Medicine information and patient discharge

Abstract

Medicine reconciliation is vital to the discharge process and can be improved by evaluation, reducing errors and readmissions, saving resources and improving quality of life. The scope of the study was to analyse prescribing trends and changes during hospitalisation and to identify frequency of drug classes. Clinical pharmacist compliance with discharge Standard Operating Procedure (SOP) and patient knowledge on medication changes during hospitalisation were assessed to find gaps in the process, along with healthcare professionals’ perception on medication reconciliation. The 30 patients recruited were over 18 years of age, had a chronic disease, were currently taking two or more drugs, had no severe cognitive impairment, and were discharged back to their private residence. Medication forms were compiled from patient files. Medicine reconciliation for each patient was observed at discharge. A patient questionnaire was filled, and SOP compliance was assessed. A questionnaire aimed at healthcare experts about the medication reconciliation process at discharge was carried out. A Likert scale of 1-5, with 5 being the highest, was used for the questionnaires. The study was carried out at Karen Grech Rehabilitation Hospital (KGRH). Outcome measures included medicine use in elderly patients, knowledge about medication changes at discharge, and healthcarer perception of medicine reconciliation. Twenty nine patients were aware of medicine changes. The mean patient rating of effectiveness of reconciliation was 4.5. The experts (n = 7) rated the process feasibility as 4.3, effectiveness as 4.7, and were willing to spend 20 minutes on patient reconciliation. The most common class, regimen and route in use during hospitalisation were antihypertensives (13.4%), daily (41.6%) and orally (88.1%). Chi-square tests identified significant associations between drug class and changes in dosage regimen (p = 0.022), as well as with changes in dose (p = 0.009), route of administration (p = 0.010), starting (p < 0.001) and stopping (p = 0.012) medications. The mean number of medications taken per patient is not significantly affected by age group (p = 0.896) but is higher for females (two-tailed p = 0.026). In conclusion, patients and professionals are satisfied with medicine reconciliation. Emphasis must be made during reconciliation, especially on antihypertensive changes.