Evaluation of the antibiotic prescription in a hospital emergency department: Pilot study

OBJECTIVE

A study about the adherence of the antimicrobial prescriptions to the local guidelines of treatment of infections was conducted in a hospital emergency department to study the clinical and epidemiological characteristics of the patients who received these treatments. Conducting a feasibility study for supporting the design and execution of future studies, addressing specific aspects of the appropriateness of the antimicrobial prescription.

METHOD

Observational, descriptive and cross-sectional pilot study, with retrospective data collection about the antimicrobial prescription in a hospital emergency department. Seven cross sections were made, corresponding to 7 different days of the week, in 7 consecutive weeks.

INCLUSION CRITERIA

patient over 14 years of age, with at least one first dose of antimicrobial treatment prescribed on the day of recruitment. The main variable was the inappropriate antimicrobial prescription according to the local guidelines. Epidemiological and clinical parameters of the patients were collected as secondary variables. In order to determine inappropriate prescription a revision was carried out by 2 specialists in emergencies, 2 pharmacists and one specialist in infectious diseases, all unrelated to prescriptions.

RESULTS

One hundred sixty eight patients with 192 prescriptions were evaluated. 76 (39.6%) of the prescriptions were not conformed to the local treatment guidelines. Of these, 55% were with active antimicrobial coverage against the microorganism but not recommended, 23.5% with inactive drugs, 13.7% presented an inappropriate dose and 7.8% were unnecessary treatment. The strength of agreement in the evaluation of the adequacy of treatment between doctors and pharmacists was high (kappa=0.71).

CONCLUSIONS

A high rate of inappropriate antimicrobial prescriptions was obtained in a hospital emergency department according to local guidelines. The hospital pharmacist has an opportunity to improve the use of antimicrobials in this area.

[Translated article] Evaluation of the antibiotic prescription in a hospital emergency department: Pilot study

OBJECTIVE

A study about the adherence of the antimicrobial prescriptions to the local guidelines of treatment of infections was conducted in a hospital emergency department to study the clinical and epidemiological characteristics of the patients who received these treatments. Conducting a feasibility study for supporting the design and execution of future studies, addressing specific aspects of the appropriateness of the antimicrobial prescription.

METHOD

Observational, descriptive and cross-sectional pilot study, with retrospective data collection about the antimicrobial prescription in a hospital emergency department. Seven cross sections were made, corresponding to seven different days of the week, in seven consecutive weeks.

INCLUSION CRITERIA

patient over 14 years of age, with at least one first dose of antimicrobial treatment prescribed on the day of recruitment. The main variable was the inappropriate antimicrobial prescription according to the local guidelines. Epidemiological and clinical parameters of the patients were collected as secondary variables. In order to determine inappropriate prescription a revision was carried out by two specialists in emergencies, two pharmacists and one specialist in infectious diseases, all unrelated to prescriptions.

RESULTS

168 patients with 192 prescriptions were evaluated. Seventy-six (39.6%) of the prescriptions were not conformed to the local treatment guidelines. Of these, 55% were with active antimicrobial coverage against the microorganism but not recommended, 23.5% with inactive drugs, 13.7% presented an inappropriate dose and 7.8% were unnecessary treatment. The strength of agreement in the evaluation of the adequacy of treatment between doctors and pharmacists was high (kappa = 0.71).

CONCLUSIONS

A high rate of inappropriate antimicrobial prescriptions was obtained in a hospital emergency department according to local guidelines. The hospital pharmacist has an opportunity to improve the use of antimicrobials in this area.

Consensus on the criteria for patient prioritization in hospital clinical pharmacy services: a Delphi study

BACKGROUND

Hospital pharmacists cannot provide extensive clinical pharmacy service to every inpatient because the demand for these services can exceed pharmacists' available work time. A way to solve this issue is hospital pharmacists to prioritize their clinical tasks. Tool prioritization could determine which patients would benefit from clinical pharmacists' input.

AIM

Establishing consensus on which criteria are relevant for prioritizing patients for clinical pharmacy services.

METHOD

The Delphi method was performed with criteria identified from a previously published Scoping Review. The panel of experts included hospital pharmacists, who evaluated the clinical significance of criteria in a three-round Delphi panel from July to December 2020. They determined the need for sub-criteria and evaluated their clinical significance. The experts also analyzed the criteria/sub-criteria as to their applicability in clinical practice. Consensus criteria were defined as 70% or more participants scoring the criteria as critical and 15% or fewer scoring the criteria as unimportant.

