Assistant professor, pharmacist, PhD, MPH
Joo Hanne Poulsen Revell
The Hospital Pharmacy, University Hospital Sønderjylland, Denmark The Hospital Pharmacy Research Unit, University Hospital Sønderjylland, Denmark
| Project management | ||
| Project status | Open | |
| Data collection dates | ||
| Start | 01.11.2023 | |
| End | 31.03.2024 | |
INTRODUCING PHARMACIST-LED MEDICATION REVIEWS AT AN ORTHOPEDIC WARD - DEVELOPING A MODEL FOR PRIORITISATION OF MEDICATION REVIEWS
Short summary
Lack of medication treatment coordination among older, multi-morbid patient's results in suboptimal medication treatment, medication errors and hospital admissions. Pharmacist-led medication review are introduced to improve the quality, safety and appropriate use of medicine to elderly patients admitted with hip injury or fracture at an orthopedic ward. Different risk prioritisation scores are used for comparison reason in order to identify, which patients will benefit the most from a review.
Rationale
Lack of medication treatment coordination among especially multi-morbid patient's results in suboptimal medication treatment, medication errors, hospital admissions and premature death. In addition, an aging population is a challenge to healthcare systems worldwide as older adults are vulnerable to non-communicable diseases and particularly multi-morbidity. Half of the Danish people aged 65 and above suffer from coexisting diseases1, and a high proportion of elderly aged 70+ in several municipalities in Southern Jutland already accounts for more than a third of all hospital days2. Thus, there is a need for interventions to improve the quality, safety and appropriate use of medicine to elderly, multi-morbid patients. Multi-morbidity is defined as the coexistence of two or more chronic conditions in an individual3, and it is associated with concomitant multiple medication use (polypharmacy), potentially inappropriate prescriptions (PIPs), and substantial costs for health systems and patients4. PIPs are also independently associated with adverse drug events (ADEs). Most ADEs are potentially avoidable but often underestimated in clinical practice5. Consequently, various pharmacist-led interventions have been explored to meet these challenges, and a frequent, central component of such an intervention is the pharmacist-led medication review6,7. However, no exact model for medication review exists, as difference in intervention types, settings, and outcomes, often challenge the possibilities of comparing, transferring and reproducing study findings8. Further, different screening criteria for patient inclusions are used, which also complicates the comparison options. As an attempt to detect patients at high risk of medication errors, a Medicine Risk Scores (MERIS) was designed in Denmark in 2015, see Table 17. MERIS and its risk score was supposed to correctly allocate acutely admitted patients into low and high risk of potential ADEs by predefined a detection limit, where 15 out of a total score of 37 points was found the most effective cut-off value9. However, variables like age and comorbidities are not included in MERIS. An under-studied patient group within polypharmacy and PIPs are patients with dementia creating inequality among patient groups. The use of polypharmacy and PIPs are widespread in this patient group, and even more so compared to the general Danish elderly population10. This demonstrates the need for interventions to improve medication treatment in people with dementia. Thus, this patient group is also of interest in this project, as this diagnosis is well-known to have a negative effect on overall mortality11,12.
Pharmacist-led medication reviews in an orthopedic ward
Several studies explore the effect of implementing pharmacist-led services to orthopedic wards in terms of preventing adverse events and improve medication safety13-16. Outcomes, such as performing medication reconciliation to admitted patients, improving sub-optimal treatment, and supporting healthcare professional in the medication process are positively described13-16. Buck et al. (2007) explored pharmacist screening for sub-optimal prescriptions within ten target-interventions at Danish orthopedic wards, where 20% of included patients had sub-optimal prescriptions. Nearly 70% of these were changed by the physician according to the recommended intervention 13. Further, Serandour et al. (2020) introduced a pharmaceutical team to compare medication reconciliation and hospital prescription to admitted patients and one year after admittance a follow-up showed that 96% of nearly 2900 recommended interventions were accepted by the prescribers 14. Additionally, medication errors at the orthopedic surgery unit decreased by almost 80% after the initiation of the study 14. Another study, reported of a reduction of incidence of preventable ADEs was reported in the SUREPILL study, where pharmacy practitioners performed bedside medication reconciliation and hospital pharmacists undertook regular medication reviews in an orthopedic study wards 16. In contrast, a Danish study found a lower acceptance rate of medication review recommendations (nearly 20%) from a team of a pharmacist and a pharmacology among physicians in an orthopedic setting 15. Possible explanations were provided, such as the wards' physicians might be reluctant to change the regular medication because of respect for the GP's competence on overall drug treatment 15. In addition, a setting like an orthopedic surgery has been described as a complex area, as it implicates many different professionals and patient