Impact of a multidisciplinary medication reconciliation program on clinical outcomes: A pre-post intervention study in surgical patients

Implementation and User Satisfaction Analysis of an Electronic Medication Reconciliation Tool (ConciliaMed) in Patients Undergoing Elective Colorectal Surgery

Background/Objectives: Medication reconciliation is an essential strategy to improve patient safety, especially in polymedicated and chronic patients undergoing surgery. This study describes the implementation of an electronic medication reconciliation tool, ConciliaMed, in a multidisciplinary medication reconciliation programme performed for patients undergoing elective surgery and assesses user satisfaction with the tool since its release. Methods: A prospective observational study was carried out on "high-risk" patients undergoing colorectal surgery. In the medication reconciliation programme, ConciliaMed was mainly used to obtain an optimised and reconciled patient medication list by using the "Perioperative medication reconciliation" and the "Therapeutics equivalents" modules included in the tool. Data were registered about the reconciled medications, medication discrepancies and interventions made to optimise the reconciled medication list. Concerning the users' satisfaction analysis, data about users' registration and feedback were collected. Results: Seventy-three patients were enrolled in this study who were mainly polymedicated. A 10.1% of medication discrepancies were identified from the total of 553 reconciled drugs. The pharmacotherapeutic groups most involved in medication discrepancies were psycholeptics or diuretics. Regarding the optimisation of the reconciled drugs, stopping medication before surgery was the most frequent recommendation provided by the tool. According to the results of the satisfaction surveys, high overall satisfaction with the tool (4.45 ± 0.80) was reported by users. Conclusions: Stopping medication before surgery was the most common preoperative medication management recommendation provided by the tool. ConciliaMed was evaluated by pharmacists, nurses and physicians who reported a high level of satisfaction with the tool. A more comprehensive evaluation of this tool in other types of scheduled surgical patients is expected.

ConciliaMed: an interactive mobile and web tool to reconcile chronic medications of patients undergoing elective surgery

OBJECTIVE

The last decade has seen exponential growth in electronic health tools. However, only a limited number of electronic medication reconciliation tools have been developed and implemented in healthcare settings. Here, we present ConciliaMed, a mobile and web-based tool for healthcare professionals to reconcile the chronic medications of patients undergoing elective surgery.

METHODS

A research team of pharmacists and internists worked together with a technology company to design and develop ConciliaMed. Evidence-based guidelines were collected for inclusion in the tool. A group of experts conducted a simulation with a preliminary version of ConciliaMed to identify bugs and technical improvements and to assess their satisfaction with the application. The final prototype of the tool was disseminated through clinical meetings and the Google Store.

RESULTS

Four easy-to-use and interactive modules can be used to reconcile chronic medications through the app, while the web platform is designed for consultation and learning. A higher level of satisfaction with the tool was achieved by the test participants (4.67±0.58). The triggering of dose and duplication alerts for users or the integration of ConciliaMed with electronic prescription systems were some of the more requested adaptations by the test participants.

DISCUSSION

The ability to generate an editable reconciliation report or transfer information between users are some of the features of ConciliaMed that encourage its use. The integration of ConciliaMed into the healthcare workflow is expected.

CONCLUSION

The web platform is freely available online (https://conciliamed.chronic-pharma.com), as is the mobile application through the Google Store, making it easily accessible to healthcare professionals.

Medication Management of Patients With Cancer Undergoing Surgery From Preadmission to Discharge: A Mixed-Methods Systematic Review

AIM(S)

To identify and synthesise available evidence about regular medication management processes, from preadmission to discharge from hospital, in patients with cancer undergoing surgery.

DESIGN

Mixed-methods systematic review.

METHODS

Studies published from inception of each database until February 2023 were screened, utilising four main search concepts. The JBI methodology for mixed-methods systematic review was followed in this review.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, APA PsycINFO, Scopus and Web of Science.

RESULTS

Eight out of 717 screened studies were included. Two themes related to patients' medication management were identified. Preoperative factors such as polypharmacy, potentially inappropriate medications, delirium-inducing medications and preoperative discontinuation-requiring medications were associated with several postoperative complications in patients with cancer. Additionally, pharmacist-led interventions and collaborative efforts between nurses and patients were shown to improve the medication management process across the perioperative pathway.

CONCLUSION

This systematic review emphasises the necessity of effectively managing regular medication, especially before surgery, to mitigate postoperative complications in patients with cancer. It offers critical insights into how involving pharmacists and nurses enhances medication management outcomes, benefiting health care professionals and institutions aiming to optimise perioperative medication therapy.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Enhancing patients' regular medication management through comprehensive reviews before surgery, and improving collaborative practices among pharmacists, nurses and patients via targeted interventions introduced by health care organisations, ensure safe medication use throughout the perioperative pathway.

IMPACT

Improving regular medication management process can reduce risk of medication errors and adverse drug events and enhance postoperative outcomes.

REPORTING METHOD

SWiM reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Practice-enhancing publications about the medication-use process in 2021

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2021 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring, and monitoring/medication reconciliation. Articles evaluating at least one step of the MUP were assessed for their usefulness toward practice improvement.

