Acceptance Rate Of Recommendations Research Articles

Analysis of clinical outcomes in older individuals who received pharmaceutical care and posthospital discharge follow-up.

Previous evidence underscores the need to assess potential clinical outcomes resulting from pharmaceutical care interventions and to monitor patient's progress to evaluate their clinical evolution, which is crucial for bolstering the relevance of implementing pharmaceutical care in healthcare services. To conduct an in-depth analysis of pharmaceutical care practices in a geriatric ward and monitor the clinical outcomes of older people served. This interventionist study was conducted in the geriatrics ward of a Brazilian university hospital. The research intervention occurred between January and May 2022, with a follow-up conducted for up to 90 days after patients' hospital discharge. Older patients in the geriatrics ward received pharmaceutical care, including medication reconciliation, medication review,and pharmacotherapeutic follow-up, aimed at identifying and resolving drug-related problems (DRPs). The clinical relevance of DRPs and pharmaceutical recommendations was evaluated. Additionally, analyses were conducted on mortality and rehospitalization outcomes in older patients at 30, 60,and 90 days following initial hospital discharge. Of the patients evaluated, a significant 88.3% exhibited at least one DRP (with an average of 2.6 ± 1.9 DRPs per patient), with the majority classified as need/indication problems (38.9%). The acceptance rate of pharmaceutical recommendations was 80.9%, with the majority categorized as very significant relevance (60.4%). DRPs were predominantly of serious clinical relevance (50.9%). In patients whose clinical indicators could be monitored, 95.5% showed some clinical response (in vital signs, laboratory testsand/or clinical status evolution) potentially related to resolved DRPs. Association analysis revealed that a higher number of medications in use before hospitalization correlated with a greater identification of DRPs during hospitalization (p = 0.03). At hospital discharge, 23.6% of patients were no longer using polypharmacy. In total, 16 patients (26.7%) died during the study period. Among patients who did not die during hospitalization (n = 54), 20 patients (37%) experienced rehospitalizations within 90 days following discharge. This study facilitated the consolidation of pharmaceutical care implementation in a geriatric ward. We conducted identification, evaluation,and proposed evidence-based solutions, as well as monitored cases for outcome analysis. It is anticipated that this methodology will inspire future research and the implementation of pharmaceutical care-related services.

Pharmacist-Driven Alcohol Use Disorder Screening May Increase Inpatient Utilization of Extended-Release Naltrexone: A Single Center Pilot Study.

Individuals with mental illness have a high incidence of comorbid substance use, with one of the most prevalent being alcohol use disorder (AUD). Naltrexone, FDA-approved for AUD, decreases reward associated with alcohol-related social cues. This study aimed to determine if a pharmacist-driven screening tool would increase the use of extended-release naltrexone (XR-NTX) in patients with AUD and a comorbid psychiatric condition. Pharmacists screened and recommended XR-NTX for adults admitted to the inpatient psychiatric unit, who had a DSM-5 diagnosis of AUD, a negative urine drug screen for opioids, and were hospitalized for at least 1 day. Endpoints evaluated included the number of XR-NTX doses administered during the screening period to the prescreening period, 30-day readmission rates, recommendation acceptance rates, and reasons for not administering XR-NTX. Pharmacists identified 66 of 641 screened patients who met the inclusion criteria and were candidates for XR-NTX. Compared to the preintervention period, more patients received XR-NTX for AUD (2 vs. 8). Readmission rates were similar between those with AUD who received XR-NTX and those who did not. Pharmacist-driven screening for AUD led to greater administration of XR-NTX when compared to the same 4-month period the year prior to initiating the study.

Clinical Pharmacist-Led Medication Review in Hospitalized Confirmed or Probable Patients with COVID-19 During the First Wave of COVID-19 Pandemic.

