Clinical Telepharmacy: Addressing Care Gaps in Diabetes Management for an Underserved Urban Population Using a Collaborative Care Model.

Introduction: Optimal chronic care management is limited by low health care access and health literacy among underserved populations. We introduced clinical pharmacy services to enhance our patient-centered home model, which serves mostly Medicare/Medicaid-insured patients. Primary care providers (PCP) refer patients with uncontrolled diabetes to the pharmacist for chronic disease management between PCP appointments to bring A1c to goal under a collaborative agreement. This workflow existed before the COVID-19 pandemic and was primarily in-person visits. Our model transitioned to telehealth, where pharmacy services continued via audio/video visits to avoid disruption in care. Methods: A collaborative scope of practice within care guidelines was developed with PCPs. Established patients with uncontrolled diabetes were referred to the clinical pharmacist. The workflow remained consistent through January 1, 2019 to January 31, 2020 (pre-COVID), and April 1, 2020 to October 31, 2021 (post-COVID). February and March 2020 were excluded due to changing operational processes at the pandemic onset. The pharmacist independently saw patients for medication-related interventions and ordered associated labs within the scope of practice. The program was retrospectively evaluated via process metrics (visit volume and intervention types) and clinical outcome (A1c reduction). Results: A total of 105 patients were referred for diabetes management during the study period. These were in-person pre-COVID (95%) and shifted to entirely audio/video (100%) post-COVID. Impact of pharmacy services was sustained through the change in care model: an A1c reduction of more than 0.5% was observed in 65% (n = 20) and 69% (n = 49) of patients managed by the pharmacist, pre- and post-COVID, respectively. Pharmacy visit volumes were 86 versus 308, respectively. Conclusion: Pharmacy referral and visit volumes increased over the pandemic, made possible via telehealth. The goal attainment rate observed pre-COVID was amplified even with the growth in services over time. Clinical pharmacy services delivered through audio/video telehealth visits may be equally effective compared to face-to-face services.

Effect of care transfer model led by the hospital clinical pharmacist on reduction of hospital readmissions in the elderly.

Transfer of care is a critical point for patient safety and requires an optimal care transfer model in order to ensure safe pharmacotherapy transfer. Polypharmacy among elderly is associated with adverse health consequences such as hospital readmissions. Hospital readmissions represent priorities in health care research and are one of the measures for assessing patient safety. Medication-related problems among elderly are associated with polypharmacy. The aim of the study was to show the impact of a developed model of care transfer led by a hospital clinical pharmacist on the number of hospital readmissions in the 12-months period in the elderly. A randomized controlled study of patients aged 65 or more was conducted at Dubrava University Hospital, Community Health Centre Zagreb - East and community pharmacies in the City of Zagreb and Zagreb County, Croatia. An intervention group received specially designed care transfer led by the hospital clinical pharmacist. Model included high-intensity pharmacotherapy interventions delivered at admission, during hospital stay and discharge, transition to primary care and post-discharge and cooperation between all healthcare professionals. In all, 182 patients in the intervention and 171 in the control group were analysed. The total number of hospital readmissions and emergency readmissions, within one year from the hospital discharge, was lower in the intervention group than in the control group (41.7% vs. 58.3%, p=0.005; 40.8% vs. 59.2%, p=0.008). The model of the health care transfer applied in this research thus significantly reduced hospital readmissions in the 1-year period in elderly patients. Therefore, the hospital clinical pharmacists should design and coordinate the transfer between hospital and primary care.

Impact of selected clinical pharmacy services on medication safety and prescription cost of patients attending a selected primary healthcare setting: a translational experience from a resource-limited country.

