1
|
Drennan JC, Sheehan TO, Schroeder T, Haller JT. Implementation of a Nurse-Initiated Protocol to Improve Enteral Medication Administration Documentation in Stroke Patients. J Neurosci Nurs 2024:01376517-990000000-00108. [PMID: 39231433 DOI: 10.1097/jnn.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
ABSTRACT BACKGROUND: Medication documentation falls under the "7 rights" of medication administration, but strategies to prevent medication administration documentation errors (MADEs) related to route of administration are underreported in the literature. This study aimed to report the outcomes of a nurse-initiated protocol designed to prevent MADEs and align both actual and documented medication administration routes in hospitalized stroke patients with feeding tubes (FTs). METHODS: This was a retrospective descriptive study conducted at a Comprehensive Stroke Center and large academic medical center in the Western United States. Adults admitted with the diagnosis of stroke between February 2022 and August 2023, who had an FT on arrival, or placed during admission, and received at least 1 enteral medication ordered for by mouth (PO) administration, were included. The protocol allowed nurses to place a communication order to a pharmacist via the electronic health record, requesting all enteral medications ordered for PO administration be changed to FT administration. RESULTS: There were 481 patients included with a median age of 68 years (interquartile range, 58-76 years). The nurse-initiated protocol was used in 170 patients (35.3%), with 99 patients (58.2%) having all enteral medication orders converted completely by a pharmacist. Of the 170 patients in which the protocol was initiated, 145 (85.3%) had all scheduled enteral medication orders converted. For the 71 patients who did not have all enteral medication orders converted completely, the median number of potential MADEs was 2 (1-4.5). CONCLUSION: A nurse-initiated protocol designed to prevent MADEs and improve the accuracy of actual and documented route of medication administration for patients hospitalized for stroke with FTs had modest use. The nurse-initiated protocol in this study is the first of its kind and may help guide further research on preventing and reducing MADEs.
Collapse
|
2
|
Kir F, Al-Sulaiti FK, Sahin S. Evaluation of in vitro dissolution profiles of modified-release metoprolol succinate tablets crushed using mortar and pestle technique. Eur J Pharm Sci 2024; 194:106694. [PMID: 38191064 DOI: 10.1016/j.ejps.2024.106694] [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: 05/19/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
PURPOSE Clinical practice guidelines advise against crushing modified-release dosage forms. Metoprolol succinate modified-release (MS-MR) tablets are commonly crushed in clinical practice to facilitate administration to patients with swallowing difficulties or using feeding tubes. To date, the effect of this practice remains unexplored. The in vitro effects of crushing commercially available MS-MR tablets were explored using a holistic approach. METHODS Dissolution profiles of crushed versus whole MS-MR tablets were compared. Tablets were crushed to powder state using pragmatic method mimicking hospital practices. For standardization purposes, the same operator, duration (60 seconds), hand, and mortar-pestle apparatus were used. Dissolution studies were conducted per U.S. Pharmacopeia at pH 1.2, pH 4.5, and pH 6.8 with USP apparatus 2 (paddle) at rotation speed of 50 rpm at 37±0.5 °C in 500 mL dissolution media. Samples were withdrawn at predetermined time points. Percent drug dissolved was measured by validated UV-vis Spectrophotometry. Comprehensive analysis of the dissolution data was conducted using model-independent, model-dependent, and ANOVA-based approaches (SPSS v.23 at α=0.05). Similarity (f2) and difference (f1) factors were calculated to compare the dissolution profiles between crushed (CT) and whole tablets (WT). Goodness of fit (GOF) analysis examined the compliance between in vitro dissolution behaviors and several drug release models. Model selection was based on GOF plots, Akaike criteria and adjusted coefficient of determination (R2adj). Imaging and particle size distribution analysis were conducted to examine associated surface and morphologic changes. RESULTS The dissolution profiles were not similar at pH 4.5 (f2=45.43, f1=18.97) and pH 6.8 (f2=31.47, f1=32.94). CT best fitted with Higuchi (pH 1.2: R2adj=0.9990), Weibull (pH 4.5: R2adj=0.9884), and Korsmeyer-Peppas (pH 6.8: R2adj=0.9719). Contrastingly, WT best fitted with Hopfenberg (pH 1.2: R2adj=0.9986), logistic (pH 4.5: R2adj=0.9839) and first-order (pH 6.8: R2adj=0.9979) models. A significant difference in the dissolution profiles was found between CT and WT using multivariate analysis of variance per time points and between the tablet forms (p=0.004). This was confirmed by unparalleled dissolution profiles. Crushing resulted in variations in particle size and surface morphological changes to the micropellets. CONCLUSION Crushing practices change the dissolution profile of MS-MR tablets by deforming the surface morphology of embedded micropellets. Amounts of drug dissolved between CT and WT were not the same at the compared time points across gastrointestinal pH ranges. This suggests potential clinical impact on plasma-concentration profiles of critically ill patients using feeding tube.
