Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model – impact on all‐cause emergency department revisits

What is known and objective: Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug‐related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post‐discharge hospital revisits or death. Methods: This prospective, controlled study included all patients hospitalized in three internal medicine wards in a university hospital, between 1 January 2006 and 31 May 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group (n = 1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients (n = 2758) attended the wards before implementation of the intervention. Results and Discussion: No impact of medication reconciliation and reviews on ED revisits [hazard ratio (HR), 0·95; 95% confidence interval (CI), 0·86–1·04]or event‐free survival (HR, 0·96; 95% CI, 0·88–1·04) was demonstrated. In the intervention group, 594 patients (48·8%) visited the ED, compared with 1416 (51·3%) control patients. In total, 716 intervention (58·9%) and 1688 (61·2%) control patients experienced any event (ED visit, hospitalization or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 (P < 0·05), we re‐examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 (P = 0·608). What is new and conclusion: Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, re‐hospitalizations or mortality over 6‐month follow‐up.     

Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans

What is known and background: Unintended bleeds are a common complication of warfarin therapy. We aimed to determine the impact of general practitioner–pharmacist collaborative medication reviews in the practice setting on hospitalization‐associated bleeds in patients on warfarin. Method: We undertook a retrospective cohort study using administrative claims data for the ambulatory veteran and war widow population, Australia. Participants were veterans, war widows and their dependents aged 65 years and over dispensed warfarin. The exposed groups were those exposed to a general practitioner (GP)–pharmacist collaborative home medication review. The service includes GP referral, a home visit by an accredited pharmacist to identify medication‐related problems, a pharmacist report with follow‐up undertaken by the GP. The outcome measure was time to next hospitalization for bleeding. Results: There were 816 veterans exposed to a home medicines review and 16 320 unexposed patients, with an average age of 81·5 years, and six to seven co‐morbidities. Adjusted results showed a 79% reduction in likelihood of hospitalization for bleeding between 2 and 6 months (HR, 0·21 95% CI, 0·05–0·87) amongst those who had received a home medicines reviewed compared to the unexposed patients. No effect was seen in the time period from review to 2 months, nor in the time period 6 to 12 months post a review. What is new and conclusion: Medicines review in the practice setting delays time to next hospitalization for bleeding in those treated with warfarin in the period 2 to 6 months after the review, but is not sustained over time. Six monthly medication reviews may be required for patients on warfarin who are considered at high risk of bleeding.     

Impact of a self-administration of medications programme on elderly inpatients' competence to manage medications: a pilot study

What is known and objectives: Changes to medication regimens and failure to involve patients in management of their medications whilst in hospital may result in medication errors or non‐adherence at home after discharge. Self‐administration of medications programmes (SAMP) have been used to address this issue. The objective of this study was to assess the impact of a SAMP on elderly hospital inpatients’ competence to manage medications and their medication adherence behaviours. Methods: The SAMP comprised three stages: education, progressing to supervised self‐administration and finally to independent self‐administration. Decisions to progress patients to the next level, and whether they passed or failed the SAMP, were made by the ward pharmacist and nursing staff. The Drug Regimen Unassisted Grading Scale (DRUGS) was used to assess patients’ competence to manage medications at various time points. Tablet count and the Tool for Adherence Behaviour Screening (TABS) were used as adherence measures. Results and discussion: Participants (n = 24) with a mean age of 77·4 years, were mainly female and generally had a high level of functioning. They were prescribed a mean of 9·0 medications at the time of commencing the SAMP. Twenty‐two of the 24 participants successfully completed the SAMP. DRUGS scores at discharge improved significantly (P < 0·001) compared with that before commencement of medication self‐administration. Participants reported a significant decrease (P = 0·02) in non‐adherent behaviour and a trend towards improved adherent behaviour (P = 0·08) after participation in the SAMP. What is new and conclusion: An inpatient SAMP improved elderly patients’ ability to competently manage and adhere to their prescribed medications regimen. This finding needs to be confirmed in a larger controlled trial.     

