Critical pathways: the role of pharmacy today and tomorrow

Clinical impact of an individualised clinical pharmacy programme into the memory care pathway of older people: an observational study

BACKGROUND

In older patients, medication exposure [i.e. polypharmacy, potentially inappropriate medications (PIMs), medications with anticholinergic and/or sedative properties] is a modifiable risk factor associated with cognitive iatrogenic risk and dementia.

AIM

To assess the potential clinical impact of the implementation of an individualised clinical pharmacy programme at the initiation of the Memory care pathway in older patients with a cognitive complaint.

METHOD

This prospective observational study included older patients with high-risk of adverse drug event (HR) admitted in a French geriatric university hospital to explore the cognitive complaint or the cognitive disorder between January and November 2021. Drug-related problems (DRPs) were identified during a medication review performed in HR patients, and pharmaceutical interventions (PIs) notified in the patient's hospitalisation report were collected. The clinical impact of PIs was assessed by an expert panel (geriatricians and clinical pharmacists) using the Clinical, Economic, and Organisational (CLEO) tool.

RESULTS

Overall, 326 patients were eligible and 207 (63.5%) were considered as HR patients. Among HR patients, 88.9% (n = 184) were treated using at least 5 medications (polypharmacy), and 36.7% (n = 76) received at least one PIM with cognitive iatrogenic risk. During the medication review, 490 PIs were provided and their clinical impact was rated as minor for 57.3% (n = 281), moderate for 26.7% (n = 131), and major for 2.5% (n = 12).

CONCLUSION

The integration of clinical pharmacist secured the Memory care pathway of older patients with a cognitive complaint by identifying an important number of DRPs and PIMs with potential cognitive iatrogenic risk.

Building digital patient pathways for the management and treatment of multiple sclerosis

Recent advances in the field of artificial intelligence (AI) could yield new insights into the potential causes of multiple sclerosis (MS) and factors influencing its course as the use of AI opens new possibilities regarding the interpretation and use of big data from not only a cross-sectional, but also a longitudinal perspective. For each patient with MS, there is a vast amount of multimodal data being accumulated over time. But for the application of AI and related technologies, these data need to be available in a machine-readable format and need to be collected in a standardized and structured manner. Through the use of mobile electronic devices and the internet it has also become possible to provide healthcare services from remote and collect information on a patient's state of health outside of regular check-ups on site. Against this background, we argue that the concept of pathways in healthcare now could be applied to structure the collection of information across multiple devices and stakeholders in the virtual sphere, enabling us to exploit the full potential of AI technology by e.g., building digital twins. By going digital and using pathways, we can virtually link patients and their caregivers. Stakeholders then could rely on digital pathways for evidence-based guidance in the sequence of procedures and selection of therapy options based on advanced analytics supported by AI as well as for communication and education purposes. As far as we aware of, however, pathway modelling with respect to MS management and treatment has not been thoroughly investigated yet and still needs to be discussed. In this paper, we thus present our ideas for a modular-integrative framework for the development of digital patient pathways for MS treatment.

Development of clinical pharmacy programs integrated into patient care pathways using adverse event risks

BACKGROUND

In the strained actual economic context, all clinical pharmacy activities cannot be achieved for all patients of all care pathways. So finding a way to prioritize moments and patients needing those activities is essential. This is the challenge of the "5P project" (Patient personalized clinical pharmacy program integrated into care pathway).

OBJECTIVE

To present adverse event (AE) risk management approach applied to develop clinical pharmacy programs integrated into care pathway, using two methods.

METHOD

Used as a priori AE risk management approach, the Delphi method and inductive approach analysis of semi-directed interviews were realized from April 1st to October 3rd^, 2019, respectively in orthogeriatric (OG) and pediatric kidney transplantation (PKT) care pathways. Complementarily to bibliographic research, participants were medical and paramedical healthcare providers involved in the concerned care pathway. They have been interrogated regarding AE risks to identify the clinical pharmacy activities required, the patients who need them, and the appropriate steps of the care pathway.

RESULTS

The Delphi method for OG care pathway has revealed: 1/. Patients were prioritized by the presence of at least 2 among the following 4 criteria: age ≥90 years old, cardiovascular diseases, prescribed potentially inappropriate medication for elderly patients, obesity or diabetes; priority steps were the post-operative and rehabilitation care steps. 2/. Prescription reviews, medication reconciliation and targeted pharmaceutical informative interview about oral anticoagulants were required. Nine semi-directed interviews used for PKT care pathway has revealed: 1/. Clinical pharmacy activities were carried out for all patients. Priority steps were pre-transplantation, immediate post-operative, and post-transplantation. 2/. Prescription reviews and educative interviews were required.