pathways through different units (anesthesia, intensive care, operating room etc.)14. Thus, alongside these patient pathways, there is a risk of an increased medication error rate, and consequently, clinical pharmacists or pharmacy teams have been introduced to orthopedic wards to increase overall medication safety14. Thus, in order to ensure implementation of the pharmacist-led recommendations, they should focus on being within the physician's specialty, whereas potential recommendations regarding e.g. the medical treatment of comorbidities should be directed towards the patient's GP15. Supportive measures from hospital pharmacy can be delivered in every step of the medication process; prescription; dispensing/preparation of medicine; administration and monitoring17. When considering the types and numbers of the reported adverse drug events (ADEs) in 2022 from the orthopedic ward in Hospital Sønderjylland, there are particularly potential for the pharmacist to support the ward with prevention of medicine-related errors in regard to phases of prescription (32 ADEs), dispensing/ preparation of medicine (3 ADEs), and administration (3 ADEs)17. Even though the ADEs seem small in number, it is important to emphasize that these findings do not uncover the entire problem, as incident reporting systems are known to only reveal 'the tip of the iceberg'18-20. Further, the National Survey of Patient Experience (LUP) from 2022 performed after hospital discharge revealed that nearly 50% of patients admitted at the orthopedic ward reported lack of information about the effect and potential side effects of the new medicine prescribed17. Thus, there is a potential for pharmacist to meet these reported ADEs and support patients before discharged with information about their new medicine. Age is also proposed to have an impact on the number of pharmaceutical interventions suggested by the pharmacists, just as the physician's acceptability of pharmacist-led recommendations are increasing alongside a higher age of the patient in question14,15. This supports that patient inclusion for a medication review should be based on individual patient's risk for ADEs rather than an overall standardized intervention15. Thus, screening criteria for patient inclusion to pharmacist-led medication review can be combinations between carefully chosen screening variables from components, such as MERIS and/or CCI, together with clinical experience, inspiration from previous studies/procedures, and the literature. However, no obvious medication review model to admitted patients in orthopaedic setting exists at this moment, just as it is unknown, which patients would benefit the most from a medication review during admission at the orthopedic ward in Hospital Sønderjylland. Thus, there is a need to develop, test and evaluated a model for patient prioritisation of pharmacist-led medication review at the hospital.
Description of the cohort
General inclusion criteria are patients aged 65+ with an expected in-hospital length of stay (LOS) of a minimum of 48 hours. Further, besides obtaining the medication list through FMK and/or EPJ, the medication list must be validated through interview with patients, attorney-in-facts and/or nursing staff at nursing homes or home care. The number of patients < 65 years, but otherwise eligible for inclusion due to diagnosis will be registered by number. General exclusion criteria are hospitalized patients admitted less than 48 hour, suicidal patients, and terminal patients. Further, patients who are unable to give written consent (with no attorney-in-fact) to evaluate the patient satisfaction with the medication review will be excluded in the evaluation.
A historic Control Group (CG) will be introduced in the project and consist of patients (with the same inclusion criteria as above) admitted to the orthopedic ward in 2022.
Data and biological material
The pharmacist-led procedures contains the following elements: 1) screening process of patients admitted to the orthopedic ward, 2) medication reconciliation and review preferably through validation using interview with patients, attorney-in-facts and/or nursing staff at nursing homes or home care, and 3) documentation and recommendations sent to the GP or the medical doctor at the ward. After the screening process of admitted patients to the orthopedic ward, the inclusion entails a medication reconciliation and medication review conducted by a clinical pharmacist at the hospital. The assessment will be based partly on medication history, medication management and optimization of medicine based on current guidelines e.g., the discontinuation list, recommendations (anticholinergic burden, START/STOPP etc.), and local/regional recommendations. Further, the pharmacist will ensure that the medication during hospitalization is in accordance with the patient usual medicine administration at home. Finally, in situations where patients are self-administering their medicine, the pharmacist will provide information about potentially newly started medicine during admission, and hence ensure that these patients are familiar with the new medicine after discharge. The pharmacists will write a medication plan and either discuss the findings with the ward round doctor or write the recommendations to the patients' GP through the discharge summary.
Collaborating researchers and departments
Othopedic department, University Hospital Sønderjylland, Denmark
- Jens Eggers, Cheflæge, MOL
- Merete Hellerup, Chefsygepl.
- Jesper Schønnemann, Ledende Overlæge, PhD
Publications associated with the project