SUMMARY

A PubMed search was conducted in January 2022 for articles published in calendar year 2021 using targeted Medical Subject Headings (MeSH) keywords, and searches of the table of contents of selected pharmacy journals were conducted, providing a total of 7,178 articles. A thorough review identified 79 potentially practice-enhancing articles: 15 for prescribing/transcribing, 17 for dispensing, 4 for administration, 21 for monitoring, and 22 for monitoring/medication reconciliation. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of their importance within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful publications. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS®) Programs

Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.

The prevalence of chronic medication therapy problems and pharmacists' interventions among hospitalized perioperative patients: a retrospective observational study

BACKGROUND

Inadequate preoperative management of chronic medications can place perioperative patients at risk and cause unnecessary delays in surgical procedures. This study aims to investigate the prevalence of chronic medication therapy problems (CMTPs) in hospitalized perioperative patients and assess the relevance of pharmacists' interventions.

METHODS

We conducted a retrospective study of pharmacist-led preoperative management of chronic medications in hospitalized adult patients from November 2018 to April 2019. The recorded drug-related problems (DRPs) were retrospectively reviewed and categorized according to the Pharmaceutical Care Network Europe classification V9.1 and were analyzed with a multinomial regression model to identify risk factors.

RESULTS

A total of 254 DRPs were recorded, with an average of 0.52 DRPs per patient. Treatment safety (66.9%) was the most common DRP. The most frequent causes of perioperative DRPs and nonperioperative DRPs were drug selection (72.9%) and patient related (50.8%), respectively. Of the 292 documented interventions, 71.6% were fully accepted by the clinicians and patients. The majority (68.9%) of the recorded problems were completely resolved. The number of comorbidities (OR = 3.815) and the number of chronic medications taken (OR = 1.539) were risk factors for the occurrence of DRPs.

CONCLUSION

The findings of this study suggest that pharmacist-led chronic medication therapy management in surgical wards may be an effective method to help reduce medication-related surgical risks and optimize the medication therapies used for the long-term treatment of chronic diseases.

Effect of Medication Reconciliation at Hospital Admission on 30-Day Returns to Hospital: A Randomized Clinical Trial

IMPORTANCE

According to international recommendations, hospitals should use medication reconciliation to prevent medication errors and improve patient safety.

OBJECTIVE

To assess the impact of medication reconciliation at hospital admission on patient-centered health care outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This parallel group, open-label randomized controlled trial used centralized randomization to the intervention group (ie, individuals with medication reconciliation) or control group (ie, individuals with only standard, physician-acquired medication history). Outcome assessors and data analysts were blinded to group allocation. Participants included 1702 patients aged 85 years or older, with more than 10 medications at hospital admission, or meeting both conditions at 2 regional secondary teaching hospitals in southern Switzerland. Study duration was 14.5 months, from November 1, 2018, to January 15, 2020. Data were analyzed from December 2018 through March 2020.

INTERVENTIONS

Medication reconciliation was performed at hospital admission in 3 steps: (1) the pharmacy assistant obtained the list of the patient's current medications (ie, the best possible medication history [BPMH]); (2) the clinical pharmacist led reconciliation of the BPMH with the list of home medications recorded at hospital admission by the attending physician (according to the hospital standard procedure); and (3) medication discrepancies were communicated to the attending physician, and, when necessary, medications prescribed at admission were adapted.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite postdischarge health care use variable quantified as the proportion of patients with unplanned all-cause hospital visits (including visits to the emergency department and hospital readmissions) within 30 days after discharge from the hospital when medication reconciliation took place. A time-to-event analysis was performed.

RESULTS

Among 1702 patients (median [interquartile range] age, 86.0 [79.0-89.0] years; 720 [42.3%] men), 866 patients (50.9%) were allocated to the intervention group and 836 patients (49.1%) to the control group. The primary outcome occurred among 340 participants (39.3%) in the intervention group and 330 participants (39.5%) in the control group (P = .93). In time-to-event analyses at study closeout, unplanned all-cause hospital visits to the emergency department (log-rank P = .08) and unplanned all-cause hospital readmissions (log-rank P = .10) occurred similarly in the intervention and control groups.

CONCLUSIONS AND RELEVANCE

These findings suggest that medication reconciliation at hospital admission has no impact on postdischarge health care outcomes among patients aged 85 years or older, with more than 10 medications at hospital admission, or meeting both conditions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03654963.

Anaesthesia for the elderly: a narrative review

As octogenarians in the operation room are no longer an exemption but the norm, perioperative management needs to be adopted to meet the special requirements of this group of patients. Anaesthesia does not need to be re-invented to fit the elderly. However, as elderly patients are among those most affected by adverse postoperative outcomes, the same diligence that is as a matter of course exercised in anaesthesiologic care of the youngest patients needs to be exercised for the eldest as well. Aging is associated with characteristic physiologic changes and an overall reduction in compensation width. However, the individual relevance of these changes varies distinctly. A comprehensive preoperative assessment is therefore essential to identify those at high risk. Maintaining functionality and preventing cognitive decline are central elements of perioperative care for frail elders, often only requiring unspectacular, but effective adjustments to established routine care processes. This review focuses on current recommendations in the perioperative anaesthesiologic management of elderly patients with a view towards assisting clinical anaesthesiologists in implementing respective structures in their setting and adjusting care pathways to meet the needs of this vulnerable but growing group of patients and improve their postoperative outcome.