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Patel P, Whinney C. Perioperative Medication Management. Med Clin North Am 2024; 108:1135-1153. [PMID: 39341618 DOI: 10.1016/j.mcna.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Medication management in the perioperative period is a critical part of the decision-making prior to surgery. While randomized trial levels of evidence in this space are scant, retrospective data and expert consensus provide practical guidance for these decisions. Clinicians must understand risks and benefits of withholding versus continuing medications, stop medications based on pharmacokinetics and effect on primary disease and surgical risk, and resume medications after surgery in a timely manner. Knowing alternate routes of medication administration can help keep chronic disease processes stable through surgery.
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Affiliation(s)
- Preethi Patel
- Department of Hospital Medicine, Cleveland Clinic Lerner College of Medicine, Integrated Hospital Care Institute, Cleveland Clinic, 9500 Euclid Avenue, M2 Annex, Cleveland, OH 44195, USA
| | - Christopher Whinney
- Department of Hospital Medicine, Cleveland Clinic Lerner College of Medicine, Integrated Hospital Care Institute, Cleveland Clinic, 9500 Euclid Avenue, M2 Annex, Cleveland, OH 44195, USA.
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2
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Shahrami B, Arabzadeh AA. Medication Management in Patients Undergoing Surgery: Beyond a Protocol-Based Approach. Am J Ther 2024; 31:e342-e346. [PMID: 38219231 DOI: 10.1097/mjt.0000000000001690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Affiliation(s)
- Bita Shahrami
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; and
| | - Amir Ahmad Arabzadeh
- Department of Surgery, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
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3
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Lindbloom TJ, Corbo JM, Blacksmith HP, Tarnowski A, Frei CR. Evaluation of pharmacists' role in preoperative medication review in a Veterans Affairs Health Care System. Am J Health Syst Pharm 2024; 81:S1-S7. [PMID: 37996069 DOI: 10.1093/ajhp/zxad291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Indexed: 11/25/2023] Open
Abstract
PURPOSE Use of high-risk medications preoperatively may increase the incidence of postoperative complications. Available literature evaluating pharmacists' role in preoperative medication review is limited, and guidance is not currently available on which patients should have a medication review performed by a pharmacist before surgery. A preoperative rehabilitation pilot project in which clinical pharmacists reviewed medication profiles before scheduled surgeries was developed. This review aimed to evaluate pharmacists' role in reviewing medication profiles preoperatively and to identify specific patient factors that suggest a medication review is warranted. METHODS This retrospective review utilized the electronic medical records of nonfrail adults undergoing preplanned surgeries enrolled in the pilot project from August 2021 to April 2022. Endpoints were determined using descriptive statistics and regression models. A multivariate analysis was performed evaluating high-risk medications and VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) polypharmacy risk score. RESULTS Forty patients were included, with at least one recommendation made in 83% of chart reviews. Many patients (95%) were taking at least one high-risk medication. Of the high-risk medication classes evaluated independently, only antiplatelets were predictive of pharmacy intervention (P = 0.01). Only high-risk medications were independently predictive of pharmacist intervention (P < 0.01) when multivariate analysis was performed. CONCLUSION Pharmacists made a recommendation in the majority of medication reviews and were most likely to make a recommendation in patients taking high-risk medications. A larger sample size may provide more insight regarding patient-specific factors warranting a preoperative medication review.
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Affiliation(s)
- Tori J Lindbloom
- South Texas Veterans Health Care System, San Antonio, TX
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Jason M Corbo
- South Texas Veterans Health Care System, San Antonio, TX
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Heather P Blacksmith
- South Texas Veterans Health Care System, San Antonio, TX
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Amy Tarnowski
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX, and Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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4
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Mengato D, Pivato L, Codato L, Faccioli FF, Camuffo L, Giron MC, Venturini F. Best Possible Medication History Collection by Clinical Pharmacist in a Preoperative Setting: An Observational Prospective Study. PHARMACY 2023; 11:142. [PMID: 37736914 PMCID: PMC10514880 DOI: 10.3390/pharmacy11050142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND A Best Possible Medication History (BPMH) collected by clinical pharmacists is crucial for effective medication review, but, in Italy, it is often left to the nursing staff. This study aims to compare the quality and accuracy of a clinical pharmacist-documented BPMH with the current standard practice of ward staff-collected BPMH in an Italian preoperative surgical setting. METHODS A 20-week prospective observational non-profit study was conducted in a major university hospital. The study comprised three phases: a feasibility, an observational, and an interventional phase. During the feasibility phase, 10 items for obtaining a correct BPMH were identified. The control group consisted of retrospectively analyzed BPMHs collected by the ward staff during the observational phase, while interventions included BPMHs collected by the clinical pharmacist during the third phase. Omissions between the two groups were compared. RESULTS 14 (2.0%) omissions were found in the intervention group, compared with 400 (57.4%) found in the controls (p < 0.05); data collection was more complete when collected by pharmacists compared to the current modality (98.0% of completed information for the intervention versus 42.6%; p < 0.05). CONCLUSIONS The involvement of a pharmacist significantly reduced the number of omissions in preoperative surgical-collected BPMHs. This intervention holds the potential to decrease the risk of medication errors associated with inaccurate or incomplete BPMHs prior to surgical hospitalization.
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Affiliation(s)
- Daniele Mengato
- Hospital Pharmacy Department, Padova University Hospital (Azienda Ospedale-Università Padova), Via Giustiniani 2, 35128 Padua, Italy
| | - Lisa Pivato
- Hospital Pharmacy Department, Padova University Hospital (Azienda Ospedale-Università Padova), Via Giustiniani 2, 35128 Padua, Italy
| | - Lorenzo Codato
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Pharmacology Building, Via Marzolo 5, 35131 Padova, Italy
| | - Fernanda Fabiola Faccioli
- Hospital Pharmacy Department, Padova University Hospital (Azienda Ospedale-Università Padova), Via Giustiniani 2, 35128 Padua, Italy
| | - Laura Camuffo
- Hospital Pharmacy Department, Padova University Hospital (Azienda Ospedale-Università Padova), Via Giustiniani 2, 35128 Padua, Italy
| | - Maria Cecilia Giron
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Pharmacology Building, Via Marzolo 5, 35131 Padova, Italy
| | - Francesca Venturini
- Hospital Pharmacy Department, Padova University Hospital (Azienda Ospedale-Università Padova), Via Giustiniani 2, 35128 Padua, Italy
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5
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Stolzenberg L, Usman M, Huang A, Ibrahim M, Kihara C, Bodiford BM. Intraoperative Complications During Orthopaedic Spinal Surgery in a Polypharmacy Patient With Multiple Comorbidities. Cureus 2023; 15:e39949. [PMID: 37416050 PMCID: PMC10319594 DOI: 10.7759/cureus.39949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/04/2023] [Indexed: 07/08/2023] Open
Abstract
Orthopedic spinal surgeries, such as laminectomies or decompressions, have the potential to significantly increase quality of life for patients suffering from a spectrum of health issues ranging from neuropathy to chronic pain. Patients suffering from neurological symptoms such as weakness or neuropathy may lose significant function and become unable to perform the activities of daily living, however these delicate surgical interventions also come with significant risks to the health and well-being of those same patients. This is especially true with patients who have predisposing health conditions. Here, we discuss the effects of surgery on a patient with severe obesity, multiple confounding pre-existing conditions, and significant polypharmacy. An initially unremarkable spinal laminectomy and decompression surgery resulted in severe intraoperative complications that necessitated direct admission to the intensive care unit for significant post-operative management before he was able to be discharged safely. Although not a case of incredible rarity, we hope it can contribute to the growing body of data about the role of predisposing health conditions and polypharmacy in calculating and understanding the risks of orthopaedic surgery.
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Affiliation(s)
| | - Mohammad Usman
- Anesthesiology, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Austin Huang
- Neurology, Alabama College of Osteopathic Medicine, Dothan, USA
| | | | - Colby Kihara
- Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Brandy M Bodiford
- Family Medicine, Alabama College of Osteopathic Medicine, Dothan, USA
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Coldwell C, Craig W. How should anaesthetic skills best be deployed for quality, safety and efficiency of care? Anaesthesia 2023; 78:279-281. [PMID: 36410053 DOI: 10.1111/anae.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 11/22/2022]
Affiliation(s)
- C Coldwell
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - W Craig
- Department of Surgery, Royal Lancaster Infirmary, Lancaster, UK
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Cheng HT, Zhao M, Liu HT, Shen GL, Zhao T, Feng ZE. The prevalence of chronic medication therapy problems and pharmacists' interventions among hospitalized perioperative patients: a retrospective observational study. BMC Health Serv Res 2022; 22:1483. [PMID: 36474239 PMCID: PMC9724277 DOI: 10.1186/s12913-022-08897-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Inadequate preoperative management of chronic medications can place perioperative patients at risk and cause unnecessary delays in surgical procedures. This study aims to investigate the prevalence of chronic medication therapy problems (CMTPs) in hospitalized perioperative patients and assess the relevance of pharmacists' interventions. METHODS We conducted a retrospective study of pharmacist-led preoperative management of chronic medications in hospitalized adult patients from November 2018 to April 2019. The recorded drug-related problems (DRPs) were retrospectively reviewed and categorized according to the Pharmaceutical Care Network Europe classification V9.1 and were analyzed with a multinomial regression model to identify risk factors. RESULTS A total of 254 DRPs were recorded, with an average of 0.52 DRPs per patient. Treatment safety (66.9%) was the most common DRP. The most frequent causes of perioperative DRPs and nonperioperative DRPs were drug selection (72.9%) and patient related (50.8%), respectively. Of the 292 documented interventions, 71.6% were fully accepted by the clinicians and patients. The majority (68.9%) of the recorded problems were completely resolved. The number of comorbidities (OR = 3.815) and the number of chronic medications taken (OR = 1.539) were risk factors for the occurrence of DRPs. CONCLUSION The findings of this study suggest that pharmacist-led chronic medication therapy management in surgical wards may be an effective method to help reduce medication-related surgical risks and optimize the medication therapies used for the long-term treatment of chronic diseases.
