Social determinants of health and COVID-19 recovery after inpatient rehabilitation.

BACKGROUND: Neighborhoods with more social determinants of health (SDOH) risk factors have higher rates of infectivity, morbidity, and mortality from COVID-19. Patients with severe COVID-19 infection can have long-term functional deficits leading to lower quality of life (QoL) and independence measures. Research shows that these patients benefit greatly from inpatient rehabilitation facilities (IRF) admission, but there remains a lack of studies investigating long-term benefits of rehabilitation once patients are returned to their home environment. OBJECTIVE: To determine SDOH factors related to long-term independence and QoL of COVID-19 patients after IRF stay. DESIGN: Multisite cross-sectional survey. SETTING: Two urban IRFs. MAIN OUTCOME MEASURES: Primary outcome measures were Post-COVID Functional Status Scale (PCFS) and Short Form-36 (SF-36) scores. Secondary outcomes were quality indicator (QI) scores while at IRF and a health care access questionnaire. Results were analyzed using analysis of variance and multivariate logistic regression analyses. RESULTS: Participants (n = 48) who were greater than 1 year post-IRF stay for severe COVID-19 were enrolled in the study. Higher SF-36 scores were associated with male gender (p = .002), higher income (≥$70,000, p = .004), and living in the city (p = .046). Similarly, patients who were of the male gender (p = .004) and had higher income (≥$70,000, p = .04) had a greater odds of a 0 or 1 on the PCFS. Age was not associated with differences. Women were more likely to seek follow-up care (p = .014). Those who sought follow-up care reported lower SF-36 overall and emotional wellness scores, p = .041 and p = .007, respectively. Commonly reported barriers to health care access were financial and time constraints. CONCLUSIONS: Patients with SDOH risk factors need to be supported in the outpatient setting to maintain functional gains made during IRF stays. Female gender, income, and urban setting are potential predictors for long-term QoL and independence deficits after rehabilitation for COVID-19 infection. Low emotional wellness is an indicator for patients to seek out care as far out as 1 year from their rehabilitation stay.

A transitions of care (TOC) PharmD elective and its impact on students' perceptions on their TOC knowledge, skills, and attitudes.

INTRODUCTION: Transitions of care (TOC) continue to evolve as a problem within our health care system and is a direct driver to worsened patient outcomes. Currently information of in-depth instruction and application of TOC content within health care education, especially pharmacy, is limited. In 2012, a small team of faculty members created a specialized TOC pharmacy elective for third year doctor of pharmacy students. The purpose of this paper is to describe the impact of this TOC course on students' perceptions on their TOC knowledge, skills, and attitudes over the four years course span. METHODS: A pre-/post-paper anonymous survey was distributed to the students. Descriptive statistics captured the analyzed survey questions into four main themes. Within each respective theme, quantitative data were provided for pre- and post-survey responses to illustrate the difference in the scores with corresponding P values to showcase if significance was present. RESULTS: The response rate of the survey was 100%. Within all of the respective themes, all of the survey questions, pre- to post-responses, had a significant shift toward a higher degree of agreement. CONCLUSIONS: This study illustrates the impact a course dedicated to TOC has on student's learning.

Pharmacy, physical therapy, occupational therapy, and physician assistant professional students' perspectives on interprofessional roles and responsibilities.

Understanding roles and responsibilities within the interprofessional practice is a key competency of interprofessional education (IPE). Students in health professions programs can have limited understanding and perceptions of health professions, including their own and other professions. The purpose of this study was to understand students' perceptions of the roles and responsibilities of other health-care professionals. Students enrolled in occupational therapy, pharmacy, physical therapy, and physician assistant programs at a university participated in a three-hour IPE workshop. Throughout this workshop, they worked in small interprofessional teams to identify unique and shared roles and responsibilities of health professions. Students used a "dream catcher" graphic organizer to compare and contrast these roles and responsibilities. Researchers used thematic analysis of completed graphic organizers to identify themes in students' perceptions. Students identified many shared and unique characteristics about their professions' values and expertise, patient care process, practice settings, patient populations, education, and regulations. While students correctly identified many aspects of their professions, there were some inaccuracies that were addressed by small group faculty facilitators.

A pilot IPE workshop integrating OT, pharmacy, PT, and PA programs.

