Evaluation of medication changes following severe COVID-19 infection: a multicentre evaluation

BackgroundCritically ill patients often experience several transitions of care following critical illness. Research has explored the challenges which patients have with medication management across these transitions. It is unclear whether patients admitted to critical care due to COVID-19 will have similar challenges. The aim of this study was to explore medication management in critical care survivors following severe COVID-19.MethodsBetween 3 and 7 months post hospital discharge, patients who had been admitted to critical care due to severe COVID-19 were invited to an established recovery service. During the clinic consultation a medication review was performed by a pharmacist. This included medicines reconciliation, assessing the appropriateness of each of the prescribed medications and identification of medication changes. We also assessed changes to pain management in the discharge period.ResultsIn total, 78 patients had a full medication review available. Over 70% of patients were taking an increased dose of medicine or a new medicine at clinic. There was a significant overall increase in new medication during the clinic consultation, across different British National Formulary classifications (OR: 1.73 (95% CI: 1.28 to 2.34), p<0.001). Compared with pre critical care admission, there was a significant increase in the number of patients taking regular analgesia following severe COVID-19 infection (23 (29.5%) vs 39 (50%), p<0.001).ConclusionFollowing severe COVID-19, patients may require new or increasing doses of medicines. Ongoing review of these patients is crucial to ensure optimal outcomes.

Principles of drug therapy

Key principles of clinical pharmacology inform prescribing in palliative care. Concepts discussed in this chapter include issues surrounding patient compliance, the importance of medicines reconciliation, the use of guidelines and formularies, and the role of unlicensed medications. Differences between efficacy, effectiveness, and cost-effectiveness; the nature of a benefit-to-risk analysis; and the meaning of pharmacokinetic variation and pharmacokinetic–pharmacodynamic relationships are then explored. Drug interactions, including adverse drug reactions, are discussed and finally, the topic of pharmacogenomics is covered. More extensive information about general pharmacology is available in comprehensive pharmacology textbooks.

Medicines reconciliation of biologics on a primary care clinical system

With increasing number of biologics gaining approval from the National Institute for Health and Care Excellence for a wide variety of both cancer and non-cancer clinical indications in secondary care, the need for accurate medicines reconciliation in primary care also increases. The risk of patient harm from incomplete medicines reconciliation is a consideration, particularly when patient data is transferred from a secondary care setting to a primary care setting. As part of a prescribing quality improvement project, a list of biologics prescribed by secondary care providers were reconciled on to patients' primary care clinical systems (EMIS) by clinical pharmacists and pharmacy technicians at a Clinical Commissioning Groups. Patients were identified by cross-referencing high cost drug reports with clinical diagnostic codes (a mixture of READ codes and SNOMED-CT terms) on primary care clinical systems. In total, 192 medicines were reconciled safely on the relevant patients' notes across 16 different GP practices A further 81 medicines had already been reconciled at the start of the quality improvement project. The purpose of this article is three-fold; to expand the awareness of biologics in the context of medicines optimisation in the primary care arena, to discuss medicines reconciliations of biologics in primary care, including the role(s) of pharmacy professionals, and to discuss the wider implications of prescribing biologics in the light of ethical considerations such as veganism.

An audit of the use of psychotropic medications over the course of admission to a specialist dementia ward

