MEDICAL ACADEMY FACULTY OF PHARMACY
DEPARTMENT OF CLINICAL PHARMACY
MADELINE HASHIM ELSHEIKH
THE EVALUATION AND IMPACT OF A PATIENT PRIORITIZATION TOOL
FOR CLINICAL PHARMACY SERVICES: HOSPITAL SETTING
Master thesis
Thesis supervisor: Lect. Dr. Rima Minkutė
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF PHARMACY
DEPARTMENT OF CLINICAL PHARMACY
APPROVED: Prof. Ramūnė Morkūnienė ________________ Date (________________)
THE EVALUATION AND IMPACT OF A PATIENT PRIORITIZATION TOOL
FOR CLINICAL PHARMACY SERVICES: HOSPITAL SETTING
Master thesis
Master thesis supervisor Lect. Dr. R. Minkutė __________________________ (Signature) (Date)
Reviewer Master Thesis is accomplished by
Name/Surname/Signature Madeline Hashim Elsheikh, ________________
Date (____________) Date (________________)
TABLE OF CONTENT
SUMMARY ... 5
SANTRAUKA ... 6
ACKNOWLEGDEMENTS ... 7
CONFLICTS OF INTEREST ... 7
ETHICS COMMITTEE CLEARANCE ... 7
ABBREVIATIONS ... 8
GLOSSARY OF TERMS & DEFINITIONS ... 9
INTRODUCTION ... 10
BACKGROUND: ... 11
AIMS AND OBJECTIVES OF THESIS ... 12
AIM ... 12
OBJECTIVES ... 12
1. LITERATURE REVIEW ... 13
1.1.THEORETICAL BACKGROUND ... 13
1.2.CLINICAL PHARMACISTS’CONTRIBUTIONS... 13
1.3.ADVANCES IN TOOLS WORLDWIDE ... 15
2. REARCH METHODS AND METHODOLOGY ... 18
2.1.STUDY SETTING ... 18
Development of ART: ... 18
2.2.STUDY DESIGN, AREA AND PERIOD ... 19
2.3.INCLUSION AND EXCLUSION CRITERIA ... 19
2.4.SAMPLE SIZE AND SAMPLING TECHNIQUES ... 19
2.5.DATA COLLECTION PROCEDURE AND INSTRUMENTS ... 20
2.6.SURVEY ... 21
2.7.DATA ANALYSIS... 21
2.8.ETHICAL CONSIDERATION ... 22
4. RESULTS ... 23
4.1.NEED FOR ASSESSMENT RISK TOOL... 23
4.2.COMPARATIVE ANALYSIS OF ART ... 23
4.2.1. Endorsed vs Not Endorsed drug charts ... 23
4.2.2. Medication Reconciliation ... 28
4.3.ASSESSMENT OF COMMUNICATIONS BETWEEN PRESCRIBER AND PHARMACIST ... 30
4.4.EVALUATION OF SURVEY TAKEN BY PHARMACIST ... 32
Section 1: Satisfied with ART ... 32
Section 2: Impact of ART ... 33
Section 3: Comparative Intake ... 35
5. DISCUSSION ... 36
6. CONCLUSIONS ... 39
7. PRACTICAL RECOMMENDATIONS ... 40
9.ANNEXES ... 45
9.1.QUESTIONNAIRE(BEFORE&AFTERSTUDY) ... 45
9.2.2SURVEY–QUESTIONNAIRE ... 46
SUMMARY
Master Thesis of M. H. Elsheikh “The Evaluation and Impact of a patient prioritization tool for clinical pharmacy services: Hospital Setting”. Scientific supervisor Lect. Dr. R. Minkutė; Lithuanian University of Health Sciences, Faculty of Pharmacy, Department of Clinical Pharmacy. – Kaunas
The Aim of this thesis: To evaluate the impact of a validated Assessment Risk Tool had on clinical pharmacists at Midland Regional Hospital, Tullamore, Ireland.
Objectives of this research: (1) To evaluate the impact of the ART by performing a comparative analysis between the before- after study since implementation. (2) To assess the communication between prescriber and pharmacist. (3) To conduct a survey that evaluates the pharmacist’s preference on the implementation of the ART.
Methodology: The before – after study was carried out focusing on specific measures from July 2017 to March 2018. A quantitative review was conducted with a selected number of drug charts to evaluate the full impact of the Assessment Risk Tool. For the before study 149 drug charts was assessed and for the after study 140. Prescribers actions were followed in response to pharmacists interventions. A total of 15 pharmacists, after implementation of the ART, were surveyed to evaluate the impact the tool had on daily work as clinical pharmacists. Data were analysed using Excel and SPSS software program. Descriptive statistics were generated in the form of numbers and percentage. To evaluate statistical significance of relation between variables chi-square (χ2) test was applied.
Results: Comparative analysis between before- and after - study showed an increase in endorsement of drug charts for P1 (19 % vs 36.8%) and P2 (39.5% vs 54.0%) and a decrease in P3 drug charts (40.7% vs 9.2%). Evidence from the study shows a low response rate from prescribers to pharmacist’s interventions: 43% no response rate of drug charts with a recommendation from a pharmacist – 29% was P1 and 34.1% P2 patient drug charts. Surveyed pharmacists were overall satisfied (87.6%) with the ART and a positive preference when working with the ART. 66.7% have followed by agreeing to the ART has assisted in identifying patients who are more medically complicated and the tool has made them notice certain aspects of patient care management pre-implementation.
SANTRAUKA
M. H. Elsheikh magistro baigiamasis darbas „Klinikinių farmacijos paslaugų pacientų prioritetų nustatymo priemonės įvertinimas ir įtaka ligoninės aplinkoje“, mokslinė vadovė lekt. dr. R. Minkutė; Lietuvos sveikatos mokslų universiteto Farmacijos fakulteto Klinikinės farmacijos katedra. – Kaunas
Tyrimo tikslas: įvertinti patvirtinto rizikos įvertinimo instrumento (angl. ART) įtaką klinikinių vaistininkų darbui Midlando regioninėje ligoninėje, Tullamore, Airijoje.
Tyrimo uždaviniai: (1) Įvertinti ART įtaką, atlikus lyginamąją analizę prieš ir po ART įdiegimo; (2) įvertinti gydytojo ir vaistininko bendravimo lygį; (3) atlikti apklausą, įvertinančią vaistininko požiūrį į ART tinkamumą.