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Affiliation(s)
- Hai-Ting Cheng
- grid.24696.3f0000 0004 0369 153XDepartment of Pharmacy, Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050 China
| | - Ming Zhao
- grid.506261.60000 0001 0706 7839Department of Pharmacy, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, 100730 China
| | - Hong-Tao Liu
- grid.24696.3f0000 0004 0369 153XDepartment of Pharmacy, Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050 China
| | - Guo-Liang Shen
- grid.24696.3f0000 0004 0369 153XDepartment of Pharmacy, Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050 China
| | - Ting Zhao
- grid.24696.3f0000 0004 0369 153XDepartment of Pharmacy, Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050 China
| | - Zhi-En Feng
- grid.24696.3f0000 0004 0369 153XDepartment of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, 100050 Beijing, China
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Holden TR, Kushner BS, Hamilton JL, Han B, Holden SE. Polypharmacy is predictive of postoperative complications in older adults undergoing ventral hernia repair. Surg Endosc 2022; 36:8387-8396. [PMID: 35182214 DOI: 10.1007/s00464-022-09099-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ventral hernias are common in older adults, and may be repaired via a transversus abdominus release (TAR). Older adults undergoing surgery have unique age-related risk factors, including polypharmacy. Polypharmacy is highly prevalent in older adults and is associated with adverse postoperative outcomes. Our aim was to examine the prevalence and association of polypharmacy with clinical outcomes in older adults undergoing a TAR. METHODS Patients 60 years and older who underwent elective open or robotic bilateral TAR were included in the study. Average daily medications taken preoperatively was collected and stratified by tertiles. Baseline demographic data, peri- and postoperative outcomes, and 30-day outcomes were collected. RESULTS There were 132 total patients with an average age of 67.8 years. The number of daily medications ranged from 0 to 28, with an overall mean of 11.2 medications. Patients in tertile 1 took an average of 5.3 medications, tertile 2 10.5 medications, and tertile 3 17.9 medications. Patients in tertile 3 had more than double the rate of in-hospital complications (0.7) compared to tertiles 1 and 2 (0.3 and 0.3, respectively; p = 0.03). A greater number of daily medications was independently associated with postoperative delirium [odds ratio (OR) 1.2, 95% confidence interval (CI) 1.0-1.3], cardiac events (OR 1.2, 95% CI 1.0-1.3), ICU stay (OR 1.2, 95% CI 1.0-1.3), and discharge to a skilled nursing facility (SNF) (OR 1.2, 95% CI 1.0-1.5). CONCLUSIONS Polypharmacy was very common in older adults undergoing a TAR, and was associated with in-hospital complications, postoperative delirium, cardiac events, ICU stay, length of stay, and discharge to a SNF. Additional study is needed to assess if preoperative interventions to limit polypharmacy will improve outcomes for older adults undergoing a TAR.
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Affiliation(s)
- Timothy R Holden
- Division of Geriatrics and Nutritional Science, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Mail Stop Code 8303-0021-0003, St. Louis, MO, 63110, USA.
| | - Bradley S Kushner
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Julia L Hamilton
- Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Britta Han
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Sara E Holden
- Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
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Vallecillo T, Slimano F, Moussouni M, Ohl X, Bonnet M, Mensa C, Hettler D, Kanagaratnam L, Mongaret C. Development and validation of a ready-to-use score to prioritise medication reconciliation at patient admission in an orthopaedic and trauma department. Eur J Hosp Pharm 2022; 29:264-270. [PMID: 33293282 PMCID: PMC9660597 DOI: 10.1136/ejhpharm-2020-002283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/14/2020] [Accepted: 11/17/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Medication reconciliation (MR) is recognised as an important tool in preventing medication errors such as unintentional discrepancies (UDs). The aim of this study was to identify independent predictive factors of UDs during MR at patient admission to an orthopaedic and trauma department. The secondary objective was to build and validate a ready-to-use score to prioritise patients. METHOD A retrospective study was performed on 3.5 years of pharmacist-led MR in the orthopaedic and trauma department of a large university teaching hospital. Independent predictors of UD were identified by multivariable logistic regression. A priority score to identify patients at risk of at least one UD was constructed from the odds ratios of the risk factors, and validated in a separate cohort. Performance was assessed with sensitivity, specificity, C-statistic and Hosmer-Lemeshow goodness-of-fit. RESULTS In total, 888 patients were included and 387 UDs were identified, mainly drug omissions (65.1%). Five independent predictors of UD were identified: age >75 years (OR 2.05, 95% CI 1.41 to 3.00; p<0.001), admission during school holidays (OR 1.69, 95% CI 1.17 to 2.44; p=0.005), female gender (OR 2.20, 95% CI 1.53 to 3.16; p<0.001), emergency hospitalisation (OR 2.05, 95% CI 1.45 to 2.92; p<0.001), and ≥5 medications on the best possible medication history (BPMH) (OR 3.29, 95% CI 2.20 to 4.94; p<0.001). Based on these predictors, a priority score ranging from 0 to 10 was built and internally and externally validated (C statistic 0.72, 95% CI 0.67 to 0.76). CONCLUSIONS This study confirms the high prevalence of UD in patients admitted to orthopaedic and trauma surgery departments. Five independent predictive factors of UD during MR were identified (female gender, emergency hospitalisation, hospitalisation during school holidays, age ≥75 years, and ≥5 medicines on the BPMH). The developed risk score will help to prioritise MR among patients at risk of medication error and is ready-to-use in other orthopaedic and trauma departments.
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Affiliation(s)
| | - Florian Slimano
- Pharmacy, CHU Reims, Reims, France
- MEDyC UMR CNRS/URCA n°7369, Reims Champagne-Ardenne University Faculty of Pharmacy, Reims, France
| | | | - Xavier Ohl
- Orthopaedic Surgery, CHU Reims Pôle Locomoteur, Reims, France
- EA 4691, Reims Champagne-Ardenne University Faculty of Pharmacy, Reims, France
| | | | | | | | | | - Céline Mongaret
- Pharmacy, CHU Reims, Reims, France
- EA 4691, Reims Champagne-Ardenne University Faculty of Pharmacy, Reims, France
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To TP, Braat S, Lim A, Brien JA, Heland M, Hardidge A, Story D. Impact of a policy to improve the management of oral medications when patients are fasting before a procedure: an interrupted time series analysis. BMJ Open Qual 2022; 11:bmjoq-2021-001768. [PMID: 35577400 PMCID: PMC9114966 DOI: 10.1136/bmjoq-2021-001768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Managing medications inappropriately when patients have oral intake restrictions can cause patient harm. This study evaluated the impact of a medication policy separating fasting from nil by mouth with respect to giving oral medications in patients fasting before a diagnostic or interventional procedure. Methods The policy stipulated that ‘fasting’ means oral medications should be given with a sip of water up to 1 hour before a procedure, unless there is a clinical reason to withhold, while ‘nil by mouth’ means nothing to be given orally, including medications. The policy was implemented in Surgical areas in February 2015 and Medical areas in March 2015 at a tertiary referral hospital in Melbourne, Australia, and included bedside signs, clinical champions and education sessions. The study was conducted in 2020. Admission and medication records were matched for non-elective procedure patients from January 2014 to May 2016. The monthly proportion of doses omitted inappropriately and overall omissions pre/post-policy implementation were compared using segmented regression. Results Pre-implementation, the proportion of doses withheld inappropriately and total omissions in medical areas were 18.1% and 28.0%, respectively. Post-implementation, an absolute reduction of 13.4% (95% CI 9.0% to 17.7%) and 11.1% (95% CI 2.6% to 19.6%), respectively, was seen. Post-implementation linear trend showed a 0.3% (95% CI 0.0% to 0.6%) increase in inappropriate omissions but not overall omissions. In Surgical areas, pre-implementation proportions for inappropriate and overall omissions were lower than Medical areas’. Post-implementation, there was an absolute decrease in doses withheld inappropriately (8.3%, 95% CI 0.8% to 15.7%, from 11.9% pre-implementation) but not total omissions. Conclusions Distinguishing fasting from nil by mouth appeared to provide clarity for some staff: a reduction in inappropriate omissions was seen post-implementation. Although the small increase in post-implementation linear trend for inappropriate omissions in Medical areas suggests sustainability issues, total omissions were sustained. The policy’s concepts require verification beyond our institution.
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Affiliation(s)
- The-Phung To
- Pharmacy, Austin Health, Heidelberg, Victoria, Australia .,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Lim
- Anaesthesia, Austin Health, Heidelberg, Victoria, Australia.,Anaesthesia, Eastern Health Foundation, Box Hill, Victoria, Australia
| | - Jo-Anne Brien
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,St Vincent's Hospital Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Melodie Heland
- Surgery, Anaesthesia & Procedural medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Hardidge
- Orthopaedic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - David Story
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
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Bui T, Fitzpatrick B, Forrester T, Gu G, Hill C, Mulqueen C, Penno J, Yu A, Munro C, Mellor Y. Standard of practice in surgery and perioperative medicine for pharmacy services. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1805] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Thuy Bui
- Surgery and Perioperative Medicine Leadership Committee The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
- Pharmacy Department Alfred Health Melbourne Victoria Australia
| | - Brennan Fitzpatrick
- Surgery and Perioperative Medicine Leadership Committee The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
- Pharmacy Department The Royal Melbourne Hospital Parkville Victoria Australia
| | - Tori Forrester
- Surgery and Perioperative Medicine Leadership Committee The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
- Pharmacy Department Princess Alexandra Hospital Woolloongabba Queensland Australia
| | - Galahad Gu
- Surgery and Perioperative Medicine Leadership Committee The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
- Pharmacy Department Eastern Health Box Hill Victoria Australia
| | - Courtney Hill
- Pharmacy Department Princess Alexandra Hospital Woolloongabba Queensland Australia
| | - Caitlin Mulqueen
- Surgery and Perioperative Medicine Leadership Committee The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
- Pharmacy Department Alfred Health Melbourne Victoria Australia
| | - Janelle Penno
- Surgery and Perioperative Medicine Leadership Committee The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
- Pharmacy Department Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Abby Yu
- Surgery and Perioperative Medicine Leadership Committee The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
- Pharmacy Department Royal Brisbane and Women’s Hospital Herston Queensland Australia
| | - Courtney Munro
- The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
| | - Yee Mellor
- The Society of Hospital Pharmacists of Australia Collingwood Victoria Australia
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12
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Mohseni S, Behnam-Roudsari S, Tarbiat M, Shaker P, Shivaie S, Shafiee MA. Perioperative Hypertension Etiologies in Patients Undergoing Noncardiac Surgery in University Health Network Hospitals–Canada from 2015–2020. Integr Blood Press Control 2022; 15:23-32. [PMID: 35340537 PMCID: PMC8942122 DOI: 10.2147/ibpc.s347395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/03/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Perioperative hypertension, defined as increased blood pressure around the surgery, is a known risk factor for perioperative complications, including cardiovascular events. Identifying reasons associated with hypertension in each period is of great help in preventing and better managing perioperative hypertension. Objective The aim of the study was to explore common etiologies of hypertension during the perioperative period (pre, intra, and post-operation) in patients who underwent noncardiac surgeries in University Health Network (UHN) hospitals, Canada, from 2015 to 2020. Patients and Methods We retrospectively analyzed the medical records of 174 patients undergoing noncardiac surgeries who experienced perioperative hypertension. We assessed the prevalence of 10 reasons for perioperative hypertension as a whole and also each period separately according to the physicians’ notes in patients’ medical records. Two-way measurements ANOVA was used to determine the change of mean hypertension among patients for specific etiology. Results The common etiologies of perioperative hypertension were poorly controlled hypertension (21.8%), excessive fluid therapy (19.5%), excessive vasopressor (18.4%), and medication withdrawal (13.7%). Regarding each period separately, the most common reasons were poorly controlled hypertension for pre (42.9%) and intraoperative period (22.7%) and fluid overload for the postoperative period (20.1%). Poor control of hypertension showed both within-subject statistical significance for systolic and between-subject statistical significance for diastolic blood pressure. Conclusion Poorly controlled hypertension is the most significant etiology of perioperative hypertension in patients undergoing noncardiac surgeries. Apart from poorly controlled hypertension, as a patient-related factor, iatrogenic factors such as excessive vasopressor therapy, aggressive fluid replacement and poor management of antihypertensive medications can also cause perioperative hypertension.