Drug-related problems (DRPs) result in serious problems among hospitalized patients, high rates of morbidity and mortality, and increased healthcare costs. This study aimed to identify DRPs by clinical pharmacist-led medication review in hospitalized probable patients with coronavirus disease-2019 (COVID-19) during the first wave of the COVID-19 pandemic. This retrospective cross-sectional study was conducted at the COVID-19 inpatient services of a tertiary university hospital in Türkiye for 3 months (between March 2020 and June 2020) and included hospitalized confirmed or probable COVID-19 patients. The World Health Organization and Turkish Ministry of Health Guidelines case definitions were used to define confirmed and probable COVID-19 patients. Six clinical pharmacy residents provided medication review services during their education and training. DRPs were classified based on the Pharmaceutical Care Network Europe V9.00. The physician's acceptance rate of clinical pharmacists' recommendations was assessed. Among 202 hospitalized patients with probable or confirmed COVID-19, 132 (65.3%) had at least one drug-related problem. Two hundred and sixty-four DRPs were identified. Drug selection (85.6%) and dose selection (9.2%) were the most common causes of these problems. Among the 80 clinical pharmacist interventions, 48.8% were accepted by the physicians. Clinical pharmacists identified a significant number of DRPs during the COVID-19 pandemic, particularly those related to drug interactions and drug safety, such as adverse drug reactions. This study highlights the importance of detecting and responding to DRPs in the COVID-19 pandemic.

1235. A Retrospective Review of Antimicrobial Stewardship Audit and Feedback: Assessing Acceptance of Stewardship Recommendations During the COVID-19 Pandemic

Abstract Background Antimicrobial stewardship is an underutilized strategy to mitigate the impact of antimicrobial resistance. It is well documented that many Antimicrobial Stewardship Programs (ASPs) were tasked with assisting healthcare teams in navigating the COVID-19 pandemic, leaving less time/fewer resources for day-to-day ASP activities. The aim of this study was to evaluate the acceptance of stewardship recommendations during a season when the ASP had less time to perform regular educational activities and handshake stewardship. Methods A retrospective study of patients receiving antimicrobial therapy at Saint Francis Hospital during 12/30/2020-10/01/2022, for which audit and feedback by the ASP was conducted. A well-established ASP existed prior to the pandemic. Independent variables included the reason for intervention, type of infection by organ system, and type of intervention. Interventions included recommendations to stop antibiotics, de-escalation, duration of therapy, ID consultation, or change the route of administration. The primary outcome was the audit and feedback acceptance rate, and the secondary outcome was whether the intervention resulted in infectious disease consultation. Results 297 patients underwent audit and feedback. Interventions most accepted by providers included changing the route of administration (100%) and consulting ID formally (92%). Adjusting the duration of therapy was the least accepted intervention at 78%. Regardless of intervention, 33% of providers requested a formal ID consult. The number of interventions varied sporadically, coinciding with periods of decreased availability by the ASP team and during peak waves of the COVID-19 pandemic. Conclusion Our ASP team, despite decreased resources while battling an ongoing pandemic, were still able to perform audit and feedback to providers with a good acceptance rate of recommendations, consistent with current literature. Having not only an existing but robust ASP prior to the pandemic, allowed continued success with ASP intervention acceptance rates, despite less dedicated time for typical ASP activities during the pandemic. Fostering good relationships between providers and ASP teams, as well as continued support and funding from hospital leadership, are vital to ongoing success. Disclosures All Authors: No reported disclosures

1263. The Experience of an Antimicrobial Stewardship Program at a Tertiary Referral Hospital in a Low/Middle Income Country

