An evaluation of paediatric medicines reconciliation at hospital discharge into the community

OBJECTIVE: A UK national survey of primary care physicians has indicated that the medication information on hospital discharge summary was incomplete or inaccurate most of the time. Internationally, studies have shown that hospital pharmacist's interventions reduce these discrepancies in the adult population. There have been no published studies on the incidence and severity of the discrepancies of the medication prescribed for children specifically at discharge to date. The objectives of this study were to investigate the incidence, nature and potential clinical severity of medication discrepancies at the point of hospital discharge in a paediatric setting. METHODS: Five weeks prospective review of hospital discharge letters was carried out. Medication discrepancies between the initial doctor's discharge letter and finalised drug chart were identified, pharmacist changes were recorded and their severity was assessed. The setting of the review was at a London, UK paediatric hospital providing local secondary and specialist tertiary care. The outcome measures were: - incidence and the potential clinical severity of medication discrepancies identified by the hospital pharmacist at discharge. KEY FINDINGS: 142 patients (64 female and 78 males, age range 1 month - 18 years) were discharged on 501 medications. The majority of patients were under the care of general surgery and general paediatric teams. One in three discharge letters contained at least one medication discrepancy and required pharmacist interventions to rectify prior to completion. Of these, 1 in 10 had the potential for patient harm if undetected. CONCLUSIONS: Medicines reconciliation by pharmacist at discharge may be a good intervention in preventing medication discrepancies which have the potential to cause moderate harm in paediatric patients.

Medicines reconciliation at the point of hospital discharge for children

Objectives: Hospital discharge is a transition of care, where medication discrepancies are likely to occur and potentially cause patient harm. The purpose of our study was to assess the prescribing accuracy of hospital discharge medication orders at a London, UK teaching hospital. The timeliness of the discharge summary reaching the general practitioner (GP, family physician) was also assessed based on the 72 h target referenced in the Care Quality Commission report.1 Method: 501 consecutive discharge medication orders from 142 patients were examined and the following records were compared (1) the final inpatient drug chart at the point of discharge, (2) printed signed copy of the initial to take away (TTA) discharge summary produced electronically by the physician, (3) the pharmacist's amendments on the initial TTA that were hand written, (4) the final electronic patient discharge summary record, (5) the patients final take home medication from the hospital. Discrepancies between the physician's order (6) and pharmacist's change(s) (7) were compared with two types of failures – ‘failure to make a required change’ and ‘change where none was required’. Once the patient was discharged, the patient's GP, was contacted 72 h after discharge to see if the patient discharge summary, sent by post or via email, was received. Results: Over half the patients seen (73 out of 142) patients had at least one discrepancy that was made on the initial TTA by the doctor and amended by the pharmacist. Out of the 501 drugs, there were 140 discrepancies, 108 were ‘failures to make a required change’ (77%) and 32 were ‘changes where none were required’ (23%). The types of ‘failures to make required changes’ discrepancies that were found between the initial TTA and pharmacist's amendments were paracetamol and ibuprofen changes (dose banding) 38 (27%), directions of use 34 (24%), incorrect formulation of medication 28 (20%) and incorrect strength 8 (6%). The types of ‘changes where none were required discrepancies’ were omitted medication 15 (11%), unnecessary drug 14 (10%) and incorrect medicine including spelling mistakes 3 (2%). After contacting the GPs of the discharged patients 72 h postdischarge; 49% had received the discharge summary and 45% had not, the remaining 6% were patients who were discharged without a GP. Conclusion: This study shows that doctor prescribing at discharge is often not accurate, and interventions made by pharmacist to reconcile are important at this point of care. It was also found that half the discharge summaries had not reached the patient's family physician (according to the GP) within 72 h.

