Paste your eBackground:
I currently work as a Medical Officer in a ten bedded hospice offering both inpatient and day therapy services. We care for patients aged eighteen and over who are at various stages in their illness trajectory. I am one of a team of four medical officers working alongside our consultant colleagues. We also have four non-medical prescribers working in both services.
Clinical audit is defined by NHS England (2015) as a way to find out if healthcare is being provided in line with standards letting both care providers and patients/families know that their service is doing well and identifying areas that could be improved upon. The overall aim of clinical audit is to improve patient care both locally and nationally.
Introduction:
The focus of this audit is to look at our medication reviews and deprescribing within both the inpatient and day therapies setting.
We know locally that we complete a lot of ad-hoc medication reviews. Most prescription charts you look at will have multiple drugs crossed off or omissions. Recently we have noted flaws in our system. There have been several serious adverse clinical incidents within my workplace pertaining to medication errors, whereby medicine have been omitted due to transcription error but not picked up by any members of the team as they incorrectly assumed that they had been discontinued on purpose. This in one case led to a patient not receiving steroids for almost two weeks, which had massive implications to the patient. The investigation into this incident highlighted that we are not reviewing medicines in a structured way nor are we documenting the changes made and reasons why in accordance with General Medical Council guidance (GMC 2016). In medicine we cannot make these assumptions we need to be making evidence based decisions and we need for all of these decisions to be clearly documented and communicated with both the team involved as well as the patient and their carers.
The National Institute for Clinical Excellence (NICE 2009) states that healthcare professionals should have a clear purpose for medication reviews and we need to optimise medications to enable the best possible patient outcomes. The medication review should be “a structured, critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste”. We know that inappropriate prescribing and polypharmacy is a common problem with often serious adverse events in older people as discussed by Hilmer and Gnjidic (2008). Polypharmacy is defined by Duerden et al (2015) as being the use of five or more medications, this is often associated with a reduction in quality of life, however they say polypharmacy may be appropriate in those with complex conditions or problematic, prescribed in a way to not realise the benefit or harm of the drug.
Zermansky et al (2001) conducted a randomised controlled trial looking at medication reviews in General Practice they found that although these reviews although part of the Quality Outcomes Framework (QoF 2015) that they often do not happen in a timely manner or with a structured approach with the patient. Their study showed that a clinical pharmacist undertaking these reviews not only had an impact on patient compliance and in effect have a negative impact on both the patient as well as being financially draining to the health economy as well as freeing up more time for General Practitioners.
In my experience within the hospice the majority of patients being admitted to us are prescribed more than ten drugs some of which they have been on for years. Even patients who are approaching the end of their lives remain on drugs like statins despite the fact that we know their use is limited.
The appropriate prescription of medications is the foundation of good medical management; however, I feel that we forget that sometimes it as important to take something away as it is to add in another tablet. The older populations especially the frail elderly are indeed more likely to have varying issues with multiple co morbidities but we need to carefully weigh up the benefit versus harm for each medicine. Having to take multiple medicines can not only increase the risk of drug interactions but also it is highlighted by Frank (2014) that the individual is more likely to have side effects from the drug prescribed which often results in another drug to try and minimise the side effect.
We are also seeing increasing numbers of our frail elderly population admitted to hospital and it would be interesting to see how many of these hospital admissions correlate to falls or other side effects related to medications.
Hughes and Kerse (2012) state that ideally the medication review and optimization should be multi-disciplinary and involve not only physicians but also pharmacists and hospital and clinic nurses as they may have a different understanding of the adherence to medications. However as often it is the GPs responsibility to prescribe it is likely that the GP will need to have clinical input to ensure suitability and possible monitoring requirements are not missed.
The British Geriatric Society (2016) states that It should be noted that a medication review does not imply a large or whole-scale reduction in prescribing (although that is often the case), and in fact some medications may be increased (to more effective doses) or added (if important indications have not been addressed.
Medication reviews should be completed in a structured way considering need of medications, possible adverse reactions or interactions, non-adherence. There are several check lists such as BEERS criteria Resnick and Fick (2012) and STOPP/START toolkit (2014) which helps to identify medicines that are high risk or of limited benefit. These aids were recommended for use by NICE (2014) When doing this is important to consider life expectancy and benefits of medications.