RESULTS

A total of 19 criteria and 230 sub-criteria were included for evaluation by panel experts based on scoping review. Twenty-nine, 22, and 17 experts participated per round, respectively. After completing the three rounds, experts suggested the inclusion of one criterion, the exclusion of one criterion, and the inclusion of 29 sub-criteria. The final list consisted of 18 criteria and 177 sub-criteria, divided into 28 groups.

CONCLUSION

The result was comprehensive and coherent, potentially contributing to developing an instrument for prioritizing hospitalized patients for clinical pharmacy services.

Measuring the proportion of time spent on work activities of clinical pharmacists using work sampling technique at a public hospital in Malaysia

Background:

The clinical pharmacy service to the ward was established in 2005 in Malaysia, as the number of pharmacists working in the public service sector began to grow. Yet, there has been little local research done on reporting the range of work activities of clinical pharmacists and the amount of time that they spent on their work activities.

Objective:

This study aimed to identify the range of work activities of clinical pharmacists by observation and to estimate the proportion of time spent on different work activities by using the work sampling technique.

Methods:

The time spent by clinical pharmacists on various activities was measured using the work sampling technique over 30 working days. The work activities of clinical pharmacists were pre-identified and customized into an activity checklist. Two observers were placed at the study site and took turns recording the activities performed by the clinical pharmacists by following a randomly generated observation schedule.

Results:

1,455 observations were made on five clinical pharmacists with a total of 3493 events recorded. Overall, clinical pharmacists spent 78.8% (n=2751) of their time providing clinical services whereas 12.3% (n=433) of their time was spent on non-clinical activities. They were found to be idle from work for 8.9% of the time. There was no difference in bed occupancy rate in the study site regardless of the presence of the observer (p=0.384). Clinical pharmacists were found to report a higher average daily cumulative work unit of 9.8 (SD=4.3) when under observation compared to an average daily cumulative work unit of 6.5 (SD=4.6) when no observer was present (p=0.005).

Conclusions:

The results revealed that clinical pharmacists spent a significant amount of time on non-clinical work. Their responsibilities with non-clinical work should be properly taken care of so they can allocate more time to providing patient care.

Perspectives on the pharmacist's "product": a narrative review

Clarity about the pharmacist’s “product” is fundamental to developing and communicating the value of pharmacy offerings. It is clear within the profession that pharmacists use their scope of knowledge and technical skills to address medication-related needs of individuals and populations. However, confusion still remains in the professional and public literature about what a pharmacist precisely produces for society. Is it a drug, service, program, solution, or something else? As the profession evolves from one that focuses on dispensing drugs to a profession that seeks to achieve positive patient health outcomes, pharmacists need to better conceptualize and articulate what they produce. This narrative review explores ideas from the marketing, business strategy, and entrepreneurship literature to discuss diverse perspectives on the pharmacist’s product. The four perspectives are the product as (1) a tangible product, (2) an intangible service, (3) a “smart, connected” good or service, and (4) a solution to a customer problem in whatever form provided. Based upon these perspectives, the pharmacist’s product can be any combination of tangible or intangible, face-to-face or virtual offering produced by pharmacists that seeks to satisfy medication-related needs and wants of pharmacy patients and customers. Ideas discussed in this review include the total product concept, classification schemes from the services marketing literature, the theory of service-dominant logic, the concepts of “smart, connected” products and industrialized intimacy, and the jobs-to-be-done framework. These various perspectives offer lessons for pharmacists on how to innovate when serving patients and customers and to communicate the pharmacist’s value proposition to the people they serve.

Improving outpatient medication counselling in hospital pharmacy settings: a behavioral analysis using the theoretical domains framework and behavior change wheel

Background:

Despite the importance of medication counselling for patients, it is common knowledge that it is often sub-optimally carried out by pharmacy staff. While some interventions have been designed to help improve counselling, no study till date has used the Capability Opportunity and Motivation behavior model (COM-B) or Theoretical Domains Framework (TDF) as a basis for identifying evidence-based intervention strategies to improve medication counselling.

Objective:

To understand barriers/facilitators to optimal medication counselling by conducting a behavioral analysis using the COM-B model and TDF, and use the Behavior Change Wheel (BCW) as a basis for identifying evidence-based intervention strategies and policy categories that could be used to improve outpatient medication counselling by pharmacy staff in hospital settings located within Northwest Nigeria.

Methods:

Semi-structured interviews were used to collect data from 25 purposively sampled pharmacy staff working at eight major public hospitals, from January till March 2020. Data from the interviews were then transcribed and deductively coded using the COM-B model and TDF. These findings were then used to identify areas requiring change, as well as the intervention type and policy functions required to support these changes.