Post discharge follow up of children on long term medication

Background: There have been no published studies observing what happens to children post hospital discharge and if medication discrepancies occurred between the hospital and General Practitioner (GP) interface.1 Objectives: To identify the type of discrepancies between hospital discharge prescription and the patient's medicines after their first GP prescription. Method: Over a 3 month period (March–June 2012) across two London NHS hospital sites, parents of children on long term medications aged 18 years and under, were approached and consented prior to discharge from the ward. The patients were followed up 21 days after discharge by telephone call or home visit depending on their preference. The parent was asked if they had contacted their GP for further medications during the follow up, and if not the follow up was rescheduled. The parents were interviewed to find out if there were any discrepancies that occurred post discharge by comparing the patient's hospital discharge letter and medication at follow up. All this information was captured on a data collection form. Results: Eighty-eight patients were consented and 60 patients (68%; 60/88) were followed up by telephone call 21 days post discharge. A total of 317 medications were ordered at discharge among the 60 patients. Of the 60 that were followed up, nine were lost to follow up, one died post discharge, one was excluded from the study, and 11 had not contacted the GP and were to be followed up at a later date. Of the 38 patients who were followed up, 254 medications were ordered. Of the 38 patients there were 12 (32%) patients who had discrepancies that occurred between the discharge letter and GP, 19 (50%) had no issues, and seven (18%) mentioned issues to do with post discharge that were not discrepancies. Of the 12 patients who had at least one medication discrepancy (total 34 medications, range 1–7 discrepancies per patient), six patients had GP discrepancies, four had discrepancies resulting from a hospital outpatient appointment, one related to the discharge letter order and one was a complex discrepancy. An example: a patient was discharged on amiodarone liquid 16.5 mg daily as opposed to 65 mg daily of amiodarone from the GP. Upon interview the parent used volume units to communicate dose as opposed to the actual dose itself and the strengths of liquid had changed. Conclusions: The preliminary results from the study have shown that discrepancies due to several causes occur when paediatric patients leave hospital.

Epidemiology of medication discrepancies upon hospital admission in children - a systematic review

Objectives: NICE/NPSA excluded children under 16 from their guidance concerning medicines reconciliation (MR) upon admission.1 Our aims and objectives of conducting the literature review was to identify the epidemiology of medication discrepancies upon admission, transfer and discharge in children, and if they require MR. Method: Six bibliographical databases (Medline, Embase, CINAHL, International Pharmaceutical Abstracts, Web of Science and Biosis Previews) and selected key words were used to find epidemiological studies on medication discrepancies in children upon hospital admission, transfer and discharge (key words included ‘medication discrepancy’; ‘medication reconciliation’; ‘hospital admission’; ‘hospital discharge’; ‘hospital transfer’); studies where the data for children could be extracted were included. Results: From the 1239 articles found (in May 2011), eight of the articles had extractable paediatric information, (five from Canada, two from USA, one from UK). Five of the studies involved discrepancies on admission, one involved discrepancies on admission and transfer, one involved discrepancies at transfer and one considered discharge. The reference point used to compare against the admission, transfer and the discharge order differed in each of the studies. Four studies used a rating scale to assess the clinical significance of the discrepancies to demonstrate the potential adverse clinical outcome of patients in the absence of clinical intervention. Two studies2 3 used a rating scale that was used in adults.4 A study of paediatric neurosurgical patients found that initial hospital prescriptions for children differed from the preadmission prescriptions in 39% of occasions and 50% of all prescribing variations had the potential to cause moderate or severe discomfort or clinical deterioration.2 A study by Coffey et al in general paediatric admissions in Canada showed 22% of patients experienced at least one discrepancy and 29% of the discrepancies had the potential to cause moderate or severe discomfort or clinical deterioration.3 By comparison an epidemiological study in discrepancies in adults on admission had 38.6% of the discrepancies identified with a potential to cause moderate or severe discomfort or clinical deterioration.4 All the studies involved small samples or specific patient groups such as medically complex patients. However all of the studies demonstrated that discrepancies occurred among paediatric populations during transitions in care settings and mentioned MR as an intervention. Conclusion: The results have shown that discrepancies of medication upon hospital admission, transfer and discharge occur regularly in children. With only one published study in the UK looking at hospital admission in children, and no published articles on the incidence and epidemiology of medication discrepancies upon hospital transfer or discharge further research is required in a wider paediatric population. Further work is also required to define the required interventions to improve practice.

