Clinical Pharmacist Involvement Research Articles

Progression of pediatric febrile seizure to status epilepticus: A case report

Managing pediatric febrile seizures progressing into status epilepticus (SE) presents challenges due to diagnostic complexities and the evolving nature of symptoms. This case report presents the management of a 1-year-old pediatric patient who experienced a febrile seizure progressing into SE. Laboratory findings reflected common variations observed in febrile illnesses and seizures. Treatment comprised a multidrug regimen involving antibiotics, anticonvulsants, and supportive care, primarily focused on seizure control, infection management, and symptomatic relief, aligning with established protocols for SE management in pediatric patients. However, the potential for drug interactions, particularly with carbapenems, underscores the importance of medication selection, especially in patients predisposed to seizures or neurological complications. This case report emphasizes the necessity for a multidisciplinary approach involving pediatricians, neurologists, and clinical pharmacists in optimizing treatment strategies for SE. The involvement of clinical pharmacists in medication review, dosage adjustments, monitoring for drug interactions, and patient education played a pivotal role in achieving positive outcomes in this critical scenario. This report sheds light on the complexities and challenges inherent in managing pediatric febrile seizures advancing to SE and underscores the significance of collaborative, multidisciplinary care in such cases.

Evaluation of Stages, Treatment Protocols, and Outcomes of Colorectal Cancer among West Bank Patients.

Background: Colorectal cancer (CRC) is the second most widespread cancer among Palestinian patients. As cancer care improves in hospitals across the West Bank, services like palliative care, targeted therapy, bone marrow transplantation, and individualized therapy are still limited. This study aimed to assess the CRC stages, treatment protocols, and survival rates of patients in the West Bank. Methodology: This retrospective study collected data from the medical records of Al-Najah University Hospital (NUH), which specializes in the care of cancer patients. Patients with confirmed CRC (stages I-IV) undergoing surgical or medical treatment were included in the study. Data collection was standardized by using a data collection form to gather information from the medical records included in the study. All statistical analyses were performed using SPSS (version v27), and survival was assessed using a regression analysis of the number of days from the time of diagnosis to the most recent visit against the type of treatment (e.g., surgery, chemotherapy, radiotherapy). Results: A sample of 252 patients with CRC from NUH was collected, including 143 males and 109 females aged between 27 and 86 years, with the average age being 60.6 ± 11.4 years. The sample included 183 patients (72.6%) diagnosed with colon cancer only, 29 patients (11.5%) diagnosed with rectal cancer only, and 40 patients (15.9%) diagnosed with both. Diagnosis took place at CRC stage I for 3 patients (1.2%), stage II for 33 patients (13.1%), stage III for 57 patients (22.6%), and stage IV for 159 patients (63.1%). Surgery was the most prevailing mode of treatment for 230 patients (91.3%), while 227 patients (90.1%) received chemotherapy treatment, and 38 patients (15.1%) received radiotherapy. Of the 252 patients, 40 patients (15.8%) received FOLFOX (i.e., folinic acid, fluorouracil, oxaliplatin), and 25 patients (9.9%) received FOLFIRI (i.e., folinic acid, fluorouracil, irinotecan), while the 187 remaining patients (74.2%) were treated with capecitabine, oxaliplatin, bevacizumab, cetuximab, regorafenib, cisplatin, etoposide, gemcitabine, or a combination thereof. The sample was categorized into six outcomes: (1) death, (2) cure, (3) disease progression, (4) disease recurrence, (5) under-treatment, and (6) unknown. Mortality was high, with 104 patients (41.3%) dying within a short time after diagnosis, and may have been attributable to delayed diagnosis. Surgical treatment had a positive impact on increasing the survival years, and it was significant (p = 0.033). Conclusions: A high percentage of patients were diagnosed in advanced CRC stages. The treatment modes were adopted from general international guidelines; however, the cure rates were low, and mortality was high. More studies need to be undertaken to investigate the actual application of chemotherapy protocols, and survival would benefit from the involvement of clinical pharmacists in the chemotherapy protocol selection, dosing, frequency, and follow-up. The present study advocates for greater public awareness of CRC and attests to the merits of screening by primary care professionals, which can help to avoid this serious illness and to promote a better prognosis.