PURPOSE OF THE STUDY: The impact of clinical pharmacy (CP) services on primary healthcare (PH) is less well studied in resource-limited countries. We aimed to evaluate the effect of selected CP services on medication safety and prescription cost at a PH setting in Sri Lanka. STUDY DESIGN: Patients attending a PH medical clinic with medications prescribed at the same visit were selected using systematic random sampling. A medication history was obtained and medications were reconciled and reviewed using four standard references. Drug-related problems (DRPs) were identified and categorised, and severities were assessed using the National Coordinating Council Medication Error Reporting and Prevention Index. Acceptance of DRPs by prescribers was assessed. Prescription cost reduction due to CP interventions was assessed using Wilcoxon signed-rank test at 5% significance. RESULTS: Among 150 patients approached, 51 were recruited. Nearly half (58.8%) reported financial difficulties in purchasing medications. DRPs identified were 86. Of them, 13.9% (12 of 86) DRPs were identified when taking a medication history (administration errors (7 of 12); self-prescribing errors (5 of 12)), 2.3% (2 of 86) during reconciliation, and 83.7% (72 of 86) during medication reviewing (wrong indication (18 of 72), wrong strength (14 of 72), wrong frequency (19 of 72), wrong route of administration (2 of 72), duplication (3 of 72), other (16 of 72)). Most DRPs (55.8%) reached the patient, but did not cause harm. Prescribers accepted 65.8% (56 of 86) DRPs identified by researchers. The individual prescription cost reduced significantly due to CP interventions (p<0.001). CONCLUSIONS: Implementing CP services could potentially improve medication safety at a PH level even in resource-limited settings. Prescription cost could be significantly reduced for patients with financial difficulties in consultation with prescribers.

Curbing proton pump inhibitor overprescribing: Multifaceted strategies in an academic hospital.

WHAT IS KNOWN AND OBJECTIVE: Proton pump inhibitors (PPI) have become essential in the management of upper gastrointestinal disorders, yet they are prescribed without an indication in up to 89% of cases and the number of prescribed PPIs is on the rise. A working group developed several multifaceted strategies in our multihospital trust to curb inappropriate PPI use. We describe herein these strategies and assess their impact on PPI consumption in a hospital belonging to this trust. METHODS: From 2012 to 2019, our actions included the publication and presentation of a review of emergent PPI side effects, the development of an appropriate use leaflet, medication audits, journal club meetings, and prescription analysis. We considered that a decrease in PPI consumption could be a relevant surrogate criterion for the appropriation and acceptance of these interventions; this was assessed from 2012 to 2019 and expressed as defined daily dose (DDD)/1000 patient-days. RESULTS AND DISCUSSION: There was a clear downward trend in the consumption of PPIs, both in medical and surgical wards. The overall PPI use decreased by 17.1% (from 566 to 468 DDD/1000 patient-days). IV PPI consumption dropped by 37.7% (from 146 to 91 DDD/1000 patient-days), while oral PPIs consumption decreased by 10% (from 420 to 378 DDD/1000 patient-days). WHAT IS NEW AND CONCLUSION: Sustained strategies aimed at curbing PPI overprescribing led to a sustained decrease in PPI consumption in our hospital. This decrease encourages us to pursue this strategy and to diversify our actions.

Role of clinical pharmacists in telemonitoring for patients with Coronavirus Disease 2019 (COVID-19).

WHAT IS KNOWN AND OBJECTIVE: Clinical pharmacists actively participate in patient care via patients' medication use. Yet the setting of Coronavirus Disease 2019 (COVID-19) limits patient contact with healthcare personnel. We aimed to review the services provided and drug-related problems detected using telemonitoring methods to guide clinical pharmacists in providing service in treating COVID-19 patients. COMMENT: At a tertiary care hospital in Thailand, clinical pharmacists provided pharmaceutical care services for COVID-19 patients via telemonitoring using the hospital's computerized physician order entry system. The pharmacists were able to provide therapeutic drug monitoring services, especially for anticoagulants. Many patients were considered special populations, with individualized requirements for drug dosing. Some adverse drug reactions were observed. Drug-related problems were mostly related to medication use in critically ill patients. WHAT IS NEW AND CONCLUSION: Telemonitoring is a viable method for clinical pharmacists to provide pharmaceutical care and meet the challenges posed by treating patients with COVID-19.

