Accuracy of pharmacist electronic discharge medicines review information transmitted to primary care at discharge

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review

Background

Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions.

Objective

To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions.

Methods

This 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1.

Results

In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions.

Conclusions

This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2020-045596

Exploring the time required by pharmacists to prepare discharge medicine lists: a time-and-motion study

BACKGROUND  : Discharge medicine lists provide patients, carers and primary care providers a summary of new, changed or ceased medicines when patients discharge from hospital. Hospital pharmacists play an important role in preparing these lists although this process is time consuming. AIM  : To measure the time required by hospital pharmacists to complete the various tasks involved in discharge medicine handover. METHOD  : Time-and-motion study design was used to (1) determine the time involved for pharmacists to produce discharge medicine lists, (2) explore how pharmacists utilise various software programs to prepare lists, and (3) compare the time involved in discharge medicine handover processes considering confounding factors. An independent observer shadowed 16 pharmacists between 22 February and 12 March 2021 and recorded tasks involved in 50 discharge medicine handovers. Relevant information about each discharge was also collected. RESULTS  : Pharmacists observed represented a range of practice experiences and inpatient units. Mean time to complete discharges was 26.2 min (SD 13.6), with over half of this time used to check documentation and prepare discharge medicine lists. A mean of 4.0 min was spent on manually retyping and reconciling medicine lists in different software systems. Medical inpatient unit discharges took 4.6 min longer to prepare compared to surgical ones. None of the 50 discharges involved support from pharmacy assistants; all 50 discharges had changed or ceased medicines. CONCLUSION : There is a need to streamline current discharge processes through optimisation of electronic health software systems and better delegation of technical tasks to trained pharmacy assistants.

Exploring pharmacist involvement in the discharge medicines reconciliation process and information transfer to primary care: an observational study

Background Medication errors can occur because of incomplete or poorly communicated information at the transition from hospital to community. Following an audit in 2016, a project was undertaken to determine if pharmacists could improve the quality of medication information in discharge summaries by introducing a discharge medication reconciliation process. Pharmacists recorded any changes to the patient's medication in the electronic prescribing system during their inpatient stay and summarised these changes on discharge. Objective To compare medication information in discharge summaries with recognised standards for the clinical structure and content of patient records, and to assess the impact of the pharmacist process on compliance with certain elements of these standards. Setting A 750 bed teaching district general hospital in England. Method A retrospective observational study examining all patient discharge summaries over a 1 week period for compliance to national standards. Main outcome measure The main outcome measures were compliance with standards for medication started, stopped or changed in hospital and any differences between extent of recording this information by doctors and pharmacists. Results Data were collected and analysed for 243 patients, of whom 94 (38.7%) attracted a discharge medicines reconciliation process by a pharmacist. Discharge summaries were compliant with basic standards for changed medication in 42% of patients or 51.4% with the input of a pharmacist. This increase of 9.4% was statistically significant (p = 0.0365). At an enhanced level, pharmacists increased compliance from 39.1 to 46.5%, this did not represent a significant increase (p = 0.0989). Conclusion Pharmacists undertaking a discharge medication reconciliation process significantly improves the quality of discharge summaries.

Practice-enhancing publications about the medication-use process in 2019

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change.

SUMMARY

A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Pharmacist-Physician Collaboration to Improve the Accuracy of Medication Information in Electronic Medical Discharge Summaries: Effectiveness and Sustainability

Inaccurate or missing medication information in medical discharge summaries is a widespread and intractable problem. This study evaluated the effectiveness and sustainability of an intervention in which ward-based hospital pharmacists reviewed, contributed and verified medication information in electronic discharge summaries (EDSs) in collaboration with physicians. Retrospective audits of randomly selected EDSs were conducted on seven wards at a major public hospital before and after implementation of the intervention and repeated two years later on four wards where the intervention was incorporated into usual pharmacist care. EDSs for 265 patients (prescribed a median of nine discharge medications) were assessed across the three time points. Pharmacists verified the EDSs for 47% patients in the first post-intervention audit and 68% patients in the second post-intervention audit. Following the intervention, the proportion of patients with one or more clinically significant discharge medication list discrepancy fell from 40/93 (43%) to 14/92 (15%), p < 0.001. The proportion of clinically significant medication changes stated in the EDSs increased from 222/417 (53%) to 296/366 (81%), p < 0.001, and the proportion both stated and explained increased from 206/417 (49%) to 245/366 (67%), p < 0.001. Significant improvements were still evident after two years. Pharmacists spent a median of 5 (range 2-16) minutes per patient contributing to EDSs. Logistics, timing and pharmacist workload were barriers to delivering the intervention. Additional staff resources is needed to enable pharmacists to consistently deliver this effective intervention.