Exploration of ‘micro’ level factors that affect the involvement of clinical pharmacists in interprofessional ward rounds in hospitals: Through the lens of social cognitive theory

BackgroundMacro and meso level factors that influence the participation by clinical pharmacists in ward rounds include pharmacy management culture, commitment to ward rounds and adequate time for ward rounds being included in workload models. The ‘micro’ level factors that affect the involvement of clinical pharmacists in ward rounds have not been widely explored. ObjectiveExplore ‘micro’ level factors to gain insight into clinical pharmacists' participation in interprofessional ward rounds in inpatient settings through the lens of social cognitive theory. MethodA qualitative focused ethnographic study with five clinical pharmacists, four medical practitioners, one allied health professional and one nurse was conducted in three metropolitan hospitals in Southern Australia. Seven hours of semi-structured interview (n = 11) and 76-h of observations (n = 5) were conducted. A qualitative descriptive analysis was conducted (guided by Spradley) followed by reflexive thematic-analysis (according to Braun and Clarke's technique). ResultsThree micro level factors influencing clinical pharmacist participation in ward rounds are: (1) Cognitive mindset of clinical pharmacists, (2) Behavioural conduct of clinical pharmacists, and (3) Social rules of the ward. Clinical pharmacists that did not participate in ward round reconciled their moral distress by transferring information without clinical judgement or interpretation of the patient scenario to medical practitioners. Clinical pharmacists that did participate in ward rounds demonstrated credibility by making relevant recommendations with a holistic lens. This enabled clinical pharmacists to be perceived as trustworthy by medical practitioners. Positive experiences of participating in ward rounds contributed to their cognitive upward spiral of thoughts and emotions, fostering continued participation. ConclusionClinical pharmacists participate in ward rounds when they develop a positive mindset about ward round participation and perceive ward rounds as an enabler to the establishment of trusted professional relationships with medical practitioners. This trusted relationship creates an environment where the pharmacist develops confidence in making relevant recommendations.

Pediatric oncology services in Nepal: A special focus on pharmacy practice.

The role of clinical pharmacists or oncology pharmacists in pediatric oncology has been established as important in anticancer regimen review, dose calculation, recommendation, chemocounseling, identification of drug-related problems, its resolution, and, prevention and monitoring of adverse drug reactions within high-income countries. With several hospitals providing pediatric oncology services in Nepal, clinical pharmacist involvement in these hospitals is very poor. Upon reviewing the reputed organization and association focused on pediatric oncology pharmacy practice, it looks imperative for Nepal to initiate clinical pharmacy services which will further help in improving patient health outcomes. As such in this commentary, we try to accentuate the pediatric oncology services and pediatric pharmacy practice within Nepal and try to pinpoint the potential areas for clinical pharmacists to focus if they intend to provide services in pediatric oncology pharmacy practice.

Insights into participation in ward rounds in hospitals: A survey of clinical pharmacists' perceptions.

Clinical pharmacists' participation in ward rounds (WRs) has been a great chance to contribute to team-based care in the hospital setting and significantly improve patient outcomes and quality of life. Hence, the objective of this investigation was to explore the perceptions of clinical pharmacists in Yemen regarding their participation in WRs and the factors influencing their involvement. An online survey of Yemeni clinical pharmacists was conducted and lasted for two months. Descriptive statistics were used to analyse the survey responses. a total of 120 participants were involved. About 3 out of 10 pharmacists had not previously participated in WRs, with only 30% having always or most of the time participated in word rounds alongside physicians. The results showed a positive perception of WR participation, with a median and IQR of 5(4-5). However, a lack of awareness of WR roles and the time-consuming nature of participation were the reasons for non-involvement. The study highlights the positive perceptions of Yemeni clinical pharmacists towards ward rounds, but emphasises the need to address awareness and time constraints. Emphasising patient-centered care and longer internship durations can improve clinical pharmacist involvement. Future research should focus on optimising clinical pharmacist participation for better patient outcomes and care quality.

