1. Implementation and a Randomized Controlled Evaluation of Pharmacist Medication Assessments in a Surgical Pre-Admission Clinic Yvonne Kwan, BScPhm 1 ; Olavo Fernandes, PharmD 1,2 ; Jeff Nagge, PharmD 1 ; Gary Wong, BScPhm 1 ; Jin-Hyeun Huh, BScPhm 1 ; Deborah Hurn, RN, MA 1 ; Jana Bajcar, MScPhm, EdD, FCSHP 2 1 Department of Pharmacy - University Health Network, 2 Leslie Dan Faculty of Pharmacy - University of Toronto Non-randomized investigations have suggested pharmacist involvement in a surgical pre-admission clinic (PAC) may reduce clarifications in the post-operative period Acknowledgements Barbara Courtman, Jeffrey Doi, Nadia Gad, Gino Gizzarelli, Rosanna Guidoccio, Anita Jakovcic, Patricia Kim, Valerie Marshall, Sonia Matos, Kyung Ae Park, Elaine Rosenberg, Shun Wong, Clement Yuen Stephanie Ong, Bassem Hamandi, Gregory Pond TGH Pre-Admission Clinic StaffBackgroundResults Results continued Methods continued **References available upon request Objectives Methods Primary Objective: Evaluate the impact of structured pharmacist medication assessments in the surgical PAC and the use of a post-operative order form on the incidence of patients with at least one post- operative medication discrepancy related to home medications in patients undergoing planned elective surgeries Secondary Objectives: Characterize the types of post-operative medication discrepancies Determine the clinical impact of the post-operative medication discrepancies by blinded measurements performed by clinical experts Design: Randomized, prospective, parallel study 1. Established the optimal practice model Phase 2 Implementation of Model Phase 1 Development of Model - Establish the optimal model - Design of tools - Baseline data collection Phase 1 Development of Model - Establish the optimal model - Design of tools - Baseline data collection Phase 3 Randomized Evaluation - Identification - Characterization - Clinical Assessment Baseline Characteristic Intervention(N=154) Standard Care (N=156)Age Mean ± SD, years 56.5 ± 14.5 56.4 ± 14.3 GenderMaleFemale 75 (48.7%) 79 (51.3%) 87 (55.8%) 69 (44.2%) Number of Home Medications* MedianRange Mean ± SD 40-17 5.1 ± 3.9 30-21 3.9 ± 3.7 Outcome Intervention (N=154) Standard Care (N=156) p-value Patients with at least 1 post-operative medication discrepancy related to home medications 30 (19.5%) 68 (43.6%) <0.001 Potential to Cause Patient Discomfort and/or Clinical Deterioration if Discrepancy was Unresolved Intervention (N=47 discrepancies) Standard Care (N=125 discrepancies) (N=125 discrepancies)Unlikely2144 Possible1835 Probable846 Conclusions Post-operative hospital admission is a key medication- related vulnerable moment where patients are at increased risk of medication discrepancies that potentially can lead to adverse drug events Figure 1. Key Vulnerable Moments for the Surgical In-Patient Surgical Admission Unit ICU ER Vulnerable Moment #1 Vulnerable Moment #2 Vulnerable Moment #3 Pre- Admission Clinic Assessment OR In-Patient Unit Home Figure 2. Project Design Phase 3: Randomized Evaluation Phase 1: Development of Model Phase 1 Development of Model Phase 1 Development of Model 2. Designed the following practice and research tools Preprinted Post-Operative Order Form for Pre-Operative Home Medications Classification system for categorization of discrepancies Ranking system for clinical impact of discrepancies Worksheets and checklists outlining tasks at the PAC and on the unit Template for medical chart documentation 3. Collected baseline data Data collected on post-operative medication discrepancies between March 22 to April 14, 2005 in all patients who had a PAC visit and were admitted to participating in-patient units A post-operative medication discrepancy was defined as any medication clarification that was made by the pharmacist during the post-operative period Phase 2: Implementation of Model 1. Designed and provided education for surgical pharmacists on: Strategies for conducting medication histories at the PAC 2.Designed and provided in-services for PAC nurses and clerks, in-patient nurses, surgeons, and residents Approximately 140 in-patient nurses and 30 surgeons and residents were in-serviced between April 11 to April 18, 2005 Inclusion Criteria All consecutive patients who had a PAC appointment at Toronto General Hospital between April 19 to June 3, 2005 prior to undergoing surgical procedures (ENT, Urology, Gynecology Oncology, Plastics, General Surgery, and Thoracics) Exclusion Criteria Patients scheduled for discharge the same day as their surgery Qualitative Analysis of Expert Interviews OptimalModel LiteratureReview Stakeholders Phase 2 Implementation of Model Phase 3 Randomized Evaluation Figure 3. Components Used to Establish the Optimal Practice Model Figure 4. Design of Evaluation Phase Intervention (Structured pharmacist medication assessment and generation of a post-operative medication order form) Randomization Eligible Surgical Patients at PAC Standard Care (Nurse-conducted histories and surgeon- generated orders) Discussion/Limitations Our results confirm the benefit demonstrated in previous investigations with respect to pharmacist involvement in the PAC Fewer patients in the intervention arm had at least one post- operative medication discrepancy related to home medications compared to the standard care arm Patients in the intervention arm had statistically higher mean number of home medications, possibly suggesting that pharmacists had identified more home medications at the PAC through the structured medication assessments Limitations of this project include: Unblinding identification and reporting of medication discrepancies Retrospective clinical assessment of discrepancies Table 1. Baseline Characteristics Phase 3: Randomized Evaluation Phase 3 Randomized Evaluation Table 2. Incidence of Primary Endpoint Figure 5. Total Number of Post-Operative Medication Discrepancies A pharmacy practice model that creates a combined intervention of a structured pharmacist medication assessment and a post-operative order form and supports medication prescribing in surgical patients at the time of post- operative hospital admission can be successfully implemented in the PAC The combined pharmacist intervention can reduce significantly the incidence of post-operative medication discrepancies related to a patient’s home medications Pharmacist involvement in the PAC may be beneficial at improving patient safety Figure 6. Characteristics of Post-Operative Medication Discrepancies Related to Home Medications Table 3. Clinical Assessment of Post-Operative Medication Discrepancies Related to Home Medications *p=0.039 ICU = Intensive Care Unit OR = Operating Room ER = Emergency Room