Analgesic stewardship in Australian residential aged care facilities: Retrospective audit of a collaborative approach to optimising opioid use.

OBJECTIVE: To evaluate retrospectively an analgesic stewardship role of a non-dispensing pharmacist as part of a general practice team providing primary care services to residential aged care facilities (RACF). METHODS: Our general practice implemented an analgesic stewardship program to optimise and monitor opioid usage for our patients located across 12 RACF in Canberra from March 2019 to September 2020. The primary objective was the development of a multidisciplinary chronic pain care plan to document treatment and monitoring strategies for optimising pain control. The pharmacist reviewed and documented existing pain management strategies in a care plan for each patient and discussed recommendations for optimisation with the general practitioner. The general practitioner implemented accepted recommendations and distributed finalised care plans to the RACF. A retrospective audit of care plans was undertaken to assess the outcomes: mean daily oral morphine equivalence to monitor opioid usage, and pain scores to monitor for any potential harm associated with analgesic stewardship. RESULTS: One hundred and sixty-seven residents received an initial care plan. Residents were scheduled for a follow-up care plan after 6 months, which was achieved for 100 residents (60%). Scope for optimising opioid therapy was identified for 47 residents (28%) at baseline and 23 residents (23%) at follow-up. Mean opioid usage and pain scores were reduced at follow-up; 19.4 mg (SD 40.8) versus 13.4 mg (SD 22.8), and 4.2 (SD 2.3) versus 3.9 (SD 2.0), respectively. CONCLUSIONS: A systematic, multidisciplinary analgesic stewardship approach may optimise pain management plans and reduce opioid usage in RACF residents.

Pharmacist-led medication reviews in aged care residents with dementia: A systematic review.

OBJECTIVES: To evaluate outcomes associated with pharmacist-led medication reviews in residential aged care facility (RACF) residents with dementia. METHODS: Six scientific databases were searched. All study designs investigating pharmacist-led medication reviews in RACF residents with dementia were considered. The protocol was registered with PROSPERO (CRD42019121681). RESULTS: One randomised controlled trial (RCT) and five observational studies were identified. Two studies reported reductions in medication usage per resident, and one study reported improved appropriateness of psychotropic use following reviews as part of multi-faceted, collaborative interventions. In three studies, reviews undertaken as an isolated intervention or by a visiting pharmacist with minimal collaboration with physicians were associated with low implementation rates of recommendations to alter therapy. CONCLUSION: Pharmacist-led medication reviews, when conducted collaboratively, may improve the use of medicines in RACF residents with dementia. However, robust conclusions cannot be drawn, largely due to the low quality of evidence available, including only one RCT.

Residential Aged Care Pharmacist: An Australian Pilot Trial Exploring the Impact on Quality Use of Medicines Indicators.

BACKGROUND: This pilot study aimed to assess whether an on-site pharmacist could influence indicators of quality use of medicines in residential aged care. Methods: A pharmacist was embedded in a residential aged care home for six months. A similar control site received usual care. Polypharmacy, drug burden index, antipsychotic and benzodiazepine use, hospital admission rates and length of stay, and emergency department presentation rates were outcomes used to indicate medication use quality. Data were extracted from participating resident health records. Results: Fifty-eight residents at the study site and 39 residents at the control site were included in the analysis. There was a reduction in the proportion of residents at the study site who had at least one hospital admission at follow-up (28% to 12%, p < 0.01), but no significant difference in other outcomes. Conclusions: This pilot study suggests that a residential care pharmacist may positively influence indicators of medication use quality in aged care; however, further research is needed to expand on these findings.

The role of a residential aged care pharmacist: Findings from a pilot study.

OBJECTIVE: To explore the feasibility of integrating a residential care pharmacist and describe the activities they subsequently undertake in an established residential aged care facility. METHODS: A residential care pharmacist was integrated part-time (15 hours per week) into a 104-bed residential aged care facility in the Australian Capital Territory, for 6 months. The pharmacist documented all activities performed during the study period. RESULTS: The residential care pharmacist documented 335.3 hours performing 284 activities. The two broad classes of activities were as follows: (1) organisation-oriented, which were system-level interventions to improve medication safety, and (2) resident-oriented, which were clinical interventions conducted at the individual level. The activities most frequently performed were pharmaceutical opinion, quality improvement and comprehensive medication review. The stakeholder and organisational demand for these activities indicated feasibility for the role. CONCLUSION: Pharmacists working collaboratively as part of a multidisciplinary aged care team can perform a range of clinically and operationally beneficial activities.

Canaries in the coalmine: Stakeholder perspectives of medication management reviews for residents with dementia.

