Program Helps Transition Infants Home on Complex Medication Schedules

West Virginia University (WVU) Medicine Ruby Memorial Hospital is a 500+ bed academic teaching hospital located in Morgantown, West Virginia. WVU Medicine Children’s is located within Ruby. Services offered include a level I trauma center, a 39-bed level III NICU (neonatal intensive care unit), a 20-bed pediatric intensive care unit, and a state-of-the-art cancer center. The hospital has an outpatient pharmacy onsite, which in 2012 launched a Transition of Care (TOC) Pharmacy to offer bedside consulting service and post-discharge prescription service to any patient within our facility. Since its inception, the program has reached more than 40,000 patients in 4 years and had up to a 62% capture rate.¹

From 2007 through 2011, the national 30-day, all-cause, hospital readmission rate averaged 19%. During the calendar year 2012, the readmission rate averaged 18.4%.² TOC pharmacies have been shown to reduce readmissions by up to 50% and potentially reduce health care spending $2 for every dollar spent.² Having a seamless transition at discharge could avoid unnecessary spending according to an article in 2011. A lack of good coordination could result in $25 to $45 billion in spending and attribute to an increase in readmissions.³ The outpatient pharmacy staff worked with many health care staff including the inpatient clinical pharmacists and was an integral part of the multidisciplinary team to focus on improving the transitions home for patients admitted at this institution.

Background

Although the “meds to beds” discharge pharmacy service targets specific disease states identified as high risk for readmission, all patients are eligible for the service. Having a seamless discharge that includes counseling on medication assists with patients’ remaining compliant and lowering readmission rates. Since the inception of the discharge program, our pharmacy has discovered that other services and disease states value the pharmacist’s intervention in their health care. One area that effectively uses the discharge pharmacy program is the children’s hospital. The discharge pharmacy works closely with our inpatient pediatric clinical pharmacists, who help identify the patients who would benefit from our pharmacy services.

One crucial area that benefits from this service is the NICU. Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy.⁴ According to the West Virginia Health Care Authority, between 2007 and 2013, NAS significantly increased approximately 400% per 1000 live births per year. These infants were shown to have more complications and increased length of stays at the hospital.⁵ Medication preparation, delivery, and counseling are vital services provided by the TOC Pharmacy for the parents or caregivers of NAS patients who are being discharged. Due to the value of this service, inpatient clinical pharmacists and physicians are dedicated to attaining 100% of the patients using the TOC Pharmacy.

Program Overview

Once the discharge pharmacy is notified, prescriptions are received prior to discharge, allowing enough time to process, dispense, and counsel patients or caregivers regarding their medications. Physician in-services are done to inform providers of the TOC program to aid in timely notification of anticipated discharges. Pharmacy compounding requires advanced notice for preparation. Our hospital serves patients throughout our state of West Virginia and surrounding states. Patients may have long journeys home, and ensuring that they can have compounding services is a priority. Compounding is a highly valued skill our program uses to ensure medication compliance. Commonly seen compounds include dilutions of morphine, methadone, and even clonidine. The discharge program communicates with the health care team to ensure the proper dosage, stability, and handling instructions for each pediatric product made.

For patients on complex medication tapers, all NAS patients and those patients with iatrogenic withdrawal “pre-drawn” syringes accompanied in separate packaging to ensure compliance and proper administration. A typical morphine taper that our NAS patients receive upon discharge might be 0.04 mg/kg every 8 hours for 2 days, then every 12 hours for 2 days, and then every 24 hours for 2 days. A medication taper can be confusing for many patients.

Many factors, including health literacy, fatigue, caring for a newborn going through withdrawal, and the fragile nature of the mother’s disorder contribute to the complexity surrounding these infants. The benefits of pre-drawn morphine syringes include improved patient compliance and ensuring proper medication administration. These pre-drawn syringes allow for the dispensing of just enough medication to treat the child, ensuring that the child is not accidently overdosed by a parent or caregiver, which can lead to respiratory depression and ultimately readmission.

Example of an NAS compound

Morphine 0.4mg/ml solution

Use 1ml morphine 20mg/5ml oral solution

Use distilled water qs 10ml

Stability: Refrigerate

Expires in 7 days

Discussion

The "med to beds" program has allowed many pediatric patients to transition home sooner due to caregiver and provider confidence in the accurate administration of complex tapers. Caregivers have reported that the prefilled syringes give them added security, and they value the extra counseling services provided by both inpatient and outpatient pharmacists. To date, no patient using this services has been readmitted due to errors or noncompliance.

Acknowledgements

This study was coauthored by Kelsey Briggs, PharmD, BCPPS; Courtney Sweet, PharmD, BCPPS; Cinda Deem, Rph; and Valerie Elder, PharmD Candidate.

References

1. Calemine L, Stinehart A. Reduction in 30-day readmissions through implementation of medication to beds and reconciliation at discharge. Poster presented at: ASHP Midyear 2014: The 49th ASHP Midyear Clinical Meeting and Exhibition; December 6-10, 2014; Anaheim, CA.

2. Gerhardt G, et al. (2013). Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2).

3. Medication reconciliation slashes readmissions. Health Leaders Media website. healthleadersmedia.com/leadership/medication-reconciliation-slashes-readmissions.

4. Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2): e547-561.

5. Stabler ME, et al. (2016). Neonatal abstinence syndrome in West Virginia substate regions, 2007-2013. J Rural Health. 2016.