Clinical Pearls: Prioritization of Clinical Pharmacy Services in Patients with High Risk of Adverse Events
July 2, 2024
By: Mojan Fazelipour
This article is part of a series appearing in Interactions
, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps
them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.
Background
In Canada, approximately 1.7 million emergency department visits annually are attributed to Adverse Drug Events (ADEs), constituting nearly 12% of all such visits. Disturbingly, 37% of these cases require hospitalization.1 Furthermore, two-thirds of these ADEs are preventable, with a significant proportion resulting from inadvertent re-prescriptions of previously harmful drugs by healthcare professionals.1 ADEs further strain healthcare systems, leading to unplanned hospitalizations and extended stays.2,3 Identified risk factors include age, polypharmacy, renal dysfunction, and specific drugs such as anticoagulants.4 Post-discharge ADEs introduce further complexities, yet pharmacist-led transitional care has shown potential in mitigating related readmissions.5
Given resource limitations, optimizing pharmacy services becomes critical.6 Prioritizing patients with complex drug needs is recommended, and while various tools exist for this purpose, many, predominantly adult-focused, lack rigorous validation.7
Internationally, drug-related problems contribute significantly to emergency visits and medication-induced hospitalizations, many of which are preventable.7 Clinical pharmacy services, anchored by pharmacists and pharmacy technicians, aim to enhance drug therapy outcomes. However, challenges such as financial constraints and staffing issues necessitate innovative service delivery models.7 Particularly in regions like Australia, addressing high-risk patients is emphasized due to resource scarcity.8 The burgeoning need for patient prioritization calls for the development of robust, evidence-based tools tailored for high-risk populations.
The Imperative for Prioritization
In contemporary hospital settings, the necessity for adept patient care prioritization cannot be overstated. With hospitals grappling with escalating patient influx, timely identification and prioritization of high-risk individuals become indispensable. In this matrix, the role of hospital pharmacists in alleviating medication-induced complications is accentuated.4
The effects of pharmacists' work in in-patient care are well-known, but their early involvement in emergency departments is less studied.9
Resource constraints necessitate pharmacy departments to adopt a discerning lens in evaluating their service delivery paradigms.6 A nuanced strategy would channel clinical pharmacy services towards high-risk patients, who are situated to derive maximal benefit from specialized pharmacist interventions.6
A myriad of patient prioritization tools have emerged over time, encompassing both paper-based and electronic modalities.6 A notable proportion of these tools cater predominantly to the adult demographic and often lack empirical validation, casting doubts over their efficacy in accurately identifying high-priority patients.6 Overall, the current healthcare system, facing rising patient numbers and medication errors, urgently needs a better patient prioritization system using clinical pharmacists' skills.
Risk factors for ADE
The Society of Hospital Pharmacists of Australia (SHPA) categorizes risk factors for ADEs into three distinct groups.9:
| Medicine-specific |
Examples include Vancomycin, aminoglycosides, anticonvulsants, and anticholinergics. |
| Population group-specific |
Factors like age, BMI, and polymorbidity, etc. |
| Patient-specific |
Examples include recent ADEs and non-adherence risks. |
Table1. Risk factor categories (adopted from Risk factors for medication-related problems, by [The Society of Hospital Pharmacists of Australia (SHPA)] [2023], [www.shpa.org.au].
Medications, compared to other healthcare interventions, have a heightened vulnerability to errors, profoundly affecting patient care quality and costs.10 SHPA emphasizes the importance of tailoring clinical pharmacy services to these high-risk groups, promoting decisions rooted in evidence and aligned with organizational goals.
A systematic review shed light on the assessment tools that hospital pharmacies use to determine patient priority and complexity.7:
Drug-related factors:
- High-risk medications (88% prevalence): Highlighting the need for regular monitoring.
- Polypharmacy (76.5% prevalence): Generally referring to the use of multiple medications concurrently.
Patient-related factors:
- Age (76.5% prevalence): The elderly, particularly those aged 65 and above, face increased risks.