Results:

Findings from the behavioral analysis revealed shortfalls in pharmacy staff capability, opportunity and motivation with respect to outpatient medication counselling. To improve their counselling behaviors, change was identified as necessary in eight TDF domains namely ‘knowledge’, ‘interpersonal skills’, ‘memory’ ‘environmental context’, ‘social influences’, ‘intentions’, ‘reinforcement’ and ‘beliefs about capabilities’. Seven intervention functions including ‘education’, ‘training’, ‘modelling’, ‘enablement’ and ‘environmental restructuring’, in addition to three policy categories (‘guidelines’, ‘regulations’ and ‘environmental/social planning’) were also identified as relevant to future intervention design.

Conclusions:

Various factors were identified as affecting medication counselling by the pharmacy staff, with several of them requiring changes if counselling was to be improved upon. Multi-component interventions combining several of these intervention functions are recommended for hospital authorities and other relevant stakeholders to improve outpatient medication counselling.

Applicability of American College of Clinical Pharmacy (ACCP) competencies to clinical pharmacy practice in Egypt

Background

The American College of Clinical Pharmacy (ACCP) prepared clinical pharmacist competencies that have specific recommendations. Recently, many efforts to advance clinical pharmacy services in Egypt exist. The literature revealed that no country has assessed the extent of applicability of ACCP competencies in its current pharmacy practice setting. Egyptian pharmacists can provide feedback about applicability of such competencies in clinical pharmacy settings in Egypt.

Objective

The objective of this study was to investigate the extent to which ACCP competencies were implemented by Egyptian clinical pharmacists and therefore evaluate development of clinical pharmacy practice in Egypt. The study also investigated factors affecting the applicability of such competencies in the current clinical pharmacy practice setting in Egypt.

Methods

Four hundred and ninety-five randomly selected clinical pharmacists from several hospitals were invited to participate in a cross sectional survey using a self-administered validated questionnaire composed of 31 questions classified into six domains. This questionnaire was designed to determine the pharmacists' perception about applicability of ACCP competencies to clinical pharmacy practice in Egypt.

Results

The response rate was 64% as 317 out of 495 pharmacists completed the questionnaire. These pharmacists were categorized according to age; gender; qualifications; years of previous work experience, years since BSc. and type of hospitals they are currently working at. Analysis of data revealed the professionalism domain to have the highest percentage of acceptance among pharmacists, while the system-based care & population health domain had the lowest percentage of acceptance. Results also showed that qualifications of participants did not affect their response in three domains; "Direct Patient Care", "Systems-based Care & Population Health" and "Continuing Professional Development" (p=0.082, 0.081, 0.060), respectively. Nevertheless, qualifications of participants did affect their response in the other three domains; "Pharmacotherapy Knowledge", "Communication" and "Professionalism" (p<0.05). The age of pharmacists, gender, years of previous work experience, and graduation year did not affect their responses in all six domains. The type of hospital they are currently working at, though, affected their responses where, there was a highly statistically significant increase of the mean score of all domains among participants working at the NGOs/private hospitals compared to governmental hospitals (p<0.001).

Conclusions

Egyptian pharmacists generally apply high percentage of ACCP competencies but the provided clinical pharmacy services need to be improved through applying the standards of best practice.

Survey of undergraduates' perceptions of experiential learning in the MPharm programme: The TELL Project

Objective:

To determine the perception of undergraduate pharmacy students of their experiential learning (EL) placements both in the community and hospital settings.

Methods:

A cross-sectional survey was conducted utilizing a six-item online survey consisting of one open-ended and five closed-ended questions, the latter utilising five-point Likert-type scales ranging from strongly disagree (1) to strongly agree (5). All undergraduate pharmacy students from the School of Pharmacy (N=496) were included in the study. Survey questions assessed students’ perceptions on the effectiveness of the EL, tutors and placements sites, and organisation and structure of the EL. Thematic content analysis was performed on the open-ended comments, where relevant themes were generated.

Results:

From the 139 responses (response rate: 28%), 121 responses were analysed, and of these, 72.5% already had part-time jobs in community pharmacies. Close to 85% felt that their part-time work should contribute to EL hours, which is currently not recognised by the university. Respondents were positive about the effectiveness of EL in developing their professionalism and communication (M=3.84, SD=1.05), clinical (M=3.42, SD=1.22), and technical skills (M=3.32, SD=1.25) Respondents provided favourable feedback about their experience in the hospital as it gave them a real-world exposure to the role of a hospital pharmacist. Community placements were not viewed favourably and this was mainly attributed to the poor experience with tutors whom they felt used them as an extra pair of hands. This was thought to impede their learning experience. They also felt that hospital placements were of insufficient duration, reported by 72.5% of respondents. Respondents also felt they should be sent to other sites such as primary care for placements.

