Standard of practice in surgery and perioperative medicine for pharmacy services

Established and emerging roles for pharmacy in operating theatres: a scoping review

BACKGROUND

Pharmacy services at surgical pre-assessment clinics and on inpatient wards are well-documented, but services to theatre appear comparatively under-developed. High-risk and high-cost medicines are used routinely in theatre; pharmacists are well-qualified to optimise their use and improve patient care.

AIM

To determine the range, extent and nature of pharmacy services to theatre internationally, and to describe any reported outcomes of these services.

METHOD

This scoping review was conducted and reported as per PRISMA-ScR and Joanna Briggs Institute methodology. A search was conducted across MEDLINE, Embase, CINAHL, PsycInfo, Bielefeld Academic Search Engine, Canada's Drug and Health Technology Agency, Google and Google Scholar in April 2023. One reviewer screened titles and abstracts. Two reviewers screened full texts. Data extraction was completed by one reviewer. Two reviewers used the Mixed Methods Appraisal Tool (MMAT) to perform quality appraisal. For work completed by one reviewer, a 10% sample was randomly selected for screening by a second reviewer.

RESULTS

Ninety-two publications were included from 3924. Fifty-seven were primary research articles. Other publication types included conference abstracts, journal columns, letters to the editor, practice standards/guidelines, opinion papers, narrative reviews and newsletter articles. Medication management and clinical services across five continents were described. Most reported outcomes related to cost savings. Nine of the 57 articles met the criteria for MMAT appraisal: of these, adherence to quality criteria ranged from 40 to 100%.

CONCLUSION

Evidence for theatre pharmacy services is extensive and varied. Empirical research of high methodological quality is required to assess the outcomes of these services.

Medication use and potential drug-drug interactions in a general surgery clinic: A descriptive study

Aim

Perioperative pharmacies optimize medication safety and patient-centered care during surgery. This research aims to assess medication usage and potential drug-drug interactions (pDDIs) in a general surgery clinic.

Methods

This prospective and descriptive research was carried out in a general surgery clinic at a hospital in Turkey. The patients who were admitted for any surgical procedure and stayed for a minimum of 24 h were included in the study. Information on prior medication use as well as pre- and post-operative medications was documented. pDDIs were assessed using the Lexicomp database.

Results

The study involved 95 patients, with a median age of 54 (ranging from 19 to 86). It was found that 66.3 % of the patients had at least one comorbidities. The average number of medications administered during the post-operative period was greater than during the preoperative period (5.7 vs 4.5, p < 0.0001). Furthermore, the incidence of pDDIs identified in doctors' orders after surgery was higher compared to before surgery (p < 0.05).

Conclusion

In this study, the majority of patients scheduled for surgery had at least one comorbidity. We suspect that the elevated number of medications administered postoperatively could have led to pDDIs Consequently, we expect that clinical pharmacy services will help ensure the safe and rational use of medications in surgical clinics.

Introduction of a Pre-admission Pharmacist Service Utilising the Surgical Ward Pharmacist

Background: The challenge with obtaining a best possible medication history (BPMH) post-surgery is the delay in clarifying medications due to decreased post-operative cognitive status and pain, which can lead to missed or late administration of medications. Studies have suggested that unintentional medication discrepancies at the time of admission are common in general medical patients. Objectives: To investigate if a pre-admission pharmacist completing BPMHs for adult elective surgery patients with planned overnight admission increases the proportion of patients with (i) a BPMH completed, (ii) medication reconciliation completed and (iii) all home medications charted correctly within 24 hours of admission. Methods: Patients in the pre-intervention group had a BPMH completed on admission as standard of care. Patients in the post-intervention group were contacted by the pre-admission pharmacist 1 to 3 business days prior to admission to complete a BPMH. The pre-admission pharmacist role was performed by a surgical ward pharmacist in addition to their daily workload. Descriptive statistics, Chi-squared test and Mann-Whitney U test were used to analyse the data. Results: The post-intervention group had more patients with a completed BPMH (47.2% vs 25.3%, P = .005), medication reconciliation (43.8% vs 15.5%, P = .0001) and all home medications charted correctly (36% vs 16.9%, P = .007) within 24 hours of admission compared with the pre-intervention group. Conclusion: The introduction of a pre-admission service utilising the surgical ward pharmacist increased the proportion of patients with a completed BPMH, medication reconciliation and home medications charted correctly within 24 hours of admission.