Medication review step by step approach. Reeve, Shabib et al (2014)
Deprescribing:
Deprescribing is part of an active review process which encourages the Doctor to consider medications which may no longer be advantageous to the patient. It may be that newer drugs may be more appropriate, or that there needs to be a dose adjustment, or that the risks now outweigh the benefit to the patient. This is especially important if there has been a change in the patients’ illness trajectory.
The underlying key action here is to communicate with the patient and their carers about what this means, patient become very attached to their medicines and it is a hard concept to grasp that a drug that was given to possibly prolong their life is now being stopped. This discussion should not be rushed, the patient should be given the opportunity to discuss their concerns and expectations. The Doctor involved should give the patient the evidence for their treatment in terms that they are able to understand but before this takes place it is important to ensure that the patient understands the reasons why you are considering stopping medications and if it is thought that the patient is approaching the end of their life or that the risks outweigh the benefit, then these conversations need to be had, as difficult as they may be. This could potentially open the gates to discuss broader topics such as advanced care planning. It is also part of encouraging patients to make autonomous decisions regarding their health and should have a positive impact on the doctor- patient relationship, however it does require time and sensitivity.
Deprescribing says Boyd et al (2005) requires a shift in choice of clinical outcomes and in the process of prescribing medications for frail older patients. It is also important to consider our own beliefs and feelings about treatment options and how often as a Doctor we feel that we need to prescribe a medication to be seen as doing something, I feel having worked previously as a GP that this is definitely the case and there is often a lack of focus on the non-pharmacological methods and often due to time constraints limited consultation with patients over these important matters.
Within the hospice setting we are very used to deprescribing as we are in a privileged position to have lengthy discussions with our patients which enable us to understand how they feel about the medication burden they often face and also to discuss the difficult issues around death and dying. As we know we do this process reasonably well it is difficult to understand why so many medication errors are occurring. It is the purpose of this audit to determine if there is a clear reason for this.
Audit Criteria and Standards:
Three key areas were identified for audit.
1) Were medications on admission checked and discussed with the patient
2) If medications were initiated or discontinued was this discussed and documented in the patient’s records?
3) Do we notify General Practitioners with the rationale for discontinuation upon patient discharge?
The initial process involved looking at patient notes over a four-month period. During this period there were 47 admissions to the inpatient unit.
All patients that are admitted to the inpatient unit would have their medications reviewed on admission, if there was a change in their disease trajectory and upon discharge as standard. All patients attending day-therapies would have an initial clerking to include a medication review and this would be revisited at twelve weekly intervals. All patients should be given the opportunity to discuss their medications and that we should work in partnership with patients and their families. If patients were admitted for end of life care and were only prescribed end of life medications, then they would be obvious outliers.
Audit standards define a clear outcome to be measured against a preset standard. It is important that this standard is defined in a clear concise manner and ideally it should be expressed as a percentage.
In order to set our standards locally we had several meetings with both medical and non-medical prescribers.
Standard 1} 90% of patients admitted to both the inpatient or day therapy units should have their medications checked using a clear structured review process.
Standard 2) 100% of patients having medications initiated or discontinued should have this discussed with them or their families and it should be clearly documented in the patient notes.
Standard 3) 100 % of patients that are discharged should have a discharge letter sent to their GP within 24 hours of discharge which highlights medications prescribed and any changes made and adverse reactions. It should also highlight the reason for any discontinuance of medication.
I included a count of medications altered in the prescription chart to enable me to compare how many changes there had been in comparison to how many reviews had been documented this was not a set standard.
Methods
The data has been collected retrospectively reviewing patient admission between September 2015 and December 2015. This retrospective analysis includes reviewing patient notes, prescription charts and discharge summaries.
It was my expectation that we review around 80% of our patient’s medications but I suspected that there would be little to no documentation and little evidence of discussion with patients and their families.
