The Pharmacist’s Role and Responsibilities During Transitions of Care

Case Summary

A 54-year old man being treated for a diabetic foot infection died due to an intracerebral hemorrhage secondary to thrombocytopenia complicating vancomycin therapy. The patient was initially treated in Hospital A and after discharge was treated as an outpatient for approximately four days. Upon readmission to Hospital A the patient’s condition deteriorated and he was transferred to Hospital B where he subsequently died.

Case History

The patient had a history of type ll diabetes mellitus x 20 years, hypertension, hypothyroidism, erectile dysfunction and recent cataract surgery. It was also noted that he was allergic, from childhood, to penicillin (described as causing a rash). The patient was urgently admitted from the Skin and Soft Tissue Clinic at Hospital A. The Infectious Disease Service was consulted and recommended ciprofloxacin and clindamycin prior to admission.

Course of Treatment

On admission the patient was prescribed vancomycin, ciprofloxacin and metronidazole (all IV) based on the results of cultures and sensitivities from the day of admission.

While in hospital, the patient received IV ciprofloxacin and metronidazole. In addition he received vancomycin 1g IV q12h (serum creatinine = 117 umol/L) on day 1 and 2. This dose was increased over the next few days based on trough vancomycin and serum creatinine levels (see summary dosing chart). On day 7 the dose was reduced to 1.25g IV q8h and continued until discharged from hospital on day 9. On the day of discharge a level drawn before administering the third dose of 1.25g, was 20 mg/L (serum creatinine = 85).

Patient Discharge

The patient was discharged on the following medications: vancomycin 1.25 g IV q8h x 10 days, ciprofloxacin 750mg po bid x 10 days, metronidazole 500mg po bid x 10 days and Fluconazole 100mg po bid x 30 days. Home medications to be continued on discharge included: hydromorphone 2-4mg po q4-6h prn, novovmix 30 new dose, levothyroxine 0.75mg po daily, metformin 500mg po daily, ramipril/hydrochlorothiazide 5/12.5mg po daily, rosuvastatin 20 po daily, testosterone 80mg po bid.

Home care was arranged for the patient through the local Community Care Access Centre (CCAC).

On his first day home following discharge, the patient indicated to the CCAC care provider that he was feeling unwell and was no longer able to walk with his cane and now needed a walker. Two days after discharge he contacted the care provider about swelling of his feet and asked about water pills. Four days after discharge he developed a rash and returned to the ER at Hospital A where he was re-admitted.

Summary Dosing Chart (Vancomycin dosing, trough levels and serum creatinine)

Patient Re-admission

Upon re-admission the patient was suffering from acute renal failure and thrombocytopenia. His serum creatinine was 551umol/L and vancomycin level was 77 mg/L. Over the next 3 days in hospital his condition continued to worsen and he had increased epistaxis and hypertension. On the fourth day, he was found unresponsive in his hospital bed. A CT scan of his head showed extensive left-sided subarachnoid hemorrhage with midline shift and cerebral edema. He was transferred to the intensive care unit (ICU) at Hospital A and later that day transferred to Hospital B, where he was assessed by neurosurgery. At this time it was determined that he was not a surgical candidate. He was put on life support and treated with a platelet transfusion, IV steroids and started on dialysis. The day after admission to Hospital B his neurological condition continued to deteriorate and life support was
withdrawn. He died later that evening.

Lessons Learned

This is a complex case involving issues related to transitions of care from hospital to home. The patient suffered adverse complications from extremely high levels of vancomycin and elevated serum creatinine due to inappropriate management of vancomycin therapy. This case highlights the importance of coordinated care transitions that must include a detailed patient care plan at discharge, such as assigning responsibility for patient monitoring and follow-up in the community. Key contributing factors identified in this incident include:

• the absence of a medication review prior to discharge to determine if a less complicated
  treatment plan was possible;
• lack of clarity with respect to detailed follow-up requirements including the roles and responsibility
  of post-discharge care providers for laboratory monitoring (serum creatinine) and drug levels
  (vancomycin levels); and
• the need to ensure community care practitioners have the contact information needed to reach the discharging physician, hospital pharmacist, etc. should questions arise.