BACKGROUND AND PURPOSE: This article describes the development, implementation, and evaluation of an interprofessional education (IPE) experience. EDUCATIONAL ACTIVITY AND SETTING: The IPE experience included 53 student learners from occupational therapy, pharmacy, physical therapy, and physician assistant programs at the University of the Sciences (USciences). This experience used an icebreaker activity and a stroke case-based activity as the activities within the workshop. The core faculty utilized the jigsaw technique to increase student confidence with uni-profession and interprofessional discussions of the patient case. Learners were asked to evaluate their perceptions of the IPE learning experience. FINDINGS: Results from a summative quality improvement evaluation indicated that learners had positive perceptions of this curricular innovation. DISCUSSION: This pilot IPE workshop illustrates the possibilities for collaboration among health professional programs at USciences, a private health sciences university without an affiliated medical center. SUMMARY: Discussion of the process to create, implement, and evaluate this pilot IPE activity is imperative due to increased expectations within professional accrediting guidelines in regards to IPE.

Impact of a pharmacy technician-centered medication reconciliation program on medication discrepancies and implementation of recommendations.

OBJECTIVES: To evaluate the impact of a pharmacy-technician centered medication reconciliation (PTMR) program by identifying and quantifying medication discrepancies and outcomes of pharmacist medication reconciliation recommendations. METHODS: A retrospective chart review was performed on two-hundred patients admitted to the internal medicine teaching services at Cooper University Hospital in Camden, NJ. Patients were selected using a stratified systematic sample approach and were included if they received a pharmacy technician medication history and a pharmacist medication reconciliation at any point during their hospital admission. Pharmacist identified medication discrepancies were analyzed using descriptive statistics, bivariate analyses. Potential risk factors were identified using multivariate analyses, such as logistic regression and CART. The priority level of significance was set at 0.05. RESULTS: Three-hundred and sixty-five medication discrepancies were identified out of the 200 included patients. The four most common discrepancies were omission (64.7%), non-formulary omission (16.2%), dose discrepancy (10.1%), and frequency discrepancy (4.1%). Twenty-two percent of pharmacist recommendations were implemented by the prescriber within 72 hours. CONCLUSION: A PTMR program with dedicated pharmacy technicians and pharmacists identifies many medication discrepancies at admission and provides opportunities for pharmacist reconciliation recommendations.

Nurses' attitudes and behaviors on patient medication education.

BACKGROUND: Medication education is vital for positive patient outcomes. However, there is limited information about optimal medication education by nurses during hospitalization and care transitions. OBJECTIVE: Examine nurses' attitudes and behaviors regarding the provision of patient medication education. The secondary objectives were to determine if nurses' medication education attitudes explain their behaviors, describe nurses' confidence in patient medication knowledge and abilities, and identify challenges to and improvements for medication education. METHODS: A cross sectional survey was administered to nurses servicing internal medicine, cardiology, or medical-surgical patients. RESULTS: Twenty-four nurses completed the survey. Greater than 90% of nurses believed it is important to provide information on new medications and medical conditions, utilize resources, assess patient understanding and adherence, and use open ended question. Only 58% believed it is important to provide information on refill medications. Greater than 80% of nurses consistently provided information on new medications, assessed patient understanding, and utilized resources, but one-third or less used open-ended questions or provided information on refill medications. Most nurses spend 5-9 minutes per patient on medication education and their attitudes matched the following medication education behaviors: assessing adherence (0.57; p<0.01), providing information on new medications (0.52; p<0.05), using open-ended questions (0.51; p<0.01), and providing information on refill medications (0.39; p<0.05). Nurses had higher confidence that patients can understand and follow medication instructions, and identify names and purpose of their medications. Nurses had lower confidence that patients know what to expect from their medication or how to manage potential side effects. Communication, including language barriers and difficulty determining the patient's understanding of the information, was the most common challenge for nurses and they suggested utilization of translator services and patient-friendly drug information resources as a way to improve. CONCLUSION: Nurses have positive attitudes toward patient medication education. However, their attitudes do not fully explain their behaviors and many nurses are spending limited time with patients on medication education. Enhancements to medication education could include resources on communication and collaboration with pharmacists.

Predictors of Response in Emergency Department Patients Receiving Intravenous Opioids for Severe Pain.