A pilot study to evaluate the self-medication system for liver transplant patients at the Queen Elizabeth Hospital in Birmingham

Background and Objective: Medication non-compliance is a considerable obstacle in achievinga therapeutic goal, whichcan result in poorerhealthcare outcomes, increased expenditure, wastage and potential for medication resistance. The UK Government’s Audit Commission’s publication ‘A Spoonful of Sugar’1 addresses these issues and promotes self-medication systems as a possible solution. The self-medication system within the Liver Transplant Unit (LTU) was implemented to induct patients onto new post- transplantation medication regimes ready for discharge. The system involves initial consultations with both the Liver Transplant Pharmacist and Trans- plant Co-ordinator, supported with additional advice as and when necessary. Design: Following ethical approval, evaluation of the self-medication sys- tem for liver transplant patients was conducted between January and March 2004 via two methods: audit and structured post-transplantation interview. The audit enabled any discrepancies between current Hospital guidelines and Liver Transplant Unit (LTU) practices to be highlighted. Patient interviews generated a retrospective insight into patient acceptance of the self-medication system. Setting: LTU, Queen Elizabeth Hospital, Birmingham, England. Main Outcome Measures: LTU compliance with Hospital self-medication guidelines and patient insight into self-medication system. Results: A total of seven patients were audited. Findings illustrated that self- medication by transplant patients is a complex process which was not fully addressed by current Hospital self-medication guidelines. Twenty-three patients were interviewed, showing an overwhelming positive attitude to- wards participating in their own care and a high level of understanding towards their individual medication regimes. Following a drugs counselling session, 100% of patients understood why they were taking their medica- tion, and their doses, 95% understood how to take their medication and 85% were aware of potential side effects. Conclusions: From this pilot evaluation it can be stated that the LTU self-medication system is appreciated by patients and assists them in fully understanding their medication regimes. There appear to be no major defects in the system. However areas such as communication barriers and on-going internet education were illustrated as areas for possible future investigation. References: 1. Audit Commission. A spoonful of sugar – medicines management in NHS hospitals. London: Audit Commission; 2001.

Financial consequences of one-stop dispensing at Birmingham Children's Hospital

Poster session - Costs for one stop dispensing and the use of patients’ own drugs (PODs) were compared with traditional dispensing costs - It was found that operating a one-stop dispensing scheme, with the use of PODs where applicable, could save an average of £4.35 per patient per day on ward A and £5.19 per patient per day on ward B - These saving would equate to annual savings of £24,000 on ward A and £34,000 on ward B - Additional savings can be made to the secondary care budget as no in-patient drugs would be wasted upon patient discharge - These additional savings are an average £25.19 per patient on ward A and £13.42 per patient on ward B

Does anticholinergics drug burden relate to global neuro-disability outcome measures and length of hospital stay?

Primary objective: To assess the relationship between disability, length of stay (LOS) and anticholinergic burden (ACB) with people following acquired brain or spinal cord injury. Research design: A retrospective case note review assessed total rehabilitation unit admission. Methods and procedures: Assessment of 52 consecutive patients with acquired brain/spinal injury and neuropathy in an in-patient neuro-rehabilitation unit of a UK university hospital. Data analysed included: Northwick Park Dependency Score (NPDS), Rehabilitation complexity Scale (RCS), Functional Independence Measure and Functional Assessment Measure FIM-FAM (UK version 2.2), LOS and ACB. Outcome was different in RCS, NPDS and FIM-FAM between admission and discharge. Main outcomes and results: A positive change was reported in ACB results in a positive change in NPDS, with no significant effect on FIM-FAM, either Motor or Cognitive, or on the RCS. Change in ACB correlated to the length of hospital stay (regression correlation = −6.64; SE = 3.89). There was a significant harmful impact of increase in ACB score during hospital stay, from low to high ACB on NPDS (OR = 9.65; 95% CI = 1.36–68.64) and FIM-FAM Total scores (OR = 0.03; 95% CI = 0.002–0.35). Conclusions: There was a statistically significant correlation of ACB and neuro-disability measures and LOS amongst this patient cohort.