Influence of hospitalization on prescribing safety across the continuum of care: an exploratory study

Designing a tool ensuring older patients the right medication at the right time after discharge from hospital- the first step in a participatory design process

BACKGROUND

On average, older patients use five or more medications daily, increasing the risk of adverse drug reactions, interactions, or medication errors. Healthcare sector transitions increase the risk of information loss, misunderstandings, unclear treatment responsibilities, and medication errors. Therefore, it is crucial to identify possible solutions to decrease these risks. Patients, relatives, and healthcare professionals were asked to design the solution they need.

METHODS

We conducted a participatory design approach to collect information from patients, relatives, and healthcare professionals. The informants were asked to design their take on a tool ensuring that patients received the correct medication after discharge from the hospital. We included two patients using five or more medications daily, one relative, three general practitioners, four nurses from different healthcare sectors, two hospital physicians, and three pharmacists.

RESULTS

The patients' solution was a physical location providing a medication overview, including side effects and interactions. Healthcare professionals suggested different solutions, including targeted and timely information that provided an overview of the patient's diagnoses, treatment and medication. The common themes identified across all sub-groups were: (1) Overview of medications, side effects, and diagnoses, (2) Sharing knowledge among healthcare professionals, (3) Timely discharge letters, (4) Does the shared medication record and existing communication platforms provide relevant information to the patient or healthcare professional?

CONCLUSION

All study participants describe the need for a more concise, relevant overview of information. This study describes elements for further elaboration in future participatory design processes aimed at creating a tool to ensure older patients receive the correct medication at the correct time.

[Scoring tool to identify patients at increased risk for drug-related problems: results of a point prevalence study at hospital admission]

INTRODUCTION

Drug therapy is a high-risk process and requires special attention, especially at sectoral borders. Pharmaceutical services such as medication review are appropriate measures to identify drug-related problems and thus improve the safety of drug therapy. Risk-scoring tools have been described in the literature as helpful for prioritizing medication reviews for patients at high risk for drug-related problems.

METHODS

In a multi-centre point prevalence study, we identified patients at increased risk for medication-related problems at hospital admission using the medication risk tool. In addition, the current level of implementation of pharmacy services was surveyed.

RESULTS

A total of 11 (58%; 11/19) hospital pharmacies in Saxony participated in the point prevalence survey. The scoring tool identified 32% (279/875) of patients at increased risk for medication-related problems (Meris score >12 group) at admission. Thereby, the number of drugs in the Meris score >12 group was 10.6 (average; standard deviation 3.5; n=279), while in the Meris score ≤12 group it was only five drugs per patient (average 4.6; standard deviation 2.8; n=596). The age of patients in the Meris score >12 group averaged 75.9 ± 11 years, while the age of patients in the Meris score ≤12 group averaged 60.6 ± 17.9 years.

DISCUSSION

Prioritization with the help of a risk-scoring tool is essential as pharmacy services in Saxon hospitals still need to be regularly established and in order to identify patients with an increased risk for drug-related problems at an early stage.

Handling polypharmacy -a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals

BACKGROUND

On average, older patients use five or more medications daily. A consequence is an increased risk of adverse drug reactions, interactions, or medication errors. Therefore, it is important to understand the challenges experienced by the patients, relatives, and healthcare professionals pertinent to the concomitant use of many drugs.

METHODS

We conducted a qualitative study using focus group interviews to collect information from patients, relatives, and healthcare professionals regarding older patients' management of prescribed medicine. We interviewed seven patients using five or more medications daily, three relatives, three general practitioners, nine nurses from different healthcare sectors, one home care assistant, two hospital physicians, and four pharmacists.

RESULTS

The following themes were identified: (1) Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/pill organizers.

CONCLUSION

Medication is the subject of concern among patients and relatives. They become confused and insecure about information from different actors and the package leaflets. Therefore, patients often request a thorough medication review to provide an overview, knowledge of possible side effects and interactions, and a clarification of the medication's timing. In addition, patients, relatives and nurses all request an indication of when medicine should be taken, including allowable deviations from this timing. Therefore, prescribing physicians should prioritize communicating information regarding these matters when prescribing.

The FORTA (Fit fOR The Aged)-EPI (Epidemiological) Algorithm: Application of an Information Technology Tool for the Epidemiological Assessment of Drug Treatment in Older People

BACKGROUND

To improve drug treatment in older people, who often present with multimorbidity and related polypharmacy, the FORTA (Fit fOR The Aged) List was developed via a Delphi consensus procedure. As a patient-in-focus listing approach (PILA), it has been clinically validated (VALFORTA trial). Unlike drug-oriented listing approaches (DOLAs), its application requires knowledge of patients' characteristics, including diagnoses and other details. As a drug list with discrete labels, application of FORTA seems particularly amenable to electronic support.