Abstract Background Antimicrobial Stewardship Programs (ASP) play a crucial role in optimizing antimicrobial utilization and limiting the use of broad-spectrum antibiotics, to reduce antimicrobial resistance. During the COVID-19 pandemic, there was a noticeable increase in antimicrobial consumption globally. The ASP at the American University of Beirut Medical Center (AUBMC) began formal operations in January 2019. In this study, our aim is to evaluate the activities of the ASP -since implementation and during the pandemic- at our institution, a tertiary referral hospital in Beirut. Methods The ASP team performed handshake stewardship rounds and daily reviews of antimicrobial use. It provided educational activities in a multi-disciplinary approach in addition to implementing a carbapenem sparing strategy and ongoing monitoring of antibiotic consumption. This study is a retrospective review of those activities. We compiled the ASP recommendations from January 2019 until December 2021. Data collected included the number of ASP recommendations and their sub-categories in addition to acceptance rates. Results We recorded a total of 9922 recommendations during this three-year period. Recommendations aiming at reducing antimicrobial consumption were the most common (42%), and included: duration of therapy, de-escalation, and duplicate coverage (Figure 1). Rates of acceptance of these recommendations were 88%, 92% and 95% in 2019, 2020 and 2021 respectively. The number of recommendations increased during the pandemic and coincided with COVID-19 surges in Lebanon (figure 2). There was also an increase in the acceptance rate of recommendations to reduce antibiotic consumption (Figure 3) over this period.Figure 1.Distribution of ASP Interventions per sub-CategoryFigure 2.Number of ASP Recommendations pre- and During COVID-19Figure 3.ASP recommendations to Reduce Antibiotic Consumption and Acceptance Rate Conclusion Despite the challenges imposed by the pandemic and the involvement of the ASP in the COVID-19 response, the team maintained its efforts and involvement to mitigate antibiotic misuse. The results are encouraging and attest to the important role of ASP in driving culture change regarding the judicious use of antimicrobials even during a pandemic. Disclosures Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

Pharmacist-driven deprescribing initiative in primary care

BackgroundPolypharmacy, a broad term to describe the use of numerous and often unnecessary medications, has been connected to frailty, hospital admissions, falls, and even mortality. The Veterans Health Administration (VHA) developed the VIONE (vital, important, optional, not indicated, and every medication has an indication) dashboard to identify patients with polypharmacy and serve as a framework for deprescribing of medications across VHA facilities where it is used in a variety of practice settings by different disciplines. ObjectiveThis study aimed to describe the implementation of a pharmacist-led, system-wide, deprescribing initiative in the primary care setting. Practice descriptionInterdisciplinary education was provided through academic detailing. Subsequently, patients were identified for inclusion in the project using the VIONE dashboard focusing on those at highest risk of polypharmacy and moving down to the lowest risk. Interested patients underwent a medication reconciliation. A clinical pharmacist practitioner (CPP) then contacted the patient to discuss potential deprescribing options. Recommendations were relayed to the primary care provider (PCP) for final approval and communicated to the patient by the pharmacy team. Practice innovationPrimary care CPPs (n = 3) integrated deprescribing into their standard workload. This service was implemented in the primary care setting across an entire health care system consisting of 16 different primary care teams. Evaluation methodsThe initiative’s impact was measured by the number of discontinued medications, the acceptance rate of recommendations by the PCP, the potential annualized cost avoidance, and the number of patients referred to CPP medication management clinics. ResultsAmong 63 patients, a total of 352 medications were deprescribed resulting in a potential annualized cost avoidance of $184,221. The acceptance rate of discontinuation recommendations was 96.7%. Subsequently, 25.4% of patients were referred to pharmacist-led clinics for disease state management. ConclusionEmbedding deprescribing into standard CPP workflow within the primary care setting facilitated a way for polypharmacy reduction and allowed the expansion of pharmacy-led services at VA Butler Healthcare System.

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.

Evaluation of clinical effects of a multidisciplinary-collaborated cancer support team for gastrointestinal cancer chemotherapy: prospective observational study protocol of M-CAST study

BackgroundAlthough the multidisciplinary-collaborated team approach in cancer treatment has recently become popular, prospectively evaluated evidence is limited. We started a multidisciplinary-collaborated cancer support team (MCST) to facilitate cooperation across multidisciplinary medical staff in our hospital and established clinical evidence of supportive care. This study aimed to prospectively evaluate the clinical activity and effect of MCST in patients with gastrointestinal cancer receiving chemotherapy.MethodsThis is a single-center, single-arm, observational study. Patients with gastrointestinal cancer scheduled to receive chemotherapy are enrolled and supported by the MCST. The primary endpoints are the number of interventions by medical staff and the number of patients who showed improvement in side effects. The secondary endpoints are the severity of side effects, medical expenses, number of consultations, the acceptance rate of prescription recommendations, adjuvant chemotherapy completion rates, dose intensity, and time required for co-medical intervention. In addition, medical staff and attending physicians evaluate all adverse events.DiscussionThis study is expected to contribute to establishing new cancer-supportive care teams for patients with gastrointestinal cancer receiving chemotherapy and those with cancer receiving chemotherapy.Trial registrationThis trial was registered in the Japan Registry of Clinical Trials (jRCT) as jRCT1030220495.The date of first registration, 29/11/2022, https://jrct.niph.go.jp/search