Metodika. “Prieš ir po” įrankio įdiegimo tyrimas atliktas 2017 m. liepos mėn. - 2018 m. kovo mėn. nagrinėjant konkrečias problemas. Atlikta kiekybinė pasirinkto skaičiaus vaistų kortelių analizė, kad būtų įvertinta pilną rizikos vertinimo priemonės įtaka. Tyrime “prieš” buvo įvertintos 149 vaistų kortelės, tyrime “po” - 140. Gydytojų veiksmai įvertinti jų atsakymu vaistininko intervencijoms. Po ART įdiegimo apklausiant 15 vaistininkų buvo įvertinta priemonės įtaka kasdieniam klinikinio vaistininko darbui. Duomenys buvo analizuojami naudojant Excel ir SPSS programinę įrangą. Aprašomoji statistika pateikiama skaičiais ir procentais. Chi-kvadratas (χ2) taikytas statistinio ryšio tarp
kintamųjų įvertinimui.
Rezultatai: lyginamoji “prieš” ir “po” tyrimų analizė parodė, kad padidėjo vaistų kortelių peržiūra esant P1 (19% lyginant su 36,8%) ir P2 lygmeniui (39,5% lyginant su 54,0%) bei sumažėjo P3 lygmens kortelių peržūra (40,7% lyginant su 9,2% ). Iš tyrimo duomenų matyti, kad gydytojai mažai reaguoja į vaistininko intervencijas: 43% kortelių nėra atsako į vaistininko rekomendacijas, tarp jų 29% - P1 ir 34,1% P2 lygmens. Apklausti vaistininkai (87,6%) buvo patenkinti ART ir linkę dirbti naudojantis šią priemone. 66,7% apklaustųjų laikėsi nuomonės, kad ART padeda identifikuoti pacientus, kurie yra mediciniškai sudėtingesni ir šis įrankis leido pastebėti tam tikrus pacientų priežiūros aspektus.
ACKNOWLEGDEMENTS
I would like to express my deepest appreciation to my clinical supervisors Lect. Dr. Rima Minkute and Chief II Pharmacist Oisín Ó hAlmhain for their patience, guidance and encouragement during my final year project. Their efforts and excellent teaching enabled me to develop an understanding and interest of the subject. I would also like to thank Jūratė Tomkevičiūtė who helped me with all the statistical analysis of my data. I am deeply grateful for her kindness, sound advice and help during my research.
CONFLICTS OF INTEREST
“The authour reports no conflicts of interest“ETHICS COMMITTEE CLEARANCE
“The evaluation and impact of a patient prioritisation tool on clinical pharmacy services: Hospital Setting”
ABBREVIATIONS
ADE – Adverse drug eventsADR – Adverse drug reactions
aPTT – activated Partial Thromboplastin Time ART – Assessment Risk Tool
CCM – Chronic Care Management CCU – Coronary Care Unit
COPD – Chronic Obstructive Pulmonary Disease DRP – Drug Related Problems
eGFR – estimated Glomerular Filtration Rate eMMs – electronic Medication Management system ELECTIVE – Orthopaedic Elective
GP – General Practitioner
GSPAML – Gold standard Pre-Admission Medication List HbA1c – Haemoglobin A1c
ICU – Intensive Care Unit.
INR – International Normalised Ratio iPM – iPatient Manager (System) ME – Medication Error
MED – Medical Ward
MedRec – Medication Reconciliation
MRHT – Midland Regional Hospital, Tullamore OHIU - Oncology/Haematology Inpatient Unit, PCV – Premature Ventricular Contraction P1 – Priority 1
P2 – Priority 2 P3 – Priority 3
QI – Quality Improvement SCr – Serum Creatinine
TRAUMA - Orthopaedic Trauma UK – United Kingdom
GLOSSARY OF TERMS & DEFINITIONS
Assessment Risk Tool is an application for monitoring pre-specified clinical ‘flags’ for high-risk medication use and other ADE risk factors.
Endorsed Drug Chart: a term used by pharmacist to show they have revised the medication chart.
Incident Reports: is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient.
Medication reconciliation is the process of evaluating current medication treatment to manage the risk and optimize the outcomes of medication treatment by detecting, solving, and preventing medication-related problems.
PharmActive is a database used for monitoring of activity and reporting of incidents by clinical pharmacists at MRHT.
Poly-pharmacy status: Polypharmacy is the concurrent use of multiple medications by a patient. With respects to this write up, 8 or more medications.
INTRODUCTION
Clinical pharmacists contribute positively to medication reconciliation on admission to hospitals and they should be engaged to deliver this service within 24 hours of admission to prevent any possible prescribing errors or possible adverse drug events. Adverse events in health care have received increasing attention over the past two decades because many of them are preventable. Errors surrounding the selection or dosing of medications have been described as one of the most prominent areas in health care that result in preventable adverse events [20]. Clinical pharmacy’s positive contribution towards patient care has been proven countlessly; classifying and predicting errors of inpatient medication reconciliation gives way for pharmacists to prevent unfavourable decisions which effectively prevents potential harm to patients [3].
Adverse drug events are an epidemic patient safety issue occurring in 5% - 40% of hospitalized patients and in 12% - 17% of patients after hospital discharge [4,5]. Through specific interventions, clinical pharmacists are most trained to reduce ADEs. Focusing on patients who are most likely to benefit from clinical pharmacy services is an appropriate approach to ensuring optimal patient care in the absence of increased resources which would allow a pharmacist to review all patients who are most in need of medication reviews to be seen on a priority basis in line with available resources [6]. Both nursing and medical professionals have developed prioritisation techniques to help assess patient acuity and guide the levels of hospital care and staffing required in Ireland and the United Kingdom [7,8]. However, there are no current articles published about a tool that delivers patient acuity and complexity of pharmaceutical regimens to identify patients at greater risk of adverse events in Ireland. Pharmacist involvement is favourable around the hospital and by allowing this service to be more efficient and frequent, both patients and pharmacists will benefit greatly [10].
The rapidly ageing population and the health impacts of socioeconomic deprivation pose health care challenges within Irish Hospitals [27]. The Pharmacy Department at Midland Regional Hospital Tullamore, Ireland has taken interest to the idea of a prioritisation tool, which will aim to conduct interventions in a more timely and targeted manner. In 2016, the total number of patients admitted was 15,715; recorded interventions were at 15,103 and a total of 1,786 incident were reported. The next year it was recorded a total number of patients admitted 15,701; recorded interventions were 25,778 with incident reports being 3,557. This increase in number over a relatively short period of time is concerning to all health care professionals.
Assessment Risk Tool adapted from a study by Falconer et al – Annex -3 [6, 32]. In this study, the theoretical prediction is the ART will improve patient care by pharmacists time being more resourceful. Performed study revealed the gap between prescribers and pharmacists – the demand to increase communication is clear. Disucssions with prescribers would increase the probability the tool can become more effective with pharmacists actions with patient management. Pharmacists response to the Assessment Risk Tool with their preference is to be likely postive once shown effective on a practical level.