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Affiliation(s)
- Sana Mohseni
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Sahar Behnam-Roudsari
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Mohammad Tarbiat
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Pouyan Shaker
- College of Medicine, Kansas City University, Kansas City, MO, USA
| | - Seyedmohammadshahab Shivaie
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Mohammad A Shafiee
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
- Correspondence: Mohammad A Shafiee, Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, 200 Elizabeth Street, 14 EN-208, Toronto, ON M5G 2C4, Canada, Tel +1 416-340-4800 ext 6244, Fax +1 416-595-5826, Email
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13
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Chen C, Zhang L, Almansa C, Rosario M, Cwik M, Balani SK, Lock R. Evaluation of the Pharmacokinetics of Felcisetrag (TAK-954), a 5-HT 4 Receptor Agonist, in the Presence and Absence of Itraconazole, a Potent CYP3A4 Inhibitor. Clin Pharmacol Drug Dev 2022; 11:142-149. [PMID: 34989180 DOI: 10.1002/cpdd.1046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/10/2021] [Indexed: 12/12/2022]
Abstract
The 5-hydroxytryptamine type-4 receptor agonist felcisetrag (TAK-954) is being investigated for improving gastrointestinal motility in postoperative gastrointestinal dysfunction. Polypharmacy often occurs in this setting, and as in vitro data indicate, felcisetrag is primarily metabolized by cytochrome P450 (CYP) 3A4, its CYP3A4-mediated drug-drug interaction potential requires consideration. This phase 1, fixed-sequence, open-label, crossover trial (ClinicalTrials.gov identifier NCT03173170) investigated the effect of itraconazole, a potent CYP3A4 inhibitor, on felcisetrag pharmacokinetics in healthy adults. Over 2 study periods (period 1, 6 days; period 2, 9 days), participants received a single felcisetrag 0.2-mg intravenous dose (day 1, period 1; and day 4, period 2), and once-daily oral itraconazole 200-mg doses (days 1-8, period 2). For felcisetrag alone, felcisetrag total systemic exposure was lower than with itraconazole coadministration. The geometric mean ratio for area under the plasma concentration-time curve from time 0 to infinity of felcisetrag plus itraconazole: felcisetrag alone was 1.49 (90% confidence interval, 1.39-1.60). Peak exposure was similar between regimens (geometric mean ratio, 1.06; 90% confidence interval, 0.96-1.18), and both treatments were well tolerated. These data suggest limited CYP3A4-mediated drug-drug interaction inhibition for felcisetrag.
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Affiliation(s)
- Chunlin Chen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA.,Bayer Pharmaceuticals, Whippany, New Jersey, USA
| | - Liming Zhang
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Cristina Almansa
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA.,Ironwood Pharmaceuticals, Boston, Massachusetts, USA
| | - Maria Rosario
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA.,Syros Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Michael Cwik
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Suresh K Balani
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
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14
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Koprowski MA, Nagengast AK, Finlayson E, Brasel KJ. Surgical Trainees and The Geriatric Patient: A Scoping Review. JOURNAL OF SURGICAL EDUCATION 2022; 79:179-189. [PMID: 34294567 DOI: 10.1016/j.jsurg.2021.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/25/2021] [Accepted: 06/26/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE There is an increasing emphasis on surgical trainees learning how to appropriately provide care for the geriatric patient. We hypothesized that little published formal curriculum on the topic exists. We sought to perform a scoping review to test this hypothesis. DESIGN PubMed, OVID Medline, and EMBASE databases were queried from inception, supplemented by hand search of references and the grey literature. Included English language abstracts and articles described trainee perceptions of geriatric patients and/or description of dedicated geriatric curricula for trainees. RESULTS There were 21 included abstracts or papers, which were categorized into 8 survey-based studies, 6 descriptions of curricular design, and 7 interventional studies with pre- and post-intervention knowledge tests. General surgery residents were most frequently included. Self-rated confidence and comfort were typically higher than objective measures of resident performance in the care of geriatric patients. Residents were commonly unaware of the standardized assessment tools and recommendations that exist. Medication and delirium management were frequently-identified topics posing the widest gaps in resident knowledge. CONCLUSION There are few published examples of curricula on the care of geriatric patients for surgical trainees. More work is needed for the creation of specialty-specific and needs-based geriatric surgical curricula.
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Affiliation(s)
- Marina Affi Koprowski
- Department of Surgery, Oregon Health and Science University (OHSU), Portland, Oregon
| | - Andrea K Nagengast
- Division of Trauma, Critical Care, and Acute Care Surgery, OHSU, Portland, Oregon
| | - Emily Finlayson
- Department of Surgery, University of California at San Francisco (UCSF), San Francisco, California
| | - Karen J Brasel
- Division of Trauma, Critical Care, and Acute Care Surgery, OHSU, Portland, Oregon.
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15
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Ouweini AE, Karaoui LR, Chamoun N, Assi C, Yammine K, Ramia E. Value of pharmacy services upon admission to an orthopedic surgery unit. J Pharm Policy Pract 2021; 14:103. [PMID: 34872605 PMCID: PMC8646011 DOI: 10.1186/s40545-021-00384-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 11/24/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In Lebanon, the role of the pharmacist remains underestimated in the medication reconciliation process, especially in surgical departments. This study aims to assess the impact of pharmacist-conducted medication reconciliation performed within 48 h of hospital admission to the orthopedic surgical department. METHODS This was a prospective single-arm study conducted in a tertiary-care teaching hospital in Lebanon between October 2019 and April 2020. Participants were adult inpatients hospitalized for orthopedic surgeries with ≥ 1 outpatient medications. Properly trained pharmacy resident obtained the Best Possible Medication History (BPMH) and led the reconciliation process. The primary endpoint was the number of reconciliation errors (REs) identified. Descriptive statistics were used to report participants' responses and relevant findings. Linear regression was performed with the number of REs as a continuous dependent variable using backward method. Results were assumed to be significant when p was < 0.05. RESULTS The study included 100 patients with a mean age of 73.8 years, admitted for elective (54%) or emergency (46%) surgeries. Half of the study population had ≥ 5 home medications. The mean time for taking BPMH was around 8 min. A total of 110 REs were identified in 74 patient cases. The most common discrepancies consisted of medication omission (89.1%) and the most common medications involved were antihyperlipidemic agents. Twenty-four REs were judged as clinically significant, and four as serious. The most common interventions included the addition of a medication (71.9%). Most of the relayed interventions (84.5%) were accepted. The number of home medications was the only variable significantly associated with the number of REs (β 0.492; p < 0.001). CONCLUSION Pharmacy-led medication reconciliation upon admission to orthopedic surgery department can reduce reconciliation errors and improve medication safety. TRIAL REGISTRATION Retrospectively registered in the Lebanon Clinical Trials Registry (LBCTR2020124680).
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Affiliation(s)
- Ahmad El Ouweini
- Lebanese American University, School of Pharmacy, P.O. Box S-23, Byblos, Lebanon
- Lebanese American University Medical Center – Rizk Hospital (LAUMC-RH), Beirut, Lebanon
| | - Lamis R. Karaoui
- Lebanese American University, School of Pharmacy, P.O. Box S-23, Byblos, Lebanon
| | - Nibal Chamoun
- Lebanese American University, School of Pharmacy, P.O. Box S-23, Byblos, Lebanon
- Lebanese American University Medical Center – Rizk Hospital (LAUMC-RH), Beirut, Lebanon
| | - Chahine Assi
- Lebanese American University Medical Center – Rizk Hospital (LAUMC-RH), Beirut, Lebanon
- Lebanese American University – School of Medicine, Byblos, Lebanon
| | - Kaissar Yammine
- Lebanese American University Medical Center – Rizk Hospital (LAUMC-RH), Beirut, Lebanon
- Lebanese American University – School of Medicine, Byblos, Lebanon
| | - Elsy Ramia
- Lebanese American University, School of Pharmacy, P.O. Box S-23, Byblos, Lebanon
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16
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Hamilton J, Kushner B, Holden S, Holden T. Age-Related Risk Factors in Ventral Hernia Repairs: A Review and Call to Action. J Surg Res 2021; 266:180-191. [PMID: 34015515 PMCID: PMC8338875 DOI: 10.1016/j.jss.2021.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/29/2021] [Accepted: 04/02/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND As the population ages, the incidence of ventral hernias in older adults is increasing. Ventral hernia repairs (VHR) should not be considered low risk operations, particularly in older adults who are disproportionately affected by multiple age-related factors that can complicate surgery and adversely affect outcomes. Although age-related risk factors have been well established in other surgical fields, there is currently little data describing their impact on VHR. METHODS We performed a systematic review of the literature to identify studies that examine the effects of age-related risk factors on VHR outcomes. This was conducted using Cochrane Library, Embase, PubMed (Medline), and Google Scholar databases, all updated through June 2020. We selected relevant studies using the keywords, multimorbidity, comorbidities, polypharmacy, functional dependence, functional status, frailty, cognitive impairment, dementia, sarcopenia, and malnutrition. Primary outcomes include mortality and overall complications following VHR. RESULTS We summarize the evidence basis for the significance of age-related risk factors in elective surgery and discuss how these factors increase the risk of adverse outcomes following VHR. In particular, we explore the impact of the following risk factors: multimorbidity, polypharmacy, functional dependence, frailty, cognitive impairment, sarcopenia, and malnutrition. As opposed to chronological age itself, age-related risk factors are more clinically relevant in determining VHR outcomes. CONCLUSIONS Given the increasing complexity of VHR, addressing age-related risk factors pre-operatively has the potential to improve surgical outcomes in older adults. Preoperative risk assessment and individualized prehabilitation programs aimed at improving patient-centered outcomes may be particularly useful in this population.