#3648 INDIVIDUALIZED ANEMIA THERAPY IMPROVES HEMOGLOBIN OUTCOMES AND DECREASES EPOETIN BETA DRUG EXPOSURE IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Anemia is a common complication in hemodialysis (HD) patients. Its treatment with erythropoiesis-stimulating agents (ESAs) is challenging due to a nonlinear dose-response relationship and time delays between ESA administration and hemoglobin (Hgb) response. Anemia treatment protocols are frequently used in clinical settings. However, high variability of patient-specific disease characteristics complicate attainment and maintenance of desired Hgb levels. We developed a novel fully personalized ESA dose recommendation tool and present clinical results of a multi-center, randomized controlled trial (RCT) using this software. Method We conducted an RCT in adult HD patients in six dialysis facilities in the US. Patients were randomized 1:1 and treated with our personalized ESA dose recommendation tool for twenty-six weeks (intervention group) or continued to be treated using an anemia protocol that was used as part of standard of care in those clinics (control group). The recommendation tool utilized a physiology-based model of anemia to estimate patient-specific physiological key characteristics, such as red blood cell lifespan, to create a patient-individual model from recent routine clinical data (gender, height, weight, Hgb measurements, and ESA treatment). These key characteristics and model-based outcome predictions were used to generate patient-specific ESA dose recommendations to stabilize Hgb levels in a target window of 10–11 g/dL. Dose recommendations were disseminated to the anemia managers of patients enrolled in the study for evaluation and further decision-making (Figure 1). This procedure was repeated biweekly with updated clinical data. Results Ninety-six patients were enrolled in the RCT. Patients were included in the statistical analysis when they remained in the clinical study for at least 30 days (n = 45 control group, n = 46 intervention group). We evaluated outcome measures showing efficacy and efficiency of the treatment in achieving target Hgb levels. Hgb-related outcomes were significantly different between the two study groups, with an improved Hgb control in the intervention arm, manifesting in a reduction of the Hgb distance to target by more than 30%. Epoetin-beta utilization in the intervention group was decreased by over 20%, while iron-related parameters showed no difference between the two arms (Table 1). Acceptance rate of dose recommendations was high; roughly 95% of the recommendations were accepted and implemented by the clinical staff. Conclusion A therapy software for personalized anemia management was developed for use with epoetin beta. The model-based ESA dose recommendation tool was evaluated in a clinical RCT in HD patients. Hgb control improved significantly in the group using the novel software tool, while ESA usage decreased, thus providing more efficient anemia management for the individual patient while reducing epoetin-beta drug exposure.

