6 Unplanned medicines-related readmissions to mental health wards and crisis resolution home-treatment teams (CRHTTs)

Introduction Hospital readmission is common in mental health1. Unplanned readmission within 30 days of discharge is considered a poor indicator of quality of care provided1. In 2011, unplanned readmission rates for schizophrenia and bipolar disorders in 15 OECD countries were reported as 13% and 11% respectively1 and worldwide, over 14% admitted with a mental health illness are readmitted within 30 days.2 We investigated the potential role of medication related factors in unplanned readmissions to mental health wards and CRHTTs and whether a collaborative multidisciplinary Quality Improvement (QI) approach helps to reduce medicines-related readmissions. Methods Notes for patients admitted to 16 wards and 6 CRHTTs over a 2-week period were checked to identify a previous admission. For the 213 cases identified, notes were reviewed and GP practices and patients interviewed to assess if medication contributed to readmission either ‘significantly’, ‘partly’ or ‘not’. Where readmission was identified as medicines related, we identified whether: patient received discharge medication at previous discharge and left with their medication; discharge notification was sent and received by patients’ GP; post discharge follow-up was completed.5 Subsequently, collaborative multidisciplinary QI methodology was adopted to assess impact of systemwide changes on medicines-related readmissions. Results 82 out of 126 readmissions were considered to be related to medicines. 14 out of 82 had no medication on discharge. For the remaining 68, 8 patients did not receive or collect their discharge medication at last discharge. Medication partly (n=5) or significantly (n=3) contributed to all 8 readmissions; 2 of these readmissions occurred within 60 days of discharge. Out of the 126 previously admitted patients, 86 (68%) had their last discharge notification sent to their GP; 40 (32%) did not. Of these, medication was significant to readmission in 17 cases and ‘partly’ in 11 cases. 7 of these 28 patients were readmitted within 60 days of discharge. Of the 86 patients whose last discharge notification was sent to their GP, practices confirmed receipt in 95% of cases. All four whose discharge notification were not received by GP, had a medication-related readmission. 24 patients did not receive post discharge follow-up, medication was significant to readmission in 9 cases and partly in 6. Of these 15 patients, 4 were admitted within 30 days and 3 within 31–60 days of discharge. QI methodology reduced medicines-related readmissions from 58% to 2 - 5% in 6 months. Discussion Readmission is distressing to patients and their families and has a negative impact on the health economy.3 Medicines are the most common healthcare intervention. Medication changes during admission are common and timely communication to GP post-discharge is essential to avoid discrepancies.4 QI methodology can significantly reduce medicines-related readmissions by adopting a multidisciplinary approach to discharge planning and continuity of care. References Donisi V, et al. Pre-discharge factors predicting readmissions of psychiatric patients: a systematic review of the literature. BMC Psychiatry 2016;16(1):449. Medication Without Harm. WHO Global Patient Safety Challenge. World Health Organisation 2017. Frontier Economics. Exploring the cost of unsafe care. A report prepared for department of health. October 2014. https://www.frontiereconomics.com/media/2459/exploring-the-costsof-unsafe-care-in-the-nhs-frontier-report-2-2-2-2.pdf Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 2005;165:1842–7. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes NICE Guideline 5. National Institute for Health and Care Excellence. (March 2015).

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   Pre-discharge factors predicting readmissions of psychiatric patients: a systematic review of the literature · 2016

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