Join Section

Quality Improvement & Patient Safety Section Newsletter - NACS Quality Director Ferroggiaro Letter

* Reproduced in part

The ED is a crucial element in the Medication Reconciliation program. If the program is to be successful, a high percentage of compliance with the measure, then some focus needs to be directed to the EDs.

  • Consider that 40-50% nationally of hospital admissions are through EDs; the ED is shouldering the burden of medication reconciliation for the hospital 40-50% of the time, and this does not include the > 70% outpatients who also require medication reconciliation before they are discharged. All under a time-dependent practice.

  • A fascinating article in Annals of Emergency Medicine indicated that ADEs accounted for > 10% all ED visits in population > 65 years old and that 31% of patients had at least one potential adverse drug interaction within the medication list.

    Hohl et al. "Polypharmacy, Adverse Drug-Related Events, and Potential Adverse Drug Interactions in Elderly Patients Presenting to an Emergency Department" Ann Emerg Med. Dec 2001;38:666-671.

    • It is in the ED that these patients can be identified and safety managed with a well-supported medication reconciliation program.

  • Clearly then the EDs, as an access point, are in a unique position to impact the safety of the Health system patients. The challenge is to not injure the already overburdened EDs.

    • Our five-ED system sees > 200,000 patients annually; about one patient every 2.5 minutes.

    • Moreover, the IOM has singled out the generic 'Emergency Department' for a focused report this year; "Hospital-Based Emergency Care: At the Breaking Point"

      • The Report has a subtitle which frames the conflict within this site in healthcare - "THE CHALLENGE OF HIGH DEMAND AND INADEQUATE SYSTEM CAPACITY"

        • Between 1993 and 2003… nationally ED visits rose by a 26 percent increase.

        • " ...patients coming to the ED are older and sicker, and require more complex and time-consuming workups and treatments.

        • " [and] a net loss of 425 hospital EDs...

    • It is unique and telling of its importance that one hospital site receives such focus from the IOM.

      • The ED is unlike any other department in the hospital system - including the outpatient clinics - patients come to the ED because they think they are dying; and they are. We are time-dependent care.

    • Thus the ED is in a precarious balance between two of the six IOM aims presented in "Crossing the Quality Chasm."

      • Safe - avoiding injuries to patients from the care that is intended to help them.

      • Timely - reducing waits and sometimes harmful delays for both those who receive and those who give care.

      • There is a tenuous balance between quality and safety of care for the specific patient vs. quality and safety for all the ED patients. Resources and focus are critical to this balance.

  • ED and Health System Cost of the Current Med Reconciliation Program

    • Consider 145 patients per day average census as the capacity of the ED.

    • Increase each patient LOS an additional 20 minutes [current average time for med reconciliation per pt].

      • 14-15 fewer patients being seen daily.

        • Increased LOS and ED congestion

        • Further atrophy of patient satisfaction

      • Increase in LWBS high-risk patients

        • Currently at 2-3% - potential to rise to 11%

        • Patients who have LWBS have potentially life-threatening complaints [Chest Pain, Abdominal Pain, etc]

      • Increase in divert time

        • Limiting influx of new patients

      • Cost: $250,000 monthly potential billing deficit.

      • Any operational stresses to these systems that have positive growth will compromise the EDs ability to retain or expand market share and thus the Health System's ability to retain or expand market share.

  • The current HEALTH SYSTEM Medication Reconciliation format requires the ED RN to obtain a medication list, enter this list, produce a copy for the ED MD to review and reconcile.

    • If the ED RN is entering data, then the ED RN is not administering medications, monitoring a patient, or providing other therapy that is of primary responsibility. 

    • If the ED MD is entering data or attempting to reconcile a list, then the ED MD is not with the next patient diagnosing or intervening in illness that is of primary responsibility. 

    • "Clinical Pharmacy Manager Victor Cohen, who works in the emergency department (ED) at 635-bed Maimonides Medical Center in New York City, reviewed the accuracy of the medication list as obtained by ED RNs - a mean accuracy rate of 42.6% [and] the ED physicians had relied on [this] when making a diagnosis or ordering a test." See ASHP News.

      • Clearly this shows that other systems have tried to use ED RNs for obtaining the medication list and the outcomes have been poor. Moreover, the fact that that error-prone list has been used for decision-making by the MD compounds the potential for injury.

    • "Data collected by Northwestern Memorial researchers for the new study showed that in the absence of a pharmacist intervention, 22 percent of medication discrepancies may have resulted in patient harm during hospitalization and 60 percent may have resulted in patient harm if continued beyond discharge." See Public Health News.

      • It would not be practical or successful to refocus those non-pharmacists to a medication-focused role when pharmacists and staff already have this focus and can affect outcomes.

  • There clearly is a need for other staff to manage this new requirement.

    • Customization - "...a potential problem is when an organization wholly adopts another's form and procedure." See ASHP News.

      • Health system must consider customizing its medication reconciliation approach based on departmental function. This article indicates that one process does not fit every hospital or every department in a hospital.

    • "Medication reconciliation is a multidisciplinary process. Selecting who should be involved in each step along the way should be based on available resources and who can best complete the task. For example, a physician, nurse, pharmacist, or pharmacy technician can collect the medication history.(9) Although pharmacists have been identified as being more effective in taking such a history, there is no reason that they cannot train others to do this well." See IHI's National Forum.

    • "A new medication reconciliation system, implemented in 2005 as part of the UHC Medication Safety 2005-2006 Implementation Project, is working well for North Carolina Baptist Hospital (Wake Forest University Baptist Medical Center). The new process, developed by a multidisciplinary team, requires a pharmacy technician to collect a medication history, including allergy information." See AHRQ article and outcome data on website.
  • Pharmacy Technician average salary = $25-30K annually

    • Community College training - 200 hours - Level 1 Pharm Tech

    • Compared to the above potential billing loss at $3 million annually.

Again, the ED has a large role in the safety of all patients accessing the department and perhaps an even larger role within the healthcare system. Let us be sure we are not compromising Everyman's quality and safety through system programs. It is immensely wise, efficient, and economical to learn from others, successful and mistaken - and hopefully this letter has opened new options.

Anthony Ferroggiaro, MD, FACEP
NACS Quality Director

Click here to
send us feedback