a clinical discussion between a pharmacist and a medical officer to co-develop a treatment plan and chart medications) in the ED. The early BPMH arm included a pharmacist-documented BPMH, followed by a medical officer-led traditional medication charting in the ED (without a clinical discussion and partnered charting). The usual care arm included the traditional medication charting approach, without a pharmacist-collected BPMH in the ED. In each arm, independent ward pharmacists subsequently conducted medication reconciliation - a process of matching the medicines a patient should be prescribed to those they were actually prescribed. Patients presenting to the ED between 01/06/2020 and 17/05/2021, with a subsequent planned admission to an eligible acute medical unit, taking at least one regular pre-admission medication and receiving medication reconciliation on the ward within 48 hours of ED transfer were included in the evaluations.<br>The first study evaluated PPMC’s impact on medication discrepancies and errors, and their clinical significance. Medication discrepancies were undocumented differences between medication charts and inpatient medication reconciliation. Five blinded multidisciplinary expert panels assessed the discrepancies’ clinical significance using a standardised tool, with ‘unintentional’ discrepancies deemed ‘errors’. The analysis included 1,048 adults aged 18 or older. PPMC significantly reduced the prevalence of discrepancies and clinically significant errors<i> </i><i>(</i><i>p</i> < 0.001). Fewer patients in the PPMC group had at least one error (3.5%) than in the early BPMH (49.4%) and usual care group (61.4%). The numbers of patients who need to be treated with PPMC to prevent at least one high/extreme error were estimated as 4.6 and 4.0 compared to the early BPMH and usual care group, respectively.<br>In the second study, the impact of PPMC on potentially inappropriate medication (PIM) use at ED presentation, ED departure and hospital discharge was evaluated using the latest Beers Criteria. In this study, 321 patients who were 65 years of age or older were included, with 107 patients in each group. PPMC demonstrated a significant reduction in PIM use on leaving ED (<i>p</i> = 0.040), but not at hospital discharge.<br>The third study evaluated the impact of PPMC on time to continue pre-admission time?critical medicines (from ED presentation to the first dose administered), the occurrence of in-hospital adverse drug reactions (ADRs) using International Classification of Diseases codes, completeness of medication orders and conduct of venous thromboembolism risk assessment. PPMC facilitated quicker administration of preadmission time-critical medicines (<i>p</i> < 0.001); median times (interquartile range) for the PPMC, early BPMH and usual care group were 8.8 (6.3 to 16.3), 17.5 (7.8 to 22.9) and 15.1 (8.2 to 21.1) hours, respectively. PPMC improved the completeness of medication orders and the percentage of patients with venous thromboembolism risk assessed (p < 0.001). However, documented in-hospital ADRs did not differ significantly between the groups (<i>p</i> = 0.59).<br>The fourth study used a 1:1 nearest neighbour propensity score matching to evaluate PPMC’s impact on health economic outcomes, specifically length of hospital stay, relative stay index, length of ED stay, in-hospital mortality, 30-day hospital readmissions or ED revisits, and PPMC’s cost-effectiveness and cost-benefit. The relative stay index is a risk-adjusted, relative hospital stay metric standardised across diagnosis-related groups, care type, age, hospital admission type, arrival source, discharge destination and comorbidity level. PPMC reduced the relative stay index by 15.4% (p = 0.029) but had no statistically significant impact on the other absolute health-related outcomes. The hospital spent approximately $282.40 per patient on PPMC care to avert at least one high/extreme risk medication error. On average, PPMC saved approximately $1,233 per admission per patient through the reduced relative stay index.<br>In the third phase, a cross-sectional survey using a self-administered online questionnaire was conducted to explore ward pharmacists’ awareness, perceptions, and experiences of PPMC. All eligible ward pharmacists working at the Royal Hobart Hospital were invited to participate, and 17 of them provided complete responses. PPMC was generally perceived positively, with most reporting positive experiences. With a PPMC pharmacist activity in the ED, a ward pharmacist saved approximately 41 minutes per patient, allowing them to focus on other newly admitted patients or other clinical duties. Areas where the PPMC service could be improved, as mentioned by the participants, included short staffing, issues with the PPMC credentialling program, limited PPMC service coverage, poor documentation of PPMC paperwork and delayed ward clinical pharmacy activities.<br>In conclusion, PPMC within ED, which incorporates a pharmacist and medical officer discussion, generally improved QUM (at least early in hospitalisation) and saved hospital admission costs. Obtaining an early BPMH alone and providing this to the medical officer did not improve key outcomes, highlighting the importance of the co-charting process. The findings support the continuation of PPMC in the ED to maintain collaborative, accurate and safe medication management for patients. As in ED, close interprofessional collaboration is required on the wards to sustain QUM outcomes until discharge.</p>