METHODS

An information technology (IT) algorithm was developed to analyze bulk data on International Classification of Diseases (ICD)-coded diseases and Anatomical Therapeutic Chemical (ATC)-coded drugs. FORTA-labeled diagnoses and drugs were used to compute the FORTA score, an automatically generated score that describes medication quality by adding up points assigned for errors related to over- and under-treatment. The algorithm detects mismatches between diagnoses and drugs, suboptimal drugs, omitted drugs, and deficient medication escalation schemes. The read-out produces explanations for each error point.

RESULTS

A total of 5603 and 7954 patients ≥ 65 years were included from two claims datasets (> 30,000 patients each, public health insurance). The FORTA scores were comparable (mean ± standard deviation 4.29 ± 3.37 vs. 4.17 ± 3.16), and similar to that determined in VALFORTA (pre-intervention 3.5 ± 2.7). Under-treatment was two times more prevalent than over-treatment. The main areas of under-treatment were pain, type 2 diabetes mellitus, and depression, and the main areas of over-treatment were gastrointestinal (proton pump inhibitors), pain (non-steroidal anti-inflammatory drugs), and arterial hypertension (β-blockers). The FORTA score is positively correlated with higher age, a higher Charlson Comorbidity Index, and more frequent hospitalizations. Patients in disease management programs run by public health insurers had higher scores than comparators.

CONCLUSIONS

The algorithm produces plausible analyses of medication errors in older people, pointing to established areas of therapeutic deficiencies. Though individual recommendations exist, the algorithm cannot employ the full potential of FORTA as important details (e.g., blood pressure values, pain intensity) are not (yet) included. However, it seems capable of detecting medication problems in large cohorts-FORTA-EPI (Epidemiological) is designed to support epidemiological analyses, e.g., on comparisons of large cohorts, interventional impact, or longitudinal trends.

Structure and Content of Drug Monitoring Advices Included in Discharge Letters at Interfaces of Care: Exploratory Analysis Preceding Database Development

BACKGROUND

Inadequate drug monitoring of drug therapy after hospital discharge facilitates adverse drug events and preventable hospital readmissions.

OBJECTIVE

This study aimed to analyze the structure and content of drug monitoring advices of a representative sample of discharge letters as a basis for future electronic information systems.

METHODS

On 2 days in November 2016, all discharge letters of 3 departments of a university hospital were extracted from the hospital information system. The frequency, content, and structure of drug monitoring advices in discharge letters were investigated and compared with the theoretical monitoring requirements expressed in the corresponding summaries of product characteristics (SmPC). The quality of the drug monitoring advices in the discharge letters was rated with the domains of an adapted systematic instructions for monitoring (SIM) score.

RESULTS

In total, 154 discharge letters were analyzed containing 1180 brands (240 active pharmaceutical substances), of which 50.42% (595/1180) could theoretically be amended with a monitoring advice according to the SmPC. In reality, 40 discharge letters (26.0%, 40/154) contained a total of 66 monitoring advices for 57 brands (4.83%, 57/1180), comprising 18 different monitoring parameters. Drug monitoring advices only addressed mean 1.9 (SD 0.8) of the 7 domains of the SIM score and frequently did not address reasons for monitoring (86%, 57/66), the timing of monitoring, that is, the start (76%, 50/66), the frequency (94%, 63/66), the stop (95%, 63/66), and how to react (83%, 55/66).

CONCLUSIONS

Drug monitoring advices were mostly absent in discharge letters and a gold standard for appropriate drug monitoring advices was lacking. Hence, more effort should be put in the development of tools that facilitate easy presentation of clinically meaningful drug monitoring advices at the point of care.

[Medication safety in hospitals : Integration of clinical pharmacists to reduce drug-related problems in the inpatient setting]

Drug-related problems (DRPs) are a significant and often preventable cause for morbidity and mortality. Hospitalization is associated with a high risk for DRPs, especially due to a lack of information transfer at transitions of care. At the same time, interventions during inpatient treatment usually require a change in drug therapy and additionally increase the risk of DRPs. Thereby, DRPs can occur at all levels of the medication process and can be caused by different groups of professionals. One way to improve medication safety in hospitals is to integrate clinical pharmacists into the medication process.According to available data, the integration of a clinical pharmacist in multi-professional teams during admission, hospitalization and discharge can significantly reduce DRPs, costs and increases efficacy of drug therapy. In addition, drug supply with unit-dose systems in combination with digitalization of the medication process can achieve an improvement in medication safety. Improvement in continuity of medical care through a structured medication review and seamless transmission of medically relevant information upon discharge contribute to a significant reduction of hospital readmissions and emergency admissions due to ABPs, as well as health costs. With a university education, the hospital pharmacist specialized in clinical pharmacy is the only professional group that can comprehensively support the physician in the field of drug therapy.

