Final Report

FINAL REPORT
PROVISION OF CONSUMER MEDICINE INFORMATION IN A REHABILITATION UNIT OF
WAR MEMORIAL HOSPITAL, WAVERLEY, NSW
WAR MEMORIAL HOSPITAL
and
COMMUNITY HEALTH SERVICES PRINCE OF WALES HOSPITAL
February 2001
Provision of consumer medicine information in a rehabilitation unit of War Memorial Hospital, Waverley NSW
Acknowledgments
The chief investigator acknowledges the Commonwealth Department of Health and Aged Care via the
Pharmaceutical Education Program for the funding to conduct this project.
Thanks go to the project officers, all the nurses who participated in the project and to the War Memorial
Hospital administration for their cooperation and support.
Finally, all the invaluable information about current practices from health professionals was much
appreciated.
1
Terminology
APAC Australian Pharmaceutical Advisory Council
CIAP Clinical Information Access Project
CMI Consumer Medicine Information
CNC Clinical Nurse Consultant
CPI Consumer Product Information (not used any longer)
IT Information Technology
NESB Non English speaking background
NUM Nurse Unit Manager
PHARM Pharmaceutical Health and Rational Use of Medicines
SEH South East Health
SHPA Society of Hospital Pharmacists of Australia
TGA Therapeutic Goods Administration
WMH War Memorial Hospital, Waverley
2
CONTENTS
EXECUTIVE SUMMARY.............................................................................................4
Recommendations ........................................................................................................................................ 5
INTRODUCTION .........................................................................................................7
BACKGROUND............................................................................................................8
Literature Review........................................................................................................................................ 9
Current Practice ........................................................................................................................................ 13
AIMS AND OBJECTIVES...........................................................................................14
METHODOLOGY.......................................................................................................15
RESULTS ...................................................................................................................16
DISCUSSION OF RESULTS.......................................................................................22
PROJECT OUTCOMES ..............................................................................................25
CMI pathway for the pharmacist............................................................................................................. 25
CMI pathway for the nurse ...................................................................................................................... 26
EVALUATION............................................................................................................26
Process........................................................................................................................................................ 26
Impact ......................................................................................................................................................... 28
Outcome ...................................................................................................................................................... 30
CONCLUSION............................................................................................................31
APPENDIX ONE.........................................................................................................32
3
EXECUTIVE SUMMARY
Legislation for the provision of Consumer Medicine Information (CMI) was passed in 1993 and by 1994
it was agreed that the electronic delivery of CMI was the preferred method. There is little evidence in the
literature of processes for CMI delivery by nurses or in the hospital system by pharmacists. The Clinical
Information Access Project (CIAP) has been available to NSW hospitals for three and a half years,
thereby making electronic CMI available. War Memorial Hospital, with a relatively uniform patient
demographic and one pharmacist, provides an ideal environment in which to examine the processes to
efficiently deliver CMI to patients.
The aim of the project was to provide CMI for every medication of every patient, prior to discharge from
the rehabilitation ward of the War Memorial Hospital, Waverley, NSW.
A steering committee was formed and an action plan and timetable was developed. A series of education
sessions for the nurses were conducted covering historical background; legislative and professional
obligations; CMI content and current availability; project objectives and phases; and practical computer
training.
The pilot phase was carried out over one month and the process, documentation and all problems were
reviewed, with modifications made. Data was collected in the study phase for 6 months.
Patients who received CMI mostly did so for new medication. There are still a significant number of
drugs for which an electronic CMI is not yet available. The times taken to discuss procure and provide
CMI was usually between five and fifteen minutes. Only a small number of patients was either not
offered CMI or could not accept it because they did not speak or understand English.
4
During the course of the study the pharmacist completed 3.5 times more interventions than the nurses did.
Nursing issues resulted in more changes in procedure after the pilot phase than did pharmacist issues.
The concept of nurse provision of CMI is not well established and effective change management
strategies could facilitate a move to practice change when appropriate. The technology resources required
for this project were less available at the ward level than in the pharmacy.
Recommendations
Each hospital must review its current IT infrastructure to determine that it meets reasonable requirements
for CMI delivery. Resources must be allocated where necessary to upgrade or provide this.
Within each hospital; nursing, pharmacy and medical representatives must determine the most appropriate
protocols for the provision of CMI in that hospital’s various units or services. The provision and
dissemination of background information and the allocation of appropriate resources for consultation and
deliberation must be sufficient to develop workable and sustainable protocols.
Information about CMI availability for most medications should be contained in the hospital’s admission
brochure. This information would briefly explain the purpose of CMI with the intention of reducing the
time spent by ward and pharmacy staff doing this, thus allowing more time to discuss the use and side
effects of the medication.
The CIAP database should be the first choice for staff to access CMI.
Formal submission should be made to NSW Health for modification to CMI format from CIAP, so that
printing results in a reduction of pages produced.
5
Further investigation should be undertaken to determine the written medication information requirements
of people of non-English speaking backgrounds.
Patients being discharged to their own home and who have been commenced on new medication during
their hospital stay should routinely be offered CMI. Patients may request CMI for other medications or
hospital staff may identify that the patient needs CMI for previously prescribed medication.
Further work should be done to determine the effectiveness of the pathways used in this project to
facilitate quality use of medicine.
Kristin Mbothu, Chief Project Director
Fiona Russell, Other Project Director
Mikala Five, Other Project Director
Anne Pendergast, Other Project Officer
Jenny Blennerhassett, Project Pharmacist and Report Author
6
INTRODUCTION
War Memorial Hospital (WMH) is a rehabilitation and respite hospital with one part-time pharmacist (30
hours). The project aimed to:
- examine the provision of Consumer Medicine Information (CMI) to patients in the rehabilitation (not
respite) unit by registered nurses when the pharmacist is off duty and by the pharmacist when
present.
- examine the suitability of a particular method of CMI procurement.
The project is essentially a quality assurance project. Every patient provides an opportunity for data
collection, but none of this data will be about the patient, rather about the processes undertaken.
There is little evidence in the literature of processes for CMI delivery by nurses or in the hospital system
by pharmacists.
Information provision and the philosophy of patient rights are continually impacting on health
professional practice, therefore creating impetus for revising practice guidelines.
War Memorial Hospital provides the ideal environment in which to run such a project. The self-contained
nature of the unit, the presence of only one-part pharmacist and the relative uniformity of the patient
demographic, minimise some of the independent variables that may otherwise influence the project
outcomes.
The availability of electronic CMI via a simple retrieval mechanism provides an opportunity to determine
