Safer Medicine Admissions Review Team (SMART)

Carl Eagleton and Hannah O’Malley

on behalf of the SMART Working Group

The Need… Increasing General Medicine patient volumes

Volu

me

EC arrival year

The Need…Increasing patient wait times in Emergency Care (EC)

LOS

(Hou

rs)

EC arrival year

The Innovation

• Streamline the admission process• Improve patient and medication safety • Meet national Medication Reconciliation (MR)

targets• ThedaCare’s ‘Admission Trio’ mapping the way

‘MAP’ Model of Care

• Team-based admitting pharmacists• Pharmacist at the front of the hospital• Collaborative patient review with admitting

doctor • Medication history and reconciliation in EC• Continuity of care

Adapting the ‘Admissions Team’

• IHI Model for Improvement • TRIO to PAIR = MAP model• 5 week pilot study

Aim

The SMART model (a doctor and pharmacist working together) will be applied to 90% of

triage category 2-5 patients presenting to EC who are referred to GM between the hours of

8am and 10pm, Monday to Friday.

Objectives and MeasuresSafer• Reduce unintended medication errors to zero • Complete MR ≤ 6 hours of GM referralFaster• 80% of patients referred to GM will be seen by SMART within 60

minutes of referral• With 95% seen within 90 minutesPatient-focused• Improve patient experienceSystematic• Improve Medication History documentation to 100%• Reduce length of stay by 0.25 days per patient

Process Improvement – PDSA’sChange Tested Outcome

1 Evening shift PDSAs 1 pharmacist 2 pharmacists 3 pharmacists

2 Shared model of care – tested whether two pharmacists sharing 3 teams provides sufficient cover

PDSA confirmed adequate cover using this model of care. Clinician concern regarding possible fragmented care – to monitor subspecialty cover

3 Alerting staff to unsigned medications chart

Tested green cards inserted into medication charts (Fell out)Stickers on medication chart

Process Improvement - DataElectronic ReportsWith help from statistician a daily report was developed

capturing the # of patients SMARTed versus total # in target group, time to be seen, time to MR, and LOS

Manual Data CollectionManual data collection is needed to record interventions and

contributions by pharmacists – an electronic data collection form is being developed to streamline this process

DashboardA dashboard has been developed to track progress on measures

which are updated weekly or monthly

SMART Collaborative Dashboard – End October 2013

Average time from Gen Med Referral to Gen Med Seen By for SMARTed patients compared with historical baseline

(I chart)

UCL

LCL

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

Jul-2

012

Aug

-201

2

Sep

-201

2

Oct

-201

2

Nov

-201

2

Dec

-201

2

Jan-

2013

Feb

-201

3

Mar

-201

3

Apr

-201

3

May

-201

3

Jun-

2013

Jul-2

013

Aug

-201

3

Sep

-201

3

Oct

-201

3

Nov

-201

3

Dec

-201

3

Jan-

2014

Feb

-201

4

Mar

-201

4

Apr

-201

4

May

-201

4

Jun-

2014

Ho

urs

SMARTed patients only

Average Time from Gen Med Referral to Gen Med Seen By for SMARTed Patients(X-bar Chart)

UCL

LCL

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

7/29

/13

8/5/

13

8/12

/13

8/19

/13

8/26

/13

9/2/

13

9/9/

13

9/16

/13

9/23

/13

9/30

/13

10/7

/13

10/1

4/13

10/2

1/13

10/2

8/13

11/4

/13

11/1

1/13

11/1

8/13

Week beginning

Hou

rs Mean = 0.970 (58 mins)

Average time from Gen Med Referral to Medicines Reconciliation (I chart)

UCL

LCL

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

Jul-

20

13

Au

g-2

01

3

Se

p-2

01

3

Oct

-20

13

No

v-2

01

3

De

c-2

01

3

Jan

-20

14

Fe

b-2

01

4

Ma

r-2

01

4

Ap

r-2

01

4

Ma

y-2

01

4

Jun

-20

14

Ho

urs

General Medicine eMedication Reconciliation Forms Completed on Admission (P Chart)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Week beginning

SMART starts

Average LOS for Inpatients who were SMARTed compared with historical averages (I chart)

UCL

LCL

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Day

s

SMARTed patients only

1

2

3

4

5

6

Percent of Patients Presenting to EC Between 8am and 10pm Mon-Fri who were SMARTed each week

0%

5%

10%

15%

20%

25%

30%

35%

40%

7/2

9/1

3

8/5

/13

8/1

2/1

3

8/1

9/1

3

8/2

6/1

3

9/2

/13

9/9

/13

9/1

6/1

3

9/2

3/1

3

9/3

0/1

3

10

/7/1

3

10

/14

/13

10

/21

/13

10

/28

/13

11

/4/1

3

11

/11

/13

11

/18

/13

11

/25

/13

12

/2/1

3

12

/9/1

3

12

/16

/13

12

/23

/13

12

/30

/13

Week beginning

P harmacy staff absences

Additional teams rolled out

1

Percent of Patients Presenting to EC Between 8am and 10pm Mon-Fri who were SMARTed each week

0%

5%

10%

15%

20%

25%

30%

35%

40%

7/2

9/1

3

8/5

/13

8/1

2/1

3

8/1

9/1

3

8/2

6/1

3

9/2

/13

9/9

/13

9/1

6/1

3

9/2

3/1

3

9/3

0/1

3

10

/7/1

3

10

/14

/13

10

/21

/13

10

/28

/13

11

/4/1

3

11

/11

/13

11

/18

/13

11

/25

/13

12

/2/1

3

12

/9/1

3

12

/16

/13

12

/23

/13

12

/30

/13

Week beginning

P harmacy staff absences

Additional teams rolled out

Percent of patients seen increasing as SMART tests new combinations and

rolls out new teams

Safety Data• Clinical input by pharmacist occurs sooner and is proactive rather than

reactive• More convenient communication and collaboration allowing errors to

be prevented or rectified faster• 747 patients seen by SMART since August 2013• 302 contributions recorded and 65 interventions• Examples:

“Patient had run out of epoetin injections and didn't know to continue them. Hb = 80g/L (anaemic), recommended to prescriber to restart”“HbA1c 79mmol/mol advised increase glipizide dose”“Citalopram 10mg charted but patient normally on escitalopram 10mg. Medication corrected.”

Key SuccessesImproved working relationship between pharmacists,

doctors and nursing staffRolling out eight general medical teams with the shared

model of care covering 8am-10pmSignificant reduction in time to MR from >2 days to <6

hours and increased # of patients receiving MREarlier contribution by pharmacist has led to fewer

medication errors Winning medication safety and innovation award and

best paper award at NZHPA

Buy In• Various stakeholders including pharmacy, nursing, medical staff and allied

health union

• Meetings held with Key EC nursing staff and presentations at EC nursing handovers

• Presentations at medical RMO/SMO handovers to educate doctors about SMART

• Email and poster communications

• Weekly SMART updates at Medical Pharmacist meetings

• SMART themed week involving all clinical pharmacists aimed to educate, engage and identify potential issues

Challenges• Several measures require multiple methods of data collection• Quality of historical data such as number and type of

interventions and contributions has not been reliable – needed to investigate more reliable ways of collecting

• Risk of medicines charted by pharmacist being administered before being signed

• Changing work hours of pharmacists – ensuring issues identified and addressed is important

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