The Pharmacist’s Role and Responsibilities During Transitions of Care

Transitions of care, or “care transitions” refers to the transfer of patients between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness¹. This may include moving between areas within a hospital (i.e. between patient care units, from an inpatient unit to the ICU, from surgery to the patient care unit), moving to another institution (i.e. from hospital to a rehab centre, nursing home or continuing care centre), or returning home and
receiving community care (e.g. home care from a visiting healthcare professional, monitoring by the family physician or community pharmacist).

At a time when more acutely ill and complex patients are being discharged for monitoring in the community setting, coordinated care transitions are critical to ensure optimal care and to prevent avoidable errors and readmissions. Evidence demonstrates that when patients move between care settings (within and between institutions, and from hospital to home) they are at high risk of adverse drug events (ADEs), particularly when communication and care coordination are suboptimal.²

Canadian acute care studies have shown that 40% of patients at discharge transitions of care experience unintentional medication discrepancies or potential errors.³

The case presented here emphasizes the responsibility of the pharmacist, as part of the interdisciplinary healthcare team, in preventing adverse events during hospital discharge.

Hospital pharmacists are in a unique position to review and assess a patient’s medication regimen prior to discharge, particularly when a patient is to be discharged on a medication that requires ongoing monitoring and follow-up for dosage adjustments. Reviewing the indication and appropriateness of new medications initiated in hospital on discharge creates further opportunities to collaborate with the most responsible physician (MRP) to determine if more suitable alternative treatments are required.

The College’s Code of Ethics (the Code) outlines the ethical principles and standards which guide the practice of pharmacists and pharmacy technicians and outlines the responsibilities that pharmacy professionals have to both protect patients from harm (non-maleficence) and actively benefit patients (beneficence). In practical terms this means taking steps to ensure that the patient’s medication at discharge is the most appropriate to maximize benefit while minimizing harm. In this case if a discharge medication review, and discussion with the MRP (and/or the infectious disease service) about appropriate alternatives, had occurred, it could have resulted in an adjustment to a less complicated medication regimen.

Pharmacists can also assist with care transitions by providing a complete list of medications to the patient and the pharmacy where the patient will be receiving their prescriptions, whether it is a community pharmacy or another pharmacy service provider. In some cases patients will require further monitoring such as bloodwork and/or drug levels once they go home. Providing relevant patient information to other healthcare providers or facilities when involved with a patient’s transition of care -to ensure that the transition is safe and effective – is critical and therefore included as a standard within the Code.

The hospital pharmacist in this case could have ensured that appropriate monitoring in the community would occur by collaborating with the patient’s community pharmacy. By contacting the community pharmacy directly, both the pharmacist in the community and the hospital pharmacist can ensure there is a clear understanding of monitoring requirements and the plan for follow-up. The pharmacist providing the medications in the community also had a responsibility to reconcile discharge medications with medications on the patient record and confirm that necessary drug monitoring and follow-up was in place. Inter-professional collaboration creates an opportunity for both hospital and community pharmacists to clarify information to ensure they are confident that individual roles and responsibilities are clear.

Upon discharge from the hospital, patients receive a lot of information in a short period of time, usually on the day they are going home. It can be confusing and sometimes even overwhelming. During a hospital stay new medications can be started, including those that will only be continued for a limited period of time after discharge, and medications used prior to admission can be stopped or undergo dosage adjustments. When both the community and hospital pharmacist review the discharge medications with the patient, it acts to clarify and reinforce the information provided and ensure the patient understands his or her new medication regimen.

With more patients going home from the hospital on complicated medication regimens, some requiring monitoring and dose adjustments, the need for all pharmacists involved in the patient’s transition to recognize their professional responsibilities is crucial to support positive patient outcomes. Practitioners need to be diligent in identifying and responding to red flag situations that present in practice and ensure that when an issue is identified collaboration and communication are used to resolve the problem and optimize patient care.

References:

1. www.caretransitions.org accessed Aug 14, 2016
2. American College of Clinical Pharmacy. ACCP White Papers; Improving Care Transitions: Current Practice and Future Opportunities for Pharmacist. Pharmacotherapy 2012;32(11):e335).
3. Optimizing Medication Safety at Care Transitions – Creating a National Challenge. National Invitational Summit. ISMP Feb 10 2011, Toronto.
4. Ministry of Health and Long-Term Care. Professional Pharmacy Services Guidebook 3.0. July 2016 p.32, 65.
5. https://www.ismp-canada.org/transitions/ accessed August 12, 2016. Hospital to Home – A Medication Safety Checklist for Transitions (free download)