Collapse
Affiliation(s)
- Fatma Kir
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - Fatima K Al-Sulaiti
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - Selma Sahin
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey.
| |
Collapse
|
3
|
Teder K, Karjagin J, Antoniak KM, Saar M, Volmer D. Development of an Administration Guideline of Oral Medicines to Patients with Dysphagia. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1913. [PMID: 38003962 PMCID: PMC10673523 DOI: 10.3390/medicina59111913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/18/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: There is increasing evidence that patients with dysphagia often have limited access to suitable oral dosage forms, especially when administered via an enteral feeding tube (FT). In addition, there is a lack of clear and readily available information from drug manufacturers on how to administer medications to patients with dysphagia. This study aimed to develop a practical guide for healthcare professionals to increase the safe and effective administration of oral medications to patients with dysphagia. Materials and Methods: The data were collected from existing English databases and handbooks available to develop an easy-to-use tabular guideline presenting all relevant information using keywords and short expressions. The working group differentiated 514 formulation types, and the information was collected and added to the guideline separately. In addition, the instructions for the patients taking the medicines orally or via FT were described separately. Results: The guideline consisted of 24 keywords or short expressions developed by the working group and described the instructions to use them. The guideline contained 343 active pharmaceutical ingredients and 19 fixed-dose combinations. Conclusions: Knowledge about proper medication preparation and administration for patients with swallowing difficulties is limited but essential. It is crucial to encourage drug manufacturers to provide this information as a standard to ensure the safe and effective use of medications for all patient groups.
Collapse
Affiliation(s)
- Kersti Teder
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
- Pharmacy Department, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
| | - Juri Karjagin
- Institute of Clinical Medicine, University of Tartu, L. Puusepa 8, 50406 Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
| | - Kairi Marlen Antoniak
- Pharmacy Department, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
- Pharmacy Department, East-Tallinn Central Hospital, Ravi 18, 10138 Tallinn, Estonia
| | - Marika Saar
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
- Pharmacy Department, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
| | - Daisy Volmer
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
| |
Collapse
|
4
|
Dickerson RN, Bingham AL, Canada TW, Chan LN, Cober MP, Cogle SV, Tucker AM, Kumpf VJ. Significant Published Articles in 2021 for Pharmacy Nutrition Support Practice. Hosp Pharm 2022; 57:673-680. [PMID: 36081538 PMCID: PMC9445547 DOI: 10.1177/00185787221095765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2021 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 211 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 18 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
Collapse
Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
| | | | - Todd W. Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sarah V. Cogle
- Auburn University – Harrison School of Pharmacy, Auburn, AL, USA
| | - Anne M. Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | |
Collapse
|
5
|
Zuccari G, Macis S, Alfei S, Marchitto L, Russo E. The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients. J Pers Med 2022; 12:jpm12081307. [PMID: 36013259 PMCID: PMC9410388 DOI: 10.3390/jpm12081307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Usually, the administration of drugs by feeding tube in dysphagic patients involves handling of marketing licenses outside their term, due to the lack of suitable formulations. This circumstance has put health professionals in the dilemma of choosing the formulation whose manipulation possibly does not alter the effectiveness of the drug. In this regard, a practical guide providing indications on the prescription, handling, and administration of drugs through enteral feeding tube could be of paramount utility. For this purpose, we have considered the 1047 solid oral pharmaceutical forms included in the formulary of San Paolo Hospital (Savona, Italy). From our analysis, it emerges that 95% of medicinal products are worryingly used off-label and 40% have to be managed by the hospital pharmacists without having suitable indications by either the manufacturers or by literature studies. To fill this gap, we have compiled a detailed table containing missing indications derived from pharmacist expertise and evidence-based practices, with the aim that the sharing of our procedures will contribute to make uniform pharmacological therapies from one hospital to another. This study will allow doctors to have easy access to information on drugs that can be prescribed and nurses to become familiar only with the pharmaceutical forms that can be administered.
