Evaluation of a Pharmacist-Led Implementation of Standardized Medication Administration Times for Inpatients Receiving Hemodialysis.

BACKGROUND: Missed medication doses are a common and often preventable medication-related error that have been associated with an increased length of stay and mortality. Hemodialysis is a common, relatively predictable reason that patients are unavailable, resulting in missed doses. OBJECTIVE: To evaluate the implications of a pharmacist-led intervention to standardize the medication administration times for patients requiring hemodialysis who were prescribed antihypertensives, antiepileptics, apixaban, and/or antimicrobials. METHODS: A retrospective preanalysis and postanalysis of a pharmacist-led intervention were performed at a single-center, safety net hospital. Patients receiving dialysis and prescribed one of the targeted medications were included. The primary endpoint was the composite of missed and delayed doses. RESULTS: A total of 25 patients receiving 126 dialysis sessions in the preintervention group and 29 patients receiving 80 dialysis sessions in the postintervention group were included for analysis. For the primary endpoint, 118 (18%) versus 57 (9.3%) doses were missed or delayed in the preintervention versus postintervention group, respectively (P < 0.001). The primary endpoint was driven by fewer delayed doses in the postgroup. The number of antimicrobials given on a correct schedule increased in the postintervention group (98.3% vs 99.1%, P = 0.044). CONCLUSION AND RELEVANCE: A pharmacist-led intervention for standard medication administration times in patients requiring hemodialysis increased the number of prescribed medication doses given and given on time. The intervention also led to more antimicrobials administered at appropriate times relative to dialysis sessions.

Deprescribing opportunities for elderly inpatients in an academic, safety-net health system.

BACKGROUND: Deprescribing is one way to reduce inappropriate polypharmacy in older adult patients. Although algorithms have been published to guide practitioners in deprescribing, it is still unknown how applicable these algorithms are to the general older adult population. OBJECTIVES: The primary objective was to assess the applicability of published deprescribing protocols in hospitalized older adult patients. METHODS: This retrospective study included patients aged 65 years or greater who were discharged from an internal medicine team between January 1, 2017 and June 30, 2017. Along with age and admission to internal medicine wards, other eligibility criteria were extracted from published deprescribing protocols. The primary endpoint was the proportion of patients eligible for deprescribing based on published algorithms. Secondary endpoints included the proportion of patients receiving medications which were included in an algorithm, proportion of patients using medications included in the algorithms who were eligible for deprescribing, and proportion of patients with medications deprescribed during the hospital stay. RESULTS: Two hundred sixty-seven patients were included and 124 (46.4%) used a medication with a published deprescribing algorithm. Thirty-four percent of all patients and 74% (92/124) of patients prescribed medications included in algorithms were eligible for deprescribing. Seven percent (6/92) of patients eligible for deprescribing had medications deprescribed during the hospital stay. CONCLUSION: The application of deprescribing algorithms in hospitalized older adults identified a significant opportunity to initiate deprescribing practices.

Implementation and Preliminary Clinical Outcomes of a Pharmacist-managed Venous Thromboembolism Clinic for Patients Treated With Rivaroxaban Post Emergency Department Discharge.

OBJECTIVE: The objective was to describe the implementation, work flow, and differences in outcomes between a pharmacist-managed clinic for the outpatient treatment of venous thromboembolism (VTE) using a non-vitamin K oral anticoagulant versus care by a primary care provider (PCP). METHODS: Patients in the studied health system that are diagnosed with low-risk VTE in the emergency department are often discharged without hospital admission. These patients are treated with a non-vitamin K oral anticoagulant and follow-up either in a pharmacist-managed VTE clinic or with their PCP. Pharmacists in the VTE clinic work independently under a collaborative practice agreement (CPA). An evaluation of 34 patients, 17 in each treatment arm, was conducted to compare the differences in treatment-related outcomes of rivaroxaban when managed by a pharmacist versus a PCP. RESULTS: The primary endpoint was a 6-month composite of anticoagulation treatment-related complications that included a diagnosis of major bleeding, recurrent thromboembolism, or fatality due to either major bleeding or recurrent thromboembolism. Secondary endpoints included number of hospitalizations, adverse events, and medication adherence. There was no difference in the primary endpoint between groups with one occurrence of the composite endpoint in each treatment arm (p = 1.000), both of which were recurrent thromboembolic events. Medication adherence assessment was formally performed in eight patients in the pharmacist group versus no patients in the control group. No differences were seen among other secondary endpoints. CONCLUSIONS: The pharmacist-managed clinic is a novel expansion of clinical pharmacy services that treats patients with low-risk VTEs with rivaroxaban in the outpatient setting. The evaluation of outcomes provides support that pharmacist-managed care utilizing standardized protocols under a CPA may be as safe as care by a PCP.