Kidney transplant patients are on complex medication regimens at the time of their hospital admission for transplant. Following transplant, their medications are completely altered to incorporate additional agents that prevent organ rejection and infections.
At the Medical University of South Carolina (MUSC), patients have a relatively short hospitalization (average 3.9 days) following kidney transplant. However, data from 2005 and 2006 showed that 29 percent of patients had a prolonged hospitalization, and 10 to 15 percent of patients were readmitted at 7, 14 and 30 days.
A multidisciplinary team – which included pharmacists, physicians, nurses, other health care professionals and hospital executives – determined that medication management played a role in both the delayed discharges and readmissions for patients who had a kidney transplant.
Longer hospital stays were related to delayed availability of outpatient medications and subsequent delays in the provision of medication education to patients and their caregivers. Preventable readmissions were often due to adverse drug events (ADEs) related to medications used for control of blood pressure and diabetes.
Over an 18-month period MUSC implemented a multi-step initiative to decrease length of stay, preventable readmissions and ADEs for patients who received a kidney transplant. These included:
• review and revision of renal transplant protocols, order sets, and clinical pathways
• establishment of a Diabetes Management Service to manage inpatient and outpatient glucose control
• improvements in the outpatient pharmacy medication dispensing process
• improved medication assistance program access
• development of a new medication reconciliation process
• revision of the inpatient medication education process
• discharge to a local hotel with home health nurse follow-up and ensuring that patients return to the clinic on the day following discharge for additional education
• team review of all delayed discharges.
Follow-up analysis demonstrated an improvement in the completion rate and quality of medication reconciliation, with a reduction in medication discrepancies and 100-percent compliance with the reconciliation process. Upon completion of program implementation, pharmacists were reviewing 100 percent of discharge medication orders. MUSC experienced a 40-percent reduction in medication errors and ADEs, a 25-percent reduction in acute rejection rates and a 10-percent decrease in infection rates. MUSSC also reduced delayed discharges by 14 percent, and decreased 7-day readmission rates by 50 percent. Institutional costs for the care of these patients remained flat while services were expanded and quality improved.
This pharmacist-led medication safety initiative at MUSC demonstrates that a systematic and team-based quality improvement process focused on a high-risk patient population can improve quality of care and patient outcomes.
Heather Kokko, Pharm.D., Team Chair
David Taber, Pharm.D., BCPS
Nicole Pilch, Pharm.D., MSCR, BCPS
Prabhakar Baliga, M.D.
Debbie Cassidy, R.N.
Kenneth Chavin, M.D., Ph.D.
Heather Crego, R.N.
Kelly Crowley, Pharm.D.
Chris Fortier, Pharm.D.
M. Fracesca Egidi, M.D.
Kathie Hermayer, M.D., M.S.
Cindy Hough, R.N.
Joe Mazur, Pharm.D., BCPS
Don Neuroth, R.Ph.
Kim Phillips, R.N.
Charlie Smith, R.Ph.