I have paid lip service to the importance of continuity of care for almost a decade, but it is time to hold myself accountable for leading my staff to meeting our collective responsibility. Who could legitimately argue the importance of ensuring that every patient's drug therapy is successfully transitioned from home into the hospital and effectively transitioned back home at discharge? It sounds so easy and sensible, but I believe we do not appreciate its importance.
The most compelling reason for pharmacists to perform an admission history is to ensure patient safety. Patients are frequently poor historians, and admitting physicians are often hurried and focused on the primary cause of the admission. Performing the admission drug history allows us to make certain that patients understand their drug regimen and to monitor for outcomes and side effects that may have been encountered. Finally, it gives us "face time" with patients so that we can educate them about what their pharmacist can do.
Discharge counseling is equally important. Reviewing patient discharge prescriptions should enable the patient to understand changes made since admission and represents an opportunity to begin the counseling process, which will be completed by the pharmacist when prescriptions are filled. Formulary restrictions, diagnosis- related therapy changes, or hospitalbased physician preferences will likely have resulted in changes from therapy on admission. It is essential that the patient understands what has changed, including doses and frequencies of each medication, and, perhaps most importantly, which medications have been replaced or eliminated. We are all aware of instances in which an ongoing therapy such as a calcium channel blocker is replaced by a similar agent during hospitalization. Without effective patient education, the patient may continue the old therapy and the new drug concomitantly.
The pharmacists, technicians, and support staff of the Department of Pharmacy at University of North Carolina Hospitals are incredibly talented and experienced. They work hard and are genuinely committed to their critically important role in the care of patients. Yet, everyone is so busy meeting current expectations that assuming new responsibilities of performing admission histories and counseling patients prior to discharge is daunting. We recently conducted a pilot study that validated that a significant opportunity exists to improve continuity of care when pharmacists perform a complete drug history upon admission. We found that in some patient groups as many as 1 in 3 patients required a pharmacist intervention to ensure a successful transition into the hospital. In most cases, lapses in continuity of drug therapy were caused by poor histories given by the patient, misidentification of a medication brought by the patient, a hurried resident or intern taking the history, a poor allergy history, or contraindications of ongoing therapy with newly prescribed drugs.
Similar opportunities to improve care exist as the patient is discharged. Verifying the accuracy and completeness of each prescription and continuation of therapy as indicated should be the first step, followed by patient education. By reviewing each prescription with the patient, we begin the process that should be completed by the community pharmacist. And the redundancy should result in a well-informed patient prepared for self-care.
Why should hospital pharmacists perform medication histories when the admitting physician already does, or counsel patients on discharge in lieu of nurses? Simple?we are the drug experts who will be more effective in assuming the new responsibilities than other providers. The "face time" with patients will enhance our image. Both activities enable the optimization of drug therapy outcomes, which is our societal role.
The penultimate solution in guaranteeing successful continuity of care will be realized when community pharmacists provide the patient with a historical medication profile for review by the admitting pharmacist. Likewise, the discharging pharmacist should give the patient a brief note about the hospital course, especially regarding pharmacotherapy used and the intentions of drugs prescribed. Would not that be a wonderful world in which to practice?
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