Impact of the clinical pharmacist on readmission in patients with acute coronary syndrome

BACKGROUND: Previous studies have reported a positive impact of pharmacists on care of patients with chronic illnesses. The impact of the clinical pharmacist on hospital readmission in patients with acute coronary syndromes (ACS) has yet to be evaluated, as of this writing. OBJECTIVE: To evaluate the impact of the clinical pharmacist as a direct patient-care team member on cardiac-related readmission in patients admitted to the general cardiology unit with ACS. METHODS: A prospective, nonrandomized observational study compared patients who received standard practice care with patients admitted to a service with a clinical pharmacist to provide care at the bedside. Patients admitted to and discharged from the general cardiology unit for ACS were included. The primary endpoint of the study was cardiac-related readmission at 30 days following hospital discharge. Secondary endpoints included length of stay and medication utilization. Interventions provided by the clinical pharmacist in the study group were documented. RESULTS: Cardiac readmission at 30 days was similar between the groups (p = 0.59). In the subset of patients with unstable angina, readmission in the study group was significantly lower than in the control group (1.3% vs 9.1%; p = 0.04). Patients in both groups were similarly managed using drug therapy and invasive coronary interventions. The medical staff's rate of acceptance of recommendations provided by the pharmacist was 94.4%. The most common interventions were medication education and identification of indicated therapy. CONCLUSIONS: The addition of pharmacists did not decrease readmission in patients with ACS. The finding of significant reduction in readmission in the subset of patients with unstable angina should be considered "hypothesis generating" for future randomized studies to confirm the results.     

Impact of a pediatric clinical pharmacist in the pediatric intensive care unit

OBJECTIVE: To study the impact of a clinical pharmacist in a pediatric intensive care unit. The goals of the study were to determine the type and quantity of patient care interventions recommended by a clinical pharmacist and to specifically examine cost savings (or loss) that resulted from clinical pharmacist recommendations. DESIGN: A prospective case series. SETTING: Ten-bed pediatric intensive care unit in a university-affiliated children's hospital. PATIENTS: All patients admitted to the pediatric intensive care unit during the study period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the 24-wk study period, the pediatric clinical pharmacist documented all interventions that occurred during her shift. She rounded with the pediatric intensive care unit team approximately two times a week and reviewed medication lists daily. Drug acquisition costs were used to calculate drug cost savings. Demographic information was collected on all the patients in the pediatric intensive care unit during the study period. There were 35 recommendations per 100 patient days. The most common interventions were dosage changes (28%), drug information (26%), and miscellaneous information (22%). The average time spent per day by the clinical pharmacist in the pediatric intensive care unit was 0.73 hrs or 0.02 full-time equivalent. The total cost direct savings for the study period was $1,977. Extrapolated to direct cost savings per year, the total amount saved was $9,135/year or 0.15 full-time equivalent. Indirect savings from educational activities, avoidance of medication errors, and optimization of medical therapies represent an additional nonquantifiable amount. CONCLUSION: We conclude that a clinical pharmacist is an important and cost-effective member of the pediatric intensive care unit team.     

Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans

Background:The Medication Appropriateness Index (MAI) has demonstrated reliability in several outpatient settings. Clinical pharmacists play key roles as members of an interdisciplinary team in determining medication appropriateness.Objective:The goal of this study was to examine medication appropriateness using the MAI and the degree of recommendation acceptance associated with clinical pharmacist medication reviews for veterans enrolled in the Home-Based Primary Care (HBPC) program.Methods:A retrospective analysis of clinical pharmacist medication reviews was performed by accessing the computerized patient medical record. Patients included in the study were enrolled in the HBPC program between March 2002 and January 2004. The data were examined to determine a total MAI score associated with medication recommendations after each review. The number and types of pharmacist recommendations, their acceptance rate, and the total number of medications discontinued were also evaluated.Results:Seventy-nine patients (mean [SD] age, 75.3 [10.3] years) identified through the pharmacy database met the inclusion criteria and were included in the study. No patients identified were excluded from the analysis. A statistically significant decrease in the overall MAI score was observed from the initial review to the end of the study (P < 0.001). Recommendations to patients' primary care providers included medication initiation/discontinuation, laboratory monitoring, dosage adjustment, and other issues associated with appropriate prescribing that could be categorized using the MAI. Recommendations to home health nurses included monitoring for medication adherence, efficacy, and adverse events. Pharmacist recommendation acceptance rates for primary care providers and home health nurses were 69% and 56%, respectively. Overall, 121 medications were discontinued during the study period.Conclusions:By using the MAI for evaluation, pharmacist recommendations significantly improved the appropriateness of medication use among veterans receiving home health care. A majority of pharmacist recommendations were accepted.     