Collapse
Affiliation(s)
- Guendalina Zuccari
- Department of Pharmacy, University of Genoa, Viale Cembrano, 16148 Genoa, Italy
- Correspondence: (G.Z.); (E.R.)
| | - Sara Macis
- Hospital Pharmacy, Department Technical Health, San Paolo Hospital, Via Genova, 17100 Savona, Italy
| | - Silvana Alfei
- Department of Pharmacy, University of Genoa, Viale Cembrano, 16148 Genoa, Italy
| | - Leonardo Marchitto
- Department of Sciences for the Quality of Life, University of Bologna, Corso D’Augusto 237, 47921 Rimini, Italy
| | - Eleonora Russo
- Department of Pharmacy, University of Genoa, Viale Cembrano, 16148 Genoa, Italy
- Correspondence: (G.Z.); (E.R.)
| |
Collapse
|
6
|
Defining Potentially Inappropriate Prescriptions for Hypoglycaemic Agents to Improve Computerised Decision Support: A Study Protocol. Healthcare (Basel) 2021; 9:healthcare9111539. [PMID: 34828585 PMCID: PMC8622925 DOI: 10.3390/healthcare9111539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/05/2021] [Accepted: 11/07/2021] [Indexed: 12/21/2022] Open
Abstract
In France, around 5% of the general population are taking drug treatments for diabetes mellitus (mainly type 2 diabetes mellitus, T2DM). Although the management of T2DM has become more complex, most of these patients are managed by their general practitioner and not a diabetologist for their antidiabetics treatments; this increases the risk of potentially inappropriate prescriptions (PIPs) of hypoglycaemic agents (HAs). Inappropriate prescribing can be assessed by approaches that are implicit (expert judgement based) or explicit (criterion based). In a mixed, multistep process, we first systematically reviewed the published definitions of PIPs for HAs in patients with T2DM. The results will be used to create the first list of explicit definitions. Next, we will complete the definitions identified in the systematic review by conducting a qualitative study with two focus groups of experts in the prescription of HAs. Lastly, a Delphi survey will then be used to build consensus among participants; the results will be validated in consensus meetings. We developed a method for determining explicit definitions of PIPs for HAs in patients with T2DM. The resulting explicit definitions could be easily integrated into computerised decision support tools for the automated detection of PIPs.
Collapse
|
7
|
Teder K, Jõhvik L, Meos A, Saar M, Visbek A, Volmer D, Karjagin J. Solid oral medications' suitability for use in enteral feeding tubes. Nurs Crit Care 2021; 27:698-705. [PMID: 34755443 DOI: 10.1111/nicc.12729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/18/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is a lack of specific data about the efficacy and safety of medications administered via feeding tubes, although there is a general awareness that not all drug formulations are suitable. AIMS AND OBJECTIVES To overview the current situation with solid medications administered through feeding tubes in the Tartu University Hospital intensive care units. To evaluate the availability of information on the suitability of drug formulations for administration via feeding tubes. DESIGN This was a descriptive retrospective document analysis study. METHODS During visits to the intensive care units, medication data for current patients were collected from paper medical charts and nurses. In addition, package information leaflets, summaries of product characteristics, and two practical handbooks were used for evaluating the medicines' suitability for administration via feeding tubes. A request for information was also sent to manufacturers or marketing authorization holders. RESULTS In 3 months, data were collected from 113 intensive care patients' medical charts. A total of 306 medication administrations via feeding tubes were documented and analysed, 67% of which were solid oral dosage forms. Exactly 91.2% of these were conventional tablets. After the analysis of information availability, 88% of the medications were classified as suitable for administration via feeding tubes, but only 48% had the manufacturer-provided information. CONCLUSION This study showed that the information about the suitability of formulations administration through a feeding tube is not readily available for almost half of the medications. The manufacturers seem to have the relevant information, but it is not always added to their medications' official information, putting these patients at higher risk for errors. RELEVANCE TO CLINICAL PRACTICE This study shows that if there is no clear statement about administration through feeding tubes on official manufacturers' information, this should be sought directly from manufacturers or marketing authorization holders, and the data could be incorporated into local guidelines.
