Abstract
Effective medication reconciliation is an integral and vital part of the care transitions process. The hospitalist team of St. Joseph Hospital (SJH) discharge patients from the hospital and refer them to the hospice. However, the appropriate comfort care and medications provision is not always available. Patient caregivers and the hospice staff faced some unforeseen problems and difficulties upon enrolling patients into hospice after their discharge from the hospital. Among other problems, these difficulties include inaccessibility of medications and appropriate prescription for them. At times, scripts for opiates, anxiolytics, laxatives and antiemetic agents for symptom management were not available at all. The availability of these appropriate medications becomes increasingly important as the symptoms worsen in a relatively short period. Hereby, such difficulties and distress affect patients, families and the staff involved negatively. We have been attempting to improve the process of transition the patient from the hospital to the hospice with appropriate comfort focused medications’ prescription and availability.
Preceding achievements
The past two Palliative/Hospice fellows in Marshfield Clinic have done the Quality Improvement projects to identify the problems and improvement strategies for appropriate medication prescription for hospice discharges.
The first Plan, Do, Study, Act (PDSA) cycle in 2013-2014 designed and implemented the provision of Laminated Medication Guidelines cards to the hospitalists. According to this, ascertaining the appropriate symptom helps to organize the direct discharging of medications for hospice patients with a focus on the Ministry/Marshfield hospice system.
The second PDSA cycle done in 2014-2015 designed a two-step intervention. The first step is that the Ministry Hospice Admissions Coordinator informs the Palliative Pharmacist (Ministry St. Joseph Hospital) about a planned discharge to the hospice. The second step is that the palliative pharmacist makes a call to the discharging provider to offer assistance and consultation services to review and provide dose adjustment for the appropriate symptom directed discharge medications. The team provided the staff involved in this processes with the pharmacist call numbers and timings.
Despite these two interventions, there are still cases of difficulties. The third PDSA cycle aims to identify the failure factors and the processes needed to improve the availability and prescription of medication for the hospice patients upon hospital discharge.
The content of the work and the methods used
We conducted a survey with exploratory questions to the nursing staff and the pharmacist about issues of different classes of medication including opiates, laxatives, antiemetics and anxiolytics. We also recollected information about any other unforeseen events.
We conducted a telephone interview for the accepting nursing team in September and October 2015. The respondents were not able to recall any significant issues faced at the time of hospice enrollment for procurement of the medication during the months of September and October 2015. We assume it relates to the time lapse between the data collection and telephonic interview.
We implemented the review of 130 charts in September 2015, 138 charts in October 2015, 132 charts in November 2015 for the patient of Marshfield and Stevens Point Ministry hospice. We identified twenty-five patients referred for the hospice from St Joseph Hospital.
We conducted six telephonic interviews in the month of November 2015 for the patients discharged from SJH with hospice. Our goal was to identify any issues, sources and barriers experienced by the patients, caregivers and the staff. We tried to understand how to support the patients with a smooth transition from hospital discharge to the hospice setting with appropriate medication availability (opioids, laxatives, anxiolytics, anti- secretory, antiemetics and anti-agitation).
We conducted the interview within a week’s range of hospice enrollment. The participants for the interview were the discharging pharmacist (from the hospital) and the accepting hospice nurse.
The list of questions for the pharmacist:
Did the staff/Admission Coordinator or the discharging provider contact the palliative pharmacist for assistance for the comfort-focused medication? Did the pharmacist advise any changes?
In your opinion, what is the thing to do to improve the discharge process to hospice with appropriate comfort focused medications?
Results from the Pharmacist. The primary discharging physicians did not contact the pharmacist for assistance at all.
The list of questions for the admission team and nursing staff:
Did you need to call the provider within 24 hours of patient’ arrival to hospice home for comfort medications prescriptions including opiates, anxiolytics, laxatives and antiemetics and anti-agitation agents?
What medications did you need? (pain/opiates, nausea/vomiting, anxiety/agitation, anti-secretory medication, laxatives)
What in your opinion is the biggest issue and the concern in regards to the above medication prescription and availability prior to discharge and acceptance to hospice?
What in your opinion is the thing to do to resolve the issue,you may write three suggestions.
Results from the admission team and nursing staff (Table 1).
However, some patients do not need pain medications at discharge but the anticipated needs in the hospice home warrants the prescription of limited supply of comfort focused medication prescription if situation arises.
The analysis of the result
The accepting team made four main recommendations according to the resulting table.
The need to reflect on the patient’s medication list in terms of patient goals (a comfort focused plan)
The need to prescribe a limited supply of comfort focused medication at the time of discharge (opiates, anxiolytics, laxatives, anti-agitation and antiemetics)
The need to ensure that comfort focused medications (opiates, anxiolytics,anti-agitation agents, laxatives and antiemetics) were available for 100% of the patients at discharge.
The House Of Dove nursing staff preferred the prescriptions sent to the outpatient Marshfield pharmacy especially for the patients discharged in the after hours, weekends or later part of the day for easy access to medication availability.
Methods/Measures implemented post data gathering and analysis (Nov 2015-May 31st 2016):
We proceeded with meeting and discussions with the Pharmacy Manager about the best way to accomplish the goals for a 100% success rate for the four mentioned issues. We found out that electronic consult placed might lead to better results.
We met with the palliative team providers on 27th Jan 2016 to discuss our suggestions about creating an electronic order set for Discharge (DC) planning for hospice and offer the Palliative team services for the consult for medication review if the primary provider prefers so. All the Palliative providers agreed for the electronic order set.
We organized a meeting with the hospitalist group on 17th Feb for their input suggestions and discussion about our suggested plans to implement an electronic order set for discharge planning for hospice enrollment. The hospitalist team was very appreciative of our proposal for the electronic order set to be created in Centricity for planning with hospice discharge. They agreed to place the orders one day prior to actual discharge themselves and appreciated our willingness for assistance if needed.
Meetings and discussion with CPOE personal(Jen Kops) to develop electronic order set for Preparation for Hospice Discharge. We met with her on 29th March to finalize the order set prior to the implementation.
The order set was created as below and went live on April 13th 2016.
We made multiple calls and e-mails to Asera Care Hospice, Wausau, Hospice touch,Tomah Wi, and to Ministry/Marshfield Hospice team and gathered the data post implementation of the live DC preparation for hospice enrollement in May 2016.
Out of 18 patients discharged on hospice from SJH in the month of May, 10 patients had my newly introduced order set used and many discharging providers have found it very helpful.
One physician stated that repeat reminders to the hospitalist team would be helpful.
Many physicians stated that the order set is difficult to locate.
No acute medication issues were reported by the nurses team for Ministry hospice/ascension home care hospices.
Asera care hospice stated that they didn`t have any referees from SJH in the month of May until 18 May 2016.
The Tomah hospice has never given any data.
Conclusion
We will continue to study and gather data with the above measures for evaluation of the impact and improvements for continued quality improvement measures.
We may need another PDSA for ongoing quality measures and calculation of the expected changes in the next coming year.
Works Cited
Patients discharged from St. Joseph Hospital, Marshfield. Personal interviews. September- October, 2015.
Charts of the patients discharged to the hospice from St. Joseph Hospital, Marshfield. September- October, 2015.
Kops, Jen. Personal interview. 29 May 2016.
