Fernando Martínez-Martínez

Impact of implementing smart infusion pumps in a pediatric intensive care unit

PURPOSE The impact of smart infusion pumps on the interception of errors in the programming of i.v. drug administrations on a pediatric intensive care unit (PICU) is investigated. METHODS A prospective observational intervention study was conducted in the PICU of a hospital in Madrid, Spain, to estimate the patient safety benefits resulting from the implementation of smart pump technology (Alaris System, CareFusion, San Diego, CA). A systematic analysis of data stored by the devices during the designated study period (January 2010-June 2011) was conducted using the system software (Guardrails CQI Event Reporter, CareFusion). The severity of intercepted errors was independently classified by a group of four clinical pharmacists and a group of four intensive care pediatricians; analyses of intragroup and intergroup agreement in perceptions of severity were performed. RESULTS During the 17-month study period, the overall rate of user compliance with the safety software was 78%. The use of smart pump technology resulted in the interception of 92 programming errors, 84% of which involved analgesics, antiinfectives, inotropes, and sedatives. About 97% of the errors resulted from user programming of doses or infusion rates above the hard limits defined in the smart pump drug library. The potential consequences of the intercepted errors were considered to be of moderate, serious, or catastrophic severity in 49% of cases. CONCLUSION The use of smart pumps in a PICU improved patient safety by enabling the interception of infusion programming errors that posed the potential for severe injury to pediatric patients.

Identification of validated questionnaires to measure adherence to pharmacological antihypertensive treatments.

Background Low adherence to pharmacological treatments is one of the factors associated with poor blood pressure control. Questionnaires are an indirect measurement method that is both economic and easy to use. However, questionnaires should meet specific criteria, to minimize error and ensure reproducibility of results. Numerous studies have been conducted to design questionnaires that quantify adherence to pharmacological antihypertensive treatments. Nevertheless, it is unknown whether questionnaires fulfil the minimum requirements of validity and reliability. The aim of this study was to compile validated questionnaires measuring adherence to pharmacological antihypertensive treatments that had at least one measure of validity and one measure of reliability. Methods A literature search was undertaken in PubMed, the Excerpta Medica Database (EMBASE), and the Latin American and Caribbean Health Sciences Literature database (Literatura Latino-Americana e do Caribe em Ciências da Saúde [LILACS]). References from included articles were hand-searched. The included papers were all that were published in English, French, Portuguese, and Spanish from the beginning of the database’s indexing until July 8, 2013, where a validation of a questionnaire (at least one demonstration of the validity and at least one of reliability) was performed to measure adherence to antihypertensive pharmacological treatments. Results A total of 234 potential papers were identified in the electronic database search; of these, 12 met the eligibility criteria. Within these 12 papers, six questionnaires were validated: the Morisky–Green–Levine; Brief Medication Questionnaire; Hill-Bone Compliance to High Blood Pressure Therapy Scale; Morisky Medication Adherence Scale; Treatment Adherence Questionnaire for Patients with Hypertension (TAQPH); and Martín–Bayarre–Grau. Questionnaire length ranged from four to 28 items. Internal consistency, assessed by Cronbach’s α, varied from 0.43 to 0.889. Additional statistical techniques utilized to assess the psychometric properties of the questionnaires varied greatly across studies. Conclusion At this stage, none of the six questionnaires included could be considered a gold standard. However, this revision will assist health professionals in the selection of the most appropriate tool for their individual circumstances.

Agreement Between Community Pharmacy, Physician’s Office, and Home Blood Pressure Measurement Methods: The Palmera Study

BACKGROUND The usefulness of the community pharmacy blood pressure (BP) (CPBP) method in assessing the effectiveness of antihypertensive treatment has not been adequately studied. The aim of this study was to assess the agreement between community pharmacy, home, and physician office BP (POBP) measurement methods in treated hypertensive patients. METHODS BP was measured at the pharmacy (three visits), at home (4 days) and at the physician office (three visits). The Lin correlation-concordance coefficient (CCC) was used to evaluate the quantitative agreement. The qualitative agreement between methods to establish the patients hypertensive state was evaluated using the κ-coefficient. Using home BP (HBP) monitoring as the reference method, the sensitivity, specificity, positive and negative likelihood ratios of the CPBP and POBP measurement methods were calculated. RESULTS The study included 70 patients. Agreements were acceptable-moderate between CPBP and HBP (CCC (systolic BP (SBP)/diastolic BP (DBP)) = 0.79/0.66; κ = 0.56), moderate between CPBP and POBP (CCC = 0.57/0.61; κ = 0.35), and moderate-poor (CCC = 0.56/0.49; κ = 0.28) between POBP and HBP. The sensitivity, specificity, positive and negative likelihood ratio for the CPBP and the POBP measurement methods were: 60.7%, 92.9%, 8.5, 0.4 and 75.0%, 54.8%, 1.7, 0.5, respectively. CONCLUSIONS In this sample of treated hypertensive patients, the agreement between the community pharmacy and HBP measurement methods was acceptable-moderate and greater than other agreements. The CPBP measurement method was more reliable than the POBP measurement method for detecting the presence of both uncontrolled and controlled BP and could be a good alternative to HBP monitoring when the latter lacks suitability.

