Sabrina De Winter

Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department

Background Recent literature revealed that medication histories obtained by physicians and nurses are often incomplete. However, the number of patients included was often low. Study objective In this study, the authors compare medication histories obtained in the Emergency Department (ED) by pharmacists versus physicians and identify characteristics contributing to discrepancies. Methods Medication histories were acquired by the pharmacist from patients admitted to the ED, planned to be hospitalised. A structured form was used to guide the pharmacist or technician to ensure a standardised approach. Discrepancies, defined as any difference between the pharmacist-acquired medication history and that obtained by the physician, were analysed. Results 3594 medication histories were acquired by pharmacy staff. 59% (95% CI 58.2% to 59.8%) of medication histories recorded by physicians were different from those obtained by the pharmacy staff. Within these inaccurate medication histories, 5963 discrepancies were identified. The most common type of error was omission of a drug (61%; 95% CI 60.4% to 61.6%), followed by omission of dose (18%; 95% CI 17.6% to 18.4%). Drugs belonging to the class of psycholeptics, acid suppressors and beta blocking agents were related to the highest discrepancy rate. Acetylsalicylic acid, omeprazole and zolpidem were most commonly forgotten. Conclusion This large prospective study demonstrates that medication history acquisition is very often incomplete in the ED. A structured form and a standardised method is necessary. Pharmacists are especially suited to acquire and supervise accurate medication histories, as they are educated and familiar with commonly used drugs.

Impact of Temperature Exposure on Stability of Drugs in a Real-World Out-of-Hospital Setting

STUDY OBJECTIVE The aim of this study is to determine the content of 5 important emergency medical services (EMS) drugs after being stored at the recommended refrigerated temperature, room temperature, or in an emergency physician transport vehicle operating under real-world working conditions. METHODS Adrenaline hydrochloride, cisatracurium besylate, lorazepam, methylergonovine maleate, and succinylcholine chloride were stored for 1 year under the 3 conditions. For each storage condition, samples of the drugs were taken after 1, 2, 3, and 4 weeks and after 2, 4, 6, 8, 10, and 12 months. For adrenaline hydrochloride, however, the samples were taken after 1, 2, 4, 6, 8, 10, and 12 months. The samples were analyzed with a validated high-performance liquid chromatography assay. A drug was considered stable if its content was above 90%. RESULTS Adrenaline hydrochloride and methylergonovine maleate remained stable for 1 year at room temperature and in the emergency physician transport vehicle. At room temperature and in the emergency physician transport vehicle, lorazepam became unstable within 4 weeks. Succinylcholine chloride was stable for 2 months at room temperature and for 1 month in the emergency physician transport vehicle. Cisatracurium besylate became unstable within 4 months at room temperature. However, it remained stable for 4 months in the emergency physician transport vehicle. CONCLUSION When stored at room temperature or in the emergency physician transport vehicle, lorazepam became unstable within weeks, whereas succinylcholine chloride and cisatracurium besylate became unstable within months. Adrenaline hydrochloride and methylergonovine maleate remained stable for several months, even under room temperature and emergency physician transport vehicle conditions. Thus, real-world EMS working conditions pose challenges for maintaining optimal efficacy of these important EMS drugs.

Intravenous lipid emulsion for intentional Chloroquine poisoning

To the Editor:Intravenous lipid emulsion (ILE) has successfully been used in local anesthetic toxicity and in poisonings with several other lipophilic drugs.1 There is evidence supporting the use o...

Predictors for unintentional medication reconciliation discrepancies in preadmission medication: a systematic review