Background:
MRHT is a public hospital that holds 180 in-patient beds and 66-day beds with an approximately 1200-1300 monthly patient admission to 12,000 patients annually. Staff members carried out a needs assessment and prioritization were seen as a possible means of improving the efficiency of clinical pharmacy services. MRHT faces with a challenge of limited pharmacist resources and growing number of hospital admissions making it challenging to undertake medication reconciliation for all patients across the continuum of care. The pharmacy department currently concentrates on medicines reconciliation for the most recently admitted patients on each ward. Prioritisation is manually done for patients based on the individual pharmacist’s clinical judgment and experience and was a subjective and time-consuming process. As priorities may vary independently of the available resources, concern was raised that follow up might not reach the standards of consistency which the pharmacists were aiming for.
AIMS AND OBJECTIVES OF THESIS
Aim
To evaluate the impact of a validated Assessment Risk Tool had on clinical pharmacists at Midland Regional Hospital, Tullamore, Ireland.
Objectives
1. To evaluate the impact of the ART by performing a comparative analysis between the before- after study since implementation.
2. To assess the communication between prescriber and pharmacist.
1. LITERATURE REVIEW
1.1. Theoretical background
Adverse drug reactions represent one of the prime topics to be assessed in the modern times. According to World Health Organisation, an ADR can be defined as “any response of a drug which is noxious and unintended, that occurs at doses used in humans for the prophylaxis, diagnosis or therapy of disease; or for the modification of physiologic function knowingly excludes therapeutic failures, overdoes, drug abuse, non-compliance, and medication errors” [39]. Depending on what type of ADR (Table 1), medically teams act correspondingly.
Table 1. Types of Adverse Drug Reactions
Types of ADRs Characteristics
Type A -Dose-related
Related to a pharmacological action of drug -Predictable from known pharmacology
Type B -Not dose-related
-Uncommon
-No relation to a pharmacological action of the drug
Type C -Uncommon
-Long term exposure of drugs
Type D Prolonged exposure to a drug
Type E Termination of treatment
As we accumulate more and more information on drug responses, we must not lose sight of the sobering fact that about half of the cases of drug-related injury are from potentially avoidable adverse drug reactions. Investigations (such as plasma concentration measurement, biopsies, and allergy tests) can aid diagnosis, establish baselines for organ function and provide a means for monitoring what happens after changes in therapy. They may also rule out alternative diagnoses. The time relation between the use of the drug and the occurrence of the reaction should be assessed [41].
1.2. Clinical Pharmacists’ Contributions
performed in an Accident and Emergency department investigated what contributions clinical pharmacists had on medication histories for adults [20]. Outcomes showed from 134 patients, total of 1556 medications were taken and their activity in identifying discrepancies between GSPAML and admission medication lead to show that 97% of patients had at least one intentional discrepancy identified. 81.5% of patients had at least one medication change was intentional but documentation justifying this discrepancy was made in only 5 records (3.8%) of the total 134 surveyed. Majority of patients experienced (n =115, 85.5%) at least one difference compared to the GSPAML, which could not be rationalized by the pharmacist. Concluding that the clinical significance of unresolved unintentional discrepancies had the potential to cause moderate harm, pharmacists should engage to deliver these services within 24 hours on admission.
Assessment of pharmacist interventions in multicenter settings has been proven effective while monitoring patients [21,22]. P. Bedouch et al lead a study in France demonstrating that “pharmacist contributes to preventing drug-related problems during medication order validation is applicable”. This study suggests that a few types of drugs and errors represent a substantial proportion of pharmacist interventions. A sample of 1800 randomized interventions showed 4.66 PI’s per 100 medication orders; 25.9% targeted psychotropic drugs, 15.9% antithrombotic drugs. Nearly half (42.2%) of the pharmacist’s recommendations were related to drug choice, followed by dose adjustment (23.3%), optimization of administration (21.9%) and need for drug monitoring (12.2%). Rate of physician’s acceptance was 73.4%.
Evidence demonstrates that MedRec has the potential to identify many medication discrepancies and then proving reduced potential harm. A systemic review was carried out to evaluate the impact of medication reconciliation [23]. It was identified that unintentional discrepancies are found within 3.8% - 98.2% of patient’s medication histories. Furthermore, it was noticed that medication reviews identified medication related problems or possible adverse drug reactions in 17.2% - 94.0% of patients. The outcomes for the clinically complicated patients improve scientifically when a clinical pharmacist is present on time of admission, due to their extensive knowledge of medication [22].
Management of adverse drug events is a pressing concern in today’s health care systems [24]. A Swedish study has also indicated adverse drug reactions as 7th most common cause of death [25]. The
patients-day before intervention to 3.5 after interventions. Pharmacists made 366 recommendations related to drug ordering, of which 362 were accepted by the physician [26].
“Clinical pharmacists are uniquely trained in therapeutics and provide comprehensive drug management to patients and providers such as physicians and other health care professionals. Pharmacist’s intervention outcomes include economic, health-related quality of life, patient satisfaction, medication appropriateness and management of ADE and ADR” [2,3]. However, with scarcity resources and hospitals struggling to fully implement medication reconciliation across the continuum, it may seem natural to target patients who will most benefit from medication reconciliation [11].
1.3. Advances in tools worldwide
In a study conducted in New Zealand (Falconer et al, 2014) by the clinical pharmacy department at Middlemore Hospital, developed a patient prioritization tool [6]. The tool was designed to improve pharmacist’s management for patients at high risk for medication – related harm. To receive early interventions, using available resource, with the aim of reducing MEs and ADEs. Thirty-eight electronic “flags” were used to provide an assessment of risk score indicating a low, medium or high-risk patient. These flags were then categorized into five groups: Patient Profile (Demographics), Patient encounters (Frequency of hospital visits and types), Clinical Profiles (Patients with known chronic diseases), High-risk Medications and Laboratory Values. The authors concluded that by facilitating the identification and monitoring of patients at high risk for medication errors and adverse drug events, the tool has aided the clinical pharmacists to conduct interventions such as medication reconciliation and clinical review in a more timely and targeted manner which in effect decreased the likelihood of patients at higher risk for complications to be seen first.
are ‘readmission within 30 days’ and ‘ diabetic medications on admission’. They have concluded the ART has effectively assisted in prioritising patients for medication review.