Conclusions:

Tutor-training is key to ensure tutors are aware of the responsibilities and expectations. Similarly, quality assurance measures should be adopted to ensure tutors and placement sites are capable of providing students with an effective placement experience. While placement durations are a concern, the focus should be on the quality of the placement experience, and ensuring there is structure and flexibility. Content changes are also needed to include emerging placement sites such as primary care to prepare students for evolving pharmacist roles in the changing healthcare system.

Assessment and use of drug information references in Utah pharmacies

OBJECTIVE

To determine which drug references Utah pharmacists use most frequently. To determine which types of drug information questions are most commonly asked, and whether Utah pharmacists have access to adequate references to respond to these questions.

METHODS

A 19-question survey was created using Qualtrics, LLC (Provo, Utah) software. An electronic survey link was sent to 1,431 pharmacists with a valid e-mail address listed in the Department of Professional Licensing database. Questions focused on available references in the participant's pharmacy, how current the references are, and the participant's use of the references. Surveys were analyzed for participants practicing in either community or hospital pharmacies in the state of Utah.

RESULTS

A total of 147 responses were included in the analysis. Approximately 44% of respondents practiced in the community, and 56% practiced in a hospital setting. The most commonly used references by Utah pharmacists are Micromedex, Lexicomp, UpToDate, Clinical Pharmacology, and Drug Facts & Comparisons. Pharmacists in the community frequently receive questions related to adverse drug reactions, drug interactions, and over-the-counter medications. Pharmacists in the hospital frequently receive questions relating to dosage and administration, drug interactions, and adverse drug reactions. About 89% of community pharmacists and 96% of hospital pharmacists feel available references are adequate to answer the questions they receive.

CONCLUSIONS

Utah pharmacists generally use large reference suites to answer drug information questions. The majority of pharmacists consider the references available to them to be adequate to answer the questions they receive.

Relation between safe use of medicines and Clinical Pharmacy Services at Pediatric Intensive Care Units

OBJECTIVE

Clinical Pharmacy Services (CPS) are considered standard of care and they are endorsed by the Joint Commission International, the American Academy of Pediatrics, and the American College of Clinical Pharmacy. In Brazil, single experiences have been discreetly arising and the importance of these services to children and adolescents care has led to interesting results, but certainly are under reported. This short report aims to discuss the effect of implementing a bedside CPS at a Brazilian Pediatric Intensive Care Unit (PICU).

METHODS

This is a cross-sectional study conducted in a 12 bed PICU community hospital, from Campo Largo/Brazil. Subjects with<18 years old admitted to PICU were included for descriptive analysis if received a CPS intervention.

RESULTS

Of 53 patients accompanied, we detected 141 preventable drug-related problems (DRPs) which were solved within clinicians (89% acceptance of all interventions). The most common interventions performed to improve drug therapy included: preventing incompatible intravenous solutions (21%) and a composite of inadequate doses (17% due to low, high and non-optimized doses). Among the top ten medications associated with DRPs, five were antimicrobials. By analyzing the correlation between DRPs and PICU length of stay, we found that 74% of all variations on length of stay were associated with the number of DRPs.

CONCLUSIONS

Adverse drug reactions due to avoidable DRPs can be prevented by CPS in a multifaceted collaboration with other health care professionals, who should attempt to use active and evidence-based strategies to reduce morbidity related to medications.

Cost evaluation of therapeutic drug monitoring of gentamicin at a teaching hospital in Malaysia

BACKGROUND

Therapeutic drug monitoring (TDM) makes use of serum drug concentrations as an adjunct to decision-making. Preliminary data in our hospital showed that approximately one-fifth of all drugs monitored by TDM service were gentamicin.

OBJECTIVE

In this study, we evaluated the costs associated with providing the service in patients with bronchopneumonia and treated with gentamicin.

METHODS

We retrospectively collected data from medical records of patients admitted to the Hospital Universiti Sains Malaysia over a 5-year period. These patients were diagnosed with bronchopneumonia and were on gentamicin as part of their treatment. Five hospitalisation costs were calculated; (i) cost of laboratory and clinical investigations, (ii) cost associated with each gentamicin dose, (iii) fixed and operating costs of TDM service, (iv) cost of providing medical care, and (v) cost of hospital stay during gentamicin treatment.