A multicentre, double-blind, randomised, controlled, parallel-group study of the effectiveness of a pharmacist-acquired medication history in an emergency department.

BackgroundAdmission to an emergency department (ED) is a key vulnerable moment when patients are at increased risk of medication discrepancies and medication histories are an effective way of ensuring that fewer errors are made. This study measured whether a pharmacist-acquired medication history in an ED focusing on a patient’s current home medication regimen, and available to be used by a doctor when consulting in the ED, would reduce the number of patients having at least 1 medication discrepancy related to home medication.MethodsThis multicentre, double-blind, randomised, controlled parallel-group study was conducted at 3 large teaching hospitals. Two hundred and seventy participants were randomly allocated to an intervention (n = 134) or a standard care (n = 136) arm. All consecutive patients >18 years old admitted through the ED were eligible. The intervention consisted of pharmacists conducting a standardised comprehensive medication history interview focusing on a patient’s current home medication regimen, prior to being seen by a doctor. Data recorded on the admission medication order form was available to be used by a doctor during consultation in the ED. The admission medication order form was given to doctors at a later stage in the control arm for them to amend prescriptions. The effect of the intervention was assessed primarily by comparing the number of patients having at least 1 admission medication discrepancy regarding medication being taken at home. Secondary outcomes concerned the characteristics and clinical severity of such medication discrepancies.ResultsThe intervention reduced discrepancies occurring by 33% (p < 0.0001; 0.1055 odds ratio, 0.05-0.24 95% confidence interval), despite recall bias. Regarding total discrepancies, omitting medication occurred most frequently (55.1%) and most discrepancies (42.7%) were judged to have the potential to cause moderate discomfort or clinical deterioration.ConclusionsA pharmacist-acquired medication history in an ED focusing on a patient’s current home medication regimen available to be used by a doctor at the time of consulting in the ED reduced the number of patients having at least 1 home medication-related discrepancy.Trial registrationCurrent Controlled Trials ISRCTN63455839.

Comparison of the white-coat effect in community pharmacy versus the physician's office: the Palmera study.

The aim of this study was to measure the community pharmacy white-coat effect (CPWCE) in treated hypertensive patients and to compare its magnitude with the WCE in the physicians office (POWCE). This cross-sectional study attempted to cover the treated hypertensive population, of more than 18 years of age and users of a rural CP located in Palmera (Valencia, Spain). Blood pressure (BP) was measured at three different settings, according to clinical guidelines: CP (three visits), PO (three visits), and home (4 consecutive days). The WCE was defined as the difference between the average CPBP or the average PO BP and the average home BP: CPWCE and POWCE, respectively. Differences between BP measurements were assessed by paired t-tests. The study sample consisted of 70 patients. The CPWCE was not significant, both for systolic BP (SBP) and for diastolic BP (DBP): 1.4 mmHg [standard deviation (SD): 11.3; 95% confidence interval (CI): −1.3 to 4.1] and −1.1 mmHg (SD: 7.5; 95% CI: −2.9 to 0.7), respectively. The POWCE was positive and statistically greater than 0 for SBP [13.3 mmHg (SD: 11.5); 95% CI: 10.5–16.0] and for DBP [2.4 mmHg (SD: 9.3); 95% CI: 0.2–4.6]. Finally, the POWCE was greater than the CPWCE both for SBP and for DBP (P<0.001). In this sample of treated hypertensive patients, the CPWCE was not statistically significant and was statistically lower than the POWCE.