Diffusion of pharmacist interventions within the framework of clinical pharmacy activity in the clinical ward

BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.     

Improving the transition of highly complex patients into the community: impact of a pharmacist in an allogeneic stem cell transplant (SCT) outpatient clinic

Purpose

Patients having undergone allogeneic stem cell transplantation (SCT) require complex medication regimens. To ensure the safe and effective management of this patient group, specialised care in a centre with a dedicated and experienced healthcare team is essential. The aim of this study was to evaluate the effectiveness of a specialty clinical pharmacist working in an ambulatory SCT clinic.

Methods

A prospective cohort study was conducted on patients post SCT and discharged to the ambulatory setting. Patients were reviewed by a clinical pharmacist weekly for six visits. At these visits a medication review was undertaken. Interventions from these reviews were recorded. Interventions were then assigned a risk rating by a multidisciplinary panel. Adherence was also assessed by a Morisky questionnaire and review of dose administration aids. Comparison of data over the six-visit period was undertaken.

Results

In total 23 patients were enrolled in the study. All six visits were completed in 17 patients and 161 interventions were recorded at an average of 1.4 interventions per patient visit. The panel rated 40 % of interventions as high risk, 46 % as medium risk and 14 % as low risk. At all visit points high- and medium-risk interventions constituted >80 % of the total. Morisky scores improved by an average of 1.53 (p?<?0.0001) between visits 1 and 6. All patients were scored as highly adherent by visit 6.

Conclusions

A specialist clinical pharmacist in the SCT outpatient clinic resulted in regular and effective intervention contributing to improved medication management and adherence.     

Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure

BackgroundUncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S. population. Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can be implemented at scale in real-world settings. It is also uncertain how telehealth interventions impact patient experience compared to traditional clinic-based care.Aims/objectivesTo compare the effects of two evidence-based blood pressure care strategies in the primary care setting: (1) best-practice clinic-based care and (2) telehealth care with home BP telemonitoring and management by a clinical pharmacist. To evaluate implementation using mixed-methods supported by the RE-AIM framework and Consolidated Framework for Implementation Research.MethodsThe design is a cluster-randomized comparative effectiveness pragmatic trial in 21 primary care clinics (9 clinic-based care, 12 telehealth care). Adult patients (age 18–85) with hypertension are enrolled via automated electronic health record (EHR) tools during primary care encounters if BP is elevated to ≥150/95 mmHg at two consecutive visits. The primary outcome is change in systolic BP over 12 months as extracted from the EHR. Secondary outcomes are change in key patient-reported outcomes over 6 months as measured by surveys. Qualitative data are collected at various time points to investigate implementation barriers and help explain intervention effects.ConclusionThis pragmatic trial aims to inform health systems about the benefits, strengths, and limitations of implementing home BP telemonitoring with pharmacist management for uncontrolled hypertension in real-world primary care settings.     

