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Kelowna General Hospital
Renal – Pharmacy
Collaboration
Pharmacist Managed MedRec and Care of End
Stage Renal Disease in Patients
Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Background
• Patients with end-stage renal disease (ESRD) are at
high risk for drug-related problems (DRPs),as these
individuals take numerous drugs, have multiple comorbidities, and experience frequent medication
changes
• The project will target patients with end stage renal
disease (on dialysis) who are admitted to Kelowna
General Hospital acute care during the 6 month pilot
project duration.
• Hospitalization of patients with ESRD can contribute
to the risk of DRPs.
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Background
• Medication reconciliation is part of a broad process of
pharmaceutical care, which is the collection of relevant
drug, disease, and patient information through a chart
review and interview with the patient and/or family
members and healthcare providers, followed by an
interpretation of all available information to identify,
characterize, and resolve the patient’s actual and
potential DRPs.
• The project will enable a multidisciplinary team to
develop appropriate tools and an efficient process for a
medication reconciliation and pharmaceutical care
service in the ESRD inpatient population.
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Background
• The project will also help to identify the system
problems, characterize the incidence, type, and timing of
discrepancies and DRPs (and their associated
medications) throughout the entire hospital stay.
• Furthermore, having this preliminary pilot data may
increase the political will to allocate adequate resources
to expand clinical pharmacy services to the renal (or
other) areas throughout IHA.
• Expected start date is dependant on securing funding for
the project
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Objectives
• The purpose of this pilot project is to develop a
pharmacist-managed medication reconciliation and
pharmaceutical care service in the ESRD inpatient
population to identify, characterize, and resolve
medication discrepancies and DRPs, and collect
preliminary information on drug acquisition cost changes
and pharmacist time requirements to perform this
activity.
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Goals
• To collect pertinent baseline information on the incidence
and type of medication discrepancies and DRPs;
• To develop useful tools and an efficient process for the
provision of medication reconciliation and
pharmaceutical care;
• To identify, characterize, and resolve unintentional and
undocumented intentional medication discrepancies, and
calculate the medication reconciliation success index;
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Goals
• To assess the potential impact and relationship to gaps
in the medication information transfer process of
unintentional and undocumented intentional medication
discrepancies and DRPs;
• To determine the number, type, and medications
associated with identified DRPs;
• To determine the acquisition medication cost impact of
medication reconciliation and pharmaceutical care;
• To determine and characterize the time required for a
pharmacist to perform medication reconciliation and
pharmaceutical care.
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Team Members
Dr. Gerry Karr, Richard Slavik,
Sue Bannerman, Cathy Farrow,
Paul Filiatrault, Susan Haskett,
Sean Hickey, Wrae Hill,
Holly Morgan, Christina Krause,
Norma Malanowich, Gordon McGreevy,
Kevin Peters
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Team in Developmental Stage
• We have submitted our project proposal for
funding
• We have written our MedRec charter
• We have started process mapping of an
acute care episode for chronic renal patients
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Next Steps
•
Obtain funding for project
• Finish process mapping
• Initiate project
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Process Map
Possible sources of Med History:
·
PharmaNet
·
Patient’s PROMIS list
·
Chart (if former KGH pt)
·
Patient themselves
·
INTERRAI ((Community
Care Med List)
·
Nephrologist consult and
med review
·
·
·
Other Identified Issues:
PharmaNet – Could be out of date, Patient may not be
compliant, Changes may not be recorded e.g. increase in
dosage
Patient may be taking samples provided by physician
Many med histories do not contain Over The Counter meds,
Herbals, Home Remedies, etc.
Medication Reconciliation of Hemodialysis Patients admitted to KGH – Current process
Emergency
Department RN
Ward
RN/ LPN
PSS RN
-Outpatient
-Acute Transfers
-Residential
Transfers
Physician/
Specialist
Pharmacy/ Allied
Health
Professionals
Hemodialysis
Unit RN
PROMIS
Physician orders
direct admit
·
Contains lab work,
history, meds, comorbidity (c/b
complete history)
Review and Update
Meds every 3
months
Issue Med List to
patient after update
·
·
Patient admitted to
ER
·
·
·
·
·
·
·
·
Medication orders from:
General Practitioner
Nephrologist
Cardiologist
Vascular Surgeon
Rheumatologist
Gastroenterologist
·
Anaesthesiologist
·
Haematologist
·
Respirologist
·
Dentist
·
Eye Surgeon
·
Psych consults
·
Homeopathic Dr.
Transferring specialists consult
with Receiving specialists
Nurse reviews chart
Contacts MRP
MRP writes med
orders
RN Contacts Hemo
Unit for:
1) Dialysis info
2) Med sheet
Nurse faxes orders to
pharmacy
Patient referred to
PSS
1) PSS nurse requests
PROMIS med list from
Hemo unit
2)Anaesthesiologist
reviews meds
3) Pharmanet info
pulled??
·
Practices
Vary
Hemo and Family Dr.
may be unaware of
Discharge Meds
ALL Hemo
Patients
on 15 – 20
meds
All changes done
by Hemo RN
Med changes
may/may not be
reported
Rely on patient to
update records
·
Patient admitted to
Ward
Community
Pharmacist
Patient
Pharmacist may
contact Hemo re:
meds not taken
Hemo RN sends
PROMIS med list
·
·
Physician signs
discharge
prescription
Written by
Whomever
discharges
patient
Hemo Unit
open only:
Pharmacy
receives orders
and fills meds
0700 – 2400 hrs
Mon– Sat
Gives PharmaNet profile of drugs
dispensed only by that particular
pharmacy
Multiple Pharmacies involved
(both local and non-local, as
certain meds dispensed only by
McDonald’s in Vancouver)
0700 – 1900 hrs
Sun
Pharmacy clarifies
and unclear orders
Surgery performed
Discharge
Orders may not
include
Hemodialysis
Med Orders
All
have ability to
change meds
Patient transferred
to ward
Two MAR’s:
1. Inpatient
2. Hemo Unit
IP MAR travels to
Hemo Unit and back
with patient chart
PSS faxes med
list to Hemo
RN Faxes
Discharge
prescription to
next location
meds on
formulary?
IV Meds
sent from
Yes
Ward to
Hemo
order filled
No
Hemo nurse
provides EPO or
Fe
LOGISTIC ISSUE
- drugs are
dispensed by
syringe
Discharge
prescription, med
list received by
Hemo RN and
entered into
PROMIS
Meds filled by
another source
(if Renegal, then
patient provides)
Patient provides
Hemo RN with
med update
Community,
Residential
Services enters
med list into chart.
Some drugs are
given on ward/
some in Hemo Unit
Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Contact Information
Sue Bannerman
Lead, Renal Program
Interior Health Authority
#210 - 1815 Kirschner Road
Kelowna, BC V1Y 4N7
Phone: (250) 870-4690 Fax: (250) 870-4795
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Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative
Med Rec Charter
Coming Full Circle: AMI & Med Rec Across the Continuum
Western Node Collaborative