The Importance Of Initiating Change

Initiating change: We discussed these findings during our monthly Doctors meetings, the team were surprised by the findings but agreed that we all tend to look at the patient notes and cross off medications frequently but do not always discuss or document the changes. Both medical and none medical prescribers agreed that this could potentially result in a drug error whereby the incorrect medication had been omitted and there would not be any supporting written evidence. We revisited the General Medical Council (2016) and Nursing and Midwifery Council (2016) guidance on prescribing, and discussed issues surrounding deprescribing at length. The nurse prescribers were also involved in discussions as to how and why we stop medications and they
expressed concerns that they often did not understand the rational for which medicines were continued/stopped and they were very reluctant to stop medications unless it had been something they had prescribed which had led to side effects or not been tolerated by the patient. We considered the available tools to help with medication reviews and we decided to use the BEERS criteria tool within the inpatient and day unit setting. We also discussed having a space within the prescription chart to list medication changes and the rationale with the hope of improving documentation and understanding and reducing drug errors.
The most alarming fact was our lack of communication with our GP colleagues whom we rely on to issue prescriptions but we failed to give them the appropriate information to do this in a safe and timely manner.
Barriers to change:
A new way of working can often be challenging and I think having the tool on the prescription chart would be a great idea as it acts as a clear prompt. Doctors felt that if the patient was not able to have the discussion due to them being too unwell and if there was no relative present that this would be an issue. However, we agreed that if this is the case we would still make the changes acting in the patient’s best interest but would discuss this as a team and we would ensure we documented this in the patients’
records.

Phase 2 results:
The data has been collected retrospectively reviewing patient admission between March 2016 and June 2016. This retrospective analysis includes reviewing patient notes, prescription charts and discharge summaries. There were 35 admissions during this time period.
It was my expectation that we would attain much better results after implementing teaching sessions and discussion around prescribing and documentation. However, some of the changes that I wanted to instigate such as a review box on the treatment sheet and a tick box prompt on the IT system had not been put in place.

Medications altered in prescription charts: 89%
Standard 1) Structured medication review and changes documented in notes:80%
Standard 2) Documentation of discussions with patient/family: 56%
Standard 3) Documentation of changes forwarded to GP: 90%

Comparison of Phase 1 versus Phase 2 results:

Analysis of reaudit data:
Although our results had improved across all domains the greatest improvement was in our communication with our GP colleagues. I feel that there is still room for improvement with our medication reviews and more so our documentation but at the moment I do not feel our prescribing system supports this, we currently use paper prescriptions and electronic patient notes. The prescription chart currently does not have a space for medicines reconciliation or documentation of change, nor do we have regular pharmacist support.
On discussion with my colleagues it was highlighted that we are failing the standard we set regarding discussion with patients and their families.
Colleagues reported that they felt that often the patient is too unwell to have those conversations with and the Doctors/Nurse prescribers do not feel it is appropriate to be “burdening” the carers with any more information regarding stopping medicines as they thought this may cause may distress, we discussed how this was actually good practice and could help open conversations with loved ones regarding the patient approaching the end of their life. It is not always possible to have these conversations as some patients so not have anyone close but we should try where we can to be open and honest. We have organised a communication skills day in the new year where we can role play some of these discussions so they do not feel as daunting.
Having completed this audit, we have highlighted several key areas for further improvement. We are going to try and move towards an electronic prescribing system which links in with the electronic patient notes, the software is already in place we all just need training on how to use this and how it will link in with our pharmacy support. In the mean time we have now added drop boxes onto our clinical notes which act as a prompt to check patient’s medication and document any changes.
Once these changes have taken effect and our staff have completed the communication skills study day I would like to
re-audit. This time I would like to separate day therapies and the inpatient unit as I believe the day therapy unit is achieving its set standards and may be skewing the inpatient data.

Conclusion:
Upon reviewing the literature, it seems to suggest that medication review and deprescribing can be done in a controlled manner with the net outcome being patient benefit rather than harm.
This audit has improved the way we review and document medications however there is still room for improvement. During the time period of the re-audit there were no further clinical incidents with regards to medication omissions which leads me to believe we are being more careful in our prescribing, communication has improved both within the team and with our patients’ and their carers, as well as our documentation. This in turn will lead to improved patient care as well as easing some of the medication burden that faces some of our patients also helping to provide some cost benefits to the health economy. I believe our greatest improvement has been our communication with our primary care colleagues who will hopefully find our rationale for stopping certain medicine useful and in turn it may influence their practices in the future.
We know that inappropriate polypharmacy can have many negative patient impacts and I feel we are in a unique position within the hospice setting to discuss these issues with our patients enabling them to make an informed choice and oversee the tapering or stopping of medications.