PurposeDiscrepancies in preadmission medication (PAM) are common and potentially harmful. Medication reconciliation is able to reduce the discrepancy rate, yet implementation is challenging. In order for reconciliation efforts to be more cost-effective, patients at high risk for reconciliation errors should be identified. The purpose of this systematic review is to identify predictors for unintentional discrepancies in PAM.MethodsMedline and Embase were searched systematically until June 2017. Only studies concerning adult subjects were retained. Quantitative studies were included if predictors for unintentional discrepancies in the PAM had been determined on hospital admission. Variables were divided into patient-, medication-, and setting-related predictors based on a thematic analysis. Studies on identification of predictors for discrepancies and potentially harmful discrepancies were handled separately.ResultsThirty-five studies were eligible, of which 5 studies focused on potentially harmful discrepancies. The following 16 significant variables were identified using multivariable prediction models: number of preadmission drugs, patient’s age, availability of a drug list, patients’ understanding of medication, usage of different outpatient pharmacies, number of high-risk drugs, discipline for which the patient is admitted, admitting physician’s experience, number and type of consulted sources, patient’s gender, type of care before admission, number of outpatient visits during the past year, class of medication, number of reimbursements, use of an electronic prescription system, and type of admission (elective vs emergency). The number of preadmission drugs was identified as a predictor in 20 studies. Potentially harmful discrepancies were ascertained in 5 studies with age found to have a predictive value in all 5 studies.ConclusionMultiple suitable predictors for PAM-related discrepancies were identified of which higher age and polypharmacy were reported most frequently.

Initiatives promoting seamless care in medication management: an international review of the grey literature

Background Patients’ transition between hospital and community is a high-risk period for the occurrence of medication-related problems. Aim of the review The objective was to review initiatives, implemented at national and regional levels in seven selected countries, aiming at improving continuity in medication management upon admission and hospital discharge. Method We performed a structured search of grey literature, mainly through relevant websites (scientific, professional and governmental organizations). Regional or national initiatives were selected. For each initiative data on the characteristics, impact, success factors and barriers were extracted. National experts were asked to validate the initiatives identified and the data extracted. Results Most initiatives have been implemented since the early 2000 and are still ongoing. The principal actions include: development and implementation of guidelines for healthcare professionals, national information campaigns, education of healthcare professionals and development of information technologies to share data across settings of care. Positive results have been partially reported in terms of intake into practice or process measures. Critical success factors identified included: leadership and commitment to convey national and local forces, tailoring to local settings, development of a regulatory framework and information technology support. Barriers identified included: lack of human and financial resources, questions relative to responsibility and accountability, lack of training and lack of agreement on privacy issues. Conclusion Although not all initiatives are applicable as such to a particular healthcare setting, most of them convey very interesting data that should be used when drawing recommendations and implementing approaches to optimize continuity of care.

Higher versus standard amikacin single dose in emergency department patients with severe sepsis and shock: a randomized controlled trial

Recent studies suggest that intensive care unit patients treated with amikacin frequently do not attain the desired pharmacokinetic/pharmacodynamic (PK/PD) target, i.e. peak amikacin concentration (Cpeak) to minimum inhibitory concentration (MIC) ratio of ≥8, when a single dose of 15 mg/kg is used. No data are available for patients admitted to the emergency department (ED). The aim of this prospective randomised controlled study was to determine PK/PD target attainment in ED patients presenting with severe sepsis or septic shock treated with 15 mg/kg versus 25 mg/kg amikacin. Patients were randomly assigned to receive amikacin 25 mg/kg or 15 mg/kg. Amikacin Cpeak values were determined. The primary outcome was target attainment defined as Cpeak/MIC ≥ 8 both using EUCAST susceptibility breakpoints and actually documented MICs as denominator. A total of 104 patients were included. The EUCAST-based target was attained in 76% vs. 40% of patients assigned to the 25 mg/kg vs. 15 mg/kg dose groups (P <0.0001). Target attainment using actual MICs (median of 2 mg/L, documented in 48 isolated Gram-negative pathogens) was achieved in 95% vs. 94% of patients in the 25 mg/kg vs. 15 mg/kg dose groups (P = 0.969). Risk factors associated with PK/PD target failure were identified in the multivariable analysis. At least 25 mg/kg amikacin as a single dose should be used in ED patients with severe sepsis and septic shock to attain the EUCAST-based PK/PD target. However, when using local epidemiology as denominator, 15 mg/kg appears to be sufficient. [ClinicalTrials.gov ID: NCT02365272.

