Medication Adherence and Operating Room Efficiency for a Surgical Subspecialty Kiersten Norby, MD; Koijan Kainth, MD; Rosanne Ganzel, RN; Julie A. Wagner, RN; and Cornelius H. Lam, MD, PhD The implementation of a 5-step reminder process and pharmacist consultation/visit improved medication adherence and reduced operative delays. nefficiencies in the operating room while reducing costs.2 pacted by medication nonadherence (OR) can occur before, during, and About 187 million Americans take and preoperative education.9-13 Fur- between cases and lead to mul- at least 1 prescription drug.3 An esti- thermore, studies using large-scale Itiple problems, including delays mated 20% to 50% of patients do not databases have found medically treat- in the delivery of patient care. They take their medications as prescribed able conditions as a significant source also have a negative financial impact and are said to be nonadherent with of surgical delay.14 Had these condi- for the institution and cause frustra- therapy.4,5 Nonadherence to medica- tions been treated a priori, delay in tion for surgeons, anesthesiologists, tion also has been shown to result surgery would not have occurred. and other OR staff. Ultimately, delays in increased health risks and costs Unfortunately, it is not clear whether lead to dissatisfaction among patients of up to $290 billion.6 Patients who the delays were the result of missed and health care providers. Operat- receive pharmacist services achieve preoperative checks or medication ing room efficiency increasingly is better clinical outcomes for chronic nonadherence. becoming a marker of the quality of diseases than national standards.7 Ensuring patient safety, includ- surgical care. Among patients with a chronic ing reducing medical errors and ad- The Institute of Medicine (IOM) disease, poor adherence tends to re- verse events (AEs), is imperative in identified timeliness and efficiency as sult in poor outcomes and increased the surgical workflow. In 1999, the 2 of 6 areas for improvement for U.S. medical costs. Yet these are the pa- IOM estimated that medical error hospitals.1 Organizations such as the tients who face the most risks in was a leading cause of death in the Centers for Medicare and Medicaid surgery and require the most pre- U.S. and resulted in up to 100,000 Services, Agency for Healthcare Re- operative care. Several studies have deaths annually.15 search and Quality, IOM, Institute for evaluated the frequency of medica- In a retrospective study of 15,000 Healthcare Improvement, The Joint tion nonadherence prior to surgery cases, Gawande and colleagues found Commission, Leapfrog Group, and and its effect on surgery cancella- that 66% of all AEs were surgical and National Quality Forum are begin- tions. These studies have examined 54% of these were preventable.16 In ning to monitor patient care work- a variety of factors related to patient addition to improving reporting sys- flow in order to improve quality preoperative education, medications, tems, creating a culture of safety with food intake, bowel prep, etc. all members of the health care team Dr. Norby is a surgery resident; at the time this In a VA Puget Sound Health Care and building a partnership with pa- article was written, Dr. Kainth was a neurosur- gery resident; and Dr. Lam is a professor of neu- System study, 23% of patients under- tients during preoperative visits can rosurgery; all at the University of Minnesota in going ambulatory surgery were non- ensure increased adherence and re- Minneapolis. Ms. Ganzel and Ms. Wagner are adherent to preoperative medication duced medication AEs. In a neurosur- nurses, and Dr. Lam is the chief of neurosurgery 8 at Minneapolis VAMC. Dr. Kainth is currently a instructions. Studies have found that gical cohort of patients, Bernstein and neurosurgeon in private practice. up to 7% of cancellations were im- colleagues found that 85% of patients 16 • FEDERAL PRACTITIONER • MARCH 2017 www.fedprac.com Figure 1. Patient Interactions and Preoperative Instruction Map No - treatment plan given. Patient discharged Patient seen in clinic Is patient a candidate for consult for surgery? Yes - Surgery form completed/to be scheduled file Patient seen in clinic 2 Write orders for med pre-op 1 Coordinator contacts patient to for consult and neurosurgery pre-op appts/send schedule pre-op appts, surgery letter with med instructions date and reviews medication & Med pre-op and 3 4 Scheduled surgery arrival date neurosurgery pre-op/ one-on-one Cleared for surgery 5 Call from pharmacist pre-op teaching and consent were subjected to at least 1 error; 10% Data were extracted from this study records. Delays were defined as ei- of the errors were major, and 65% to test the stated hypothesis and ther cancellations of the case due to were deemed preventable.17 compare with historic data. medication nonadherence, which The purpose of this study is to Fifty consecutive patients un- would make it unsafe to proceed evaluate whether redundancy built dergoing neurosurgical procedures with surgery, or minor delays due to into the