According to the Centers for Disease Control and Prevention (CDC), adverse drug events (ADEs) cause approximately 1.3 million emergency department (ED) visits each year and approximately 350,000 patients each year need to be hospitalized for further treatment after emergency visits for ADEs. As people age, they typically take more medicines, therefore the risk of adverse events increases as individuals take more medicines.
EDs are known to be high-volume, high-pressure environments where decisions need to be made in an instant—at times with incomplete information. Additionally, patients are sometimes unable to communicate, consequently making manual or verbal confirmation of a patient’s home medication list difficult.
The South Weymouth, Mass.-based South Shore Hospital has over 300 patient visits per day to the ED, and a third of those patients are routinely admitted. South Shore Hospital’s leaders wanted to improve clinicians’ use of processes and tools that gather a patient’s medication history within the ED. Generally, hospitals depend on the nursing department to collect and confirm a patient’s medication list, but South Shore Hospital pioneered assigning ownership of medication history to the pharmacy department.
In 2021, South Shore Hospital’s, clinical pharmacy manager, Rachel Blum, Pharm.D., and her team implemented endeavored to create more complete medication history system to provide more complete medication history data, reducing the time staff must spend calling pharmacies and providers to gather and confirm that information. They partnered with DrFirst’s MedHx in the hospital’s Epic electronic health record (EHR). To ensure pharmacy technicians focus their efforts on high-risk patients, Blum led a pilot project to create a patient complexity score embedded in the EHR to help identify and prioritize medically complex patients and evenly assign these patients across the pharmacy team.
The complexity score was built on factors such as age, active problems (such as congestive heart failure, diabetes, COPD, and pulmonary hypertension) and high-risk medications on the prior-to-admission list (such as warfarin, immunosuppressives, anticonvulsants, and antiplatelets) The higher number of points assigned to the patient, the higher they rank on the pharmacy team’s priority list.
The team used the Epic foundation to build around complexity scoring for patients (in the context of medication reconciliation). This framework allowed the hospital to score and organize patients directly within their workflow. They also customized the ED track board with a ranked patient list for pharmacy technicians, which organized patients by complexity but also noted patients that had been missed in the ED and were now on an inpatient floor.
Today, South Shore Hospital is finding clinically actionable medication history on 91 percent of those patients queried. Not only is the staff prioritizing high-risk patients, but they are also getting more information on high-risk medications than previously. In the first five months, the team was able to document the following medications as being high risk:
•7,712 abuse-related medications
•2,962 cardiovascular medications
•1,515 thyroid disease medications
•1,274 steroids and immunosuppressants
•598 diabetic therapy medications
Mapping out and identifying the medication reconciliation process
In speaking with Healthcare Innovation, team leaders see clearly which elements of their work have been groundbreaking. For example, Blum says that South Shore Hospital was not the first organization to enlist pharmacy colleagues to take medication history.
“We know that medication history is more accurate when it's done by a pharmacy team, so I think we have taken that model and that knowledge and truly expanded it to get to 100 percent of admissions,” Blum comments. “I think most organizations are starting to go down that pathway, but I do think that we are on the cutting edge of that.”
Blum notes that they do get requests from hospitals requesting to talk about their innovative process. “We are a Community Hospital where 13 miles South of Boston, so it’s rewarding for me to get phone calls from free movement hospitals saying things like, ‘Hey, what’s your process? Can you walk us through this? We want to try to emulate that.’ It’s nice to be involved in that and helping share our process and make it better for organizations outside of South Shore Hospital.”
Regarding the mapping out the medication reconciliation process, Kristopher Young, chief pharmacy officer, says that the first step was defining what the needs were. He also mentions one of the major challenges was where the information comes from—meaning it could be an electronic source, a caregiver source, or a patient who is on their own.
“It's been an iterative, continuously improving processes over the years,” Young adds. “As new components and new challenges have been brought to us, we've tried to do things with a lean approach—bring those who do the work to the table to help us try to shape the direction moving forward.”
Identifying the Medication Reconciliation Committee
And who was around the table? Blum says that “The Medication Reconciliation Committee, which was a hospital-based committee at first, had physicians, nursing colleagues, informaticists, pharmacy—both staff pharmacists like me—and Kris [Young] was there at the table as well, for leadership purposes.”
Blum explains that it really started out as really an acute care focus and then after the launch of Epic they involved their ambulatory care. She also adds that it was important to involve key stakeholders at every point of the process and make sure that they were represented in the committee.
Establishing documentation standards
When it comes to training pharmacy technicians, Young and medication safety officer, Erica Fredette, point out Blum’s training manual. “Rachel [Blum] has a 20-page training manual [and it] is probably the most comprehensive training manual I've ever seen in my 20 plus years of being a pharmacist,” Young comments.
“When we have a new hire come on board, it is a several week process of training them,” Blum explains. “It starts with the very basics, but then we give them a little bit more leeway as they get more comfortable. The system of interviewing patients and documenting, it's different. It's not the standard hospital pharmacy technician [role] so we have to really spell out every single expectation. With medication reconciliation, there's a variety of ways that you could document and [create a] medication list, but we wanted to make sure we're all following the same standard, so our providers know what to expect when they look into a patient’s chart.”
Proving value to administration with a tight budget
As for the challenges around implementing the medication reconciliation process, Young explains that the biggest challenge they faced as a team was proof of concept and having to explain the value to their administrators. Administration understood there would be a reduction in errors but, like lots of hospitals, budgets are tight. “Once we demonstrated the value and showed that we consistently meet those targets, the program really took off,” Young states.
Fredette adds that the team not only had to prove the value of the team itself but also had to prove the need to reintegrate DrFirst (which was used previously) once the switch had been made to Epic. “We lost that really good resource, and we had to prove why we needed it back, and then why we wanted to integrate it into Epic,” she says.
Blum concludes by saying that “I am so appreciative of this team’s passion to get things right and their openness to feedback, because it's so necessary. A continuous improvement loop requires constantly looking at every new safety event that comes through that was related to a home medication list and going back and saying, ‘OK, we, we thought we knew how to enter this, but now we just need to tweak it this little bit so that next time it's perfect.’”