Implementing smart pump technology in a pediatric intensive care unit: A cost-effective approach

OBJECTIVE To analyze the cost effectiveness of implementing smart infusion pump technology in a pediatric intensive care unit (PICU). MATERIAL AND METHODS An observational, prospective, intervention study with analytical components was carried out. A drug library was developed and integrated into the Carefusion Alaris Guardrails® infusion systems. A systematic analysis of all the data stored on the devices during use was performed by the data processing program Guardrails® CQI v4.1 Event Reporter. Intercepted errors were classified in terms of their potential severity and probability of causing an adverse effect (PAE) had they reached the patient. Knowing the estimated cost of a preventable adverse effect (AE), we analyzed costs saved and the profit/cost ratio resulting from the implementation process. RESULTS Compliance with the drug library was 92% and during the study period 92 infusion-related programming errors were intercepted, leading to a saving of 172,279 euros by preventing AEs. This means that 2.15 euros would be obtained for each euro invested in hiring a pharmacist to implement this technology. DISCUSSION The high percentage of use of safety software in our study compared to others allowed for the interception of 92 errors. The estimation of the potential impact of these errors is based on clinical judgment. The cost saved might be underestimated because the cost of an AE is usually higher in pediatrics, indirect and intangible costs were not considered and pharmacists involved do not spend the whole day on this task. CONCLUSIONS Smart pumps have shown to be profitable in a PICU because they have the ability to intercept potentially serious medication errors and reduce costs associated with such errors.

Intervention mapping for developing pharmacy-based services and health programs: A theoretical approach

Current challenges in pharmacy practice include the development, implementation, and evaluation of pharmacy services and the integration of pharmacists into the healthcare team. Implementation failure may be a result of poor planning during the development of services. To address such challenges,

Priorización de facilitadores para la implantación del seguimiento farmacoterapéutico en las farmacias comunitarias españolas mediante la aplicación de análisis factorial exploratorio

OBJECTIVE to prioritize previously identified in Spain facilitators for the implementation of new Pharmaceutical Services that allow designing strategies for the implementation of Medication Review with follow-up (MRFup) service. DESIGN, SETTING AND PARTICIPANTS Exploratory factor analysis (EFA). A draft of a questionnaire was performed based on a previous literature review and following the RAND/UCLA methodology. An expert panel worked with it and generated a definitive questionnaire which, after piloting, was used with a representative sample of pharmacists, owners or staff members, who were working in community pharmacy, using computer-assisted telephone interviewing (CATI) methodology. To understand underlying constructs in the questionnaire an EFA was performed. Different approaches were tested such as principal components factor analysis and principal axis factoring method. The best interpretability was achieved using the Factorization of Principal axis method with Direct Oblimin rotation, which explained the 40.0% of total variance. RESULTS This produced four factors defined as: «Incentives», «External campaigns», «Expert in MRFup» and «Professionalism of the pharmacist». CONCLUSIONS It can be stated that for implementation and sustainability of MRFup Service it is necessary being paid; also it must be explained to health professional and society in general. Practice of MRFup service demands pharmacists receiving a more clinical education and assuming more responsibilities as health professionals.

Effect of a pharmacist intervention in Spanish community pharmacies on blood pressure control in hypertensive patients

PURPOSE The effect of a protocol-based pharmacist intervention on blood pressure (BP) control among treated hypertensive patients who use community pharmacies was studied. METHODS A quasi-experimental study with a control group was conducted at 13 community pharmacies in Jaén and Granada in Spain. Hypertensive patients over age 18 years who were receiving antihypertensive treatment were eligible for participation. The protocol-based intervention consisted of three components: (1) patient education about hypertension, (2) home blood pressure monitoring (HBPM), and (3) referral to a physician through personalized reports when necessary. The control group received the standard of care. BP control was assessed at the beginning and end of the study. Results Data were collected from 176 patients. In the intervention group (n = 87), significant baseline-to-endpoint reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were observed: 6.8 mm Hg (p < 0.001) and 2.1 mm Hg (p = 0.032), respectively. The changes in SBP and DBP in the intervention group at the end of the study were significantly greater than those in the control group (difference between adjusted mean change, 5.7 mm Hg for SBP [p = 0.001] and 2.6 mm Hg for DBP [p = 0.013]). The odds of achieving BP control in the intervention group was 2.46 times higher than in the control group (95% confidence interval, 1.15-5.24; p = 0.020). CONCLUSION A protocol-based community pharmacist intervention in combination with HBPM significantly reduced SBP and DBP and increased the percentage of patients with controlled BP compared with patients receiving the standard of care.

Application of the SCORE and Wilson–Grundy methods for the assessment of cardiovascular risk in community pharmacies

Background:  The assessment and follow‐up of patients with risk factors, or with cardiovascular disease (CVD), involves estimating and monitoring their CVD risk (CVDR). There are different opinions about the most appropriate method for this.