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Medication History Taking and confirming and reconciling medication on admission Ian Coombes Session Objectives – Understand importance of consultation skills – Improve communication skills – Be able to determine what patients actually take prior to admission – Learn about common ‘error traps’ in history taking – Limitations of different information sources – Assessment of compliance – Consider how ‘medicines/lack of’ cause admission – reconciliation Effective drug therapy Personal views, experiences, seen other patients, read literature Improve quality of life Understand pathophysiology, pharmacology, pharmacokinetics, EBM. Safe drug therapy Aims of Pharmaceutical Care Understand multiple pathologies, other pharmacologies, appreciate consequences of errors, safe practice Knowledge of BNF, hospital formulary, pharmacology, EBM Economic drug therapy Interpreting data Gathering data Problem solving Providing a solution Consultation Skills Monitoring outcomes Effect What is a Medication History? • A record of all medicines being taken at time of hospital admission/presentation and - previous adverse drug events (ADEs) and allergies - recently ceased or changed medicines - Identifies patients’ understanding of their disease and their medicines - Begins to identify medicine taking behaviour ie adherence (compliance/concordance) behaviours • The baseline from which: - drug treatment will be continued at time of admission - therapeutic interventions will be made - self-caring will continue post discharge The Importance of Medication Histories • 14.5% of consumers are on ≥ 4 medicines (ABS, 1999) • 5-20% of medical admissions drug related (Roughhead, MJA, 2000) • On admission, up to 50% of patients have an incomplete medicine list provided, resulting in a medicine not being administered during the hospital stay (Stowasser, AJHP, 1997) • A full medication history – Identifies patients’ needs – Explores the patient’s perspective of illness and its treatment (needs and concerns) Example of Drug-Focused Care • Will it work • Furosemide 80mg bd • Adverse drug effects – – – – Hypokalaemia Hypocalcaemia Hypotension Renal Function • Drug interactions • Legal • Cost • Yes, it should do • Dose ok • Blood results – – – – K+ ok Ca++ ok BP ok Creatinine ok • No other medicines • Prescription signed • Cheap What sort of things are going through the mind of Mrs CCF at the moment? Fear of the disease Fear of future disease management •I’ve got heart failure, it must be the end of •I’m going to have to take medicines for the line, I’m going to die in this horrible the rest of my life aren’t I, what if I hospital forget? •If I survive this, how am I gong to cope in •I saw something on the news last week future? My family and friends are going to about antidepressants, are all the get sick of me, I may as well give up now medicines they prescribe going to kill me? Trust healthcare professionals Other anxieties •I’ve heard horrible stories about these •Oh no, I have an appointment at the places, people going in fit and well, and eye clinic on Monday, they’re going coming out in boxes to be expecting me, I’ll never get •What about Shipman, are they all after my another appointment money? By focusing care on the patient • She is still having difficulty breathing – “I feel like I’m drowning” • Has to go to the toilet throughout the night, can’t sleep properly • Mrs CCF doesn’t know what furosemide is for • Mrs CCF hasn’t been taking her ACE-inhibitor at home because the patient information leaflet scared her General points for good consultation about medicines • • • • • • • • Clear purpose Builds rapport Builds relationship Actively listens to the patient Open questions Identifies patients’ needs Full medication history Explores the patient’s perspective of illness and its treatment Obtaining an accurate Medication History: What does it involve? • Structured process – Review of sources of patient information – Patient/carer medication history interview – Organisation of patient data • Confirmation – Ensuring completeness and accuracy • Not relying on a single source 11 Medication History Interview - 8 steps 1. 2. 3. 4. 5. 6. 7. 8. Obtain relevant patient background Open the consultation Confirm/ document allergies/ ADR Take/document medication history Undertake a thorough adherence assessment Assess medication management ability Confirm medication history Reconcile medication history with medication chart and current medical problems 12 Accurate Medication History • Structured process - review of sources of patient information (not relying on a single source) - medication history interview - organisation of patient data • Confirmation - ensuring completeness and accuracy Confirming Medication History • • • • • • carer/s other doctors (e.g. GP) community pharmacists ? patient’s medicines/list of medicines ? patient’s prescriptions ? medical notes -discharge card -previous outpatient visit/s (Obtain patient consent to contact other health care providers) Benefits/ limitations of own medication Positive: • Used as prompt/ prop: – Can you show me what you take? – Do you take these? – How many of these do you take? • Labels and dates – Idea re adherence – Contact details – Multiple pharmacy • Identify errors Negative: • Not all brought in: – Inhalers, drops, injections, patches, fridge items left behind – Webster packs not all medicines included • Doses on labels may have changed – multiple repeats over months • Not all own medicines Video Medication History