the suitability of the current arrangements to effectively and efficiently deliver CMI.
7
BACKGROUND
Legislation for the provision of patient information (CMI or Consumer Medicine Information) for all new
drugs and variations to existing drugs approved after 1 January 1993 was passed. Originally this was
called CPI (Consumer Product Information) and it is the manufacturer’s responsibility to submit CMI to
the Therapeutic Goods Administration for review before distribution. CMI content is standardised to be
consistent with the product information and within therapeutic areas. A Quality Assurance Reference
Group was established to monitor quality and consistency and a CMI Taskforce was instituted under
PHARM for legislation, implementation and delivery. By 1994, the electronic method of delivery was
confirmed as the preferred method of delivery.
At the commencement of this project, November 1999, there were 550 CMI available for CMI electronic
delivery (57% of total). However, this accounted for 80% of the volume as 19 out of the top 20
companies by volume provide electronic CMI.
At the conclusion of the study phase, November 2000, there were 687 CMI available for CMI electronic
delivery (62.5% of total), accounting for 80+% of the volume. There are 30 manufacturers supplying
CMI for electronic delivery.
The mechanism for CMI provision has not been tested or defined at War Memorial Hospital. When the
pharmacist is off duty, there are instances when patients’ discharge arrangements do not coincide with the
pharmacist’s planned session with each patient.
There has been no research done on the ability or willingness of registered nurses to provide drug
information.
8
War Memorial Hospital recognises an obligation to efficiently and effectively provide drug information to
patients; and also the requirements for CMI provision.
Patients at WMH are admitted for rehabilitation or respite. The average stay is 28 days and there are 35
rehabilitation beds. A minimum of 400 patients has been discharged each year for the last three years.
The overwhelming majority of the patients are orthopaedic or stroke rehabilitation patients referred from
St Vincent’s Hospital, Sydney and Prince of Wales Hospital, Sydney.
The average age is greater than 75 years and a small, but consistent number of these patients are NESB.
There is no documented procedure or policy for the delivery of CMI by the pharmacist, although it is
regarded as part of standard clinical practice and is provided when and if possible.
The suitability of the current CMI format will be tested for NESB patients.
Literature Review
The debate about the availability and provision of quality medical information for consumers is in a very
developed stage in Australia. Australia ‘was one of the first countries to introduce legislation requiring
CPI (sic).’1 In fact, ‘the debates about how to introduce and use CPI (sic) are….occurring against a
background in which it is already being produced and distributed’.1
One of the core roles of the pharmacist is the provision of information about medication2 . Community
pharmacy is the professional group with the longest experience and easiest access to CMI. In contrast,
hospital pharmacy departments have much more varied availability of electronic resources and have been
less able to produce current CMI as part of routine clinical practice.
There is some published data about community pharmacists’ CMI distribution in its various formats.
Aslani et al3 found that 47% of community pharmacists surveyed used only package inserts when they did
9
provide CMI to customers, 2% used either package insert or electronic CMI and 16% used all 3 formats.
This reliance on package inserts cannot be emulated in the hospital pharmacy department, due to bulk
packaging, multiple use of single packs and the specific nature of hospital formularies. Registered nurses
on wards obviously cannot rely on package inserts, as almost all discharge medication is re-packaged
from original manufacturers’ containers by the hospital pharmacy.
Both the Pharmaceutical Society of Australia and the Society of Hospital Pharmacists of Australia
(SHPA) publish Standards of Practice for CMI provision in each of the pharmacy practice settings. The
PHARM CPI Taskforce confirmed in April 1994 the preference for electronic CMI distribution, 4 however
in the hospital setting this has been limited by available technology. For example, Royal North Shore
Hospital’s Drug Committee decided to defer confirmation of PHARM guidelines on CMI provision until
electronic CMI was tested and in place5 . Patient counselling policies and procedures for pharmacists at
this hospital include CMI provision and the documentation of the supply on the medication chart6 , but
hospital wide guidelines awaited technology. John Hunter Hospital prioritises medicine information
provision and is in the process of establishing an electronic CMI distribution method.7
By January 1999, there were 470 CMI available electronically, representing about 67% of the total
required by 20028 . These were available to all dispensing software companies who service community
pharmacies in Australia. In contrast, very few hospital pharmacy dispensing programs have simple
access to these electronic CMI, due to the variance between hospital networks and the competing needs
within each network.
The general guidelines for Health Professionals on Consumer Product Information concedes “that
provision of CPI (sic) within institutional settings is more challenging…”9 , but continues by saying that
the obligation to provide CMI remained the same as in the community setting.
10
A brief review of the nursing literature showed very little discussion of CMI or indeed the Quality Use of
Medicine. The Australian Journal of Advanced Nursing offers no comment on these subjects over 1996-
1999. No reference to CMI was evident in the years 1997 to 1999 in “The Lamp”, the widely circulated
nursing journal in NSW. No nursing policy of Community Health Services and Programs (Northern
sector) includes any reference to quality use of medicine or CMI.
In October 2000, the Federal Council of SHPA updated a practice standard for the Provision of CMI by
Pharmacists in Hospitals 10 . This comprehensive document reflects the range and complexity of issues
associated with CMI delivery by hospital pharmacists.
Community support continued11 for CMI. In late 2000, a Quality Use of Medicine hospital discharge
survey audit found that CMI was received by only 5% of the audited patients.12 Koo et al13 set out to
investigate the impact of CMI on consumers. Most participants were aware of the existence of written
medication information but were not familiar with the term ‘Consumer Medicine Information’ or its
potential benefits.
In an article by a health policy officer for the Australian Consumers’ Association, the author asserts that
consumers find it difficult to obtain CMI from both pharmacists and doctors. With the concept of ‘direct-
to- consumer’ advertising still lingering, the article concluded that it is time that health professionals
worked with consumers and the industry to make CMI more readily available as these are a balanced
source of information. 14
Overseas experience appears to be similar. In a study in Canada examining medication education of
acutely hospitalised older patients, 30% of patients reported receiving written information about their
medications. However, only 11% were given any advice on potential side effects, indicating that contents
of this particular written information differs from content in the Australian CMI.
11
Physicians and pharmacists claimed that there were barriers to providing medication education in 50%
and 80% of patient encounters respectively. Lack of time and cognitive impairment were the most
commonly cited barriers for both. 15 An Australian health fund has promoted CMI in its publications for
members.16
Since legislation in 1993, progress has been made towards the effective provision of quality written
information about medication to consumers. Clearly, issues are still outstanding.
References:
1. Shenfield GM, Tasker JL. History in the making: the evolution of Consumer Product Information
(CPI). MJA 1997; 166: 425-428.
2. Appel S. Consumer Product Information affects us all, pharmacist view. Australian Prescriber 1996;
19(2): 33.
3. Aslani P, Benrimoj SI, Krass I. Use of CMI by NSW Community Pharmacists – a baseline study.
Australian Pharmacist 1998; 17(8): 15-20.
4. Thomas, R. Ed, CMI, Postgraduate Studies in Drug Development Sciences, UNSW, 1997; 7(3):29
5. Duguid M. Director of Pharmacy, Royal North Shore Hospital, NSW. January 1999 (oral
communication)
6. RNSH Pharmacy Department Policies and Procedures, Policy No:C4.2
7. Dowling H. Director of Pharmacy, John Hunter Hospital, NSW. January 1999 (oral communication)
8. Robb A. Amfac-Chemdata, January 1999.
9. Commonwealth Department of Human Services and Health. General Guidelines for Health
Professionals on Consumer Product Information. May 1995.
10. Low J. Hospital Talk. Australian Journal of Pharmacy 2001; 82:119.
11. Shenfield G et al. Summary report of a pilot study into community attitudes to medicine information
and evaluation of Consumer Product Information. PHARM (unpublished)

