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Unplanned hospital readmission figures are frequently used within healthcare as an indicator of quality, with rapid readmissions, particularly those within 30 days, being considered poor
. Medication-related admissions are a national concern; a 2014 report commissioned by the Department of Health, ‘Exploring the costs of unsafe care in the NHS’, found that between 5% and 8% of unplanned hospital admissions are owing to medication issues, such as “prescribed drugs not taken because of a failure to monitor and properly encourage and instruct patients”
. Therefore, a better understanding of barriers to medicine optimisation and preventable adverse events could help improve discharge planning and reduce the burden and cost of medicines-related readmissions.
In the authors’ experience, best practice indicates that hospitals have discharge policies to ensure that patients receive an adequate supply of medicines on discharge (usually 14 or 28 days’ supply). In addition, information about medicines should be communicated to GPs within 24 hours of discharge, to minimise the risk to patient safety.
Discharge planning is essential to allow busy hospital pharmacies time to prepare and deliver discharge medication in advance, avoiding delays in patients waiting on the wards for their medication. However, not all discharges are planned and, if medication is not available at the point of discharge, nursing and medical staff may allow patients to return to the ward to collect their discharge medicines later that day to avoid them having to wait. This may help free up beds for any potential new admissions, but it carries the risk of patients not returning to collect their medicines.
This study investigated the number of uncollected discharge medicines on mental health wards in one division (Jameson) at Central and North West London NHS Foundation Trust and aimed to understand if this had an impact on medicines-related readmissions.
Data were collected by ward-based medicine optimisation pharmacy technicians over a two-week period (22 June to 5 July 2020). During this period, staff checked the medicine cupboards across 18 wards to identify the number of uncollected discharge medications found for patients who had already been discharged from the ward. Data were recorded on a locally designed data collection tool and determined using both the contents of the bag of uncollected medication and the patients’ electronic notes.
For patients identified as not having collected their medication, their electronic record was accessed on 5 August 2020 to identify whether they had a readmission and, if so, whether there was evidence documented to suggest that this was related to medication, such as a relapse in mental state owing to medication non-compliance. The factors that contributed were classified as follows:
- ‘Yes’ – if medicine was considered the main reason for readmission and there were no other contributory factors;
- ‘Partly’ – if there were other significant contributory factors in addition to medicines, such as illicit drug use or social factors;
- ‘No’ – if medicine was not considered a factor, such as relapse owing to relationship or financial difficulties.
Uncollected discharge medication was identified on 8 out of 18 wards. A total of 11 bags were found during the two-week period. There was documented evidence that nursing staff had contacted seven of these patients to collect their medicines, but all remained uncollected. Of these, 82% (n=9) of the 11 patients were on psychotropic medication. None were on high-risk medication (classified as clozapine, lithium or valproate). It is assumed that these patients did not receive an adequate supply of medication on discharge. Poor medication adherence has been shown to be a major contributor to poor outcomes, including relapse, across a range of mental health diagnoses, including schizophrenia, bipolar disorder and depression,,
Of these 11 patients identified as not having collected their medication, follow-up identified that 73% (n=8) had unplanned readmissions; 50% (n=4) within 30 days, 25% (n=2) within 31–65 days, and 25% (n=2) after 65 days.
Of the eight unplanned readmissions, 75% (n=6) were considered to be related to medicine, either partly (33%, n=2) or a major factor (67%, n=4). Of those medicines-related readmissions, the length of stay (LOS) of one of these patients is unknown (as they were admitted to another trust), but the collective LOS of the remaining 5 patients was 113 days (mean 23; range 2–38).
In summary, there were a total of 52 unplanned readmissions during the two-week data collection period. Of these, 21% (n=11) were patients who had uncollected discharge medicines. Of this group, 55% (n=6) were readmitted with medicines-related issues being either partly, or a major, contributory factor. Based on 2018–2019 readmission figures for Jameson division within the trust (n=818), obtained from data analytics tool Tableau, getting this right the first time has the potential to reduce 11.5% (n=94) of medicines-related unplanned readmissions per year.
Following these findings, Central and North West London NHS Foundation Trust has introduced several steps to improve discharge planning and post-discharge follow-up to minimise the number of people being discharged without an adequate supply of medicines. These include:
- A multidisciplinary approach, where pharmacy or nursing staff physically check the medicines cupboard every morning and feed back any uncollected discharge medicines in the daily ward review for prompt follow-up;
- Nursing staff considering early involvement of home treatment team or care co-ordinators to deliver discharge medication to patients unable or refusing to collect;
- Patient-centred medicines education, led by pharmacy, embedded into routine practice as part of the discharge process;
- Asking about medicines incorporated into the ‘three-day nurse follow-up’.
The impact of these findings will be evaluated three months after implementation.
Yogita Dawda, lead pharmacist for mental health at Central and North West London NHS Foundation Trust
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