News at UI Health

By: Elizabeth Gardner

When University of Illinois Hospital & Health Sciences System pharmacist Adam Bursua started calling his hospital patients a few days after their discharge to see how things were going with their medications, he always- always-found that something wasn't right.

"Every single patient I called had some kind of problem," says Bursua, a clinical assistant professor in the College of Pharmacy. "There would be a medication that I didn't know they were taking, or it would turn out that a medication was too expensive and so they hadn't filled the prescription. Or they had lost a prescription, or their medication list wasn't consistent with their discharge plan, or they had talked to their brother who had told them, 'I would never take that medication,' and so they decided not to take it either."

Sometimes, he added, newly diagnosed patients with diabetes, who had learned in the hospital how to give themselves insulin injections, lost confidence in their training once they were home.

While alarming, Bursua's experience reflects a common state of affairs. The Institute of Medicine has estimated that medication errors injure 1.5 million patients a year and cost the nation's healthcare system $3.5 billion annually-and that's just the errors that cause identifiable damage. Millions more go unnoticed, but patients don't get the full benefit of their medications and may even wind up back in the hospital as a result. Transitional periods such as immediately after hospital discharge are the most likely times for medication errors to occur.

Bursua had started phoning his patients because he had read many studies showing that such follow-up calls can have a major impact on patients' well being, sometimes even saving their lives. But the calling was labor-intensive and was difficult to incorporate into his everyday practice. In response, he turned to a new labor pool-pharmacy students-and with colleague Mat Thambi created a six-week rotation called RxCARES, where students follow a specific medication management protocol for patients being discharged from the hospital's internal medicine service. The protocol includes a full complement of services and assessments such as:

Reconciliation: Students create detailed medication histories, resolve medication list discrepancies, review discharge plans and make follow-up phone calls after discharge in order to ensure the patient was able to obtain new medications.

Drug interaction screening: Using a computerized tool, students identify possible clinically significant interactions and recommend dosing alterations or alternative medications.

Continuity: Students remind discharge patients about all upcoming appointments and forward a medication list, with updates highlighted, to the primary care physician.

Access and adherence: During follow-up phone calls, students ensure the patient is adhering to the prescribed plan. Any barriers to adherence (insurance, transportation, education) are identified and resolved.

Risk reduction: Students perform medication-specific interventions to reduce risks.

Evidence-based medicine: Students identify any opportunities to employ mortality-reducing or disease-modifying therapy.

Savings: Students review the indications for high-cost medications to see if there are less costly alternatives that do not sacrifice safety or efficacy, especially when patients have problems affording their medications.

Not only do the students perform a vital service, but they also acquire an invaluable education in all the things that can go wrong with medications once patients get home. The rotation made its debut in September 2011 and is now in its second full school year.

RxCARES focuses on patients who are admitted to the internal medicine service and who are at particular risk for medication errors: those who have more than 10 prescriptions, those older than 65 who have five or more prescriptions, those who have been hospitalized more than once in the past year and many patients on high-risk medications such as blood thinners or insulin. So far, the program has helped over 300 patients.

There are two students per rotation. Starting with admission, they work with the patient to develop a "gold standard" medication history. In addition to interviewing the patient and checking with his or her primary care physician to confirm what medications have been prescribed, they do detective work with the patients' pharmacies and insurance companies to see which prescriptions have been filled and paid for. "More than 80 percent of patients have at least one change, and the majority have multiple changes in their medication list as a result of this process," Bursua says.

While the patient is in the hospital, the students primarily keep an eye on any changes in prescriptions. At discharge, they go over the medication list and make sure that it's consistent with the admission list and any subsequent orders to start or stop medications. Then they make follow-up calls three to five days after discharge.

One novel aspect of the protocol is interaction with outside pharmacies. Patients often leave the hospital with a new list of prescriptions that supersede what they were taking before, but because they still have refills on file at their pharmacy, they go ahead and take their former pills anyway. The students check in with the pharmacy and make sure any potentially harmful refills are cancelled. "Let's say a patient comes in with angioedema because of an ACE inhibitor," Bursua says. "We will stop it in the hospital and take it off the medication list, but then the patient goes to the pharmacy and says, 'I need my refills.' They may not have the health literacy to say, 'Except lisinopril.' I know my mom is a smart lady but I'm sure she doesn't list her medications one by one, with the dose, when she talks to her pharmacy. We are trying to include the outpatient pharmacy in a way that influences the patient's care."

Roseanne Miksanek, now a first-year pharmacy resident, signed on for the rotation last year. She's applying its lessons to all the patients she sees, and she's also studying it as her residency project, looking at 115 patients who received the RxCARES protocol and matching them with 150 control patients who received normal post-discharge care. Early into her project, Miksanek is already seeing the importance of teamwork in preventing medication errors.

"This is definitely something I want to do as a hospital pharmacist, and I'd like to bring this model with me to a smaller community hospital," she says.