Improving the Pediatric Medication Discharge Process 2017 ANCC National Magnet Conference Session Number C406 Wednesday, October 11, 2017 11:30 AM Melanie R Lord RN BSN CPN Nicole Manchester MSN, RN, CNL Lorraine L McElwain MD The Barbara Bush Children’s Hospital at Maine Medical Center, Portland Maine Disclosures Presenters have no relevant financial relationships with the manufacturer of any commercial product and/or provider of commercial services discussed. Learning Objectives 1. Identify benefits of caregiver teach-back with new medications and side effects. 2. Investigate new methods to improve the hospital medication discharge process.
Setting • Maine Medical Center is an academic, urban hospital with 600 licensed beds in Portland Maine • The Barbara Bush Children’s Hospital is embedded within Maine Medical Center • Maine Medical Center received it’s 3 rd Magnet designation in 2017 The Barbara Bush Children’s Hospital • 116 licensed beds including the following: - 30 inpatient pediatric beds - 7 short stay beds - 8 PICU beds - 51 NICU/CCN beds - 20 newborn beds • The only children’s hospital in the state of Maine, serving Maine and eastern New Hampshire Background • Pediatric Hospital Medicine (PHM) joined Project IMPACT ( Im proving Pediatric Pa tient-Centered C are T ransitions), a National AAP QI Project in 2013. The project’s aim was to improve the discharge process for patients and families and to help create a best practice pediatric discharge bundle. • Discharge Bundle elements tested by our Discharge Improvement Team : 1. Pre-discharge teach-back education 2. Discharge readiness checklist 3. Inpatient to outpatient provider handoff 4. Follow-up phone call to family caregiver 6
Our Baseline Data • Follow up phone calls revealed opportunities for improvement with discharge medications • Medication errors: 7% of caregivers/family members unable to teach-back medications correctly • HCAHPS responses on questions regarding medication teaching were below national average Goal: Improve the discharge medication process • Examples of discharge medication errors: - Did not pick-up medication on way home (child sick, did not want to wait at pharmacy, pharmacy was closed, liquid form of medication not available) - Did not have the money to pay for the medication - Prior Authorization was needed for the medication, medication not obtained - Did not know how or when to give medication - Did not realize the medication should be started right away (as opposed to waiting until after the weekend) 8 Interventions • Formed an inter-professional team • Refresher for staff on Teach-Back technique • EHR optimization - created the “Consult to Outpatient Pharmacy” order to enhance communication with our on -site retail pharmacy • Expanded capacity of bedside delivery • Pharmacist or Nurse education at bedside with medications in hand - Discuss reason for medicine, potential side effects - Employ teach-back method
Primary Driver: Improve access to new medications: • Increase % of patients leaving the hospital with new medications in hand from ~2% to 50% by the end of a 2-year 1 st study period (Discharge Improvement Team). • Increase the % further in the 2 nd study period (Discharge Medication Process Improvement Work Group). 11 Primary Driver cont. Improve understanding of new medication plans: • Improve family member understanding of medication plans as measured by ability to accurately “teach - back” details on a post-discharge phone call. • Improve family member experience and satisfaction with explanation of side effects of new medications and how to take new medications to or above national average as measured by our HCAHPS tool 12
Secondary Drivers: - Improve access to new medications: 1. Access to onsite retail pharmacy 2. Availability of bedside delivery 3. Earlier identification of financial barriers 4. Earlier identification of prescription errors 13 Secondary Drivers: - Improve understanding of new medication plans: 1. Teaching with medications in hand 2. Teach-back technique 3. Discharge medication teaching by pharmacists, reinforced by nursing staff 14 Nursing Teach-Back • An evidence-based method to improve understanding and retention of discharge instructions • Chosen as the preferred method of discharge teaching by Project IMPACT • Educated staff nurses on the inpatient pediatric unit utilizing one on one teaching and computer based education modules
