HealthCERT Aged Residential Care Medication Management Audit Data Comparison 2009 and 2012 Dr Michal Boyd, RN, NP, ND Sr Lecturer and Gerontology Nurse Practitioner School of Nursing and Freemasons’ Department of Geriatric Medicine University of Auckland

OPAL Results: Medications Mean number of medications for all residents in 1993, 1998 and mean number of medications by care type

Development of ARC Medication Guidelines November 2009 HealthCERT analysed 320 audits against the 2008 standards (introduced on 1 June 2009) – 140 audits (44%) medicine management partial attainment MOH contracted Dr Michal Boyd to work with sector representatives to develop a safe management of medicines guide for residential aged care. Completed in 2011.

HealthCERT Auditing Process Changes Since 2009, – increased accreditation of auditors – HealthCERT spot audits – publishing audit summaries online – Increased medication management and compliance training for auditors by HealthCERT – Introduction of the Medication Care guides

Medicines Care Guides (MOH 2011) The aim of the Medicines Care Guides is to provide a quick medicine management reference tool for all care staff working in residential aged care in New Zealand. Guidance is provided for key medicine safety topics relevant to the care of older adults. This guidance is based on current legislation, best available evidence and published guidelines, “Ground up” development process

48 Medicines Care Guides Two Main Functions Goal is to improve compliance and care quality: General medication safety guides for residential aged care Information about specific high risk medications

Comparison of Medication Management Audit Data July 2009 and June 2010 (561 Facilities) and January to December 2012 (516 Facilities) – The data were in free text format within an Excel spread sheet – One column was used for each of the eight categories of evidence contained in the auditor’s notes – Each record was highlighted and numbered according to the theme and the category that had been developed from the baseline 2010 report.

Medication Management Categories

Medication Management

Only one sub-category improved significantly in 2012 compared to This category was: – Staff competency updating and recording PAs decreased significantly in 2012 (0.4%) compared to 2010 (2.1%). – Unused medications not returned to pharmacy category showed slight improvement in 2012 compared to 2010 but it was not statistically significant.

Medication Management Signing documentation and records: Pas 8.4% in 2010 and 17.8% in 2012, p<.001, Examples: – Failure to sign medication charts – Controlled drugs checking – Fridge temperatures Administration of medications: PAs 3.2% 2010 and 16.9% 2012 (p<.001), Examples: – medications not being administered at the right time of day – not being administered when prescribed, – medication being left out. Labelling of medications absent/unclear: 0.9% 2010 and 11.6% 2012 (p<.001), Examples – eye-drops that had been opened with no date recorded of the opening date. Controlled drugs checking and record keeping: 7.5% 2010 and 10.1% 2012 (p<.001), – carrying out the weekly controlled drug checks. Transcribing medications and prescription onto charts: 1.2% 2010 and 7.0% 2012 (p<.001)

Medication Management (Cont) Three monthly medication reviews not completed by GP: 1.6% 2010 and 4.1% 2012 (p<.001) Standing orders procedures inadequate or not followed: 1.2% 2010 and 2.9 % 2012 (p<.05) No resident photo identification : 1.1% 2010 and 2.7% 2012 (p<.05) Documenting and record keeping 5.7% 2010 and 8.3% 2012 (ns) – failure to document processes following medication lapses – failure to administer warfarin – lack of evidence showing doctor’s signatures. Medication reconciliation and Medication errors were not significantly different between 2010 and 2012.

Nurse Practitioners in Aged Residential Care National contract included Nurse Practitioners – Can do admission and quarterly assessments Nurse Practitioner Intern Positions have been created in ARC NP in aged care evaluation - >20% fewer hospitalisations (Peri, Boyd, Stillwell & Foster, 2013, Health Workforce New Zealand)

Medication Management (Cont) Expired Medications in Use 1.2% 2010 and 6.8% 2012 (p<.001) Storage of medications: 6.4% 2010 and 9.3% 2012 ( (p = 0.07) security of storage, maintenance of the fridge temperature storage of medications within the main fridge used for foods Maintaining and using medication charts: 1.2% 2010 and 4.8% 2012 (p<.001) Block signing document: 1.2% 2010 and 3.9% 2012 (p<.001) Three monthly medication reviews not completed by GP 1.6% 2010 and 4.1% 2012 (p<.001)

Medicines Care Guides: Medication Storage

Policies and Procedures

Policies and Procedures (NS)

