The effect of emergency department pharmacists on drug overuse and drug underuse in patients with an ADE-related hospitalisation: a controlled intervention study.

BACKGROUND: Drug overuse or drug underuse are the most common causes of adverse drug events and can lead to hospital admissions. Using clinical pharmacists in the emergency department may improve patient safety as they are specialised in recognising of adverse drug events and tackling drug overuse and drug underuse. This study tested the effect of an emergency department pharmacist on the number of medication changes for drug overuse and drug underuse taking place in patients with an adverse drug event-related hospitalisation following an emergency department visit. METHODS: A multicenter prospective non-randomized controlled intervention study was conducted in a university hospital and a general teaching hospital. Trained emergency department pharmacists included patients in the intervention group with a hospital admission related to an adverse drug event. The interdisciplinary intervention consisted of a pharmacist-led medication review, patient counselling regarding medication, and information transmission to general practitioners and community pharmacies after discharge. The control patients were also admitted after an emergency department visit and received the usual care. The primary outcome was the number of medication changes for drug overuse and drug underuse that took place during hospital admission and persisted 6 months thereafter. Poisson regression analysis was used to estimate the difference in these medication changes between the intervention group and the control group. RESULTS: A total of 216 patients were included (intervention group 104, control group 112). In the intervention group, 156 medication changes for drug overuse and drug underuse persisted 6 months after admission compared to 59 in the control group (adjusted rate ratio 1.22 [95%CI 1.01-1.49] p = 0.039). CONCLUSION: Emergency department pharmacists do contribute to reduction of drug overuse and drug underuse of medication in patients with a hospitalisation related to adverse drug events after an emergency department visit.

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

BACKGROUND: Although medication reconciliation (MedRec) is mandated and effective in decreasing preventable medication errors during transition of care, hospitals implement MedRec differently. OBJECTIVE: Quantitatively compare the number and type of MedRec interventions between hospitals upon admission and discharge, followed by a qualitative analysis on potential reasons for differences. METHODS: This explanatory retrospective mixed-method study consisted of a quantitative and a qualitative part. Patients from six hospitals and six different wards i.e. orthopaedics, surgery, pulmonary diseases, internal medicine, cardiology and gastroenterology were included. At these wards, MedRec was implemented both on hospital admission and discharge. The number of pharmacy interventions was collected and classified in two subcategories. First, the number of interventions to resolve unintended discrepancies (elimination of differences between listed medication and the patient's actual medication use). And second, the number of medication optimizations (optimization of pharmacotherapy e.g. eliminating double medication). Based on these quantitative results and interviews, a focus group was performed to give insight in local MedRec processes to address differences in context between hospitals. Descriptive analysis (quantitative) and content analysis (qualitative) was used. RESULTS: On admission 765 (85%) patients from six hospitals, received MedRec by trained nurses, pharmacy technicians, pharmaceutical consultants or pharmacists. Of those, 36-95% (mean per patient 2.2 (SD ± 2.4)) had at least one discrepancy. Upon discharge, these numbers were among 632 (70%) of patients, 5-28% (mean per patient 0.7 (SD 1.2)). Optimizations in pharmacotherapy were implemented for 2% (0.4-3.7 interventions per patient upon admission) to 95% (0.1-1.7 interventions per patient upon discharge) of patients. The main themes explaining differences in numbers of interventions were patient-mix, the type of healthcare professionals involved, where and when patient interviews for MedRec were performed and finally, embedding and extent of medication optimization. CONCLUSIONS: Hospitals differed greatly in the number of interventions performed during MedRec. Differences in execution of MedRec and local context determines the number of interventions. This study can support hospitals who want to optimize MedRec processes.

Transition of care in stroke patients discharged home: a single-center prospective cohort study.

INTRODUCTION: Approximately two-thirds of the patients admitted to the hospital with an ischemic stroke are discharged directly home. Discontinuity of care may result in avoidable patient harm, re-admissions and even death. We hypothesized that the transfer of information is most essential in this patient group since any future care for these patients relies solely on the information that is available to the care provider responsible at that time. AIM: The objective of this study was to evaluate the continuity of transmural care in ischemic stroke patients by assessing 1) the transfer of clinical information through discharge letters to general practitioners (GPs), 2) subsequent documentation of this information and early follow-up by GPs and 3) the documentation of medication-related information in discharge letters, at GPs and community pharmacies (CPs). METHODS: This prospective cohort study was conducted from September 2019 through March 2020 in OLVG, Amsterdam, the Netherlands, in patients with a first stroke discharged directly home. Outcome measures were derived from national guidelines and regional agreements. Results were analyzed using descriptive analysis. RESULTS: A total of 33 patients were included. Discharge letters (n = 33) and outpatient clinic letters (n = 24) to GPs contained most of the essential items, but 16% (n = 9) of the letters were sent in time. GPs (n = 31) infrequently adhered to guidelines since 10% (n = 3) of the diagnoses were registered using the correct code and 55% (n = 17) of the patients received follow-up shortly after discharge. Medication overviews were inaccurately communicated to GPs since 62% (n = 150) of all prescriptions (n = 243) were correctly noted in the discharge letter. Further loss of information was seen as only 39% (n = 95) of all prescriptions were documented correctly in GP overviews. We found that 59% (n = 144) of the prescriptions were documented correctly in CP overviews. CONCLUSION: In this study, we found that discontinuity of care occurred to a varying extent throughout transmural care in patients with a first stroke who were discharged home.

Medication management during transitions from hospital to home: a focus group study with hospital and primary healthcare providers in the Netherlands.

Background Medication management is jeopardized during a patient's transition from hospital to home. Insight is required from both hospital and primary healthcare providers on how care should be organised to achieve continuity of medication management. Objective This study aimed to identify perspectives of hospital and primary healthcare providers on barriers to the continuity of medication management during a patient's transition from hospital to home and facilitators to overcome these. Setting A qualitative descriptive study was conducted within hospital and primary healthcare settings in the Netherlands. Method Two focus groups were performed with two community care registered nurses, two community pharmacists, four general practitioners, two hospital nurses, two hospital pharmacists, four outpatient pharmacists, two pharmacy technicians, and one physician. A semi-structured interview guide was used to identify perspectives of participants on barriers to continuity of medication management and facilitators to overcome these. Data were analysed following thematic content analysis. Main outcome measure Barriers to the continuity of medication management during a patient's transition from hospital to home would be enumerated, along with facilitators to overcome these barriers. Results Three main themes of barriers and facilitators were identified: (1) healthcare provider collaboration, including the transfer of medication information and effective collaboration; (2) patient's medication use, including information about medication, personalised care, and supervision after discharge; and (3) organisation of healthcare, including the connection between information systems and the supply of medication. Conclusion Barriers and facilitators to continuity of medication management during the transition from hospital to home occur at the provider, patient, and healthcare-system levels. Future interventions should focus on all levels through interprofessional healthcare teams, tailoring care to patient needs, and on the use of a uniform, nationwide patient electronic health record.

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality.

BACKGROUND: After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation. METHODS: In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden. DISCUSSION: This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care. TRIAL REGISTRATION: NTR6316 . Date of registration: April 6, 2017.