Meeting CHF core measures with medication reconciliation upon discharge

[blynnRN]

I am currently in an RN to BSN on-line program. I am completing my practicum requirement on a telemetry floor. I have an assignment for school to correspond with another nurse in another region about a current issue in my practicum area.

I am taken back by the paperwork and the research the nurse is responsible for upon the discharge of a core measure patient. The nurse is responsible for making sure the md has checked on the medication reconciliation sheet which medications are to be continued at home. Most of the time, the md does not check the box and the nurse has to call the md. Also, the nurse has to ensure that patient is discharged on a beta blocker and an ACE, or ARB. If they are not, the nurse has to research through the chart to see if the md has charted a contraindication for being on these medications. The nurse then has to call the md to make them aware that the patient is on these medications, and needs a reason why.

This is such a major process. The mds do not take as much responsibility as I think they should. In addition, the nurse also has to reconcile the medications to make sure that they are being sent home on what they came in with. For example, if the pt is diabetic, the nurse has to make sure the md is sending them home on their diabetic medication.

Some nurse have said that they have heard that in other areas of the country that the pharmacist completes the medication reconciliation. This current process leave room for multiple errors.

Is anyone currently practicing a better method at their hospital. I am supposed to identify the nurse and the region that they practice when I post my assignment. I understand if that is a problem, but I do not know where else to communicate online with other nurses. My name is Becky & I practice in Memphis, TN. I have been a nurse for 13 years.

I appreciate anyone's help.

[dianah, ASN]

Here is tjc's statement on this:

https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/

From the above, under risk reduction strategies:

Assign responsibility for comparing admission orders to the home medication list, identifying discrepancies, and reconciling variances to someone with sufficient expertise.

Reconcile medications within specified time frames (within 24 hours of admission; shorter time frames for high-risk drugs, potentially serious dosage variances, and/or upcoming administration times).

Also, under requirements and recommendations:

Patients, and responsible physicians, nurses and pharmacists should be involved in the medication reconciliation process.

Without accountability, no one but the nurse involved here (from what you've described of the system) will take responsibility.

Seems a system overhaul is in order.

[AnnaN5]

I work on a cardiac stepdown floor and we see many CHF patients. We just got our recognition for advanced CHF center. In the last 6 months of so we implemented a discharge form that must be filled out by all physicians for each patient (whether they were admitted for chf or not). The must state when they need to follow up, if their EF qualifies for follow up for AICD placement, diet & activity recommendations. Then the bottom half of the form is the following medications: ASA, beta blocker, ACE/ARB, statins, and plavix. The physician has to either check the box of ordered, contraindicated, or not applicable to this patient. If they mark contraindicated they must state the reason why: such as renal insufficiency for ACE/ARB. This has really helped in making sure the physicians are ordering the appropriate meds at discharge. It was met with some resistance at first but now the docs know their patient isn't leaving until they fill out the form.

As far as home med reconciliation. The nurse or physician fills out a med rec form at admission. It looks something like this:

Med----Dose----Frequency------Order----Do Not Order-------------Continue at discharge

The physician indicates if they want the medication continued or stopped at admission then when the patient is ready for discharge they check the box if they want the patient to go home on that medication. There is also room at the bottom of the form to add new medications the patient will be discharged on. The patient can not be discharged without this form filled out by the physician.

I hope this is the kind of information you are looking for, if not, sorry for my long response!

[Snickerdoodles]

I work on a cardiac floor and I swear you were writing this from my own unit! It is a very mundane task. We also have to have the discharge paperwork checked by our charge nurse. They have new system that we are introducing that will have 2 columns, one with medications the patient received in house and the other one with the home medications. It is supposed to cut down on us having to call, and those errors of forgetting the ACE/ARB. Or policy is only if the EF is below 40%. Is this also the same at your facility?

Either way it can take an hour to do these discharges and then you have to wait for the charge nurse who may have 2 other ones ahead of yours! I agree the docs should have more liability on this. Our pharmacy does random checks on the CHF patients, but it is not on every patient so it doesnt really help.... wish their was a better way!

