Autopopulation of Medicine sick-day rules
Dr Rod Sampson (GP Partner), Elaine Townshend (Health Board Pharmacist), Dr Douglas Naismith (FY2)
- To raise awareness of “Medicine sick-day rules” with clinicians and patients
- To encourage conversations around “Medicine Sick day rules” between professionals and patients
- To provide an automatic and durable prompt
- To transfer “Medicine sick-day rules” information from a card to the actual generated prescription (and thus the dispensed medication)
- Use the “Medicine sick-day rules” present on the generated prescription to act as both a reminder for clinicians (to discuss “Medicine sick-day rules” with patients) and patients.
- Remove the human element of having to remember “Medicine sick-day rules” by embedding the automatic population of an “at-risk” medication script, by the primary care software system.
The National Confidential Enquiry into Patient Outcomes and Death found that: “20-30% of cases of AKI are avoidable and better management of AKI may save up to 12,000 lives each year.”  Many prescribed medicines are known to increase risk of acute kidney injury (AKI) in dehydrated patients; drugs such as Metformin, diuretics, non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin-II receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACEi’s).It is important to highlight “Medicine sick-day rules” in primary care as 61% of AKI is of community origin. 
Clare Morrison (Pharmacist) and Martin Wilson (Geriatrician) created a “Medicine Sick Day Rules” card as a new patient safety initiative in NHS Highland. [3-5] The card served as a reminder, but also importantly a prompt to encourage discussion between a health care professional and a patient. Information on the card stressed the importance of stopping “at-risk” medications should the patient suffer a dehydrating illness.
As a practice, we found the cards useful for their intended purpose, but didn’t always have cards available, and wondered for some patients whether the card could simply be lost. Practice audit also revealed low recording of conversations centred on “Medicine sick-day rules.”
It is within this context that we considered the introduction of similar “Medicine sick-day rules,” but via a different method.
Our health board pharmacist set up our primary care software system (in our case INPS Vision) to auto-populate all new prescriptions of “at-risk” medicines with an agreed “Medicine sick-day rules” message.
All new prescriptions of “at-risk” medications are now auto-populated with a “Medicine sick-day rules” message (Box 1)” The prompt has served as a useful reminder for clinicians when prescribing “at-risk” medicines, to have a conversation with the patient highlighting the “Medicine sick-day rules.”
Our intervention has usefully helped raise awareness amongst clinical staff of the issues around “at-risk” medications, risks of acute kidney injury (AKI), and the importance of “Medicine sick-day rules.” Our experience is that this has been especially so when prescribing an “at-risk” medication for the first time.
Given the “Medicine sick-day rule” message is part of the prescription, there is less of an issue in relation to re-ordering “Medicine sick-day rule” cards, and for the patient, less of an issue if the card is lost (the “Medicine sick-day rules,” being part of the prescription (see picture 1) also appears on the prescribed medication label). Also, as a component of the prescription, the auto-populated message serves as a regular reminder.
Picture 1: example of a prescription and dispensed medication with “Medicine sick-day rules” applied.
We have taken away the human element in terms of automatic generation of the reminder, but we are still reliant on the clinician remembering to have the conversation with the patient. Both clinicians and patients may get “reminder fatigue,” and cease to take notice of what is important information.
Implications for practice and future research
Quantitative research methods may be utilised to determine whether the issue of “Medicine sick-day rules” in any form make a difference in terms of risk of AKI and/or AKI related hospital admission.
There may be value in comparing methods of delivery of “Medicine sick-day rules” in terms of effectives:
- a. Which method is better at helping the patient retain information?, and,
- b. Which method serves as a better prompt in relation to the clinician raising the issue with the patient?
Given that when patients are referred from primary to secondary care, their medication list “goes with them,” information on “Medicine sick-day rules” linked to their repeat medication may also serve as a useful prompt/reminder to clinicians in secondary care.
- National Confidential Enquiry into Patient Outcomes and Death (NCEPOD), Published 2009, Accessed 15/04/2015
- Selby NM et al, CJASN, “Use of Electronic Results Reporting to Diagnose and Monitor AKI in Hospitalized Patients” 2012; 7(4) 532
- Morrison, C., Wilson, M., Highland Quality Approach, “Medicine Sick Day Rules – Interim Evaluation”, July 2014
- Morrison, C., Wilson, M., NHS Highland “Medicines and Dehydration: Patient Information”, Jan 2015
- NHS Highland SPSP Primary care Working Group, “Medicine Sick Day Rules” cards, April 2013