Reconciliation Standards Debut July 1

ACEP News

Reconciliation Standards Debut July 1 

BY MARY ELLEN SCHNEIDER 

 

Starting in July, there will be new medication reconciliation requirements from the Joint Commission, but thanks to the American College of Emergency Physicians' work on behalf of its members, the burden of those changes will be minimal.

Officials at the standards-setting body have approved a revised national patient safety goal on medication reconciliation that requires providers at accredited organizations to find out what medications patients are taking when they are admitted to the hospital or arrive at the facility, and compare that information with any new medications ordered. Providers must also give the patient or family a list of the medications that should be taken once they leave the facility.

The Joint Commission is also asking providers to do something new: educate patients and their families about the importance of maintaining a list of current medications. For example, hospital staff could fulfill this goal by advising patients to give the reconciled medication lists to their primary care physicians.

But the new standards include some added flexibility for emergency departments. Under the revised patient safety goal, EDs can define what types of medication information should be collected. This allows emergency departments to use a three-tiered approach to medication reconciliation that was championed by ACEP, said Dr. Frederick C. Blum, a past president of ACEP and an associate professor of emergency medicine at West Virginia University Hospital in Morgantown. He said the approach would vary based on the patient's situation.

In the first tier - screening reconciliation - a triage nurse asks the ED patient about current medications. If needed, emergency physicians could move to the second tier - focused reconciliation. At this point, the emergency physician would obtain additional information such as the exact dosage and route of medications from the patient's pharmacy, primary care physician, and family. How far a physician should go to get the information depends on each patient's situation, Dr. Blum said. If a patient is placed on warfarin and there's a concern that they are taking another medicine that could alter its effect, the physician should devote the time needed to resolve the issue fully, Dr. Blum said. But if a physician prescribes a short-term medication following an ankle sprain, the same level of investigation into the base medications isn't necessary, he said.

If a patient is admitted to the hospital, the third tier of the process - full reconciliation - should be completed by the receiving inpatient unit and pharmacist.

Dr. Blum advised emergency departments to have a plan for medication reconciliation but to build in some flexibility. "It's not simply a one-size- or one-method-fits-all situation for the ED patient."

Dr. Blum said he was also pleased to see more flexibility in the standard related to providing patients with written information about their medications when they leave the hospital. The standard states that when the only new medications prescribed are for a short duration, the hospital staff can provide patients with a list that includes only that new information. This is critical, Dr. Blum said, because if a patient provides an inaccurate list of medications upon arrival at the hospital, parroting that back at discharge would only create further problems.

The Joint Commission's new requirements replace a national patient safety goal on medication reconciliation from 2009, which was placed on hold due to concerns from physicians and hospitals that it was too prescriptive. Since then, officials at the Joint Commission have been talking to physicians and other providers about their concerns, and working to revise the requirements.

"We really tried to work with the field to find out what the goal should be all about," Maureen Carr, project director for the division of health care quality evaluation at the Joint Commission, said in an interview.

Ms. Carr said the previous medication reconciliation goal included requirements related to several elements of the care process that were already addressed in other Joint Commission goals. This time around, officials tried to simplify the requirements by focusing on "risk points" associated with medication reconciliation. They also tried to minimize the documentation requirements.

The revised goal also spells out that making a "good faith effort" to get an accurate list would meet the intent of the standard. Officials at the Joint Commission understand that it's difficult to get a correct medication list from patients for a number of reasons, ranging from patients who withhold information to those who simply forget, Ms. Carr said. It has been the position of the Joint Commission that a good faith effort is enough, but they decided to make that explicit in the policy, she added.

Col. Linda L. Lawrence, a past president of ACEP and an emergency physician at Lackland (Tex.) Air Force Base, said that overall the changes are positive because they are less prescriptive but also provide clearer guidance to emergency departments. She advised emergency departments to work with inpatient units at their hospitals to ensure they have adopted a medication reconciliation process for admitted patients. Emergency physicians also need to determine when a more focused reconciliation process is needed, such as when prescribing new medications or changing medication doses.

Dr. Blum agreed the revised goal appears to be a positive change, but cautioned that the impact will likely depend on how the individual Joint Commission surveyors interpret it. And for the average emergency physician, an even more important question may be how his or her hospital will interpret the new standards. In the past, many hospitals have introduced processes that go over and above what is really needed, he said.

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