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Affiliation(s)
- Julia Hamilton
- Department of Surgery, Washington University School of Medicine. St. Louis, Missouri.
| | - Bradley Kushner
- Department of Surgery, Washington University School of Medicine. St. Louis, Missouri
| | - Sara Holden
- Department of Surgery, Washington University School of Medicine. St. Louis, Missouri
| | - Timothy Holden
- Department of Medicine, Division of Geriatrics and Nutritional Science, Washington University School of Medicine, St. Louis, Missouri
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17
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Wang S, Ren W, Tan X, Lv X, Liu Y, Gong Y. High-Risk Perioperative Medications in the Chinese Elderly Population. Clin Interv Aging 2021; 16:1201-1213. [PMID: 34211269 PMCID: PMC8239167 DOI: 10.2147/cia.s309063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/31/2021] [Indexed: 11/27/2022] Open
Abstract
Background Inappropriate perioperative medications among elderly patients increase the risk of adverse events and undermine surgical outcomes. This study aimed to assess the prevalence of high-risk medications in elderly surgical patients and verify the effectiveness of a new-developed high-risk perioperative medications (HRPOMs) list for the elderly. Methods A cross-sectional, single-center study was conducted at Jinshan Hospital of Fudan University. A total of 810 elderly surgical patients were included in the study. The HRPOMs list was applied to patients’ data to identify the HRPOMs including chronic medications and medications related to surgery. Results A total of 2113 HRPOMs were identified in 810 patients who fulfilled the inclusion criteria. Of these, 1067 (50.5%) involved medications related to surgery, and 982 (46.5%) involved chronic medications. The prevalence of HRPOM exposure, which was defined as at least one HRPOM was 76.3%. Patients that were 70 years or older (adjusted odds ratio [AOR] =2.118, 95% confidence interval [CI], 1.420~3.159), hospitalized over two weeks (AOR =4.192, 95% CI, 1.493~11.771), with more than 2 distinct diagnoses (AOR =3.407, 95% CI, 2.224~5.220) and with 16 or more medications during hospitalization were more likely to be exposed to HRPOMs. Patients who underwent surgeries of Grade IV were at 1.73 increased odds of HRPOM exposure compared with those who received surgeries of Grade III or lower (P=0.071). Conclusion HRPOMs are more common in patients of 70 years or older, with 3 or more distinct diagnoses, with 16 or more medications and hospitalized for 15 days or longer. Our study showed the validity of the HRPOMs list in the perioperative medication review for the elderly and may induce further research to reveal the impact of HRPOMs upon the surgical outcomes of the elderly.
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Affiliation(s)
- Shuying Wang
- Department of Pharmacy, Jinshan Hospital of Fudan University, Shanghai, People's Republic of China
| | - Weifang Ren
- Department of Pharmacy, Jinshan Hospital of Fudan University, Shanghai, People's Republic of China
| | - Xiaofang Tan
- Department of Pharmacy, Jinshan Hospital of Fudan University, Shanghai, People's Republic of China
| | - Xiaoqun Lv
- Department of Pharmacy, Jinshan Hospital of Fudan University, Shanghai, People's Republic of China
| | - Yujuan Liu
- Department of Pharmacy, Jinshan Hospital of Fudan University, Shanghai, People's Republic of China
| | - Yuan Gong
- Department of Pharmacy, Jinshan Hospital of Fudan University, Shanghai, People's Republic of China
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18
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Montemurro P, Hedén P, Behr B, Wallner C. Controllable Factors to Reduce the Rate of Complications in Primary Breast Augmentation: A Review of the Literature. Aesthetic Plast Surg 2021; 45:498-505. [PMID: 32358668 DOI: 10.1007/s00266-020-01726-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/09/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Aesthetic augmentation mammoplasties are one of the most demanded procedures performed in the aesthetic surgical sector. Because of the high epidemiological impact, the evaluation of measures to reduce the risk of complications is highly needed. The goal of this review is to evaluate the current literature for successful actions to reduce the risk of complications in aesthetic breast augmentation. METHODS We searched Medline-listed journals for "complications primary breast augmentation" and defined surgeon-dependent and patient-dependent factors within those. RESULTS Most of the strategies to reduce the risk of any complication are based on meticulous hygienic precautions and adequate training of the surgeon. The current literature suggests complications such as capsular contracture, infection and BIA-ALCL are closely linked with bacterial contamination and therefore can be avoided with different hygienic measures. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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19
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Hanlon JT, Tjia J. Avoiding Adverse Drug Withdrawal Events When Stopping Unnecessary Medications According to the STOPPFrail Criteria. Sr Care Pharm 2021; 36:136-141. [PMID: 33662236 DOI: 10.4140/tcp.n.2021.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide clinicians with information about avoiding adverse drug withdrawal events (ADWEs) when discontinuing unnecessary medications as per the STOPPFrail criteria. DATA SOURCES Searches of MEDLINE (1970-June 2020), the Cochrane Database of Systematic Reviews (through June 2020), Google Scholar (through June 2020). STUDY SELECTION Reviews and original studies of ADWEs. DATA EXTRACTION Tapering protocols for specific drugs/ classes from randomized controlled deprescribing trials. DATA SYNTHESIS Six drug classes were identified as being high risk for physiological ADWEs. CONCLUSION The occurrence of ADWEs is rare in comparison to adverse drug reactions in older adults. Few drugs/classes have been reported to have physiological ADWEs with abrupt discontinuation. For these we provide information about tapering protocols and symptom monitoring to avoid ADWEs.
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Affiliation(s)
- Joseph T Hanlon
- 1University of Pittsburgh, Department of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Tjia
- 3University of Massachusetts Medical School, Department of Population and Quantitative Health Sciences, Worcester, Massachusetts
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20
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Guerin K, Quinlan P, Wessolock R, Goldberg S, Nguyen JT, Stone PW. Impact of a Unit-Based Clinical Pharmacist on Communication of Medication Information in an Orthopedic Hospital. HSS J 2020; 16:333-338. [PMID: 33380965 PMCID: PMC7749900 DOI: 10.1007/s11420-019-09739-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/29/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Medication management, a complex yet essential part of patient care, requires that clinicians and patients understand indication, dosage, frequency, and adverse effects in order to maximize benefits and minimize errors, as well as to transition patients from hospital to home. Clinical pharmacists improve care transitions and safety by interacting with patients, prescribers, and nurses on medication management and self-care. However, little is known on the use of clinical pharmacists on interdisciplinary teams at the unit level within orthopedics. QUESTIONS/PURPOSES This study sought to measure the impact of unit-based clinical pharmacists on patient perceptions of communication specific to medication during hospitalization at an orthopedic specialty hospital and on the frequency of medication errors. METHODS A retrospective, quasi-experimental, two-group evaluative design with nonequivalent controls was used. Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data on six inpatient units was analyzed 6 months before and 6 months after assignment of clinical pharmacists to half these units. Data specific to questions that measure quality of communication as well as medication understanding were analyzed. Additionally, data on medication error frequency were collected and compared between units with and without clinical pharmacists. RESULTS A total of 2022 surveys were analyzed. The percentage of patients who reported receipt of medication information and medication understanding increased significantly after the implementation of unit-based clinical pharmacists. Comparison of intervention and non-intervention groups showed no statistically significant difference in the frequency of medication errors. CONCLUSION Results suggest that a clinical pharmacist assigned to an inpatient unit in orthopedics significantly influences patient perceptions of communication about and understanding of their medications.
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Affiliation(s)
- Kelly Guerin
- Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021 USA
| | - Patricia Quinlan
- Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021 USA
| | - Robert Wessolock
- Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021 USA
| | - Stephanie Goldberg
- Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021 USA
| | - Joseph T. Nguyen
- Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021 USA
| | - Patricia W. Stone
- Center for Health Policy, New York-Presbyterian/Columbia University Irving Medical Center, 617 W. 168th Street, New York, NY 10032 USA
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21
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Abstract
Many perioperative clinical pathways, and therefore patient journeys, are focused around provider, rather than patient, convenience. Business process re-engineering (BPRE) offers a framework for transformative process-change with the aim of improving 'consumer experience' and efficiency and may be an effective driver for improving patient experience and value within healthcare. Involvement of patients in service and pathway design, through experience-based codesign, is increasingly prevalent and may be an effective complement to BPRE. The elective perioperative pathway offers an opportunity to rethink the patient journey with the aim of maximising opportunities for effective shared decision making and improving preparation for surgery through prehabilitation and management of long-term conditions (comorbidity/multimorbidity management). Additional opportunities include improved management of transitions of care and effective medicines management to minimise polypharmacy. Pathway mapping, deconstruction and reconstruction enables such changes and is a method of service transformation that may have relevance for a spectrum of other elective/scheduled pathways.
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Affiliation(s)
- Michael Pw Grocott
- University of Southampton, Southampton, UK and Acute, Critical and Perioperative Care Research Group, Southampton, UK
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22
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AbuRuz S, Jaber D, Basheti I, Sadeq A, Arafat M, AlAhmad M, Said A. Impact of pharmacist interventions on drug-related problems in general surgery patients: a randomised controlled trial. Eur J Hosp Pharm 2020; 28:e72-e78. [PMID: 32661104 DOI: 10.1136/ejhpharm-2020-002206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/07/2020] [Accepted: 06/08/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The inappropriate use of medications is harmful and is a common issue in hospitalised patients. Patients hospitalised in general surgery wards are usually at high risk for drug-related problems (DRPs). This randomised controlled trial aimed to explore the value of a pharmaceutical care service conducted in general surgery wards in the identification and reduction of DRPs in comparison with standard medical care. METHODS This study was conducted in general surgery wards including abdominal, cardiovascular, vascular, endocrine, orthopaedic and oncological surgeries at one of the largest teaching hospitals in Jordan over a period of 6 months. Recruited patients were randomised into intervention or control groups. Clinical pharmacists assessed patients' DRPs and submitted recommendations to resolve the identified DRPs in the intervention group. RESULTS Patients in the intervention group (n=63) and the control group (n=60) had a mean age of 55±14.4 years, with 52.0% being women. A total of 1062 DRPs were identified, with a mean of 8.6±3.6 per patient (intervention group, 8.65±4.2; control group, 8.62±2.6; p=0.56). The commonly identified DRPs included safety (20.2%) and efficacy (19.0%) issues. The acceptance rate for pharmacists' recommendations by physicians was very high (90%) with a good DRP correction rate of 58.9% during patients' hospital stay. The value of pharmaceutical care was significantly reflected in the achievement of the therapeutic outcomes and prevention of morbidity (resolved/improved or prevented) of 68.2% (24.2%+44%) in the intervention group compared with 19.2% (12.4%+6.8%) in the control group (p<0.001). CONCLUSIONS This study shows that DRPs are common among general surgery patients in Jordan, especially those related to drug safety and efficacy. Pharmacists' recommendations contributed substantially to resolving most of the identified DRPs and had a significant impact on improving medications used in general surgery patients.