12
12. Mant A. Conference proceedings. Discharge Survey, Quality Use of Medicines. Society of Hospital
Pharmacists of Australia (NSW branch) July 2000; 16.
13. Koo M, Krass I, Aslani P. The Use of CMI by Consumers. The Australian Journal of Pharmacy
2001; 82: 18.
14. Ballenden N. In Whose Interests is Consumer Medicines Information Served? Australian Pharmacy
Trade Sept 7, 2000; 14
15. Shabbir MH et al. Medication Education of Acutely Hospitalised Older Patients. J Gen Intern Med
1999; 14:610-616.
16. Living Well February 1999.
Current Practice
Of the metropolitan Sydney hospital pharmacy departments surveyed in January 2001, nine replies were
received. The majority of these hospitals do not provide CMI to inpatients as part of routine clinical
practice. The main reasons cited were lack of technical facilities –computers, printers, appropriate
software - and time. The hospitals that have been routinely providing CMI to all patients indicated that
new medications commenced during the admission are targeted.
All nine hospitals indicated that only pharmacists were providing patients with CMI.
There are several sources of electronic CMI in current use in the hospital pharmacy departments
surveyed. There are weaknesses and strengths associated with each of them.
Four hospitals have written policies and one hospital has a draft policy. Most indicated that their policy is
in line with the SHPA policy guidelines that were revised in October 2000.
One hospital pharmacy department has had their hospital drug committee approve the CMI policy which
includes procedures for CMI provision.

