Title: mediCines Optimisation oN iNtensivE Care uniT patiEnt Discharge (CONNECTED)
Funder: Health Education England

Abstract: Research Question: How should medication reviews be conducted for intensive care patients prior to ward discharge? What are the core elements of the medication review and can the intervention be developed for routine clinical delivery enabling future full evaluation? Background: Intensive care unit (ICU) patient care is complex, delivered by healthcare teams, in a demanding and pressurised environment. Medication errors are the most common medical error ICU patients experience and can occur throughout the ICU patient pathway. However, for these vulnerable patients, ward discharge is a particularly high-risk period. ICU patient care results in multiple changes in medication therapy. On ward discharge, interruption in continuity of care (important chronic medication not restarting and potentially inappropriate medication continuing), can create problematic polypharmacy. However, there are no nationally agreed best practice or standards on the optimisation of ICU patient medication therapy prior to ward discharge. Variable delivery of discharge medication review in ICU patients potentially contributes to the large variation in patient post-ICU hospital lengths of stay, and the high unplanned hospital readmission rates. Aims and Objectives: To identify and develop a medication review intervention for ICU patients on ward discharge. 1. To identify candidate components for an ICU patient structured medication review on ward discharge. 2. To identify clinically important ICU discharge patient and medication outcome measures. 3. To develop and describe an ICU discharge medication review intervention with potential for effective and routine patient delivery. Methods: We will, (1) conduct a systematic review of medication-related interventions used in studies of ICU patient ward discharges. Identifying: (i) empirical evidence that interventions have clinical effects; (ii) theory on proposed intervention mechanisms of actions leading to effects. We will then, (2) undertake an international electronic Delphi consensus process to identify clinically important ICU discharge patient and medication outcome measures, appropriate and suitable for routine assessment in a quality improvement (QI) programme; enabling refinement of a structured ICU discharge medication review intervention. UK focus groups will then be used to: (i) finalise the intervention core components and medication and patient outcomes with a deliverable UK emphasis; (ii) map intervention components to mechanisms of action and targets, developing them into an intervention to be tested. Finally, we will use a QI approach to, (3) develop and describe the ICU patient discharge medication review intervention for effective and routine delivery. In a single general ICU, Plan Do Study Act cycles will be used to develop and then refine the intervention. Interviews and questionnaires will capture patient, family and staff experiences related to communication of medication discharge plans and delivery respectively. The implementation team will consider intervention spread and create supporting education and training packages on completion. Time lines for delivery: All objectives will be delivered over the 3-year fellowship. Anticipated Impact and Dissemination: The programme will deliver an intervention ready to be first feasibility tested prior to a definitive RCT. The results of which will inform NHS ICUs how to undertake medication reviews in ICU patients on ward discharge, with benefits for patients and the NHS.

Lay abstract: Patients cared for in Intensive Care Units (ICUs) are some of the sickest patients in a hospital and often need many different medicines. The way their bodies respond to these medicines may change and it is necessary that any medicines they were taking before coming to ICU are checked to see if they are still appropriate. This process is called a 'medication review'. The medicines patients were taking before coming to ICU may be continued, have the doses changed or paused, until the patient is well enough to take them again safely. Whilst on ICU, patients will receive many new and some high-risk medicines. This is a type of 'polypharmacy' (many medicines), and it is key that we ensure the patient needs all these medicines and that they work well together. They may need some of these medicines for a long time, but many should not continue when they are discharged from the ICU to a ward or from the hospital. When the patient is ready to leave ICU to go to a ward, we need to make sure the patient continues the medicines they need, whilst stopping or gradually reducing those no longer needed. This medication review can be complex, take a lot of time and involve many different staff. However, it is important staff do this medication review carefully before the patient leaves the ICU, to reduce the risks of patients having problems due to polypharmacy including, medication errors and unwanted effects on the ward or after leaving hospital. For ICU patients, there is no nationally agreed best practice or standards for their medication review before ward discharge. So the quality of medication review a patient gets before their ward discharge can vary greatly, increasing the chances of problems with their medicines afterwards. This research aims to provide solutions to this urgent problem and improve patient care. We will work with patients, family and staff to identify, develop and test how ICU staff should perform a medication review for patients before they leave the ICU and how patients, family and ward staff are consulted and kept informed. We will first identify and develop a new discharge medication review process, then we will look at how we need to adapt it to make sure it can be used well by staff in a single large ICU. To do this we will form a team of ICU staff, ward staff and patients, who will work to test the delivery of the medication reviews done and see how these may be improved until we are happy with how well it works in the ICU. We will seek staff opinions about the use of the new medication review process and ask patients and their families how well informed and satisfied they were with the planning and information they got about their medicines on transfer to the ward. Two larger studies would follow to check if more ICUs can use the new medication review process and, then test how effective the new discharge medication review process is compared to usual methods and whether it improves patient care. We have worked throughout with patient groups on how the study is designed and run. Patient groups have full input into the research itself, the ethics, how information should be provided to patients and staff and how the results will be made widely available. When completed, this research could lead to better ongoing care and safer ward transfer for ICU patients in the future. Patients may need less time in hospital or be less likely to need readmission to hospital because of medication problems or errors.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE