Pharmaceutical care at discharge for patients with feeding tubes.

Introduction: Objective: to assess and analyse a medication adaptation pathway for feeding tube administration followed by clinical pharmacists for patients at discharge, and to analyse the level of physician acceptance of the recommendations issued by pharmacists in pharmaceutical care reports to improve patient therapy. Methods: a multidisciplinary protocol for treatment adaptation to feeding tube administration at discharge was implemented in a 350-bed hospital during 2019, in which pharmacists prepared feeding tube medication-adaptation reports during pharmaceutical care visits. The number of recommendations related to adaptation of a drug to route of administration was recorded and classified as need for change of active substance or change of pharmaceutical form. Physician acceptance of pharmacist recommendations was analysed in a one-year retrospective observational study. Results: a total of 66 pharmaceutical care visits were recorded for 57 patients (1.2 visits per patient). In 47 of these 66 visits (71.2 %), at least one drug modification was required in a patient prescription, and the median number of drugs per patient needing to be modified was 2. Overall, 93 of the 489 prescribed drugs (19.0 %) required some changes to be suitable for administration via feeding tube: change of active substance in 52.7 % (49/93) of cases, and change of pharmaceutical form in 47.3 % (44/93) of cases. The physicians' level of acceptance of recommendations was 43.0 % (40/93), and change of pharmaceutical form was less accepted than change of active substance. Conclusion: the inclusion of clinical pharmacists in multidisciplinary teams leads to an improvement in adapting medication to feeding tube administration, but also shows a lack of communication or understanding of pharmacist recommendations by physicians resulting in a low rate of prescription changes.

Introducción: Objetivo: evaluar y analizar un circuito de adaptación de la medicación para la administración por sonda de alimentación llevado a cabo por farmacéuticos clínicos para pacientes al alta, y analizar el nivel de aceptación por parte de los médicos de las recomendaciones emitidas por los farmacéuticos en los informes de atención farmacéutica para mejorar la terapia de los pacientes. Métodos: durante el año 2019 se implementó en un hospital de 350 camas un protocolo multidisciplinario de adaptación del tratamiento para la administración por sonda de alimentación al alta, en el cual los farmacéuticos elaboraron informes de adaptación de la medicación por sonda de alimentación durante las visitas de atención farmacéutica. Se registró el número de recomendaciones relacionadas con la adecuación del fármaco a la vía de administración y se clasificaron como necesidad de cambio de principio activo o cambio de forma farmacéutica. La aceptación de las recomendaciones de los farmacéuticos por parte de los médicos se analizó en un estudio observacional retrospectivo de un año. Resultados: se registraron un total de 66 visitas de atención farmacéutica para 57 pacientes (1,2 visitas por paciente). En 47 de estas 66 visitas (71,2 %) se requirió al menos una modificación de medicamentos en la prescripción de los pacientes, y la mediana de medicamentos por paciente que necesitaban modificarse fue de 2. En total, 93 de los 489 medicamentos prescritos (19,0 %) requirió algunos cambios para ser aptos para la administración por sonda: cambio de principio activo en el 52,7 % (49/93) de los casos y cambio de forma farmacéutica en el 47,3 % (44/93) de los casos. El nivel de aceptación de las recomendaciones por parte de los médicos fue del 43,0 % (40/93), siendo menos aceptado el cambio de forma farmacéutica que el cambio de principio activo. Conclusión: la inclusión de farmacéuticos clínicos en equipos multidisciplinarios conduce a una mejora en la adaptación de la medicación a la administración por sonda de alimentación, pero también muestra que existe una falta de comunicación o comprensión de las recomendaciones de los farmacéuticos por parte de los médicos, lo que resulta en una baja tasa de cambios en la prescripción.

Pharmaceutical care at discharge for patients with feeding tubes / Atención farmacéutica al alta para pacientes con sondas de alimentación

Objective: to assess and analyse a medication adaptation pathway for feeding tube administration followed by clinical pharmacists for patients at discharge, and to analyse the level of physician acceptance of the recommendations issued by pharmacists in pharmaceutical care reports to improve patient therapy. Methods: a multidisciplinary protocol for treatment adaptation to feeding tube administration at discharge was implemented in a 350-bed hospital during 2019, in which pharmacists prepared feeding tube medication-adaptation reports during pharmaceutical care visits. The number of recommendations related to adaptation of a drug to route of administration was recorded and classified as need for change of active substance or change of pharmaceutical form. Physician acceptance of pharmacist recommendations was analysed in a one-year retrospective observational study. Results: a total of 66 pharmaceutical care visits were recorded for 57 patients (1.2 visits per patient). In 47 of these 66 visits (71.2 %), at least one drug modification was required in a patient prescription, and the median number of drugs per patient needing to be modified was 2. Overall, 93 of the 489 prescribed drugs (19.0 %) required some changes to be suitable for administration via feeding tube: change of active substance in 52.7 % (49/93) of cases, and change of pharmaceutical form in 47.3 % (44/93) of cases. The physicians’ level of acceptance of recommendations was 43.0 % (40/93), and change of pharmaceutical form was less accepted than change of active substance. (AU)

Objetivo: evaluar y analizar un circuito de adaptación de la medicación para la administración por sonda de alimentación llevado a cabo por farmacéuticos clínicos para pacientes al alta, y analizar el nivel de aceptación por parte de los médicos de las recomendaciones emitidas por los farmacéuticos en los informes de atención farmacéutica para mejorar la terapia de los pacientes. Métodos: durante el año 2019 se implementó en un hospital de 350 camas un protocolo multidisciplinario de adaptación del tratamiento para la administración por sonda de alimentación al alta, en el cual los farmacéuticos elaboraron informes de adaptación de la medicación por sonda de alimentación durante las visitas de atención farmacéutica. Se registró el número de recomendaciones relacionadas con la adecuación del fármaco a la vía de administración y se clasificaron como necesidad de cambio de principio activo o cambio de forma farmacéutica. La aceptación de las recomendaciones de los farmacéuticos por parte de los médicos se analizó en un estudio observacional retrospectivo de un año. Resultados: se registraron un total de 66 visitas de atención farmacéutica para 57 pacientes (1,2 visitas por paciente). En 47 de estas 66 visitas (71,2 %) se requirió al menos una modificación de medicamentos en la prescripción de los pacientes, y la mediana de medicamentos por paciente que necesitaban modificarse fue de 2. En total, 93 de los 489 medicamentos prescritos (19,0 %) requirió algunos cambios para ser aptos para la administración por sonda: cambio de principio activo en el 52,7 % (49/93) de los casos y cambio de forma farmacéutica en el 47,3 % (44/93) de los casos. El nivel de aceptación de las recomendaciones por parte de los médicos fue del 43,0 % (40/93), siendo menos aceptado el cambio de forma farmacéutica que el cambio de principio activo. (AU)

The role of clinical pharmacists in the optimisation of medication prescription and reconciliation on admission in an emergency department.

OBJECTIVES: To describe a clinical pharmacist's (CP) activity in an emergency department (ED) regarding medication reconciliation and optimisation of pharmacotherapy of patients at hospital admission. METHODS: A 1-year prospective observational study was conducted to analyse the activity of a CP in the ED of a 350-bed hospital in Spain. The CP reviewed home medications and medical prescriptions of patients to perform medication reconciliation if required and intervene if medication errors were detected. RESULTS: The CP reviewed medications and medical orders of 1048 patients. 816 patients had home medication: 440 patients (53.9%) were correctly reconciled by the physician; 136 (16.7%) were reconciled by the physician with unintentional discrepancies; and 240 (29.4%) by the CP, with a higher percentage in patients admitted to surgical departments (χ2:38.698; P<0.001). Following pharmaceutical validation, 434 pharmaceutical interventions were performed. CONCLUSIONS: The presence of a CP in an ED could increase the detection of reconciliation errors and help resolve medication errors.

An admission medication reconciliation programme carried out by pharmacists: impact on surgeons' prescriptions.

OBJECTIVES: To describe a medication reconciliation (MR) procedure prepared by the pharmacist for patients admitted for elective surgery and to assess the surgeon's degree of acceptance. METHODS: A 1-year retrospective observational study was conducted. The patient population consisted of patients aged ≥18 years admitted during 2016 for elective surgery and whose planned length of hospital stay was >24 hours. A pharmacist performed MR following a specific protocol. A review of the reconciliations prescribed later by the surgeons was conducted. Statistical analyses were performed for qualitative and quantitative variables. RESULTS: The pharmacist prepared a total of 1986 reconciliation reports. The 179 patients reviewed in this study had a mean age of 65.7±11.8 years, 49.2% were women and 98.9% of patients were reconciled by the surgeon in the operating theatre using an electronic prescribing system (85.5% were fully reconciled). CONCLUSION: The hospital's MR protocol resulted in almost 100% of patients being reconciled within the subgroup of elective surgery patients by the prescribing surgeons.

Effects of cyclic parenteral nutrition on parenteral-associated liver dysfunction parameters.

INTRODUCTION: One of the most common complications of parenteral nutrition (PN) is liver dysfunction (LD). Therapeutic approaches for LD include, among others, administering cyclic parenteral nutrition (cPN), allowing some hours for metabolic rest. The purpose of this study was to evaluate the effectiveness of cPN in treating PN-associated LD. MATERIALS AND METHODS: A retrospective observational study was carried out at the Costa del Sol Hospital in Spain between 2013 and 2014. The study involved inpatients ≥18 years old prescribed with cPN due to the development of PN-associated LD. The hepatic biochemical parameters measured at baseline and after completion of cPN included aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP) and total bilirubin (TB). Quantitative values (age, biochemical parameters) were compared using matched Student's t-test; the mean change in qualitative variables (sex, indication of PN, hepatic comorbidities, presence of insulin in cPN, infection during cPN, management of LD prior to cPN administrarion) was estimated using Mann-Whitney U test, and bivariate correlation between quantitative variables was determined by Spearman's coefficient of correlation. RESULTS: Thirty-seven patients met inclusion criteria. All hepatic function parameters except ALP improved after the administration of cPN, with statistically significant differences (p < 0.05) in AST GGT and TB. CONCLUSION: cPN improves PN-associated LD by restoring abnormal AST, GGT, and BT levels to normal, and reducing ALT levels close to normal. The results obtained suggest that the administration of cPN is effective in reverting PN-associated LD.