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Affiliation(s)
- Salah AbuRuz
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates .,Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Deema Jaber
- Department of Clinical Pharmacy, School of Pharmacy, Zarqa University, Zarqa, Amman, Jordan
| | - Iman Basheti
- Department of Clinical Pharmacy and Therapeutics, Applied Science University, Amman, Jordan
| | - Aya Sadeq
- College of Pharmacy, Al Ain University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Mosab Arafat
- College of Pharmacy, Al Ain University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Mohammad AlAhmad
- College of Pharmacy, Al Ain University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Amira Said
- College of Pharmacy, Al Ain University, Al Ain, Abu Dhabi, United Arab Emirates
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23
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Lemus Barrios GA, Cárdenas Castellanos JM, Curcio Borrero CL, Moreno Gómez GA. Efectos de la fragilidad en los resultados adversos de la cirugía cardiaca en ancianos. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2018.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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24
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Tefera GM, Feyisa BB, Umeta GT, Kebede TM. Predictors of prolonged length of hospital stay and in-hospital mortality among adult patients admitted at the surgical ward of Jimma University medical center, Ethiopia: prospective observational study. J Pharm Policy Pract 2020; 13:24. [PMID: 32549990 PMCID: PMC7296702 DOI: 10.1186/s40545-020-00230-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Data regarding prolonged length of hospital stay (PLOS) and in-hospital mortality are paramount to evaluate efficiency and quality of surgical care as well as for rational resource utilization, allocation, and administration. Thus, PLOS and in-hospital mortality have been used as a surrogate indicator of satisfactory treatment outcome and efficient utilization of resources for a given health institution. However, there was a scarcity of data regarding these issues in Ethiopia. Therefore, this study aimed to assess treatment outcome, length of hospital stay, in-hospital mortality, and their determinants. Methods Health facility-based prospective observational study was used for three consecutive months among adult patients hospitalized for the surgical case. Socio-demographic, clinical history, medication history, in-hospital complications, and overall treatment outcomes were collected from the medical charts' of the patients, using a checklist from the day of admission to discharge. PLOS is defined as hospital stay > 75th percentile (≥33 days for the current study). To identify predictor variables for both PLOS and in-hospital mortality, multivariate logistic regression was performed at p-value < 0.05 using SPSS version 20. Written informed consent was sought and secured. Results Of 269 study participants, 91.8% were improved and discharged. PLOS was recorded in 25.3%; at least 33 days of hospital stay. Overall in-hospital mortality was 4.8%; which is equal to an incidence rate of 0.00193 per person-days, 5.2% in-hospital sepsis, and 2.6% of Hospital-acquired pneumonia (HAP), during their hospital stay. After adjusting for other factors; female gender (p = 0.003), emergency admission (p = 0.015), presence of Poly-pharmacy (p = 0.017), and presence of sepsis (p = 0.006) were found to be independent predictors for in-hospital mortality. On top of this, female gender (p = 0.026), patients who was paid by government (p = 0.007), burn-related surgery (p = 0.049), presence of cancer (p = 0.027), > 2 antibiotic exposure (p < 0.0001), and waiting for surgery for > 7 days (p < 0.0001) were independent predictors for PLOS. Conclusion In-hospital mortality rate was almost comparable to reports from developing countries, though it was higher than the developed countries. However, the length of hospital stay was extremely higher than that of reports from other parts of the world. Besides, different socio-demographic, health facility's and patients' clinical conditions (baseline and in-hospital complications) were identified as independent predictors for both in-hospital mortality and PLOS. Therefore, the clinician and stakeholders have to emphasize to avoid the modifiable factors to reduce in-hospital mortality and PLOS in the study area; to improve the quality of surgical care.
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Affiliation(s)
| | | | - Gurmu Tesfaye Umeta
- Department of Pharmacy, Clinical Pharmacy Unit, Ambo University, Ambo, Ethiopia
| | - Tsegaye Melaku Kebede
- School of Pharmacy, Department of Clinical Pharmacy, Jimma University, Jimma, Ethiopia
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25
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Tefera GM, Zeleke AZ, Jima YM, Kebede TM. Drug Therapy Problems and the Role of Clinical Pharmacist in Surgery Ward: Prospective Observational and Interventional Study. Drug Healthc Patient Saf 2020; 12:71-83. [PMID: 32440225 PMCID: PMC7210033 DOI: 10.2147/dhps.s251200] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Drug therapy problems (DTPs) are of major concern in health care because of the associated increased cost of treatment, morbidity, and mortality. Thus, clinical practice should constitute the mainstream practice of clinical pharmacy in every ward. However, nothing is known about DTPs and the role of clinical pharmacist in the surgical ward of Ethiopia (the neglected ward). OBJECTIVE To assess the prevalence of DTP among patients hospitalized at the surgical ward and the role of clinical pharmacists in their identification and resolution. METHODS Hospital-based prospective observational and interventional study design was used with daily patients' chart review using a semi-structured questionnaire among hospitalized adult patients at the surgical ward. After identification of DTP, verbal communication was used as a means of intervention with the treating physician. Acceptance of clinical pharmacist's intervention was considered only if a change was made to the patients' medication order. To identify determinants of DTPs, multiple stepwise forward logistic regression analysis was done by SPSS version 20.0. Statistical significance was considered at p-value < 0.05. Written informed consent was sought and the data were secured. RESULTS The response rate was 97.1% (300) for the final analysis. The mean (±SD = standard deviation) age of the participants was 42.62 ±18.29 with male (67%) predominance. DTP was identified in 76% of study participants. A total of 449 DTPs were identified, which equates with an average of 1.97 per patient. Dose too low 124/449 (27.6%) and dose too high 81/449 (18.0%) were found to be the most common types of DTPs. The intervention rate was 86.0% (196/228 per patients) and 86.2% (387/449 DTPs), with the acceptance rate of 85.2% (167/196 per patients) and 78% (302/387 per DTP) which mean (67.3%) 302/449 of the problems were fully resolved by the clinical pharmacist. Poly-pharmacy [AOR, 7.23; 95% CI, 2.29-22.13: P-value < 0.001] and hospital stay > 20 days [AOR, 5.42; 95% CI, 2.74-10.70; p < 0.001] were the only independent predictors for DTPs. CONCLUSION AND RECOMMENDATION This study identified a high prevalence of DTP which was independently predicted by the presence of poly-pharmacy and >20 days of hospital stay. The rate of intervention provided and acceptance from the physician was high, which is one indicator that the role of clinical pharmacists in the identification and resolution of DTP was paramount in the surgery ward and should be implemented as a must not as optional.
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Affiliation(s)
| | | | | | - Tsegaye Melaku Kebede
- School of Pharmacy, Department of Clinical Pharmacy, Jimma University, Jimma, Ethiopia
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To TP, Brien JA, Story DA. Barriers to managing medications appropriately when patients have restrictions on oral intake. J Eval Clin Pract 2020; 26:172-180. [PMID: 30968525 DOI: 10.1111/jep.13139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Investigation of several serious adverse events in our organization highlighted that medications were managed inappropriately when patients have oral intake restrictions. The aim of this work was to identify the barriers to optimal medication management when patients have restrictions on their oral intake. METHOD Data were feedback and comments obtained between 2011 and 2014 from a hospital-wide quality assurance project. Data had not been purposefully collected and were in response to a general request for feedback regarding managing oral medications when patients have oral intake restrictions. Data came from a range of clinical staff and from various forums associated with the quality assurance project, including 37 presentations, 34 group meetings, and over 50 one-on-one meetings, as well as emails and other sources. Data were analysed using the thematic analysis approach. Data were coded inductively, and the domains of the Theoretical Domains Framework were used to categorize the data. Subthemes and themes were then developed. RESULTS Barriers could be broadly grouped into systems-level issues (organizational guidance and work environment) and the individual person-level issues (staff knowledge and beliefs). These barriers highlight the complexity of the medication management task. The lack of standardized guidance and consistent terminology regarding medication administration when patients have restrictions on oral intake, particularly when fasting or nil by mouth, were important systems factors, as were workflow issues and the "culture" of the environment in which staff practiced. Lack of knowledge about medication administration, social influences, and role interpretation were important individual person factors. CONCLUSION Systems- and individual person-level issues were significant contributors to inappropriate medication management when patients have oral intake restrictions. Many of the barriers may be addressed with systems approaches such as hospital-wide guidance that simplifies and standardize oral medication administration instructions, particularly regarding fasting and nil by mouth terminology.
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Affiliation(s)
- The-Phung To
- Pharmacy Department, Austin Health, Melbourne, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jo-Anne Brien
- St Vincent's Hospital, University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - David A Story
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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Association of Polypharmacy with Survival, Complications, and Healthcare Resource Use after Elective Noncardiac Surgery: A Population-based Cohort Study. Anesthesiology 2019; 128:1140-1150. [PMID: 29443701 DOI: 10.1097/aln.0000000000002124] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Polypharmacy is increasingly prevalent in older patients and is associated with adverse events among medical patients. The impact of polypharmacy on outcomes after elective surgery is poorly described. The authors' objective was to measure the association of polypharmacy with survival, complications, and resource use among older patients undergoing elective surgery. METHODS After registration (NCT03133182), the authors identified all individuals older than 65 yr old having their first elective noncardiac surgery in Ontario, Canada, between 2002 and 2014. Using linked administrative data, the authors identified all prescriptions dispensed in the 90 days before surgery and classified people receiving five or more unique medications with polypharmacy. The associations of polypharmacy with 90-day survival (primary outcome), complications, length of stay, costs, discharge location, and readmissions were estimated after multilevel, multivariable adjustment for demographics, comorbidities, previous healthcare use, and surgical factors. Prespecified and post hoc sensitivity analyses were also performed. RESULTS Of 266,499 patients identified, 146,026 (54.8%) had polypharmacy. Death within 90 days occurred in 4,356 (3.0%) patients with polypharmacy and 1,919 (1.6%) without (adjusted hazard ratio = 1.21; 95% CI, 1.14 to 1.27). Sensitivity analyses demonstrated no increase in effect when only high-risk medications were considered and attenuation of the effect when only prescriptions filled in the 30 preoperative days were considered (hazard ratio = 1.07). Associations were attenuated or not significant in patients with frailty and higher comorbidity scores. CONCLUSIONS Older patients with polypharmacy represent a high-risk stratum of the perioperative population. However, the authors' findings call into question the causality and generalizability of the polypharmacy-adverse outcome association that is well documented in nonsurgical patients.