13
AIMS AND OBJECTIVES

Aim: To provide CMI for every medication of every patient, before discharge, from the rehabilitation
ward of the War Memorial Hospital, Waverley, NSW.
Objectives:
1. To determine the appropriateness of the Area Health Service intranet as a source of CMI
2. To identify the appropriateness of current CMI for NESB patients
3. To critically evaluate the pathway developed for distribution of CMI by nurses
4. To critically evaluate the pathway developed for distribution of CMI by the pharmacist
5. To satisfy statutory regulations and guidelines for distribution of CMI.
6. To facilitate the quality use of medicines.
7. To facilitate the enhancement of quality assurance practices.
14
METHODOLOGY
NSW Health provides access to MIMS on-line® via the Clinical Information Access Project (CIAP).
MIMS on-line ® provides access to electronic CMI. The project aimed to provide CMI via this site,
accessed by the nurse or pharmacist who will be discussing discharge medications with the patient.
A steering committee was formed, comprising the Chief Project Director, Community Health Services,
Prince of Wales Hospital; Project pharmacist, Community Health Services, Prince of Wales Hospital;
Other Director, Director of Nursing at War Memorial Hospital; Project Officer, Chief Pharmacist WMH;
and Clinical Nurse Consultant (CNC), WMH. An action plan and timetable was developed at the initial
steering committee meeting. The Steering Committee met bi-monthly and reviewed procedures and
outcomes to that point. Necessary modifications were implemented.
The steering group decided that the project pharmacist and the CNC would liaise to plan the general
information as well as the computer training education sessions. These were conducted over a series of
days and times to ensure all nursing staff could attend. Presentations including historical backgrounds,
legislative and professional obligations, CMI content, current availability, CIAP use, and project
objectives and phases were presented. These education sessions specifically included instruction on data
collection procedures.
The CMI provision process was piloted for one month. The project pharmacist was located on-site and
accessible for staff during this time. The study phase was implemented after review of the pilot phase. A
data collection form was completed for each patient discharged from the rehab ward during the study
phase. See Appendix 1
15
RESULTS
PATIENTS in STUDY 161
TOTAL PATIENTS DISCHARGED 219
PERCENT 73.5%
Survey Forms by Month
40
35
30
No. of forms
25
20
15
10
5
0
May June July August September October
The influence of education sessions can be seen in May and August. The pharmacist was away in
October.
CMI LEAFLETS GIVEN TO PATIENTS
Frequency Percent
Given all drugs 1 .6
some drugs 12 7.5
new drugs only 9 5.6
none given 139 86.3
Total 161 100.0
16
Total number of CMI given was 57 out of 154 drugs ordered for discharge. 22 patients (13.7%) received
CMI, 14 females and 8 males (1.75:1; F: M). 87 females and 52 males did not receive any (1.67:1; F: M).
Of the 22 patients who received CMI, only 1 of these received them for all their medications. Of the
other 21, the reasons given are:
Not available from CIAP - 9 patients
Has from another source – 1
New medication only - 9
Not specified - 2
When patients requested CMI for all their medications, the most common reason for not receiving CMI
for all their medications was that it was not available from CIAP.
Given all Given some Given new NONE given
drugs drugs drugs only
Female Count 1 8 5 87
% within 100% 66.6% 55.6% 62.6%
Male Count 4 4 52
% Within 33.3% 44.4% 37.4%
TOTAL Count 1 12 9 139
The surveyed study group showed that slightly more females received CMI compared to males. However
slightly more males requested CMI for new drugs.
17
CMI given
all drugs
1%
some drugs
7%
new drugs
only
6%
none given
86%
Time taken to discuss and produce CMI when all or some CMI given:
TIME FREQUENCY PERCENT
5 minutes 4 18.2%
5-15 minutes 16 72.7%
15 minutes or greater 2 9.1%
Total 22 100.0%
Time taken to discuss and search for CMI when NO CMI was given:
TIME FREQUENCY PERCENT
5 minutes 77 95.1%
5-15 minutes 4 4.9%
15 minutes or greater 0
Total 81 100%
This shows that when CMI was given to patients, it took between 5 and 15 minutes in approximately
three-quarters of the patients for staff to discuss and retrieve the CMI from CIAP.
When no CMI was given, it took staff 5 minutes or less to discuss and/or search for CMI on CIAP in the
majority (95%) of patients.
18
PATIENT VIEW OF CMI
Of the 22 patients who received CMI, 9 patients received it at their own request, 2 at the request of a carer
and on 11 occasions it is not recorded or unknown who requested the information.
PATIENT VIEW FEMALE MALE TOTAL
Positive 20 19.8% 11 18.3% 31 19.3%
Indifferent 37 36.7% 25 41.7% 62 38.5%
Negative 6 5.9% 2 3.3% 8 5.0%
Not Applicable 38 37.6% 22 36.67% 60 37.3%
Total 101 100% 60 100% 161 100%
19
REASONS NOT GIVEN
REASON NOT GIVEN NUMBER PERCENTAGE
Not available 11 7.7
Patient/carer refused 21 14.7
Already has 31 21.7
Transferred 4 2.8
Poor vision/speech 10 6.9
Doesn’t speak English 6 4.2
Dementia 37 25.9
Technical Difficulties 1 0.7
Patient Died 1 0.7
Not Enough Time 13 9.1
No Reason 8 5.6
Double Reason -4
TOTAL 139 100
PATIENT DESTINATION AFTER DISCHARGE
80
68
60
40
20
16
Percent
13
0
Nursing Home Hostel Own home transfer
Home To
20
Patients Discharged to own home and reasons no CMI given
Not Refused Already Blind/ Dementia Does not Technical Not time Total
available has poor speak/ problems to offer
on CIAP vision understand
English
10 15 28 9 14 5 1 12 93
10.8% 16.1% 30% 9.7% 15.1% 4.3% 1.1% 12.9%
100
90
80
60
49
40
Home To
20
20
Own Home
Count
0 Other Institution
All or Some Given None Given
Info
Risk Estimate
95% Confidence
Interval
Value Lower Upper
Odds Ratio for Info
(All or Some Given / 5.444 1.221 24.269
None Given)
For cohort Home To
= Own Home 1.404 1.172 1.681
For cohort Home To