The primary objective of this study was to identify significant environmental and patient characteristics of emergency department (ED) patients who responded to intravenous (IV) hydromorphone and IV morphine for severe pain. Secondary objectives were to investigate the individual effect of the significant environmental and patient characteristics of responders, and to assess the nature and strength of the correlation of initial dose and change in pain score from arrival to pre-administration. A retrospective chart review was performed in patients who received IV hydromorphone or morphine in the ED for severe pain. Key evaluated patient characteristics included patient demographics, recent opioid use, history of drug or alcohol abuse, and pain location, among others. Key evaluated environmental characteristics included initial opioid administered, time to first dose, initial pain score, and initial dose of opioid administered, among others. Environmental and patient characteristics associated with response to pain management were first identified using bivariate analyses and then entered into a multiple stepwise logistic regression mode. Patients were excluded if they were younger than 18 years, did not have a follow-up pain score within 2 hours of drug administration, or if they were discharged from the ED within 1 hour of administration. Patients meeting the inclusion criteria were grouped into two cohorts based on response and lack of response to treatment. A total of 200 patients were included. A decrease in pain score from arrival until pre-administration pain score and an inactive tobacco history had a positive association with response (odds ratio [OR] 1.488, 95% confidence interval [CI] 1.088-2.036, p=0.013, and OR 1.835, 95% CI 0.801-4.200, overall p=0.022, respectively). A higher initial dose and an active tobacco history had a negative association with response (OR 0.715, 95% CI 0.580-0.881, p=0.002, and OR 0.582, 95% CI 0.296-1.144, overall p=0.022, respectively). Two characteristics were associated with response to IV opioid pain management in the ED, inactive tobacco history and an increase in pain score from arrival until pre-administration, and two characteristics were associated with nonresponse to IV opioid pain management in the ED, active tobacco history and a higher initial dose. Previous literature supports both characteristics identified as risk factors but does not support either characteristic identified as protective factors, prompting the need for further research.

Variables Affecting Pharmacy Students' Patient Care Interventions during Advanced Pharmacy Practice Experiences.

Objective. To identify the temporal effect and factors associated with student pharmacist self-initiation of interventions during acute patient care advanced pharmacy practice experiences (APPE). Methods. During the APPE, student pharmacists at an academic medical center recorded their therapeutic interventions and who initiated the intervention throughout clinical rotations. At the end of the APPE student pharmacists completed a demographic survey. Results. Sixty-two student pharmacists were included. Factors associated with lower rates of self-initiated interventions were infectious diseases and pediatrics APPEs and an intention to pursue a postgraduate residency. Timing of the APPE, previous specialty elective course completion, and previous hospital experience did not result in any significant difference in self-initiated recommendations. Conclusion. Preceptors should not base practice experience expectations for self-initiated interventions on previous student experience or future intentions. Additionally, factors leading to lower rates of self-initiated interventions on infectious diseases or pediatrics APPEs should be explored.

Development and implementation of a transitions of care elective course.

BACKGROUND: To develop and implement a transitions of care (TOC) course, assess students׳ knowledge, participation and communication skills during in-class activities, and obtain students׳ perspectives and feedback on the course. Educational Activity-this was a two-credit elective course offered to third professional year Doctor of Pharmacy students (P3) at the Philadelphia College of Pharmacy at the University of the Sciences. It was designed using an interactive, hands-on approach through the use of patient cases, simulation, interprofessional education, student presentations, and a capstone project. The content of the course included TOC concepts relevant to pharmacists practicing within different health care settings. Several assessments were used to evaluate the students using various rubrics and self-reflection. Quantitatively, the students achieved high grades on individual assignments ranging from B to A+. Critical analysis of the educational activity overall, the students described the course as a "great experience" based on the qualitative thematic analysis. CONCLUSION: Developing and implementing a TOC elective provided P3 students with an opportunity to learn about pharmacists׳ role during various points of the TOC process and may have future implications in their performance on rotation and career choice.

Optimizing care transitions: the role of the community pharmacist.