Phase 1 result:
Medications altered in prescription charts: 87%
Standard 1) Medication review completed and changes documented in notes: 36%
Standard 2) Documentation of discussions with patient/family: 13%
Standard 3) Documentation of changes forwarded to GP: 20%
Initiating change:
We discussed these findings during our monthly Doctors meetings, the team were surprised by the findings but agreed that we all tend to look at the patient notes and cross off medications frequently but do not always discuss or document the changes. Both medical and none medical prescribers agreed that this could potentially result in a drug error whereby the incorrect medication had been omitted and there would not be any supporting written evidence. We revisited the General Medical Council (2016) and Nursing and Midwifery Council (2016) guidance on prescribing, and discussed issues surrounding deprescribing at length. The nurse prescribers were also involved in discussions as to how and why we stop medications and they expressed concerns that they often did not understand the rational for which medicines were continued/stopped and they were very reluctant to stop medications unless it had been something they had prescribed which had led to side effects or not been tolerated by the patient. We considered the available tools to help with medication reviews and we decided to use the BEERS criteria tool within the inpatient and day unit setting. We also discussed having a space within the prescription chart to list medication changes and the rationale with the hope of improving documentation and understanding and reducing drug errors.
The most alarming fact was our lack of communication with our GP colleagues whom we rely on to issue prescriptions but we failed to give them the appropriate information to do this in a safe and timely manner.
Barriers to change:
A new way of working can often be challenging and I think having the tool on the prescription chart would be a great idea as it acts as a clear prompt. Doctors felt that if the patient was not able to have the discussion due to them being too unwell and if there was no relative present that this would be an issue. However, we agreed that if this is the case we would still make the changes acting in the patient’s best interest but would discuss this as a team and we would ensure we documented this in the patients’ records.
Phase 2 results:
The data has been collected retrospectively reviewing patient admission between March 2016 and June 2016. This retrospective analysis includes reviewing patient notes, prescription charts and discharge summaries. There were 35 admissions during this time period.
It was my expectation that we would attain much better results after implementing teaching sessions and discussion around prescribing and documentation. However, some of the changes that I wanted to instigate such as a review box on the treatment sheet and a tick box prompt on the IT system had not been put in place.
Medications altered in prescription charts: 89%
Standard 1) Structured medication review and changes documented in notes:80%
Standard 2) Documentation of discussions with patient/family: 56%
Standard 3) Documentation of changes forwarded to GP: 90%
Comparison of Phase 1 versus Phase 2 results:
Analysis of reaudit data:
Although our results had improved across all domains the greatest improvement was in our communication with our GP colleagues. I feel that there is still room for improvement with our medication reviews and more so our documentation but at the moment I do not feel our prescribing system supports this, we currently use paper prescriptions and electronic patient notes. The prescription chart currently does not have a space for medicines reconciliation or documentation of change, nor do we have regular pharmacist support.
On discussion with my colleagues it was highlighted that we are failing the standard we set regarding discussion with patients and their families. Colleagues reported that they felt that often the patient is too unwell to have those conversations with and the Doctors/Nurse prescribers do not feel it is appropriate to be “burdening” the carers with any more information regarding stopping medicines as they thought this may cause may distress, we discussed how this was actually good practice and could help open conversations with loved ones regarding the patient approaching the end of their life. It is not always possible to have these conversations as some patients so not have anyone close but we should try where we can to be open and honest. We have organised a communication skills day in the new year where we can role play some of these discussions so they do not feel as daunting.
Having completed this audit, we have highlighted several key areas for further improvement. We are going to try and move towards an electronic prescribing system which links in with the electronic patient notes, the software is already in place we all just need training on how to use this and how it will link in with our pharmacy support. In the mean time we have now added drop boxes onto our clinical notes which act as a prompt to check patient’s medication and document any changes.
Once these changes have taken effect and our staff have completed the communication skills study day I would like to re-audit. This time I would like to separate day therapies and the inpatient unit as I believe the day therapy unit is achieving its set standards and may be skewing the inpatient data.
Conclusion:
Upon reviewing the literature, it seems to suggest that medication review and deprescribing can be done in a controlled manner with the net outcome being patient benefit rather than harm.
This audit has improved the way we review and document medications however there is still room for improvement. During the time period of the re-audit there were no further clinical incidents with regards to medication omissions which leads me to believe we are being more careful in our prescribing, communication has improved both within the team and with our patients’ and their carers, as well as our documentation. This in turn will lead to improved patient care as well as easing some of the medication burden that faces some of our patients also helping to provide some cost benefits to the health economy. I believe our greatest improvement has been our communication with our primary care colleagues who will hopefully find our rationale for stopping certain medicine useful and in turn it may influence their practices in the future.
We know that inappropriate polypharmacy can have many negative patient impacts and I feel we are in a unique position within the hospice setting to discuss these issues with our patients enabling them to make an informed choice and oversee the tapering or stopping of medications.
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