.258 .067 .985
= Other Institution
N of Valid Cases 161
Patients discharged to their own homes are 1.4 times more likely to be given CMI than not (95%
confidence interval [1.17,1.68]). Therefore patients being discharged to their own home are significantly
more likely to get CMI than not. Patients being discharged to other institutions are significantly less
likely (relative risk=.258) to get CMI rather than get it.
21
PHARMACIST/REGISTERED NURSE PATHWAYS
120
111
100
80
60
40
Done By
28
20
Nurse
Count
14
0 8 Pharmacist
All or Some Given None Given
Info
Risk Estimate
95% Confidence
Interval
Value Lower Upper
Odds Ratio for Info
(All or Some Given 2.265 .865 5.931
/ None Given)
For cohort Done
By = Nurse 1.805 .948 3.438
For cohort Done

.797 .575 1.105
By = Pharmacist
N of Valid Cases 161
DISCUSSION OF RESULTS
During the pilot phase 37.5% of patients received either all or some CMI. During the study phase 13.7%
of patients received either all or some CMI. Refining the “offering CMI” process meant that, as time
progressed and the staff education sessions targeted more specific information, CMI were not printed
before the patients’ needs or requests were known.
22
During the study phase approximately 41% of patients who requested CMI did not receive it because it
was unavailable from CIAP. 41% of patients requested CMI for new medications only, reflecting the
refining of the “offer” process and targeting new medications for written information.
Two- thirds of patients discharged from War Memorial Hospital during the six-month study phase of the
project were females. Females comprised slightly more than two thirds of the pilot group and slightly
less than two thirds in the study group, where data collection forms had been received. CMI were given
to an overwhelming majority of females (90%) during the pilot phase, however this dropped back to two-
thirds during the study phase, corresponding to the overall female/male ratio discharge patterns.
In approximately 75% of patients, the time taken to discuss and produce CMI was between five and
fifteen minutes. As might be predicted, it took staff five minutes or less for this process in the majority of
patients. For the few patients where it took longer than five minutes, the reason was usually that CMI
was searched for in CIAP, but was unavailable. Often a decision was made not to offer CMI to patients
who were known to be confused, anxious or aggressive. During the pilot phase the CMI for two patients
was provided to the carer, but it is unknown whether the information was specifically offered to the carer
or whether the carer was present when the nurse was offering/discussing CMI with the patient and
expressed an interest.
Those patients who received CMI were positive about CMI. However, out of those who did not receive
any CMI, the majority was indifferent, rather than negative about CMI. Approximately 63% of surveyed
patients were asked about their view of CMI. Of this 63%, approximately one third were indifferent to
CMI because they already had the CMI from another source. A positive view of CMI accounted for about
11% of patients asked for their view of CMI, but who did not receive any because it was unavailable from
CIAP.
23
Those patients deemed to be confused, many who were discharged either to a nursing home or to a hostel
and who were not offered or given any CMI, were not asked their view of CMI. Male and female views
of CMI were very similar.
The most common reason that patients did not receive any CMI, was confusion/anxiety. In most of these
cases, it was not appropriate to offer CMI. Many were to be discharged to nursing homes and hostels
where medications are supervised. If the confused patient were to be discharged to either their own home
or a relative’s home, then this would be the occasion where the relative or carer could be offered CMI.
Approximately one quarter of surveyed patients who did not receive any CMI already had the CMI from
another source.
Thirteen percent of surveyed patients rejected the offer of CMI. Of the patient group who did not receive
CMI, only 7.7% of these did not because it was unavailable from CIAP. However, the total number of
patients who did not receive CMI because it was unavailable from CIAP was 12.4%, as there were a
number of patients who received some CMI, but not all, because it was not all available from CIAP.
Only 4% of surveyed patients did not receive any CMI because they were unable to speak or understand
English.
Sixty-eight per cent of patients were discharged to their own home. Patients going to their own home are
significantly more likely to receive CMI (95% confidence interval [1.17 , 1.68] and patients going to
other institutions are significantly less likely to receive CMI. Of the patients discharged to their own
homes who did not receive any CMI, one third already had the CMI from another source.
24
PROJECT OUTCOMES
CMI pathway for the pharmacist
For the project, the pharmacist made a process change in the production of CMI by procuring CMI from
CIAP and not using a combination of other sources. The necessity to record activities on the data
collection form led to a formalized protocol being developed from previous practice. The pharmacist
routinely checked whether the patient had received CMI for existing medications, either by asking the
patient or checking the patients’ own medication packages. If the patient’s own medications were to be
returned for discharge and these contained CMI, then CMI would not be offered for that medication. The
pharmacist focussed particularly on new medications commenced during the admission.
The pharmacist has continued to offer CMI to appropriate patients who are to be discharged to their own
home, particularly for new medications and this has been occurring at about the same rate as throughout
the project.
Pharmacist Procedure
A system was developed so that when patients were admitted and their medications written onto
medication charts, the pharmacist wrote the brand name of the medication issued by the hospital above
the doctor’s order.
During admission, the pharmacist would identify whether the patient was suitable to be offered CMI.
