Implementation Plan

Institutional leadership commitment.  Implementation of this program requires a significant allocation of nursing, pharmacy and respiratory staff time.  It is imperative that senior institutional leadership commit the needed resources to provide the time and attention needed to successfully implement an ongoing patient education program. 

Although there are no additional requirements placed on the medical staff by this program it is imperative to have the support of the medical staff in moving the educational program forward. 

Location. The intervention can be performed on all medical and surgical units with a hospital. 

Patients in intensive care units (ICU) can be excluded.  However, patients in ICU step-down units who are able to interact with health care professionals in a meaningful way can be included.

Patient eligibility.  All patients on medical and surgical units who are on at least one non-prn (prn = as needed only) oral medication.  Patients exluded include those to be discharged to a long-term care or skilled nursing facility or individuals who will not be responsible for their own medication administration at home (e.g., dementia, severe neurological disease, other significant cognitive impairment).

Intervention process.  The figure below outlines the process and workflow of the intervention for nursing, pharmacy, and respiratory therapy staff, delineating educational procedures.  In addition, the schematic portrays patient involvement.

Initial medication education (i.e., distribution of medication information leaflet, review of drug, dose, regimen, indication, and side effects) occurs with the first administration of a medication.  With each subsequent medication administration, the drug name, dose, regimen, and indication is reviewed. 

Pharmacy and respiratory consults are designed to occur during the daylight shifts and within 24 hours of receipt of a request for consult.

Nursing: On admission, a personalized patient education folder is created using your local clinical information system to determine patient medications.  This folder is compiled by nursing with the assistance of unit secretarial support staff.

This folder contains: 1. “medication helpful hints” sheets (commercially available); 2. “Questions I Want to Ask by Doctor” 3. telephone number contact for your insitutions pharmacy or drug information support staff for medication-related questions, and 4) specific medication information sheets.  We used those created by MedAdmin, www.efactsonline.com - part of Facts and Comparisons, Inc., St. Louis, Missouri detailing each non-prn medication that the patient is currently prescribed.

Similarly, upon receipt of a new medication order or therapeutic substitution the nurse reviews the order and depending on the HIT capacity of your institution an updated medication information form is generated manually or electronically.  An internet linked system is preferred. 

Importantly, one time doses, doses with predetermined stop dates, and intravenous infusions are excluded from the education program as patients are not likely to be discharged on these agents.

At each medication administration, the nurse will pick one specific item to teach about, and document in the appropriate record what has been discussed.  This process is designed to account for the capacity of sick individuals to accept only small amounts of information at a time, and to assure that nursing staff does not duplicate education efforts, while allowing multiple nurses to both reinforce what has been taught and to assure that new information is presented at each administration regarding the particular medication.

When medications are discontinued the nurse informs the patient and removes that Facts and Comparisons drug information leaflet from the folder.  Nursing continuously assess the patients’ medication education knowledge and encourage questions using the health behavior change model. 

Nursing may request pharmacy consult for further medication education information if the patient does not appear to have been successfully taught by the nursing staff. On the day of discharge, the nurse reviews the patient’s folder to ensure that all medication education leaflets are current and complete and provide verbal education. A medication information card is given to the patient, and nursing will encourage the patient to complete it, present it to outpatient pharmacy for review, and maintain it for future physician visits and medical appointments.

Pharmacy:  There are two mechanisms through which a pharmacist is consulted on a patient. 

The majority of consults will be generated through the use of automatic triggers generated by your HIT system any time the patient is:  1) scheduled to have more than five daily medication administration times; 2) on 10 or more medications total, and 3) on five or more new medications are started during the hospitalization. 

Additionally, pharmacy may be consulted directly by nursing staff if 1) the patient’s nurse feels that nursing-directed educational efforts are insufficient to meet the particular patient’s educational needs, 2) the patient was admitted for drug-related problem (e.g., wrong medication, wrong dose, drug interaction, adverse drug reaction).

The pharmacist meets daily with the nurse in charge to determine the patients that are eligible for pharmacy education.  We utilize a decentralized pharmacist or clinical pharmacy specialist covering a nursing units who is available to provide pharmacy education using the health behavior change model and assess patient understanding of the information provided.

If appropriate, the pharmacist will review the patient’s medication regimen, conduct a complete medical history, provide oral and written medication education using the health behavior change model, assess the patient’s understanding of the information provided, and provide the patient with a pill box to prepare for hospital discharge.

The pharmacist providing medication education will initial any written information provided to the patient and document the education intervention in the medication administration application system.  In addition, a progress note is generated to call the consultation to the attention of the medical staff.  If deemed appropriate by the pharmacist, the pharmacist will recommend a medication change to the physician caring for the patient that may simplify the patient’s medication regimen.

Respiratory Therapy:  The respiratory therapy staff are responsible for a significant number of delivered medications for many hospitalized patients.  Many of these medications are aerosolized medications for which patient education and training can be valuable.  In order to simplify the identification of patients our respiratory therapy department elected to educate all patients on aerosolized medications, rather than attempting to determine who might or might not be discharged on such medications.  By incorporating education into the process of each therapy patients are assured of receiving information on both the delivered drug and appropriate techniques for using delivery vehicles.   Respiratory therapists use the health behavior change model and assess patient understanding of information provided when interacting with patients.  A respiratory therapist will initial any information provided to the patient in the patient’s medication education folder. Other steps will parallel those for the pharmacists.

Patient: In order to empower the patient and reinforce the importance of understanding and adhering to the medication regimen, he or she is encouraged to independently read the medication information leaflets in his or her personalized bedside folder.  The patient is encouraged to ask questions regarding medications throughout the hospital stay.  Due to the nature of ongoing education through the course of the day, and as a consequence of confidentiality concerns, patients’ families are not a formal component of this intervention.  However, should a patient request a family member to remain present during an educational encounter, this is acceptable and encouraged.