Handshake stewardship on adult acute-care surgical services

Background: Handshake stewardship is a variation of prospective audit and feedback that entails the individual review of patient charts by a physician–pharmacist collaborative team followed by in-person feedback to primary teams to communicate recommendations regarding optimal antibiotic use. Handshake stewardship has been shown to have durable effects in reducing antimicrobial use in children’s hospitals, but data regarding this intervention in adult hospitals are scarce. In particular, no data are available regarding the impact of this type of stewardship intervention on adult surgical units. We examined the effect of a handshake stewardship intervention at a large academic medical center on adult trauma and acute- and critical-care surgery (ACCS) units. Methods: The antimicrobial stewardship program (ASP) at Barnes-Jewish Hospital launched a handshake stewardship intervention targeting surgical floor teams in January 2022. These teams included the ACCS teams and a number of other surgical services. The intervention consisted of once weekly reviews and in-person rounds with the surgical floor teams along with the establishment of a 7 day per week “hotline” in which the surgical teams could contact an ID physician or pharmacist with questions regarding antibiotic use. Patients with formal ID consultations were not reviewed. Recommendations were tracked including the type, the antibiotic targeted, and recommendation acceptance or rejection. Descriptive statistics were performed to analyze these results. At the end of 12 months, antibiotic use in the floors covered by the ACCS teams were pulled from the NHSN AU module to perform an interrupted time-series analysis 12 months before and after the intervention. Results: Overall, 3,127 charts were reviewed during the intervention period and 637 recommendations were made to all the surgical teams. Opportunities for antibiotic use optimization were identified in ~20% of antibiotic orders. The overall recommendation acceptance rate was 71%. In the ACCS units, 272 interventions were recommended, with an acceptance rate of 67%. The most frequent recommendations were for antibiotic discontinuation (37%), antibiotic de-escalation (17%), shortening duration (12%), and broadening coverage (12%). Antibiotic usage trends (Fig. 1) on the ACCS floors, which were showing a nonsignificant increasing trend (P = .70) before and after the intervention, now show a nonsignificant decreasing trend (P = .20). Conclusions: There are numerous opportunities for antibiotic optimization on adult surgical floors. Although handshake stewardship is a labor-intensive intervention, preliminary findings after 1 year show that, on ACCS units, there may be a trend toward a sustained impact.Disclosures: None

KLİNİK ECZACILIK UZMANLIK PROGRAMI KAPSAMINDA İÇ HASTALIKLARI SERVİSLERİNDEKİ MÜDAHALELER: RETROSPEKTİF BİR ÇALIŞMA

Objective: Drug-related problems are a common health problem in hospitalized patients, affecting optimal patient outcomes. The aim of the study is to classify the drug-related problems detected by clinical pharmacy resident in hospitalized patients during their rotations and evaluate their interventions to the healthcare team. Material and Method: This is a retrospective study in which the drug-related problems of the patients hospitalized in the internal medicine wards between April and November 2018 were examined during the rotations of the clinical pharmacy resident. Patients’ demographics, prescribed medicine, laboratory findings were recorded. Drug-related problems are classified with the Pharmaceutical Care Network Europe Version 9.1 system. Result and Discussion: Ninety-two patients were included in the study. The median age of patients was 60.5 years and 59.8% of them were female. Most of the patients (63%) had three or more comorbidities. The most frequent comorbidities were hypertension (21.70%) and diabetes mellitus (10.64%). One hundred forty-seven drug-related problems were detected in 57 patients (62%). Potential drug-drug interactions (55.78%), errors in dosing timing instructions (9.52%), and inappropriate drug use according to guidelines (8.16%) were the most common causes of drug-related problems. The acceptance rate of interventions for resolving drug-related problems was 65%. The most common drug-related problems in this study were due to drug selection. The acceptance rate of recommendations for drug-related problems was lower than in the literature. However, this initial acceptance rate can be considered successful in a center where clinical pharmacy services have not been established.

Pharmacist-Driven Geriatric Medication Assessment at an Acute Care Teaching Hospital

Older patients are often prescribed many medications and are at higher risk for medication-related problems. Pharmacists can help to identify potentially inappropriate medication use that may precipitate adverse drug events resulting in mental status changes, falls, and hospitalization. A Pharmacist-Driven Geriatric Medication Assessment program was established by clinical pharmacists to evaluate medication use in older patients admitted to a pilot unit of an acute care hospital as part of an Age-Friendly Care initiative. This article describes the implementation of this program and the types of medication interventions pursued by the pharmacists. Pharmacist recommendation acceptance rate by the health care team was greater than 90% overall for medication reconciliation, potentially inappropriate medications, and other medication interventions.