Evaluation of the effectiveness regarding the participation of pharmacists in perioperative blood glucose management via the iGMS: a pilot RCT

BackgroundExcellent blood glucose management is a key guarantee for successful progress of surgery. However, the impact of clinical pharmacists on blood glucose management of perioperative patients needs to be further investigated. To investigate the effectiveness regarding the participation of pharmacists in blood glucose management via the informatized glucose management system (iGMS) on perioperative patients with type 2 diabetes mellitus (T2DM).MethodsThe working mode of clinical pharmacists participating in blood glucose management of perioperative patients with diabetes was constructed. A total of 300 patients with T2DM who underwent elective surgery were recruited and divided into a clinical pharmacist management group (intervention group) of 150 patients (94 men and 56 women; mean age: 44.38 ± 14.03 years) and a control group of 150 patients (101 men and 49 women; mean age: 47.85 ± 12.26 years) between September 2019 to April 2020. The outcomes of perioperative blood glucose management, and healthcare indicators such as preoperative waiting time, total hospitalization time, postoperative infection rate and other indicators were analyzed statistically between the two groups.ResultIn the blood glucose management team of the whole hospital, the physicians, clinical pharmacists and nurses of blood glucose management in endocrinology department were the core members, and were responsible for perioperative blood glucose management of the participants in the intervention group. All subjects had lower blood glucose after 3 days of management compared to the time of admission, and blood glucose was significantly lower in the intervention group compared to the control group (P < 0.05). As compared with the control group, subjects in intervention group demonstrated significant differences in outcome measures. The relevant parameters included preoperative blood glucose compliance rate (60.67% vs. 35.33%, P<0.05), preoperative waiting time [(5.27 ± 3.34) vs. (7.45 ± 4.38), P<0.05], length of hospitalization [(11.11 ± 4.56) vs. (14.87 ± 5.39), P<0.05], incidence of hypoglycemia (8.67% vs. 18.00%, P<0.05), incidence of hyperglycemia (32.00% vs. 62.67%, P<0.05) and postoperative infection rate (18.00% vs. 24.67%, P > 0.05).ConclusionThe involvement of clinical pharmacists in blood glucose management utilizing the iGMS can control the blood glucose level of patients with T2DM in the perioperative period more stably and effectively, thereby leading to an improvement in the quality of healthcare.

Standards of practice for clinical pharmacists

AbstractThis document sets forth ACCP's expectations for clinical pharmacists within the United States and countries around the world where clinical pharmacy is emerging or already well established. It is also intended to serve as a reference for those designing and assessing clinical pharmacy education and training programs. In addition to articulating the clinical pharmacist's process of care, the eight standards described within address the clinical pharmacist's involvement in collaborative team‐based, patient‐centered care; credentialing and privileging; professional development and maintenance of competence; professionalism and ethics; research and scholarship; and other professional responsibilities. The standards define for the public, healthcare professionals, and policymakers what they can and should expect of clinical pharmacists.

Acceptance rate of clinical pharmacists' recommendations-an ongoing journey for integration.

Introduction: Multidisciplinary expert team collaboration in the clinical setting, which includes clinical pharmacist involvement can facilitate significant improvements in outcomes and optimize patient management by preventing drug-related problems (DRP). This type of collaboration is particularly valuable in patients with multi-morbidity and polypharmacy such as diabetic foot patients. Evidence regarding the successful integration of a new clinical pharmacist, without previous experience into a unit is still scarce. Therefore, this study aimed to describe and evaluate the actual successful integration process of the clinical pharmacist into a diabetic foot unit by measuring the change in recommendation acceptance rate over time. Methods: A prospective, exploratory treatment effectiveness study based on the recommendation acceptance rate of a new clinical pharmacist introduced into the diabetic foot unit was conducted over a 9- month period. The clinical pharmacist identified medical and drug-related problems (DRP) or any discrepancies in the prescribing and administration of medications. Each identified DRP was documented and formulated as a recommendation by the clinical pharmacist. The main outcome measure was the acceptance rate of recommendations over time. Results: A total of 86 patients, of which 67% were men, averagely aged 66.5 (SD 11.8) years were evaluated. Calculated BMI was 30.2 (SD 6.2). The average number of medical diagnoses was 8.9 (SD3.2), and 11.1 (SD 3.7) prescribed drugs for each patient. Cardiovascular disease was presented by 95% (n = 82) of the patients and 33% of them (n = 28) had uncontrolled hyperglycemia. Averagely, 3.3 (SD 1.9) DRPs were identified pre patient. The efficacy-related DRP recommendation acceptance rate increased over the study period from 37.8% in the first 4months to 79.4% after a period of 4.75months. Safety-related DRP recommendation acceptance rate increased from 56% to 67.6%. Conclusion: Improved clinical outcomes and optimized pharmacologic patient management may be achieved by the successful integration of a clinical pharmacist into the team. This study provides evidence of the increasing recommendation acceptance rate of integrated, pharmacist-driven comprehensive medication management in an unexperienced unit. To overcome challenges, team members should collaborate to fully integrate the clinical pharmacist into the team-based structure and utilize proper strategies to minimize and transcend barriers.

