Pharmacist-driven antimicrobial optimization in the emergency department

This article reviewed the influence of a pharmacist-driven antimicrobial stewardship/ optimization service in a non-trauma emergency department of a hospital. The impact of a nurse-driven chart review was compared with a pharmacist-driven chart review. Impact was based on the number of clinical interventions made, along with resistance patterns identified from wound and urine cultures. The nurses assessed 499 patients with positive cultures, and intervened on 50% of the cultures which indicated the need for an intervention. The pharmacists assess 473 patients with positive cultures, and intervened on 80% of those that needed intervention. Interventions were based on inappropriate therapy. Also, E. coli, the most frequently isolated urinary organism, displayed a fluoroquinolone resistance rate of 38%.

This antimicrobial stewardship program showed 30% more pharmacist interventions compared to nurse interventions for “bug-drug” mismatches. Proper prescribing of antibiotics is an essential part of offsetting antibiotic resistance. This program shows that pharmacists are a key part of modifying antimicrobial therapies when needed. The high fluoroquinolone resistance rate suggests that alternative therapies may be better for some urinary tract infections, such as nitrofurantoin.

I thought this was an interesting article, because of the increase in antibiotic resistance and various efforts to offset this increase. It seems that the pharmacists are in a better position to assess and address proper prescribing of antibiotics than the nurses, because ultimately they are the medication experts. With this in mind, do you think it is beneficial for pharmacists to be able to prescribe antibiotics to patients?

Davis, L., Covey, R., Weston, J., et al. Pharmacist-driven antimicrobial optimization in the emergency department. Am J Health Pharm. 2016; 73:49-56. Doi: 10.2146/sp150036.

 

Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant’s Usability

When physicians prescribe medications to patients with certain disease states, there is no way of determining whether the medication that is being prescribed will work for the patient. For example, obtaining adequate control of chronic disease states may involve a process of testing different medications on a patient until one can be deemed as an appropriate treatment option. There are different programs that have been established in the past to provide aid to physicians looking to initiate therapy options on a patient; however, they have not been proven to cause changes in care that lead to clinically significant improvement. For this reason, a new tool referred to as STRIP (Systemic Tool to Reduce Inappropriate prescribing) has been developed to optimize the prescribing process by conducting medication reviews in the primary care setting. This program is a computer-based technology that allows physicians to analyze patients medication histories and preferences to determine the best form of therapy.

In this study, 42 physicians were asked to optimize medical records of patients utilizing multiple medications by both the traditional manner and by the STRIP analysis. Utilization of the STRIP assistance program was linked to an increase in the number of appropriate medication decisions (to 76% from 58% without). Along with this, physicians on average spent more time meeting with patients and discussing treatment options using the program. The only major negative result gathered from the study was the fact that it received a below-average score by physicians examining the usability of the system. Therefore, the STRIP assistance program was determined to be an effective tool for providing medication reviews.

I believe this study is important because it shows how one of the main roles of a pharmacist (providing medication reviews) benefits the overall experience that a patient will have with their medication. I believe having systems like this in place to aid physicians in the process of decision making will allow pharmacists to eventually become more active in the process of prescribing medications. This is something that I think is important due to the amount of knowledge that pharmacists have about medications. Optimization of prescribing methods will not only benefit the health of the individual receiving the medication, but it will also ensure that we are limiting the cost that adverse effects from drugs have on the health care system. I believe that the role of a pharmacist will only continue to expand over the next couple of decades, and as a result, the profession will be more respected by the public.

Self-Reported Medication Adherence Barriers Among Ambulatory Older Adults with Mild Cognitive Impairment

Medication nonadherence in elderly patients is a huge problem affecting more than half of patients visiting community pharmacies and is expected to lead to greater than $100 billion costs to patients and healthcare systems. Furthermore, nearly 20% of this elderly patient population, aged 65 and over, has a diagnosis of mild cognitive impairment (MCI). MCI is an early stage impairment which increases a person’s risk of developing dementia. Because a majority of the elderly population suffers from multiple medical comorbidities and requires many different medications, it is important to address their cognitive ability and how it can impact their capability to be adherent to their medications.