Assessment of drug-related problems at the emergency department in older patients living with frailty: pharmacist-led medication reviews within a geriatric care team

BackgroundOlder patients are vulnerable to experiencing drug related problems (DRPs), which may result in emergency department (ED) visits. However, it is not standard practice to conduct medications reviews during ED visit. The aim of this study was to assess the number of DRPs in older patients living with frailty at the ED, identified through pharmacist-led medication reviews within a geriatric care team, and to determine the acceptance rate of pharmacists’ recommendations among hospital physicians and general practitioners or elderly care specialists.MethodsA retrospective observational study was performed in patients ≥ 70 years living with frailty at the ED at Tergooi Medical Center. Pharmacist-led medication reviews were conducted to identify and classify DRPs as part of a larger geriatric assessment. The acceptance rate of given recommendations was determined during follow-up.ResultsA total of 356 ED visits were included. The mean (standard deviation, SD) age of patients was 83 (6.8) years. About 76% of patients had at least one DRP. In total, 548 DRPs were identified with a mean of 1.5 DRP (SD 1.3) per patient. The acceptance rate of medication recommendations in admitted patients was 55%, and 32% among general practitioners/elderly care specialists in discharged patients.ConclusionsPharmacist-led medication reviews as part of a geriatric care team identified DRPs in 76% of older patients living with frailty at the ED. The acceptance rate was substantially higher in admitted patients compared to discharged patients.

949. Impact of Antimicrobial Stewardship Pharmacist Participation in Pediatric Infectious Diseases Rounds on Prospective Audit and Feedback Recommendations

Abstract Background Prospective audit and feedback (PAF) is a core strategy of antimicrobial stewardship programs (ASPs). To improve communication of PAF recommendations to the inpatient pediatric infectious diseases (ID) consult service, the ASP pharmacists at our hospital were integrated into ID rounds. The purpose of this study was to assess the impact of ASP pharmacy participation in ID rounds on the rate of ASP recommendations. Methods Prior to implementation of the ASP pharmacist rounding service, the ASP pharmacist did not routinely attend rounds or communicate PAF recommendations directly to the ID consult service. Starting 1/3/22, the ASP pharmacists had daily (M-F) in-person discussions with the ID team regarding their patients’ antimicrobials. Audits performed between 1/4/21-12/30/21 and 1/3/22-4/29/22 on patients with an ID consult were included in the non-rounding cohort (NRC) and rounding cohort (RC), respectively. We compared PAF recommendation rates, characteristics, and acceptance rates between the two cohorts. Results There was an increase in PAF recommendation rate in the RC compared to NRC (188/485 [39%] vs 359/1234 [29%], p < 0.001). Antibiotics were the antimicrobial category mostly likely to have a recommendation and the rate of antibiotic PAF recommendations was higher in the RC compared to the NRC (132/341 [39%] vs. 271/934 [29%], p = 0.001) (Table 1). The most common recommendation types in both cohorts were to optimize the antimicrobial dose and antimicrobial discontinuation. Recommendations were more frequently communicated to the ID team in the RC compared to NRC (125/188 [66%] vs. 107/359 [30%], p < 0.001). The recommendation acceptance rate was similar between the two cohorts (159/188 [85%] RC vs. 290/359 [81%] NRC, p = 0.29). CNS: Central nervous system; IV: Intravenous; NRC: Non-rounding cohort; PAF: Prospective audit and feedback; PO: Per os, oral; RC: Rounding cohort; SSTI: Skin and soft tissue infection; UTI: Urinary tract infection. Conclusion Implementation of a pediatric ASP pharmacist rounding service increased the PAF recommendation rate and improved recommendation communication with the pediatric ID consult service. Participation in rounds may better inform ASP pharmacist PAF recommendations. Future studies describing the potential benefit to the ID team by having an ASP pharmacist present on rounds are warranted. ASPs should consider formal integration of ASP pharmacists as part of the ID consult service to further improve the quality of antimicrobial prescribing. Disclosures All Authors: No reported disclosures.

Feasibility of a collaborative pharmacist prescribing model for patients with chronic disease(s) attending Australian general practices: a preliminary study.