Transitions of care (TOC) refer to the movement of patients across institutions, among providers, between different levels of care, and to and from home. Medication errors that occur during TOC have the potential to result in medical complications that are serious for the patient and costly to the health care system. Positive outcomes have been demonstrated when pharmacists are involved in providing TOC services, including reducing preventable adverse drug reactions, medication-related problems, and rehospitalizations, as well as improving the discharge process. This review explores TOC models involving community pharmacy practice, the current impact of pharmacist interventions in TOC, and patient satisfaction with TOC services provided by community pharmacists. Common barriers and potential solutions to TOC services provided in the community pharmacy, such as patient identification, information gathering, standardization of services, administrative support, reimbursement, and time restraints, are also discussed.

A practical guide for pharmacists to establish a transitions of care program in an outpatient setting.

OBJECTIVES: To improve understanding of the logistics of transitions of care (TOC) clinics and to provide guidance to pharmacists in developing and implementing a new TOC clinic or improving an existing one. SETTING: Outpatient TOC clinic within an ambulatory care practice. PRACTICE DESCRIPTION: Two general internal medicine practices collaborated with a university health system to create an interdisciplinary TOC clinic to improve quality and continuity of patient care. The clinic accommodates any patients of the practice who are not able to get an appointment with their primary care physician within 1 to 2 weeks of discharge from any hospital. Physician residents, an attending physician, a clinical pharmacist, a nurse, medical assistants, and a social worker (if necessary) are involved in the patient's care during the transition process. PRACTICE INNOVATION: Pharmacists can play a vital role in developing and implementing a TOC clinic or enhancing a current one. There are many logistical components to consider in developing a clinic, and this article provides guidance in the various steps required in creating a clinic, including support and coordination, personnel, workflow, operations, reimbursement, marketing, metrics, and measures. CONCLUSION: This tool may help pharmacists implement or enhance an outpatient TOC clinic to improve patient care, quality, and continuity.

Retention of advanced cardiac life support knowledge and skills following high-fidelity mannequin simulation training.

OBJECTIVE: To assess pharmacy students' ability to retain advanced cardiac life support (ACLS) knowledge and skills within 120 days of previous high-fidelity mannequin simulation training. DESIGN: Students were randomly assigned to rapid response teams of 5-6. Skills in ACLS and mannequin survival were compared between teams some members of which had simulation training 120 days earlier and teams who had not had previous training. ASSESSMENT: A checklist was used to record and assess performance in the simulations. Teams with previous simulation training (n=10) demonstrated numerical superiority to teams without previous training (n=12) for 6 out of 8 (75%) ACLS skills observed, including time calculating accurate vasopressor infusion rate (83 sec vs 113 sec; p=0.01). Mannequin survival was 37% higher for teams who had previous simulation training, but this result was not significant (70% vs 33%; p=0.20). CONCLUSION: Teams with students who had previous simulation training demonstrated numerical superiority in ACLS knowledge and skill retention within 120 days of previous training compared to those who had no previous training. Future studies are needed to add to the current evidence of pharmacy students' and practicing pharmacists' ACLS knowledge and skill retention.

Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings.

OBJECTIVE: To introduce pharmacists to the process, challenges, and opportunities of creating transitions of care (TOC) models in the inpatient, ambulatory, and community practice settings. METHODS: TOC literature and resources were obtained through searching PubMed, Ovid, and GoogleScholar. The pharmacist clinicians, who are the authors in this manuscript are reporting their experiences in the development, implementation of, and practice within the TOC models. RESULTS: Pharmacists are an essential part of the multidisciplinary team and play a key role in providing care to patients as they move between health care settings or from a health care setting to home. Pharmacists can participate in many aspects of the inpatient, ambulatory care, and community pharmacy practice settings to implement and ensure optimal TOC processes. This article describes establishing the pharmacist's TOC role and practicing within multiple health care settings. In these models, pharmacists focus on medication reconciliation, discharge counseling, and optimization of medications [corrected]. CONCLUSION: Optimizing the TOC process, reducing medication errors, and preventing adverse events are important focus areas in the current health care system, as emphasized by The Joint Commission and other health care organizations. Pharmacists have the unique opportunity and skillset to develop and participate in TOC processes that will enhance medication safety and improve patient care.

Levetiracetam: an unusual cause of delirium.

