Discharge medication

There are many barriers to the transfer of a patient's medication history between the hospital and the community. It is just as important to have good information on discharge as it is to have an accurate medication history when the patient is admitted. Discharge summaries may be illegible, inaccurate and inconsistent in the use of generic and trade names. Timely transfer of discharge information is also a challenge. Telephone calls are helpful for discussing changes to medications, but must be used in conjunction with a written list of discharge medications. There is currently limited use of fax and email to transfer discharge medication information. Many hospitals issue a limited supply (3-5 days) of medication, so the patient may need another prescription before the general practitioner receives the discharge summary by conventional mail.

There is a need to transfer more information than a list of current drugs. Changes made to treatment and the reasons for those changes should be communicated. This should include information about drugs which have been tried and found to be ineffective or to have caused adverse reactions. Specialist knowledge about the use of medications (for example, the need to monitor for adverse drug reactions) and about compliance should also be transferred. The hospital staff must communicate with the community pharmacist if a blister pack is needed (increasingly required in residential aged care) and with the family or community nurses if they are needed to assist with drug administration.

Trials of interventions to improve the transfer of drug information from the hospital to the community have been disappointing. We found that hand-held medication cards given to patients were infrequently used and often inaccurate.¹ A South Australian study of patients discharged from hospital to residential care used a pharmacist to co-ordinate medication management transfer summaries, timely medication reviews by community pharmacists, and case conferences with physicians. These interventions prevented a post-discharge decline in the quality of prescribing (measured by the Medication Appropriateness Index) and prevented worsening of pain, but had no effect on adverse drug events, falls, mobility, behaviour or confusion eight weeks after discharge.² In Sydney, workshops and audits were used to improve the exchange of medication information between hospitals and general practitioners. The intervention increased the proportion of general practitioners receiving discharge summaries directly by fax from 2% to 27%.³ However, only 29% of general practitioners reported receiving a discharge referral which included the reasons for changing medications.

Healthcare agreements between the Commonwealth and state governments aim to implement the Australian Pharmaceutical Advisory Council's guiding principles for achieving continuity in medication management.⁴ To implement the 'provision of a sufficient supply of medicines in a planned and timely way', public patients in most states will soon receive up to one month's supply of medication through the Pharmaceutical Benefits Scheme (PBS) on discharge from hospital. Medications can be prescribed in hospital and, where possible, dispensed from the hospital pharmacy.

Provision of a PBS prescription on discharge will allow time for the discharge summary to reach the general practitioner by mail before a new prescription is required. However, issuing PBS prescriptions from the hospital requires training of junior medical officers and an investment of their limited time, in addition to writing medication lists on discharge summaries. In our hospital, discharge prescriptions are screened by clinical pharmacists and errors are detected for about 12% of patients.⁵ Issuing PBS prescriptions from the hospital will require new systems to check discharge drugs and to transfer instructions about their use.

Accurate, timely transfer of discharge medication information from the hospital to the community requires co-operation between doctors, pharmacists and nurses in the hospital and in the community. Lists of discharge medications should be typed to improve legibility and include reasons for any changes. The drugs must be ordered in time for the pharmacist to check them, dispense them (or organise dispensing in the community) and provide the patient with the information to manage their medications. There should be timely transfer of the discharge information by as many routes as possible to the patient and/or carer and the general practitioner. The community pharmacist needs to know if a blister pack is required and the community nurse needs to be informed if administration is required. Medication cards can provide the patient with their own record on discharge.

Electronic systems can transfer computerised discharge summaries and medication lists rapidly by fax or email, but require new processes for checking and correcting discharge prescriptions. The Commonwealth Government has trialled a 'Medi Connect' record for consenting patients.⁶ An electronic medication list was stored by Medicare Australia and could be added to and accessed by doctors, pharmacists and hospital staff. The findings will be implemented as part of the 'Health Connect' strategy for electronic health information. However, for all records, paper or electronic, accuracy depends upon timely and accurate data entry. For example, it is important that electronic prescribing records are updated to reflect changes in treatment. Ultimately the most useful and accurate record of patients' medications may be the 'plastic bag' or basket (Fig. 1) containing all their drugs, including discharge medications.¹

Fig. 1 Medicines brought to a geriatric outpatients clinic by a patient

Conflict of interest: none declared