Lee Robin, Malfair Suzanne, Schneider Jordan, Sidhu Sukjinder, Lang Caitlin, Bredenkamp Nina, Liang Shu Fei Sophie, Hou Alice, Virani Adil
, BScPharm, BSc, is a Pharmacist with the Surrey Memorial Hospital and the Jim Pattison Outpatient Care and Surgery Centre, Surrey, British Columbia.
, BSc(Pharm), ACPR, PharmD, FCSHP, BCPS, is Coordinator, Clinical Pharmacy Services, with Lions Gate Hospital and The University of British Columbia, North Vancouver, British Columbia.
Can J Hosp Pharm. 2019 Mar-Apr;72(2):111-118. Epub 2018 Apr 30.
Discharge medication reconciliation (Discharge MedRec) was implemented on one unit at a large urban teaching hospital, and was to be expanded across the rest of the hospital and the health authority's various sites by the end of 2018. Clinical pharmacists on the Acute Care for the Elderly unit carried out discharge planning and led Discharge MedRec during a pilot period, to inform the future implementation.
The primary objective was to examine the number and type of medication discrepancies before and after implementation of Discharge MedRec. The secondary objectives were to compare documented medication changes, pharmacist recommendations, discharge counselling, communication with community pharmacists, polypharmacy, and 30-day readmission rates.
Patients seen in December 2015 constituted the control (pre-implementation) group, who received usual care. Patients seen from January to April 2016 constituted the intervention group, for whom pharmacists performed Discharge MedRec and other discharge activities as per the hospital-to-home checklist of the Institute for Safe Medication Practices Canada.
There were 66 patients in the control group and 306 in the intervention group. Median discrepancies per patient decreased from 6.5 to 3 ( = 0.007), median number of documented changes without rationale increased from 2 to 3 ( = 0.01), and median number of documented changes with rationale increased from 1 to 2 ( < 0.001). Pharmacists made a per-patient median of 1 progress note recommendation in the control group and 2 progress note recommendations in the intervention group ( = 0.007), and a per-patient median of 2 orders in both the control and intervention groups ( = 0.62). Median recommendation acceptance was 100% for both groups, but twice as many recommendations were made per patient for the intervention group. Discharge counselling increased from 22.7% to 65%. Communication with community pharmacists increased from 10.6% to 60.8%.
Clinical pharmacist involvement improved Discharge MedRec planning and documentation. Decreases in medication discrepancies, combined with an increase in discharge counselling, should improve continuity of care across the health care team and increase patient adherence with medication therapy. This study further demonstrates the leadership role that pharmacists play in the assessment and clear documentation of medication changes at all transitions of care.
一家大型城市教学医院的一个科室实施了出院用药核对（Discharge MedRec），并计划在2018年底推广至医院其他科室以及卫生当局的各个站点。老年急性护理科室的临床药师在试点期间开展出院计划并主导出院用药核对，为未来的实施提供参考。
主要目的是检查出院用药核对实施前后用药差异的数量和类型。次要目的是比较记录的用药变化、药师建议、出院指导、与社区药师的沟通、多重用药情况以及30天再入院率。
2015年12月就诊的患者构成对照组（实施前），接受常规护理。2016年1月至4月就诊的患者构成干预组，药师按照加拿大安全用药实践研究所的医院到家清单为其进行出院用药核对和其他出院活动。
对照组有66例患者，干预组有306例患者。每位患者的差异中位数从6.5降至3（P = 0.007），无理由记录的变化中位数从2增加到3（P = 0.01），有理由记录的变化中位数从1增加到2（P < 0.001）。对照组药师每位患者的病程记录建议中位数为1条，干预组为2条（P = 0.007），对照组和干预组每位患者的医嘱中位数均为2条（P = 0.62）。两组的建议接受率中位数均为100%，但干预组每位患者的建议数量是对照组的两倍。出院指导从22.7%增加到65%。与社区药师的沟通从10.6%增加到60.8%。
临床药师的参与改善了出院用药核对计划和记录。用药差异的减少，加上出院指导的增加，应能改善整个医疗团队的护理连续性，并提高患者对药物治疗的依从性。本研究进一步证明了药师在护理各阶段用药变化评估和清晰记录中所起的领导作用。
