Evaluation of Pharmacist Intervention on Discharge Medication Reconciliation

Discharge medication reconciliation (Discharge MedRec) was implemented on one unit at a large urban teaching hospital, and was to be expanded across the rest of the hospital and the health authority's various sites by the end of 2018. Clinical pharmacists on the Acute Care for the Elderly unit carried out discharge planning and led Discharge MedRec during a pilot period, to inform the future implementation.

The primary objective was to examine the number and type of medication discrepancies before and after implementation of Discharge MedRec. The secondary objectives were to compare documented medication changes, pharmacist recommendations, discharge counselling, communication with community pharmacists, polypharmacy, and 30-day readmission rates.

Patients seen in December 2015 constituted the control (pre-implementation) group, who received usual care. Patients seen from January to April 2016 constituted the intervention group, for whom pharmacists performed Discharge MedRec and other discharge activities as per the hospital-to-home checklist of the Institute for Safe Medication Practices Canada.

There were 66 patients in the control group and 306 in the intervention group. Median discrepancies per patient decreased from 6.5 to 3 (p = 0.007), median number of documented changes without rationale increased from 2 to 3 (p = 0.01), and median number of documented changes with rationale increased from 1 to 2 (p < 0.001). Pharmacists made a per-patient median of 1 progress note recommendation in the control group and 2 progress note recommendations in the intervention group (p = 0.007), and a per-patient median of 2 orders in both the control and intervention groups (p = 0.62). Median recommendation acceptance was 100% for both groups, but twice as many recommendations were made per patient for the intervention group. Discharge counselling increased from 22.7% to 65%. Communication with community pharmacists increased from 10.6% to 60.8%.

Clinical pharmacist involvement improved Discharge MedRec planning and documentation. Decreases in medication discrepancies, combined with an increase in discharge counselling, should improve continuity of care across the health care team and increase patient adherence with medication therapy. This study further demonstrates the leadership role that pharmacists play in the assessment and clear documentation of medication changes at all transitions of care.