Implementation of an innovative surgical pharmacy service to improve patient outcomes-Twelve-month outcomes of the Enhanced Surgical Medicines Optimization Service

The role of pharmacists in mitigating medication errors in the perioperative setting: a systematic review

INTRODUCTION

Medication errors occur at any point of the medication management process and are a major cause of death and harm globally. The perioperative environment introduces challenges in identifying medication errors due to the frequent use of time-sensitive, high-alert medications in a dynamic and intricate setting. Pharmacists could potentially reduce the occurrence of these errors because of their training and expertise.

AIM

To provide the most up-to-date evidence on the roles and effects of pharmacist interventions on medication errors in perioperative settings.

METHODS

PubMed, CINAHL, and Embase were searched from inception to September 2023. Studies were included if they tested a pharmacist-led intervention aimed at reducing medication errors in adult perioperative settings. The included studies were assessed for quality using the Crowe Critical Appraisal Tool. Data were extracted and synthesized using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool). Screening, quality assessment, and data extraction were performed by two independent researchers.

RESULTS

Sixteen studies were eligible. All included studies incorporated multicomponent interventions, primarily medication reconciliation (n = 13), medicine-related recommendations (n = 12), staff education (n = 6), and patient counselling (n = 4). The development of implemented interventions was poorly reported across all papers. A diverse range of error reporting was observed, and none of the included studies provided definitions or basis for the categorization of errors. Although the studies showed that pharmacist interventions were associated with a reduction in overall medication errors rates, some studies showed inconsistent findings regarding error subtypes. The most common pharmacist intervention was medication optimization via holding or switching between agents.

CONCLUSION

While there is some evidence of positive impact of the pharmacist-led interventions on medication errors in perioperative setting, this evidence is generally of low quality and insufficient volume. Heterogeneity in study design, definitions, and case detection is common; hence, high-quality research that applies more stringent controls and uses clearer definitions is warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023460812.

Interventions and impact of pharmacist-delivered services in perioperative setting on clinically important outcomes: a systematic review and meta-analysis

Background

The perioperative arena is a unique and challenging environment that requires coordination of the complex processes and involvement of the entire care team. Pharmacists' scope of practice has been evolving to be patient-centered and to expand to variety of settings including perioperative settings.

Objectives

To critically appraise, synthesize, and present the available evidence of the characteristics and impact of pharmacist-led interventions on clinically important outcomes in the perioperative settings.

Design

A systematic review and meta-analysis.

Methods

We searched PubMed, Embase, and CINAHL from index inception to September 2023. Included studies compared the effectiveness of pharmacist-led interventions on clinically important outcomes (e.g. length of stay, readmission) compared to usual care in perioperative settings. Two independent reviewers extracted the data using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and undertook quality assessment using the Crowe Critical Appraisal (CCAT). A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and standard mean difference (SMD) for continuous data] with 95% confidence intervals (CIs).

Results

Twenty-five studies were eligible, 20 (80%) had uncontrolled study design. Most interventions were multicomponent and continuous over the perioperative period. The intervention components included clinical pharmacy services (e.g. medication management/optimization, medication reconciliation, discharge counseling) and education of healthcare professionals. While some studies provided a minor description in regards to the intervention development and processes, only one study reported a theoretical underpinning to intervention development. Pooled analyses showed a significant impact of pharmacist care compared to usual care on length of stay (11 studies; SMD -0.09; 95% CI -0.49 to -0.15) and all-cause readmissions (8 studies; OR 0.60; 95% CI 0.39-0.91). The majority of included studies (n = 21; 84%) were of moderate quality.

Conclusion

Pharmacist-led interventions are effective at improving clinically important outcomes in the perioperative setting; however, most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions; therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. Future research should prioritize the development and evaluation of multifaceted theory-informed pharmacist interventions that target the whole surgical care pathway.

Implications of a technician-led pharmacy service on a day case unit in a tertiary oncology centre

INTRODUCTION

Medicines Management Technicians have been shown to be an underused resource in medicines optimisation and medicines waste. In the United Kingdom, there are national recommendations for the clinical pharmacy service in cancer services ambulatory units, despite these recommendations, there was no clinical pharmacy service on the day case unit at a specialist tertiary centre in England. A lot of the patient pathways had been in place for many years and had not progressed with the changes in the clinical pathways. The main objectives of this study were to analyse how a medicines management technician could reduce medicines waste, improve the current pathway, increase medicines optimisation and ultimately improve the patient experience in an oncology day case unit at a specialist tertiary centre in England.

METHODS

A prospective mixed methods study was carried out at Weston Park Hospital. Descriptive statistical analysis was conducted on the quantitative data collected, and thematic analysis was carried out on the qualitative data collected by questionnaire to staff members and patients.

RESULTS

This study has shown that a medicines management technician can complete some of the tasks more traditionally done by the chemotherapy nurses on the day case unit, increasing their capacity for more clinically appropriate tasks. A medicines management technician can work as part of the wider multidisciplinary team on a day case unit contributing to medicines optimisation and cost savings for the oncology directorate.

CONCLUSIONS

This study has shown that a medicines management technician can act as a valued member of the wider multidisciplinary team, improving communication and patient pathways, improving medicines optimisation and contributing to cost saving initiatives. Further studies are required to assess whether a medicines management technician role can be of the same value on a haematology day case unit.

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.

Preoperative Deprescribing for Medical Optimization of Older Adults Undergoing Surgery: A Systematic Review

OBJECTIVE

To summarize the evidence for preoperative deprescribing and its effect on postoperative outcomes in older adults undergoing surgery.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

All available studies.

