Category: Professional Posters
Purpose: Critically ill patients are subjected to approximately 1.7 medication errors per day. Pharmacy involvement in medication reconciliation has been described in the literature as one mean of reducing errors. Within our institution, emphasis has been placed on medication histories for patients admitted from the emergency department or discharged from general medicine units. A multidisciplinary group was established to ensure appropriate medication reconciliation for all ICU patients with pharmacists playing a significant role in all transitions of care. The purpose of the study is to highlight the role of the ICU pharmacist in transitions of care in promoting medication error reduction.
Methods: A multidisciplinary group consisting of attending intensivists, medical residents, advanced practice providers (APPs), and critical care pharmacists was established to create a standard work flow for patient admission, transfer, and discharge medication reconciliation. Areas of opportunity identified by the group for our institution included direct admission patients who bypassed the emergency department, transfer out of the ICU, and discharges to other facilities or home directly from the ICU. For patients admitted to the ICU, pharmacists were responsible to review of admission medication list, obtain an accurate list if not previously done, and complete standardized documentation within the EMR via a progress note for visibility. For patients transferring from the ICU, post multidisciplinary round huddles with providers and pharmacists were to occur and pharmacists would ensure appropriate home medications were ordered or held, stop dates for antimicrobials and other applicable drugs were in place, and unnecessary medications were discontinued. At discharge, after visit summaries (AVS) were reviewed by the pharmacist for accuracy and high risk patients identified by the institution’s readmission reduction scoring were considered for discharge counseling if appropriate. An analysis of three months pre- and post-implementation was conducted.
Results: The medication reconciliation process began in December 2018 in four intensive care units. Prior to implementation of a formal documentation process, 314 medication reconciliation activities were documented by a critical care pharmacist in the preceding three months. Of those activities documented, more than half lacked an allotted time spent or a standard format. In the 90 days following application of the standardized process, documented medication reconciliation capture rate increased by 52.9% in all ICUs. Critical care pharmacist documentation for the medical and neuro ICUs increased by approximately 45.6% and 46.4%, respectively, and more than doubled in the surgical ICU. Resources used by pharmacists for medication reconciliation, including time, prior to a formal documentation process was virtually unknown. After standardization, 83.9% of the recorded activities reflected time spent by the critical care pharmacist. Pharmacists spent approximately 11.13 minutes per patient on medication reconciliation, with a range from 5-45 minutes. In total, 89 hours were devoted by critical care pharmacists to review patients’ medication lists at critical points in transitions of care including admission, transfer and discharge over the 3 month time period.
Conclusion: Multidisciplinary attention to the medication reconciliation process and increased pharmacist involvement greatly impacted patient care for ICU patients at our institution. In addition to other patient care activities, critical care pharmacists provided 89 hours of documented medication reconciliation time that previously would not have been captured with previous institution workflows. Multidisciplinary team engagement increased buy-in to the process and is reflected in current daily ICU care. Identified opportunities for continuous improvement of the process include communication regarding new admissions, transfers, and discharges as well as electronic medical record optimizations to help facilitate more timely review by critical care pharmacists.