Patients considered unsuitable may be aggressive, confused, highly anxious or agitated. Often the
confused patients were to be discharged to a nursing home.
The pharmacist then offered CMI to the patient and ascertained whether the patient already had CMI at
home for any of the medications. If new medication was commenced, the pharmacist encouraged the
patient to accept CMI for that.
A system was developed, in the form of an inpatient masterlist, to clarify communication between the
nurses and the pharmacist about who had offered CMI to a patient, to avoid duplication.
The CMI was given to the patient and the medication use and potential side effects were explained in the
usual discharge practice.
25
CMI pathway for the nurse
In the post-project survey of nurses, the most frequent comment reflected lack of time to effectively
provide CMI. It was time consuming to describe a CMI, outline its benefits, determine its availability,
procure it and then discuss all aspects of the particular medication with the patient. One nurse felt that the
shift nature of their work made it difficult to follow through and complete the process. The length of
CMI from CIAP, often seven to eight pages long, was cited by nurses as another deterrent to offering and
giving CMI to patients.
One nurse reported a continuation of CMI provision after the project.
The results support the literature that there has been little opportunity for nurses to identify issues and
develop solutions to effectively deliver CMI.
Nurse Procedure
Flowcharts were developed to assist nurses in accessing CIAP and in choosing the correct brand of CMI.
The pharmacist, as mentioned above, clarified the brand of medication stocked on the ward drug trolley.
Nurses and the pharmacist communicated via the CMI masterlist, referred to in the pharmacist procedure,
about which patients had been offered CMI.
EVALUATION
Process
Process development for the project recognised certain conditions and practice issues. There are many
projects conducted at WMH and staff are regularly asked to absorb extra tasks. There is often only one
registered nurse on duty in any one shift and often there may be agency registered nurses or casual staff.
There is one computer on each ward and the printers may not be nearby.
It was emphasised that the role of the WMH pharmacist would remain the same and there may be
occasions where she has already provided CMI in the normal course of her work.
26
The IT officer supported requests to resolve various technical problems. The project team developed
education sessions that were reviewed and modified as needs were identified; particularly when new staff
commenced, specific requests were made or when specific issues such as CMI brand specificity arose.
The steering committee and the presence of the project pharmacist on site during the pilot, effectively
served to capture or identify these needs.
Matching the CMI given to the patient with the brand of medication dispensed for or returned to the
patient for discharge proved an issue for nurses. To minimise the impact, a procedure was established
and added to subsequent education sessions.
The pilot demonstrated three related issues. An offered CMI may not be available on CIAP; an offer or
discussion may have been made by one clinician, but not documented, so risking duplication by another
clinician; and which brand medications the patient would take home. Communication between staff was
imperative to begin to overcome these structural issues. It was also clarified that nurses would provide
CMI when the pharmacist (part-time) is not at work.
For patients discharged from the hospital, data collection forms were completed for approximately 90 %
during the pilot phase and 75% during the study phase. The high rate for the pilot phase is probably
explained by several factors. The newness of the project, combined with a short period of time (1 month
Vs 6 months) whereby extra tasks can be sustained for a shorter duration. The NUMS from both wards
were involved in offering and/or producing CMI more during the pilot phase.
During the project, access to CMI via CIAP was reported as almost completely successful. On only one
occasion was CMI unavailable due to a technical problem. This was probably a local issue, rather than a
fault with CIAP.
27
All nurses attended both CMI training and project procedure education sessions. Many attended more
than one and some attended all. The project pharmacist recorded the attendance. The support of the CNC
and the Director and Deputy Director of Nursing was consistent and committed, facilitating and
encouraging participation.
The data collection form was reviewed and modified after the pilot. It must be noted that dementia as a
data collection category did not necessarily reflect actual diagnosis, but rather a subjective description of
patient cognition.
As reported earlier, 4% of patients did not receive a CMI because they did not speak or understand
English. There was not an alternative and the needs for medication information for these patients could
only be met verbally via a trained interpreter or a family member translating.
Impact
Not all CMI required during the study were available from CIAP. The limitations to the availability of
electronic CMI are documented elsewhere. As stated earlier, 12.4% of patients did not receive CMI
because it was not available electronically. However, comparative exercises between CIAP and
electronic CMI from a pharmacy dispensing software package indicated that CMI formatting from CIAP
created longer documents. The legislated condition that CMI be current was met in CIAP.
The time to generate a CMI as measured by logon, search and print was no longer than expected, and not
the rate limiting step in the process. The time measures recorded in the study included the total process –
description of CMI, its potential benefit, whether or not the patient needed or required CMI for all drugs,
procuring the document and then discussing each medication’s actions and possible side effects. Over the
course of the project, the processes undertaken by the nurses and the pharmacist were modified to
recognise these variables.