[destiny67]

Hey Snickerdoodle:

We just started a new program at our hospital, because we were having the same problems. The goal is to create a comprehensive and reliable discharge plan, which will help to reduce preventable readmission for Heart Failure patients. The team consists of an RN, pt's physician, pharmacist, case managers and therapists. The RN follows the pt from admission thru discharge. She reviews the medical history, medication reconciliation, initiate care plan and checklist. She follows up with the patient on the unit and does teaching (the floor RN also reinforces the teaching) clarify any concerns with health care team and discusses patient's concern. She also follows up with patient, when he/she is discharged via phone calls. The team pharmacist verify the physician orders, reconcile the pts meds with meds from home, collaborate with care team specific discharge needs, reconcile meds upon discharge and assist with patient medication questions. All the team members work together to reinforce medication reconciliation, reconcile discharge plan with national guidelines, follow-up appointments, outstanding tests, post-discharge services, written discharge plan, what to do if a problem occurs, patient education, assess patient understanding, and telephone reinforcement. This method ensures a better hospitalization and outcome for the patient. Hope this helps

[jjjoy, LPN]

Our facility has tried several different approaches and is still working on it. Hopefully, some of the upcoming electronic charting changes will help. Still, to ever hope to meet CM 100% requires continous, consistent concurrent enforcement... and that requires a much bigger investment of manpower than just giving someone (be it a nurse or a physician) a form and demanding "you need to do this".

[RNTwin]

unrealistic expectation... that is it

currently were i work the nurse is suppose to fill the home med req but we also have been told if the pt doesnt' come with Rx bottles or a med req from an outside facility we are not to write them down. b/c what is happening is that people are coming in saying i take toprol 50 mg bid when i reality they are taking toprol 25 mg bid or visversa also people are coming in saying they take "vicodin" for their "back pain" and in reality they are not taking anything

[soxfan80]

I work in MA on tele, and what you describe is pretty much how we do it as well. It is nursing who enters the drugs that the pt reports in the computer. The ED initiates this, and sometimes, we get reports that say "Prostatewe Pill" or "blue pill", but no drug name or dose. It is up to the discharging nurse to figure out what the med is as most of the time, the MD will give DC directions to "continue Prostate pill per PCP''. We have to make phone calls to figure this out. It's an annoying, time cosuming, frustrating process, and there needs to be a better way to do this!

[jjjoy, LPN]

were i work the nurse is suppose to fill the home med req but we also have been told if the pt doesnt' come with Rx bottles or a med req from an outside facility we are not to write them down.

Hello Rock, Hello Hard Space... let me just get settled in here

I work on a cardiac stepdown floor and we see many CHF patients. We just got our recognition for advanced CHF center. In the last 6 months of so we implemented a discharge form that must be filled out by all physicians for each patient (whether they were admitted for chf or not)... It was met with some resistance at first but now the docs know their patient isn't leaving until they fill out the form.

Amazing! Who had to be 'the enforcer' and hold up the discharge when the form first rolled out and some physicians may have refused to fill the form out. I ask because sometimes the staff is told "make sure the physicians do (X)" but then have no real system in place to back it up. If a physician refuses and just walks away, the staff can't just hold everything til the physician comes back and fills in the form. If they did, they'd get slammed by administration for holding things up. So I'm wondering how your facility backed up the front-line staff on this.

[CCL RN, RN]

Physicians are responsible for filling out the med rec form where I am too. And if they don't? Then the pt doesn't get discharged. Period. But it's easy. The med rec form is started in ED, and continued in through their stay.

[jjjoy, LPN]

The med recs do get done but it can be like pulling teeth. To add yet *another* form (such as for core measures) that needed to be filled out at discharge would be very strongly resisted by both physicians and nurses. And I can see why. They've got various forms coming out their ears! That's why I'm asking how Anna5N's facility is managing compliance with their core measures discharge form.

[AnnaN5]

The med recs do get done but it can be like pulling teeth. To add yet *another* form (such as for core measures) that needed to be filled out at discharge would be very strongly resisted by both physicians and nurses. And I can see why. They've got various forms coming out their ears! That's why I'm asking how Anna5N's facility is managing compliance with their core measures discharge form.

Needless to say the doctors were not happy when this first rolled out but they have realized that they do not have a choice. We are an advanced chest pain and CHF center so the heads of those programs started by doing alot of education with the physician groups. Our medical directors are on board and if there is any resistance met by a physician it is reported to the medical director and they deal with the individual physicians. We are allowed to fill out the form for the physician if we go over it on the phone with them so we have to ask them if they want the patient on an ACE/ARB, Beta, ASA, Plavix, Statin, etc and if not they have to give us a rationale such as renal insufficiency, bradycardia, etc. Sometimes it still feels like we are babysitting the physicians to remind them to fill out the Med Rec and Cardiac Discharge sheet but it seems to be getting the job done.