Many interventions have been implemented to assist older adults in being adherent to their medications, but only one intervention focused on helping patients diagnosed with an MCI has been identified and involved reminder phone calls at each dosing time throughout the day. This article focuses on a study that compared barriers to adherence faced by older adults with MCI and those without at outpatient or home-care programs. The identification of barriers was used to create new interventions that would aid in adherence among this population. Patients were surveyed using a 17-item questionnaire to determine barriers to adherence related to knowledge, cost, behavior, and physical ability. Of the 200 participants surveyed, 82.5% reported to having at least one barrier to medication adherence. There was found to not be a significant different to the average number of barriers per patient between the MCI and non-MCI group. 49% of the barriers were categorized as difficulty remembering the time or number to take for the medication.

Many self-reported barriers to medication adherence were identified, regardless of whether or not the patient had been diagnosed with a cognitive disability. Overall, the need for multi-component intervention for older adults is important to recognize and these intervention program must make targeting a barrier caused by memory their priority. These interventions must be tailored to each patient’s need and work to minimize and adherence barriers.

The information presented in this article is important to recognize as a pharmacist. As an accessible healthcare provider present at the time of dispensing, we can play a very influential role in promoting adherence to our patients. By learning to recognize common barriers or challenges that certain populations are facing, we can address these concerns or identify resources available that can improve the overall health of our patients. I think this article also presents a very interesting point in that the prevalence of barriers to adherence in older patients. Regardless of an MCI diagnosis or not, patients still reported to facing roughly the same number and type of challenges, highlighting the fact that regardless off health conditions, most patients are still plagued by challenges leading to nonadherence. Once we learn to recognize these problems and identify the cause, we can develop strategies to help these patients.

Reference:

Pharmacotherapy. 2016;36:196-202.

http://onlinelibrary.wiley.com/doi/10.1002/phar.1702/epdf

TransitionRx: Impact of community pharmacy postdischarge medication therapy management on hospital readmission rate

It has been found that nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge. This high incidence of readmission can lead to increased costs for Medicare and its beneficiaries.  Because of this, the Centers for Medicare and Medicaid Services have begun penalizing hospitals with readmission rates higher than the national average for a particular disease state by decreasing reimbursement back to the hospital. The leading cause for readmission of these patients was attributed to a medication-related problem. A study conducted in Ohio looked to determine the impact that pharmacist intervention can have when implemented during transition of care.

Kroger pharmacies partnered with two small community hospitals in the Cincinnati area for patient referral as part of the TransitionRx program. At the time of hospital discharge, nurses counseled the patients on their medications with no input from pharmacists. Patients included in the study were aged 18 or older and diagnosed with either CHF, COPD, or pneumonia. Seven clinical pharmacists received training to provide MTM services with a special focus on counseling post-discharge patients. At the time of discharge, the hospitals faxed patient information, including discharge instruction and medications to the pharmacists at the designated Kroger locations. Pharmacists then made phone calls to these patients to schedule an in-person MTM session ideally within 3 days of discharge. During these appointments, the pharmacists provided a discussion of any changes in medication, a comprehensive medication review, and disease-state education, with a special focus on “red flags”. “Red flags” were defined as specific symptoms that patients could monitor for that could indicate their disease is deteriorating. Patients were provided with a personal medication record, health action plan, an appointment list, a self-monitoring log, if applicable, and a summary of the visit was sent to the patient’s physician. A follow-up was conducted via telephone.

90 patients participated in the study and 30 received the pharmacist intervention. Of the 60 patients that did not receive discharge counseling from a pharmacist, 20% were readmitted to the hospital within 30 days, while only 7% of patients in the intervention group were readmitted. Over 200 unique interventions were made by the pharmacists to the 30 patients that they saw, with 7 interventions per patient on average.

I enjoyed reading this article because the MTM sessions carried out by the pharmacists are extremely similar to what we have been learning to do in POP with standardized patients and with SilverScripts. It is encouraging to know that even as P1’s we are already preparing for our future careers and learning skills that will be essential to patient care in the future. Understanding Medicare STAR ratings and hospital reimbursements as the future of healthcare and realizing that patient health is the priority will help to develop a patient-centered approach as pharmacists. This article also highlights the need for pharmacists working with the interprofessional healthcare team and the benefits that can be provided. With just 7 participating pharmacists being able to identify over 200 drug therapy problems in 30 patients, the need for intervention is clear to see.