CONCLUSIONS

The two presented methods can be used to both develop patient prioritization and targeting steps for clinical pharmacy activities, and integrate it into care pathway. Today, those two developed programs have been executed in our teaching hospital.

Descriptive assessment of graduates' perceptions of pharmacy-related competencies based on the Lebanese pharmacy core competencies framework

Background

Pharmacists possess a unique and complex body of knowledge, skills, attitudes, and behaviors necessary to enable them to optimize health outcomes. Pharmacy organizations publish routinely updated versions of professional competencies that help pharmacy schools integrate advances into their curricula. In Lebanon, no national framework for pharmacy education is officially adopted yet. In 2017, the Official Pharmacists' Association in Lebanon [OPL - Order of Pharmacists of Lebanon] took the initiative to develop a pharmacy core competency framework.

Objective

The primary objective of this survey was to evaluate graduates' perceptions of pharmacy-related competencies "taught" across Lebanese pharmacy schools/faculties, based on the suggested Lebanese Pharmacy Competencies Framework. This study also explored the association between graduates' demographics, university attributes, and self-assessed competency performance.

Methods

A cross-sectional study involving pharmacists who graduated from Lebanese universities was performed through a 40-minute online questionnaire distributed over social media platforms and groups of pharmacists.

Results

Pharmacists perceived their competence as moderate upon graduation, the lowest scores being in fundamental knowledge and medicine supply; the highest reported scores were in personal skills and safe/rational use of medicines. Moreover, females, younger graduates, PharmD holders, and pharmacists working in hospitals/clinical settings and academia had the highest perception of their competencies. Pharmacists in the public sector and medical laboratory directors had the lowest perception of competence.

Conclusions

When comparing the taught curriculum to the suggested Lebanese Pharmacy Competency Framework, all domains need to be improved to optimize the perception, education, and practice of pharmacists. It is essential to emphasize fundamental knowledge, medicines supply, and public health competencies in undergraduate curricula and improve continuing professional education.

Analysis of processes and costs of alternative packaging options of sterile goods in hospitals - a case study in two German hospitals

BACKGROUND

Hospitals should monitor the costs of all direct and indirect processes in order to achieve efficiency and safeguard financial sustainability. One neglected process with significant costs is the processing of reusable medical devices and their packaging performed in the central sterilisation supply department and the operating room. The objective of this research is to analyse and compare processes and costs of four different packing alternatives, i.e. non-woven sterilisation wrap with two sheets, one-step wrap, sterilisation container with inner wrap and sterilisation container without inner wrap.

METHODS

We defined sub-processes that are directly related to the packaging options and measured them through a comprehensive time study. For all sub-processes and the total processes a distribution fitting and a Monte-Carlo-Simulation were performed. We calculated the costs for all sub-processes, i.e., costs for personnel, variable costs and the respective share of fixed and jump-fixed costs (e.g. depreciation of containers) associated with each packaging option. All results are discussed through various scenarios to evaluate the advantageousness of all packaging options.

RESULTS

The four packaging options are associated with different costs. "Sterile container without inner wrap" causes 2.05€ per use. The options "sterile container with inner wrap" (3.24€), "one-step sterilisation wrap" (3.44€) and "two sheets sterilisation wrap" (3.87€) cause higher costs. With regard to personnel costs the option "sterile container without inner wrap" clearly causes the lowest costs. In addition, variable costs are lower in case of sterile container. Sterile container only cause higher costs in the aspect of fixed and jump-fixed costs per packaging.

CONCLUSIONS

The analysis shows that even under a broad set of scenarios the "sterile container without inner wrap" is the most cost-effective alternative. The evaluation of the options "sterile container with inner wrap" and "one-step sterilisation wrap" remains particularly interesting as they often yield comparable results. Both options cause approximately the same personnel costs, so the decision appears to be more dependent on the material prices for wrap or the frequency and duration of use for container. It turns out that the personnel time and consequently the personnel costs significantly influence the rational choice of the packaging options.

Pharmacists as Interprofessional Collaborators and Leaders through Clinical Pathways

Pharmacists possess pivotal competencies and expertise in developing clinical pathways (CPs). We present a tertiary care facility experience of pharmacists vis-a-vis interprofessional collaboration for designing and implementing CPs. We participated in the development of CPs as leading members of a collaborative team of healthcare professionals. We reviewed literature, aligning it with hospital formulary and institutional standards, and participated in weekly team meetings for six months. Several tools and services were adapted to guide prescribing and standardization of care through time-bound order sets. Fifteen CPs leading to admissions in medical wards were developed and integrated into Computerized Prescriber Order Entry (CPOE) sets. Tools and services included (1) reporting of creatinine clearance to guide optimum dosing; (2) advisory flags for dosing and infusion rates; (3) piloting of medication reconciliation and counseling services before discharge were initiated; (4) Arabic drug leaflets were designed to educate patients; and (5) five CPs were included in pragmatic randomized control trials with a clinical pharmacist as co-investigator. Clinical pharmacists conducted continuous orientation to various healthcare professionals throughout the process. CPs provide unique opportunities for establishing and evaluating patient-centered pharmaceutical services and allow clinical pharmacists to demonstrate interprofessional leadership in collaboration with multidisciplinary teams.