28
The data from the study does not indicate a decrease in time taken for the CMI provision process. There
is agreement that the times recorded often do not include the actual discussion about the medications.
The report of patient view was positive or indifferent for more than half of the patients. This group
included both those who did and did not receive CMI. It must be noted that more than a third of the
patients were not surveyed for their view, because they were designated as unsuitable for CMI provision
due to cognitive/behaviour status or discharge destination. It was important that the patient view was
about the provision of CMI for their specific medications, and not the total concept of CMI, a point made
in the education sessions.
Nurse views have been partly discussed in the outcome. The nurses expressed strong reservations about
the provision of CMI in their exit survey. The principle reason expressed was time constraints, with some
comments about whether nurses should have a role in CMI provision.
The completion of project documentation did decrease over the course of the study. Education sessions
during the project preceded increases in documentation. The pilot over one month had a higher
participation rate than any month in the study.
The project team developed the initial procedure for nurse provision of CMI and no consultation was
undertaken with the ward nurses. The project pharmacist provided the information about the study to the
nurses, although regular nurse meetings did confirm the study’s significance. Meetings with the ward
nurses subsequent to the development of the initial pathway included much feedback, discussion and
modifications. In the context of busy ward activities and nursing workforce shortages, it was not always
possible to increase nursing hours for the project.
29
The project established a task sequence for the nurses to provide CMI. There is no historical context for
nurses to provide written drug information; both the current literature and education curricula are only
now beginning to address this complex issue.
Outcome
Data was gathered for one hundred and sixty one patients. Twenty-two of these received CMI for some or
all of their medications and only one received CMI for all of their medications. It became apparent in the
pilot that CMI provision to all patients for all medications was neither practical nor necessary. Therefore,
the project commenced with a modification that CMI provided for new medications only would be a data
collection item.
Procedures for provision of CMI by the pharmacist prior to the project were in place but not documented.
The project stimulated some small changes. These changes facilitated communication with nurses and
adjustments to technical infrastructure.
The changes to nursing procedure to accommodate the project were more extensive than for the
pharmacist. There was no precedent for medication information provision by nurses, so a procedure had
to be developed. In the context of the project, the procedure was sufficient after review and modification;
but in the context of routine clinical practice it clearly lacked integration. The project could be said to
have exposed the nurses to the concept of medication information provision and the attendant work
necessary to make it work.
The project has demonstrated the need to more fully explore the potential modes of medication
information provision. Nurses have not yet had the opportunity to fully debate and deliberate on the
possibilities of medication information provision.
30
CONCLUSION
Provision of CMI should be available to all inpatients for all the medications that they take, but especially
to patients being discharged to their own homes and who have been commenced on new medications
during their hospital stay.
Hospital pharmacists are in the best position to provide this service once the technical apparatus is in
place, especially in ensuring that the CMI brand given matches the brand of the discharge medications
and for targeting new medication prescribed. The pharmacist would be able to answer, or have access to
resources, to answer any further questions about the medication.
Nurses are usually in the best position to offer CMI to the patient’s carer or agent, if appropriate.
Mechanisms for nurse and pharmacist communication can be organised to suit a local situation.
CMI is a tool to assist verbal explanation about medication use, with the aim of enhancing medication
management and adherence to medication regimens. Facilities need to commence discussion between the
different groups of clinicians to determine procedures for CMI provision and to customise this provision
of CMI to individual situations.
31
APPENDIX ONE
32