Systematic review of interventions to enhance preceptors’ role in undergraduate health student clinical learning

AimEvaluate interventions to prepare preceptors for their role in undergraduate health student clinical education.BackgroundPreceptor training and development are crucial to quality clinical learning experiences for undergraduate health students. The efficacy of education interventions designed for preceptors and use of reliable, valid outcome measures are unclear.DesignA systematic literature review informed by PRISMA Guidelines.MethodsMajor databases CINAHL, Medline and Google Scholar were searched between January 2010 and November 2021. 1253 articles were initially retrieved. Removal of duplicates and screening by title, abstract and keywords yielded 156 papers. Twenty-one papers fulfilled the inclusion criteria and were assessed using an adapted ‘Critical Appraisal Checklist for Reports of Educational Interventions’ and the New World Kirkpatrick Model.ResultsMost interventions were developed for the nursing profession and evaluated using pre-post-test (86%) or post-test only (5%). Two studies were considered high quality. Most studies (81%) reported positive short-term impact on preceptor knowledge, skills, attitudes and confidence. Two thirds (62%) of included studies measured preceptor behaviour change. No study measured impact related to quality of health care. Small sample sizes limited inferential analyses. Psychometric testing of tools to measure preceptor outcomes was inconsistent and validity and reliability were not reported in most studies.ConclusionsStructure and content of interventions were diverse and lacked rigour in outcome measurement. Most interventions demonstrated some positive impact on preceptor development. Objective measures determining longer term impact or how enhanced preceptor development translated into quality clinical student learning support was lacking. Future research should consider how best to measure the impact of educational interventions on broader outcomes such as quality of client care.     

A Review of the Role of the Pharmacist in Heart Failure Transition of Care

This article reviews current literature on the role of pharmacists in the transition of care (TOC) for patients with heart failure (HF) and the impact of their contributions on therapeutic and economic outcomes. Optimizing the TOC for patients with HF from the hospital to the community/home is crucial for improving outcomes and decreasing high rates of hospital readmissions, which are associated with increased morbidity, mortality, and costs. A multidisciplinary team approach to the management of patients with HF facilitates the transition from the hospital to the ambulatory care setting, allowing for the consideration of medical, pharmacological, and lifestyle variables that impact the care of individual patients. Pharmacist participation on both inpatient and outpatient teams can provide a variety of services that have been shown to reduce hospital readmission rates and benefit patient management and treatment. These include medication reconciliation, patient education, medication dosage titration and adjustment, patient monitoring, development of disease management pathways, promotion of medication adherence, and postdischarge follow-up. In addition, as new pharmacologic treatments for HF become available, pharmacists can raise awareness of optimal drug use by maximizing education related to efficacy (e.g., adherence) and safety (e.g., potential side effects and drug interactions). Improving understanding of HF and its treatment will enable increased pharmacist involvement in the TOC that should lead to improved outcomes and reduced healthcare costs.Funding: Novartis.     

A systems-based medication reconciliation process: with implications for home healthcare

This article describes the medication reconciliation process applied on hospital discharge of patients to home with home care services within Seton Health System, an integrated health delivery network located in Troy, New York. The project, which was not research based, was characterized by an intensive pharmacotherapeutic medication reconciliation at hospital discharge by the hospital-based pharmacist with continued pharmacist support available to home healthcare nurses collaboratively at the time of start of care and resumption of care. The goal of this process was to identify and resolve medication-related problems and reduce hospital readmissions.     

The impact of interprofessional collaboration on nurses’ satisfaction and comfort with intranasal fentanyl

BackgroundHealthcare providers’ beliefs and comfort with analgesics can impact medication decisions. Interprofessional educational interventions (IPE) improve medication delivery processes ultimately resulting in better patient care. The purpose of this study was to determine the impact on nurses’ satisfaction and comfort with administering intranasal fentanyl for pediatric pain management in the Emergency Department (ED) before and following IPE.MethodsA protocol for administering intranasal fentanyl for children age 1–15 years with acute pain was introduced to the ED Nursing staff by an educational session conducted by a clinical pharmacist. Nurses’ level of satisfaction and comfort was surveyed prior to and following IPE. Compliance with patient monitoring was determined by chart review.ResultsEighty percentage of the nurses were very satisfied with the analgesic effect of intranasal fentanyl but barriers for its use included personal comfort, nurse monitoring time and age appropriateness. Most nurses felt comfortable administering intranasal fentanyl but showed increased comfort with intravenous morphine (83% versus 98%, p < 0.05). Benefits cited by nurses included having a pharmacist available in the ED to assist in the delivery of intranasal fentanyl.ConclusionThe use of IPE facilitated knowledge sharing to improve nurses’ comfort with administering analgesic medication and the quality of patient care services.     