Similarly, in Australia, a study was preformed aimed to investigate the impact of the introduction of an electronic medication management system on the proportion of patients with a recorded medication reconciliation on admission, the time from admission to when medication reconciliation was performed, and the characteristics of patients receiving this intervention pre-and post-implementation [12]. A retrospective observational study was conducted in three wards across two phases. A total of 370 patients were included, 179 pre- and 191 post-implementations. The proportion of recorded admission medication reconciliation significantly increased post-implementation in all study wards. After evaluation of results the study reports to more high-risk patients receiving this service on admission to hospital and in a timelier manner. Few studies have investigated the rate at which admission medication reconciliation occurs in clinical practice and the impact an electronic medication management system has on any intervention. In this study, there was a significant increase in the rate of admission medication reconciliation in all study wards. Bringing it closer to national and international targets of 100% and 80% admission medication reconciliation rates as set by the NSW Health Government and the World Health Organization, respectively [13,14].
pharmacists’ adherence to the tool; and identity’s when pharmacists do not adhere to the tool. In total, 15/35 (43%) patients had pharmacist-documented patient acuity level that did not adhere to pharmacy department Pharmaceutical Assessment Screening Tool guidance.
Related ideas have been brought to the attention of many hospitals in the expectations of decreasing ADEs. ‘The effect of an electronic medication reconciliation application’ proved effective in an article by Schnipper et al [17]. It evaluated and concluded that a computerized medication reconciliation tool was associated with a decrease in unintentional medication discrepancies with potential for patient harm by ADE occurring. Additionally, Cadwallader et al investigated the use and optimization of facilitating clinician – focused decision making by aiming to design an application to assist with medication reconciliation. By displaying information from multiple sources, indicates discrepancies among sources, displays information about adherence, and sorts the medication list in a useful display for clinical decision making [18].
Nurses and Physicians have prioritisation tools to help assess patient insight and guide the levels of hospital care and staffing required in the UK [19]. The ‘Productive Ward’ and Early Warning Scores’ are of the most prominent lean-based healthcare QI initiatives in the UK, and has received considerable international attention [7,8]. Given health care professionals are adapting to the new age and society; clinical pharmacy services are too to pledge greater patient pharmaceutical care.
2. REARCH METHODS AND METHODOLOGY
2.1. Study Setting
The clinical pharmacy team at MRHT took the initiative in developing an Assessment Risk Tool. This quality improvement initiative intends to enhance pharmaceutical care throughout the hospital. A literature search based on prioritization of patients who are most at risk of adverse drug events was carried out to find – a study in New Zealand (Falconer et al, 2014) established parameters to identify patients who are most in need. A before – after implementation study evaluated the impact of the tool. Once the study was completed, pharmacists where surveyed on their preference.
Development of ART: The tool was adapted in accordance to pharmacy services at MRHT. The ART, a predictive risk-profiling tool was developed based on specific clinical criteria known to be associated with risks of ADEs and MEs. The ART was designed with a total of 36 risk “flags”, divided into 5 groups: Patient Profile (age, ethnicity), Patient Encounter type (frequency and type of hospital visits), Clinical Profile (known chronic disease states), High-risk Medications (number and type) and Laboratory Values. Each flag was assigned a scoring range from 1 to 10 with 10 being the highest possible score for an individual flag (Annex - 3). In using the ART, the scores are summed for all triggered flags to provide a patient’s total risk score (X). Based on the total score, patients are divided into high, medium and low risk for ADEs and MEs (Priority 1, Priority 2, and Priority 3). Pharmacists receive a list of patients in order of priority every morning; highlighted with a specific colour (Table 2) calculated by the tool. The clinical pharmacy team currently has a system (PharmActive V2, 2016) in place that facilitates the ART, developed by the Chief II clinical pharmacist specialized in medication safety and IT.
Table 2. Risk Score Assessment
Priority level Score Colour Risk Priority 1 (P1) X > 22 Pink High Priority 2 (P2) 11 ≤ X ≥ 22 Yellow Medium Priority 3 (P3) X ≤ 10 White Low
2.2. Study design, area and period
The before – after study was carried out focusing on specific criteria from July 2017 to March 2018. A quantitative review (Annex - 1) was conducted with a selected number of drug charts (n = 289). The final date of implementation of the ART was on the 11th of November 2017. Once completed, the
priority scores for the selected sample in the before group (n =149) were calculated and separated into three classifications, P1, P2 and P3, to identify which patients are more at risk. During final assessments the after – study was followed up by taking a sample (n =140) from January – March 2018. Following the criteria specified for the before study, a comparative analysis for the interventional study will identify the impact of the ART.
2.3. Inclusion and exclusion criteria
Inclusion Criteria: Exclusion Criteria:
1. Coronary Care Unit, 1. Children & Adolescent Ward 2. Oncology/Haematology Inpatient Unit, 2. Oncology/Haematology Day Unit 3. Orthopaedic Ward – Trauma & Elective 3. Day Hospital Unit
4. Surgical ward 4. Renal & Dialysis Day Unit
5. Medical Ward 1, 2 & 3 5. Emergency Department
2.3. Study population
Sample population included all patients at Midland Regional Hospital Tullamore that were admitted into the wards stated in the inclusion criteria, during the timeline stated were eligible to be included in this study.
2.4. Sample size and sampling techniques
Convenient sampling method was used to collect data. Patient drug charts which were found during the study period that fulfilled the inclusion criteria were sampled.
• n = is the sample size required;
• N = is the whole target population in question;
• p = is the average proportion of records expected to meet the various criteria (1-p) is the average proportion of records not expected to meet the criteria;
• A = is the margin of error deemed to be acceptable (calculated as a proportion) e.g. for 5% error either way A = 0.05;
• c = is a mathematical constant defined by the Confidence Interval chosen i.e. (how sure we need to be of the result)
N = 2000 as this is the approximate admissions for 6 months within the 8 wards stated. p is assumed to be 10% as it is unknown the expected incidence. A is the margin of error which is 0.05 and lastly c is the Confidence interval chosen for this study, 95%. Sample Size calculated is 130 [40]. 400 patients were selected from the PharmActive V2 system, 200 even for both before and after study to ensure to meet the 130 sample size calculated. For the before study 149 drug charts were found during ward rounds and similarly for the after – study 140 drug charts were found. Drug charts not present on ward rounds were excluded from study sample.
2.5. Data collection procedure and instruments
Endorsed drug charts states pharmacists responsible for the ward have signed off at the medication chart and if needed then reconciled the medications. Not endorsed then was assumed the pharmacist had not signed off on the drug chart hence medications were not looked at. To show the differences the ART has done, a structured questionnaire (Annex -1) consisting of closed questions which were used for this research. Following the inclusion criteria patient drug charts for both before and after study were examined by checking if the following occurred from the selected sample: Endorsed drug charts by pharmacist, complete medication reconciliation, amount of days between patient admission and date of completed MedRec, notes for prescriber, response from prescriber, proof of response from the prescriber and lastly priority level was collected. This was executed on Pharmactive
V2 where it was to be stored until finalization of ART. Remaining information needed for study; Ward,
GP Registration, Nursing Home Resident, Polypharmacy Status and High-Risk Medications found on
PharmActive V2.
2.6. Survey
Pharmacists at MRHT, after - implementation of the ART, were surveyed to evaluate the impact the tool had on daily work as clinical pharmacists. The questionnaire (Annex- 2) consisted of combined open and closed questions aimed to evaluate if: pharmacists were satisfied, its positive impact on daily work life and lastly a comparative section to how information is presented to the pharmacist. At the time of this study, a total of 10 pharmacists worked in the department and 5 pre-registration pharmacists. From this, all pharmacists were eligible to take this survey. In March 2018, the survey was sent via Google forms for evaluation. The results of this survey were analysed to assess pharmacist’s preference with the ART, if they were satisfied, the impact it had on their clinical skills and lastly a comparative intake with the previous system they had in place.
2.7. Data Analysis
2.8. Ethical consideration
4. RESULTS
A sample of 289 drug charts in total was estimated to be sufficient for full evaluation of this study. A total of 15 pharmacists participated in the survey. The results were presented in the form of tables and figures for convenience.
4.1. Need for Assessment Risk Tool
Number of days between admission and interventions are crucial, studies show that the greater the number of days, the more likely the patient is at risk of an adverse event. Pharmacists must target most at risk in a timely amount of days but due to time and resource restrictions this is not always possible or feasible [28]. The Figure 1 implies that pharmacists perform MedRec the most within 0-3 days with a relatively even distribution of patients. A pressing concern was found when patients were not seen by a pharmacist on the 4th day or more after admission. Among those patients were 65 years old or above and held a poly-pharmacy status. Pharmacists had taken up to 8 days after admission to perform medication reconciliation for patients whom are considered of this risk.
Fig. 1. Before – study: Time (Days) between admission date and MedRec intervention for patients who are 65 and above & Polypharmacy status, n= 149 (p-value = 0.446)
4.2. Comparative Analysis of ART
4.2.1. Endorsed vs Not Endorsed drug charts
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% 0 1 2 3 4 5 7 8 P r op or ti on of p at ie n ts w it h a P ol y -p h r m c y st at u s (% )
Number of Days before MedRec
The ART is aimed to deliver pharmaceutical care to the patient who are most at risk of an adverse event. Figure 2 displays a comparative illustration in delivering medication management by pharmacists before and after implementation of the ART. A total of 149 drug charts were selected for the Before study, 54.4% (n = 81) drug charts were Endorsed by a pharmacist and 45.6% (n = 68) not Endorsed. These figures were compared to the priority levels provided by the ART, it is shown not all patient charts of high-risk (P1 and P2) were endorsed by a pharmacist. For the After Study, 140 drug charts were taken, 62% (n = 87) drug charts were Endorsed and 38% (n = 53) not Endorsed. These figures were compared to the priority levels provided to assess if the ART had assisted in summing up the number of patients who are considered to be at a higher risk. 100% of drug charts held a P3 level status indicating the Assessment Risk Tool has assisted in targeting patients who are more medically complex – the percentage of endorsed charts in P1 (19.8% vs 36.8%) and P2 (39.5% vs 54.0%) levels increased and P3 levels decreased (40.7% vs 9.2%) statistically significant after implementation of the tool.
Fig. 2. Priority Level by percentage of Drug Charts (Endorsed or Not Endorsed). Comparison
between Before-After implementation of ART (Before p-value = 0.175, *After p-value = <0.001)
Overall comparison of Endorsed or Not endorsed drug charts pre- and post – implementation of ART is presented in Table 3. Characteristics such as Gender, Age, GP Registration, Nursing home residency, Medication reconciliation and Poly- pharmacy status of patients were analysed in the table to demonstrate the effects of the Assessment Risk Tool. Endorsed drug charts of patients Nursing home residency, Poly-pharmacy status and patients’ Age displayed the following results. Nursing home residents are at high risk of having an ADE. Particular attention should be directed at new residents, those with multiple medical conditions, those taking multiple medications, and those taking
19.8% 13.2% 36.8%* 0.0% 39.5% 30.9% 54.0%* 0.0% 40.7% 55.9% 9.2%* 100.0% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0%
Endorsed NotEndorsed Endorsed NotEndorsed
Before After P r op or ti on of D r u g C h ar ts (% ) P1 P2 P3
psychoactive medications, opioids, or anti-infective drugs [43]. Nursing home residents (8 vs 13) show no evidence of effects of ART in endorsement of chart in the before and after study (p-value = 0.321). Patients with 8 or more medications (35 vs 67) who are considered of a poly-pharmacy status demonstrate positive effects of implementation signifying a statistical significance in endorsed drug charts (p-value < 0.001). Patients age 65 or above (55 vs 70) and lower (26 vs 17) indicated no evidence in increased endorsement of drug chart pre- and post – ART endorsed drug charts (p-value = 0.321).
Table 3. Comparative Analysis between the Before - After Study with Endorsed vs not Endorsed Drug charts
Before n= 149 After n= 140
Drug Charts Endorsed = 81,(54.4%) NotEndorsed = 68, (45.6%) Statistical significance (p-value) Endorsed = 87, (62%) NotEndorsed = 53, (38%) Statistical significance (p-value) Gender Female Male 38 (46.9%) 43 (53.1%) 34 (50.0%) 34 (50.0%) 0.707 45 (48.3%) 42 (48.8%) 24 (45.3%) 29 (54.7%) 0.460 Age 65 >65 55 (67.9%)* 26 (32.1%)* 38 (55.9%) 30 (44.1%) 0.131 <0.001 70 (80.5%)* 17 (19.5%)* 18 (34.0%) 35 (66.0%) <0.001 <0.001 GP Registered Yes No 81 (100%) 0 (0.0%) 68 (100%) 0 (0.0%) <0.001 85 (97.7%) 2 (2.3%) 53 (100%) 0 (0.0%) 0.266 Nursing Home Resident
Yes No 8 (9.9%)* 73 (90.1%) 6 (8.8%) 62 (91.2%) 0.826 13 (14.9%)* 74 (85.1%) 0 (0.0%) 53 (100%) 0.003 Medication Reconciled Yes No 81 (100%) 0 (0.0%) --- <0.001 83 (95.4%) 4 (4.6%) --- <0.001 Poly-Pharmacy Status (8 medications or More)
Yes No 35 (43.2%)* 46 (56.8%) 22 (32.4%) 46 (67.6%) 0.174 67 (77.0%)* 20 (23.0%) 1 (1.9%) 52 (98.1%) <0.001 * Cross-tabulations between before and after study to further assess statistical significance
medications to cause an adverse event. Taking this into consideration it was necessary to measure the frequency of ‘high-risk medications’ which are presented in Table 4. Before study consisted of 81 endorsed drug charts. Of these charts 43.2% (n = 35) had zero high-risk medications listed in their drug chart, 22.2% (n = 18) only 1 medication and 34.6% (n = 28) had 2 or more from the high-risk group. The after-study had 87 (62.1%) endorsed drug charts. 18.4% (n = 16) had zero medications from the high-risk classification, 32.2% (n = 28) had 1 medication and the remaining 49.4% (n = 43) had 2 or more high-risk medications. An increase of approximately 15% (34.6% vs 49.4%) of endorsements by pharmacists for patients who are on higher-risk medications was identified. The ART has allowed pharmacists to target patients most in need of medication reconciliation.
Table 4. Frequency of High-Risk Medications Before-After implementation of ART
Before n = 149 After n= 140
Drug Charts Endorsed = 81,(54.4%) NotEndorsed = 68, (45.6%) Statistical significance (p-value) Endorsed = 87,(62.1%) NotEndorsed = 53, (37.9%) Statistical significance (p-value) Anti-epileptic’s Yes 1 (1.2%) 2 (2.9%) 0.460 3 (3.4%) 0 (0.0%) 0.172 No 80 (98.8%) 66 (97.1%) 84 (96.6%) 53 (100%)
Cardiovascular (3 or More medication)
Yes *21 (25.9%) 13 (19.0%) 0.249 *42 (48.3%) 7(13.2%) <0.001 No 60 (74.1%) 55 (80.9%) 45 (51.7%) 46 (86.8%) Anticoagulants Yes 22 (25.9%) 13 (19.1%) 0.324 29 (33.3%) 7 (13.2%) 0.008 No 59 (72.8%) 55 (80.9%) 45 (51.7%) 46 (86.8%) Diabetic Medicines Yes 19 (23.5%) 8 (11.8%) 0.065 20 (23.0%) 0 (0.0%) <0.001 No 62 (76.5%) 60 (88.2%) 67 (77.0%) 53 (100%) Opioids Yes 16 (19.8%) 10 (14.7%) 0.419 25 (28.7%) 11 (20.8%) 0.295 No 65 (80.2%) 58 (85.3%) 62 (71.3%) 42 (79.2%)
Therapeutic Drug Monitoring Group
Yes 8 (9.9%)* 7 (10.3%) 0.933 15 (17.2%)* 0 (0.0%) <0.001
No 73 (90.1%) 61 (89.7%) 72 (82.8%) 53 (100.0%)
* Cross-tabulations between before and study to further assess statistical significance.
results (p-value = 0.165). The after study shows 4 groups having a statistical significance in the amount of endorsed drug charts versus the not endorsed, i.e. Cardiovascular group (p-value = <001), Anticoagulants value = 0.008), Diabetic medications value< 0.001) and TDM medications (p-value < 0.001).
As shown below in table 5 the proportion of patients with a P1 and P2 priority level (n = 9 and 21) did not have documented endorsed drug chart before implementation of the tool. Comparing to after implementation of ART, 0% (n = 0) of patients who are at a higher risk of ADEs (P1 and P2 patients) are endorsed by a clinical pharmacist illustrating the positive effects of the ART. Regardless, if these specific patients are theoretically at a higher risk, the risk assessment carried out by the tool based on all parameters: patient demographics, encounters, clinical profile, high-risk medication and laboratory results, showed that the patients are not as needed for an intervention as others. Allowing pharmacists to be more effective on wards when time and resources are scarce.
Table 5. Categories of Priority Level Patients
Before n = 149 After n= 140
Drug Charts Endorsed = 81,(54.4%) Not Endorsed = 68, (45.6%) Statistical significance (p-value) Endorsed = 87, (53%) Not Endorsed = 53, (38%) Statistical significance (p-value) Priority 1 16 (19.8%) 9 (13.2%) 0.175 32(36.8%) 0 (0.0%) <0.001 Priority 2 32 (39.5%) 21 (30.9%) 0.175 47(54.0%) 0 (0.0%) <0.001 Priority 3 33 (40.7%) 38 (55.9%) 0.175 8 (9.2%) 53 (100.0%) <0.001
P1 and P2 have been endorsed by a pharmacist. P3 patients on wards CCU, OHIU, Surgical and Orthopaedic – Trauma have been endorsed but as shown in fig 5, on day 2, 3 or 4 after admission. Overall, pharmacist now target patients in specific wards implying pharmacists assist where most needed.
Table 6. Comparison of Endorsed drug charts before and after implementation of ART. Distribution of patient priority levels among wards
Ward Before (p-value = 0.723) After (p-value = 0.010) * P1 (n = 16) P2 (n = 32) P3 (n = 33) P1 (n = 32) P2 (n = 47) P3 (n = 8) CCU 1 (6.3%) 3 (9.4%) 4 (12.1%) 4 (12.5%) 7 (14.9%) 2 (25.0%) ELECTIVE 0 (0.0%) 0 (0.0%) 1 (3.0%) 2 (6.3%) 8 (17.0%) 0 (0.0%) MED 1 2 (12.5%) 8 (25.0%) 5 (15.2%) 11 (34.4%) 9 (19.1%) 0 (0.0%) MED 2 2 (12.5%) 4 (12.5%) 4 (12.1%) 9 (28.1%) 9 (19.1%) 0 (0.0%) MED 3 6 (37.5%) 8 (25.0%) 7 (21.2%) 4 (12.5%) 3 (6.4%) 0 (0.0%) OHIU 2 (12.5%) 5 (15.6%) 3 (9.1%) 1 (3.1%) 2 (4.3%) 2 (5.0%) SURGICAL 2 (12.5%) 3 (9.4%) 2 (6.1%) 0 (0.0%) 5 (10.6%) 1 (12.5%) TRAUMA 1 (6.3%) 1 (3.1%) 7 (21.2%) 1 (3.1%) 4 (8.5%)* 3 (37.5%)*
4.2.2. Medication Reconciliation
Fig. 3. Proportion of patients receiving MedRec (%) vs Priority levels – Before and After implementation (*p-value < 0.001)
Literature sources recommend admission MedRec should be conducted within 24-hours of all hospital admission, or at least before the end of the next working day, to reduce the potential adverse events [28]. As discussed above, pharmacists should target patients more at risk in a timely and targeted manner. Figure 4 shows patients of all priority levels were seen between 0-8 days after admission before the implementation of ART.
Comparative analysis between figures 4 and 5 shows the positive effect the ART had on patients who were of a P1 and P2 status. Days between MedRec have decreased significantly, 8 days down to 4 since implementation of ART. In fig. 5 patients who were a P3 status were seen by a pharmacist either on day 3 or 4; on day 1 and 3 it is seen that some P1 status patients were seen, this is due to patient’s priority levels fluctuating within hospital stay. This analysis shows that all high-risk patients were seen in adequate time and patients who were not as high-risk were seen in a reasonable time frame. The ART has halved the number of days between date of admission and number of days before MedRec was completed, giving additional reasoning to believe the ART has allowed pharmacists to work effectively and efficiently to all patients across.
