Heart Failure Management in Nursing Homes: A Scoping Literature Review

Heart failure (HF) affects 20% of nursing home (NH) residents, causing high morbidity and mortality. The optimal approach to HF management in NHs remains elusive. We conducted a scoping review of published guidelines and HF management interventions in NHs. A search for English publications since 1990 was conducted using PubMed, EMBASE, CINAHL, and Scopus, for scientific statements, guidelines, recommendations, or intervention studies that addressed at least 1 principle of HF management. Of 2545 records retrieved, 19 articles were retained after screening, and 2 additional articles identified through reference list manual searches. Six articles represented 5 guidelines and 15 described interventions. All guidelines endorsed the applicability of general HF guidelines to NH residents, tailored to comorbidities, frailty, and advance care preferences. Four addressed quality assurance but not feasibility and sustainability. Methodological quality of the interventions was poor, although results suggest that guideline-based HF management in NHs can improve nursing staff knowledge and job satisfaction, prescribing, and reduce acute care utilization. Clinically-based education for staff, and access to specialist mentorship are important. NH physician involvement was limited, and resident/family education potentially ineffective. Concerns about feasibility, sustainability, and quality assurance were identified in most interventions, and advance care planning was rarely addressed. HF guidelines for NH support the applicability of general HF guidelines to the care of NH residents, and published interventions suggest that guideline-based HF management in NHs is effective. Future work should support greater physician and resident engagement, advance care planning, and provide robust guidelines on developing feasible and sustainable interventions.     

The effects of physical environments in medical wards on medication communication processes affecting patient safety

Physical environments of clinical settings play an important role in health communication processes. Effective medication management requires seamless communication among health professionals of different disciplines. This paper explores how physical environments affect communication processes for managing medications and patient safety in acute care hospital settings. Findings highlighted the impact of environmental interruptions on communication processes about medications. In response to frequent interruptions and limited space within working environments, nurses, doctors and pharmacists developed adaptive practices in the local clinical context. Communication difficulties were associated with the ward physical layout, the controlled drug key and the medication retrieving device. Health professionals should be provided with opportunities to discuss the effects of ward environments on medication communication processes and how this impacts medication safety. Hospital administrators and architects need to consider health professionals' views and experiences when designing hospital spaces.     

Adaptation of the health literacy universal precautions toolkit for rheumatology and cardiology – Applications for pharmacy professionals to improve self-management and outcomes in patients with chronic disease

Over a decade of research in health literacy has provided evidence of strong links between literacy skills of patients and health outcomes. At the same time, numerous studies have yielded insight into efficacious action that health providers can take to mitigate the negative effects of limited literacy. This small study focuses on the adaptation, review and use of two new health literacy toolkits for health professionals who work with patients with two of the most prevalent chronic conditions, arthritis and cardiovascular disease. Pharmacists have a key role in communicating with patients and caregivers about various aspects of disease self-management, which frequently includes appropriate use of medications. Participating pharmacists and staff offered suggestions that helped shape revisions and reported positive experiences with brown bag events, suggestions for approaches with patients managing chronic diseases, and with concrete examples related to several medicines [such as Warfarin^©] as well as to common problems [such as inability to afford needed medicine]. Although not yet tested in community pharmacy sites, these publically available toolkits can inform professionals and staff and offer insights for communication improvement.     

Extended‐release antiepileptic drugs: A comparison of pharmacokinetic parameters relative to original immediate‐release formulations

Many antiepileptic drugs (AEDs) have short half‐lives with large fluctuations in peak‐to‐trough plasma concentrations. Consequences of these pharmacokinetic (PK) properties may include adverse events (AEs) and breakthrough seizures, potentially leading to poor adherence. To address these challenges, newer formulations of these AEDs have been developed using unique extended‐release (ER) technologies. These technologies extend the dosing interval such that dosing frequency can be minimized, which may improve patient adherence. Available ER formulations have the potential to minimize the spikes in maximum plasma concentrations (C_max) at steady‐state that often contribute to AEs during treatment with immediate‐release (IR) products. In so doing, tolerability advantages may lead to increased AED effectiveness by improving adherence and allowing higher doses if clinically indicated. Direct PK comparison studies of IR and ER formulations (e.g., carbamazepine, divalproate sodium, lamotrigine, oxcarbazepine, levetiracetam, and phenytoin) have found that dose‐normalized ER formulations may or may not be bioequivalent to their IR counterparts, but most ER formulations have a lower fluctuation index ([C_max–C_min]/C_avg) compared with the IR versions. This results in flatter concentration‐time plots. Not all ER preparations improve the various PK parameters to the same extent, and PK nuances may impact the effectiveness, tolerability, and adherence rates of various ER formulations.     

Utilizing an Ingestible Biosensor to Assess Real-Time Medication Adherence

Medication adherence monitoring has relied largely on indirect measures of pill ingestion including patient self-report, pharmacy refills, electronically triggered pill bottles, and pill counts. Our objective is to describe an ingestible biosensor system comprising a radio-frequency identification (RFID)-tagged gelatin capsule. Once the capsule dissolves in the stomach, the RFID tag activates to transmit a unique signal to a relay device which transmits a time-stamped message to a cloud-based server that functions as a direct measure of medication adherence. We describe a constellation of mobile technologies that provide real-time direct measures of medication adherence. Optimizing connectivity, relay design, and interactivity with users are important in obtaining maximal acceptability. Potential concerns including gut retention of metallic components of the ingestible biosensor and drug dissolution within a gelatin capsule should be considered. An ingestible biosensor incorporated into a medication management system has the potential to improve medication compliance with real-time monitoring of ingestion and prompt early behavioral intervention. Integration of ingestible biosensors for multiple disease states may provide toxicologists with salient data early in the care of poisoned patients in the future. Further research on device design and interventions to improve adherence is needed and will shape the evolving world of medication adherence.     

Medications and the Culture of Safety: Conference Title: At the Precipice of Quality Health Care: The Role of the Toxicologist in Enhancing Patient and Medication Safety Venue ACMT Pre-Meeting Symposium, 2014 North American Congress of Clinical Toxicology,New Orleans,LA

Medication mishaps are a common cause of morbidity and mortality both within and outside of hospitals. While the use of a variety of technologies and techniques have promised to improve these statistics, instead of eliminating errors, new ones have appeared as quickly as old ones have been improved. To truly improve safety across the entire enterprise, we must ensure that we create a culture that is willing to accept that errors occur in normal course of operation to the best of people. Focus must not be on punishment and shame, but rather building a fault tolerant system that maintains safety of both staff and patients.