Pharmacists' medication reconciliation interventions during admission and transfer from an emergency department at a tertiary care hospital: a randomized pilot study and evaluation of physician and patient perceptions.

The study aimed to assess the impact of pharmacist interventions during the transition of care. Medication discrepancies can occur at various levels of transition, such as during admission, the transition from emergency to special wards or from special to general wards, and during discharge. Discrepancies can be detected through the process of medication reconciliation. The objective of the study was to compare discrepancies among patients exposed to pharmacist intervention groups and those who were not and assess the perception of healthcare professionals and patients towards integrating pharmacists in the transition care process. A pharmacist-led interventional study was conducted for six months on patients above 18 years of age and either sex who were admitted to the emergency department, had chronic diseases, and subsequently transferred to another department (any). The patients were randomized into intervention and control groups. The pharmacist performed a medication reconciliation and medication review to identify discrepancies in every transition in both the groups, and then reported to the treating physician to resolve in the intervention group. Among the 73 patients recruited in the study, 152 discrepancies were identified. The total discrepancies observed in the control and intervention groups were 78 (51.3%) and 74 (48.6%), respectively. The majority, 35.53%, were found during the transition from emergency to special wards. The physician, upon pharmacist recommendations, accepted and resolved 48 discrepancies in the intervention group. The healthcare professional acceptance rate of pharmacist interventions was 64.86%. The transitions of care are at risk for errors due to medication discrepancies, and pharmacists could potentially identify and resolve discrepancies. Healthcare professionals and patients reported to be satisfied by the involvement of clinical pharmacists in the healthcare team.

Investigation of drug-related problems in patients hospitalized in chest disease wards: A randomized controlled trial.

Objective: According to the World Health Organization (WHO), chest diseases are among the 10 diseases that cause the highest mortality worldwide. Drug-related problems (DRPs), readmission, and antimicrobial resistance are critical problems in chest disease wards. Active involvement of clinical pharmacists (CPs) who are focused on reducing the risks of potential problems is needed. The aim of this study is to investigate the effects of pharmaceutical care (PC) services on the pulmonology service. Method: A randomized controlled trial at a university hospital in Istanbul was conducted between June 2020 and December 2021. The participants were randomized into the control group (CG) and intervention group (IG). In the CG, CPs identified and classified the DRPs according to Pharmaceutical Care Network Europe v9.0 (PCNE) and provided solutions to DRPs for the IG. The effect of PC services was evaluated by the number and classification of DRPs, and readmissions within 30days were compared between the two groups. Results: Out of 168 patients, 82 were assigned to the IG. The average number of medicines administered per patient in the CG and IG was 14.45 ± 7.59 and 15.5 ± 6.18, respectively. In the CG and IG, the numbers of patients with DRPs were 62 and 46, respectively. The total number of DRPs was 160 for CG and 76 for IG. A statistically significant difference was found in favor of the IG, in terms of the number of patients with DRPs, the total number of DRPs, and readmission within 30 days (p < 0.05). Conclusion: In this study, CP recommendations were highly accepted by the healthcare team. Pharmaceutical care services provided by CPs would decrease possible DRPs and led to positive therapeutic outcomes. Cognitive clinical pharmacy services have beneficial effects on health care, and these services should be expanded in all settings where patients and pharmacists are present.

Evaluating clinical pharmacists' involvement in postoperative acute pain services: a multicenter survey in Guangdong Province, China.

