Introduction: Adverse drug reactions (ADRs) account for 6% of hospital admissions, 1 in 25 hospital bed days and cost over £450 million/year. Older patients are particularly vulnerable as age-related physiology changes, multiple morbidity and functional dependency make prescribing complex and challenging. The STOPP tool is a validated research instrument developed to identify potentially inappropriate medications (PIMs) in older patients. There has been little work to translate this methodology (65 criteria) into practice in the time-pressured high turnover environments of acute hospital care.
Methods: Process mapping on three acute care hospital sites (Imperial College Healthcare NHS Trust) was employed to gain a detailed understanding of medicines management processes, subsequently validated by patient shadowing.
Modified: Driver diagrams (action effect) suggested the need for a user-friendly medication review form for use on the Acute Medical Unit for all patients >70 years. To gain expert consensus on content and usability of the form, a modified Delphi process was delivered via electronic questionnaire. The results of each round were feedback to participants of successive rounds to assess agreement and facilitate consensus. Clinicians and allied health professionals caring for older patients in primary and secondary care (Northwest London) were invited to participate.
Results: Response rates over three successive rounds were 50% (9/18), 86% (56/65) and 67% (56/84). By round three, there was 100% agreement on the five most common ADR presentations (falls/postural instability, bleeding, confusion, metabolic disturbances, constipation) and drug classes with PIMs (opiates, benzodiazepines >1 month, diuretics, NSAIDS/warfarin, antihypertensives) observed in acute care, thus the Delphi was halted. Top suggestions for usability include brevity [no longer than one (A4) page], documentation of drug change (including reason) and ease of use (tickboxes).
Conclusions: We have employed QI methodology to gain expert consensus opinion to develop a structured medication review form, translating evidence to practice for acute care.