Opportunities for collaboration between pharmacists and clinical pharmacologists to support medicines optimisation in the UK.

Medicines optimisation is a clinician-driven, person-centred ongoing process. Pharmacists and clinical pharmacologists have medicines-related expertise to deliver medication review which optimises clinical and cost-effective use of medication, aligned with patient preferences, contributing to improved health outcomes. There is a large pharmacy workforce, directly accessible to patients, who can provide expert medicines-related care on the high street, and increasingly in general practice and care homes settings. There are a small number of clinical pharmacologists in practice, mainly working in a hospital setting. Potential opportunities for collaboration are extensive, including local initiatives in collaborative education, formulary/medicines management, electronic prescribing, service evaluation, research, direct clinical services as well as strategic planning through the Regional Medicines Optimisation Committees. Pharmacists and clinical pharmacologists have complementary skill sets and through acknowledging the differences in their approaches and valuing their unique skills, health services can ensure that patients are signposted to appropriate services.

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation.

AIMS: To develop and evaluate a feasible, authentic pharmacist-led prescribing feedback intervention for doctors-in-training, to reduce prescribing errors. METHODS: This was a mixed methods study. Sixteen postgraduate doctors-in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi-structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically. RESULTS: During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist-led video-stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice. CONCLUSIONS: Feedback to doctors-in-training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.

Effect of pharmacy-led medication reconciliation in emergency departments: A systematic review and meta-analysis.

WHAT IS KNOWN AND OBJECTIVE: Medication reconciliation is recommended to be performed at every transition of medical care to prevent medication errors or adverse drug events. This study investigated the impact of pharmacy-led medication reconciliation on medication discrepancies and potential adverse drug events in the ED to assess the benefits of pharmacy services. METHODS: The systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The PubMed, Ovid Embase and Cochrane library databases were searched up from inception to 1 July 2018. Studies comparing the effectiveness of the medication reconciliation service performed by pharmacy personnel to usual care (nurses or physicians) in the ED were included. Duplicated studies, non-clinical studies, studies with ineligible comparators or study designs were excluded. RESULTS AND DISCUSSION: Eleven studies were eligible for qualitative analysis, and 8 studies were included in meta-analysis. Pharmacy-led medication reconciliation substantially reduced medication discrepancies in the ED. The most common medication discrepancies included medication omission and incorrect/omitted dose or frequency. Unlike usual care, pharmacy-led medication reconciliation significantly reduced the proportion of patients with medication discrepancies by 68% (response rate 0.32; 95% confidence interval (CI): 0.19-0.53, P < .0001) and the number of medication discrepancy events by 88% (response rate 0.12; 95% CI 0.06-0.26, P < .00001). Intervention decreased the number of discrepancies per patient by 3.08 (mean difference -3.08; 95% CI: -4.76 to -1.39, P = .0003). Subgroup analysis revealed no differences between pharmacists and pharmacy technicians in medication reconciliation performance pertaining to medication discrepancies. The patients with several comorbidities or those administered numerous medications received marked benefits related to reduced medication discrepancies from pharmacy-led medication reconciliation. Moreover, a randomized controlled trial revealed decreased risk of potential adverse drug events by pharmacy-led medication reconciliation in patients receiving care in the ED. WHAT IS NEW AND CONCLUSION: Pharmacy-led medication reconciliation significantly decreased the number of medication discrepancies. However, only one study investigated potential adverse drug events in patients receiving care in the ED. Therefore, further studies investigating the direct clinical impact of decreased medication discrepancies are required.

The impact of implementing a hospital electronic prescribing and administration system on clinical pharmacists' activities - a mixed methods study.

