Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study)

Abstract

ObjectivesTo test the impact of a hospital pharmacist-prepared interim residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital to residential care.DesignProspective pre-intervention and post-intervention study.SettingOne major acute care hospital and one subacute aged-care hospital; 128 residential care facilities (RCF) in Victoria, Australia.Participants428 patients (median age 84 years, IQR 79–88) discharged to a RCF from an inpatient ward over two 12-week periods.InterventionSeven-day IRCMAC auto-populated with patient and medication data from the hospitals' pharmacy dispensing software, completed and signed by a hospital pharmacist and sent with the patient to the RCF.Primary and secondary outcome measuresPrimary end points were the proportion of patients with one or more missed or significantly delayed (>50% of prescribed dose interval) medication doses, and the proportion of patients whose RCF medication chart was written by a locum doctor, in the 24 h after discharge. Secondary end points included RCF staff and general practitioners' opinions about the IRCMAC.ResultsThe number of patients who experienced one or more missed or delayed doses fell from 37/202 (18.3%) to 6/226 (2.7%) (difference in percentages 15.6%, 95% CI 9.5% to 21.9%, p<0.001). The number of patients whose RCF medication chart was written by a locum doctor fell from 66/202 (32.7%) to 25/226 (11.1%) (difference in percentages 21.6%, 95% CI 13.5% to 29.7%, p<0.001). For 189/226 (83.6%) discharges, RCF staff reported that the IRCMAC improved continuity of care; 31/35 (88.6%) general practitioners said that the IRCMAC reduced the urgency for them to attend the RCF and 35/35 (100%) said that IRCMACs should be provided for all patients discharged to a RCF.ConclusionsA hospital pharmacist-prepared IRCMAC significantly reduced medication errors and use of locum medical services after discharge from hospital to residential care.

Standard of practice in geriatric medicine for pharmacy services

“…It is recommended that hospitals provide an interim medication administration chart for all patients discharged to RACFs and home care . Interim charts significantly reduce the incidence of medication administration delays and errors, which are common during the first 24–72 hours after discharge . They also eliminate the need for urgent general practitioner or locum doctor attendance on the day of discharge to prepare a medication chart .…”

“…6,8 There is evidence that clinical pharmacy services improve medication management and safety for older people in inpatient, [8][9][10][11][12] residential care 13,14 and ambulatory settings 8,[15][16][17][18] , and during transitions of care between settings. [19][20][21] Benefits include: prevention, identification and resolution of adverse drug reactions (ADR), medication errors and other medication-related problems, 8,10,18,20,21 improved quality of prescribing, 8,[11][12][13][14][15][16]19 and better medication adherence. 11,21 In some patient groups (e.g.…”

Hospital pharmacists' perceptions of medication counseling: A focus group study

“…This is critical as poor communication and inadequate transfer of patient information after discharge from hospital can have serious implications to patients' health. [38][39][40][41][42] The pharmacist's role as a transition enabler is well described in the literature. Hospital pharmacists have been key players in providing continuity of care from hospital to community settings communicating with and transferring information to community pharmacists and primary care physicians about patients' medications.…”

Investigating the effectiveness of communication taking place between hospital pharmacists and patients during medication counselling

“…This is critical as poor communication and inadequate transfer of patient information after discharge from hospital can have serious implications to patients' health. [290][291][292][293][294] The pharmacist's role as a transition enabler is well described in the literature. Hospital pharmacists have been key players in providing continuity of care from hospital to community settings communicating with and transferring information to community pharmacists and primary care physicians about patients' medications.…”