Reference:

J Am Pharm Assoc. 2015;55:246-254.

http://www.japha.org/article/S1544-3191(15)30055-8/pdf

Effectiveness of Sun Protection Program for Young Children

I felt this study was important and interesting because it emphasizes sun protection behaviors that may minimize sun damage and lifelong sun protection behaviors that will reduce the likelihood of developing skin cancer. This study was a randomized controlled clinical trial with a 4-week follow-up that included 300 parents who brought their child (2-6 years of age) to a Medical Group clinic. They were randomly assigned to receive a read-along book. swim shirt, and weekly text message reminders related to sun protection behaviors. 147 were randomly assigned to receive the information usually provided at a well-child visit.

Outcomes were caregiver-reported use of sun protection by the child using a 5-point Likert scale, duration of outdoor activities and number of children who had sunburn or skin irritation. Of the 300 caregiver-child pairs, the 153 children in the intervention group had significantly higher scores related to sun protection behaviors. Examination of pigmentary changes revealed that the children in the control group had significantly increased  their melanin levels, whereas the children in the intervention group did not have change.

In conclusion, this intervention was associated with increased sun protection behaviors among young children. Do you think interventions like this could be really helpful? Getting things started in early childhood could really lead to healthy behaviors as adults. This study is really interesting in pointing that out. Also, do you think this study has a flaw in that the results were self-reported? This was a really interesting study in the effects of interventions in young children that could lead to healthy behaviors later in life.

JAMA Pediatr. Published online February 08, 2016. doi:10.1001/jamapediatrics.2015.4373

A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care

Each year, the United States emergency department treats up to 158,520 children for adverse drug effects. According to previous studies, up to 21$ of these are caused by medication errors. In this study, researchers performed a prospective intervention study in the University of Heidelsberg’s children hospital. 18 beds were systematically studied through a three-step intervention to prevent medication errors in the drug-handling processes.

Each step of the intervention was directed at different causes of errors. After three interventions, there was a significant decrease in the frequency of errors performed by the nurses, from 91% to 26%. There was also a decrease from 88% to 49% in the number of patients who were exposed to at least one medication error. It is evident that the three step intervention decreased the amount of medication errors in the hospital setting.

This study is important and interesting because while performing pediatric care, it is necessary to be certain of what medications the patient needs administered. Implementation of this three-step intervention in other hospitals around the world will decrease the amount of emergency visits children take. It is worth it in the end to take the extra precautions to reassure that the medication being administered to the patient is correct.

Niemann D, Bertsche A, et al. A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care. Journal of Clinical Nursing. 2015;24:101-14.

http://onlinelibrary.wiley.com/doi/10.1111/jocn.12592/full

Preventing infant mortality: Pharmacists’ call to action

The United States has a higher infant mortality rate than many other developed countries.  6.1 of every 1000 babies born in the U.S. dies within their first 12 months of life, not including miscarriages or stillbirths.  The leading causes of death in this country are preterm births (when the baby is born before the 37th week of the pregnancy), sudden infant death syndrome (SIDS), or low birth weight.  These deaths aren’t caused by a single factor, but a multitude of them.  Pharmacists can impact society more than they know by informing the population of the factors that contribute to infant mortality and hopefully reduce their frequency.

For example, tobacco use during pregnancy increases the likelihood of all of the leading causes of infant death in the U.S. in addition to birth defects.  Both smoking and smokeless tobacco have affects on the baby  even after it is born and can lead to complications.  Pharmacists can intervene by providing information and advice on smoking cessation as well as recommend products to help mothers quit.  Alcohol, illicit drugs, and marijuana all can have deleterious affects as well, and pharmacists can spread knowledge about these too.

Vaccines are also highly recommended to pregnant women to prevent infants from susceptibility to those diseases and infections.  The inactive forms are preferred and can range from flu to tetanus.  Pharmacists can educate their pregnant patients as well as administer these immunizations to prevent death from preventable causes.

Pharmacists can also inform the public on the advantages of breastfeeding, for instance babies who are breast fed have a lower risk of death due to SIDS.  Critical vitamins during pregnancy are another counseling point for pharmacists.

Overall, including pharmacists in the education of mothers during and after pregnancy can and should have a profound effect.  Together with their inter-professional health team, they can reduce infant mortality rates by informing the public on preventable actions that cause infant death.

DiPietro Mager N. Preventing infant mortality: Pharmacists’ call to action. JAPhA. 2016;56(1):82-87