Patient's drug therapy: Clinical impact of pharmacist's intervention in neurological rehabilitation units

Abstract

Inpatients in neurological rehabilitation units are often polymedicated. This polypharmacy is at risk of adverse events. It justifies the analysis of prescriptions by a pharmacist. The objective is to describe drug-related problems detected by pharmacist, pharmaceutical interventions (PI) performed and PI clinical impact over a period of 1 year. The computerized prescriptions of 165 beds were analyzed by one pharmacist and one resident pharmacist once a week based on the methodology of the French Society of Clinical Pharmacy. Detected drug related problems and proposed PI were collected. Their clinical impact was evaluated by two physicians and two hospital pharmacists independently, according Hatoum 1988 [1] : zero impact (−), significant (+), highly significant (++), lifesaving (+++). Four thousand two hundred and twenty-eight prescriptions resulted in 999 PI (24%) and 788 accepted by physicians (79%). The most involved drugs were: analgesics/anti-inflammatory drugs (25%), anti-acids (20%), psychotropic drugs (17%) and anti-infectives (14%). The main problems found were: no clinical indication (26%), non-conformity with guidelines (16%) and supra or infratherapeutic dose (15%). Most common suggestions (PI) were drug discontinuation (33%) and dose adjustment (22%). After excluding IP only having an economic impact, 842 IP were evaluated in a clinical point of view. They concerned mainly: antiacids ( n = 198), analgesic/anti-inflammatory drugs ( n = 170), psychotropic drugs ( n = 136), anti-infectives ( n = 110) and anticoagulants ( n = 76). The evaluations were: no impact ( n = 96); significant ( n = 574) very significant ( n = 169); lifesaving ( n = 3). These 3 PI were related anticoagulants. Drugs with a great number of IP (++) were: anticoagulants (60%), intravenous electrolytes (43%), anti-infectives (37%) and analgesics/anti-inflammatory drugs (24%). Physicians have found a large number of PI (++) concerning anti-infectives compared pharmacists (43% versus 30%). Conversely, pharmacists felt more PI (++) involving intravenous electrolytes (71% versus 15%) and psychotropic drugs (21% versus 8%). Pharmacists detected many drug-related problems during analysis of prescriptions. Their potential adverse clinical consequences are supported by a high rate of acceptance, objectivized by prescription modification.