A Primer on Clinical Pathways

Leaders in health-system pharmacy are challenged to maintain the highest quality pharmacy service at the lowest cost. Clinical pathways are evidence-based road maps that assist in reducing variations in clinical practice. Integration of clinical pathways within the electronic health record further helps to facilitate evidence-based practice. This article reviews the evolution of the clinical pathways, describes their clinical and economic impact, and identifies ways pharmacy directors can successfully implement these pathways into their institutions. Pharmacy directors can utilize their skills in this area or task clinical pharmacists to serve as members of the clinical pathway development team to further enhance patient-centered pharmacy services.

Big data in pharmacy practice: current use, challenges, and the future

Pharmacy informatics is defined as the use and integration of data, information, knowledge, technology, and automation in the medication-use process for the purpose of improving health outcomes. The term "big data" has been coined and is often defined in three V's: volume, velocity, and variety. This paper describes three major areas in which pharmacy utilizes big data, including: 1) informed decision making (clinical pathways and clinical practice guidelines); 2) improved care delivery in health care settings such as hospitals and community pharmacy practice settings; and 3) quality performance measurement for the Centers for Medicare and Medicaid and medication management activities such as tracking medication adherence and medication reconciliation.

Development and implementation of a performance improvement project in adult intensive care units: overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study

INTRODUCTION

In 2005 the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) published guidelines for managing hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP). Although recommendations were evidence based, collective guidelines had not been validated in clinical practice and did not provide specific tools for local implementation. We initiated a performance improvement project designated Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) at four academic centers in the United States. Our objectives were to develop and implement the project, and to assess compliance with quality indicators in adults admitted to intensive care units (ICUs) with HAP, VAP, or HCAP.

METHODS

The project was conducted in three phases over 18 consecutive months beginning 1 February 2006: 1) a three-month planning period for literature review to create the consensus pathway for managing nosocomial pneumonia in these ICUs, a data collection form, quality performance indicators, and internet-based repository; 2) a six-month implementation period for customizing ATS/IDSA guidelines into center-specific guidelines via educational forums; and 3) a nine-month post-implementation period for continuing education and data collection. Data from the first two phases were combined (pre-implementation period) and compared with data from the post-implementation period.

RESULTS

We developed a consensus pathway based on ATS/IDSA guidelines and customized it at the local level to accommodate formulary and microbiologic considerations. We implemented multimodal educational activities to teach ICU staff about the guidelines and continued education throughout post-implementation. We registered 432 patients (pre- vs post-implementation, 274 vs 158). Diagnostic criteria for nosocomial pneumonia were more likely to be met during post-implementation (247/257 (96.1%) vs 150/151 (99.3%); P = 0.06). Similarly, empiric antibiotics were more likely to be compliant with ATS/IDSA guidelines during post-implementation (79/257 (30.7%) vs 66/151 (43.7%); P = 0.01), an effect that was sustained over quarterly intervals (P = 0.0008). Between-period differences in compliance with obtaining cultures and use of de-escalation were not statistically significant.

CONCLUSIONS

Developing a multi-center performance improvement project to operationalize ATS/IDSA guidelines for HAP, VAP, and HCAP is feasible with local consensus pathway directives for implementation and with quality indicators for monitoring compliance with guidelines.

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting

While collaborative, team-based care has the potential to improve medication use and reduce adverse drug events and cost, less attention is paid to understanding the processes of well functioning teams. This paper presents the findings from key informant interviews and reflective journaling from pharmacists, physicians and nurse practitioners participating in a multicentre, controlled clinical trial of team-based pharmacist care in hospitalized medical patients. A phenomenological approach guided the data analysis and content analysis was the primary tool for unitizing, categorizing and identifying emerging themes. Pharmacists experienced highs (developing trusting relationships and making positive contributions to patient care) and lows (struggling with documentation and workload) during integration into the medical care team. From the perspective of the participating pharmacists, nurse practitioners and physicians, the integration of pharmacists into the teams was felt to have facilitated positive patient outcomes by improving team drug-therapy decision-making, continuity of care and patient safety. Additionally, the study increased the awareness of all team members' potential roles so that pharmacists, nurses and physicians could play a part in and benefit from working together as a team. Focussed attention on how practice is structured, team process and ongoing support would enable successful implementation of team-based care in a larger context. (ClinicalTrials.gov number, NCT00351676).