METHODS

We searched EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), and PubMed from inception to January 12, 2021. Settings included outpatient settings during the waiting period for surgery (ie, preoperative clinic) through to the preoperative period in the hospital. Participants who were older adults, aged ≥65 years, undergoing planned or emergency surgery with deprescribing or medication-related interventions were included for review.

RESULTS

We identified 3 different methods of deprescribing intervention delivery during the preoperative period: geriatrician-led (n = 2), interdisciplinary team-led (n = 8), and pharmacist-led (n = 6). Outcomes were related to health care utilization, patient outcomes, and medication changes; however, results were difficult to compare because of heterogeneous outcomes within the topics. Overall, results were either positive or neutral.

CONCLUSIONS AND IMPLICATIONS

The evidence for deprescribing during the preoperative period for older adults undergoing surgery is weak because of the heterogeneity of intervention delivery and outcomes, inclusion of nonoperative cases in some studies, and low power. This review highlights the need for future research, which may consider the following: (1) interdisciplinary approach, (2) coordination of deprescribing efforts with primary care provider from the waiting period for surgery up to after hospital discharge, and (3) validated deprescribing criteria such as STOPP/START that is easy to implement. It is important to note that results yielded positive and neutral results, not negative ones, which should reassure clinicians to implement deprescribing for older adults during the surgical period. Additionally, policy initiatives such as integrated electronic medical records or increased reimbursement of deprescribing efforts for primary care providers and/or hospitals should be pursued to prevent adverse postoperative events for this population.

Assessing the Impact of a Clinical Pharmacist in a Postsurgical Inpatient Population

OBJECTIVE

To quantify the number and type of clinical pharmacist interventions with an impact on patient care in a postsurgical nonintensive care patient population.

BACKGROUND

Studies have shown that pharmacists are able to improve the quality of patient care; however, the pharmacist role in postsurgical nonintensive care areas is not well defined.

METHODS

A clinical pharmacist provided care for 2 postsurgical floors for 2 weeks and collected information about the number and type of interventions made and adverse events avoided. In addition, the study team conducted an anonymous survey amongst the multidisciplinary team who collaborated with the pharmacist at the end of the trial period to understand the perception of having access to a clinical pharmacist who was designated to their floor.

RESULTS

In a 2-week time period, the clinical pharmacist was able to make 218 interventions, including 38 recommendations for optimization of antimicrobials, 26 recommendations for anticoagulation optimization, and providing education for 20 patients planned for discharge on high-risk medications. Interventions made by the clinical pharmacist helped decrease adverse events, improve patient safety and knowledge, and potentially avoid readmissions and reduce hospital length of stay. The survey results revealed that 100% strongly agreed that a clinical pharmacist should be a member of the multidisciplinary team for the postsurgical floors.

CONCLUSION

This data signifies that having a clinical pharmacist dedicated to the postsurgical patient population allows for optimization of antimicrobial and anticoagulant use, improves outcomes for patients through medication education, and enhances provider satisfaction.

Practice Transformation Driven through Academic Partnerships

Evidence-based interventions have been shown to improve the quality of patient care, reduce costs, and improve overall health outcomes; however, adopting new published research and knowledge into practice has historically been slow, and requires an active, systematic approach to engage clinicians and healthcare administrators in the required change. Pharmacists have been identified as important agents of change and can enhance care delivery in primary care settings through evidence-based interventions. Utilizing the Consolidated Framework for Implementation Research (CFIR) we identify, assess, and share barriers and facilitators to program development, as well as growth and expansion efforts across five discrete, university-subsidized, embedded-pharmacy practices in primary care. We identified two overarching modifiable factors that influence current and future practice delivery and highlight the role of academia as an incubator for practice change and implementation: Data collection and information sharing. Conceptual frameworks such as CFIR help establish a common vernacular that can be used to facilitate systematic practice site implementation and dissemination of information required to support practice transformation.

Pharmacist-driven multidisciplinary initiative continuously improves postoperative nausea and vomiting in female patients undergoing abdominal surgery

WHAT IS KNOWN AND OBJECTIVE

The incorrect or insufficient prophylaxis of postoperative nausea and vomiting (PONV) is common in practice. A clinical pharmacist-led guidance team (CPGT) was established and included in general surgery teams.

OBJECTIVE

This study aimed to evaluate the effects of the CPGT on the improvement of PONV and prophylaxis administration.

METHODS

A prospective before-after study was conducted on 156 female patients undergoing abdominal surgery at a Chinese tertiary teaching hospital from December 2016 to December 2017. A total of 82 patients were enrolled in the preintervention period, and 74 patients were included in the post-intervention period. The CPGT established the evidence-based criteria for prophylactic anti-emetic administration and conducted interventions, including a review of medical records, provision of feedback, educational outreach, and dedicated support. Primary outcomes included the incidence of PONV within 24 hours of surgery, administered number of prophylactic anti-emetics, and accuracy of the timing for prophylactic anti-emetics. Outcomes were analysed by logistic regression or multivariable linear regression.

RESULTS AND DISCUSSION

After intervention, patients reported significantly less PONV (33.78% vs 56.10%; odds ratio [OR]: 0.29; numbers needed to treat [NNT]: 3.47), vomiting (29.73% vs 45.12%; OR: 0.42; NNT: 5.16) and nausea (31.08% vs 56.10%; OR: 0.24; NNT: 3.19) within 24 hours of surgery. The accuracy of the timing for prophylactic anti-emetics significantly increased (OR: 3.66; P: .003). Anaesthesiologists administered increased numbers of prophylactic anti-emetics (OR: 5.82; P < .001). The improvement of PONV did not decrease during the four-month period after intervention (P: .639).

WHAT IS NEW AND CONCLUSION

The CPGT is a valuable service model to continuously improve PONV and optimize prophylaxis administration.