Objective: Postoperative pain management is an important part of surgical pharmacy. Postoperative acute pain services in China are in their initial stages. This survey aimed to investigate the attitudes, involvement, and knowledge of clinical pharmacists in China regarding postoperative acute pain services. The results can provide valuable information to guide clinical pharmacists in developing targeted strategies to improve their postoperative acute pain service capabilities. Methods: A questionnaire was distributed to the pharmacy departments of 133 grade A tertiary hospitals in Guangdong province, and the responses were collected electronically. Results: 123 completed questionnaires were collected from clinical pharmacists. Although 95.93% of clinical pharmacists believed they should participate in postoperative pain services, only 62.6% reported substantial involvement. Overall satisfaction with the postoperative pain service was 93.5%. Understanding of non-steroidal anti-inflammatory drugs and opioid analgesics by clinical pharmacists was comparable (p > 0.05). Furthermore, 98.37% of clinical pharmacists desired systematic learning in postoperative pain management, and 40.65% expressed a strong need. Conclusion: Clinical pharmacists in China demonstrate a positive attitude toward participating in postoperative acute pain services. However, the actual level of involvement was concerning, and the lack of systematic training and well-established work protocols may be contributing factors. Efforts should be made to establish comprehensive and standardized processes and work protocols for postoperative acute pain services and provide systematic and hierarchical professional training to enhance clinical pharmacists' capabilities in postoperative acute pain services.

Drug Therapy Problems and Associated Factors Among Hypertensive Patients in North Wollo Public Hospitals, Northeast Ethiopia: Institutional-Based Cross-Sectional Study.

Drug therapy problems (DTPs) are common in people with hypertension and may threaten the effective management of the disease. The purpose of this study was to determine the prevalence and predictors for DTPs in hypertensive people in North Wollo public hospitals. On patients with hypertension, a cross-sectional study based in a health institution was carried out using an interviewer-administered structured questionnaire and medical record review from 6 November 2022 to 18 January 2023. All hypertensive patients, ages 18 and older, who underwent regular follow-ups for at least 12 months were included in the study using a simple random sampling method. Multivariate logistic regression analysis was used to establish the association between independent variables and the occurrence of DTPs. Unnecessary drug therapy, the need for additional drug therapy, ineffective drugs, dosage too low, dosage too high, adverse drug reactions, and noncompliance were the outcome variables. The study included 376 hypertensive patients. Of the total participants, 258 (68.6%) were female. The mean number of drug therapy problems per patient was 1.55 ± 0.307, with 298 participants (79.3%) reporting having at least one such problem. This study found that the need for additional drug therapy was the most prevalent problem (149, 39.66%). Polypharmacy (AOR = 2.487, 95% CI = 1.375-4.499, p = 0.003), presence of comorbidity (AOR = 1.886, 95% CI = 1.035-3.439, p = 0.038), and uncontrolled BP (AOR = 2.961, 95% CI = 1.669-5.254, p = <0.001) predicts the development of drug therapy problems. Patients with hypertension who are on follow-up experience drug therapy problems frequently. Promoting the involvement of clinical pharmacists in designing, implementing, and monitoring therapeutic plans is recommended to decrease the occurrence of drug therapy problems.

The impact of pharmacists’ interventions within the Closed Loop Medication Management process on medication safety: An analysis in a German university hospital