Implications of involving pharmacy technicians in obtaining a best possible medication history from the perspectives of pharmaceutical, medical and nursing staff: a qualitative study

OBJECTIVES

In recent years, the involvement of pharmacy technicians in medication reconciliation has increasingly been investigated. The aim of this study was to assess the implications on professional roles and collaboration when a best possible medication history (BPMH) at admission is obtained by pharmacy technicians.

DESIGN

Qualitative study with semistructured interviews. Data were analysed using a qualitative content analysis approach.

SETTING

Internal medicine units in two mid-sized Swiss hospitals.

PARTICIPANTS

21 staff members working at the two sites (6 pharmacy technicians, 2 pharmacists, 6 nurses, 5 physician residents and 2 senior physicians).

RESULTS

Pharmacy technicians generally appreciated their new tasks in obtaining a BPMH. However, they also experienced challenges associated with their new role. Interviewees reported unease with direct patient interaction and challenges with integrating the new BPMH tasks into their regular daily duties. We found that pharmacists played a key role in the BPMH process, since they act as coaches for pharmacy technicians, transmit information to the physicians and reconcile preadmission medication lists with admission orders. Physicians stated that they benefitted from the delegation of administrative tasks to pharmacy technicians. Regarding the interprofessional collaboration, we found that pharmacy technicians in the study acted on a preliminary administrative level and did not become part of the larger treatment team. There was no direct interaction between pharmacy technicians and physicians, but rather, the supervising pharmacists acted as intermediaries.

CONCLUSION

The tasks assumed by pharmacy technicians need to be clearly defined and fully integrated into existing processes. Engaging pharmacy technicians may generate new patient safety risks and inefficiencies due to process fragmentation. Communication and information flow at the interfaces between professional groups therefore need to be well organised. More research is needed to understand if and under which circumstances such a model can be efficient and contribute to improving medication safety.

Transition of care: A set of pharmaceutical interventions improves hospital discharge prescriptions from an internal medicine ward

BACKGROUND

Continuity of care between hospitals and community pharmacies needs to be improved to ensure medication safety. This study aimed to evaluate whether a set of pharmaceutical interventions to prepare hospital discharge facilitates the transition of care.

METHODS

This study took place in the internal medicine ward and in surrounding community pharmacies. The intervention group's patients underwent a set of pharmaceutical interventions during their hospital stay: medication reconciliation at admission, medication review, and discharge planning. The two groups were compared with regards to: number of community pharmacist interventions, time spent on discharge prescriptions, and number of treatment changes.

RESULTS

Comparison between the groups showed a much lower (77% lower) number of community pharmacist interventions per discharge prescription in the intervention (n=54 patients) compared to the control group (n=64 patients): 6.9 versus 1.6 interventions, respectively (p<0.0001); less time working on discharge prescriptions; less interventions requiring a telephone call to a hospital physician. The number of medication changes at different steps was also significantly lower in the intervention group: 40% fewer (p<0.0001) changes between hospital admission and discharge, 66% fewer (p<0.0001) between hospital discharge and community pharmacy care, and 25% fewer (p=0.002) between community pharmacy care and care by a general practitioner.

CONCLUSION

An intervention group underwent significantly fewer medication changes in subsequent steps in the transition of care after a set of interventions performed during their hospital stay. Community pharmacists had to perform fewer interventions on discharge prescriptions. Altogether, this improves continuity of care.

What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners' experiences in the case of acute kidney injury

OBJECTIVES

To examine the role of individual and collective cognitive work in managing medicines for acute kidney injury (AKI), this being an example of a clinical scenario that crosses the boundaries of care organisations and specialties.

DESIGN

Qualitative design, informed by a realist perspective and using semistructured interviews as the data source. The data were analysed using template analysis.

SETTING

Primary, secondary and intermediate care in England.

PARTICIPANTS

12 General practitioners, 10 community pharmacists, 7 hospital doctors and 7 hospital pharmacists, all with experience of involvement in preventing or treating AKI.

RESULTS

We identified three main themes concerning participants' experiences of managing medicines in AKI. In the first theme, challenges arising from the clinical context, AKI is identified as a technically complex condition to identify and treat, often requiring judgements to be made about renal functioning against the context of the patient's general well-being. In the second theme, challenges arising from the organisational context, the crossing of professional and organisational boundaries is seen to introduce problems for the coordination of clinical activities, for example by disrupting information flows. In the third theme, meeting the challenges, participants identify ways in which they overcome the challenges they face in order to ensure effective medicines management, for example by adapting their work practices and tools.

CONCLUSIONS

These themes indicate the critical role of cognitive work on the part of healthcare practitioners, as individuals and as teams, in ensuring effective medicines management during AKI. Our findings suggest that the capabilities underlying this work, for example decision-making, communication and team coordination, should be the focus of training and work design interventions to improve medicines management for AKI or for other conditions.