Clinical impact of a pharmacist–physician co-managed programme on hyperlipidaemia management in Hong Kong

Objective: The study aimed to investigate the clinical impact of pharmacist–physician co‐managed programme on the management of hyperlipidaemia. Methods: The study was a prospective randomized controlled trial. Adult patients were selected if: (i) they were taking one or more lipid‐lowering agents with a valid lipid panel before their next follow up; (ii) had a baseline lipid profile within the previous 6 months; (iii) their lipid panel did not reach the targeted low‐density lipoprotein‐cholesterol (LDL‐C) goal based on the National Cholesterol Education Programme Adult Treatment Panel III. Pharmacists interviewed patients in the intervention group for 15–30 min to provide consultation on the drug regimen and lifestyle modifications. A telephone follow‐up every 4 weeks and a follow‐up interview on the date of the physician visit were scheduled. Patients in the control group received routine conventional care. The primary outcome measurement was the change in lipid panel between baseline and at the end of study. Results: One hundred and eighteen patients were recruited to the study [58 patients in intervention group (mean age 63 ± 10 years old) and 60 in control group (mean age 61 ± 12 years old)]. Starting with similar baseline levels, the end of study LDL‐C and total cholesterol levels for the intervention and control groups were LDL‐C: 2·80 ± 0·89 mmol/L and total cholesterol 4·75 ± 1·08 mmol/L vs. LDL‐C: 3·24 ± 0·78 mmol/L and total cholesterol 5·18 ± 0·93 mmol/L, respectively. The differences were statistically significant (P < 0·0015). Conclusion: The study showed that a pharmacist–physician co‐managed programme for hyperlipidaemic patient was effective in getting more patients to reach their target lipid levels.     

Effectiveness of a community pharmacist intervention in diabetes care: a randomized controlled trial

What is known and Objective: There is little evidence from well‐designed randomized controlled trials of the impact of community pharmacist intervention on the clinical management of patients with type 2 diabetes. It is also not known how sustainable any observed effects on glycaemic control are, over time. This study was initiated to address both these issues. Methods: A 6‐month, randomized, controlled parallel‐group trial in 66 community pharmacies was conducted in Belgium. Patients were randomly assigned to receive usual pharmacist care (n = 135) or a predefined pharmacist intervention (n = 153). The intervention mainly focused on correct medication use, medication adherence and healthy lifestyle promotion. Primary outcome was glycaemic control, as measured by fasting plasma glucose and HbA1c. Sustainability of changes in glycaemic control was assessed by additional glucose measurements 18 months after the end of the study. Results and Discussion: The intervention significantly reduced HbA1c (between‐group difference: 0·5%, P = 0.009). The largest impact on HbA1c was observed when pharmacotherapy changes (i.e., type and/or dose of hypoglycaemic agents) initiated by the physician were sustained with pharmaceutical care: HbA1c was reduced by 1·05% in the intervention group, whose medication was changed, compared with a reduction of 0·02% in the therapy‐modification only, group. It was also found that the diabetes education program resulted in improved self‐management and better knowledge of diabetes. Eighteen months after the end of the formal study period, the mean HbA1c of the intervention group did not differ significantly from the control group (7·4% vs. 7·2%). What is new and Conclusion: This study provides new evidence, from a randomized controlled trial, of the beneficial effect of community pharmacist intervention in the clinical management of type 2 diabetic patients. However, questions remain about the sustainability of the observed improvements.     

A training package for primary care nurses in conducting medication reviews: their views and the resultant outputs