Developing a decision rule to optimise clinical pharmacist resources for medication reconciliation in the emergency department

Background The process of obtaining a complete medication history for patients admitted to the hospital from the ED at hospital admission, without discrepancies, is error prone and time consuming. Objectives The goal of this study was the development of a clinical decision rule (CDR) with a high positive predictive value in detecting ED patients admitted to hospital at risk of at least one discrepancy during regular medication history acquisition, along with favourable feasibility considering time and budget constraints. Methods Data were based on a previous prospective study conducted at the ED in Belgium, describing discrepancies in 3592 medication histories. Data were split into a training and a validation set. A model predicting the number of discrepancies was derived from the training set with negative binomial regression and was validated on the validation set. The performance of the model was assessed. Several CDRs were constructed and evaluated on positive predictive value and alert rate. Results The following variables were retained in the prediction model: (1) age, (2) gender, (3) medical discipline for which the patient was admitted, (4) degree of physician training, (5) season of admission, (6) type of care before admission, number of (7) drugs, (8) high-risk drugs, (9) drugs acting on alimentary tract and metabolism, (10) antithrombotics, antihaemorrhagics and antianaemic preparations, (11) cardiovascular drugs, (12) drugs acting on musculoskeletal system and (13) drugs acting on the nervous system; all recorded by the ED physician on admission. The final CDR resulted in an alert rate of 29% with a positive predictive value of 74%. Conclusion The final CDR allows identification of the majority of patients with a potential discrepancy within a feasible workload for the pharmacy staff. Our CDR is a first step towards a rule that could be incorporated into electronic medical records or a scoring system.

INT-009 Development and implementation of ‘check of medication appropriateness’ in a large tertiary care centre

Background During the last decade, healthcare shifted from a disease-focused approach towards a more patient-focused approach. Hospital pharmacy services experienced a similar development. Traditional drug-oriented services expanded towards patient-oriented services by imbedding computerised clinical decision support systems (CDSSs) in the prescribing process and implementing bedside clinical pharmacy services. However, due to limited resources, clinical pharmacy services are not implemented on a hospital-wide basis in Belgian hospitals. Purpose To guarantee patient safety, a central check of medication appropriateness (COMA) was developed and implemented since March 2016 in the University Hospitals Leuven. Materials and Methods Based on a risk analysis, high-risk prescriptions are checked by a hospital pharmacist for appropriateness. A daily check (0.5 FTE) of automatically generated queries is performed using standardised algorithms. The queries are a result of the screening of all new prescriptions in the electronic prescribing system of the last 24 hours. Interventions are performed via electronic warnings in the patient’s file or phone calls to the treating physician. Results Twelve hospital pharmacists are now involved in the COMA and 79 specific algorithms were developed, covering five pharmacotherapeutic areas of interest: drugs with restrictive indication; overruled interventions raised by CDSS; medication-related biochemical changes; sequential therapy for bio-equivalent drugs; and reimbursement of drugs. During a 18 month period, 92 050 prescriptions were checked for which 24 943 (27%) electronic warnings were sent and 637 (1%) phone calls were carried out. When analysed without automatic warnings for sequential therapy, 39 481 prescriptions were checked for which 2568 (7%) electronic warnings were sent and 637 (2%) phone calls were carried out. Conclusion For the future we obtain the next goals: Evaluation of the acceptance of the current COMA process. Fine–tuning the screening queries with an emphasis on improving specificity. Determining inter–rater validity. Development of new algorithms, also expanding to other areas of interest. Development of an easy access training tool for hospital pharmacists to perform COMA.

Pharmacokinetic changes after placement of a transjugular intrahepatic portosystemic shunt

To the Editor, Cirrhotic patients with a transjugular intrahepatic portosystemic shunt (TIPS) may be particularly vulnerable to exaggerated effects of drugs [1, 2]. We report for the first time a case with ß-adrenergic blocker (BB) and calcium channel antagonist (CCA) toxicity caused by pharmacokinetic alterations after placement of TIPS. A 76-year-old man with end-stage liver cirrhosis (ChildPugh score B8) was admitted electively to the hepatology ward for placement of a TIPS [expanded polytetrafluorethylene-