patient care protocols prior from May 2010 through July 2010 medication nonadherence, which re- to surgery helps catch errors as dem- were retrospectively reviewed and quired further preoperative assess- onstrated in time-out analyses.18 evaluated. All patients had a pre- ment and workup before proceeding Decreasing these errors would lead operative consultation with a with surgery. Cancelled cases were to fewer surgical cancellations and pharmacist and the neurosurgery defined as cases on the final copy of medical workup delays. The authors coordinator who reviewed all medi- the published OR schedule that did hypothesize that a structured preop- cations with the patient and gave not occur. erative pharmacologic workup would specific instructions on which med- result in decreased preoperative delay ications should be continued or dis- Medication Adherence Program in the surgical workflow. continued prior to the surgery date. In order to ensure medication ad- This information was documented herence prior to surgery there were METHODS on the OR Medication Compliance 5 points of contact with a patient The study protocol was reviewed Worksheet and included in the pa- from the time the patient was and determined to be a quality im- tient’s preoperative chart by the scheduled for surgery and the date provement/quality assurance ini- neurosurgery coordinator. On the of the surgery (Figure 1): tiative, which exempted it from day of surgery, all active medica- 1. The coordinator reviewed medi- institutional review board or other tions on this chart were reviewed cations with patient at time of oversight committee review, at the with the patient by the anesthesi- scheduling Minneapolis VA Health Care Sys- ologist and documented on the OR 2. A letter was sent with specific in- tem. The VA OR Efficiency Task Medication Compliance Worksheet. structions about medications Force identified medication adher- The worksheet was then sent to the 3. Preoperative medicine clearance ence as a possible source of delay. A neurosurgery coordinator for sec- 4. Preoperative neurosurgery study therefore was undertaken to ondary review and analysis. appointment determine the adherence rate and To evaluate delays, the authors 5. Call from pharmacist 1 week how it impacted operative delays. reviewed the patient anesthesiology before surgery www.fedprac.com MARCH 2017 • FEDERAL PRACTITIONER • 17 OPERATING RooM EFFICIENCY tal.2 Cancellations or simple 5-step process, medication Figure 2. Patient Adherence to delays can have signifi- adherence was > 90% and the im- Preoperative Medication Instructions cant negative financial pact of nonadherence on surgical N = 50 implications (about procedure delays was eliminated $1,500 per hour of lost during the trial period. In this sam- revenue).19 In order to ple, nonadherence did not impact improve OR efficiency surgery, which resulted in fewer de- Medication Medication nonadherence and reduce preopera- lays and cancellations. The process adherence 4% 96% tive delays, the causes emphasized repetition and com- of preoperative delays munication, involving 5 reminders must be determined. between the date of OR scheduling Some delays and and the date of the actual surgery. cancellations result The authors found that in this qual- from either preopera- ity improvement study, redundancy tive or perioperative is- in the workflow actually improved sues. Prolonged wait the efficiency of the patient’s hospi- RESULTS time and postponement may cause tal course. The authors reviewed 10 months of the preoperative delays. Perioperative Within the OR, there are many neurosurgical service prior to initiation delays include delays in getting into perspectives to consider for improv- of the protocol. Of 317 analyzed cases, the OR once the patient has arrived ing OR efficiency. For instance, Ar- 30 were delayed/cancelled. Among in the hospital as well as delays dur- cher and colleagues present several these, 5 cases with the possibility of a ing the operation. These delays can be distinct perspectives: that of the 6th were cancelled due to medication due to both human error and system health care institution, the indi- issues. Following the initialization deficiencies.20 vidual practitioner, the patient, and of the study, 50 patients underwent One Toronto, Canada study evidenced-based medicine.2 Accord- preoperative counseling with the looked at the different etiologies ing to Strum and colleagues, OR in- pharmacist and the neurosurgery co- for delays in cranial and spinal pro- efficiency is the sum of under- and ordinator and had an OR Medication cedures and found that equipment overutilized time and efficiency is Compliance Worksheet created. failure followed by physical tran- highest when OR inefficiency is Review of the OR Medication sit into the OR were the top rea- minimized.22 An OR is considered Compliance Worksheet demon- sons for delays.21 These researchers underutilized when it is staffed at strated that 2 patients were nonad- also found that first cases each day regular wages but not used for sur- herent with their medications.