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Tran T, Taylor SE, Hardidge A, Mitri E, Aminian P, George J, Elliott RA. Pharmacist-assisted electronic prescribing at the time of admission to an inpatient orthopaedic unit and its impact on medication errors: a pre- and postintervention study. Ther Adv Drug Saf 2019; 10:2042098619863985. [PMID: 31321024 PMCID: PMC6628525 DOI: 10.1177/2042098619863985] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 06/25/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prescribing and administration errors related to pre-admission medications are common amongst orthopaedic inpatients. Postprescribing medication reconciliation by clinical pharmacists after hospital admission prevents some but not all errors from reaching the patient. Involving pharmacists at the prescribing stage may more effectively prevent errors. The aim of the study was to evaluate the effect of pharmacist-assisted electronic prescribing at the time of hospital admission on medication errors in orthopaedic inpatients. METHODS A pre- and postintervention study was conducted in the orthopaedic unit of a major metropolitan Australian hospital. During the 10-week intervention phase, a project pharmacist used electronic prescribing to assist with prescribing admission medications and postoperative venous thromboembolism (VTE) prophylaxis, in consultation with orthopaedic medical officers. The primary endpoint was the number of medication errors per patient within 72 h of admission. Secondary endpoints included the number and consequence of adverse events (AEs) associated with admission medication errors and the time delay in administering VTE prophylaxis after elective surgery (number of hours after recommended postoperative dose-time). RESULTS A total of 198 and 210 patients, pre- and postintervention, were evaluated, respectively. The median number of admission medication errors per patient declined from six pre-intervention to one postintervention (p < 0.01). A total of 17 AEs were related to admission medication errors during the pre-intervention period compared with 1 postintervention. There were 54 and 63 elective surgery patients pre- and postintervention, respectively. The median delay in administering VTE prophylaxis for these patients declined from 9 h pre-intervention to 2 h postintervention (p < 0.01). CONCLUSIONS Pharmacist-assisted electronic prescribing reduced the number of admission medication errors and associated AEs.
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Affiliation(s)
- Tim Tran
- Pharmacy Department, Austin Health, 145 Studley
Road, Heidelberg, Victoria 3084, Australia
| | - Simone E. Taylor
- Pharmacy Department, Austin Health, Heidelberg,
Victoria, Australia
| | - Andrew Hardidge
- Orthopaedic Surgery, Austin Health, Heidelberg,
Victoria, Australia
| | - Elise Mitri
- Pharmacy Department, Austin Health, Heidelberg,
Victoria, Australia
| | - Parnaz Aminian
- Pharmacy Department, Austin Health, Heidelberg,
Victoria, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Monash
University, Parkville, Victoria, Australia
| | - Rohan A. Elliott
- Pharmacy Department, Austin Health, Heidelberg,
Victoria, Australia, and Centre for Medicine Use and Safety, Monash
University, Parkville, Victoria, Australia
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Wang K, Shen J, Jiang D, Xing X, Zhan S, Yan S. Development of a list of high-risk perioperative medications for the elderly: a Delphi method. Expert Opin Drug Saf 2019; 18:853-859. [PMID: 31169042 DOI: 10.1080/14740338.2019.1629416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objectives: There is a lack of direct evidence for the management of perioperative medications in elderly patients. Therefore, the authors aimed to develop a list of high-risk medications for the elderly population in China to provide indicators for clinicians to identify medication-related factors contributing to potential adverse events during the perioperative period. Methods: The initial list of high-risk perioperative medications was developed by studying all the publications that described specific high-risk medications and their risk profiles in the elderly. Delphi consultations were performed to form a consensus among the group of experts and the list was finalized. Results: The expert panel consisted of 36 experts from 29 tertiary hospitals and 18 provinces or municipalities. The consensus was reached after two Delphi rounds. Finally, a total of 86 medications of 13 medication classes and 120 screening items were included in the final list, along with perioperative risk profiles and risk aversion recommendations for each drug. Conclusion: This is the first study to establish a high-risk perioperative medication list in China, which can be used as a reference for intervention and evaluation of perioperative medications for the elderly population.
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Affiliation(s)
- Ke Wang
- a Department of Pharmacy, Xuanwu Hospital, The First Clinical Medical College of Capital Medical University , Beijing , China.,b National Clinical Research Center for Geriatric Disorders , Beijing , China
| | - Jianghua Shen
- a Department of Pharmacy, Xuanwu Hospital, The First Clinical Medical College of Capital Medical University , Beijing , China.,b National Clinical Research Center for Geriatric Disorders , Beijing , China
| | - Dechun Jiang
- a Department of Pharmacy, Xuanwu Hospital, The First Clinical Medical College of Capital Medical University , Beijing , China.,b National Clinical Research Center for Geriatric Disorders , Beijing , China
| | - Xiaoxuan Xing
- a Department of Pharmacy, Xuanwu Hospital, The First Clinical Medical College of Capital Medical University , Beijing , China.,b National Clinical Research Center for Geriatric Disorders , Beijing , China
| | - Siyan Zhan
- c School of Public Health, Peking University , Beijing , China
| | - Suying Yan
- a Department of Pharmacy, Xuanwu Hospital, The First Clinical Medical College of Capital Medical University , Beijing , China.,b National Clinical Research Center for Geriatric Disorders , Beijing , China
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Olotu C, Weimann A, Bahrs C, Schwenk W, Scherer M, Kiefmann R. The Perioperative Care of Older Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:63-69. [PMID: 30950385 PMCID: PMC6444041 DOI: 10.3238/arztebl.2019.0063] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 08/21/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Elderly patients are a growing and vulnerable group with an elevated perioperative risk. Perioperative treatment pathways that take these patients' special risks and requirements into account are often not implemented in routine clinical practice. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed, the AWMF guideline database, and the Cochrane database for guidelines from Germany and abroad, meta-analyses, and Cochrane reviews. RESULTS The care of elderly patients who need surgery calls for an interdisciplinary, interprofessional treatment concept. One component of this concept is preoperative preparation of the patient ("prehabilitation"), which is best initiated before hospital admission, e.g., correction of deficiency states, optimization of chronic drug treatment, and respiratory training. Another important component consists of pre-, intra-, and postoperative measures to prevent delirium, which can lower the frequency of this complication by 30-50%: these include orientation aids, avoidance of inappropriate drugs for elderly patients, adequate analgesia, early mobilization, short fasting times, and a perioperative nutrition plan. Preexisting cognitive impairment predisposes to postoperative delirium (odds ratios [OR] ranging from 2.5 to 4.5). Frailty is the most important predictor of the postoperative course (OR: 2.6-11). It follows that preoperative assessment of the patient's functional and cognitive status is essential. CONCLUZION The evidence-based and guideline-consistent care of elderly patients requires not only close interdisciplinary, interprofessional, and cross-sectoral collaboration, but also the restructuring and optimization of habitual procedural pathways in the hospital. Elderly patients' special needs can only be met by a treatment concept in which the entire perioperative phase is considered as a single, coherent process.
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Affiliation(s)
- Cynthia Olotu
- Department of Intensive Care Medicine, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf (UKE)
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery Klinikum St. Georg, Leipzig
| | - Christian Bahrs
- Clinic for Trauma and Reconstructive Surgery, BG Hospital, Tübingen
| | - Wolfgang Schwenk
- Department of General-, Visceral- and Vascular Surgery, Städtisches Klinikum Solingen gGmbH
| | - Martin Scherer
- Department of General Practice / Primary Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE)
| | - Rainer Kiefmann
- Department of Anesthesiology and Intensive Care Medicine, Rotkreuzklinikum München
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Nguyen AD, Lam A, Banakh I, Lam S, Crofts T. Improved Medication Management With Introduction of a Perioperative and Prescribing Pharmacist Service. J Pharm Pract 2018; 33:299-305. [PMID: 30296875 DOI: 10.1177/0897190018804961] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The medication lists in pre-admission clinic (PAC) questionnaires completed by patients prior to surgery are often inaccurate, potentially leading to medication errors during hospitalization. Studies have shown pharmacists are more accurate when obtaining a medication history and transcribing prescription orders, thereby reducing errors. OBJECTIVE To evaluate the impact of a PeRiopErative and Prescribing (PREP) pharmacist on postoperative medication management. METHODS A randomized prospective interventional study enrolled elective surgery patients at high risk for medication misadventure to receive PREP pharmacy service or usual care (control group). A best possible medication history (BPMH) was obtained by the PREP pharmacist and was available to surgical staff on admission. The PREP pharmacist also prepared discharge prescriptions for their patients. The primary outcomes for the study were accuracy of BPMH and discharge prescriptions compared to usual care. The study was powered to 80% with 2-tailed significance α of .05. RESULTS The medication history in the PREP pharmacist group had fewer errors than the control group: 9% (5/53) versus 96% (49/51; P < .001). Discharge prescriptions prepared by the PREP pharmacist had fewer errors than control group: 25% versus 78% (P < .001). Significantly, more PREP pharmacist patients received a discharge summary with a complete medication list: 75% versus 33% (P = .001). Inpatient prescribing was more accurate in the PREP pharmacist patients: 0.64 versus 1.31 errors per patient (P = .047). CONCLUSION Inclusion of the PREP pharmacist role in the elective surgery multidisciplinary team improved the accuracy of medication histories, inpatient prescribing, and discharge prescriptions for patients at high risk of medication misadventure.
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Affiliation(s)
- Anny D Nguyen
- Pharmacy Department, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia
| | - Alice Lam
- Pharmacy Department, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia
| | - Iouri Banakh
- Pharmacy Department, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia
| | - Skip Lam
- Pharmacy Department, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia
| | - Tyron Crofts
- Department of Anaesthesia, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia
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Tran T, Taylor SE, Hardidge A, Mitri E, Aminian P, George J, Elliott RA. The Prevalence and Nature of Medication Errors and Adverse Events Related to Preadmission Medications When Patients Are Admitted to an Orthopedic Inpatient Unit: An Observational Study. Ann Pharmacother 2018; 53:252-260. [DOI: 10.1177/1060028018802472] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Medication errors commonly occur when patients move from the community into hospital. Whereas medication reconciliation by pharmacists can detect errors, delays in undertaking this can increase the risk that patients receive incorrect admission medication regimens. Orthopedic patients are an at-risk group because they are often elderly and use multiple medications. Objective: To evaluate the prevalence and nature of medication errors when patients are admitted to an orthopedic unit where pharmacists routinely undertake postprescribing medication reconciliation. Methods: A 10-week retrospective observational study was conducted at a major metropolitan hospital in Australia. Medication records of orthopedic inpatients were evaluated to determine the number of prescribing and administration errors associated with patients’ preadmission medications and the number of related adverse events that occurred within 72 hours of admission. Results: Preadmission, 198 patients were taking at least 1 regular medication, of whom 176 (88.9%) experienced at least 1 medication error. The median number of errors per patient was 6 (interquartile range 3-10). Unintended omission of a preadmission medication was the most common prescribing error (87.4%). There were 17 adverse events involving 24 medications in 16 (8.1%) patients that were potentially related to medication errors; 6 events were deemed moderate consequence (moderate injury or harm, increased length of stay, or cancelled/delayed treatment), and the remainder were minor. Conclusion and Relevance: Medication errors were common when orthopedic patients were admitted to hospital, despite postprescribing pharmacist medication reconciliation. Some of these errors led to patient harm. Interventions that ensure that medications are prescribed correctly at admission are required.
