A Clinical Practice Agreement Between Pharmacists and Surgeons Streamlines Medication Management

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.

Temporal patterns of hospital readmissions according to disease category for patients after elective colorectal surgery

RATIONALE

The aim of this study was to identify temporal readmission patterns according to baseline disease categories to provide opportunities for targeted interventions.

METHODS

Retrospective analysis of consecutive adult (≥18 years) patients who underwent elective colorectal resections (2011-2017) at Mayo Clinic Rochester, MN. A prospective administrative database including patient demographics, procedure characteristics, discharge information and specifics on 30-day readmissions (to index facility) including timing and reasons was utilized. The ICD-9 codes were regrouped into the main pathologies Cancer, Crohn's disease (CD)/chronic ulcerative colitis (CUC), and diverticular disease.

RESULTS

In total, 521 (7.2%) out of 7245 patients undergoing inpatient colorectal surgery were readmitted. In all increments of time from discharge (0-2 days: 31.3% of all readmissions, 3-7 days: 32.4% of all readmissions, 8-14 days: 18% of all readmissions, and 15-30 days: 18.3% of all readmissions), reasons for readmission differed significantly (all P < 0.001). Across all disease categories, early readmissions (within 2 days of discharge) were most likely due to ileus/obstruction (53.4% of early readmissions), whereas with 42.5%, infection was the most common cause for late readmissions (>7 days). Patients with home discharge were more likely to be readmitted earlier within the 30-day observation period (P = 0.099), whereas patients with a longer length of index hospital stay (>7 days) were readmitted later (P = 0.080).

CONCLUSIONS

Reasons for readmission appear to be universal across different disease categories. Targeted educational and collaborative measures may help to mitigate the burden of hospital readmissions to index facilities.

Assessing the Impact of a Clinical Pharmacist in a Postsurgical Inpatient Population

OBJECTIVE

To quantify the number and type of clinical pharmacist interventions with an impact on patient care in a postsurgical nonintensive care patient population.

BACKGROUND

Studies have shown that pharmacists are able to improve the quality of patient care; however, the pharmacist role in postsurgical nonintensive care areas is not well defined.

METHODS

A clinical pharmacist provided care for 2 postsurgical floors for 2 weeks and collected information about the number and type of interventions made and adverse events avoided. In addition, the study team conducted an anonymous survey amongst the multidisciplinary team who collaborated with the pharmacist at the end of the trial period to understand the perception of having access to a clinical pharmacist who was designated to their floor.

RESULTS

In a 2-week time period, the clinical pharmacist was able to make 218 interventions, including 38 recommendations for optimization of antimicrobials, 26 recommendations for anticoagulation optimization, and providing education for 20 patients planned for discharge on high-risk medications. Interventions made by the clinical pharmacist helped decrease adverse events, improve patient safety and knowledge, and potentially avoid readmissions and reduce hospital length of stay. The survey results revealed that 100% strongly agreed that a clinical pharmacist should be a member of the multidisciplinary team for the postsurgical floors.

CONCLUSION

This data signifies that having a clinical pharmacist dedicated to the postsurgical patient population allows for optimization of antimicrobial and anticoagulant use, improves outcomes for patients through medication education, and enhances provider satisfaction.

Community pharmacists' experience with pharmacogenetic testing

OBJECTIVE

Appendix 1 Statements of knowledge of correct medication use Appendix 2 Statements of self-efficacy of correct medication use Appendix 3 Statements of skills of correct medication use To characterize the experiences and feasibility of offering pharmacogenetic (PGx) testing in a community pharmacy setting.

DESIGN

Pharmacists were invited to complete a survey about PGx testing for each patient who was offered testing. If the patient consented, pharmacists were also asked to complete a follow-up survey about the process of returning PGx testing results to patients and follow-up with the prescribing provider.

SETTING

Community pharmacies in North Carolina from August through November 2014.

PARTICIPANTS

Pharmacists at five community pharmacies.

MAIN OUTCOME MEASURES

Patient consent for testing, time to introduce PGx testing initially and communicate results, interpretation of test results, and recommended medication changes.

RESULTS

Of the 69 patients offered testing, 56 (81%) consented. Pre-test counseling typically lasted 1-5 minutes (81%), and most patients (55%) did not have any questions about the testing. Most pharmacists reported test results to patients by phone (84%), with discussions taking less than 1 minute (48%) or 1-5 minutes (52%). Most pharmacists believed the patients understood their results either very well (54%) or somewhat well (41%). Pharmacists correctly interpreted 47 of the 53 test results (89%). All of the incorrect interpretations were for patients with test results indicating a dosing or drug change (6/19; 32%). Pharmacists reported contacting the ordering physician for four patients to discuss results indicating a dosage or drug change.

CONCLUSION

The provision of PGx services in a community pharmacy setting appears feasible, requiring little additional time from the pharmacist, and many patients seem interested in PGx testing. Additional training may be necessary to improve test result interpretation, as well as for communication with both patients and ordering physicians.

Assessment of surveys for the management of hospital clinical pharmacy services

OBJECTIVE

Survey data sets are important sources of data, and their successful exploitation is of key importance for informed policy decision-making. We present how a survey analysis approach initially developed for customer satisfaction research in marketing can be adapted for an introduction of clinical pharmacy services into a hospital.

METHODS AND MATERIAL

We use a data mining analytical approach to extract relevant managerial consequences. We evaluate the importance of competences for users of a clinical pharmacy with the OrdEval algorithm and determine their nature according to the users' expectations. For this, we need substantially fewer questions than are required by the Kano approach.

RESULTS

From 52 clinical pharmacy activities we were able to identify seven activities with a substantial negative impact (i.e., negative reinforcement) on the overall satisfaction of clinical pharmacy services, and two activities with a strong positive impact (upward reinforcement). Using analysis of individual feature values, we identified six performance, 10 excitement, and one basic clinical pharmacists' activity.

CONCLUSIONS

We show how the OrdEval algorithm can exploit the information hidden in the ordering of class and attribute values, and their inherent correlation using a small sample of highly relevant respondents. The visualization of the outputs turns out highly useful in our clinical pharmacy research case study.

Medication reconciliation for patients undergoing spinal surgery

PURPOSE

In recent years, a marked increase of spinal operations prompted a debate on quality issues. Besides obvious factors, such as the surgical technique, medication safety has been identified as one of the major risk factors for patients undergoing anesthesia and surgery. While the issue has already been addressed by hospital pharmacist and anesthesiologists, the prescription of correct medication remains within the surgeons' responsibility. We, therefore, investigated medication-related errors in spinal instrumentation patients and applied current medication reconciliation strategies.

METHODS

We performed a data survey on all patients undergoing spinal instrumentation in 2011. Risk factors for medication safety were identified and prioritized. Specific counter-measures were introduced in 2012 and evaluated in 2013.

RESULTS

147 patients were included in the 2011 and 162 in the 2013 survey. As top five risk factors we identified the preoperative stopping of medication, recording the medication history, prescription process of postoperative analgetics and anticoagulants and the medication list at discharge. Specific counter-measures included standardization of preparations, doses and the prescription process and improving access to this information (online and via a smartphone application). In elective patients, recording the medication histories was delegated to a hospital pharmacist and informative flyers and posters were used to integrate the patients themselves into the process. Counter-measures directed against the first four risk factors resulted in a significant reduction of medication errors. The last risk factor was targeted by instructing the responsible staff only, which proved to be a rather ineffective measure.

CONCLUSIONS

Medication safety could be significantly improved by implementation of counter-measures specific to the identified risk factors.