Final Report

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FINAL REPORT

PROVISION OF CONSUMER MEDICINE INFORMATION IN A REHABILITATION UNIT OF

WAR MEMORIAL HOSPITAL, WAVERLEY, NSW

WAR MEMORIAL HOSPITAL

COMMUNITY HEALTH SERVICES PRINCE OF WALES HOSPITAL

Pharmaceutical Education Program for the funding to conduct this project.

Hospital administration for their cooperation and support.

APAC Australian Pharmaceutical Advisory Council

CIAP Clinical Information Access Project

CMI Consumer Medicine Information

CNC Clinical Nurse Consultant

CPI Consumer Product Information (not used any longer)

NESB Non English speaking background

NUM Nurse Unit Manager

PHARM Pharmaceutical Health and Rational Use of Medicines

SEH South East Health

SHPA Society of Hospital Pharmacists of Australia

TGA Therapeutic Goods Administration

WMH War Memorial Hospital, Waverley

efficiently deliver CMI to patients.

the rehabilitation ward of the War Memorial Hospital, Waverley, NSW.

deliberation must be sufficient to develop workable and sustainable protocols.

effects of the medication.

printing results in a reduction of pages produced.

of people of non-English speaking backgrounds.

facilitate quality use of medicine.

Kristin Mbothu, Chief Project Director

Fiona Russell, Other Project Director

Mikala Five, Other Project Director

Anne Pendergast, Other Project Officer

Jenny Blennerhassett, Project Pharmacist and Report Author

hours). The project aimed to:

- examine the suitability of a particular method of CMI procurement.

professional practice, therefore creating impetus for revising practice guidelines.

confirmed as the preferred method of delivery.

companies by volume provide electronic CMI.

CMI for electronic delivery.

pharmacist’s planned session with each patient.

patients; and also the requirements for CMI provision.

St Vincent’s Hospital, Sydney and Prince of Wales Hospital, Sydney.

background in which it is already being produced and distributed’.1

less able to produce current CMI as part of routine clinical practice.

from original manufacturers’ containers by the hospital pharmacy.

provision and is in the process of establishing an electronic CMI distribution method.7

within each network.

sector) includes any reference to quality use of medicine or CMI.

associated with CMI delivery by hospital pharmacists.

Overseas experience appears to be similar. In a study in Canada examining medication education of

information about medication to consumers. Clearly, issues are still outstanding.

(CPI). MJA 1997; 166: 425-428.

Australian Pharmacist 1998; 17(8): 15-20.

6. RNSH Pharmacy Department Policies and Procedures, Policy No:C4.2

8. Robb A. Amfac-Chemdata, January 1999.

Professionals on Consumer Product Information. May 1995.

10. Low J. Hospital Talk. Australian Journal of Pharmacy 2001; 82:119.

and evaluation of Consumer Product Information. PHARM (unpublished)

Pharmacists of Australia (NSW branch) July 2000; 16.

2001; 82: 18.

Trade Sept 7, 2000; 14

16. Living Well February 1999.

new medications commenced during the admission are targeted.

includes procedures for CMI provision.

AIMS AND OBJECTIVES