BACKGROUND: The increasing adoption of hospital electronic prescribing and medication administration (ePA) systems has driven a wealth of research around the impact on patient safety. Yet relatively little research has sought to understand the effects on staff, particularly pharmacists. We aimed to investigate the effects of ePA on pharmacists' activities, including interactions with patients and health professionals, and their perceptions of medication safety risks. METHODS: A mixed methods study comprising quantitative direct observations of ward pharmacists before and after implementation of ePA in an English hospital, and semi-structured interviews post-ePA. Quantitative data comprised multi-dimensional work activity sampling to establish the proportion of time ward pharmacists spent on different tasks, with whom and where. These data were extrapolated to estimate task duration. Qualitative interviews with pharmacists explored perceived impact on (i) ward activities, (ii) interactions with patients and different health professionals, (iii) locations where tasks were carried out, and (iv) medication errors. RESULTS: Observations totalled 116 h and 50 min. Task duration analysis suggested screening inpatient medication increased by 16 mins per 10 patients reviewed (p = 0.002), and searching for paper drug charts or computer decreased by 2 mins per 10 patients reviewed (p = 0.001). Pharmacists mainly worked alone (58% of time pre- and 65% post-ePA, p = 0.17), with patient interactions reducing from 5 to 2% of time (p = 0.03). Seven main themes were identified from the interviews, underpinned by a core explanatory concept around the enhanced and shifting role of the ward pharmacist post-ePA. Pharmacists perceived there to be a number of valuable safety features with ePA. However, paradoxically, some of these may have also inadvertently contributed to medication errors. CONCLUSION: This study provides quantitative and qualitative insights into the effects of implementing ePA on ward pharmacists' activities. Some tasks took longer while others reduced, and pharmacists may spend less time with patients with ePA. Pharmacists valued a number of safety features associated with ePA but also perceived an overall increase in medication risk. Pharmacy staff demonstrated a degree of resilience to ensure 'business as usual' by enhancing and adapting their role.

Implementation of a medication therapy management program in a primary care clinic.

OBJECTIVE: This study examined the use of a medication therapy management (MTM) program by clinic-embedded pharmacists within a primary care clinic primarily by evaluating the impact on patient identification for pharmacy services. Secondary outcomes included characterizing intervention type, targeted drugs and disease states, and barriers to successful interventions, SETTING: Primary care clinic. PRACTICE DESCRIPTION: CoxHealth Center Steeplechase is a primary care clinic of 13 providers with a clinic-embedded pharmacist, pharmacy residents, and student pharmacists providing chronic disease state management under collaborative practice agreements. PRACTICE INNOVATION: Community pharmacists have an established history of providing services through MTM programs. Clinic-embedded pharmacists have the potential to participate in these programs as well, and many barriers to providing patient care services reported by community pharmacists can be overcome by clinic-embedded pharmacists, potentially allowing for greater success of MTM interventions. EVALUATION: A 4-week pilot, in which clinic-embedded pharmacists dedicated 4 hours per week of effort to MTM services, examined the effectiveness of the program at identifying patients not otherwise receiving clinical pharmacy services, types of identified interventions, intervention success rates, barriers to intervention success, and revenue generation. RESULTS: The clinical pharmacy team attempted 46 interventions in 34 unique patients in this 4-week pilot. Of the identified patients, 67.7% (n = 23) had no contact with the clinical pharmacy team in the previous year. Targeted interventions were more frequently attempted (targeted interventions n = 42; comprehensive reviews n = 4) and more successful than comprehensive medication reviews (88% vs. 25% success rate). Barriers to success included patient refusal of services, inability to contact the patient, and inapplicability of targeted interventions. CONCLUSION: Implementation of an MTM program in one clinic required coordinated interdepartmental efforts to implement, but it effectively expanded pharmacy services by identifying patients not otherwise referred to the clinical pharmacy team for chronic disease management.

Continuous Care Provided Through Comprehensive Medication Management in an Acute Care Practice Model.