Staff Competence

Medication Administration Registered nurses can: Check and administer all prescribed medicines Assess and monitor for effect or reaction Registered nurses can: Check and administer all prescribed medicines Assess and monitor for effect or reaction Enrolled nurses can: Check and administer oral, topical and rectal medicines and intramuscular and subcutaneous injections under the direction and delegation of a registered nurse. Enrolled nurses can: Check and administer oral, topical and rectal medicines and intramuscular and subcutaneous injections under the direction and delegation of a registered nurse. Health care assistants/caregivers can: Check and administer oral, topical and rectal medicines and under the direction and delegation of a registered nurse (eg,oral from a unit dose pack [blister pack] topical medicines, suppositories) Insulin Administration specific competence is required for administering subcutaneous insulin. Health care assistants/caregivers can: Check and administer oral, topical and rectal medicines and under the direction and delegation of a registered nurse (eg,oral from a unit dose pack [blister pack] topical medicines, suppositories) Insulin Administration specific competence is required for administering subcutaneous insulin.

Staff Competence

Allergies Procedures

Self Administration

Medicines Care Guides: Self Medication

Self Administration

Recording and Communicating Medicines Management Information

Documentation % of total Audits % of total audits Documents/records not signed or unclearly signed 8.4%9.9% Recording of GP 3 monthly reviews 3.9%3.1% Evidence of controlled drugs checking absent 7.5%3.3%* (p=.004) Records relating to allergies or medications absent or unclear 2.1%3.9% Documentation illegible or unclear 1.8%1.7% * difference significant to p=0.05 or less; increased PAs between in 2010 to 2012 in bold.

Recording and Communicating Medicines Management Information Documentation Stock taking of medications 1.6%2.5% Recording medications expiry dates 0.9%0.4% Block signing of documents 1.2%4.3%* (p=.001) GP 3 monthly reviews out of date 1.6%1.2% Documenting allergies information 0.5%0.0% No photo ID for all residents for recognition when administering medications 1.1%1.0% Recording times and dates of medications 0.5%4.1%* (p<.001) Transcribing medications and prescriptions onto charts 1.2%4.5%* (p=.003) * difference significant to p=0.05 or less; increased PAs between in 2010 to 2012 in bold.

Recording and Communicating Medicines Management Information providers PAs – 70% moderate risk – 23% regarded as low risk – 7% facilities were considered high risk in this field. Main issues: – documents and medication records being signed – block signing of medications by GPs. – Transcribing of medications by the RN

Recording and Communicating Medicines Management Information

Listening to resident and others’ views Category not in the 2012 database In 2010, no issues were identified 555 of 561 records were reported not applicable The remaining 6 achieved full attainment This standard pertains more to mental health residential care rather than aged residential care

What is not measured? Subjective clinical indications, e.g. If the correct type medications are used in the correct situation Side effects and adverse effects

BUPA Anti-Psychotic Initiative Bupa Dr Maree Todd ANZSGM June

Where to from here? National Medication Chart – developed by Health Quality and Safety Commission – standardise medication records to reduce potential errors due to clinician unfamiliarity with medication documentation – Introduced into public hospitals – Will be rolled out to ARC facilities in the near future – has the potential to decrease issues identified in this report such as: maintaining and using medication charts block signing documents three monthly medication reviews not completed by the General Practitioner.

Electronic Medicines Management System Software to manage the charting of medication in aged care facilities Prescribers can manage individual patient medicines charting from any location through a secure access Reduces the time spent by prescribers, facilities and pharmacists managing the charts Ensures an up to date current chart is continuously available, to all users (GP, Community Pharmacy, Aged Care Facility, Hospital Specialists and Nurse Practitioners), at the same time

Electronic Medicines Management System will: Record administration of all medicines by staff Record medicines that haven’t been given and reason/s why Allow reporting by patient, unit or facility to allow prescriber's to make better informed clinical decisions Provide reporting on individual medicines, a therapeutic group etc. Provide robust authentication for charting and updating when a prescriber saves the new item/change, and notification of a change is directed to the care facility and the pharmacy for supply. Track medicine supply quantities. This will to reduce medicine wastage and ensure prescriptions exactly match the supply required within a medication cycle.

Recommendations Ministry of Health will continue to raise medication management by working closely with the sector Road Shows regarding identified themes and trends such as: – GP and RN documentation management Encourage DHB and ARC provides to enable education about medication management Continue to work with auditors regarding medication management Standardised sub-category classifications for audit report

Thank You! Questions?