Pharmacists working in general practices provide medication reviews with recommendations to general practitioners (GPs) to optimise medications. We describe a model where the pharmacist is empowered with increased responsibility to implement agreed recommendations through collaborative prescribing. To assess a collaborative pharmacist prescribing model incorporating increased pharmacist responsibility, for patients with chronic diseases in general practice. This was a pre-test-post-test quasi experimental pilot study using a pharmacist embedded in three Australian general practices. A pharmaceutical care plan was developed with patients and their GP to identify drug related problems (DRPs). The pharmacist discussed recommendations to manage DRPs with the GP and implemented recommendations agreed by the GP and patient over the six-month study period. Outcome measures included acceptance and implementation rate of recommendations made by the pharmacist. The pharmacist made 135 recommendations to optimise medicine use of which 126 (93.3%) were accepted by the GP. There were 105 (83.3%) implemented by the end of the study of which the pharmacist implemented 62 (49.3%). Compared to other Australian studies using a general practice pharmacist model, this study suggested increased pharmacist responsibility through collaborative prescribing led to high acceptance and implementation rates of recommendations to manage DRPs.

Benefit of medication reviews by renal pharmacists in the setting of a computerized physician order entry system with clinical decision support.

A 'renal pharmacist consultant service' (RPCS) reviewing patients' charts with renal impairment (RI) for drug-related problems (DRP) can foster patient safety. However, the benefit of this service in the new setting of a computerized physician order entry (CPOE)-system with a clinical decision support (CDS)-system is unknown. The aim of our study was to evaluate the general need for an RPCS on wards with a CPOE-CDS-system already in use and its effectiveness on prescription changes to ensure in-hospital patient safety. Over a period of 3 months (02-04/2021), elective orthopaedic and trauma patients with eGFRabsolute /CrCl <60 ml/min at a German University Hospital received a medication review by a renal pharmacist for all medication entered into the CPOE-system (Meona®) by the treating physicians. Written consultations explaining identified DRP and recommending interventions to solve them, for example, dose or drug adaptation, were shared with the physicians directly in the drug chart tab of Meona®. In complex cases, DRP were additionally discussed via phone. The prescription changes were evaluated retrospectively. During 53 working days, 712 (30.5%) of 2331 screened patients were included with an eGFRnon-indexed /CrCl <60 ml/min and a pharmacist-led medication review was performed for all medication presented in the CPOE-system (Meona®). In 79 of 712 (11.1%) patients, one or more DRP were detected (median 1 DRP (1-3) per patient) and written recommendations concerning 106 of 1090 (9.7%) drugs were shared via Meona®. In total, 104 DRP were identified, mostly caused by 'dosage too high' (n=55, 52.9%), 'dosage regime wrong' (n=13, 12.5%), and 'contraindication' (n=9, 8.7%). Acceptance rate of recommendations was 74.0% (n=77/104). In nine cases (8.7%), despite of specific recommendations, no adjustment of drugs was made because of lack of alternatives. In 11 (10.6%) cases, prescription remained unchanged for unknown reasons and in seven (6.7%) cases, the result was unknown due to discharge. In the setting of prescribing in a CPOE-CDS-system, that provides physicians with advice for drug or dose adaption, the pharmacist-led medication reviews still identified DRP in orthopaedic and trauma patients with RI. A RPCS forwarding recommendations to solve DRP via the electronic medical record increased appropriate prescribing by physicians and, thus, may further improve patient safety.

End-users feedback and perceptions associated with the implementation of a clinical-rule based Check of Medication Appropriateness service

BackgroundTo support appropriate prescribing hospital-wide, the ‘Check of Medication Appropriateness’ (CMA) service was implemented at the University Hospitals Leuven. The CMA concerns a clinical rule based and pharmacist-led medication review service. The aim of this study was to explore both physicians’ and pharmacists’ feedback on the optimised CMA service to further improve the service.MethodsAn anonymous e-questionnaire was sent to all physicians active in the University Hospitals Leuven (n = 1631) and to all clinical pharmacists performing the CMA service (n = 16). Feedback was collected using multiple choice questions. During a 5-month period, physicians were also contacted in case of non-acceptance of recommendations to investigate barriers affecting implementation. Thematic analysis was performed and additional acceptance after telephone contact within 24 h was registered.ResultsA total of 119 physicians (7.3%) and 16 pharmacists (100%) completed the e-questionnaire. The overall service was assessed as clinically relevant to highly relevant by 77.7% of physicians. The main reasons for non-acceptance of recommendations were related to workload, work environment and time constraints. About two thirds (66.3%) of initially not-accepted recommendations were accepted after phone contact. A nearly full consensus was reached among pharmacists (15/16) on the centralised CMA being complementary to current clinical pharmacy activities. Two major barriers were reported by pharmacists: (1) too limited time allocation and (2) a large number of irrelevant alerts.ConclusionsThe CMA was perceived as clinically relevant by the majority of end-users. Acceptance rate of pharmaceutical recommendations was further increased by calling the physician. Increasing the specificity of clinical rules in the future is imperative.

Evaluating and Comparing the Impact of an Enhanced Antimicrobial Stewardship Programme in a District Specialist Hospital: A Two-Year Retrospective Study

Antimicrobial stewardship (AMS) programme is established to optimise use of antibiotics and to contain antibiotic resistance. This single centre, cross sectional retrospective study aimed to evaluate and compare the impact of an enhanced AMS programme in 2019 with data obtained in 2018 before its implementation. Types of interventions made by the AMS team, acceptance rate of AMS recommendations, antibiotic usage (DDD/1000 patients-days) and expenditure (antibiotic usage cost, RM) of 14 antibiotics under national surveillance were reviewed. Our study demonstrated non-significant reduction in total antibiotic usage (mean 188.25 versus 183.94; p = 0.523). Nonetheless, significant decline in prescribing of cefoperazone either alone or in combination with sulbactam, ciprofloxacin and meropenem was observed. There was a significant reduction in total usage cost (mean RM80,070.39 versus RM70,858.81; 95% confidence interval (CI):1519.48, 16903.69; p = 0.022) contributed in part by decreased third generation cephalosporins, meropenem and ciprofloxacin prescriptions. During enhanced AMS period, total AMS cases (45 versus 358), frequency of rounds (12 versus 37) and ward pharmacist-initiated AMS interventions were increased. The most common intervention and recommendation encountered were inappropriate choice and de-escalation of antibiotic, respectively. There was an improvement in overall acceptance rate in 2019 (67% versus 78%; p = 0.081). In conclusion, the enhanced programme resulted in decreased overall antibiotic prescription and expenditure, besides greater acceptance of AMS recommendations.

Development and implementation of medication-related clinical rules for obstetrics, gynaecology, and paediatric outpatients

ObjectivesPrescription errors can cause serious adverse drug events. Clinical decision support systems prevent prescription errors; however, real-time clinical rules in obstetrics, gynaecology, and paediatric outpatients remain unexplored. We evaluated the...

Improving Appropriate Prescribing For Geriatric Patients Using a Clinical Decision Support System.

Purpose: Polypharmacy is a known risk factor for potentially inappropriate prescribing. Recently there is an increasing interest in clinical decision support systems (CDSS) to improve prescribing. The objective of this study was to evaluate the impact of a CDSS, with the START-STOPP criteria as main content in the setting of a geriatric ward. Endpoints were 1) appropriateness of prescribing and 2) acceptance rate of recommendations. Methods: This prospective study comparing the use of a CDSS with usual care involved patients admitted to geriatric wards in two teaching hospitals in the Netherlands. Patients were included from January to May 2017. The medications of 64 patients in the first six weeks was assessed according to the current standard, whereas the medications of 61 patients in the second six weeks were also assessed by using a CDSS. Medication appropriateness was assessed with the Medication Appropriateness Index (MAI). Results: The medications of 125 patients (median age 83 years) were reviewed. In both the usual care group and the intervention group MAI scores decreased significantly from admission to discharge (within group analyses, p<0.001). This effect was significantly larger in the intervention group (p<0.05). MAI scores at discharge in the usual care group and the intervention group were respectively 9.95±6.70 and 7.26±5.07. The CDSS generated 193 recommendations, of which 71 concerned START criteria, 45 STOPP criteria, and 77 potential interactions. Overall, 31.6% of the recommendations were accepted. Conclusion: This study shows that a CDSS to improve prescribing has additional value in the setting of a geriatric ward. Almost one third of the software-generated recommendations were interpreted as clinically relevant and accepted, on average one per patient.