BACKGROUND: Pharmacy practice models that foster pharmacists' accountability for medication-related outcomes are imperative for the profession. Comprehensive medication management (CMM) is an opportunity to advance patient care. OBJECTIVE: The objective of this study was to evaluate the impact of a CMM practice model in the acute care setting on organizational, patient, and financial outcomes. METHODS: Three adult service lines focused on at-risk patients identified using internal risk stratification methodology were implemented. Core CMM elements included medication reconciliation, differentiated clinical pharmacy services, inpatient MTM consultations, discharge services, and documentation. Mixed methods compared the effect of the CMM model before and after implementation. Historical patients served as comparative controls in an observational design. Pharmacists completed a 60-minute interview regarding their experiences. Qualitative data were analyzed using thematic coding to characterize perception of the model. RESULTS: Three pharmacists implemented the model on cardiology, hematology/oncology, and surgery transplant services and provided services to 75 patients during the study. A total of 145 medication-related problems were identified and resolved. CMM was associated with a nonsignificant reduction of 8.8% in 30-day hospital readmission rates ( P = 0.64) and a 24.9% reduction in 30-day hospital utilization ( P = 0.41) as well as a significant reduction of 86.5% in emergency department visits ( P = 0.02). Patients receiving discharge prescriptions from our outpatient pharmacies increased by 21.4%, resulting in an 11.3% increase in discharge prescription capture and additional revenue of $5780. Themes identified from qualitative interviews included CMM structure, challenges, value, and resources. CONCLUSION: This study demonstrated successful implementation of a CMM model that positively affected organizational, patient, and financial outcomes.

Critical Care Pharmacists and Medication Management in an ICU Recovery Center.

BACKGROUND: Many patients experience complications following critical illness; these are now widely referred to as post-intensive care syndrome (PICS). An interprofessional intensive care unit (ICU) recovery center (ICU-RC), also known as a PICS clinic, is one potential approach to promoting patient and family recovery following critical illness. OBJECTIVES: To describe the role of an ICU-RC critical care pharmacist in identifying and treating medication-related problems among ICU survivors. METHODS: A prospective, observational cohort study was conducted of all outpatient appointments of a tertiary care hospital's ICU-RC between July 2012 and December 2015. The pharmacist completed a full medication review, including medication reconciliation, interview, counseling, and resultant interventions, during the ICU-RC appointment. RESULTS: Data from all completed ICU-RC visits were analyzed (n = 62). A full medication review was performed in 56 (90%) of these patients by the pharmacist. The median number of pharmacy interventions per patient was 4 (interquartile range = 2, 5). All 56 patients had at least 1 pharmacy intervention; 22 (39%) patients had medication(s) stopped at the clinic appointment, and 18 (32%) patients had new medication(s) started. The pharmacist identified 9 (16%) patients who had an adverse drug event (ADE); 18 (32%) patients had ADE preventive measures instituted. An influenza vaccination was administered to 13 (23%) patients despite an inpatient protocol to ensure influenza vaccination prior to discharge. A pneumococcal vaccination was administered to 2 (4%) patients. CONCLUSIONS: Use of a critical care pharmacist resulted in the identification and treatment of multiple medication-related problems in an ICU-RC as well as implementation of preventive measures.

Evaluation of the implementation of a clinical pharmacy service on an acute internal medicine ward in Italy.