Enhancing Drug Management, Cost Savings, and Staff Satisfaction in Anesthesiology: A Quality Improvement Project in a Chinese Tertiary Hospital

INTRODUCTION

In alignment with China's national directive for improved drug management in anesthesiology, the Affiliated Hospital of Qingdao University initiated a quality improvement project, aiming to tackle the prevailing challenges of inefficiencies in drug administration, escalating drug costs, and the notable communication gap between pharmacists and anesthesiologists.

METHODS

We employed a Plan-Do-Study-Act methodology to establish a pharmacy team and execute a multidimensional pharmaceutical intervention. The interventions included the formulation of standard procedures, guidelines and regulations, assistance from an information system (including automatic dispensing cabinets and prospective prescription review system), communication feedback (via WeChat groups), and education for anesthesiology staff. The intervention spanned from April to September 2023, focusing on optimizing medication management, achieving cost savings, and enhancing the satisfaction of anesthesia team members, with an additional observation from October to December 2023.

RESULTS

Following the interventions, improvements were observed in drug management practices. These enhancements included increased compliance with accounting procedures, more rigorous registration of controlled substances, and more effective disposal of liquid residues. There was no adverse events related to high-alert medications or look-alike drug usage errors. The introduction of automatic dispensing cabinets and a prospective prescription review system markedly improved work efficiency. The utilization of a WeChat group facilitated effective communication about unreasonable prescriptions and drug-related issues. Among the 29,061 patients who underwent surgery both before and after the interventions, significant reductions were observed both in the drug proportion and the per capita drug costs (P = 0.03, P = 0.014, respectively). The per capita drug cost decreased by 20.82%, from ¥723.43 to ¥572.78, consistently remaining below ¥600 throughout the 9-month observation period. The per capita cost of monitoring drugs including dezocine, butorphanol, haemocoagulase agkistrodon, penehyclidine, and ulinastatin experienced a significant reduction (P < 0.05). Additionally, in the satisfaction questionnaires returned, a remarkable 94.44% of anesthesiology staff expressed high satisfaction with the comprehensive pharmaceutical interventions.

CONCLUSION

The quality improvement project has yielded remarkable positive outcomes, serving as a model worthy of reference and replication in similar healthcare settings.

Evaluation of the clinical pharmacist services at a gynaecological oncology preadmission clinic

Background

Pharmacists working in the multidisciplinary gynaecological oncology pre-admission clinic (PAC) are involved in the perioperative assessment of patients for a comprehensive medication history and information provision regarding withholding of medications before surgery.

Objective

To evaluate the current services provided by pharmacists to multidisciplinary staff and patients attending the PAC.

Methods

A staff and a patient feedback survey on the value and impact of PAC pharmacy services were distributed within the PAC. The impact of the PAC pharmacist was also assessed by analysing pharmacist interventions and key performance indicators documented.

Results

Fifteen staff responses were recorded, 5 nursing staff, 2 midwives and 8 anaesthetists. Eighty-seven percent (n = 13) strongly agreed or agreed that pharmacists at PAC help reduce medication errors on admission. Staff strongly agreed 73% (n = 11) pharmacists obtain a more accurate medication history. Staff reported benefits in having a pharmacist at the clinic to discuss medication related questions with 87% (n = 13) strongly agreeing or agreeing with the statement. A staff overall satisfaction rating of 4.87 out of 5 was recorded. In the patient survey, respondents (n = 6) gave a 4.83 out of 5 rating in confidence in making changes to their medication and their overall satisfaction with the service provided. In reviewing data from January to June 2022, the number of patients seen by the pharmacist were 178 of 681 patients (26.1%) who attended the clinic. The most common medications involved in the pharmacist intervention include those that were advised to be withheld and those that required other changes to therapy prior to their procedure.

Conclusion

The role of a PAC pharmacist can be greatly appreciated by the multidisciplinary team and patients. Pharmacist interventions and key performance indicators have demonstrated the important activities of clinical pharmacy services in the PAC in optimising patient care in medication management.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.