Inpatient Pharmacists Research Articles

P-2205. The impact of pharmacist-driven transitions of care protocol in the treatment of hepatitis C infection

Abstract Background Treatment for hepatitis C virus (HCV) can be delayed due to extensive documentation needed for insurance approval. Pharmacists can play critical roles in facilitating treatment approval, but the evidence regarding pharmacist-driven transitions of care protocols to facilitate HCV treatment approval and therapy initiation is limited. Therefore, we evaluated the feasibility and effectiveness of a pharmacist-driven transitions of care protocol for HCV treatment. Methods This was a non-randomized, prospective, single-center study at a large academic medical center. Adult patients admitted to the Infectious Diseases (ID) primary team were screened for HCV between 09/01/23 and 02/29/24. Exclusion criteria included decompensated cirrhosis, hepatocellular carcinoma, pregnancy/breastfeeding, current/prior HCV treatment, and transplant evaluation/receipt. Patients with HCV infection were offered treatment upon discharge at the outpatient ID clinic. Inpatient ID pharmacists performed pre-treatment workup and coordinated handoff to outpatient ID specialty pharmacists. Endpoints included treatment initiation and completion rates, time from screening to treatment initiation, and time from discharge to treatment initiation. Results Of 180 patients screened during the study, 13 (7%) were eligible for HCV treatment. The median age was 43 years, and 69% were male. More than 90% of patients were Caucasian and had a history of substance use disorder/injection drug use. Five patients (38%) were uninsured. Of the 13 patients, two had treatment approved, and one completed therapy. The remaining patients were lost to follow-up. The median times from screening to treatment initiation and from discharge to treatment initiation were 64 and 62 days, respectively. Conclusion This pharmacist-driven protocol resulted in inpatient screening of a large number of patients over six months and successfully identified 13 patients eligible to begin hepatitis C treatment after discharge. This is a novel approach to engaging patients in hepatitis C care. Despite facilitating transitions of care for these patients, the clinic no-show rate was unexpectedly high. Additional measures may be required to optimize treatment outcomes for this patient population. Disclosures All Authors: No reported disclosures

503. Antibiotic Mobile Application ABxSG - An Innovative and Effective Antibiotic Stewardship Tool that Improves Antibiotic Use and Reduces Healthcare Costs

Abstract Background At Singapore General Hospital (SGH), 50% of inpatients receive ≥1 antibiotic & 30% are inappropriate. In an in-house survey in 2020, doctors opined that access to hospital antibiotic guidelines on their mobile devices is time-saving and improves antibiotic use. A mobile application, ABxSG, was developed and launched in Mar 2023, providing a one stop platform for hospital guidelines, educational materials on disease management and curated medical calculators [Figure 1]. At 9 months post launch, there were 2,400 ABxSG users.Figure 1.Illustration of the features of ABxSG mobile application that aids clinicians in managing a hospital acquired pneumonia Methods An interrupted time series analysis using autoregressive integrated moving average model was conducted to evaluate the impact of ABxSG on the proportion of inpatients on antibiotics and the number of pharmacist interventions made pertaining to antibiotic related monitoring parameters to ensure efficacy/safety. The time period analyzed included 1 year pre- (Apr 22-Mar 23) & 9 month post-(Apr 23-Dec 23) ABxSG.Figure 2.The actual & predicted proportion of inpatients on antibiotics decreased after the launch of ABxSG Results The proportion of inpatients on antibiotic was rising 0.15%/month pre-ABxSG & slowed down post-ABxSG to 0.11%/month (p=0.67) [Fig. 2]. Notably, there was an immediate reduction of 1.5% post ABxSG (p< 0.05). At 9 months, there was a predicted 2.83% reduction (p= 0.09), translating to 600 antibiotic free days a month (with an estimated savings of ∼USD$37,000 in drug cost and 540 nursing hours a month). The rising trend in number of interventions for antibiotic related monitoring parameters pre-ABxSG was reversed post-ABxSG (p< 0.05) [Fig. 3]. At 9 months, there was a predicted ∼37 less interventions a month (p< 0.05), a nearly 50% reduction from pre-ABxSG. This reduction translates to a saving of 23 pharmacist hours a month.Figure 3.The actual & predicted number of interventions for antibiotic related monitoring parameters by inpatient pharmacists decreased after launch of ABxSG Conclusion ABxSG reduced the proportion of patients on antibiotics and the number of pharmacist interventions for antibiotic related monitoring parameters. The antibiotic mobile application is an innovative digital solution to engage and empower prescribers to use antibiotics appropriately. Additionally, it is an aid for healthcare institutions where there is a shortage of pharmacists to provide close oversight on antibiotic use. With improved antibiotic prescribing, ABxSG can potentially reduce healthcare costs in the long run. Disclosures All Authors: No reported disclosures

Descriptive Analysis of Inpatient Pharmacist Interventions at a Tertiary Care Military Hospital in Eastern Province, Saudi Arabia

Descriptive Analysis of Inpatient Pharmacist Interventions at a Tertiary Care Military Hospital in Eastern Province, Saudi Arabia

Optimizing Healthcare: Implementation of a Pharmacist-To-Pharmacist Transitions of Care Pilot Program.

Background: Transitions of care (TOC) is defined as the movement of patients between healthcare practitioners, settings and home. Ineffective TOC can lead to hospital readmissions, increased costs, and patient dissatisfaction. Pharmacists have a unique opportunity to ensure that continuity of care, in regard to medication optimization and education, is continued throughout the transition between settings. With both inpatient and ambulatory pharmacists supporting smooth discharge for hospitalized patients, an opportunity was identified to implement a pharmacist-to-pharmacist TOC program at Ascension Genesys Hospital (AGH). Objective: Implement a pharmacist-to-pharmacist TOC program at AGH. Methods: This was a single-center pilot program in which a pharmacist-to-pharmacist TOC program was implemented at AGH between January 1st and April 30th, 2024. Patients were included if they were 18 years of age and older, managed by the family medicine (FM) team, and had at least 5 medications at discharge. The FM and ambulatory pharmacists provided recommendations and all medication related problems (MRPs) and interventions were documented. Descriptive analysis was conducted. Results: A total of 25 hospitalized patients and 10 follow-up patients were included. A total of 44 inpatient MRPs and 41 outpatient MRPs were recorded. The most common inpatient MRP was antibiotic stewardship. The most common clinic MRP was medication access barrier. Conclusion: Implementation of the pilot program occurred and results were reported. These results demonstrate the importance of pharmacist involvement in TOC.

Medication administration by inpatient pharmacists: Innovative interdisciplinary care teams.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Pharmacists traditionally provide clinical pharmacy services in acute care settings. Two hospitals within our system integrated medication administration pharmacists into inpatient interdisciplinary care teams. Goals of this interdisciplinary care model were to improve productivity, quality, safety, patient satisfaction, and team member engagement while decreasing waste in the medication-use process and reliance on external nursing agency support. The new pharmacy role of medication administration pharmacist (MAP pharmacist) was integrated into the inpatient interdisciplinary care team. This new pharmacy role was not responsible for order verification in the electronic medical record. MAP pharmacists administered 99% of medications for assigned patients, averaging 100 to 120 medication administrations per day. Pharmacists educated patients about medications, including their purpose and most common adverse effects, using the teach-back method. Patient satisfaction scores increased 37% for patients' ability to understand adverse effects of medications and 44% for understanding the purpose of their new medications. Annual nursing staff turnover decreased from 30% to 7%, with a $2 million decrease in external nurse agency spend from 2022 to 2023. Pharmacist team member satisfaction scores, as measured on a Press Ganey scale ranging from 1 (poor) to 5 (very good), remained high, at a mean of 4.00 for engagement, with "progress," "quality work, and "knows what is expected" cited as strengths (mean scores of 4.23-4.46). The mean Press-Ganey score for pharmacy well-being increased from 3.80 in 2022 to 3.99 in 2023. Pharmacy opportunities identified via survey include enhanced communication and continued professional development. Post implementation, all surveyed nurses requested medication administration pharmacists on the inpatient interdisciplinary care team moving forward. The interdisciplinary care team with pharmacists enhanced medication safety and quality indicators, improved nursing satisfaction with workflow, and had a positive impact on patient satisfaction. Increased nursing capacity allowed for expanded assignments and nurse-to-patient ratios, as well as decreased reliance on external nurse agency support. Due to the overwhelming success of the initiative, MAP pharmacists' role as part of the interdisciplinary care team is being expanded to additional hospital service lines throughout the healthcare system.

Pharmacist-initiated naloxone discharge prescribing for high-risk hospitalized internal medicine patients.

Pharmacists nationwide may play a critical role in expanding naloxone access after several states enacted legislation to allow pharmacist prescribing of opioid antagonists. This created a unique opportunity for inpatient pharmacists to participate in combating the opioid epidemic by prescribing naloxone at hospital discharge. A multifaceted intervention was developed to identify and educate hospitalized patients eligible for naloxone prescribing. After implementation, 22 of 40 eligible patients (55 percent) were prescribed naloxone by inpatient pharmacists during the 3-month study period. With this pharmacist-driven intervention, there was an 848 percent increase in the number of hospitalized chronic opioid patients with naloxone prescriptions on discharge.

Supporting prescriber progression: a group concept mapping study

Abstract Introduction Education reforms allow pharmacists to become prescribers earlier in their career and from 2026, new registrants will be independent prescribers.1 In NHS Scotland, an operational framework supports the development of pharmacist independent prescribing.2 We wanted to supplement the operational framework by identifying our core areas of prescribing to articulate prescribing progression and inform education and training provision. Aim To develop a core prescribing framework to support safe prescribing and a spiral approach to expanding scope of practice. Methods We conducted a participatory mixed-method approach using group concept mapping methodology.3 Phase 1 (brainstorming): all hospital pharmacists working in a patient-facing clinical role were invited to enter statements on a cloud-based platform (Padlet®) using the prompt ‘In my day-to-day practice I prescribe and/or make prescribing recommendations about the following medicines / conditions …’. The statements were triangulated with electronic inpatient pharmacist prescribing data over the previous three months. Phase 2 (sorting and rating): a project group comprised of pharmacists with different levels of practice and areas of clinical expertise, individually sorted the statements into groups based on the statements’ conceptual similarity and rated each statement by level of practice (post-registration foundation, advancing, advanced) and importance for including in a core framework (5-point Likert scale). R software applied multidimensional scaling to sorting data to create a similarity matrix, cluster map and Go-Zones. ChatGPT generated cluster titles. The project group discussed the results and following a few revisions, consensus was achieved on the content of the prescribing framework. This study was not considered research and was approved by the pharmacy quality improvement team in line with local governance process. Results Forty-three pharmacists participated in the brainstorming phase and generated 158 statements. Fourteen pharmacists participated in the sorting and rating phase. Multidimensional scaling analysis identified three clusters of prescribing activities: initiating, adjusting and deprescribing. The data identified activities involving initiating medicines and autonomous decision making rated at advancing/advanced level practice while adjusting/deprescribing medicines (often with the caveat of within guidelines, protocols or team decisions) was rated at post-registration foundation level. The prescribing framework includes the activities considered important and is organised by cluster and level of practice. Discussion / Conclusion This study provides a structured conceptualisation of prescribing across the levels of practice. The prescribing framework reflects the needs of our patients and hospital inpatient service and provides a scaffolded approach to progressing from inexperienced to more advanced prescribing roles. Post-registration foundation prescribing activities focus on processes or types of prescribing, whilst advanced are more autonomous and complex. Limitations we didn’t collect clinical area of practice as part of the demographic information for the brainstorming phase and some specialities may not be represented. Further work includes a training needs analysis and developing entrustable professional activities for core and higher risk areas of prescribing (e.g. post-operative pain).

Reducing readmissions with pharmacist-integrated care in Medicare value-based programs.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Pharmacy transitions of care (ToC) programs have been shown to decrease 30-day hospital readmissions and improve patient outcomes, but there is limited published data on the impact of pharmacist-integrated ToC services beyond 30 days. The objective of this study was to evaluate the impact of pharmacist-integrated ToC and population health services on 30-, 60-, and 90-day all-cause readmissions in a Medicare value-based program (MV-BP) population and to compare mean times to first readmission with and without pharmacist care. A retrospective observational chart review was conducted to identify eligible hospital discharge encounters (DEs). Patients 18 years of age or older enrolled in an MV-BP were assigned to 4 study groups (a control group or one of 3 intervention arms) based on the pharmacy ToC services they received from either an inpatient ToC pharmacist or a dedicated population health pharmacist (PHP). Among 1,065 eligible DEs, 90-day follow-up was completed in 1,039 cases. The control group (n = 213) had a 90-day readmission rate of 34.74%. Intervention arm 1 (n = 201) had no significant reduction in 90-day readmissions, with a rate of 29.85% (odds ratio [OR], 0.94; 95% CI, 0.61-1.47; P = 0.80), while intervention arms 2 (n = 209), and 3 (n = 416) had significantly lower rates of readmission: 9.57% (OR, 0.26; 95% CI, 0.15-0.46; P < 0.01), and 17.07% (OR, 0.41; 95% CI, 0.27-0.61; P < 0.01), respectively. A combination of ToC and PHP services reduced 30-, 60-, and 90-day readmission rates in an MV-BP population. These results support the expansion of pharmacy-based ToC to minimize readmissions within 90 days for this Medicare population.

The inpatient oncology pharmacist experience in the era of temporary oncologists.

The inpatient oncology pharmacist experience in the era of temporary oncologists.

Clinicians' use of Health Information Exchange technologies for medication reconciliation in the U.S. Department of Veterans Affairs: a qualitative analysis.

Medication reconciliation is essential for optimizing medication use. In part to promote effective medication reconciliation, the Department of Veterans Affairs (VA) invested substantial resources in health information exchange (HIE) technologies. The objectives of this qualitative study were to characterize VA clinicians' use of HIE tools for medication reconciliation in their clinical practice and to identify facilitators and barriers. We recruited inpatient and outpatient prescribers (physicians, nurse practitioners, physician assistants) and pharmacists at four geographically distinct VA medical centers for observations and interviews. Participants were observed as they interacted with HIE or medication reconciliation tools during routine work. Participants were interviewed about clinical decision-making pertaining to medication reconciliation and use of HIE tools, and about barriers and facilitators to use of the tools. Qualitative data were analyzed via inductive and deductive approaches using a priori codes. A total of 63 clinicians participated. Over half (58%) were female, and the mean duration of VA clinical experience was 7 (range 0-32) years. Underlying motivators for clinicians seeking data external to their VA medical center were having new patients, current patients receiving care from an external institution, and clinicians' concerns about possible medication discrepancies among institutions. Facilitators for using HIE software were clinicians' familiarity with the HIE software, clinicians' belief that medication information would be available within HIE, and their confidence in the ability to find HIE medication-related data of interest quickly. Six overarching barriers to HIE software use for medication coordination included visual clutter and information overload within the HIE display; challenges with HIE interface navigation; lack of integration between HIE and other electronic health record interfaces, necessitating multiple logins and application switching; concerns with the dependability of HIE medication information; unfamiliarity with HIE tools; and a lack of HIE data from non-VA facilities. This study is believed to be the first to qualitatively characterize clinicians' HIE use with respect to medication reconciliation. Results inform recommendations to optimize HIE use for medication management activities. We expect that healthcare organizations and software vendors will be able to apply the findings to develop more effective and usable HIE information displays.

Effect of Inpatient Pharmacist-Led Medication Reconciliations on Medication-Related Interventions in Intensive Care Unit Recovery Centers.

Background: Critical care pharmacists complete comprehensive medication reviews in Post Intensive Care Syndrome (PICS) patients at Intensive Care Unit Recovery Centers (ICU-RCs) to optimize medication therapies after hospital discharge. Inpatient pharmacists often complete medication reconciliations prior to hospital discharge, which could affect interventions at an ICU-RC. However, this association remains ill-described. Objective: The purpose of this study was to, in patients with PICS, describe the effect of an inpatient, pharmacist-led medication reconciliation on the number of clinical pharmacist interventions at the first ICU-RC visit. Methods: This was a post-hoc subgroup analysis of an international, multicenter cohort study of adults who had a pharmacist-led comprehensive medication reconciliation conducted in 12 ICU-RCs. Only patients' first ICU-RC visit was eligible for inclusion. The primary outcome was the number of medication interventions made at initial ICU-RC visit in PICS patients who had an inpatient, pharmacist-led medication reconciliation compared to those who did not. Results: Of 323 patients included, 83 received inpatient medication reconciliations and 240 did not. No difference was observed in the median number of medication interventions between groups (2 vs 2, p = .06). However, a higher incidence of any intervention (86.3% vs 78.3%, p = .09) and dose adjustment (20.4% vs 9.6%; p = .03) was observed in the no medication reconciliation group. Only ICU Sequential Organ Failure Assessment score was associated with an increased odds of medication intervention at ICU-RC visit (aOR 1.15, 95% CI 1.05-1.25, p < .01). Conclusion and Relevance: No difference in the total number of medication interventions made by ICU-RC clinical pharmacists was observed in patients who received an inpatient, pharmacist-led medication reconciliation before hospital discharge compared to those who did not. Still, clinical observations within this study highlight the continued importance and study of clinical pharmacist involvement during transitions of care, including ICU-RC visits.

Implementation of a practice model for inpatient psychiatric clinical pharmacist practitioners with prescriptive authority at a veterans health care facility.

Clinical pharmacists play a valuable role on collaborative health care teams, especially in the field of mental health. However, there is a need to explore innovative practice models that optimize their potential in providing comprehensive medication management in inpatient psychiatric settings. This report aims to describe the implementation of a practice model using an inpatient psychiatric clinical pharmacist practitioner performing comprehensive medication management. The implementation of a practice model using a psychiatric clinical pharmacist practitioner was a feasible way to deliver comprehensive medication management and other clinical services in an inpatient psychiatric setting amid staffing challenges. Whereas limitations such as resource constraints must be considered, the success of this model highlights the value of a versatile psychiatric clinical pharmacist practitioner. These findings might offer insight to other health care facilities considering a similar approach to provide mental health care through the use of a psychiatric clinical pharmacist practitioner.

ASHP National Survey of Pharmacy Practice in Hospital Settings: Operations and Technology - 2023.

Results of the 2023 ASHP National Survey of Pharmacy Practice in Hospital Settings are presented. Pharmacy directors at 1,497 general and children's medical-surgical hospitals in the United States were surveyed using a mixed-mode method of contact by email and mail. Survey completion was online using Qualtrics. IQVIA supplied data on hospital characteristics; the survey sample was drawn from IQVIA's hospital database. The response rate was 21.6%. Inpatient pharmacists independently prescribe medications in 26.7% of hospitals. Advanced analytics are used in 5.7% of hospitals. Basic analytics are used in 87.3% of hospitals. Pharmacists work in ambulatory or primary care clinics in 54.2% of hospitals operating outpatient clinics. Most hospitals (86.1%) use automated dispensing cabinets as the primary method of maintenance dose distribution. Machine-readable coding is used in 73.6% of hospitals to verify doses during dispensing in the pharmacy. Autoverification functionality in the electronic health record system is used in 73.4% of hospitals. Most hospitals report some integration of pharmacy services to optimize patient care transitions (60.0%), while 24.9% report no integration. Traditional technician activities still predominate, but more advanced roles are emerging. Technologies to assist sterile product preparation are used in 62.8% of hospitals. Drug distribution continues to trend toward decentralized models with medications available closer to patients. Technologies are enabling this transition to occur without a significant negative impact on patient safety. The pharmacy workforce is stable, and more advanced responsibilities are being assigned to pharmacy technicians, enabling pharmacists to increase their clinical role.

Med rec double check: Inpatient psychiatry medication errors identified on admission using Medicaid Web portals and electronic pharmaceutical claims data.

The role of pharmacists during medication reconciliation (MR) is well established, with a number of reports describing this in the context of psychiatric hospitalizations. However, medication errors (MEs) are common during transitions of care, with no exception during psychiatric hospitalizations. Our institution uses pharmacy-performed MR processes using patient interviews and reviewing objective sources, such as electronic pharmaceutical claims data (EPCD), which includes Medicaid Web portals. The inpatient psychiatric pharmacist reviews EPCD sources against previously pharmacy-completed MRs for new admissions, where if discrepancies are found, the patient is reinterviewed to identify and correct MEs. We performed a prospective quality improvement project during 28 days to evaluate the quantity and classification of MEs upon admission to a 22-bed inpatient psychiatry unit. Of 52 included patients, where a cumulative 426 medications were reviewed, a total of 29 MEs in 16 patients were identified. Eight patients had discrepancies on their home medication lists when compared to EPCD, where 7 of these had at least 1 ME due to inaccurate MR. Of all the MEs identified, the greatest quantity was found secondary to the EPCD "double-check" method. The most common MEs in all patients were the omission of home medications (34%), wrong frequency (28%), and ordering medication the patient is not taking (10%). All patients admitted on long-acting injection antipsychotics had errors in last dose received. No MEs resulted in patient harm, and they were identified and corrected by the psychiatric pharmacist 97% of the time.

Iatrogenic hyperchloremia: An overview in hospitalized patients for pharmacists.

The purpose of this therapeutic update is to provide pharmacists with a general overview of the pathophysiology of hyperchloremia and describe strategies to help prevent development of this electrolyte abnormality in hospitalized patients. Hyperchloremia is an electrolyte abnormality associated with an increased incidence of acute kidney injury and metabolic acidosis. Intravenous (IV) fluids utilized for volume resuscitation, medication diluents, and total parental nutrition all may contribute to the development of hyperchloremia. Current evidence suggests that administration of balanced crystalloids for either fluid resuscitation or maintenance fluids may impact serum chloride levels and patient outcomes. In multiple randomized controlled trials, administering balanced crystalloids for fluid resuscitation in critically ill patient populations did not decrease mortality. However, further analyses of subpopulations within these trials have demonstrated that patients with sepsis may benefit from receiving balanced crystalloids for initial fluid resuscitation. Results from several small studies suggest that altering the composition of these IV fluids may help prevent development of hyperchloremia. Management of hyperchloremia is preventative in nature and can be mitigated through management of resuscitation fluids, medication diluents, and total parenteral nutrition. Inpatient pharmacists should be aware of the potential risk of fluid-associated hyperchloremia and assist with optimal fluid management to prevent and manage hyperchloremia.

Patient-perceived understanding of home-going medication with transitions of care services at a pediatric institution

BackgroundTransitions of care (TOC) is the coordination and continuity of health care as a patient transfers between different settings. This can include a wide range of services, such as medication reconciliation, patient counseling, bedside delivery of medications, and others that meet individual patient needs. In the pediatric population, patients are at increased risk of potential medication errors and subsequent harm owing to reduced patient and caregiver health literacy, limited dosage form availability, and errors in medication administration. The use of TOC services at the time of hospital discharge in this population has the potential to make a positive impact on patient safety and the treatment of medical conditions. ObjectivesThe primary objective of this study was to determine whether patient-perceived understanding of home-going medications was greater in patients and/or caregivers who received medication bedside delivery and education from a pharmacy-led TOC service at a large pediatric academic medical center. The secondary objective was to determine whether the primary practice area of the pharmacist providing medication education led to changes in understanding of home-going medication(s). MethodsUsing institution-wide, patient satisfaction surveys from January 1, 2021, to December 31, 2021, patient and caregiver responses were queried for 2 questions about home-going medications, relating to the understanding of administration and the potential adverse effects. Patients were divided into 2 groups depending on TOC services received, as documented in the electronic medical record (EMR). Survey responses for each of the 2 questions were categorized as top-box percentage by study group. Hypothesis testing between study groups for the primary and secondary outcomes were conducted using chi-squared tests at an alpha of 0.05. Statistical analyses were conducted using SAS version 9.4. ResultsOf the 1159 patients included in the study, 441 received TOC services, deemed the intervention group, and 718 did not receive TOC services, deemed the control group. When the intervention and control group were asked about understanding of medication administration, 96.37% versus 93.18% of patients (P = 0.007) gave the most favorable response of “yes, definitely,” respectively. Furthermore, 78.51% versus 77.44% of patients (P = 0.053) gave the most favorable response when asked about understanding potential medication adverse effects, respectively. ConclusionPatients receiving TOC services by a member of the pharmacy team had a greater score for understanding of both medication administration and adverse effects. Furthermore, this greater score was consistent among the education provided by the inpatient and outpatient pharmacist.

Evaluation of pharmacist-led transition of care program in patients with acute coronary syndrome

BackgroundGuideline-directed medical therapies (GDMTs), initiated in-hospital and continued during the transition to outpatient care, are paramount to successful outcomes for patients with acute coronary syndrome (ACS). Incomplete discharge medication prescribing and delayed follow-up lead to worse cardiovascular outcomes. ObjectivesWe investigated a system of care using inpatient and outpatient clinical pharmacists to close GDMT gaps, ensure seamless transition to outpatient care, improve patient education, and optimize therapies. MethodsWe conducted a pre-post cohort analysis of patients with ACS pre- versus post-intervention to compare process metrics and key outcomes using electronic health record data. ResultsThere were 181 and 135 patients in the pre- and post-intervention cohorts, respectively. Patients post-intervention were significantly more likely to have appropriately-timed follow-up visits scheduled with cardiology (79% vs. 51%, P < 0.0001) and primary care (57% vs. 43%, P = 0.01), to be discharged with prescriptions for P2Y12 inhibitors (87% vs. 64%, P < 0.0001), high dose statins (86% vs. 70%, P = 0.001), and beta blockers (87% vs. 76%, P = 0.01), and significantly less likely to have 30-day all-cause hospital readmissions (4% vs. 12%, P = 0.02) and emergency department (ED) visits (10% vs. 18%, P = 0.04). ConclusionsThe integration of advanced practicing pharmacists into a cardiology team at transition and post-hospitalization resulted in improved rates of posthospital follow-up visits, optimization of GDMT medications, and significantly lower 30-day hospital readmission and ED utilization.

The association between number of learners and pharmacist and technician levels of burnout.

Little is known about the relationship between learner load and pharmacist and pharmacy technician burnout. Therefore, the purpose of this study was to examine the association between burnout and the number of learners (residents, students, and new employees) assigned to pharmacists or pharmacy technicians. A validated survey to measure burnout and professional fulfillment was administered to employees of a university health system's pharmacy service in 2019. A threshold analysis determined the optimal cutoff for number of learners trained that maximized the ability to predict binary outcomes. Chi-square and Fisher's exact tests were used, and effect sizes between percentages were reported. Finally, the adjusted associations between number of learners and outcomes were assessed using logistic regression. A total of 448 pharmacy staff members were included in the analysis. Of those, 57% (n = 254) worked in ambulatory care, 27.4% (n = 122) worked in an inpatient setting, and 15.7% (n = 70) worked in infrastructure. Pharmacists working in an inpatient setting who reported training 4 or more learners per year indicated significantly higher rates of burnout than those training fewer learners on both a single-item burnout assessment (64.3% vs 31.0%; P = 0.01; effect size, 0.68) and a 10-item burnout assessment (54.8% vs 13.8%; P = 0.01; effect size, 0.91). Similar results were not observed in pharmacists working in ambulatory care and infrastructure positions or in pharmacy technicians. Added precepting and training responsibilities may be associated with higher levels of burnout among pharmacy team members, particularly inpatient pharmacists.