BACKGROUND: Successful implementation of clinical pharmacy services is associated with improvement of appropriateness of prescribing. Both high clinical significance of pharmacist interventions and their high acceptance rate mean that potential harm to patients could be avoided. Evidence shows that low acceptance rate of pharmacist interventions can be associated with lack of communication between pharmacists and the rest of the healthcare team. The objective of this study was to evaluate the effect of a structured communication strategy on acceptance rate of interventions made by a clinical pharmacist implementing a ward-based clinical pharmacy service targeting elderly patients at high risk of drug-related problems. Characteristics of interventions made to improve appropriateness of prescribing, their clinical significance and intervention acceptance rate by doctors were recorded. METHODS: A clinical pharmacy intervention study was conducted between September 2013 and December 2013 in an internal medicine ward of a teaching hospital. A trained clinical pharmacist provided pharmaceutical care to 94 patients aged over 70 years. The clinical pharmacist used the following communication and marketing tools to implement the service described: Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis; Specific, Measurable, Achievable, Realistic and Timely (SMART) goals; Awareness, Interest, Desire, Action (AIDA) model. RESULTS: A total of 740 interventions were made by the clinical pharmacist. The most common drug classes involved in interventions were: antibacterials for systemic use (11.1%) and anti-parkinson drugs (10.8%). The main drug-related problem categories triggering interventions were: no specific problem (15.9%) and prescription writing error (12.0%). A total of 93.2% of interventions were fully accepted by physicians. After assessment by an external panel 63.2% of interventions (96 interventions/ per month) were considered of moderate clinical significance and 23.4% (36 interventions/ per month) of major clinical significance. The most frequent interventions were to educate a healthcare professional (20.4%) and change dose (16.1%). CONCLUSIONS: To our knowledge this is the first study evaluating the effect of a structured communication strategy on acceptance rate of pharmacist interventions. Pharmaceutical care delivered by the clinical pharmacist is likely to have had beneficial outcomes. Clinical pharmacy services like the one described should be implemented widely to increase patient safety.

Inpatient pharmacists' patient referrals to a transitions-of-care pharmacist: Evaluation of an automated referral process.

OBJECTIVES: To evaluate the impact of a pharmacist screening and automated referral process that identifies patients at risk for readmission due to medication-related problems (MRPs). SETTING: University of Wisconsin (UW) Hospital is 505-bed flagship hospital that is part of UW Health, an academic health system. PRACTICE DESCRIPTION: The integrated pharmacy practice model at UW Health has inpatient pharmacists who perform discharge medication reconciliation. Before enhancing the screening and referral process, a transitions-of-care (TOC) pharmacist identified patients with the use of a low yield report and performed a second postdischarge medication reconciliation on selected patients. PRACTICE INNOVATION: A screening process was developed to identify patients at risk for readmission due to MRPs and allow for direct referral from inpatient pharmacists to a TOC pharmacist for postdischarge follow-up. EVALUATION: Patient characteristics, readmission risk, and readmission rate were compared between inpatient only (before referral) and inpatient plus second medication reconciliation (after referral). MRPs identified during medication reconciliation were quantified and categorized as provider or patient-associated. RESULTS: Before process improvement, 9 patients (5%) received a second medication reconciliation out of 175 patients who received standard-of-care inpatient medication reconcilation. After implementation, 45 patients (24%) received a second medication reconcilation out of 188 referrals. Patients referred for postdischarge follow-up with the TOC pharmacist had an average of 3.2 more medications and 2.7 more chronic conditions than before process implementation (P < 0.01). Both inpatient and TOC pharmacists identified at least 1 MRP in about two-thirds of patients (P = 0.60). Provider-associated MRPs were more commonly identified in both inpatient and postdischarge settings. CONCLUSION: Inpatient pharmacist screening is an effective method for identifying patients for referral to a TOC pharmacist to receive postdischarge follow-up. Despite the robustness of the inpatient medication reconciliation process in identifying provider-associated MRPs, patient-associated MRPs still emerged after discharge that warranted additional pharmacist intervention.

Evaluation of Pharmacist-Initiated Discharge Medication Reconciliation and Patient Counseling Procedures.