Background: Single elements of the Closed Loop Medication Management process (CLMM), including electronic prescribing, involvement of clinical pharmacists (CPs), patient individual logistics and digital administration/documentation, have shown to improve medication safety and patient health outcomes. The impact of the complete CLMM on patient safety, as reflected in pharmacists' interventions (PIs), is largely unknown. Aim: To evaluate the extent and characterization of routine PIs performed by hospital-wide CPs at a university hospital with an implemented CLMM. Methods: This single-center study included all interventions documented by CPs on five self-chosen working days within 1month using the validated online-database DokuPIK (Documentation of Pharmacists' Interventions in the Hospital). Based on different workflows, two groups of CPs were compared. One group operated as a part of the CLMM, the "Closed Loop Clinical Pharmacists" (CL-CPs), while the other group worked less dependent of the CLMM, the "Process Detached Clinical Pharmacists" (PD-CPs). The professional experience and the number of medication reviews were entered in an online survey. Combined pseudonymized datasets were analyzed descriptively after anonymization. Results: A total of 1,329 PIs were documented by nine CPs. Overall CPs intervened in every fifth medication review. The acceptance rate of PIs was 91.9%. The most common reasons were the categories "drugs" (e.g., indication, choice of formulation/drug and documentation/transcription) with 42.7%, followed by "dose" with 29.6%. One-quarter of PIs referred to the therapeutic subgroup "J01 antibacterials for systemic use." Of the 1,329 underlying PIs, 1,295 were classified as medication errors (MEs) and their vast majority (81.5%) was rated as "error, no harm" (NCC MERP categories B-D). Among PIs performed by CL-CPs (n = 1,125), the highest proportion of errors was categorized as B (56.5%), while in the group of PIs from PD-CPs (n = 170) errors categorized as C (68.2%) dominated (p < 0.001). Conclusion: Our study shows that a structured CLMM enables CPs to perform a high number of medication reviews while detecting and solving MEs at an early stage before they can cause harm to the patient. Based on key quality indicators for medication safety, the complete CLMM provides a suitable framework for the efficient medication management of inpatients.

Cost benefit analysis of clinical pharmacist interventions in medical intensive care unit in Palestine medical complex: Prospective interventional study

BackgroundClinical pharmacy services in the critical health care settings have expanded dramatically.Study problem.Clinical pharmacy services have limited implementation in Palestine. Many intensive care units (ICUs) patients do not get the intended beneficial effects of their treatment due to treatment related problems and their consequent cost burden. AimTo evaluate the impact of the clinical pharmacist interventions on costs of care and safety of patient by assessing treatment related problems among medical ICUs patients in Palestine. MethodologyA prospective interventional study was conducted at medical ICU of the major public hospital in Ramallah city over a 4-month period (between September and December 2020). Patients were randomly assigned to either an intervention or a control group (With / without clinical pharmacist involvement). Treatment related problems were identified in both study groups by the clinical pharmacist, but interventions were only provided to the intervention group. The total economic benefit included both cost savings from intervention and cost avoidance from preventable adverse drug events (ADEs) resulted from CP interventions. The primary outcomes with the clinical pharmacist interventions were net benefit and benefit to cost ratio, which were calculated using previously published methodologies and adjusted to the Palestinian settings. The analysis of CP interventions acceptance by physicians was performed. ResultsDuring the 4-month study period, the 117 patients admitted to the ICU were included into the analysis; 66 patients in the intervention group and 51 in the control group. The interventions made by a clinical pharmacist resulted in direct cost saving of NIS8,990.05 ($2799.63) and cost avoidance of NIS22,087.5 ($ 6878.37). Translated into a net savings of NIS188.35 ($58.65) per intervention and NIS470 ($146.36) per patient. Comparison of benefits (NIS31,077.55) ($9678.00) and costs (NIS19,043.928) ($5930.55) indicate a net economic benefit to the institution of (NIS 12,033.623) ($3747.44) and a benefit cost ratio of 1.63. ConclusionIntegrating a clinical pharmacist in the ICU team was investment that resulted in benefits in term of cost saving and cost avoidance.

Prescribing Pattern of Pediatric Cardiologists during Clinical Pharmacist Intervention versus Routine Practice: First Comparative Study in Palestine

