Summary of the example
Pharmacist medication review on admission to hospital is an important intervention to support safe transfer of care around medicines, which may highlight medicines-related risks to be resolved.
A consensus-building process between a group of senior doctors and pharmacists was used to produce guidance for pharmacists to support the identiﬁcation of patients at risk from their medicines, and outline actions and escalation processes.
A literature search established ten scenarios often encountered in newly-admitted older adults. Possible actions for each scenario were described. The senior clinicians ranked agreement with the listed actions; actions with low agreement were dropped. The process was repeated until consensus was reached and the desired action deﬁned. Guidance for review and escalation in these scenarios was produced.
The panel agreed that pharmacists and doctors both have active roles in medication review, and face-to-face communication is always preferable. Only prescribers should deprescribe if that is necessary. Pharmacists who are not also prescribers may temporarily “hold” medications in the best interests of patient care, documenting and following-up appropriately with the prescribing team.
The consensus was that age, problematic polypharmacy, and medication-related problems, were the most important factors when identifying patients that beneﬁt most from comprehensive medication review.
Why we think it’s important
Older adults are frequently admitted to hospital (transition of care) with medicines-related problems including polypharmacy, or potentially inappropriate (or unnecessary) medicines (PIM), e.g. NSAIDs, diuretics and ACEI. Local audits revealed a high prevalence of PIMs in falls-risk patients and at least one PIM was found in 19% of inpatients over 70 years old who were assessed as ‘frail’.
Furthermore, nearly a third of patients admitted took ten or more regular medicines (likely ‘problematic’ polypharmacy).
We have found, possibly like others, that it is a challenge for pharmacists to make timely care contributions. Moreover the first contact for a pharmacist may be a junior doctor, who may not be confident to make a change without consulting with a senior who may not be immediately available.
Our work aimed to improve this by providing proactive guidance on what pharmacists should do (e.g. ‘hold’ a high risk medicine) as part of their medication reviews, how to do it, and to action more quickly in order to reduce medicines-related risk. Findings so far are that pharmacists have actioned the guidance on a number of occasions, which is likely to have prevented or limited episodes of, for example, acute kidney injury.
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Aims and objectives of the work
To use a consensus approach between senior doctors and pharmacists to:
- Equip pharmacists to recognise and take appropriate actions with potentially inappropriate or unnecessary medicines for older adults admitted acutely to hospital
- Produce guidance to promote appropriate medication review and to hold or deprescribe as appropriate through a targeted review
- Gain agreement between pharmacists and medical consultants about the actions pharmacists can take to support patient care
In contrast to clinical guidelines, which are based primarily on high-level evidence, clinical consensus statements can be used where evidence is limited or lacking, but where there are opportunities to reduce uncertainty and improve quality of care. Our work involved pharmacists and doctors acting on findings from our audits (see above) and agreeing on actions and escalations for specific scenarios, and coming to a consensus on pharmacists and doctors working together in the acute setting.
We approached four consultants who were willing to establish consensus around points of pharmacist ‘action’ and ‘escalation’. The physicians attended project planning meetings and participated in discussions about the approach to dealing with hazardous medicines and combinations.
To inform the consensus-building discussions, a literature search was undertaken. Evidence from this was used to establish a set of ten scenarios. Each scenario described a situation involving potentially high-risk medicines-related harm, with six or more possible actions. The four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. As a result of the process, we developed and agreed generalised guidance for reviewing older adults’ medicines, alongside escalation processes that should be followed in a specific set of clinical situations.
Some relevant local baseline data was collected around the scale of the problem. Collecting baseline data on the timeliness of interventions and the clinical outcomes pre-implementation would have been helpful but is challenging. We appreciate that this would have allowed us to compare post-intervention with data. Our findings consist of examples of interventions made according to the guidance that could be used as the basis for future work.
Critical success factors include:
- Identifying a viable number of senior doctors willing to participate, attend meetings, agree on the nature of the guidance and implementing it
- Identifying appropriate scenarios that were both from the literature and true to life in practice
- Patience of reviewers in achieving consensus through rounds of reviews
- Buy-in with implementing the guidance and ensuring that new staff are introduced to it on induction
Unintended consequences include:
- Modelling of appropriate decision-making to junior doctors and pharmacists, not only about the clinical decisions themselves, but how doctors and pharmacists can work together in effective ways to improve patient safety was an unintended positive consequence
- Pharmacists following the guidance with medical teams where a consultant not part of the consensus group did not agree with the guidance ( we do not believe that this has been borne out)
- Misuse of the guidance e.g. not escalating appropriately or the pharmacist holding a medicine when in fact a decision has been made to continue it. The mitigation is appropriate induction on the guidance document and briefing junior pharmacists on the need to access senior support