Teach-Back • A teaching technique where family members demonstrate their understanding • Prevents incorrect understanding and reinforces retention of medical information • Uses simple language, avoids confusing medical jargon • Allows for immediate correction of misunderstandings prior to discharge • Confirms understanding after repeated clarification 16 Teach-Back • Patient initially taught discharge information • At the end of initial teaching, comprehension is tested • “I want to be sure I am explaining this well. Can you repeat this back to me to be sure it’s clear?” - Discharge medications - Follow up appointments - Contingency Plan - Home Care and/or equipment 17 Teach-Back Perceived nursing concerns: - Talked down to/paternalistic - Family offended Actual feedback: - Families appreciated the reinforcement - Sustained use of the method with ongoing evidence and education
Teach-Back • Additional focus/education on medication instructions (dosing, side effects, reason for treatment) • Comfort with teach-back technique strengthened • EHR tool developed to support technique Data Collection Interdisciplinary team: resident & attending physicians, nurses, parent representatives, care managers, and pharmacists performed series of planned sequential interventions (PDSA cycles) and plotted/interpreted data on statistical process control charts • Observational time series: Jan 2014 - Dec 2015 (2 yrs, 1 st study period) Jan 2016 - Dec 2016 (1 yr, 2 nd study period) • Population - all patients discharged from our Pediatric Hospital Medicine service ~1100 patients per year • EHR review including post-discharge phone call transcripts • HCAHPS responses • Hospital discharge time data 20 Process measures • Use of “Consult to Outpatient P harmacy” order in EHR • Bedside medication delivery • Discharge with meds in hand
Results-Process Measure Utilization of “Consult to Outpatient Pharmacy” order in EHR +3 sigma 100% 90% Percent of e-prescription to our onsite retail pharmacy with a “Discharge Medication mean=88% 80% Process Improvement corresponding “Consult to Outpatient Pharmacy” order Work Group” formed 70% “Consult to Outpatient -3 sigma Pharmacy” becomes a 60% selectable order in EHR Benefits of enhanced communication 50% with outpatient pharmacists becomes r outinely reinforced at unit’s daily 40% Interdisciplinary Care Rounds 30% Rotating providers during the Holidays mean=28% 20% 10% mean=8% 0% UCL LCL 1/1/15 2/1/15 3/1/15 4/1/15 5/1/15 6/1/15 7/1/15 8/1/15 9/1/15 10/11/15 11/1/15 12/1/15 1/1/16 2/1/16 3/1/16 4/1/16 5/1/16 6/1/16 7/1/16 8/1/16 9/1/16 10/1/16 11/1/16 12/1/16 Second study period First study period 22 Results-Process Measure Percent of pediatric patients receiving bedside delivery (as opposed to pharmacy window Percent of Prescriptions filled by Bedside Delivery 90% “Discharge Medication pick up) of their new medication prescriptions from our onsite retail pharmacy Process Improvement 80% Work Group” formed +3 sigma Bedside delivery “Consult to Outpatient Pharmacy” Order is available available 70% mean=66% in EHR 60% -3 sigma 50% 40% Onsite retail pharmacy hires additional pharmacist mean=28% for bedside delivery 30% Onsite retail (in response to increase pharmacy opens demand for service as 20% Adult Inpatient Service duplicates QI project) 10% 0% LCL UCL 1/1/15 2/1/15 3/1/15 4/1/15 5/1/15 6/1/15 7/1/15 8/1/15 9/1/15 10/1/15 11/1/15 12/1/15 1/1/16 2/1/16 3/1/16 4/1/16 5/1/16 6/1/16 7/1/16 8/1/16 9/1/16 10/1/16 11/1/16 12/1/16 First study period Second study period 23 Results-Process Measure Percent of Pediatric Hospital Medicine Service Patients Discharged with New Medications in Hand +3 sigma 100% Bedside delivery Percent of PHM patients with new prescriptions filled by our onsite retail available 90% Discharge Improvement Team mean=82% prioritizes filling medications at onsite 80% retail pharmacy prior to patient discharge 70% 60% -3 sigma mean=51% Monthly “Discharge 50% “Consult to Outpatient pharmacy prior to patient discharge Improvement Team” Hospital opens Pharmacy” order and bedside meetings with focus on onsite retail 40% Delivery rates both exceed 70% optimizing Transitions pharmacy Checklist in EHR 30% “Discharge Medication Process Improvement Work Group” formed. Monthly meetings to review and 20% address issues. “Consult to Outpatient mean=9% 10% Pharmacy” order is available UCL in EHR mean=2% 0% LCL 1/1/14 2/1/14 3/1/14 4/1/14 5/1/14 6/1/14 7/1/14 8/1/14 9/1/14 10/1/14 11/1/14 12/1/14 1/1/15 2/1/15 3/1/15 4/1/15 5/1/15 6/1/15 7/1/15 8/1/15 9/1/15 10/1/15 11/1/15 12/1/15 1/1/16 2/1/16 3/1/16 4/1/16 5/1/16 6/1/16 7/1/16 8/1/16 9/1/16 10/1/16 11/1/16 12/1/16 First study period Second study period 24
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