AimsThe aim of this audit project was to establish the practices in prescribing and de-prescribing of psychotropic medications for patients on a specialist dementia ward.BackgroundThere is a great deal of evidence demonstration high rates of polypharmacy, defined as ≥5 drugs, in older adults in general and in those with dementia more specifically. NICE guidelines recommend a structured assessment of a patient with dementia to exclude other potential causes, e.g. pain or delirium. Psychosocial interventions are recommended as first line. Antipsychotics should only be offered second line who present a risk to themselves or others. These should only be used for the shortest time possible and reassessed at least every 6 weeks.MethodData were collected for patients (n = 20) discharged from a specialist dementia ward between September 2018 and March 2019. The unit has 14 beds caring for patients with predominantly severe behavioural and psychological symptoms associated with dementia (BPSD). The team is comprised of doctors, nurses, a clinical psychologist, occupational therapists, physiotherapists and pharmacists who meet twice a week to review patients. Data were coded by drug class and counts of medication on admission, at the midpoint and at discharge were conducted. Antipsychotic and benzodiazepine dosages were converted into haloperidol and diazepam equivalence.ResultOf the 20 patients, 70% were male and 30% female. 95% of the patient (n = 19) were admitted under the Mental Health Act (1983). 20% were managed on 1 to 1 observations and 80% were on 15 min observations. In general, the results show little change in the overall rate of psychotropic prescribing. The mean number of psychotropic medications prescribed per patient on admission was 2.30, at the mid-point of admission it was 2.30 and at discharge it was 2.05. Mean benzodiazepine dosage in diazepam equivalence reduced between admission and discharge from 3.20 mg to 2.10 mg. Mean haloperidol equivalent dosages increased at the midpoint of admission from 1.11 mg to 2.27 mg before reducing to 0.78 mg at discharge.ConclusionThe results demonstrate minimal change in the overall average number and composition of drugs prescribed. There are differences in the use of regular antipsychotics and benzodiazepines between admission and discharge which are consistent with NICE guidelines. Patients had a structured assessment with regular medicines reconciliation supervised by the team pharmacist. Therefore, the ward environment did allow for detailed discussions about de-prescribing which may not be the case elsewhere.

Evaluating the Utilisation of a Service Designed to Enhance Care with Medicines Following Acute Hospital Discharge: A Retrospective Study

Introduction Medication safety challenges are common after hospital discharge and an important global health care improvement target [1,2]. ‘Transfers of Care Around Medicines’ (TCAM) services have been suggested as an intervention that may help address this problem, and are designed to enable the referral of patients on discharge from the hospital to a named community pharmacy in the surrounding Clinical Commissioning Group (CCG). A TCAM service was launched by a large NHS Trust in England in February 2019 to enhance medicines communication and optimisation between primary and secondary care following hospital discharge. The TCAM service is delivered through the PharmOutcomes™ platform, and the initial focus of the service was to support patients with new or existing Monitored Dosage Systems (MDS). Aim To evaluate the utilisation of the TCAM service in the host NHS Trust and surrounding CCG through the examination of the nature and outcome of referrals made to community pharmacy. Method Anonymised service delivery data of patients referred from the TCAM service via the PharmOutcomes™ platform between March 2019 – February 2020 were retrospectively examined. The data comprised important variables, including patient demographics, status and time of referrals, and referral outcomes including problems/errors identified with medications and services provided by the community pharmacy such as medicines reconciliation. Study approvals were obtained from the host NHS Trust and the Health Research Authority (HRA); the study was exempt from the University Research Ethics Committee (UREC) approval [2019-7048-10983]. Results A total of 3,033 TCAM referrals to 67 community pharmacies were analysed. Most referrals were for patients aged 70 and above (72%, n=2,195) and 56% (n=1,713/3,033) of the referrals were for female patients. The number of referrals varied between 215 and 310 per month (median 246, Inter quartile range [IQR] 234 - 268). Most referrals (67%, 2,038/3,033) were marked as ‘completed’ by the community pharmacies, with 32.8% (n=995) left uncompleted. The rate of referral completion varied between 59 and 80% per month (median 66.4, IQR 64.5 - 70). Five (0.2%) patients were identified by community pharmacies that had adverse drug reactions (ADRs) from the cohort of 2,038 patients with completed referrals, with 45 (2%, n=45/2,038) identified as having issues that necessitated referral to the general practitioner (GP). The most common reason for referral to GP was medication changes identified from hospital, incorrect repeat prescriptions following discharge, to request a new prescription or weekly MDS, and to inform the GP that the patient has stopped taking their medication. The most common services carried out in community pharmacies following referral were reported as medicines reconciliation (47%, n=954/2,038), followed by review of information (46.7%, n=952/2,038), home delivery of medication (39%, n=798/2,038), review MDS arrangements (23.6%, n=482/2,038), commence MDS (18.6%, n=380/2,038), and pharmacy managed repeat service (12%, n=254/2,038). The main strength of this study is the inclusion of referral data that occurred over a one-year period, while the data were limited in generalisability due to inclusion of one geographical region and only patients using MDS. Conclusion The findings of this study may inform the ongoing development of electronic pharmacy referral systems for use at hospital discharge. References 1. Alqenae FA, Steinke D, Keers RN. Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review. Drug safety. 2020 Mar 3:1–21. 2. World Health Organization. Global patient safety challenge: medication without harm. 2017; p. 1–16. http://apps.who.int/iris/bitstream/10665/255263/1/WHO-HIS-SDS-2017.6-eng.pdf?ua=1&ua=1 . Accessed 20 September 2020.