OBJECTIVE: To evaluate a recently implemented procedure of discharge medication reconciliation and patient counseling completed by pharmacists at a nursing facility. SETTING: This is a 138-bed nursing facility that houses long-term care residents as well as patients for subacute rehabilitation. PRACTICE DESCRIPTION: Discharge process involves the medical team (geriatrician, medical resident, medical students), social workers, and nurse coordinators. PRACTICE INNOVATION: Pharmacists are incorporated in the discharge process by completing medication reconciliation, patient counseling, and telephone follow-up, to improve patient understanding and satisfaction. MAIN OUTCOME MEASUREMENTS: Medication discrepancies identified by pharmacists via medication reconciliation, number of patients who were counseled by pharmacist, and number of patients encountered for telephone follow-up. RESULTS: Fifty-four patients were discharged during the study period. A total of 200 discrepancies were identified after discharge medication reconciliation by the pharmacist. On average, we found that there were 4 discrepancies per patient (range 0 to 16). Most of the discrepancies that were found were medication additions and omissions. Forty-five patients (83.3%) agreed to counseling and were then counseled by a pharmacist. Patients were often not counseled because of last-minute discharge, and no encounter was made. CONCLUSION: Involving pharmacists in patient transitions of care may be beneficial as previous studies have demonstrated; however, additional studies in a nursing facility setting are needed to validate these benefits.

Opioid exit plan: A pharmacist's role in managing acute postoperative pain.

OBJECTIVES: The benefits of a pharmacist's involvement in medication reconciliation and discharge counseling are well documented in the literature as improving patient outcomes. In contrast, no studies have focused on the initiation of a pharmacist-led opioid exit plan (OEP) for acute postoperative pain management. This paper summarizes a pharmacist-led OEP practice model and the potential role that pharmacists and student pharmacists can have at the point of admission, during postoperative recovery, and on discharge in acute pain management patients. SETTING: The pain management team at St. Joseph Mercy Hospital in Ann Arbor, MI, has developed and implemented a pharmacist-led OEP to better manage acute postoperative pain in neurosurgery and orthopedic and colorectal surgery in an effort to ensure appropriate patient and provider education and understanding of pain management. PRACTICE DESCRIPTION: OEP is a tool with the potential to expand the role of pharmacists in managing acute pain in postoperative patients at the point of admission, during the postoperative inpatient stay, and on discharge. Its benefits include medication reconciliation review and prescription drug-monitoring program search before admission, interdisciplinary rounds with the medical team to provide optimal inpatient postoperative pain management, clinical assessment of outpatient prescriptions with opioid discharge counseling, and medication evaluation of prescribed pain regimen and opioid discontinuation status at the post-discharge follow-up appointment. CONCLUSION: A hospital pain management team operating a pharmacist-led OEP can be key to guiding the appropriate prescribing practice of opioids and assisting with transitions of care on discharge. Further outcomes-based evaluations of the practice model are planned and encouraged to validate and improve the pharmacist-led OEP practice.

Federal Bureau of Prisons clinical pharmacy program improves patient A1C.

OBJECTIVE: The Federal Bureau of Prisons (BOP) currently has over 13,000 patients with diabetes and has placed an emphasis on preventing and delaying the onset or progression of diabetes-related complications. In an ongoing effort to improve patient outcomes, BOP has implemented a nationwide, dynamic system of pharmacist-delivered patient care services via pharmacist clinicians working under the auspices of a physician-pharmacist collaborative practice agreement (CPA). SETTING: The BOP Clinical Pharmacy Workgroup targets improved patient outcomes via oversight and support of institution pharmacist clinicians and physicians in establishing and maintaining physician-pharmacist CPAs. A primary emphasis is diabetes and the pharmacist-run clinic clinical outcomes data are presented. PRACTICE INNOVATION: Seventy (nearly one-half) of eligible BOP pharmacists at 37 institutions offer pharmacist-delivered patient care services via an approved CPA. In total, BOP has 111 active physician-pharmacist CPAs. MAIN OUTCOME MEASURES: Pharmacist-run diabetes clinic outcomes from 5 institutions have been reported to date. A total of 126 patients were enrolled. Patient's hemoglobin A1C, blood pressure, and LDL cholesterol level are measured before (i.e., when accepted in the diabetes clinic) and after pharmacist-delivered care has been provided. The pharmacist-run diabetes clinics reported an average baseline A1C of 10.6% and produced an average outcome decrease in A1C of 2.3% from baseline. RESULTS: Specific pharmacist clinic interventions found to have the greatest impact are: 1) timely medication adjustment when indicated to help patients meet outcome goals; and 2) timely follow-up after a change in therapy is made (often within 1-2 weeks) with continued medication adjustment when indicated until outcome goal is achieved. CONCLUSION: BOP pharmacists have become respected and trusted clinicians within the team medicine model. As demonstrated by the pharmacist-run diabetes clinic outcomes, pharmacist clinicians are a valued link to the improvement of patient outcomes in BOP.