Aims. To ascertain nurses’ views about training in and undertaking of medication reviews and to analyse documented pharmaceutical care issues (PCI) and outputs from nurse reviews. Background. Primary‐care nurses in the UK are increasingly expected to contribute effectively to chronic disease management for example by undertaking medication reviews. There are concerns that nurse education is inadequate for these new roles. Little research is published about nurse medication reviews. A pilot study in one Scottish medical practice demonstrated that, after training in systematic medication review, practice‐based nurses could identify medication‐related problems. The training, consisting of reading material, including self‐assessment questions and a training event, was subsequently offered to all practice‐based nurses in the Community Health Partnership (CHP); participants then undertook six reviews to achieve CHP accreditation. Design. Survey of participant nurses and analysis of completed documentation from reviews. Methods. A self‐completion, postal questionnaire distributed three months post‐training. Analysis of documentation from reviews for PCI and outputs. Results. Eighty‐one nurses were offered training: 64 (79%) participated; 38 (59%) returned questionnaires. Low confidence levels before training (0, very confident; 6, 16% confident) rose afterwards (8, 21% very confident; 19, 50% confident). Thirty‐two (84%) nurses indicated the training had completely or mostly met their needs. A total of 120 nurse reviews were analysed and 188 PCI documented, mean 1·6/patient, with 117 outputs, mean 1·0/patient. Twenty‐seven outputs (23%) involved prescribed medicine changes. Conclusions. A pharmacist‐supported training package in medication reviews for primary‐care nurses is feasible and generally welcome. The training met the needs of most respondents although concerns were expressed regarding time pressures and knowledge base for extended roles. Relevance to clinical practice. Medication reviews are vitally important for both patients and the NHS; this approach may be useful for nurse prescribers and non‐prescribers alike although concerns expressed will require attention.     

The contribution of patient interviews to the identification of drug‐related problems in home medication review

What is known and Objective: To determine to what extent patient interviews contribute to the identification of drug‐related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance. Methods: We performed a cross‐sectional study within the intervention arm of a randomized controlled trial. Patients were recruited from 10 Dutch community pharmacies. Patients were eligible if they were home‐dwelling, aged 65 years and over and used five or more different drugs, including at least one cardiovascular or antidiabetic drug. The community pharmacist interviewed the patient at home about the medicines and identified potential DRPs in combination with medication and clinical records. This medication review was assessed and modified by an independent pharmacist reviewers’ panel. Outcomes were the number and type of DRPs and recommendations and percentage of clinical relevant DRPs. Clinical relevance of DRPs was assessed by DRPs assigned a high priority, DRPs followed by recommendations for drug change and DRPs followed by implemented recommendations for drug change. Results: A total of 1565 potential DRPs and recommendations (10 per patient).were identified for 155 patients (median age, 76 years; 54% women). Fifty‐eight per cent of all recommendations involved a drug change; 27% of all DRPs were identified during patient interviews and 74% from medication and clinical records. Compared to DRPs identified from patient medication and clinical records, DRPs identified during patient interviews were more frequently assigned a high priority (OR = 1·8 [1·4–2·2]), were more frequently associated with recommendations for drug change (OR = 2·4 [1·9–3·1]) and were implemented recommendations for drug change (OR = 2·8 [2·1–3·7]). What is new and Conclusion: This study shows that more than a quarter of all DRPs were identified during patient interviews. DRPs identified during patient interviews were more frequently assigned a higher clinical relevance.     

Prevalence of medication-related problems among patients with renal compromise in an Indian hospital

What is known and Objective: Patients suffering from renal dysfunction often have multiple medical conditions either as a cause or as a consequence of their renal disease. These patients receive an average of 10–12 medications daily leading to complex dosing schedules and are more likely to develop medication‐related problems (MRPs). The objectives of this study were to determine the nature and extent of MRPs in renally compromised patients and to explore the potential clinical significance of the MRPs. The potential for a clinical pharmacist to contribute towards resolving or preventing some of these MRPs was also explored. Methods: A prospective study was conducted for a period of 9 months in the renal unit of Jagadguru Shri Shivaratheeshwara (JSS) Medical College Hospital, Mysore, India. Patients undergoing dialysis on outpatient basis and patients who were admitted under the care of or referred to the nephrologists for renal dysfunction from other specialties were reviewed. Patterns of the MRPs were identified using an adapted Hepler and Strand criteria. The potential clinical significance of the MRPs and the contribution of the clinical pharmacist in resolving or minimizing some of the MRPs were also explored. Results and Discussion: Three hundred and twenty‐seven MRPs were identified with 308 patients reviewed. The incidence of MRPs was found to be 1·06 ± 0·85 per patient reviewed. The most common MRP identified in our study was overdose (19·3%) followed by adverse drug reactions (19·0%). Cardiovascular agents (33·6%) followed by anti‐infective agents (26·3%) were the most common therapeutic classes of medication implicated in causing MRPs. Twenty‐six per cent of the MRPs identified were explored to be potentially moderate or major in clinical significance. The clinical pharmacists’ recommendations were accepted in 97% of the cases, which resulted in a change in therapy in 83% of the cases. What is new and Conclusion: Medication‐related problems are frequent in renally compromised patients in our patient population. The high level of acceptance of clinical pharmacist’s recommendations by the nephrologists demonstrates that clinical pharmacists may help improve overall patient care in this setting.     

