MAP Month Ward Nursing & Allied Health Staff Pharmacy, Medication Safety Working Group & WHO High 5s Working Group September 2011 Take MAP procedure, some blank MAPs

Agenda What is the MAP? Why have the MAP? How can you use the MAP?

What is the MAP form? MAP = Medication Action Plan Clinical handover of medication management Admission: BPMH & reconciliation with medication chart Daily: medication review & issues log for handover to prescribers and other clinicians Discharge: reconciliation & discharge medication record provision Kept in bedside folder: ALL clinicians have easy access A daily tool to improve patient care & planning for discharge BPMH = best possible medication history Allows clinical handover at all points of admission

Why have the MAP form? 1 in 2 patients have one regular medication omitted unintentionally on admission(1-3) MAP allows ‘MATCHING UP’ of medications at home vs charted Up to 5 medication histories documented per patient per admission(4) Do not correspond to each other, often incomplete/inadequate, on 9 possible QH forms BUT used as a baseline for future management decisions Decisions not clearly documented MAP: a defined place to record medication issues/plan vs interspersed throughout progress notes Post-it note culture No formal tool for handover/documentation/interventions Loss of information & inefficiencies eg work duplication Facilitates timely discharge & accurate information provision to patient & community health-care providers Part of Clinical Handover Issues resolved before discharge: improve bed-flow issues (1) Stowasser DA. [PhD] The University of Queensland; 2000; (2) Lum E, [MClinPharm] The University of Queensland; 2002; (3) Cornish P, Knowles S, Marchesano R, et al. Arch Intern Med 2005;165:424-9;(4) QH Sites Baseline Audit 2005 (SMPU)

Mismatch? Plan was to ‘Continue all meds’ Often happens when eg resident writes in the notes, reg writes on the med chart and the consultant instructs Plan was to ‘Continue all meds’ BUT some meds not charted; different doses charted  Which is right??

‘Dr’s Plan’ column completed on admission enables medication reconciliation with medication chart If a Dr had completed the ‘Dr’s plan’ column, we’d easily know what the plan was

Medication-Related Issues Issues identified by ALL clinicians are noted on the front page

What to document when issue identified Time & date Clear, concise detail of issue Proposed action Person responsible to solve issue & if notified Progress if appropriate Name & contact number of person identifying issue Date & result of action

Who can document on the MAP form ALL clinical team members: Doctors Pharmacists Nursing Staff Allied Health (Dieticians, Speech Pathologist, Physiotherapists, Occupational Health Therapists, Social Workers and more)

A Nursing Example A great intervention, but… No name of contact person, in case feedback is needed Not ‘formally documented’: no record of intervention Post-it can easily be lost Could have been written on the MAP A real example found by a ward pharmacist

On the MAP: documented, has contact number, responsible person, follow up etc, as well as being for a specific patient.

Some real-life examples so far Daily supply requirements – much better than relying on memory/post-its!

Allied Health Examples Physiotherapist Mobility problems worsened by medications Medications potentiating falls Speech Pathologist Safety of crushed medications Medications affecting swallow/salivation Occupational Therapist Pt requiring dose administration aids (e.g. Webster pack) Falls risk and medication

Social Worker Specialist Nurses Dietician Place of Discharge (Home Vs Nursing Home) Capability / frequency of carer Specialist Nurses Availability of alternative formulations/ drugs Medication review to identify medication worsening disease Dietician Medications affecting weight Interactions with medications and enteral feeding Nutritional supplement availability

NB: MAP doesn’t replace a phone call if issue is clinically urgent!

Best Possible Medication History (BPMH) Record of all patient’s medication history as it was just PRIOR to admission

Who looks after the medications Recent changes BPMH documentation 2+ sources required Who looks after the medications Dr’s plan & INDEPENDENT Reconciliation GP/Pharmacy/NH information Explain the different sections: Recent changes – may affect current treatment, may contribute to presenting complaint eg frusemide recently ceased, present with HF exacerbation Sources – allows for subsequent clinicians reviewing the BPMH to know the sources and assess validity/gaps etc; need to validate with more than 1 source Who looks after medications – need to know so eg don’t ask patient questions they can’t answer Community carers – for discharge planning BPMH checklist – to see if all Qs have been asked, patient risk factors eg blind/deaf etc BPMH documentation – others can add to it if more info comes to light MATCH UP – reconciliation/plan: clear decision documentation BPMH & Risk Factor Checklist

How can you use this section? Doctor’s admission plan will be documented Use to answer patient/carer queries Add to BPMH if further information comes to hand Eg ‘I haven’t received my Fosamax tablet that I usually have on Fridays’ Add further patient details as they come to hand Eg risk factors, nebuliser at home, is blind/deaf

Cross-referencing Alerts clinicians to availability of MAP and issues raised Prevents work duplication

Thank you! Questions