Challenges in posthospital care: nurses as coaches for medication management

Improving posthospital medication management in a Danish municipality: A process evaluation

AIMS AND OBJECTIVES

To evaluate an intervention developed to improve patient safety in posthospital medication management carried out by visiting nurses working in a municipality in Denmark. The intervention consisted of three elements: an initial interdisciplinary home visit by nurses, two subsequent scheduled visits and the use of an organising tool.

BACKGROUND

As a consequence of specialised treatment plans and new treatment possibilities, patients with complex care needs can now be discharged from hospital more rapidly-and in greater numbers-than previously. Medication management is identified as the most challenging component of a discharge from the hospital to the home, in which discrepancies have been found in up to 94% of medication lists.

DESIGN

A process evaluation inspired by the UK Medical Research Council's guidance.

METHODS

The process evaluation was conducted for three months in a visiting nurses' department. Data consisted of visiting nurses' self-reports of performance of the intervention and group interviews (n = 4) with visiting nurses (n = 14). Self-reports were analysed to evaluate implementation performance and elaborated with interview data to illuminate mechanisms of impact and contextual factors.

RESULTS

The implementation of the intervention highlighted the importance of the nurse-patient relationship, nursing assessment and logistics, and professional values in posthospital medication management. Complex care needs were a mediator in the high implementation rate, which involved 31 of the 38 patients in the target group.

CONCLUSION

For patients with complex care needs, posthospital medication management may be improved by a reconsideration of the activity-based funding of home health care, a recognition of the importance of organising work and a critical consideration of standard systems.

RELEVANCE TO CLINICAL PRACTICE

An increase in the number of patients with complex care needs in home health care is an international issue that affects many healthcare systems. This study points at contextual challenges and possible methods for facilitating the future development of posthospital care for these patients.

Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to Emergency Department

The purpose of this study was to evaluate the occurrence of medication discrepancies during transitional care home visits and the association with emergency department (ED) visits. Using secondary data analysis, the relationships between in-home medication discrepancies and 30- and 90-day ED utilization were examined. For every in-home medication discrepancy, the odds of being admitted to the ED within 90 days increased by 31%. This brief intervention could add a valuable component to post-hospital transition management.

Improving visiting nurses’ post-hospital medication management

Purpose

Employing a participatory approach, the purpose of this paper is to identify possible areas for improvement in visiting nurses’ post-hospital medication management and to facilitate suggestions for changes in future practices.

Design/methodology/approach

Based on a previous study on visiting nurses’ post-hospital medication management, two workshops were conducted in a visiting nurse department in a Danish municipality.

Findings

The visiting nurses emphasised knowledge of patients’ basic needs and prioritised their performance of context-specific nursing assessments, with a preventive focus as a prerequisite for improved patient safety in post-hospital medication management.

Research limitations/implications

The participatory approach can increase the acceptability and feasibility of changes regarding future practices and thereby reduce the gap between official documents and daily practice. Although the local development of suggestions for changes in practices does not provide general knowledge, a subsequent detailed description of the changes in practices can promote transferability to other healthcare settings after local adjustments are made.

Practical implications

Flexible home healthcare, with stable relationships enabling the continuous assessment of the patient’s needs and symptoms, along with subsequent adjustments being made in care and medical treatment, might enhance patient safety in post-hospital medication management.

Originality/value

This paper adds to the knowledge of the need for integrated care in medication management in patients’ homes. It argues for primary healthcare professionals as “experts in complexity” and suggests a reconsideration of the purchaser-provider division of care to patients with unstable health conditions and complex care needs during the first days following hospital discharge.

Carers' Medication Administration Errors in the Domiciliary Setting: A Systematic Review

Purpose

Medications are mostly taken in patients’ own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital setting. We aimed to review studies of how carers cause and/or prevent medication administration errors (MAEs) within the patient’s home; to identify types, prevalence and causes of these MAEs and any interventions to prevent them.

Methods

A narrative systematic review of literature published between 1 Jan 1946 and 23 Sep 2013 was carried out across the databases EMBASE, MEDLINE, PSYCHINFO, COCHRANE and CINAHL. Empirical studies were included where carers were responsible for preventing/causing MAEs in the home and standardised tools used for data extraction and quality assessment.

Results

Thirty-six papers met the criteria for narrative review, 33 of which included parents caring for children, two predominantly comprised adult children and spouses caring for older parents/partners, and one focused on paid carers mostly looking after older adults. The carer administration error rate ranged from 1.9 to 33% of medications administered and from 12 to 92.7% of carers administering medication. These included dosage errors, omitted administration, wrong medication and wrong time or route of administration. Contributory factors included individual carer factors (e.g. carer age), environmental factors (e.g. storage), medication factors (e.g. number of medicines), prescription communication factors (e.g. comprehensibility of instructions), psychosocial factors (e.g. carer-to-carer communication), and care-recipient factors (e.g. recipient age). The few interventions effective in preventing MAEs involved carer training and tailored equipment.

Conclusion

This review shows that home medication administration errors made by carers are a potentially serious patient safety issue. Carers made similar errors to those made by professionals in other contexts and a wide variety of contributory factors were identified. The home care setting should be a priority for the development of patient safety interventions.

The medication reconciliation process and classification of discrepancies: a systematic review

AIMS

Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors.

RESULTS

Ninety-five studies met the inclusion criteria. Approximately one-third of included studies (n = 35, 36.8%) utilized a 'gold' standard medication list. The majority of studies (n = 57, 60%) used an empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists.

CONCLUSIONS

We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.

Using appreciative inquiry during care transitions: an exploratory study

The purpose of the study was to evaluate the effectiveness of a transitional care coaching intervention offered to chronically ill medical patients during the transition from hospital to home. This 2-arm randomized pilot study uses a coaching framework based on appreciative inquiry theory. This article reviews the appreciative inquiry literature and identifies the characteristics of patients who participated in appreciative inquiry coaching. Lessons learned are summarized, and suggestions for future research are offered.

Implementation of a bag medication reconciliation initiative to decrease posthospitalization medication discrepancies

Medication discrepancies occur in 70% of hospital patients, especially during discharge. In community settings, bag medication reconciliation events have demonstrated effectiveness in evaluating current medication use and identifying medication discrepancies. A bag medication reconciliation process was implemented in the hospital setting to decrease medication discrepancies by encouraging evaluation of medication adherence, side effects, and monitoring at posthospitalization follow-up. After implementation, a 7% decrease in reportable errors was noted.

Discharge phone calls: a technique to improve patient care during the transition from hospital to home

The discharge process is a transitional period when the patient's care is shifted from the hospital to the home and can be stressful for patients. One technique used to improve the quality and continuity of care is the discharge phone call (DPC). A large, metropolitan hospital implemented the DPC program to improve quality of care and decrease readmission rates. Qualitative interviews were performed with 24 hospital leaders, managers, and staff to determine the impact of the DPC program on the quality of care during the discharge process. Interviewees responded that the main benefits to the DPCs related to patient's medication management, follow-up appointment reminders, and answering questions. From a hospital perspective, the DPC can provide feedback to help improve the care delivery process related to discharge planning through improved discharge instructions and reinforcement of prescribed steps upon the patient's return home.

Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital

OBJECTIVE

To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits.

DATA SOURCES/STUDY SETTING

A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011.

STUDY DESIGN

Prospective longitudinal design, multinomial logistic regression analysis.

DATA COLLECTION/EXTRACTION METHODS

Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted.

PRINCIPAL FINDINGS

Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits.

CONCLUSIONS

Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk.