IMPLEMENTATION OF PATIENT INTERVIEW IN CONNECTION WITH MEDICATION REVIEW IN AN INPATIENT PSYCHIATRIC WARD (submitted in 2019)
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Majken Nørskov Petersen, Dorthe Bonnerup, Louise Thorsen, Lona Louring Christrup, Sune Puggaard Vogt Straszek, Charlotte Olesen
Why was it done?
Medication review with patient interview provides the opportunity to clarify the patient’s overall drug intake along with identifying the patient’s experienced side effects. Medication review with patient interview we believe gives a more realistic picture of experienced drug related problems (DRP) and potentially DRP. This again makes the medication review more relevant and useful to the doctors.
What was done?
The initiative took place in the Department of Affective Disorders, at Aarhus University Hospital, Denmark. Initially, the medication review was performed by hospital pharmacists without patient interview based only on medical records. We implemented a patient interview to give a more clinically relevant medication review. The interview included a structured questionnaire on typical side effects of antipsychotics.
How was it done?
The cost of a new workflow is always weighed against the outcome. We therefore planned and conducted a pilot study. The cost was measured as the time used for the patient interview and it was 17 minutes on average. We used DRP as the outcome. DRP is an accessible measure for the immediate outcome of a medication review. Sixteen medication reviews without patient interview were conducted and the same 16 patients were interviewed for a second medication review. Patient interview increased the number of identified DRP from 52 to 68. Due to the interview 28 new DRP were identified and 12 DRP found before the interview were withdrawn due to irrelevance.
What has been achieved?
Patient interview has been implemented in one of three inpatient psychiatric wards and in one of four outpatient clinics where the pharmacists conduct medication review. The structured questionnaire has been further developed and now includes common side effects caused by antipsychotics, antidepressants, benzodiazepines and mood stabilizers.
What next?
We still use the pilot study to show how medication review can be more relevant by using patient interview. The hospital pharmacy in Aarhus works on several levels in order to implement medication review, preferably with patient interview.
INTEGRATION OF THE CLINICAL PHARMACIST IN A MULTIDISCIPLINARY TEAM IN A BURNS UNIT
European Statement
Clinical Pharmacy Services
Author(s)
Ángel Guillermo Arévalo Bernabé, Pilar Lalueza Broto, Jordi Serracanta Doménech, Jacinto Caparrós Baena, José Manuel Collado Delfa, Jordi Aguilera Sáez, Romy Rossich Verdés, Pablo Sánchez Sancho, Juan Carlos Juárez Giménez, Maria Queralt Gorgas Torné
Why was it done?
The burns unit of a third-level hospital includes a patient’s great heterogeneity depending on his population group and his clinical condition (extension, degree and depth of his burns, etiological agent of the burns and associated comorbidities), which makes the managing of these patients complex and they need multidisciplinary solutions. In addition, extensive burns provoke physiopatological alterations that involve changes in the pharmacokinetical and the pharmacodynamical modelling of some drugs. The knowledge that the pharmacist has about the changes that take place in vascular dynamics, the clearance and the distribution volume of the drugs, and the degree of union from these to plasmatic proteins, makes his active participation in the care of the burns patient, and in the optimisation of his pharmacotherapeutic plan, very interesting.
What was done?
The integration of the pharmacist into a multidisciplinary group of assistance to the burns patient constituted as the Managing Committee of Cases and was integrated by plastic surgery, intensive medicine, intensive paediatric medicine, preventive medicine, infectious diseases, psychiatry, psychology, social work and infirmary, as well as pharmacy.
How was it done?
A protocol was devised that standardises and systematises the review of the pharmacotherapeutic plan of all patients in the burns unit, including burn critical and paediatric. Also, there is included a model of record and codificate of pharmaceutical interventions. The multidisciplinary group meets weekly and every patient is analysed from all clinical points of view, the pharmacist intervening in relation to the pharmacotherapeutic and nutritional plan.
What has been achieved?
The active integration of the pharmacist has been achieved in the clinical group of assistance to the burns patient. In addition, there has been created a collaborative attitude that has benefited joint projects of investigation. The degree of acceptance of the offers of modification that the pharmacist realises is 90%.
What next?
The following step must be, depending on the obtained results, to establish improvement assistance measures, including the accomplishment of protocols and the development of investigation projects that help to generate knowledge about the use of some drugs in burns patients, such as immunoglobulin or proteolitic enzymes for the extraction of bed sores.
USING AN ELECTRONIC ALGORITHM TO IDENTIFY THE MOST RELEVANT PATIENTS FOR MEDICATION REVIEW
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Charlotte Olesen
Why was it done?
In the Regional Hospital in Horsens, Central Denmark Region (covering 217,000 citizens) medication reviews by clinical pharmacists were performed on a few wards. Patients were selected to receive medication reviews on the basis of pre-defined criteria. The criteria were not evidence-based and were individual for each ward and pharmacist. This screening was time-consuming, as we screened every patient in the EPS to find relevant patients for medication review. Assuming that patients at high risk of medication errors will benefit most from medication reviews, we wanted to identify, using an evidence-based algorithm, these patients automatically across all wards at the hospital, thereby reducing resources during screening and allowing more time on the relevant patients.
What was done?
An algorithm, to identify patients who would benefit most from a medication review, was developed using data from the Electronic Prescribing System (EPS). The system could produce a list of patients daily considered relevant for medication review.
How was it done?
MEdication RIsk Score (MERIS), a validated algorithm to identify patients in high risk of medication errors, was implemented using data from the EPS. Each hospitalised patient’s risk score was automatically calculated, and a list with risk scores was generated. Patients with highest risk were selected to receive a medication review by a clinical pharmacist. We validated the algorithm on two wards. The variables used in MERIS are reduced renal function, the total number of drugs and the risk of individual drugs to cause harm and interactions.
What has been achieved?
Instead of individual and time-consuming screening, electronic uniform screening has been implemented in our clinical pharmacy service. Our limited time is now used carrying out medication review on patients with the highest risk of medication errors instead of patients with less benefit.
What next?
The electronic version of MERIS is now used on two wards at our hospital. The next step is to include more wards so all patients with high-risk factors will receive a medication review from a clinical pharmacist. Furthermore, clinical pharmacists in other hospitals in the Central Denmark Region will also implement the electronic algorithm.
LET’S DIVERSIFY TO GUARANTEE ACCESS TO THE HOSPITAL PHARMACIST’S EXPERTISE: ALL GOOD THINGS COME IN FOURS!
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Maria Kundracikova, Petra Pölzleitner, Katharina Ocko, Bernadette Aretin, Barbara Datterl, Klara Jadrna, Eva-Luise Hobl, Martin Holbik, Sonja Steininger-Salmer, Helga Fend, Gerda Laml-Wallner, Martina Anditsch, Gunar Stemer
Why was it done?
Due to limited human ressources (8 FTE) in the medicines information and clinical pharmacy department only selected wards could be provided with daily clinical pharmacists’ presence offering medication review, patient discharge counselling and ward round participation. To expand the reach of our clinical services, two further service pillars were introduced complementing the already existing services.
What was done?
The Vienna General Hospital is a 1900 bed university hospital in which patients and health care professionals have access to hospital pharmacists’ expertise via various channels. In addition to already existing services (i.e. provision of hospital-wide medicines information and clinical pharmacy services on particularly selected wards) two new services (i.e. e-pharmacy consult and a dedicated drug interactions and pharmacotherapy clinic) have recently been implemented.
How was it done?
As ward services are staff-intensive, alternatives to expand the access of patients and health care professionals to the hospital pharmacists’ expertise were examined. An e-pharmacy consult was designed, implemented, and promoted in collaboration with the hospital IT department. E-consults can electronically be requested by all wards (e.g. for medication review, patient counselling), but mainly aim at those areas which are not regularly covered by a clinical pharmacist. E-consults are executed by the medicines information pharmacist on duty. Recently, a special clinic was implemented as a collaborative project with the clinical pharmacology department addressing the specific medicines-related needs of patients with complex medication regimens.
What has been achieved?
The scope of services provided by the department currently comprises four pillars: (1) provision of medicines information (2016: 1.200 requests), (2) clinical pharmacy services (2016: 9.000 medication-related problems prevented), (3) pharmacy e-consults, and (4) the drug interactions and pharmacotherapy clinic. While the scope and reach of services was expanded by diversification, the two new services are operated with existing ressources after reassignment of tasks.
What next?
After the implementation of new services (i.e. e-consult, clinic) constant promotion is needed to increase the awareness level among health care professionals in the hospital. Quality assurance and continuity of service provision is crucial for acceptance.
A 72 hours training program for pharmacy residents to perform secure, optimized and standardized medication review orders: a proof of concept
European Statement
Education and Research
Author(s)
Sophie Renet, Florian Le seigneur, Ratiba Haddad, Andre Rieutord, Marie Camille Chaumais
Why was it done?
The high turn over rate of medical and pharmacy residents (every 6 months) could jeopardize the patient’s care management as they generally lack of appropriate skills upon arrival. Our former process medication review was relying on individual and heterogeneous competencies of pharmacy residents likely to lead to sub-optimal medication review and treatment optimisation. We had to design a training program for residents according to the constraints of time and characteristics of related treatment of the considered clinical ward recruited patients.
What was done?
A training program for pharmacy residents was developed and implemented. The aim was to develop the skills of the residents to allow them to perform, after 72 hours, a secure, optimized and standardized (SOS) medication review orders, according to the specificities and the “real-life practice” of the clinical department.
How was it done?
Through a collaborative approach (residents and seniors pharmacists, physicians, PhD student in education sciences), ADDIE (Analyse, Design, Development, Implantation, Evaluation) method was used. First, the most frequent pathologies and drugs prescribed in the cardiology department were identified to define specificities and thus custom the educational needs and skills that residents have to acquire to ensure a SOS medication review orders. The program included a 3 steps process over 3 days: (1) recognize the organisation and learning tools; (2) practice 3 clinical medication review orders simulation; (4) assess and feed-back with a senior clinical pharmacist. Some learning tools were developed: a training tool kit to guide the learners ; an aid kit, including a SOS medication review orders algorithm to follow throughout the whole process. Two years after implementation, 4 pharmacy residents have used this training program.
What has been achieved?
Our 72-hours-training program is routinely used for new pharmacy residents. It has been implemented successfully with a high acceptance. They also felt more comfortable to suggest therapeutic advices to the physicians.
What next?
The proof of concept of SOS was successfully done. We are currently extending it for 5th year pharmacy students and develop similar training program for other clinical wards (Surgery, oncology, immunology). In 2017, we expect to share it with our pharmacist colleagues working in the two closest hospitals.
PIM-CHECK: DEVELOPMENT OF THE FIRST ELECTRONIC PRESCRIPTION-SCREENING CHECKLIST TO SUPPORT HEALTHCARE PROFESSIONALS IN THE DETECTION OF POTENTIALLY INAPPROPRIATE MEDICATION
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Aude Desnoyer, Anne-Laure Blanc, Christian Skalafouris, Rolf Hauri, Alain Lorenz, Pascal Bonnabry, Bertrand Guignard
Why was it done?
PIM (i.e. over-/under-/mis-prescriptions, and drug interactions) occurs frequently and is a well-known risk factor for adverse drug events and morbi-mortality (1). Its incidence is high and underestimated in internal medicine (2). While many paper checklists, providing explicit statements, related to PIM in geriatrics exist (3), none had been developed for adults in internal medicine. Moreover, as all these tools are only available as paper versions, they are not easily accessible in daily practice (4). Therefore, we decided to develop an electronic checklist, dedicated to adults in internal medicine.
What was done?
We developed an electronic screening checklist to detect potentially inappropriate medication (PIM) in internal medicine.
How was it done?
We conducted a 4-step study including literature review, 17 semi-structured interviews, a 2-round Delphi survey, and a forward/back-translation process (French English) to develop PIM-Check (5). Sixty-five medical specialists and pharmacists, from 22 hospitals in Belgium, Canada, France, and Switzerland were enrolled. Experts agreed on 160 statements, in 17 medical domains, and 56 pathologies. These statements were then integrated in a specifically developed web-based electronic tool. Each statement is associated with at least one pathology and one medication (1600 ATC encoded).
What has been achieved?
The application is available in French and in English on a website (www.pimcheck.org). A “Screening” function allows users to select for a specific patient, his/her co-morbidities and medications to switch on statements that are the most relevant. A “Favourites” function, gives quick access to selected statements, and a “Learning” function gives access to the list of all statements, those unread and those already read. Details regarding the conception of the tool, direct access to the references (n=333) and useful links (n=29), publications related to the tool and a contact section, are also available. Between February and September 2016, PIM-Check has been visited more than 75.000 times, in over 66 countries.
What next?
Several studies assessing the impact of PIM-Check are ongoing. The algorithm and content of the tool are constantly updated. Thanks to the English version, PIM-Check can be used in different European countries and healthcare settings (6), and will be helpful to support clinical pharmacists’ education in appropriate prescription analysis.