Added value of pharmacist-acquired drug histories in an orthopaedic ward

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis

Objective

Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST).

Methods

To identify studies, the following databases were systematically searched on October 14^th, 2018 and repeated on September 12^th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review.

Results

Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I² = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I² = 36%).

Conclusion

This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.

Impact of a preoperative pharmaceutical consultation in scheduled orthopedic surgery on admission: a prospective observational study

BACKGROUND

Medication errors have a high prevalence in surgery and management of home medication is strongly involved in these errors. In scheduled surgery, the preoperative consultation is a privileged time to inform the patient about the management of her/his home medication before admission. This study assessed the impact of a pre-anesthesia best possible medication history (PA-BPMH) on admission. The PA-BPMH was performed by a clinical pharmacist prior to the anesthesia consultation for anesthesiologists to prescribe admission medical orders for scheduled orthopedic surgery patients.

METHODS

This was a prospective observational study which was carried out in an orthopedic surgery department. All patients over 18 years old with an elective orthopedic surgery were eligible except ambulatory surgery patients. The pharmacist registered the PA-BPMH into the software making it available for anesthesiologists for the pre-admission medication order. Finally, a medication reconciliation was performed at admission. The main outcome was the percentage of patients with at least one unintended medication discrepancy (UMD) at admission. The nature, potential clinical impact and acceptance rate of each UMD detected were assessed. Also, the PA-BPMH process was described and patients and anesthesiologists satisfaction was evaluated.

RESULTS

A total of 455 patients had a pharmaceutical consultation. Medication reconciliation was performed at admission for 360 patients. Overall, at least one UMD was observed in 13.0% of patients (n = 47). A total of 63 UMD were detected. The most common type of UMD was omission (25.4%) and incorrect drug (23.8%).Two UMD (3.2%) were evaluated as life threatening. All the UMD detected were corrected on the admission medication order.

CONCLUSION

A preoperative pharmacist-anesthesiologist teamwork seems to improve the safety of perioperative management of home medication for scheduled orthopedic surgery patients. This process needs a randomized clinical trial across a wider range of surgeries before its implementation.

Potential role of a pharmacist to enhance medication-related aspects of clinical trials conducted in a dedicated clinical research unit

Purpose

Pharmacist involvement in medication reconciliation has been shown to have a positive impact on patient care in a number of settings [1−6], but there have been no evaluations of the effect of this pharmacist role on patient care during the conduct of clinical trials. Pharmacist involvement in the medication reconciliation process for clinical trials may provide improved protocol compliance.

Methods

This was a retrospective pilot study conducted in a dedicated research unit that assessed completeness of the medication reconciliation process by clinical trial teams for patients participating in a clinical trial involving investigational medication(s). Patients' medication lists in the EHR were reviewed after their study visit. Pharmacy staff evaluated the medication list for accurate inclusion of IDs and any prohibited or restricted concomitant medication(s) per the study protocol.

Results

Ninety-five patient visits over two months were evaluated and showed only 20.6% of IDs were listed in the EHR after study visits. Of those included, only 40% had the correct dose and 50% had the correct frequency listed. There were 20 potential protocol prohibited medications identified. There were four medications listed in a fashion that may have compromised maintenance of blinding status in the EHR.

Conclusions

This pilot study showed potential roles for pharmacy personnel involvement in medication reconciliation in the clinical research setting. Pharmacists have the opportunity to ensure that IDs are accurately included in patient medication lists and to identify the use of potential protocol prohibited concomitant medications.

Medication reconciliation of patients with hip fracture by clinical pharmacists

Objective

Medication reconciliation is a strategy for reducing medication discrepancies and improving patient safety. Transitions through different levels of care contribute to medication discrepancies caused by lack of communication. In October 2011, St Olav's Hospital initiated a fast-track model for patients with hip fractures, where clinical pharmacists (CPs) are a part of a multidisciplinary team. The purpose of this study was to examine discrepancies discovered in medication lists by CPs at the orthopaedic ward and consider their clinical relevance.

Method

This prospective study was conducted at an orthopaedic ward at St Olav's Hospital in the period October 2011-August 2012. Medication reconciliation by CPs was done for all patients with a hip fracture using a systematic method. Information was obtained by the CP by interview with the patient and additional sources, for example, medication list from general practitioner and nursing home. An independent expert group consisting of a geriatrician, an orthopaedist and a CP considered level of clinical relevance of the discrepancies found in the collected data.

Results

A total of 410 discrepancies were registered for all 317 patients, Discrepancies were found in 159 (50%) patients with an average of 2.6 per patient affected. Of the total amount of discrepancies, the expert group evaluated 68% and 19% as potentially moderate and severe, respectively, if they were unattended during hospitalisation and after discharge.

Conclusions

By using CPs in medication reconciliation at orthopaedic wards, discrepancies that can lead to serious discomfort or clinical deterioration of patients can be avoided.