Clinical Modules: How to Dr Eleri Clissold Gather your baseline - - PowerPoint PPT Presentation

Clinical Modules: How to

Dr Eleri Clissold

Gather your baseline data

Run a query

Save the Query builder to your desktop or in your documents Open Medtech Go to Tools > Query Builder Double click Query Store Right Click a folder Choose Import Query Open & run Export as excel

Randomize

Select a random number between 1 and 10 by picking pieces of paper out of a hat Audit every other patient starting at this number e.g. if 6 is drawn audit the 6th, 8th, 10th patient etc

Audit

Measures

 Has medication reconciliation occurred within seven

calendar days of the EDS being received?

 Has the patient's regular medication list been

updated?

 Is it documented that any significant medication

changes have been discussed with the patient or their representative?

 Overall Compliance

“ALL discharge summaries received will be reviewed, with both medications reconciled and actions completed, within seven calendar days”

Aim

Spread sheet walk-through

 No more than 10  Use the same spread sheet  No NHIs please

Send us the spread sheet

 10th of each month  audit@safetyinpractice.co.nz  Use the SAME spread sheet next month

Medication Status - STOPPED

Medication Reconciliation GP 2017-18

0% 20% 40% 60% 80% 100% Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018

Has Medication Reconciliation occurred within 7 (calendar) days of the EDS being received?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018

Has the patient's regular medication list been updated?

0% 20% 40% 60% 80% 100% Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018

Is it documented that any significant medication changes have been discussed with the patient or their representative within 7 (calendar) days of receipt?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018

Medication Reconciliation Overall Compliance

Medication Reconciliation

“Initially the team didn’t think there was a problem with Medication Reconciliation so this programme has now highlighted that some GP’s don’t update the medications” “We are now all clear that med rec is to be documented; using agreed and created shortcut keys.” “Patients really appreciate the calls to discuss their medication changes”

Support

Practice visit PHO advisors Clinical leads Improvement advisors

Prescribing Indicator Modules

Lisa Eskildsen

Prescribing safety indicators

Statement that describes a prescribing event that puts the patient at risk of harm

British Journal of General Practice April 2014

56 prescribing safety indicators Range of

 therapeutic areas  hazardous drug-drug combinations  inadequate laboratory test monitoring

Categorised according to degree of risk of

harm

 23 posed high (3) or extreme (4) risk of harm

Focus on NSAID

Reducing harm from NSAIDS

 One of main medicine groups causing death  Most commonly causing admission ~ 30%  Evidence that when risk is highlighted

practitioners reduce risk prescribing in at least 1/3 patients

 Shown reductions in admissions with GI bleeding

and acute kidney injury (AKI) in UK

Patients ≥ 65 years prescribed oral NSAID in the last month, and not prescribed a gastro- protective medicine in the last 4 months

Rationale – Risk identified

 Increased risk of GI bleeding x10 compared to NSAID use in middle age.

Recommended Action

 Review the need for NSAID OR  Prescribe a gastrointestinal protective medication.

TRIPLE WHAMMY – Prescription of oral NSAID in the last month with ACEI / ARB + diuretic combination within the last 4 months

Rationale – Risk identified

 Substantially increased risk of AKI and death  Particularly high risk if pre-existing CKD  Risk greatest in first 30 days  80% increased risk hospitalisation

Recommended Action

 Review need for NSAID at all particularly if pre-existing CKD or heart failure  Try to use alternative treatment

Prescription of oral NSAID in last month with CKD 3,4 or 5 eGFR<60ml/min

Rationale – Risk identified

 Increased risk AKI  Greatest risk at start of treatment  Especially if unwell or hypovolaemic

Recommended Action

 Review need for NSAID  Advise patients discontinue NSAID if they become unwell or dehydrated

Patients with history peptic ulcer prescribed NSAID without gastro-protection

Rationale – Risk identified

 Increased risk GI bleed

Recommended Action

 Review need for NSAID  Close monitoring

Prescription oral NSAID in last month in patient with heart failure

Rationale – Risk identified

 Exacerbation of heart failure  Doubles risk of hospital admission

Recommended Action

 Review need for NSAID

Prescription of oral NSAID in last month in combination with warfarin or novel anticoagulant in last 4 months

Rationale – Risk identified

 Increased risk GI bleed – x1.8 – 8 cf warfarin alone  Increased risk hospitalisation

Recommended Action

 Review need for NSAID  Avoid combination  Prescribe gastro-protection medication regularly even if use NSAID is intermittent

What do practices do?