Fig. 4. Patients receiving MedRec vs Days after admission (Proportion according to p-levels, p-value = 0.162) – Before implementation of ART
Fig. 5. Patients receiving MedRec vs Days after admission (Proportion according to p-levels, p-value < 0.001) – After implementation of ART
4.3. Assessment of communications between prescriber and pharmacist
Combined from the before and after study a total of 289 drug charts, 58% (n = 168) charts were endorsed by a pharmacist and 94% of endorsed charts (n = 164) were reconciled of their medications.
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 0 1 2 3 4 5 7 8 P r op or ti on of p at ie n ts r e c e ivi n g M e d e c ( % )
Number of days before MedRec is completed Before P1 P2 P3 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0% 140.0% 0 1 2 3 4 P r op or ti on of p at ie n ts r e c e ivi n g M e d R e c (% )
Number of days before MedRec Completed After
From these charts, it was assessed if the pharmacist had any requests for the prescriber, if the prescriber replied to the notes or if there was any other evidence of a response on the drug chart. Requests by a pharmacist were made for 58.5% (n = 96) of endorsed drug charts. Fig. 6 shows that 9% (n = 9) of requests had replies from prescriber and 47.9% (n = 46) of drug charts showed other evidence of a response. A remaining 43.1% (n = 41) showed that prescribers had left no response to the intervention by the pharmacist.
Fig. 6. Responsiveness of prescribers to requests made in interventions by pharmacists (p-value = 0.04)
Table 7 demonstrates 42.7% (n = 41) of patients whose drug charts have been endorsed and MedRec was applied by a clinical pharmacist have no evidence of a response in the form of a reply by a signature or changes in therapy. This information reveals patients that were at a higher risk (P1 and P2 patients) of an incident occurring did not receive the intended pharmaceutical care and proper medication reconciliation as suggested by the pharmacist.
Table 7. Response from prescriber to requests by pharmacist with relation to priority level (p-value = 0.979)
Priority Level Total
P1 P2 P3
Response
(Replies + other evidence)
4.4. Evaluation of survey taken by Pharmacist
The results of this survey were analysed to assess pharmacist’s preference with the ART. The survey was presented in three different sections: (1) if they were satisfied, (2) the impact the ART had on their clinical skills and (3) comparative intake with the previous system the department had in place.
Fig. 7. Pharmacist’s current position at time of survey (n = 15)
Figure 7 shows pharmacists’ current title at the time survey was given. Specialised senior pharmacist’s (33%) in Antimicrobials and Renal are among those. Not specialised senior pharmacists (13%) are currently under training to their preferred speciality, basic grade pharmacists (27%) are recently graduated from their master’s in pharmacy and lastly pre-Registration pharmacists (20%) are those who are in training and currently hold a bachelor’s degree in pharmacy.
Section 1: Satisfied with ART
In general majority of pharmacists are content with the performance of the ART. When asked
“Overall, are you satisfied or dissatisfied with the performance of the ART?” and “Do you think the Assessment Risk Tool is applicable for your current work place” 86.7% (n = 13) selected for “Satisfied”
and 13.3% (n=2) stated they were “Dissatisfied”. From the ‘needs-assessment’ carried out by the Clinical team it was brought to their attention that pharmacists were unhappy with their work-value by the end of the day. When the pharmacists were asked “Do you feel your work is more valuable since
implementation of the ART?”, 66.7(n = 10) said “Yes”, 6.7% (n = 1) said “No” and the remaining 26.6%
stated “No difference” after implementation of ART. Figure 8 summaries statements pharmacists related 7% 33% 13% 27% 20%
Pharmacist's Positions
Chief II Pharmacistmost too; 33.3% (n = 5) expresses that the ART has made no difference to work-life. However, the majority agree, 66.7% (n=10) to that the system has helped with patient management by noticing aspects they did not look at before – in turn increases value of work.
Fig. 8. “Please choose which one of the following statements if it applies to you”
Shown in figure 8, 33.3% (n = 5) have indicated that the ART has no difference to their daily work life as a clinical pharmacist, where, 66.7% (n = 10) have preferred to state that the ART has made the pharmacist notice and consider more aspects with regards to patient management.
Section 2: Impact of ART
Table 8 summarises a series of questions based on the influence the ART had on daily work-life of a pharmacist. Overall, 80% (n = 12) of pharmacists agreed on improvement, 66.7% agreed on the ART increasing MedRec for more complex patients. It was also illustrated that 80% (n = 12) of pharmacists selected they do not see excessive information when using the ART. The remaining 20% (n=3) of pharmacists that have disagreed with a positive impact, 33.3% of pharmacists opposed the ART increased MedRec across all patients.
0
10
0
5
0 2 4 6 8 10 12
My work life has become more manageable since implementation. All information is found
on this service.
I believe this system has made me notice certain aspects I have not considered before with
regards to patient management.
I believe this tool is too clutered and some information is not necessary for daily work. It has made no difference to my daily work life
as a pharmacist.
Table 8. Summary of impact with ART
n (%)
Do you think the ART has improved your daily activities as a clinical pharmacist?
Yes 12 (80.0%)
No 3 (20.0%)
Do you think this tool has increased medication reconciliation for patients who are more medically complex?
Yes 10 (66.7%)
No 5 (33.3%)
Do you see excessive information when using the tool?
Yes 3(20.0%)
No 12(80.0%)
The Fig. 9 represents pharmacist’s opinions on every section of ART (Annex - 2) when performing medication reconciliation. High-risk medications had most importance score of 5 (80%) over all sections followed by Lab Values and Clinical Profile at 53.3%. Least important score at 1 for MedRec by pharmacists was Patient Encounters Section at 40% followed by Patient Profile at 20%.
Fig. 9. Sections of ART evaluated by pharmacists for MedRec. Scale: 1 = Least Important, 5 = Most important 20% 40% 0% 6.70% 6.70% 40% 26.70% 6.70% 0% 13.30% 20% 20% 40% 0% 0% 20% 13.30% 0% 13.30% 26.70% 0% 0% 53.30% 80% 53.30% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Patient Profile Patient Encounters Clinical Profile High-Risk Meds Labs
Sections ranked from Most important (5) to Least important (1)
Section 3: Comparative Intake
Pharmacists were asked “What beneficial information has been added to the ‘PharmActive’
system that has made an impact with carrying out MedRec?”. 53.3% (n = 8) have found information
such as Laboratory values, high-risk medications and chronic diseases have been the most beneficial. 20% (n = 3) have found the division of patients into priority levels (P1, P2, P3) across all wards, the most helpful addition to the PharmActive system. The remaining 26.7% (n = 4) did not respond to this question.
