Comprehensive versus standard care in post-severe acute kidney injury survivors, a randomized controlled trial

Background Currently, there is a lack of evidence to guide optimal care for acute kidney injury (AKI) survivors. Therefore, post-discharge care by a multidisciplinary care team (MDCT) may improve these outcomes. This study aimed to demonstrate the outcomes of implementing comprehensive care by a MDCT in severe AKI survivors. Methods This study was a randomized controlled trial conducted between August 2018 to January 2021. Patients who survived severe AKI stage 2–3 were enrolled and randomized to be followed up with either comprehensive or standard care for 12 months. The comprehensive post-AKI care involved an MDCT (nephrologists, nurses, nutritionists, and pharmacists). The primary outcome was the feasibility outcomes; comprising of the rates of loss to follow up, 3-d dietary record, drug reconciliation, and drug alert rates at 12 months. Secondary outcomes included major adverse kidney events, estimated glomerular filtration rate (eGFR), and the amount of albuminuria at 12 months. Results Ninety-eight AKI stage 3 survivors were enrolled and randomized into comprehensive care and standard care groups (49 patients in each group). Compared to the standard care group, the comprehensive care group had significantly better feasibility outcomes; 3-d dietary record, drug reconciliation, and drug alerts (p < 0.001). The mean eGFR at 12 months were comparable between the two groups (66.74 vs. 61.12 mL/min/1.73 m2, p = 0.54). The urine albumin: creatinine ratio (UACR) was significantly lower in the comprehensive care group (36.83 vs. 177.70 mg/g, p = 0.036), while the blood pressure control was also better in the comprehensive care group (87.9% vs. 57.5%, p = 0.006). There were no differences in the other renal outcomes between the two groups. Conclusions Comprehensive care by an MDCT is feasible and could be implemented for severe AKI survivors. MDCT involvement also yields better reduction of the UACR and better blood pressure control. Trial registration Clinicaltrial.gov: NCT04012008 (First registered July 9, 2019).

A Guidance for Concomitant Drug Reconciliation Prior to Allogeneic Hematopoietic Cell Transplantation in Children and Young Adults

Pediatric diseases treated by allogeneic hematopoietic stem cell transplantation (alloHCT) are complex and associated with significant comorbidities and medication requirements that can complicate the transplant process. It is critical to reconcile pre-transplant concomitant medications (pcon-meds) in the weeks prior to alloHCT and to consider the potential for pcon-meds to cause harmful drug-drug interactions (DDIs) or overlapping toxicities with conditioning agents. In this perspective, we describe a systematic process to review pcon-meds and determine the drug modifications needed to avoid DDIs with conditioning regimens. We provide an extensive appendix with timelines for discontinuation or modification of common pcon-meds that patients are taking when presenting to the HCT medical team. The timelines are based on the pharmacokinetic (PK) properties of both the pcon-meds and the planned conditioning medications, as well as anticipated DDIs. They also account for the ages seen at pediatric transplant centers (0–30 years old). Common scenarios, such as when pcon-med discontinuation is not an option, are discussed. Since alloHCT patients are often dependent upon psychiatric medications with problematic DDIs, a table of alternative, non-interacting psychiatric medications is also presented. The appendix provides details regarding how to adjust pcon-meds prior to the start of chemotherapy for children and young adults undergoing alloHCT, however patient-specific circumstances always need to be taken into account. Careful attentiveness to pcon-meds at the time the decision is made to pursue transplant will result in more consistent HCT outcomes, with lower toxicity and increased efficacy of conditioning agents.

Comprehensive Versus Standard Care in Post-Severe Acute Kidney Injury Survivors, A Randomized Controlled Trial

Background: Currently, there is a lack of evidence to guide the optimal care for post-acute kidney injury (AKI) survivors. Therefore, post-discharge care by a multidisciplinary care team (MDCT) may improve these outcomes. This study aimed to demonstrate the outcomes of implementing comprehensive care by a MDCT in post-severe AKI survivors.Methods: This study was a randomized controlled trial conducted between August 2018 to January 2021. Patients who survived severe AKI stage 2-3 were enrolled and randomized to be followed up with either comprehensive or standard care for 12 months. The comprehensive post-AKI care integrated a MDCT (nephrologists, nurses, nutritionists, and pharmacists). The primary outcome was the feasibility outcomes, comprised of the rates of loss to follow up, specialist consultation, 3-d dietary record, drug reconciliation, and drug alert rates at 12 months. Secondary outcomes included major adverse kidney events, estimated glomerular filtration rate (eGFR), and amount of albuminuria at 12 months. Results: Ninety-eight AKI stage 3 survivors were enrolled, and randomized into comprehensive care and standard care groups (49 patients in each group). Compared to the standard care group, the comprehensive care group had significantly better in feasibility outcomes; higher rates of specialist consultation, 3-d dietary record, drug reconciliation, and drug alerts (p < 0.001). The mean eGFR at 12 months were comparable between the two groups (66.74 vs. 61.12 mL/min/1.73 m2, p = 0.54). The urine albumin: creatinine ratio (UACR) was significantly lower in the comprehensive care group (36.83 vs. 177.70 mg/g, p = 0.036), while the blood pressure control was also better in the comprehensive care group (87.9% vs. 57.5%, p = 0.006). There was no difference in the other renal outcomes between the two groups.Conclusions: Comprehensive care by a MDCT is feasible and could be implemented for post-severe AKI survivors. These resulted in a better reduction in the UACR and better blood pressure control. Trial registration: clinicaltrial.gov: NCT04012008 (First registered July 9, 2019)