Hot off the Press: SGEM #226. I Want a New Drug—One That Doesn't Cause an Adverse Drug Event

Adverse drug events (ADEs) are a significant cause of emergency department (ED) visits in North America and are frequently misdiagnosed. Despite evidence supporting improved health care outcomes for ED patients who have a pharmacist‐led medication review, EDs do not have sufficient clinical pharmacists to perform medication reviews on all patients. The study reviewed in this article aimed to validate clinical decision rules for use by clinical pharmacists and physicians to prioritize ED patients with ADEs.     

Prochlorperazine tablets repackaged into dose administration aids: can the patient be assured of quality?

Background and objective: Patients are increasingly requiring their medications to be repackaged into dose administration aids because of the positive outcomes associated with reduction in medication related hospitalization and adverse effects due to improved medicines management. Since the stability of these repackaged medications is not the responsibility of manufacturer, it is important that drug substances with potential stability issues be identified. Thus the objective of this study was to evaluate the stability of prochlorperazine, a light sensitive drug repackaged into dose administration aids (DAAs), in order to provide guidelines to the pharmacist and advice to the patient on appropriate storage. Methods: Prochlorperazine tablets were stored repackaged in DAAs and in their original packaging for 8 weeks at ambient (25 ± 1 °C; 60 ± 1·5% RH), accelerated (40 ± 1 °C; 75 ± 1·5% RH) and in‐use conditions encountered in situ both in a pharmacy and the patients’ home. They were assessed for both chemical (using a validated HPLC method) and physical stability according to British Pharmacopoeial (BP) standards. In addition, photostability testing was undertaken under ICH conditions. Results and discussion: Chemical and physical stability was confirmed to be within BP Limits.
There were, however, noticeable organoleptic changes in the tablets stored under in‐use conditions with a progressive grey discolouration over the 8 weeks, starting in week 2. Conclusion: Despite the confirmation of physical and chemical stability within BP limits, the discoloration and the potential for photodegradants to cause adverse effects in patients must lead us to draw the conclusion that the quality of this medication has been compromised. Pharmacists thus need to take this into account in repackaging and storage of prochlorperazine in DAAs and advise patients to store their DAA protected from light, heat and humidity.     

A SURVEY OF NEUROLOGICAL DISABILITY AT A DISTRICT GENERAL HOSPITAL

SUMMARY Neurological disease accounts for 20% of all admissions to medical wards, but the number of inpatients with neurological disability is unknown. The notes of all adult inpatients in a district general hospital were reviewed to identify all those with a neurological disorder. Over 40% of inpatients on medical wards and 4% on surgical wards had a neurological disorder. Stroke was the most common neurological diagnosis, accounting for 36% of neurological disorders and 22% of all patients on medical wards. Other neurological diagnoses included dementias 10%, degenerative disorders 10%, epilepsy 7%, demyelination 4%, and head injuries 3%. Neurological patients have long inpatient stays (mean 80 days), and often remain in hospital awaiting changes in accommodation. Seven patients under 65 years stayed more than 6 months awaiting long-term care. Neurological disorders contribute significantly to the inpatient workload. Identifying those requiring rehabilitation and concentrating them on one ward could improve the quality and efficiency of their care.     

