Despite national guidelines, extensive research, the availability of funding for more pharmacists to implement the APAC guiding principles for the continuum of care and professional practice standards related to clinical handover, medication management along the continuum of care is still problematic. This audit of the current discharge process has found significant issues in terms of the accuracy, quality and timeliness of delivery of the HDS to community-based practitioners responsible for the next episode of care. Studies from Europe, North America and New Zealand have produced similar results [1–4].
Our analysis of the clinical significance of medication errors or omissions in the HDS, based on information on the patient’s health status, and the accuracy and quality of information provided at discharge revealed significant risks to patient’s well-being. An alarming 43% of medication errors or omissions discovered in our review on 80 HDS were rated as moderate to catastrophic.
While our findings are also consistent with previous Australian studies [5, 6, 16], the context in which these errors and omissions occur adds extra cause for concern. Nearly 50% of patients in this audit were Aboriginal or Torres Strait Islanders (ATSI) and clinical handover was often to remote area health services. The lack of a discharge summary, or errors and omissions in the discharge medicines information provided, may be even more significant because of poorer health status, low health literacy  and the low access to medical practitioners and community pharmacy services [17, 18]. Many adult ATSI patients have multiple chronic health problems at a much younger age than non-indigenous people. Over 35% will have diabetes, often coupled with other chronic conditions such as mental health problems, arthritis and cardiovascular disease [11, 19]. Medicines management is consequently complex, with multiple medications in use.
The study hospital’s current policy for discharging patients with only 7 days of medications, with an option of an increased supply for patients returning to a remote community, may exacerbate many of the problems identified in this audit. This may have significant health consequences, when people with multiple chronic health problems visit their community pharmacist, health clinic or medical practitioner, if accurate information on medication changes associated with the hospitalisation are not available within this timeframe. Findings of this study indicate that only 47% of HDSs were delivered within 7 days from discharge.
Due to work load and time restraints the clinical pharmacists only focused on high risk patients. The ability of the clinical pharmacists’ to deliver an accurate and high quality medication discharge process, with timely delivery of the medicines discharge information to those health practitioners involved in the next episode of care was demonstrated in this project.
The time is right for a new model for the hospital discharge process. Guidance for hospital and community pharmacists to support patient discharge from hospital has recently been published by the United Kingdom National Prescribing Centre . The guidance aims to foster relationships between community pharmacists and hospital staff. In Australia, new funding is expected to be available for hospital pharmacists, GP’s and community pharmacists to deliver a comprehensive medicines discharge process, including a Hospital Initiated Home Medicines Review . Developing the relationships between community pharmacists, hospital pharmacists, medical practitioners, health clinic staff and engaging patients, will be critical success factors.
Limitations were identified while conducting this study. Pharmacists prioritised patients with complex medication-related issues for a MITF. These patients have many, and often “last minute” changes to their medications near discharge, making it difficult for those completing the HDS to accurately complete the discharge medication record. Further, medical practitioners in the hospital were not asked about how they make decisions about information to be included in their HDS. They may, for example, concentrate more on accurate recording of diagnoses, expecting pharmacists and nurses to ensure accurate recording of medication changes. Whilst the hospital’s liaison GP was asked for assistance when the clinical panel was rating the significance of omitted medicines, not having prescribers represented on the panel was a limitation that should be rectified in subsequent audits. The usefulness of information contained in the MITF has not been formally tested by requesting feedback from the community-based practitioners. There is the likelihood of confusion if a community-based practitioner received conflicting information from the hospital, as may be the case when the HDS and the MIFT have different medication management information. This may increase time demands on the community-based practitioners as they will need to contact the hospital to clarify discrepancies. Finally the small sample size was determined by the capacity of the research team to undertake this study while maintaining a full-time case load and other professional responsibilities. The magnitude of the issues uncovered, even with this small sample size, has meant however meaningful conclusions can be drawn.
Notwithstanding these limitations, this simple innovation has identified significant issues with the existing HDS and has demonstrated that the MITF delivered accurate, timely and complete handover of medication management information from the hospital service providers to community-based practitioners. The study was led by clinical pharmacists working full-time in the hospital. Its success is an important example of the usefulness of imbedded practitioner research methods . Being imbedded in the setting means that the researchers knew from conversations about the limitations of the HDS, the frustrations caused to community–based practitioners and the risk to patients when they had no discharge information or when the information provided was not correct. The researchers also knew about the hospitals culture and what was possible in terms of engagement of other health workers in the study, work force capacity and pathways to implement change based on the study results.
The promise of an information technology (IT) solution to the problem of timely and accurate clinical handover has not yet been realised. In the NT alone there are at least five different IT patient administration systems (for example primary care information systems, remote area information systems, GP prescribing software and pharmacy dispensing software) that need to be negotiated in what is a highly transient population group. The MITF provides an ideal interim measure for consideration as electronic support for discharge processes are implemented.
The results reported in this paper relate only to the introduction period of the MITF in 2009. Based on the data generated in the study, the MITFs are now required to be completed by all pharmacists as part of their daily duties. The MITF template has also been adopted by four of the five hospitals in the NT (the remaining hospital does not have a pharmacist). Training in the completion of the MITF is now also fully integrated into the orientation process for new pharmacists to the NT hospital Network. The MITF template is currently being mapped by the programmers of the electronic based hospital discharge software to provide the capability for prescribers to examine and utilise the information available in the MIFT at the time of creating their HDS.