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Affiliation(s)
- Tim Tran
- Austin Health, Heidelberg, VIC, Australia
- Monash University, Parkville, VIC, Australia
| | | | | | | | | | | | - Rohan A. Elliott
- Austin Health, Heidelberg, VIC, Australia
- Monash University, Parkville, VIC, Australia
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Matoses-Chirivella C, Navarro-Ruíz A, Lumbreras B. Development and validation of a guide for the continuity of care in perioperative medication management. J Orthop Traumatol 2018; 19:4. [PMID: 30146665 PMCID: PMC6110309 DOI: 10.1186/s10195-018-0490-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 03/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increased longevity and the prevalence of associated pathologies is leading to more hospital admissions involving chronic patients with multiple pathological problems. In orthopedic surgical patients, it is very important to individually evaluate the risk/benefit of maintaining or suppressing chronic medications. For certain medications, there are consensus recommendations, but for others, the available information may be limited or controversial. OBJECTIVE To develop and validate a new guide for the continuity of care in perioperative medication management in older orthopedic surgical patients. MATERIALS AND METHODS An expert pharmacist developed the guide by systematically reviewing each medication category according to the Anatomical Therapeutic Chemical (ATC) classification system. The Pharmacy and Therapeutics Committee at the Hospital General Universitario de Elche reviewed the guide. After a training course on the guide for pharmacists, the guide was validated by studying the interobserver variability between pharmacists as well as between each pharmacist and the expert pharmacist. Cohen's kappa index (κ) was applied to determine interrater reliability. RESULTS The guide includes 51 therapeutic groups. Each ATC pharmacological subgroup is structured according to the benefits and risks of continuing therapy. When we compared each pharmacist's recommendations with those of the expert pharmacist, the kappa value was found to be 0.8 [95% CI (0.7, 0.9)], indicating almost perfect concordance (overall percentage agreement 89.3%). CONCLUSIONS We developed a guide for the continuity of care in perioperative medication management to improve the rationalization of medicines in the perioperative environment. After the pharmacists had been trained, the guide was validated by demonstrating a high level of concordance among the pharmacists' recommendations. Formal training seems to be essential to ensure consistency in medical decisions. LEVEL OF EVIDENCE IV (Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 ).
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Affiliation(s)
- Carmen Matoses-Chirivella
- Department of Pharmacy Services, University Hospital of Elche, Camino de la Almazara 11, 03203, Elche, Spain.
| | - Andrés Navarro-Ruíz
- Department of Pharmacy Services, University Hospital of Elche, Camino de la Almazara 11, 03203, Elche, Spain
| | - Blanca Lumbreras
- Department of Public Health, History of Science and Gynecology, Miguel Hernández University, Alicante, Spain.,CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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Wong D, Tsai PNW, Ip KY, Irwin MG. New antihypertensive medications and clinical implications. Best Pract Res Clin Anaesthesiol 2018; 32:223-235. [PMID: 30322462 DOI: 10.1016/j.bpa.2018.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 01/28/2023]
Abstract
Hypertension remains a global public health issue and is a leading preventable risk factor for many causes of mortality and morbidity. Although it is generally managed as an outpatient chronic disease, anaesthetists will inevitably encounter patients with hypertension, ranging from undiagnosed asymptomatic to chronic forms with end-organ damage(s). An understanding of perioperative management of anti-hypertensive pharmacotherapy is crucial. Although many drugs are familiar, new drug groups that have relevance for blood pressure control and perioperative care have evolved in recent years. This article also describes new antihypertensive agents currently available or under development that could impact perioperative management.
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Affiliation(s)
- D Wong
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China.
| | - P N W Tsai
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong Special Administrative Region, China.
| | - K Y Ip
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China.
| | - M G Irwin
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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Post-procedural Care in Interventional Radiology: What Every Interventional Radiologist Should Know-Part I: Standard Post-procedural Instructions and Follow-Up Care. Cardiovasc Intervent Radiol 2017; 40:481-495. [PMID: 28078378 DOI: 10.1007/s00270-017-1564-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 12/31/2016] [Indexed: 02/08/2023]
Abstract
Interventional radiology (IR) has evolved into a full-fledged clinical specialty with attendant patient care responsibilities. Success in IR now requires development of a full clinical practice, including consultations, inpatient admitting privileges, and an outpatient clinic. In addition to technical excellence and innovation, maintaining a comprehensive practice is imperative for interventional radiologists to compete successfully for patients and referral bases. A structured approach to periprocedural care, including routine follow-up and early identification and management of complications, facilitates efficient and thorough management with an emphasis on quality and patient safety.
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Neupane I, Arora RC, Rudolph JL. Cardiac surgery as a stressor and the response of the vulnerable older adult. Exp Gerontol 2017; 87:168-174. [PMID: 27125757 PMCID: PMC5081280 DOI: 10.1016/j.exger.2016.04.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 12/21/2022]
Abstract
In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including "cardiac surgery, frailty, and aged" in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes.
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Affiliation(s)
- Iva Neupane
- Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, RI, United States; Warren Alpert School of Medicine at Brown University, Providence, RI, United States
| | - Rakesh C Arora
- University of Manitoba, College of Medicine, Department of Surgery, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, RI, United States; Warren Alpert School of Medicine at Brown University, Providence, RI, United States.
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A cross-sectional study of preoperative medication adherence and early postoperative recovery. J Clin Anesth 2016; 35:129-135. [PMID: 27871509 DOI: 10.1016/j.jclinane.2016.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 06/17/2016] [Accepted: 07/06/2016] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To quantify the impact of preoperative medication adherence on recovery length of stays and complication rates. DESIGN Cross-sectional analytical study. SETTING Postanesthetic care unit (PACU) of a single-center tertiary hospital. PATIENTS Surgical patients admitted for surgery at our institution over a 4-month period. INTERVENTION A data collection tool was used to collect demographic data, length of stay in recovery, prespecified conditions likely to impact on PACU recovery (chronic pain, insulin-dependent diabetes, epilepsy, hypertension, on a methadone program, and Parkinson disease), medication compliance, and complications in PACU. MEASUREMENTS Differences among categorical variables were assessed for significance using the χ2 test; continuous parametric data were compared using a time to survival analysis via Kaplan-Meier estimates and Cox proportional hazard regressions to account for possible confounders. MAIN RESULTS Preoperative medication compliance for the prespecified conditions was 65.1%. Patients with a preoperative condition spent more time in the PACU compared to patients without a preoperative condition. Time in PACU was not significantly longer for patients who took their medications compared to those who failed to take their medications. Patients with multiple prespecified conditions were more likely to incur a postoperative complication compared to patients without a prespecified condition. Patients with preoperative hypertension and insulin-dependent diabetes incurred higher complication rates in PACU for medication nonadherence compared to medication adherence. CONCLUSION This study taken together with accruing evidence suggests that preoperative medication omission remains an ongoing issue that can influence complication rates in the PACU. Patients with preoperative conditions stay longer in PACU, and medication omission was associated with higher rates of certain postoperative complications in PACU. This identifies patients likely to require more interventions and greater recovery resources. Further research into the impact of medication omission on recovery parameters after discharge from the PACU is warranted.
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Jeong YM, Lee E, Kim KI, Chung JE, In Park H, Lee BK, Gwak HS. Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment. BMC Geriatr 2016; 16:134. [PMID: 27388509 PMCID: PMC4937600 DOI: 10.1186/s12877-016-0311-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/22/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Older patients undergoing surgery tend to have a higher frequency of delirium. Delirium is strongly associated with poor surgical outcomes. This study evaluated the association between pre-operative medication use and post-operative delirium (POD) in surgical oncology patients receiving comprehensive geriatric assessment (CGA). METHODS A total of 475 patients who were scheduled for cancer surgery and received CGA from January 2014 to June 2015 were included. Pre-operative medication review through CGA was conducted on polypharmacy (≥5 medications), delirium-inducing medications (DIMs), fall-inducing medications (FIMs), and potentially inappropriate medications (PIMs). POD was confirmed by psychiatric consultation, and DSM-V criteria were used for diagnosing delirium. The model fit of the prediction model was assessed by computing the Hosmer-Lemeshow goodness-of-fit test. Effect size was measured using the Nagelkerke R(2). Discrimination of the model was assessed by an analysis of the area under receiver operating curve (AUROC). RESULTS Two models were constructed for multivariate analysis based on univariate analysis; model I included dementia and DIM in addition to age and sex, and model II included PIM instead of DIM of model I. Every one year increase of age increased the risk of POD by about 1.1-fold. DIM was a significant factor for POD after adjusting for confounders (AOR 12.78, 95 % CI 2.83-57.74). PIM was also a significant factor for POD (AOR 5.53, 95 % CI 2.03-15.05). The Hosmer-Lemeshow test results revealed good fits for both models (χ(2) = 3.842, p = 0.871 for model I and χ(2) = 8.130, p = 0.421 for model II). The Nagelkerke R(2) effect size and AUROC for model I was 0.215 and 0.833, respectively. Model II had the Nagelkerke R(2)effect size of 0.174 and AUROC of 0.819. CONCLUSIONS These results suggest that pharmacists' comprehensive review for pre-operative medication use is critical for the post-operative outcomes like delirium in older patients.
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Affiliation(s)
- Young Mi Jeong
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea.,Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Jee Eun Chung
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Hae In Park
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Byung Koo Lee
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea.