Computerized physician order entry system combined with on-ward pharmacist: analysis of pharmacists' interventions

Rationale, aims and objectives To analyse pharmacists' interventions in a setting where a computerized physician order entry system (CPOE) is in use and a pharmacist works on the ward. Method A prospective cohort study was conducted in seven wards of a French teaching hospital using CPOE along with the presence of a full‐time on‐ward pharmacy resident. We documented the characteristics of pharmacists' interventions communicated to physicians during the medication order validation process whenever a drug‐related problem was identified. Independent predictors of the physician's acceptance of the pharmacist's intervention were assessed using multiple logistic regression analysis. Results The 448 pharmacists' interventions concerned: non‐conformity to guidelines or contraindications (22%), too high doses (19%), drug interactions (15%) and improper administration (15%). The interventions consisted of changes in drug choice (41%), dose adjustment (23%), drug monitoring (19%) and optimization of administration (17%). Interventions were communicated via the CPOE in 57% of cases and 43% orally. The rate of physicians' acceptance was 79.2%. In multivariate analysis, acceptance was significantly associated with the physician's status [higher for residents vs. seniors: OR = 7.23, CI 95 (2.37–22.10), P < 0.01], method of communication [higher for oral vs. computer communication: OR = 12.5, CI 95 (4.16–37.57), P < 0.01] and type of recommendation [higher for drug monitoring vs. drug choice recommendations: OR = 10.32, CI 95 (3.20–33.29), P < 0.01]. Conclusions When a clinical pharmacist is present on a ward in which a CPOE is in use, the pharmacists' interventions are well accepted by physicians. Specific predictors of the acceptance by physicians emerge, but further research as to the impact of CPOE on pharmacist–physician communication is needed.     

Medication errors in older adults: a review of recent publications

Objective:This paper reviews recent articles examining medication errors in the elderly.Methods:MEDLINE and International Pharmaceutical Abstracts were searched for articles published in 2006 using a combination of the terms medication errors, medication adherence, medication compliance, suboptimal prescribing, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Those studies that described new measures of medication errors or had a randomized controlled design, evaluated the impact of an intervention on ≥1 measure of medication errors, and involved the community-dwelling elderly were included in the review.Results:The search identified 5 studies and a new set of explicit criteria for prescribing problems in nursing homes from the Centers for Medicare and Medicaid Services (CMS). One of the studies found a new instrument, the Medication Management Instrument for Deficiencies in the Elderly, to be a reliable and valid measure of medication management in older adults. A study in the ambulatory elderly found that 13.0% reported cost-related medication nonadherence. A randomized controlled trial of a pharmacist intervention in elderly patients at high risk for coronary events found the intervention was associated with improvements in both medication adherence and systolic blood pressure control. The report from the CMS described new explicit criteria for unnecessary drug use in elderly patients in long-term care facilities, including drugs to avoid, drugs that should be limited in dose or duration, drugs to be monitored, and drug-drug interactions. A modified Delphi survey of an expert panel reached consensus on 28 drug-disease interactions in older adults. Finally, a randomized controlled trial of computerized feedback in a health maintenance organization found improvements in inappropriate prescribing of target drugs in older adults.Conclusion:Data from recently published studies may provide guidance to practitioners and help direct future research.     

Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review

BackgroundIn hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood.ObjectivesTo inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs.Review methodsA scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of “rapid response system,” “medical emergency team,” and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management.ResultsThirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited.ConclusionsMedications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.     

