IMPACTS OF PHARMACIST’S ROLES ON REDUCING READMISSION RATE AND PROMOTING PATIENT SAFETY IN PEDIATRIC CARDIAC PATIENTS Manita Suriyarangsee Monwarat Laohajeeraphan Vimonkarn Sirisuksan Pharmacy Department, Siriraj Hospital, Mahidol University, Thailand

Introduction Objective  To study the characteristics of drug-related problems (DRPs) throughout discharge counseling and medication reconciliation process and its impacts on readmission rate and patient safety. Long term treatment Many drugs need to be taken around the clock several times/day Most of commercial cardiovascular drugs are available for adults Required to break or crush tablets to produce dosage for children Many cardiovascular drugs are categorized as high alert drugs Prevention of medication errors which will result in harm to patients encourage patients & caregiver to achieve the goal of treatment Poor adherence Pediatric cardiac patients

Setting  14 beds pediatric cardiac ward in Siriraj Hospital that is the 2,300 beds tertiary-care teaching hospital of Mahidol University, Thailand.

screened every patient who was admitted at Pediatric cardiac ward in Siriraj Hospital during October, 2009 to October, 2010 Method Caregiver administered home medications at ward 2-3 days before discharge Pharmacist Caregiver After discharge Nurses Medication Reconciliation DRPs Identification DRPs Resolved Discharge Counseling Educational Materials Phone call - one week after discharge - every 2 weeks or more Phone call - one week after discharge - every 2 weeks or more At visit date Reassessed DRPs Medication Reconciliation Reassessed DRPs Medication Reconciliation 9 high risk patients were enrolled Inclusion criteria first time received cardiovascular drugs received new item (s) of high alert drugs tends to have drug-related problems (DRPs) from limitations of age, race, and illiteracy had previous DPRs that attributed to current readmission

Educational Materials To be used in poor adherence and low health literacy patients or caregivers  Poor adherence  Many items of home medication  Complicate administration time  Unable to read drug names in English  Unable to understand drug labels Cannot read syringe scale cartoon stickers were used as a symbol to facilitate easy identification of products. Home medication schedules indicate type, time and administration method in each home medication items. In addition of cartoon sticker, they’ll be scaled the prescribed volume with red-line sticker Red-line sticker Cartoon sticker

Results 9 high risk patients were enrolled to the study. 258 pharmacist interventions and 99 DRPs were identified. DRPs were mostly found by patient chart reviews and patient or caregiver interviews at ward (43.4%) and by phone calls (35.4%). The top three identified DRPs were non-adherences (52.5%), medication errors (18.2%) and low health literacy (17.2%). All detected DRPs were resolved before it harmed to patients. 9 high risk patients were enrolled to the study. 258 pharmacist interventions and 99 DRPs were identified. DRPs were mostly found by patient chart reviews and patient or caregiver interviews at ward (43.4%) and by phone calls (35.4%). The top three identified DRPs were non-adherences (52.5%), medication errors (18.2%) and low health literacy (17.2%). All detected DRPs were resolved before it harmed to patients. Graph shows DRPs detected by pharmacists from patient chart reviews and patient or caregiver interviews at ward, interview at visit date, and by phone calls. 43.4% 35.4% 52.5% 18.2% 17.2%

Conclusion The pharmacist’s interventions could prevent DRPs that lead to readmission from non- adherences, medication errors and low health literacy. Early DRPs detection and resolving (by patient or caregiver interviews and phone calls) could generate more patient safety in vulnerable chronic disease patients.

What key lessons can we learn from your work?  “Drugs don’t work in patients who don’t take them 1 ”, so it’s one of the pharmacist’s role to improve medication adherence in order to achieve treatment goals that lead to reduce readmission from poor adherence.  Continuous follow up with patients or caregivers by telephone after discharge will assure patient understanding on pharmacist’s counseling and DRPs will be promptly detected and resolved prior to causing any harms to patients.  Medication reconciliation is an important tool to reduce medication errors and ensure patient safety.  Patient’s participation in their therapeutic regimen is one of the success strategies for improving adherence. 1 : C. Everett Koop, M.D.

Implementing policies and programs to improve the use of medicines  In short term  Provide home medication schedule in every patient  Medication reconciliation would be implemented to promote patient safety.  Provide discharge counseling by pharmacist in high risk patients  In long term  Establish pediatric cardiac care team which collaborate with multidisciplinary experts to provide holistic care

Specific studies should be included in a future research agenda  Cost effectiveness studies of pharmacist interventions on reducing readmission rate and promoting patient safety  Pharmacist interventions on promoting patient safety in other chronic diseases

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