Understanding the use of evidence-based medical therapy in patients with peripheral artery disease: A qualitative study using the Tailored Implementation for Chronic Diseases Framework.

The global burden of peripheral artery disease (PAD) has been increasing. Guidelines for PAD recommend evidence-based medical therapy (EBMT) to reduce the risks of cardiovascular events and death but the implementation of this is highly variable. This study aimed to understand the current practices regarding EBMT prescription in PAD patients and the key barriers and facilitators for implementing PAD guidelines. A qualitative study was conducted in the largest tertiary hospital in Singapore from December 2021 to March 2023. The participants included healthcare professionals and in-patient pharmacists involved in the care of PAD patients, as well as patients with PAD who had undergone a lower limb angioplasty revascularisation procedure. Data were collected through in-depth, individual semi-structured interviews conducted face-to-face or remotely by a trained research assistant. Interviews were audio-recorded, transcribed and systematically coded using data management software NVivo 12.0. The Tailored Implementation for Chronic Diseases (TICD) framework was used to guide the interviews and analysis. Twelve healthcare professionals (4 junior consultants, 7 senior consultants, and 1 senior in-patient pharmacist) and 4 patients were recruited. Nine themes in 7 domains emerged. Only a small proportion of doctors were aware of the relevant guidelines, and the generalisability of guidelines to patients with complicated conditions was the doctors' main concern. Other barriers included cost, frequent referrals, lack of interprofessional collaboration, not being the patients' long-term care providers, short consultation time and patients' limited medication knowledge. Findings from this study may inform strategies for improving healthcare professionals' adherence to guidelines and patients' medication adherence.

Implementing preemptive, multigene, pharmacogenomic testing in the inpatient setting: Preliminary results from a small, rural facility

AbstractIntroductionPreemptive pharmacogenomic (PGx) testing is on the rise among United States health care centers, with the majority of testing performed in the primary care setting. For broader implementation, there is a call for descriptions of the implementation and workflow of successful PGx programs in a large variety of health care settings.ObjectiveThe purpose of this study was to describe the implementation and initial outcomes of preemptive PGx (11‐gene, multipanel) testing in inpatient workflow at a Veterans Affairs medical center.MethodsThe inpatient clinical pharmacist incorporated patient screening, informed consent, and PGx lab ordering into their daily workflow in March 2023. Included adult patients had to be enrolled into the facility's primary care program and able to provide informed consent. Patients were excluded if they had a history of bone marrow or liver transplant, were consulted for palliative or hospice care, or had altered mental status at the time of screening. A retrospective chart review was used to collect demographics and PGx results from March to August 2023.ResultsThere were 247 patients screened for PGx testing in the 6‐month study period. Of these, 74 already had PGx performed, 31 declined or deferred testing, and 142 consented to testing. Laboratory blood draw was not performed as ordered on 12 patients, leaving 130 samples with results. Of 130 patients, 129 (99%) had an actionable PGx variant, with most having multiple variants: one variant (6%), two variants (15%), three variants (32%), four variants (24%), five variants (18%), and six variants (3%). At the time of follow‐up, 64 (49%) patients were prescribed an affected medication: one medication (38%), two medications (8%), and three medications (3%).ConclusionIncorporating preemptive PGx testing into inpatient workflow is feasible in a rural facility with a significant proportion of patients being affected by the results.