Levetiracetam is a second-generation anticonvulsant that was approved by the Federal Drug Administration in 1999 for the treatment of epilepsy. Recently, levetiracetam has become more popular for the prevention of posttraumatic seizures. Some of the well-known adverse effects of levetiracetam are somnolence, behavioral abnormalities, and less commonly, psychosis. Delirium is not a well-known adverse effect of levetiracetam. Here, we present the case of a 77-year-old Caucasian male who developed disorientation, agitation, and lethargy after initiation of levetiracetam to prevent posttraumatic seizures. Imaging on admission demonstrated a subacute subdural hematoma in the left frontal lobe without mass effect, and the patient was started on levetiracetam 500 mg intravenously twice daily. Less than 24 hours later, the patient began to display a fluctuating level of consciousness, disorientation, an inability to follow commands, and garbled speech. His symptoms continued for 12 days unabated despite episodic treatment with sedatives and antipsychotics. At one point, the patient progressed to aggressive behavior and required restraints. Laboratory tests during this period did not demonstrate signs of infection or metabolic abnormalities. Delirium from levetiracetam was suspected and the drug was discontinued. The patient's mental status improved dramatically within 24 hours after administration of the last dose of levetiracetam and he was discharged home. Based on the Naranjo scale, the episode of delirium was probably related to levetiracetam. Although the other neuropsychiatric effects of levetiracetam are well known, we highlight the first case of delirium without psychotic features associated with levetiracetam.

Implementation of a pharmacy technician-centered medication reconciliation program at an urban teaching medical center.

PURPOSE: An inpatient medication reconciliation (MR) program emphasizing pharmacy technicians' role in the MR process is described. SUMMARY: As part of quality-improvement (QI) efforts focused on MR-related adverse drug events, an urban academic medical center in New Jersey implemented a pharmacy technician-centered MR (PTMR) program targeting patients on its internal medicine, oncology, and clinical decision units. The program is staffed by five full- or part-time technicians who are trained in MR methods and work under direct pharmacist supervision, interviewing newly admitted patients and using other information sources (e.g., community pharmacies, physician offices, nursing facilities) to compile an accurate and complete medication list. About 30% of all patients admitted to the hospital are served by the PTMR program, which averages more than 500 cases each month. During one three-month period, 1748 discrepancies on preadmission medication lists were identified, most of which involved the omission of drugs (65.7% of cases) and incorrect information on dose and frequency of use (14.4%). Efforts to overcome resource constraints and other program challenges (e.g., privacy concerns, delays in community pharmacy transmittal of prescription refill lists) are ongoing. To date, most research on PTMR has been conducted in emergency departments or perioperative settings; experience with the PTMR program suggests that this approach can be applied in other hospital areas to improve MR processes and, ultimately, enhance pharmacotherapy safety and effectiveness across transitions of care. CONCLUSION: Based on experience, providers' perspectives, and QI data, the PTMR program is an effective method to obtain, document, and communicate accurate MR data for patients at this institution.

Impact of pharmacy technician-centered medication reconciliation on optimization of antiretroviral therapy and opportunistic infection prophylaxis in hospitalized patients with HIV/AIDS.

PURPOSE: This study aimed to examine the role of a pharmacy technician-centered medication reconciliation (PTMR) program in optimization of medication therapy in hospitalized patients with HIV/AIDS. METHODS: A chart review was conducted for all inpatients that had a medication reconciliation performed by the PTMR program. Adult patients with HIV and antiretroviral therapy (ART) and/or the opportunistic infection (OI) prophylaxis listed on the medication reconciliation form were included. The primary objective is to describe the (1) number and types of medication errors and (2) the percentage of patients who received appropriate ART. The secondary objective is a comparison of the number of medication errors between standard mediation reconciliation and a pharmacy-led program. RESULTS: In the PTMR period, 55 admissions were evaluated. In all, 50% of the patients received appropriate ART. In 27of the 55 admissions, there were 49 combined ART and OI-related errors. The most common ART-related errors were drug-drug interactions. The incidence of ART-related medication errors that included drug-drug interactions and renal dosing adjustments were similar between the pre-PTMR and PTMR groups (P = .0868). Of the 49 errors in the PTMR group, 18 were intervened by a medication reconciliation pharmacist. CONCLUSION: A PTMR program has a positive impact on optimizing ART and OI prophylaxis in patients with HIV/AIDS.