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González-García L, Salmerón-García A, García-Lirola M, Moya-Roldán S, Belda-Rustarazo S, Cabeza-Barrera J. Medication reconciliation at admission to surgical departments. J Eval Clin Pract 2016; 22:20-25. [PMID: 26083630 DOI: 10.1111/jep.12403] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2015] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES We aim to determine the prevalence of reconciliation errors (REs) at admission to surgery departments, report their potential clinical impact and analyse possible risk factors. METHODS Prospective observational study was conducted for 8 months in a regional public hospital in Spain. The study included patients consecutively hospitalized in the Department of Orthopedic Surgery and Traumatology or Department of Angiology and Vascular Surgery from May through December 2010. At 24-48 hours after hospital admission, the pre-admission pharmacological treatment of patients was compared with the medication received in hospital to identify REs, which were classified by type and potential severity. Multivariate logistic regression analysis was conducted with the presence of RE as dependent variable. RESULTS The study included 176 patients, 60.8% of whom were aged >65 years and consumed a mean of 5.55 (±4.33) drugs. 55.1% had ≥1 RE, with a mean of 3.21 REs per patient [95% confidence interval (CI; 2.72-3.70)]. The most frequent RE was drug omission (84.1%). No clinical risk was posed by 50.5% of the REs. Multivariate analysis evidenced fourfold higher risk of an RE in patients admitted for elective versus emergency surgery and a 1.35-fold higher risk in patients receiving a larger number of drugs. CONCLUSIONS There was a high prevalence of REs among patients admitted to the surgical departments, most frequently the omission of a drug. The risk of an RE was higher in patients admitted for elective versus emergency surgery, as well as with the receipt of a larger number of drugs before admission.
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Affiliation(s)
- Lorena González-García
- Pharmaceutical Care Research Group, University of Granada and Hospital Pharmacy Unit, Biohealth Research Institute of Granada (ibs. GRANADA), University Hospital Complex, Granada, Spain
| | - Antonio Salmerón-García
- Hospital Pharmacy Unit, Biohealth Research Institute of Granada (ibs.GRANADA), University Hospital Complex, Granada, Spain
| | - MªAngeles García-Lirola
- Pharmacy Unit, Biohealth Research Institute of Granada (ibs.GRANADA), Granada-Metropolitano Health District, Granada, Spain
| | | | - Susana Belda-Rustarazo
- Hospital Pharmacy Unit, Biohealth Research Institute of Granada (ibs.GRANADA), University Hospital Complex, Granada, Spain
| | - José Cabeza-Barrera
- Hospital Pharmacy Unit, Biohealth Research Institute of Granada (ibs.GRANADA), University Hospital Complex, Granada, Spain
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Fujita T. Feasibility of Angiotensin Inhibition for Obese Trauma Patients. J Am Coll Surg 2015; 221:1094-6. [PMID: 26611802 DOI: 10.1016/j.jamcollsurg.2015.08.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/25/2015] [Indexed: 11/29/2022]
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Chao CT, Tsai HB, Wu CY, Lin YF, Hsu NC, Chen JS, Hung KY. Cumulative Cardiovascular Polypharmacy Is Associated With the Risk of Acute Kidney Injury in Elderly Patients. Medicine (Baltimore) 2015; 94:e1251. [PMID: 26252287 PMCID: PMC4616610 DOI: 10.1097/md.0000000000001251] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Polypharmacy is common in the elderly due to multimorbidity and interventions. However, the temporal association between polypharmacy and renal outcomes is rarely addressed and recognized. We investigated the association between cardiovascular (CV) polypharmacy and the risk of acute kidney injury (AKI) in elderly patients.We used the Taiwan National Health Insurance PharmaCloud system to investigate the relationship between cumulative CV medications in the 3 months before admission and risk of AKI in the elderly at their admission to general medical wards in a single center. Community-dwelling elderly patients (>60 years) were prospectively enrolled and classified according to the number of preadmission CV medications. CV polypharmacy was defined as use of 2 or more CV medications.We enrolled 152 patients, 48% with AKI (based upon Kidney Disease Improving Global Outcomes [KDIGO] classification) and 64% with CV polypharmacy. The incidence of AKI was higher in patients taking more CV medications (0 drugs: 33%; 1 drug: 50%; 2 drugs: 57%; 3 or more drugs: 60%; P = 0.05) before admission. Patients with higher KDIGO grades also took more preadmission CV medications (P = 0.04). Multiple regression analysis showed that patients who used 1 or more CV medications before admission had increased risk of AKI at admission (1 drug: odds ratio [OR] = 1.63, P = 0.2; 2 drugs: OR = 4.74, P = 0.03; 3 or more drugs: OR = 5.92, P = 0.02), and that CV polypharmacy is associated with higher risk of AKI (OR 2.58; P = 0.02). Each additional CV medication increased the risk for AKI by 30%.We found that elderly patients taking more CV medications are associated with risk of adverse renal events. Further study to evaluate whether interventions that reduce polypharmacy could reduce the incidence of geriatric AKI is urgently needed.
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Affiliation(s)
- Chia-Ter Chao
- From the Department of Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan (C-TC); Graduate Institute of Toxicology (C-TC) and Nursing, National Taiwan University, Taipei, Taiwan (C-YW); and Department of Traumatology (H-BT, Y-FL, N-CH, J-SC) and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (K-YH)
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Effect of a ward-based pharmacy team on preventable adverse drug events in surgical patients (SUREPILL study). Br J Surg 2015; 102:1204-12. [DOI: 10.1002/bjs.9876] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/25/2015] [Accepted: 05/18/2015] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Surgical patients are at risk of adverse drug events (ADEs) causing morbidity and mortality. Much harm is preventable. Ward-based pharmacy interventions to reduce medication-related harm have not been evaluated in surgical patients.
Methods
This multicentre prospective clinical trial evaluated a protocolled, ward-based pharmacy method compared with standard pharmaceutical care in surgical patients. Allocation of study group was done by one-time randomization at ward level. Consecutive patients admitted for elective surgery with an expected hospital stay longer than 48 h were included. Pharmacy practitioners performed bedside medication reconciliation at admission and discharge, and hospital pharmacists undertook regular medication reviews in the study wards. Preventable ADEs and clinical outcomes were assessed.
Results
A total of 1094 surgical patients were studied. Some 880 specific interventions were made by the hospital pharmacist to improve pharmacotherapy in 309 of 547 patients on study wards. A further 547 patients were included on control wards. A crude non-significant reduction in incidence of preventable ADEs was seen on intervention wards in comparison with control wards (2·74 versus 3·84 preventable ADEs per 100 admissions; incidence rate ratio 0·71, 95 per cent c.i. 0·37 to 1·39; P = 0·324). After adjustment for differences in treatment groups and for potential confounding, the incidence rate ratio remained non-significant (0·82, 0·39 to 1·72; P = 0·598). No differences were seen for other outcomes, such as duration of hospital stay, number of complications and quality of life.
Conclusion
The present prospective controlled trial showed no significant reduction in medication-related harm or changes in clinical outcomes when surgical patients received protocolled ward-based pharmacy interventions.
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To TP, Story DA, Booth J, Nielsen F, Heland M, Hardidge A. Oral Medication Administration in Patients with Restrictions on Oral Intake-A Snapshot Survey. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2013.tb00249.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- The-Phung To
- Quality Use of Medicines Pharmacist, Austin Health
| | - David A Story
- Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School; The University of Melbourne
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Boeker EB, de Boer M, Ramrattan MA, van Lent-Evers N, Gombert-Handoko KB, Lie-A-Huen L, Boermeester MA, Kuks PFM. Development and Implementation of a Ward-Based Pharmacy Intervention for Dutch Surgical Patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2013.tb00214.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Paul FM Kuks
- Hospital Pharmacist; Academic Medical Center; Amsterdam The Netherlands
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Booth JC, Garrett MK, Taylor SE, Trajceska L. Establishing Clinical Pharmacy Services in the Operating Suite. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2012.tb00192.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Ljubica Trajceska
- Pharmacist for The Surgery Centre, Austin Health; Heidelberg Victoria
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Boeker EB, Ram K, Klopotowska JE, de Boer M, Creus MT, de Andrés AL, Sakuma M, Morimoto T, Boermeester MA, Dijkgraaf MGW. An individual patient data meta-analysis on factors associated with adverse drug events in surgical and non-surgical inpatients. Br J Clin Pharmacol 2015; 79:548-57. [PMID: 25199645 PMCID: PMC4386940 DOI: 10.1111/bcp.12504] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 09/02/2014] [Indexed: 11/30/2022] Open
Abstract
AIM The incidence of adverse drug events (ADEs) in surgical and non-surgical patients may differ. This individual patient data meta-analysis (IPDMA) identifies patient characteristics and types of medication most associated with patients experiencing ADEs and suggests target areas for reducing harm and implementing focused interventions. METHODS Authors of eligible studies on preventable ADEs (pADEs) were approached for collaboration. For assessment of differences among (non-)surgical patients and identification of associated factors descriptive statistics, Pearson chi-square, Poisson and logistic regression analyses were performed. For identification of high risk drugs (HRDs), a model was developed based on frequency, severity and preventability of medication related to ADEs. RESULTS Included were 5367 patients from four studies. Patients aged ≥ 77 years experienced more ADEs and pADEs compared with patients aged ≤ 52 years (odds ratios (OR) 2.12 (95% CI 1.70, 2.65) and 2.55 (95% CI 1.70, 3.84), respectively, both P < 0.05). Polypharmacy on admission also increased the risk of ADEs (OR 1.21 (95% CI 1.03, 1.44), P < 0.05) and pADEs (OR 1.85 (95% CI 1.34, 2.56), P < 0.05). pADEs were associated with more severe harm than non-preventable ADEs (54% vs. 32%, P < 0.05). The top five HRDs were antibiotics, sedatives, anticoagulants, diuretics and antihypertensives. Events associated with HRDs included diarrhoea or constipation, abnormal liver function test and central nervous system events. Most pADEs resulted from prescribing errors (90%). CONCLUSION Elderly patients with polypharmacy on admission and receiving antibiotics, sedatives, anticoagulants, diuretics or antihypertensives were more prone to experiencing ADEs. Efficiency in prevention of ADEs may be improved by targeted vigilance systems for alertness of physicians and pharmacists.
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Affiliation(s)
- Eveline B Boeker
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Rafiei M, Pieczkiewicz D, Khairat S, Westra BL, Adam T. Systemized Nomenclature of Medicine Clinical Terms for the structured expression of perioperative medication management recommendations. Am J Health Syst Pharm 2014; 71:2020-7. [PMID: 25404593 DOI: 10.2146/ajhp130593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mehrdad Rafiei
- Institute for Health InformaticsUniversity of MinnesotaMinneapolis, MN
| | | | - Saif Khairat
- Institute for Health InformaticsUniversity of MinnesotaMinneapolis, MN
| | - Bonnie L Westra
- Institute for Health Informatics and School of NursingUniversity of Minnesota
| | - Terrence Adam
- Institute for Health Informatics and College of PharmacyUniversity of Minnesota
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