Assessment of the clinical transfusion practice at a regional referral hospital in Uganda

The aim of this study was to determine the indications for transfusion, blood ordering practices and post‐transfusion complications, and to assess the clinical transfusion practice at Mbarara Regional Referral Hospital (MRRH) in Mbarara, Uganda. There are no guidelines on the appropriate use of blood at MRRH. Therefore, there was a need to assess the local clinical transfusion practice. Patients' hospital files were studied for evidence of blood transfusions in 2008. All five wards were reviewed and details on the transfusion process were recorded. A total of 1730 patients (median age, 19·0 years; range, 1 day to 88 years; female‐to‐male ratio, 1·4), for whom blood was cross‐matched, were studied. Of these, 1674 (96·8%) patients actually received transfusions, which were as whole blood in 58·4% of recipients. The mean number of units per recipient was 1·7 and the cross‐match‐to‐transfusion ratio was 1·3. The three most frequent indications for transfusion were malaria (38·8%), bleeding (27·1%) and other infections (16·1%). There were no records for pre‐transfusion haemoglobin, compatibility testing, transfusion start‐times and vital signs in 30·2, 51·8, 21·5 and 97·6% of the recipients, respectively. Transfusion reactions were recorded for 10 (0·6%) patients. Although there was no evidence of blood wastage, inadequacies were noted in the documentation of the transfusion process. There is a need to train staff in blood transfusion and to design a ‘blood transfusion form’ for easy monitoring and evaluation. A hospital transfusion committee and guidelines on the appropriate use of blood should be put in place at MRRH.     

Development and implementation of a noise reduction intervention programme: a pre‐ and postaudit of three hospital wards

Aims. By developing, implementing and delivering a noise reduction intervention programme, we aimed to attempt to reduce the high noise levels on inpatient wards. Background. Sleep is essential for human survival and sleep deprivation is detrimental to health and well being. Exposure to noise has been found to disrupt sleep in hospitalised patients which is to be expected as noise levels have been measured and reported as high. Design. A primarily nursing focused, multi‐method approach, involving development of clinical guidelines, ward environment review and a staff noise awareness and education programme, was used to target mainly nursing staff plus other healthcare staff on three wards within one hospital. Methods. This practice development initiative was carried out in three key phases (1) Preaudit of ward noise levels, (2) The development, implementation and delivery of a noise reduction intervention programme, (3) Postaudit of ward noise levels. Results. Preintervention average peak decibel levels over 24 hours were found to be 96·48 dB(A) and postintervention average peak decibel levels were measured at 77·52 dB(A), representing an overall significant reduction in noise levels (p < 0·001). Conclusions. This study describes one way to reduce peak noise levels on inpatient hospital wards. Relevance to clinical practice. Sleep deprivation is detrimental to patients with acute illness, so any developments to improve patients’ sleep are important. Nurses have a key role in leading, developing and implementing changes to reduce peak noise levels on inpatient wards in hospitals. This nurse‐led practice development programme has demonstrated how improvements can be achieved by significantly reducing peak noise levels using simple multi‐method change strategies.     

Evaluation of contextual influences on the medication administration practice of paediatric nurses

Title. Evaluation of contextual influences on the medication administration practice of paediatric nurses. Aim. This paper is a report of a study conducted to explore the impact of preidentified contextual themes (related to work environment and socialization) on nursing medication practice. Background. Medication administration is a complex aspect of paediatric nursing and an important component of day‐to‐day nursing practice. Many attempts are being made to improve patient safety, but many errors remain. Identifying and understanding factors that influence medication administration errors are of utmost importance. Method. A cross‐sectional survey was conducted with a sample of 278 paediatric nurses from the emergency department, intensive care unit and medical and surgical wards of an Australian tertiary paediatric hospital in 2004. The response rate was 67%. Result. Contextual influences were important in determining how closely medication policy was followed. Completed questionnaires were returned by 185 nurses (67%). Younger nurses aged <34 years thought that their medication administration practice could be influenced by the person with whom they checked the drugs (P = 0·001), and that there were daily circumstances when it was acceptable not to adhere strictly to medication policy (P < 0·001), including choosing between following policy and acting in the best interests of the child (P = 0·002). Senior nurses agreed that senior staff dictate acceptable levels of medication policy adherence through role modelling (P = 0·01). Less experienced nurses reported greater confidence with computer literacy (P < 0·001). Conclusions. Organizations need to employ multidisciplinary education programmes to promote universal understanding of, and adherence to, medication policies. Skill mix should be closely monitored to ensure adequate support for new and junior staff.