Effect of medicines management versus standard care on readmissions in multimorbid patients: a randomised controlled trial

ObjectiveTo investigate the effect of pharmacist-led medicines management in multimorbid, hospitalised patients on long-term hospital readmissions and survival.DesignParallel-group, randomised controlled trial.SettingRecruitment from an internal medicine hospital ward in Oslo, Norway. Patients were enrolled consecutively from August 2014 to the predetermined target number of 400 patients. The last participant was enrolled March 2016. Follow-up until 31 December 2017, that is, 21–40 months.ParticipantsAcutely admitted multimorbid patients ≥18 years, using minimum four regular drugs from minimum two therapeutic classes. 399 patients were randomly assigned, 1:1, to the intervention or control group. After excluding 11 patients dying in-hospital and 2 erroneously included, the primary analysis comprised 386 patients (193 in each group) with median age 79 years (range 23–96) and number of diseases 7 (range 2–17).InterventionIntervention patients received pharmacist-led medicines management comprising medicines reconciliation at admission, repeated medicines reviews throughout the stay and medicines reconciliation and tailored information at discharge, according to the integrated medicines management model. Control patients received standard care.Primary and secondary outcome measuresThe primary endpoint was difference in time to readmission or death within 12 months. Overall survival was a priori the clinically most important secondary endpoint.ResultsPharmacist-led medicines management had no significant effect on the primary endpoint time to readmission or death within 12 months (median 116 vs 184 days, HR 0.82, 95% CI 0.64 to 1.04, p=0.106). A statistically significantly increased overall survival was observed during 21–40 months follow-up (HR 0.66, 95% CI 0.48 to 0.90, p=0.008).ConclusionsPharmacist-led medicines management had no statistically significant effect on time until readmission or death. A statistically significant increased overall survival was seen. Further studies should be conducted to investigate the effect of such an intervention on a larger scale.Trial registration numberNCT02336113.

P52 A baseline review of the activity of the PICU pharmacists using electronically captured data

AimTo date there are no metrics for the clinical pharmacist service to PICU. It is accepted that use of a Clinical Information Management System (CIMS) has a role in medication safety,1 however there are few studies that review the information potential of a CIMS for collecting pharmacist activity.2MethodAdditional fields and custom reports were configured in the CIMS to enable PICU pharmacists to record their activity in the following areas:Medicines reconciliation within 72 hours of admission to PICUDischarge kardex reviewAnalgesia and sedation (A&S) reviewClinical pharmacy reviewOther interventions & medication error reporting continued as per normal practice. Data was analysed using Microsoft Excel®.ResultsComplete data was available from July 2017 to end of 2018.There were 1274 medicines reconciliations by a pharmacist within 72 hours of admission (78% admissions). 14% of discharge kardexes had been reviewed prior to discharge to the ward. There was an average of 190 pharmacy reviews per 100 bed days. A total of 780 Pharmacist A&S Plans were documented by the clinical pharmacists – an average of 2 per working day, and 48% of admissions.Comparisons between each six month period showed a significant increase in the number of pharmacists medicines reconciliations (p<0.001). No other differences were found.ConclusionThis study has shown that electronic tracking of pharmacist ward activity is possible. It has the potential to demonstrate compliance with external or internal standards and audits. This data continues to be collected, and therefore these results will be used as a baseline to compare future activity. The findings of this study may encourage other units to replicate, providing data that can be used for comparison. Further configuration of the CIMS to capture other metrics such as TDM, and document discrepancies in medicines reconciliation is planned.ReferencesForni A, Chu H, Fanikos J. Technology Utilization to Prevent Medication Errors. Current Drug Safety. 2010;5:13–18.Nelson S, Poikonen J, Reese T, El Halta D, Weir C. The pharmacist and the EHR. Journal of the American Medical Informatics Association. 2016;24:193–197.Health and Information Quality Authority. Guidance for health and social care providers; Principles of good practice in medication reconciliation. Dublin: HIQA; 2014