Background: Proper drug prescribing can contribute immensely to reducing overall morbidity, mortality, and cost of pharmacotherapy, particularly in the management of heart disease. Currently, no studies have been implemented on the appropriateness of cardiologist prescribing among hospitalized pediatric patients in Palestine. This study aimed to compare the prescribing pattern of pediatric cardiologists during clinical pharmacist intervention versus routine cardiologists' practice at a tertiary care hospital in Palestine. Methods: A comparative study of 48 pediatric patients who were admitted to the cardiology ward in 2020 and readmitted in 2021 was conducted. This comprised two stages: routine practice stage (S0) of cardiologists without clinical pharmacist intervention, and intervention stage (S1) where clinical pharmacist prospectively involved in cardiology teamwork. Prescribing indicators and length of hospital stay were compared between the two study stages using Pearson's chi- square and paired t-test. Results: Compared with the routine practice stage, drugs prescribed per patient were significantly lower in the intervention stage ( mean 5.98 S1 versus 6.87 S0; P=0.043). Higher drugs prescribed by generic names were found in the intervention stage (97.2% S1 versus 72.1% S0; P= 0.002). Patients in the intervention stage encountered significantly fewer antibiotics than in the routine practice stage (60.4% and 77.1%, respectively; P=0.009). The mean length of hospital stay was significantly reduced from 8.22 days in the routine practice stage to 6.93 days in the intervention stage (P=0.032). There were no significant differences in the prescribing of essential drugs (99.3% S1 versus 95.2% S0; P=0.152) and injections (75.0% S1 versus 73.0% S0; P=0.496) between the two stages. Conclusion: Clinical pharmacist intervention has optimized the prescribing pattern of pediatric cardiologists and reduced the length of stay for hospitalized pediatric patients. Palestinian health leaders have to support the involvement of clinical pharmacists in cardiology and other disciplines to promote rational prescribing and drug utilization.

Minding the gap-an examination of a pharmacist case management medicines optimisation intervention for older people in intermediate care settings.

Whilst attention has been paid within the literature to examining potentially inappropriate prescribing (PIP) for older adults in a variety of care settings, less is known about the extent within intermediate care. Furthermore, few studies have examined the utility of clinical pharmacist involvement in this care context. Determine the prevalence of PIP in intermediate care (IC) settings in Northern Ireland (NI), explore the utility of a novel pharmacist case management model at reducing PIP and to examine the association with subsequent healthcare utilisation. Secondary analysis of prospective data (N=532) collected during a medicines optimisation pharmacist case management model in three intermediate care sites in NI. Independent prescriber pharmacists delivered the intervention. Variability in Medication Appropriateness Index score change (ΔMAI) from admission to discharge was examined using multivariate linear regression analysis. Multivariate logistic and Poisson regressions were used to examine the association between ΔMAI and likelihood and numbers of unplanned hospital readmissions within 30 and 90 days of IC discharge. PIP was highly prevalent (89.5%) at baseline with significant reductions in MAI score achieved from admission (Median=14) to discharge (Median=0) (Z=-18.28, p<.001). The prevalence of PIP at discharge was 7.8%. No relationship was observed between ΔMAI score and unplanned hospital readmission. Those who received at least one educational intervention were less likely to be readmitted within 30 days of IC discharge (OR=0.15, 95% CI 0.03, 0.71, p<.001). Baseline healthcare utilisation consistently predicted healthcare utilisation post-IC discharge. Drug-related problems persist for many older adults following acute care discharge and intermediate care may provide an ideal location for medicines optimisation interventions.

Successful Integration of Clinical Pharmacists in an OPAT Program: A Real-Life Multidisciplinary Circuit.

Outpatient parenteral antimicrobial therapy (OPAT) programs encompass a range of healthcare processes aiming to treat infections at home, with the preferential use of the intravenous route. Although several barriers arise during the implementation of OPAT circuits, recent cumulative data have supported the effectiveness of these programs, demonstrating their application in a safe and cost-effective manner. Given that OPAT is evolving towards treating patients with higher complexity, a multidisciplinary team including physicians, pharmacists, and nursing staff should lead the program. The professionals involved require previous experience in infectious diseases treatment as well as in outpatient healthcare and self-administration. As we describe here, clinical pharmacists exert a key role in OPAT multidisciplinary teams. Their intervention is essential to optimize antimicrobial prescriptions through their participation in stewardship programs as well as to closely follow patients from a pharmacotherapeutic perspective. Moreover, pharmacists provide specialized counseling on antimicrobial treatment technical compounding. In fact, OPAT elaboration in sterile environments and pharmacy department clean rooms increases OPAT stability and safety, enhancing the quality of the program. In summary, building multidisciplinary teams with the involvement of clinical pharmacists improves the management of home-treated infections, promoting a safe self-administration and increasing OPAT patients’ quality of life.

Drug Utilization and Potential Drug-Drug Interactions within an Intensive Care Unit at a University Tertiary Care Hospital in Egypt.

