ED Accreditation Update

Finally! The Joint Commission revises NPSG for medication reconciliation

Difficulty of taking accurate history in ED acknowledged

At long last, The Joint Commission has completed the revision process for the National Patient Safety Goal (NPSG) that governs medication reconciliation. The new goal, which was finalized on Dec. 3, 2010, can be found at http://www.jointcommission.org/npsg_reconciling_medication.

"In January 2009, The Joint Commission took action to reduce the burden of the NPSG on medication reconciliation for organizations and determined that survey findings would not be factored into the organization's accreditation decision until a revised NPSG was developed," said the commission in a released statement. "The revised NPSG underwent a field review in the second quarter of 2010; the review reaffirmed that medication reconciliation is an important patient safety issue that should continue as a NPSG." The statement also noted that NPSG.03.06.01 replaces Goal 8 (08.01.01, 08.02.01, 08.03.01 and 08.04.01) and its related elements of performance (EPs).

James J. Augustine, MD, FACEP, chair of the Joint Commission Hospital Professional and Technical Advisory Committee, which reviewed the proposed revisions, says, "The idea of medication reconciliation is a very sound one and important across all healthcare entities, but in the outpatient setting, where most EDs function, it is sometimes extraordinarily difficult to figure out what medications people are on and reconcile them with the medications given in the ED and added as they are treated and released." Augustine also is director of clinical operations, Emergency Medicine Physicians, Canton, OH.

It was this difficulty that was among the major issues addressed in the revised goal, notes

Maureen Carr, MBA, project director, Department of Standards and Survey Methods at the Joint Commission, notes that the old NPSG will remain in effect until July 2011, but it will not count against accreditation. "We addressed the issue to the extent that we could, recognizing that the problem is going to still be there as people are people," says Carr. She is referring to the complaints The Joint Commission received from emergency medicine representatives who noted that many ED patients cannot provide their list of medications at all or cannot provide complete and accurate lists.

"What we have instructed, and noted in a note to EP 1 in the goal is that we recognize it is often difficult to make sure you have accurate and complete information," says Carr. The note says the following: "It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP."

In other words, Carr clarifies, "in terms of compliance, a good faith effort will be considered as complying." And what might be construed as a "good faith" effort? "It might involve trying to see if the patient was carrying a list or had a family member with them who could provide one," she says.

Augustine adds, "In terms of the ED, what The Joint Commission has asked in improving quality and safety is for the staff to make their best efforts at determining what comprehensive list of medicines exist and reconciling the medications the patient is going to go home on. That will be compliant with the standard."

In some cases, the patient will have a drug store or a primary care provider who would have an accurate list of the medications the patient is using on an ongoing basis, he says. In those cases, "the staff should utilize those resources even if it means an extra phone call for the ED," Augustine says. However, he adds, "the reality of the situation is that some people arrive in the ED under totally unplanned circumstances, and all they know is that they are on a blue pill, a red pill, and a green pill, and they've gotten them from different doctors and don't know where they get them filled." In those instances, he says, "the staff will not have the ability to develop an accurate list."

Providing consultation

A new EP (number 5) that is included in the revised goal also has significant implications for EDs. It reads as follows: "Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter." A note adds the following: "Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations."

Carr notes, "Counseling the patient about how important it is to keep accurate information at all times is important. It helps ensure that if they enter the system again they will be prepared to provide accurate information. While it will still continue to be an issue, hopefully over time it will improve."

While this could take place in the context of discharge instructions, Carr notes that The Joint Commission is not just talking about formal education about the drugs. "This is not so much about taking them, but about emphasizing how important it is to keep this information up to date," she explains.

Augustine says, "Many of our new ED electronic records give staff the opportunity to send patients home with a list of medications when they are discharged, as well as those they are known to be on regularly. With both the input of the staff and some medication information software programs, you are able to make sure there are no immediate medication safety issues that need to be addressed and are then able to give patients something that is able be used for future care and future interaction of that patient with the healthcare system."

It's also key for the staff to verbally remind the patient that this information is important and should be carried with them, he says. For those ED leaders who also oversee interactions with the EMS, Augustine says, be aware that practices such as the "vial of life" are being used in the field. "That's a program where they ask patients to take a small plastic container and put important healthcare documents in their freezer or refrigerator at home copies of your medications, durable power of attorney, living will, or DNR," he says. "EMS providers are then asked to look in the refrigerator/freezer for those documents." The refrigerator/freezer is designated because it's convenient and frequently used. (Under the revised goal, EDs can define the types of medication information to be collected. See the story below.)

Sources

For more information on the medication reconciliation National Patient Safety Goal, contact:

  • James Augustine, MD, FACEP, Director of Clinical Operations, Emergency Medicine Physicians, Canton, OH. Phone: (330) 493-4443. E-mail: JAugustine@emp.com.
  • Maureen Carr, MBA, Project Director, Department of Standards and Survey Methods, The Joint Commission, Oakbrook Terrace, IL. Phone: (630) 792-5000.

ED can define meds information

Another section of the revised National Patient Safety Goal (NPSG) on medication reconciliation that is of special significance to ED managers is EP 2, which says the following: "Define the types of medication information to be collected in non–24-hour settings and different patient circumstances."

A note following the EP includes the ED as an example of a non–24-hour setting. "Right now in the medication reconciliation goal, part 804.01 talks about areas in which medications are minimally used to prescribe for short duration," notes Maureen Carr, MBA, project director, Department of Standards and Survey Methods at the Joint Commission.

James J. Augustine, MD, FACEP, chair of the Joint Commission Hospital Professional and Technical Advisory Committee, which reviewed the proposed revisions, adds, "It's reasonable for the ED to have a process for evaluating the effect of those short-term medications in regard to side effects on long-term medications the patient is taking. This generally involves blood thinners."

Finally, he says, ED leaders must make sure the paperwork or electronic documentation the staff uses allows them to most easily reconcile existing lists. In addition, they should "update staff on the processes being used to collect information, educate the patient or family, and send patients to the next type of care with the best information available," Augustine says. All of this information should be covered in an inservice, he says.

"This also contributes to 'meaningful use' of systems," he says. "And the reality is that many of the new EHR programs allow you to do a very convenient medication reconciliation."