Use of the Electronic Health Record to Optimize Antimicrobial Prescribing

PurposeThis review summarizes how interventions in the electronic health record (EHR) can optimize antimicrobial stewardship across the continuum of antimicrobial decision making, from diagnosis of infection to discontinuation of therapy. In addition, opportunities to optimize provider communication and patient education are identified.MethodsA narrative review was conducted to identify how interventions in the EHR can influence antimicrobial prescribing behavior. Examples from pediatrics were specifically identified. Interventions were then categorized into high-impact/low-effort, high-impact/high-effort, and low-impact/low-effort groupings based on historical experience.FindingsEHR-based interventions can be used for stratifying patients at risk for infection and are useful in identifying patients with new-onset infections. Additional tools include automatically updated antibiograms tailored to specific patient populations, timely authorization of restricted antimicrobials, and more accurate allergy labeling. Medical errors can be reduced and communication between providers can be improved by standardized data fields. Clinical decision support tools can guide appropriate selection of therapy, and visual prompts can reduce unnecessarily prolonged therapy. Benchmarking of antimicrobial use, tailored patient education, and improved communication during transitions of care are enhanced through EHR-based interventions.ImplicationsPrescribing behavior can be modified through a range of interventions in the EHR, including tailored education, alerts, prompts, and restrictions on provider behavior. Further studies are needed to compare the effectiveness of various strategies.     

Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians

BackgroundThe quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals.ObjectivesWe conducted focus groups with older adults and primary care physicians to explore (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from patient and provider perspectives.MethodsFive focus groups (4 with older adults, 1 with physicians) were conducted by a trained moderator using a semistructured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification.ResultsTwenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe that the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist access to the medical record, and a mutually trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM.ConclusionsThis study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include being comprehensive and addressing all medication-related needs over time. The clinical pharmacist's ability to build trusting relationships with patients and providers is essential.     

Developing a reflection and analysis tool (We-ReAlyse) for readmissions to the intensive care unit: A quality improvement project

BackgroundReadmissions to the intensive care unit are associated with poorer patient outcomes and health prognoses, alongside increased lengths of stay and mortality risk. To improve quality of care and patients’ safety, it is essential to understand influencing factors relevant to specific patient populations and settings. A standardized tool for systematic retrospective analysis of readmissions would help healthcare professionals understand risks and reasons affecting readmissions; however, no such tool exists.PurposeThis study’s purpose was to develop a tool (We-ReAlyse) to analyze readmissions to the intensive care unit from general units by reflecting on affected patients’ pathways from intensive care discharge to readmission. The results will highlight case-specific causes of readmission and potential areas for departmental- and institutional-level improvements.MethodA root cause analysis approach guided this quality improvement project. The tool’s iterative development process included a literature search, a clinical expert panel, and a testing in January and February 2021.ResultsThe We-ReAlyse tool guides healthcare professionals to identify areas for quality improvement by reflecting the patient's pathway from the initial intensive care stay to readmission. Ten readmissions were analyzed by using the We-ReAlyse tool, resulting in key insights about possible root causes like the handover process, patient's care needs, the resources on the general unit and the use of different electronic healthcare record systems.ConclusionsThe We-ReAlyse tool provides a visualization/objectification of issues related to intensive care readmissions, gathering data upon which to base quality improvement interventions. Based on the information on how multi-level risk profiles and knowledge deficits contribute to readmission rates, nurses can target specific quality improvements to reduce those rates.Implications for clinical practice and researchWith the We-ReAlyse tool, we have the opportunity to collect detailed information about ICU readmissions for an in-depth analysis. This will allow health professionals in all involved departments to discuss and either correct or cope with the identified issues. In the long term, this will allow continuous, concerted efforts to reduce and prevent ICU readmissions. To obtain more data for analysis and to further refine and simplify the tool, it may be applied to larger samples of ICU readmissions. Furthermore, to test its generalizability, the tool should be applied to patients from other departments and other hospitals. Adapting it to an electronic version would facilitate the timely and comprehensive collection of necessary information. Finally, the tool’s emphasis comprises reflecting on and analyzing ICU readmissions, allowing clinicians to develop interventions targeting the identified problems. Therefore, future research in this area will require the development and evaluation of potential interventions.