Collapse
Affiliation(s)
- Kersti Teder
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Liisa Jõhvik
- Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Andres Meos
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Marika Saar
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Alesya Visbek
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Daisy Volmer
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Juri Karjagin
- Institute of Clinical Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| |
Collapse
|
8
|
Singh H, Cho SJ, Gupta S, Kaur R, Sunidhi S, Saluja S, Pandey AK, Bennett MV, Lee HC, Das R, Palma J, McAdams RM, Kaur A, Yadav G, Sun Y. Designing a bed-side system for predicting length of stay in a neonatal intensive care unit. Sci Rep 2021; 11:3342. [PMID: 33558618 PMCID: PMC7870925 DOI: 10.1038/s41598-021-82957-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 01/20/2021] [Indexed: 11/13/2022] Open
Abstract
Increased length of stay (LOS) in intensive care units is directly associated with the financial burden, anxiety, and increased mortality risks. In the current study, we have incorporated the association of day-to-day nutrition and medication data of the patient during its stay in hospital with its predicted LOS. To demonstrate the same, we developed a model to predict the LOS using risk factors (a) perinatal and antenatal details, (b) deviation of nutrition and medication dosage from guidelines, and (c) clinical diagnoses encountered during NICU stay. Data of 836 patient records (12 months) from two NICU sites were used and validated on 211 patient records (4 months). A bedside user interface integrated with EMR has been designed to display the model performance results on the validation dataset. The study shows that each gestation age group of patients has unique and independent risk factors associated with the LOS. The gestation is a significant risk factor for neonates < 34 weeks, nutrition deviation for < 32 weeks, and clinical diagnosis (sepsis) for ≥ 32 weeks. Patients on medications had considerable extra LOS for ≥ 32 weeks’ gestation. The presented LOS model is tailored for each patient, and deviations from the recommended nutrition and medication guidelines were significantly associated with the predicted LOS.
Collapse
Affiliation(s)
- Harpreet Singh
- Child Health Imprints (CHIL) Pte. Ltd, Singapore, Singapore.
| | - Su Jin Cho
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Shubham Gupta
- Child Health Imprints (CHIL) Pte. Ltd, Singapore, Singapore
| | - Ravneet Kaur
- Child Health Imprints (CHIL) Pte. Ltd, Singapore, Singapore
| | - S Sunidhi
- Child Health Imprints (CHIL) Pte. Ltd, Singapore, Singapore
| | - Satish Saluja
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar Pandey
- Department of Mathematics, Indraprastha Institute of Information Technology, New Delhi, India
| | - Mihoko V Bennett
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA.,California Perinatal Quality Care Collaborative, Stanford, CA, USA
| | - Henry C Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA.,California Perinatal Quality Care Collaborative, Stanford, CA, USA
| | - Ritu Das
- Child Health Imprints (CHIL) Pte. Ltd, Singapore, Singapore
| | - Jonathan Palma
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Avneet Kaur
- Department of Neonatology, Apollo Cradle Hospitals, New Delhi, India
| | - Gautam Yadav
- Department of Pediatrics, Kalawati Hospital, Rewari, India
| | - Yao Sun
- University of California, San Francisco, USA
| |
Collapse
|