Interview 1 Observe: • communication skills • what is done well in the interview? • what could be improved? • any limitations of technique? As you watch the video: - write down the medicines you think the patient is taking and what you wish to clarify Key Messages from 2nd Interview • Better engagement of patient • Explained purpose of interview • Use open rather than closed questions - How long have you been on them? - What do you think the medicines are for? • More active listening – followed up answer • Showed patient the tablets “brown bag” • Used patient’s own list of medications • Asked about any problems or ADRs • Linked medication with medical history Medication History • For each medicine, record: - generic and brand names - strength; form; dose; frequency - duration of therapy - indication (patient’s perception) • Any medicines started/ceased/changed? Why? • Identify what patient is actually taking pre-admission • Compare with what patient should be taking - treatment gaps and compliance issues? - possible drug related problems? • Link medical history with treatment - anything missing? - e.g. do you take anything for your diabetes? Information Obtained – interview 1 Medication (ED Dr) Old Discharge Summary aspirin 150 mg mane aspirin 150 mg mane frusemide 120 mg mane frusemide 120 mg mane hydralazine 50 mg bd hydralazine 50 mg bd GTN patch mane amlodipine 10 mg mane amlodipine 5 mg mane Imdur/ isosorbide mononitrate 120mg mane Imdur/isosorbide mononitrate 120 mg mane glipizide 10mg bd paracetamol prn paracetamol prn How does this compare to the next video?… Comparison of Information Obtained Doctor #1 Doctor #2 aspirin 150 mg mane aspirin 150 mg mane frusemide 120 mg mane frusemide 40 mg mane prn hydralazine 50 mg bd hydralazine 25 mg bd GTN patch mane GTN 5mg/24hrs patch all day amlodipine 5 mg mane Imdur® 60 mg bd Imdur® 120 mg mane glipizide 10 mg bd paracetamol prn ibuprofen 400 mg tds methotrexate 10 mg/weekly (SUNDAY) Don’t Forget • Over the counter (OTC) (especially NSAIDS; paracetamol +/- codeine) • Eye drops • Topical - patches, creams • Inhaled - puffers, sprays • Pessaries, suppositories • Herbal and complementary medications • Injections • Intermittent treatments (weekly, monthly etc.) • Recently ceased medications • Previous allergies or adverse reactions Taking the history is first step • Now we need to link it to the patient! Adding Value after taking the history 1. Matching medications with diagnoses 2. Are the medications appropriate? 3. Are the medications achieving what is expected? - Is the diagnosis correct? Is the indication appropriate? Why Reconcile Medication? 63% of reported medication errors resulting in death or serious injury were due to breakdowns in communication, and about half of the errors would have been avoided through medication reconciliation • Increased risk (3.5 fold) of preventable adverse events (Petersen, Ann Intern Med 1994) • Miss 1 medicine off discharge letter 2.3 x readmission in 30 days (Stowasser, JPPR 2002) - The Joint Commission of Accreditation of Healthcare Organisations (JCAHO)’s Sentinel Event Database (2006) Admission Med Reconciliation Clinical Handover Discharge Med Review Clinical Handover Med Reconciliation Clinical Handover Clinical Handover Lessons to Learn • Underlying failure in handover/ communication between primary and secondary care • Reliance on one source of information for medication history taking • Always need to ask patients, carers, other Drs, community pharmacists about medications 28 Reconciliation of Medications NO ß-blocker frusemide Left Ventricular Failure NO ACE Inhibitor hydralazine nitrate Reconciliation of Medications NO oral hypoglycaemics NO Insulin Diabetes aspirin NO ACE Inhibitor Precipitation of Admission? Nitrate Tolerance Low hydralazine NSAID Left Ventricular Failure Acute Renal Failure NO ß-blocker NO ACEI ?BP Controlled amlodipine dose Adherence Question the patient on concordance/noncompliance and ineffectual medications: – “People often have difficulty taking their pills all the time…have you had any difficulty taking your pills?” – “About how often would you say you miss taking your medicines?” Risks v Benefits of Treatment (Horne, 1997) Beliefs about medicines are the strongest predictor of how people use them In deciding whether to take medication many patients engage in a risk-benefit analysis Concerns Necessity Patients’ actions might not correspond to treatment recommendations (e.g. taking less) Medication Management Assess patient’s ability to manage own medicines Risk Assessment Level of Independence Patient Assessment • looks after own medicines • can read • lives in Nursing Home • can see/read labels • uses dose admin. device • understands English • uses administration aid • can open bottles • uses medication record • can measure liquids Key Issues for Practice • Most patients vary from prescribed regimen - over & under dosing, OTC meds • First histories taken in ED often not full story • All information sources have limitations • Consider drug-related contribution to admission (over or under treatment) • Consider what you are prescribing and why • If in doubt, ask! • Time spent early in admission may result in better outcomes for all Summary • Medication histories are complicated • The most readily available source of information might not be the best! • All sources have limitations • Consider PC, PMH and signs and symptoms • About 5-20% admissions are drug related • THINK: NSAIDs, cardiovascular, immunosuppressive therapy, lack of concordance Any Questions?