=Paper=
{{Paper
|id=Vol-1574/paper1
|storemode=property
|title=Moving towards a
Comprehensive Medication Dispensing Service
for Patients in Transition from Hospital to Primary Care
|pdfUrl=https://ceur-ws.org/Vol-1574/paper1.pdf
|volume=Vol-1574
|authors=Liv Johanne Wekre,Ingvild Klevan,Tor Åm
|dblpUrl=https://dblp.org/rec/conf/pahi/WekreKA15
}}
==Moving towards a
Comprehensive Medication Dispensing Service
for Patients in Transition from Hospital to Primary Care
==
https://ceur-ws.org/Vol-1574/paper1.pdf
Moving towards a
Comprehensive Medication Dispensing Service
for Patients in Transition from Hospital to Primary Care
Liv Johanne Wekre1, Ingvild Klevan1, Tor Åm2
1Central Norwegian Pharmaceutical Trust, Trondheim, Norway
2 Department of Coordinated Health Care, St Olav`s University Hospital, Trondheim,
Norway
Abstract. In primary health care it is often challenging to obtain a supply of
drugs when a patient is discharged to their home or to a nursing institution. Both
access to updated information about the (new) medication, and the practical
organization per se, present obstacles. The need for early information in the
receiving units is in conflict with the hospitals` need to make decisions
regarding treatment up until the point of discharge. The practical handling is
affected by e.g. distance to the local pharmacy and the accessibility of certified
health care workers. We aim to design and implement a medication dispensing
service to ensure that the patients who are discharged to primary health care
(home care services or nursing homes) are supplied with medication in the
transition period, until regular supply is (re)established. In this paper we
describe the complexity of the area, impacting factors to be considered and
outline a stepwise approach to design a comprehensive service for enhanced
patient safety.
Keywords: Medication dispensing service, care transition, multidose drug
dispensing, unit dose drug dispensing, clinical pharmacy, medication
reconciliation, patient safety.
1 Introduction
Ensuring the supply of drugs for a patient in transit between hospital and primary
health care is a challenging task, in particular when medication treatment regimens
are changed. The challenge consists of two subsequent and interdependent main parts;
information transmission with regards to the (changed) medication and the process for
acquiring and dispensing the drugs.
The availability of drugs is affected by distance and accessibility of health services,
e.g. 168 (39%) of the Norwegian municipalities do not have a local pharmacy [1],
which consequently impacts how fast it is possible to acquire drugs. The
administration of drugs is a task undertaken by the nurses in public health care
services. Other health care professionals may also assist, but in internal protocols the
dispensing of drugs is most often described as being a nurse’s responsibility to
safeguard. Thus, when a nurse is unavailable at the time the patient arrives, a practical
Copyright © 2016 by the paper's authors. Copying permitted for private and academic purposes.
In: G. Cumming, T. French, H. Gilstad, M.G. Jaatun, E.A A. Jaatun (eds.):
Proceedings of the 3rd European Workshop on Practical Aspects of Health Informatics
(PAHI 2015), Elgin, Scotland, UK, 27-OCT-2015, published at http://ceur-ws.org
2
problem arises. Furthermore, introduction of the multidose drug dispensing system
(MDD) has been shown to represent a lack of flexibility within the system [2].
Along with an ageing population and a shift towards increasingly advanced
medical treatments outside hospitals, new approaches to ensure patient safety are
called for. When elderly patients are transferred between care settings, an average of
two drug errors occurs [3]. Errors often occur due to poor communication about the
drug use.
The University Hospital in Trondheim, St. Olav's Hospital, has a written
cooperation agreement with local municipalities, describing e.g. interaction with
regards to the transition of patients between care settings. There are often conflicting
interests between the care providers at the time of discharge, affecting the practical
handling of the transition and consequently the transit time: The hospital wants the
flexibility to alter care regimens and therefore medication lists close to the time of
discharge. Whilst the receiving units, on the other hand, need time to prepare,
preferably during opening hours, and therefore require early discharge information.
Today these challenges are solved more or less ad hoc, e.g. the patient is given a few
tablets “in hand” at discharge, but the lack of standardized procedures leads to poor
predictability for the receiving units. To reduce the issue, we aim to design a
medication dispensing service ensuring patients in transit between hospital and home
care are provided with some days’ supply of drugs. The targeted patient group is
typically dependent on care support to be able to return home, and represent
approximately 200 of the weekly discharges from St. Olav`s Hospital.
Complex interventions – consisting of multiple behavioral, technological, and
organizational components – are common and important features of health care
practice and research [4]. Designing a medication dispensing service within the
hospital for patients in the discharge phase falls within the definition of complex
interventions. As an example, the financing of medicines in Norway is complex in
itself; covered in part by the patient itself and in part by the Government, split
between hospital-, municipality- and insurance budgets [5].
This paper presents an approach for developing a service and discusses different
conditions that need to be met. Since the project is in a very early phase, no results are
reported in this current paper.
2 Dispensing of drugs
In primary care, dispensing of drugs is primarily done by using two different
approaches; conventional, manual dispensing from tablet boxes undertaken by a nurse
or an assistant, or multidose drug dispensing (MDD). MDD (Figure 1) are drugs that
are machine-packed into dose unit bags for each time of administration [6].