RESULTS

There were 1920 patients admitted with bronchopneumonia of which 67 (3.5%) had TDM service for gentamicin. Seventy-three percent (49/67) patients were eligible for final analysis. The duration of gentamicin therapy ranged from 3 to 15 days. The cost of providing one gentamicin assay was MYR25, and the average cost of TDM service for each patient was MYR104. The average total hospitalisation cost during gentamicin treatment for each patient was MYR442 (1EUR approx. MYR4.02).

CONCLUSIONS

Based on the hospital perspective, in patients with bronchopneumonia and treated with gentamicin, the provision of TDM service contributes to less than 25% of the total cost of hospitalization.

A pre- post-evaluation of implementing an inpatient warfarin monitoring and education program

OBJECTIVE

The purpose of this study was to evaluate whether a new anticoagulation management program resulted in better monitoring of warfarin, increased warfarin patient education prior to discharge, and fewer bleeding complications associated with warfarin.

METHODS

A retrospective chart review was conducted of patients who were inpatients and received warfarin from April 1, 2008 to July 31, 2008 (control group) and from April 1, 2009 to July 31, 2009 (after implementation of the new anticoagulation program). The frequency of warfarin-related laboratory orders that included international normalized ratios (INRs), complete blood counts (CBCs), and documented patient education by pharmacy, nursing, and dietary services were determined before and after program implementation. Also, data was collected to determine frequencies of bleeding complications associated with warfarin.

RESULTS

There were 112 patients in the pre- and 115 patients in the post-program group. After implementation of the inpatient warfarin management program, obtaining baseline INRs increased from 74% to 90% (p=0.001). Orders for baseline CBCs increased from 85% to 94% (p=0.026). Obtaining CBCs every 3 days increased from 54% to 74%, (p<0.001). However, there was no significant change in orders for daily INRs (p=0.055). Education by nursing increased from 54% to 80%, (p<0.001), by pharmacy increased from 8% to 76%, (p<0.001), and by dietary increased from 11% to 79%, (p<0.001). Documentation by all three disciplines in each patient increased from 3.6% to 59%, (p<0.001). Significantly fewer patients received vitamin K and/ or fresh frozen plasma for supratherapeutic INRs with bleeding complications after the program was initiated compared to baseline (p=0.009).

CONCLUSIONS

The implementation of an inpatient warfarin management program led to better monitoring of patients receiving warfarin, and increased patient education. However, a larger and longer assessment is necessary to determine if these changes are maintained and how these changes affect long-term clinical outcomes.

Pharmacy intervention on antimicrobial management of critically ill patients

Frequent, suboptimal use of antimicrobial drugs has resulted in the emergence of microbial resistance, compromised clinical outcomes and increased costs, particularly in the intensive care unit (ICU). Mounting on these challenges is the paucity of new antimicrobial agents.

OBJECTIVE

The study aims to determine the impact of prospective pharmacy-driven antimicrobial stewardship in the ICU on clinical and potential financial outcomes. The primary objectives were to determine the mean length of stay (LOS) and mortality rate in the ICU resulting from prospective pharmacy interventions on antimicrobial therapy. The secondary objective was to calculate the difference in total drug acquisition costs resulting from pharmacy infectious diseases (ID)-related interventions.

METHODS

In collaboration with an infectious disease physician, the ICU pharmacy team provided prospective audit with feedback to physicians on antimicrobial therapies of 70 patients over a 4-month period in a 31-bed ICU. In comparison with published data, LOS and mortality of pharmacy-monitored ICU patients were recorded. Daily cost savings on antimicrobial drugs and charges for medication therapy management (MTM) services were added to calculate potential total cost savings. Pharmacy interventions focused on streamlining, dose optimization, intravenous-to-oral conversion, antimicrobial discontinuation, new recommendation and drug information consult. Antimicrobial education was featured in oral presentations and electronic newsletters for pharmacists and clinicians.

RESULTS

The mean LOS in the ICU was 6 days, which was lower than the published reports of LOS ranging from 11 to 36 days. The morality rate of 14% was comparable to the reported range of 6 to 20% in published literature. The total drug cost difference was a negative financial outcome or loss of USD192 associated with ID-related interventions.

CONCLUSIONS

In collaboration with the infectious disease physician, prospective pharmacy intervention on antimicrobial therapy in the ICU led to positive clinical outcomes and an additional drug cost expense of USD192.