Quality improvement of intravenous to oral medication conversion using Lean Six Sigma methodologies

Abstract

Introduction: Lack of medication conversion from intravenous to oral contributes to increased risk of infection, delayed discharges and higher medication costs. At our institution, intravenous to oral medication conversion rate was 76% with missed opportunity for conversion of 37%. The goal of the project was to reduce the percent of missed opportunities for intravenous to oral conversion for applicable medications.

Methods: A pharmacy-driven intravenous to oral policy and procedure was implemented. To identify potential opportunities, a patient worklist of applicable intravenous to oral medications was created for pharmacy review in real time. An intravenous to oral conversion order was implemented in the computerised provider order entry. 'Convert to oral' was added as an option in the electronic medication request and highlighted reminders were added to the electronic medication administration record for eligible medications.

Results: After improvements, the missed opportunity rate for intravenous to oral conversion decreased from 37% (19/51) to 21% (24/113) (p=0.04, two-proportion test), a 43% improvement. The trend in intravenous to oral conversion rate increased from 76% (39/51) to 85% (171/201) and severity adjusted length of stay was reduced from 8.1 days to 6.4 days post improvements (p<0.001, t-test).

Keywords: Six Sigma; antibiotic management; electronic prescribing; healthcare quality improvement; patient discharge.

Figure 1

Screenshot of the Clinical Pharmacist Worklist of applicable intravenous (IV) to oral (PO) medications used to identify potential opportunities for conversion in real time. BID, two times per day; IVPB, intravenous piggyback; Q, every.

Figure 2

Process map of intravenous (IV) to by mouth (PO) coordination of care. Before implementation of process changes, diet orders, diet tolerance and opportunity for oral conversion were re-evaluated at different points in the process by physicians, nurses and pharmacy. Due to lack of notifications or triggers, staff were often unaware of diet order changes and eligible medications. Before the automatic intravenous to oral policy, pharmacy had to page the provider or wait until rounding was completed to make the conversion. CPOE, computerised provider order entry.

Figure 3

Rate of missed intravenous (IV) to by mouth (PO) opportunities was significantly reduced from 37% (19/51) to 21% (24/113) after implementation of an intravenous to oral policy, specific conversion criteria, a Clinical Pharmacist Worklist, an additional medication request option for nurses to communicate with pharmacy and reminders in the electronic medication administration record (two-proportion test, p=0.04).

Figure 4

Intravenous (IV) to by mouth (PO) conversion rate increased from 76% to 85% post interventions (p=0.1, two-proportion test). Improvement has been sustained at an average 85%.