PHARMACIST’S ROLE IN MEDICATION RECONCILIATION TO PREVENT THE RISK OF MEDICATION ERROR AT BALI MANDARA HOSPITAL

Background: Pharmacists have an important role in implementing drug reconciliation. The implementation of drug reconciliation allows the process of identifying drug administration errors due to information gaps, which we can avoid by optimizing information as early as possible at every shift in the process of providing health services through the reconciliation process. This process is crucial, especially for groups of patients with chronic diseases who have a high risk of changing health care delivery settings. Failure to identify results in errors in administering drugs that lead to worsening clinical conditions, resulting in increased service needs and health costs. Objective: Provides information about the tendency of pharmacists who work at the UPTD Bali Mandara General Hospital to reduce drug use errors through the drug reconciliation program. Methods: Thematic analysis of structured interview results. Results: Almost all participants (6 out of 8 pharmacists) tend to be willing to be involved in the drug reconciliation process. There are three main themes of consideration that underlie the tendency of pharmacists to be willing to be involved in the drug reconciliation process, namely, related to understanding the definition, purpose, and consistency of the implementation of reconciliation. In controlling the incidence of medication errors, the biggest preventable errors through medication reconciliation are drug duplication and drug discrepancy. Conclusion: The tendency for pharmacists to be involved is good, and the tendency to control the risk of medication errors is still lacking in terms of communication and consistency in filling out by all officers. Keywords: Pharmacist’s role, drug reconciliation, risk of medication errors

Kontribusi Kelengkapan Pengisian Formulir Rekonsiliasi Obat terhadap Penggunaan Obat Rasional pada Pasien Rawat Inap di RSU X Bekasi

Drug reconciliation is needed to get rational treatment therapy. The purpose of this study was to analyze the relationship between the completeness of filling out the form of drug reconciliation and rational drug use at Bekasi X Hospital. The study design used a cross-sectional comparative study to compare between 56 completed drug reconciliation forms and 133 incomplete drug reconciliation forms. Sampling is done in total sampling. The research sample that fulfilled the inclusion criteria was 189 forms (40.6%) of all (466) drug reconciliation forms in November 2015-end April 2016 at X Hospital Bekasi. Data was analyzed using Chi-square test. The results showed that the largest percentage of filling out drug reconciliation forms was incomplete (70.4%), carried out by the pharmacist (56.1%) and not signed by a doctor (63.5%). Percentage of rational drug use by 7.9%, with details: correct diagnosis 53.4%, correct indication 53.4%, correct selection of medicine 33.9%, correct dosage 8.5%, exactly how to administer 37.6%, on time giving 13.8% and correct time giving 14.8%. There is no significant relationship between the completeness of filling out the drug reconciliation form, the types of health workers, the presence/absence of a doctor's signature and rational drug use in inpatients (p> 0.05).Tthere is no significant relationship between the completeness of filling out the reconciliation form and rational drug use in inpatients at Bekasi X Hospital (p> 0.05)

Drug-Related Problems in the transitional care of the elderly from hospital to home

ABSTRACT Objective: To identify the knowledge produced on Medication-Related Problems in the transitional care of the elderly from hospital to home. Method: Integrative review of the literature data, organized in six stages: guiding question; establishment of inclusion and exclusion criteria; extraction of data; analyze; interpretation of results; and presentation of the review. Articles were considered among 2002 and 2017, in Portuguese, English, and Spanish, in the databases LILACS, MEDLINE, CINAHL and EMBASE. Results: 10 studies were selected and analyzed. They were categorized by subject and identified in three themes: Medication Discrepancy and Reconciliation (40%); Adhesion to Medication (30%); and Adverse Drug Events (30%). Final considerations: Drug-Related Problems in the transitional care of the elderly from hospital to home, were presented as a relevant theme for nursing, involving complex issues related to care. Drug reconciliation was evidenced as a coherent and effective strategy in home care transitions for the elderly.

ICU Follow-Up Clinics

ICU follow-up clinics have been proposed and, in some cases, adopted in an effort to improve post-ICU care. Clinics are heterogeneous in staffing and organization and may provide a range of services, from drug reconciliation to mental health referrals. Some clinics integrate support services for family members and caregivers. In other cases, the clinics exist largely as a research environment where they may help to better understand long-term outcomes of survivors of critical illness. Thus far, clinical trials have not shown these clinics to improve patient-centred outcomes or to be cost-effective. However, qualitative literature does suggest a subjective sense of benefit for patients and family members. The lack of quantitative evidence in support of clinics does not mean that the long-term needs of ICU patients cannot be addressed in a formal way. However, it does suggest that clinics are not effective as delivered in the trials. Critical care researchers should be directed by both the qualitative and quantitative literature in conceiving new interventions and testing them in clinical trials. The model of an interdisciplinary clinic including rehabilitation specialists should be further explored.