Clinical Modules: How to Dr Eleri Clissold
Gather your baseline data
Run a query Save the Query Go to Double builder to Choose Open Tools > click Right Click Open & Export as your Import Medtech Query Query a folder run excel desktop or Query Builder Store in your documents
Randomize Audit every other Select a random patient starting at this number between 1 and number e.g. if 6 is 10 by picking pieces of drawn audit the 6th, paper out of a hat 8th, 10 th patient etc
Audit
Aim “ALL discharge summaries received will be reviewed, with both medications reconciled and actions completed, within seven calendar days” Measures Has medication reconciliation occurred within seven calendar days of the EDS being received? Has the patient's regular medication list been updated? Is it documented that any significant medication changes have been discussed with the patient or their representative? Overall Compliance
Spread sheet walk-through No more than 10 Use the same spread sheet No NHIs please
Send us the spread sheet 10 th of each month audit@safetyinpractice.co.nz Use the SAME spread sheet next month
Medication Status - STOPPED
Medication Reconciliation GP 2017-18 Has the patient's regular medication list Has Medication Reconciliation occurred been updated? within 7 (calendar) days of the EDS being received? 100% 90% 100% 80% 70% 80% 60% 60% 50% 40% 40% 30% 20% 20% 10% 0% 0% Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Is it documented that any significant Medication Reconciliation Overall medication changes have been discussed Compliance with the patient or their representative 100% within 7 (calendar) days of receipt? 90% 100% 80% 70% 80% 60% 60% 50% 40% 40% 30% 20% 20% 10% 0% 0% Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Medication Reconciliation “Initially the team didn’t think there was a problem with Medication Reconciliation so this programme has now highlighted that some GP’s don’t update the medications” “We are now all clear that med rec is to be documented; using agreed and created shortcut keys.” “Patients really appreciate the calls to discuss their medication changes”
Support Practice visit PHO advisors Improvement Clinical leads advisors
Prescribing Indicator Modules Lisa Eskildsen
Prescribing safety indicators Statement that describes a prescribing event that puts the patient at risk of harm
British Journal of General Practice April 2014
56 prescribing safety indicators Range of therapeutic areas hazardous drug-drug combinations inadequate laboratory test monitoring Categorised according to degree of risk of harm 23 posed high (3) or extreme (4) risk of harm
Focus on NSAID
Reducing harm from NSAIDS One of main medicine groups causing death Most commonly causing admission ~ 30% Evidence that when risk is highlighted practitioners reduce risk prescribing in at least 1/3 patients Shown reductions in admissions with GI bleeding and acute kidney injury (AKI) in UK
Patients ≥ 65 years prescribed oral NSAID in the last month, and not prescribed a gastro- protective medicine in the last 4 months Rationale – Risk identified Increased risk of GI bleeding x10 compared to NSAID use in middle age. Recommended Action Review the need for NSAID OR Prescribe a gastrointestinal protective medication.
TRIPLE WHAMMY – Prescription of oral NSAID in the last month with ACEI / ARB + diuretic combination within the last 4 months Rationale – Risk identified Substantially increased risk of AKI and death Particularly high risk if pre-existing CKD Risk greatest in first 30 days 80% increased risk hospitalisation Recommended Action Review need for NSAID at all particularly if pre-existing CKD or heart failure Try to use alternative treatment
Prescription of oral NSAID in last month with CKD 3,4 or 5 eGFR<60ml/min Rationale – Risk identified Increased risk AKI Greatest risk at start of treatment Especially if unwell or hypovolaemic Recommended Action Review need for NSAID Advise patients discontinue NSAID if they become unwell or dehydrated
Patients with history peptic ulcer prescribed NSAID without gastro-protection Rationale – Risk identified Increased risk GI bleed Recommended Action Review need for NSAID Close monitoring
Prescription oral NSAID in last month in patient with heart failure Rationale – Risk identified Exacerbation of heart failure Doubles risk of hospital admission Recommended Action Review need for NSAID
Prescription of oral NSAID in last month in combination with warfarin or novel anticoagulant in last 4 months Rationale – Risk identified Increased risk GI bleed – x1.8 – 8 cf warfarin alone Increased risk hospitalisation Recommended Action Review need for NSAID Avoid combination Prescribe gastro-protection medication regularly even if use NSAID is intermittent
What do practices do? Submit the Identify Decide what total Review these patients in actions you numbers only as a practice audit report will take in each group Spread sheet Prioritise Bite sized chunks
TRIPLE WHAMMY Proportion of Patients over 65 currently prescribed an ACEI/ARB and Diuretic who are also currently prescribed an NSAID.
NSAID prescribed to a patient aged 65 years and over without gastro-protection (bleeding risk) Patients age ≥ 65 years on NSAID Patients age ≥ 65 without GI protection years on triple Sustained 50% reduction whammy combination (ACE/ARB + diuretic + NSAID) Sustained 50% reduction
2017-18 SIP Focus on NSAID prescribing CKD 3, 4 or 5 with ‘triple whammy’ 120 100 80 60 40 20 0 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 40% reduction
Focus on: NSAID (first year in programme) Kidneys High risk medicines – prescribing and monitoring
KIDNEYS Prescribing of medicines associated with AKI 1 Prescription of metformin to a patient with renal impairment eGFR < 30 ml/min 2 TRIPLE WHAMMY - Prescription of oral NSAID with an ACE /ARB + Diuretic combination within the last 4/12 3 Prescription of an oral NSAID in a patient with CKD 3,4 or 5 (eGFR<60ml/min) Monitoring of medicines likely to cause AKI / affect renal function 4 Patients prescribed metformin without a serum creatinine in the previous 15 months 5 Patients prescribed an ACEI or ARB who have not had a creatinine and electrolytes in the previous 15 months 6 Patients aged ≥75 years prescribed a diuretic who have not had a creatinine and electrolytes in the previous 15 months Prescription generated in preceding calendar month
High Risk Medicines - appropriate prescribing and laboratory monitoring 1 Prescription of Sodium Valproate to a woman of child bearing potential (10-49 years) excluding women who have had a hysterectomy 2 Prescription of warfarin to a patient without a record of INR having been measured within the previous 9 weeks (excluding patients who self-monitor) 3 Prescription of methotrexate without a record of a full blood count and liver function within the previous 4 months 4 Prescription of Methotrexate without prescription of Folic Acid in the last 4 months 5 Amioderone prescribed without record of thyroid function (TSH) and liver function (LFT) done in the last 7 months Prescription generated in preceding calendar month
What will you do next? Download spreadsheet Save copy to add Choose your What does the to next month. prescribing safety report highlight Enter numbers indicator for your practice? from report into Send to AIP this Spread sheet audit@safetyinpractice.co.nz Plus your PHO facilitator
Equity Factors that pre-dispose populations to poorer health outcomes may also expose them to greater risks of errors, oversights, miscommunications and care which is less appropriate to their needs NSAID Greater incidence and more severe gout Higher rates of NSAID prescribing poss related to poorer contol Greater risks of CVD, CKD and AKI
Mohio Reports presented with Maori patients at top of list
Safety-in-Practice audits Patient names listed - can apply filters e.g age, Maori, high needs
What might your practice do? Share your data with your team – what is it highlighting? Discuss at clinical / practice meeting Decide what area to focus on Review patient notes Actions such as stopping the NSAID or adding gastro-protection and may require a clinical review/ letter phone call Who will do what? Discussing the benefits and risks with the patient
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