The utility of a medical admissions pharmacist in a hospital in Australia.

Background Medication-related hospital admissions in Australia have previously been estimated to account for approximately 3% of all hospital admissions, with hospital entry points being a point of vulnerability. The timely medication review and reconciliation by a pharmacist at the early stage of an admission for patients admitted to the Acute Medical Unit (AMU) would be beneficial. Setting The Emergency Department (ED) and AMU in a 300 bed tertiary teaching hospital, in South Australia. Objective To investigate the impact of a Medical Admissions (MA) pharmacist on the proportion of AMU patients who receive a complete and accurate medication history by a pharmacist prior to admission and within 4 h of presentation. Method This prospective observational study with a non-concurrent parallel study design examined a standard clinical pharmacist service within the AMU and ED to a Medical Admissions (MA) Pharmacist, in addition to the standard AMU and ED pharmacist service. Continuous variables were analysed using a two sample t test, whilst categorical data were analysed using Fisher's exact test. Risk ratios were also calculated for categorical data, with p < 0.05 taken as statistically significant. Main outcome measures Rates of completion of a complete medication history prior to admission and proportion of patients seen within 4 h of presentation by a pharmacist. Results The intervention resulted in more patients receiving a complete medication history prior to admission (2.7% in the control group vs 18.5%, p < 0.01) and being seen by the pharmacist within 4 h of presentation (1.6% in the control group vs 7.5%, p < 0.01). Conclusion Implementation of an extended hours clinical pharmacy service in the form of a medical admissions pharmacist based in the ED significantly increased the number of complete medication histories and clinical reviews completed for patients being admitted to an AMU. These were also completed earlier in the patients' admission. There was also a small trend toward increasing the proportion of patients discharged by 11 am in the intervention group.

Can Perhexiline Be Utilized Without Long-Term Toxicity? A Clinical Practice Audit.

BACKGROUND: Perhexiline, originally used as a first-line prophylactic antianginal agent, is now regarded primarily as a treatment for otherwise refractory myocardial ischemia. Recent studies have also demonstrated its short-term utility in heart failure, hypertrophic cardiomyopathy, and inoperable aortic stenosis. Its benefits on myocardial energetics state are potentially counter-balanced by risk of hepatotoxicity and peripheral neuropathy during long-term treatment if drug accumulation occurs. Since perhexiline exhibits complex pharmacokinetics with wide inter-individual variability, its long-term use requires regular plasma concentration monitoring. In this study, the risk of neuro- and hepato-toxicity during long-term perhexiline therapy in relation to the intensity of therapeutic drug monitoring was investigated. Furthermore, determinants of mortality during perhexiline treatment were evaluated. METHODS: In 170 patients treated with perhexiline for a median of 50 months (interquartile range: 31-94 months), outcomes and relationship to plasma drug concentrations were documented. RESULTS: Rationale for treatment with perhexiline included myocardial ischemia in 88% and severe systolic heart failure in 38%. Plasma concentrations were within the therapeutic range of 150-600 ng/mL on 65% of assay occasions and toxic levels accounted for 8.8% of measurements. No patient developed hepatotoxicity attributable to perhexiline while 3 developed peripheral neuropathy possibly induced by treatment. Actuarial 5-year survival rate was 83% overall, and 76.3% in patients with associated systolic heart failure. CONCLUSIONS: This first audit of a large population treated long-term perhexiline demonstrates the following: (1) Although the frequency of monitoring is less than ideal, therapeutic drug monitoring effectively limits occurrence of toxic drug concentrations and virtually eliminates long-term hepato- and neuro-toxicity and (2) Mortality rates during long-term therapy, notably for patients with concomitant heart failure, are surprisingly low.