At St. Olav's Hospital unit dose drugs (UDD) (Figure 2) dispensed at the local
Hospital Pharmacy are used. UDD is more flexible than MDD since the single dose
unit bags are labeled with drug content data only, and not with patient data and time
for intake. In primary care the changes in medicines are less frequent than in
hospitals, and most often multidose drugs are dispensed for a period of two week for
patients in home care services, and one week for patients in nursing homes.
3
Figure 1: Multidose dispensed drugs packed for two weeks’ use for a patient in
home care services
Figure 2: One tablet unit dose dispensed drug packed for a patient in hospital
2.1 Obstacles within the multidose drug dispensing system
When an intervention presents practical obstacles, or elements of the intervention are
considered unnecessary, or not meaningful, in order to complete the work,
stakeholders will redesign the work process to minimize the obstacles [7, 8]. It has
been reported that a lack of flexibility in prescriptions of drugs when implementing
the MDD system, e.g. a temporary change in dosage, was considered problematic in
the MDD system [2]. For most patients, some drugs (such as eye drops and inhalers,
as well as drugs taken irregularly) have to be maintained manually in parallel with the
multidose dispensed drugs, and for other drugs only manual dispensing is suitable.
This is an indication that the MDD system is not adequate by itself, and manual
dispensing has to be maintained together with the MDD to ensure medications are
dispensed. Thus, additional use of manual dispensing is a way to work around an
imperfect MDD system.
Although MDD systems have been called an automation of the medicines
management chain, there are manual processes within the chain. The patient’s
4
medication list is recorded several times during the process, and all the manual work
causes a risk of errors during the different steps of the process. In addition, there will
always be a risk of adverse drug events because of errors in the communications
between professionals involved in the MDD, i.e. when patients are transferred
between various health care settings [9, 10]. Therefore, automation in the processes
for updating information between relevant care providers has been called for [11]. On
the other hand, it has been emphasized that automated processes in the handling of
drugs may threaten the quality of many (hidden) manual work processes [12].
The patients in primary care are primarily elderly and sick people that move
between health care providers. Thus, health care providers outside primary care must
also act in accordance with the MDD system. There are few studies that look at how
health professionals in secondary care experience the MDD system. However, a
published paper concluded that when elderly patients are transferred from hospital to
community/primary care, the main risk factor seems to be the MDD, or rather the
process for using it [10]. More research is needed to learn how best to handle the
MDD patient when moving between different care settings.
3 Information transfer
To ensure safe, efficient and seamless patient care, it is essential to have access to
correct information regarding patient medication. Reported in one study, only 61% of
patients admitted to an emergency ward had updated medicines lists [13].
Furthermore, errors in medication prescription histories at hospital admissions are
found in up to 70% of the lists [14].
3.1 Information and communication technology solutions
Several information and communication technology solutions aim to reduce these
problems. However, introduction of new systems are not entirely unproblematic, as
new obstacles and new sources of errors may occur [15-17]. In general it could be
sensible to handle information transfer electronically with some caution as it could be
assumed that a more structural presentation of information could lead to a false sense
of security.
Since early 2013, the system for electronic prescribing has gradually been
introduced in Norway, and has later been introduced in Norwegian hospitals.
Electronic prescribing for the MDD-system is currently under development. In
addition, the national core health record is introduced and gathers selected and
important information about the patients’ health, included medications. This is
particularly useful during urgent medical assistance.
Electronic messaging (e-messaging) is commonly used for information transfer
between different parts of the health care system, e.g. between primary and specialist
care, and between primary care and general practitioners. An evaluation of the
integration of e-messaging has been conducted, and both desirable and undesirable
effects as well as large variations in the routines for using it, have been found [18].
5
The Central Norwegian Regional Health Authority is currently, in collaboration with
the regional municipalities, evaluating the need and possibility for a new, joint
electronic patient health record. This ICT solution will provide care providers across
different settings with real time patient information.
3.2 Quality assurance of information about medicines
Clinical pharmacist in Norway most commonly use the method of Integrated
Medicines Management (IMM) when involved in patient care [19]. The method
follows the patient care through three main phases: medication reconciliation at
admission, medications review during the stay, and medication reconciliation at
discharge [20]. The method is described as systematic and seamless, the latter
referring to the exchange of information across different care settings.
During the period 2014-2015 there has been a considerable increase from 11 to 25
clinical pharmacists in hospital wards within the Central Norwegian Regional Health
Authority. The clinical pharmacists are integrated in multidisciplinary teams, and are
advisors to the responsible doctors. Hopefully this initiative will drive quality
improvements in our hospitals as seen in Sweden, where systems supported by
clinical pharmacists resulted in a reduction in the frequency of errors when patients
were transferred from hospital to primary care [10].
Still, quality assurance may be done by different measures and by different health
workers. Thus, it is essential that the responsibility is clearly assigned to ensure a
systematical approach. Regardless, to ensure a medication dispensing service that
enhances patient safety, it is a prerequisite that the basis for the dispensing is a correct
medication list. Together with the dispensed medications, the drug information
following the patient at discharge should be good and coherent [21].
