In 2016, clinicians at Northwestern examined medication adherence rates among their heart failure patients 48 hours after discharge. “Looking at that, we found that they were dismal. More than 50% of patients were not taking their medications either correctly or at all on a discharge follow-up call, so that prompted us to examine what we could improve,” said Gopi Astik, MD, ACP Member, the hospital's medical director of clinical documentation and inpatient medical unit director.
Before creating an intervention, the quality improvement (QI) team interviewed patients who were readmitted with heart failure to see what went wrong and what might have helped prevent the bouncebacks.
“We found that people just didn't understand how they were supposed to be taking their medications, and when they didn't understand, they were less likely to do it because they didn't know how important it was,” said Dr. Astik, a clinical instructor at the Northwestern University Feinberg School of Medicine who led the project with another hospitalist and a heart failure cardiologist. The QI team also included medical residents and colleagues from hospital medicine, cardiology, pharmacy, social work, and nursing.
How it works
The team rolled out three main interventions that targeted the discharge medication list, as well as the patient-education process leading up to discharge. First, the team worked with the pharmacy to revamp the standard medication list and create a new, easy-to-read medication chart to help explain the purpose of medications, timing, side effects, and drug interactions. Bringing patient-friendly terms like “water pill,” “potassium pill,” and “heart rate medication” to the forefront of the instructions helped make the document easier to understand and explain for patients and clinicians, said Dr. Astik. Patients with heart failure were automatically identified and flagged so the pharmacists could start their charts prior to discharge, she said.
The other two interventions involved physicians and nurses. To give pharmacists the necessary time to create the charts, physicians were asked to get at least preliminary medication reconciliations finished as early as possible, Dr. Astik said.
“If they didn't have finalized doses, as we often don't with diuretics, at least we knew which diuretic we were using. So if they wanted it on the chart, they had to identify it early,” she said.
Meanwhile, nurses implemented a new care pathway at interdisciplinary rounds that involved a few more minutes of education for patients about heart failure and their medications and automatically placed goal-directed orders, such as daily standing weights and strict intake and output calculation. “This empowered the bedside nurses to be more engaged and involved in the process,” said Dr. Astik.
The goal was to increase the rate of patients with heart failure who were taking all of their medications correctly from 43% to 75%, as ascertained by a 48-hour postdischarge callback, Dr. Astik said. During the study period, about 600 patients reported which medications they obtained, how they were supposed to take them, and how often they were taking them, she said. “In our target intervention period, we got to about 66%. . . . We wanted to aim high, and ideally we will get [to 75% adherence] as everything gets easier,” said Dr. Astik, who presented the research as an abstract in April at Hospital Medicine 2018 in Orlando.
Nurses were quick to implement the new care pathway, but getting physicians to change practice was more difficult, Dr. Astik said. “I think our hardest thing was getting physician buy-in to say that you need to get things done early. . . but once people really understood the point of the project, it was easier,” she said. Narrowing the scope of the project was also a challenge, since clinicians from various disciplines were involved, said Dr. Astik. “There was so much more we probably wanted to do,” she said, “but I think that if we would've tried to tackle all that, we never would've gotten results.”
Dr. Astik said her biggest lessons learned were the benefits of collaboration with a pharmacy team, which she had never involved in a QI project before. “They were invaluable partners on this,” she said. “There's no way we would've done this without pharmacy assistance and without their processes that they had in place.”
The project is currently in effect on all the medicine units, and the plan is to expand the medication charts to patients with other high-risk conditions. Dr. Astik, a geriatrician, said the team is eyeing older patients with delirium and other psychological issues to see if the charts help reduce readmissions. “If we could have one good chart that can go between facilities that they can take with them and that they can understand as well, that would be really helpful for them and their caregivers,” she said.