Identify patients in audit report Submit the total numbers only in each group Review these as a practice Decide what actions you will take

Spread sheet Prioritise Bite sized chunks

TRIPLE WHAMMY Proportion of Patients over 65 currently prescribed an ACEI/ARB and Diuretic who are also currently prescribed an NSAID.

NSAID prescribed to a patient aged 65 years and

• ver without gastro-protection (bleeding risk)

 Patients age ≥ 65

years on triple whammy combination (ACE/ARB + diuretic + NSAID) Sustained 50% reduction

 Patients age ≥ 65

years on NSAID without GI protection Sustained 50% reduction

2017-18 SIP Focus on NSAID prescribing

20 40 60 80 100 120 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018

CKD 3, 4 or 5 with ‘triple whammy’

40% reduction

Focus on:

NSAID (first year in programme) Kidneys High risk medicines – prescribing

and monitoring

KIDNEYS

Prescribing of medicines associated with AKI 1

Prescription of metformin to a patient with renal impairment eGFR < 30 ml/min

2

TRIPLE WHAMMY - Prescription of oral NSAID with an ACE /ARB + Diuretic combination within the last 4/12

3

Prescription of an oral NSAID in a patient with CKD 3,4 or 5 (eGFR<60ml/min)

Monitoring of medicines likely to cause AKI / affect renal function

4

Patients prescribed metformin without a serum creatinine in the previous 15 months

5

Patients prescribed an ACEI or ARB who have not had a creatinine and electrolytes in the previous 15 months

6

Patients aged ≥75 years prescribed a diuretic who have not had a creatinine and electrolytes in the previous 15 months Prescription generated in preceding calendar month

High Risk Medicines - appropriate prescribing and laboratory monitoring

1

Prescription of Sodium Valproate to a woman of child bearing potential (10-49 years) excluding women who have had a hysterectomy

2

Prescription of warfarin to a patient without a record of INR having been measured within the previous 9 weeks (excluding patients who self-monitor)

3

Prescription of methotrexate without a record of a full blood count and liver function within the previous 4 months

4

Prescription of Methotrexate without prescription of Folic Acid in the last 4 months

5

Amioderone prescribed without record of thyroid function (TSH) and liver function (LFT) done in the last 7 months Prescription generated in preceding calendar month

What will you do next?

Choose your prescribing safety indicator Download spreadsheet Enter numbers from report into this Save copy to add to next month. Send to AIP What does the report highlight for your practice?

Spread sheet audit@safetyinpractice.co.nz

Plus your PHO facilitator

Equity

 Factors that pre-dispose populations to poorer health

• utcomes may also expose them to greater risks of errors,
• versights, miscommunications and care which is less

appropriate to their needs

 NSAID

 Greater incidence and more severe gout  Higher rates of NSAID prescribing poss related to poorer

contol

 Greater risks of CVD, CKD and AKI

Mohio

Reports presented with Maori patients at

top of list

Safety-in-Practice audits

Patient names listed - can apply filters e.g age, Maori, high needs

What might your practice do?

 Share your data with your team – what is it

highlighting?

 Discuss at clinical / practice meeting  Decide what area to focus on

 Review patient notes

 Actions such as stopping the NSAID or adding gastro-protection and

may require a clinical review/ letter phone call

 Who will do what?  Discussing the benefits and risks with the patient

Resources

Resources

Questions /Comments