4 Practical approach for designing a medication dispensing
service
Complex interventions might need complex solutions, and therefore it is of
importance that the process leading to a proposed solution for medication supply is
carried out in several steps, as depicted in Figure 3: First, a thorough mapping of
factors influencing the design of the service will be done. The complexity of the area
and the questions needed to be addressed are outlined in further detail in section 4.1
and Table 1. A thorough identification of the needs of the different users, i.e. health
care workers in both care settings, the hospital pharmacy and last but not least the
patients, form the basis for an initial design of the service. A small pilot study is then
conducted with patient discharged from one hospital ward. Finally, the service will be
evaluated for further adjustment (redesign) and implementation in more wards, which
then again needs to be tested and evaluated in a circle of continuous improvement.
6
Figure 3: Stepwise approach and continuous improvement for design and
implementation of the medication dispensing service
A new service must safeguard different considerations for the service to fulfil quite
some critical needs, and it can be assumed that “one size fits all” will not apply.
Nevertheless, the service must be of such uniformity that predictability is ensured,
which in turn will allow the receiving units to plan and restructure how they handle
patient flow. Thus, it is of critical importance to collaborate closely with the
municipalities when designing the service, to ensure commitment and beneficial
outcome for all parties. This collaboration will start by identifying needs through
work-shops and interviews with central persons from one or two included
municipalities.
The timing of the dispensing in the discharge process should be as late as possible
in order to avoid errors in the dispensing caused by changes made at a late stage of the
hospital stay. Likewise, the prescription source for the dispensing must be defined.
This depends on the location of the dispensing; at the hospital ward or in the hospital
pharmacy, and by whom the work is undertaken; by nurses or pharmacists.
As previously pointed out, thorough consideration of the differences between the
receiving units in primary care is important. The service may also be differentiated
due to patient characteristics (e.g. multidose drug user) and by the different
medications used (providing all medication or just the ones changed? etc.). These and
other considerations are listed in Table 1.
7
Table 1: Needs and impacting factors to be considered in the mapping process
Setting/Actor Need Questions
Hospital Right timing of the How much time is needed to dispense the
dispensing drugs?
How close to the point of discharge are
changes made in the prescribing?
Pharmacy/Hospital Detailed and accurate What source of information is used for
Hospital/Pharmacy/ prescription dispensing?
Municipality information for
dispensing and How should the dispensed drug be
labeling of the labelled, controlled and delivered to the
dispensed medication ward/patient
Information transfer How is information about administration
to patient and/or given to the patients along with the
primary care dispensed drugs? E.g. labeling of the unit
providers dose bags or on a separate information
note.
Should the service include a complete
updated medicines list along with the
drugs?
Hospital/ Categorization of What kind of service is the patient
Municipality patients included in discharged to?
the service
Does the patient administer the drug
him/herself or with assistance from the
health care service?
Is the patient a MDD patient or a patient
with ordinary prescribing?
Has there been made (major) changes in
the medication list during the
hospitalization?
Pharmacy/Hospital/ Categorization of Are the drugs available as unit dose drugs
Municipality medications included in the hospital?
in the service
Medication by formulation (e.g. tablets,
eye drops, and inhalers) or
Medication by dosage (only medication
taken regularly, or drugs to be used as
required, as well)?
Is the cost of the medication (low-high) a
factor to take into account
8
Table 1 (cont.)
Setting/Actor Need Questions
Municipalities Optimal period of Are there differences in needs in terms of
time (days) with the length of the dispensing period
dispensed drugs from between municipalities, depending on
the hospital before
distance to local pharmacy?
regular dispensing is
reestablished Does the need vary depending on type of
health service (nursing home, home care
services or rehabilitation institution)?
Does the need vary depending on whether
the patient is a MDD user or not?
Hospital/Pharmacy/ Clarification of roles What are the responsibilities and tasks of
Municipality and responsibilities the different participants in the medicines
management chain? These may be the
prescribers at the hospital, the nurse at the
hospital, discharge coordinator, the
clinical pharmacist, the pharmacist at the
hospital pharmacy, the patients GP, the
nurse in the municipality and others.
What are the jurisdictional frames
regulating these responsibilities?
Hospital/ Addressing the In the phase of moving between care
Municipality/the medication costs settings; who bears the cost of medicines?
patients And for the associated dispensing?
5 Conclusion
Changing between health care settings presents several challenges. Two of the main
obstacles with regards to medications have been discussed; information transfer and
medication acquiring. To enhance patient safety, a service for medication dispensing
for patients in transit between hospital and primary care is being planned. When
designing a new service it is important to understand the needs and how the problems
are solved within current conditions. Hence, the complexity of the area and all
impacting factors will be mapped out and piloted at a small scale before further
implementation. The final aim is a service that is beneficial for all involved parties.
9
Acknowledgments We would like to thank our colleagues for the input during the
work with this topic, and the commitment for establishing a service for drug
dispensing in interest of the patient moving between different care settings. Thanks
also to our leaders for having granted us the work time spent writing this paper, and to
Kirsty Holter for proofreading the manuscript.
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