There are few reports on drug utilization and drug-drug interactions in Intensive Care Units (ICUs) in Egypt. A total of 94 patients participated in this retrospective observational study. Patient’s medical records were used to collect demographics, medical history, admission and discharge dates and medications used. The mean ± SD of the Glasgow Coma Scale (GCS) scores was 9.9 ± 4.4 and the median length of stay was 7 days (range 1–47 days). The total number of prescribed medications ranged from 4–29 with a mean ± SD of 14.1 ± 5.5 medications per patient. The top three most prescribed categories belonged to (1) anti-infective agents (23.9%); (2) electrolyte, caloric and water balance agents (14.6%); and (3) blood formation, coagulation and thrombosis (11.3%). The proton pump inhibitor, esomeprazole, was the most frequently prescribed medication accounting for 6.5% of total prescriptions, followed by clindamycin and magnesium sulfate each accounting for 3.5% of total prescriptions. The potential Drug-Drug Interactions (pDDIs) showed a total of 968 pDDIs with a mean ± SD (range) of 10.2 ± 9.4 (0–43) pDDIs per patient: severe (contraindicated) (3), major (178), moderate (618) and minor (169). Overall, the drug utilization patterns in this study were consistent with ICU drug utilization from other countries in the region. The implementation of clinical decision support systems and the involvement of clinical pharmacists may help improve medication safety.

Clinical Pharmacists' Contribution to Medication Reconciliation in Outpatient Specialty Clinics in Iran.

The majority of research in medication reconciliation has focused on the inpatient settings, and little is known about the outpatient settings, particularly in developing countries. As such, we conducted this study to evaluate direct clinical pharmacist involvement in medication reconciliation in outpatient specialty clinics in Iran. This prospective interventional study was conducted from September 2019 to February 2020 in a University-affiliated clinic in Iran. For 196 patients over 18 years of age who were scheduled for an appointment with a physician, medication reconciliation intervention was carried out by a clinical pharmacist. The number and type of unintentional discrepancies, their potential harm to the patients, their correlation with the patients' demographic and clinical characteristics, and the number of accepted recommendations upon the unintentional discrepancies by the clinicians were assessed and recorded. Additionally, patients' understanding of any change made to their current medication regimen was also assessed. In total, 57.14% of patients had at least one or more unintentional medication discrepancies, with an overall rate of 1.51 (±0.62) per patient. This is while the patient understanding of their medication changes was inadequate in a significant proportion of the study patients (62.2%). Patients with older ages, lower educational levels, and a higher number of medications and comorbidities were at a higher risk of having unintentional discrepancies. The most common type of unintentional discrepancy was the omission of a drug, and almost half of the reconciliation errors might have had the potential to cause moderate or severe harm to the patient. From 145 recommendations suggested by the clinical pharmacist upon unintentional discrepancies, 131 cases (90.34%) were accepted and implemented by the clinicians. These findings further support the need for conducting medication reconciliation in outpatient settings to identify discrepancies and enhance the safety of patient medication use.

Clinical Pharmacists' Involvement in Pharmacogenomics Testing and Related Services in China.

Background: Pharmacogenomics (PGx) testing is increasingly used in clinical practice to optimize drug therapies. This study aims to understand the involvement of clinical pharmacists in PGx testing at tertiary hospitals in China and their self-assessed capacity to deliver such services. Methods: We developed a questionnaire exploring clinical pharmacists’ involvement and self-assessed level of capacity of performing PGx tests. A random sample was obtained from the Pharmaceutical Affairs Management Professional Committee of the Chinese Hospital Association. Results: A total of 1005 clinical pharmacists completed the survey. Of these, 996 (99.1%) had heard of PGx tests and 588 (59.0%) had been involved in PGx testing and related services. Some clinical pharmacists (28.9%) provided PGx services at the rate of “1–5 cases/year” while 21.9% of clinical pharmacists provided PGx services at the rate of “>30 cases/year”. Clinical pharmacists most frequently provided PGx testing for cardiovascular diseases. “Consult relevant guidelines/literature” (90.1%) was the most frequently used method to familiarize oneself with PGx testing. About 60% of the pharmacists considered themselves to have poor or fair capacity to provide PGx testing and related services. Conclusions: More than half of the pharmacists had been involved in PGx testing and related services. However, pharmacists generally had little confidence in their knowledge level of and capacity to provide PGx-related services.