BACKGROUND: Residential medication management reviews (RMMRs) are the primary strategy enabling collaborative and individualised medication reviews in Australian residential aged care homes (RACHs). Residents with dementia often have complex health needs and care goals, which makes them a useful benchmark of health service efficacy. OBJECTIVE: To analyse perspectives of pharmacists, general practitioners (GPs) and nurses on the suitability and delivery of the current RMMR model for residents with dementia; and to identify scope for improvement in medication review service delivery. METHODS: Electronic surveys were distributed to the included health professions via professional agencies. Descriptive statistics and non-parametric tests were used to summarise quantitative variables. Qualitative data obtained from open-text responses underwent iterative thematic analysis. Two researchers independently conducted the thematic categorisation; data within responses was inductively coded, then codes were linked to identify emergent themes that described the data content. In a triangulated exploratory mixed method approach, the qualitative findings were used to explain the quantitative findings. RESULTS: None of the participants agreed that the current program recommendation of a single RMMR every 24 months was suitable for the residents' needs. Participants were more likely to use written, rather than verbal, means of communication during RMMRs. RMMRs were perceived to have minimal benefit if there was minimal face-to-face interaction between stakeholders. Individualised medicine management in relation to resident goals of care was the key benefit of RMMRs. Insufficient remuneration was the primary barrier to effective face-to-face collaboration and delivery of individualised resident care. CONCLUSIONS: Increasing support for stakeholder participation in face-to-face interactions during medication reviews may enable delivery of a more patient-centred service for residents with dementia and improve health professional satisfaction and engagement.

The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial.

WHAT IS KNOWN AND OBJECTIVE: With the ageing of the population also comes increasing comorbidities and the use of multiple medications and administration methods, along with greater susceptibility to adverse drug reactions. Dosage form modification to facilitate drug administration in older adults can be potentially problematic as altering the original licensed formulation can affect medication safety and efficacy. The reporting of adverse drug reactions and medication incidents is a key strategy in avoiding preventable adverse drug events for aged care residents. This study evaluated the effect of an on-site clinical pharmacist on reducing inappropriate dosage form modification and staff time spent on medication administration, and optimizing the documentation of drug allergies, adverse drug reactions and medication incidents. METHODS: A pilot-controlled trial was performed in a purposive sample of two residential aged care homes. Both homes belonged to the same organization; the study site had 104 beds and the control site had 100 beds. All permanent residents were eligible for inclusion in the study if written consent was provided. A residential care pharmacist position was implemented at the study site for six months, with a focus on performing medication reviews and quality improvement activities. Observational audits of medication rounds were performed, and documentation relating to allergies, adverse drug reactions, and medication incidents was obtained from both sites before and after the pharmacist trial period. RESULTS: At the study site, there was a significant reduction over the trial in the proportion of inappropriate dosage form modification (from 24% to 0% of all dosage form modifications; P < 0.01). Mean time spent on medication rounds per resident reduced from 4.8 minutes per resident (SD 1.1) to 3.2 minutes per resident (SD 1.7) per round (P < 0.05). The incidence of previous allergy and adverse drug reaction documentation significantly improved from 77% of residents pre-study to 100% of residents post-study (P < 0.01). Mean monthly medication incident reports significantly improved from 13.3 (SD 7.4) pre-study to 25.7 (SD 10.8) post-study (P < 0.05). There was no change in these outcomes at the control site. WHAT IS NEW AND CONCLUSION: Including a pharmacist in a residential aged care home can improve medication administration practices by reducing inappropriate dosage form modification and staff time spent on medication administration rounds, and increasing the documentation of resident allergies, adverse drug reactions and medication incidents. These findings warrant further exploration in a large randomized controlled trial.

Pharmacist-led influenza vaccination services in residential aged care homes: A pilot study.

OBJECTIVES: The feasibility of pharmacist-led influenza vaccination services in residential aged care homes has not previously been studied. The primary objective of this pilot study was to evaluate the feasibility of this service. The secondary objective was to assess the effect of the service on employee vaccination rates. METHODS: An in-house pharmacist-led vaccination service was implemented at a single site in 2017. De-identified employee influenza vaccination records at this site for 2016 and 2017 were compared to assess the change in vaccination rate. RESULTS: The residential care pharmacist administered 37% of all influenza vaccinations to employees (n = 78) in 2017. Between 2016 and 2017, there was a significant improvement in the employee vaccination rate at the site (46.5% vs 69.2%, P < 0.01). CONCLUSIONS: It is feasible for pharmacists to administer influenza vaccinations to employees in residential aged care. The flexibility of an in-house pharmacist improves accessibility and can therefore promote uptake of influenza vaccination by employees.

Feasibility of Integrating Residential Care Pharmacists into Aged Care Homes to Improve Quality Use of Medicines: Study Protocol for a Non-Randomised Controlled Pilot Trial.

Older adults are particularly susceptible to iatrogenic disease and communicable diseases, such as influenza. Prescribing in the residential aged care population is complex, and requires ongoing review to prevent medication misadventure. Pharmacist-led medication review is effective in reducing medication-related problems; however, current funding arrangements specifically exclude pharmacists from routinely participating in resident care. Integrating an on-site clinical pharmacist into residential care teams is an unexplored opportunity to improve quality use of medicines in this setting. The primary objective of this pilot study is to investigate the feasibility of integrating a residential care pharmacist into the existing care team. Secondary outcomes include incidence of pharmacist-led medication review, and incidence of potential medication problems based on validated prescribing measures. This is a cross-sectional, non-randomised controlled trial with a residential care pharmacist trialled at a single facility, and a parallel control site receiving usual care and services only. The results of this hypothesis-generating pilot study will be used to identify clinical outcomes and direct future larger scale investigations into the implementation of the novel residential care pharmacist model to optimise quality use of medicines in a population at high risk of medication misadventure.