1. Defining Best Practice:
Ensuring Medications In Hand Prior To Discharge For Patients Admitted With Asthma
Jonathan Hatoun, MD, MPH; Laura Johnson, MD, MPH; Sandra Mumanachit, BA; and James Moses, MD, MPH
HARVARD MEDICAL SCHOOL
TEACHING HOSPITAL
BACKGROUND
Up to 40% of pediatric patients discharged from Boston Medical Center (the largest safety net hospital in New England) do not fill prescriptions after an asthma admission.
No defined best practice exists to promote medication adherence after an asthma admission.
A logical first step is ensuring patients leave the hospital with medications in hand.
The predictable timeline of an asthma admission allows patients or their families to obtain prescription medications prior to discharge.
RESULTS
Prior to PDSA Cycle 1 (Blocks 1-3), no patients were discharged with medications in hand.
Following PDSA Cycle 1 (Blocks 4-13), 50% of the 262 admissions for asthma left with their discharge medications in hand.
In months 9 and 13, >75% of patients filled prescriptions prior to discharge. In month 11, 70% of patients filled prescriptions prior to discharge.
The balancing measure “length of stay” (not shown) did not vary significantly from baseline.
Cycle 2
Cycle 3
Cycle 1
CONCLUSIONS
Asthma admissions are well suited to the provision of discharge medications prior to discharge.
The use of an expedited outpatient pharmacy process and a shift in workflow to write prescriptions earlier in the hospital stay increased the proportion of patients discharged with medications in hand.
Month-to-month variation demonstrates the challenge of sustaining resident-led QI initiatives.
AIM
Increase the rate of pediatric patients discharged home with medications in hand after an admission for asthma from Boston Medical Center to greater than 75% monthly by June 2012.
Cycle 1
INTERN EDUCATION
Monthly orientation to new clinical work flow: prescribing discharge medications on admission
Cycle 2
WORK PROCESS IMPROVEMENTS
Prescription writing guidelines, Electronic Medical Record tips, note templates
Cycle 3
PARTNERSHIP WITH PHARMACY
Specially formatted process for more rapid preparation of discharge medications
PDSA Cycles
METHODS
A resident-led team used “Plan-Do-Study-Act” cycles based on the Model for Improvement to test and implement changes to the system.
The proportion of patients discharged with asthma medications in hand was measured every four weeks from July 2011 to June 2012 with results plotted in a statistical process control chart.
NEXT STEPS
To ensure sustainability of this success, continue to introduce new process improvements, including the delivery of medications to patient rooms.
Measure impact on clinical outcomes, such as readmissions, ED visits, and medication adherence.
Extend “meds in hand” effort to other conditions.
ACKNOWLEDGEMENTS: Participating residents, nurses, and pharmacists, as well as residency program leadership’s support for the QI curriculum.