Development of clinical pharmacy key performance indicators for hospital pharmacists using a modified Delphi approach.

BACKGROUND: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). OBJECTIVE: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. METHODS: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. RESULTS: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. CONCLUSIONS: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

The potential role of clinical pharmacists in elderly patients during hospital admission.

The aim of this study was to show the potential impact of services directed by clinical pharmacists, including medication reconciliation and medication review, on the hospital admission process for elderly patients. This study was conducted in an internal medicine ward between April 24 and July 25, 2014. Patients hospitalized due to any reason were eligible if they were 65 years or older and regularly used at least one medication at home. The clinical pharmacist evaluated potentially inappropriate medications (PIM), medication related problems (MRPs) and medication discrepancies at the time when these eligible elderly patients were admitted to the hospital. The physician acceptance rate as related the clinical pharmacist's recommendation was evaluated retrospectively. A total of 133 elderly patients (mean age 76.62 ± 8.12 years old; 70 female) were included in the study. Out of 394 medication discrepancies, 88.32% were found to be unintended discrepancies among 111 elderly patients upon hospital admission. PIM was found in 19.55% of these cases. A total of 396 MRPs among 115 patients were identified, with the most common being that the drug had not been taken/administered at all. The doctor acceptance rate of the clinical pharmacist's recommendation was found to be 85.60%. In conclusion, it was found that medication related problems and inappropriate medication utilization at admission could be prevented at a high rate of success by clinical pharmacist-driven medication reconciliation and medication review services.

[Pharmacist's interventions on proton pump inhibitor prescriptions in a University Hospital]. / Interventions des pharmaciens sur les prescriptions d'inhibiteurs de la pompe à protons dans un centre hospitalier universitaire.

PURPOSE: In France, efforts to optimize prescribing of proton-pump inhibitors (PPIs) are rare. Various studies have shown that the prescription of these drugs is excessive. This has consequences regarding costs and iatrogenesis. The objective of this study was to describe the type of drug related problems (DRP) and pharmaceutical interventions reported by pharmacists practicing in a university hospital. METHODS: Drug related problems and pharmaceutical interventions (PI) made, were recorded on a database. They were classified according to the grid code of the French Society of Clinical Pharmacy. RESULTS AND DISCUSSION: Over a 3 years period, 132.890 prescriptions were analysed. 15.347 generated PI. Among them 701 (4.6%) concerned PPIs. Most frequently reported problems were: lack of indication or patients without a documented indication (24.4%), drug-drug interactions (22.4%) and inappropriate route or mode of administration (19.8%). Discontinuation has been proposed in 40.5% of cases, followed by substitution (22.0%) and dosage titration (17.3%). Physicians modified the prescription according to 51.3% of PI. The main PI, discontinuation therapy, is associated with over-prescription of this drug class. Nevertheless, the rate of DRP recorded (0.5%) is low compared to the high exposure of patients on PPIs and misuse (or overuse?) reported in the literature. CONCLUSION: PI made during the analysis of prescription contributes to rationalizing the use of PPIs. The action of the pharmacist must be strengthened through training of health professionals, and communication strategies to improve practices.