Pharmacists' Prioritization of Patients for Discharge Medication Reconciliation at a Tertiary Academic Centre

Involvement of pharmacists in discharge medication reconciliation (DMR) reduces readmissions when DMR is delivered as part of a medication management bundle. With current staffing and workload, pharmacists are unable to complete DMR for every inpatient. Consequently, it is necessary to prioritize patients for DMR interventions according to clinical need and risk.

To describe how pharmacists prioritize patients for DMR at a tertiary hospital; to identify facilitators of and barriers to pharmacist involvement in DMR; and to compare pharmacists' patient-priority assessment with scores derived using the Epic risk-of-unplanned-readmission, PRIME, and PADR-EC risk assessment tools.

Pharmacists involved in DMR participated in focus groups to explore their DMR practices, including factors considered in patient prioritization, as well as facilitators of and barriers to their involvement in DMR. For patients on their service with an expectation of discharge within 48 hours, pharmacists used a questionnaire to rank DMR priority and indicate their intent to complete DMR. For each patient, the Epic, PRIME, and PADR-EC scores were collected and compared with the pharmacist's assessment.

A total of 13 pharmacists participated in 2 focus groups, and 11 of these pharmacists completed the questionnaire (for a total of 110 patients). Twenty-two unique factors and 27 subfactors for patient prioritization were identified. The top 5 factors were complex medication regimen, high-risk medications, medication changes, medication access, and length of stay. Facilitators and barriers were categorized into 6 themes: team dynamics, pharmacist workload, prior pharmacist involvement, process for DMR, discharge planning, and technology. Pharmacists' assessments appeared to differ from scores obtained with the 3 risk assessment tools.

Pharmacists at the study institution lacked a consistent approach to prioritizing patients for DMR. Next steps will include developing and piloting a standardized process for prioritization.