Confirmed by a positive response rate (100%, n = 15); all pharmacists have agreed that the ART does not identify drug-drug interaction. Since implementation of ART, pharmacists can now easily identify poly-pharmacy status of patients and if patients suffer from impaired renal function.
Lastly, pharmacists were asked “If offered, what would you add or remove to the ART?”. Summary of information is found in Table 9.
Table 9. Summary of responses (N = 15)
Add N (%) Remove N (%)
Full medication list 2(13.3%) Patient Demographics/Encounters 3 (20%) Daily abnormal Lab values 2 (13.3%) Lab Parameters 2 (13.3%) Anti-Parkinson’s Medication 2 (13.3%) Removal of P-levels 1 (6.7%)
Drug – interactions 1 (6.8%)
Nothing 2 (13.3%) Nothing 4 (26.7%)
5. DISCUSSION
This study has found that implementation of the Assessment Risk Tool facilitated the uptake of Endorsed drug charts for high-risk patients (P1>22) by pharmacists within 24 hours of admission to hospital. Multiple studies have investigated the need for admission MedRec in reducing medication errors and discrepancies [29-31]. Very few studies have investigated the rate at which admission MedRec occurs and the impact of a similar ART study to observe clinical outcomes on interventions [12, 32]. In this analysis, there was a considerable increase in Endorsed drug charts for patients who are considered a higher risk before and after implementation. The results gathered show the percentage of endorsed charts in P1 and P2 levels increased significantly after implementation of the tool to 36.8% vs 19.8% and 54.0% vs 39.5%, respectively. Further assistance from the ART revealed the rate at which admission MedRec occurred decreased form 0-8 days to 0-4 days. These results echo similar findings in a study conducted in Australia recording a medication reconciliation of drug charts increasing from 47% pre- to 84% post – implementation within 24- hour of admission and 48-72 [16]. A USA study which implemented a similar eMMs and have too concluded and uptake from 5% to 84% after 2 years from eMMs implementation [33]. Furthermore, MedRec pre- and post-implementation of ART was not timed in this study, and there is increasingly conflicting evidence in the literature in the ability of an assessment risk tool to reduce the time needed to conduct admission MedRec overall [35, 36]. This is mainly possible due to the different design in studies, electronic systems and study wards. Nevertheless, the introduction in the proportion of MedRecs conducted in a timely manner and further supports the advantages of introducing this ART in the facilitation.
Moreover, lower rates of documented endorsed drug charts were reported pre- implementation in the Medical ward 3 and Orthopaedic – Trauma in comparison to post – impact. This shows Endorsement of drug charts rates are also driven according to the individual patient characteristics, risk factors and medical complexity rather than latest admissions. This, however is a limitation to this study. Distribution of pharmacists around the wards has become relatively uneven according to results of the After-study; hence leading to a decreased chance of a pharmacist being present by wards effected for an oral consultation between prescribers. However, with limited resources at hand, the ART has proven pharmacists are attending the patients who are more likely in need in a timely and targeted manner.
Health professionals play an important role in monitoring the safety of medicines by reporting any suspected incident reports. As health professionals, pharmacists are likely to observe adverse events to medicines and in turn submit a suspected incident report. Reporting such actions will in turn formulate effective and safe medication management. Several studies analysed interventions by pharmacists in reducing incidences related to problems in any practice setting. They have concluded pharmacists had knowledge about DRP’s, other related terms and also about reporting but most of them did not actively participate to reduce incidences because of their lack of their acceptance in society causing a lack of incentive [22, 37, 38]. This draws attention to one aspect of difficulties pharmacists must face. In this study, an assessment of communications between prescribers and pharmacists states a 43% no response rate from prescribers. From these patient drug chart, 63.4% of patients had a P1 and P2 priority status. Clearly indicating prescribers have not followed the pharmacist’s instructions in medication management. Further studies must be done to show the long - term effects of the ART in relation to acceptance from the prescribers.
6. CONCLUSIONS
1. Assessment Risk Tool was effective for prioritising patients for interventions such as medication review in a timely and targeted manner. Comparative analysis study showed an increase in endorsement of drug charts for P1 (19 % vs 36.8%) and P2 (39.5% vs 54.0%) and a decrease in P3 drug charts (40.7% vs 9.2%).
2. Evidence from the study shows a low response rate from prescribers to pharmacist’s interventions: 43% no response rate of drug charts with a recommendation from a pharmacist – 29% was P1 and 34.1% P2 patient drug charts.
7. PRACTICAL RECOMMENDATIONS
1. Additional studies are to be recommended: a continuation of the comparative analysis with a longer study period and larger sample size.
2. Education for prescribers on full workings of ART, followed by: to investigate possible changes in prescriber’s actions in response to pharmacist’s interventions.
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9.ANNEXES
Annex 1
9.1. QUESTIONNAIRE (BEFORE & AFTER STUDY)
1. Gender : Male Female
2. Age
3. Ward : CCU ELECTIVE MED 1 MED 2
MED 3 SURGICAL TRAUMA OHIU
4. GP Registration: Yes No
5. Nursing Home Resident : Yes No
6. Was the drug chart endorsed? Yes No
7. Was medication reconciliation carried out by a pharmacist? Yes No
8. How many days after admission was MedRec completed?
9. Priority score: P1 P2 P3
10. Was there any notes left for the prescriber ? Yes No 11. Did the prescriber reply to the notes? Yes No
Annex 2
9.2. 2SURVEY – QUESTIONNAIRE
1. Please choose current job title: Chief I Pharmacist (or Above) Chief II Pharmacist Senior Pharmacist (Specialist) Senior Pharmacist (Other) Basic grade Pharmacist Pre-Registration Pharmacist
2. Overall, how satisfied or dissatisfied with the performance of the Assessment Risk Tool? Satisfied
Dissatisfied
3. Do you think this tool is applicable for your current work place? Yes
No
4. Do you feel that your work life is more valuable since the implementation of the ART? Yes
5. Please choose one of the following statements if it applies to you:
My work life has become more manageable since implementation. All information is found on this service.
I believe this system has made me notice certain aspects I have not considered before with regards to patient management.
I believe this tool is too cluttered and some information is not necessary for daily work.
It has made no difference to my daily work life as a pharmacist.
6. Do you think the ART has improved your daily activities as a clinical pharmacist? Yes
No
7. Do you think this tool has increased medication reconciliation for patients who are more medically complex?
Yes No
8. Do you think it would be helpful if physicians and other prescribers had access to this ART? Yes
No
9. Do you see excessive information when using the Tool? Yes