- Renal impairments and multiple health conditions each have a 53% risk rate.
Some tools also identified unique factors, including specific drug interactions and conditions like cystic fibrosis or Parkinson's disease.7
For healthcare institutions, understanding these pronounced risk factors is vital. While existing assessment tools in clinical pharmacy provide direction for care, more research is required to gauge their impact on patient outcomes and efficient use of resources.
Clinical Decision Rules for Patient Prioritization
Clinical decision rules (CDRs) are structured algorithms or sets of criteria geared towards identifying patients in Emergency Departments (EDs) at high risk for ADEs. Navigating the demanding landscape of emergency departments requires applicable patient prioritization to optimize outcomes and efficiently use resources. CDR offer systematic methodologies tailored for immediate and effective patient care, especially in high-pressure settings like the emergency department.11,12
Clinical Decision Rules in ADE Identification and Interventions in Canada
CDRs are crucial in enhancing patient care, especially when identifying ADEs in acute settings. Various studies from Canada have embarked on the mission of validating these CDRs to identify high-risk patients who could benefit from pharmacist-led interventions such as medication reviews.11,13,14
In British Columbia, a study conducted across three hospitals evaluated the early in-hospital impact of pharmacist-led medication reviews, guided by CDRs, on high-risk patients.14 In this quasi-randomized design, a cohort of 10,807 high-risk patients were assessed using either a medication review or the standard care.14 The findings revealed an 8% reduction in the median length of hospital stay for those undergoing reviews, particularly beneficial for patients under 80 years of age. However, metrics such as re-admissions and mortality didn't see notable shifts. This suggests that early medication reviews, supported by CDRs, can influence hospital stay durations for specific age groups.14
Another multicenter, prospective study in Canada delved into the validation of CDRs designed to prioritize patients exhibiting ADEs for pharmacist-led reviews. Of the 1,529 adult patients under study, 12.0% were diagnosed with an ADE.13 The employed decision rule, encompassing elements like age and recent antibiotic usage, showcased both high sensitivity (91.3%) and specificity (37.9%). These findings affirm the utility of CDRs in directing clinical pharmacists towards patients most susceptible to significant ADEs.13
Further emphasizing the significance of CDRs, a prospective cohort study from two Canadian tertiary care hospitals set out to detect ADEs early during a patient's hospital stay.11 With 1,591 adult patients at the center, the derived CDRs presented an effective method for the early identification of ADEs. These rules integrated various determinants like comorbid conditions and recent medication alterations, highlighting the comprehensive nature of CDRs in the realm of ADE detection.11
In summary, the studies from Canada accentuate the pivotal role of CDRs in the landscape of ADE identification and subsequent pharmacist-led interventions. Their consistent application has the potential to fine-tune patient care, underscoring the need for their widespread adoption and further research.
Role of Clinical Pharmacists
Clinical pharmacists are a pivotal force in hospitals, particularly in identifying and managing risks associated with medication harm. However, their role is not without challenges. The pressures of rapid patient discharges combined with inadequate handover information are recurring obstacles these professionals face.2 With a unique skillset for identifying high-risk patients, clinical pharmacists ensure timely interventions, subsequently fostering enhanced patient outcomes.5
By actively engaging in interventions ranging from medication reconciliation at admission to follow-ups post-discharge, clinical pharmacists can bridge critical gaps in patient care. Their role becomes even more pronounced during the vulnerable post-discharge phase, underlining the importance of patient education and monitoring. Recent research suggests that the integration of pharmacists-based interventions in patient prioritization can lead to reduced ADEs and fewer hospital readmissions.5 Overall, Pharmacists play an essential role in prioritizing patients for clinical pharmacy interventions to maximize the impact of their expertise. Supported by national and international research, it's evident that pharmacist-led activities significantly bolster a patient's medication management plan and lead to reduced morbidity and costs.10
International Perspective: Approaches in Different Countries
In pediatric care, pharmacists are instrumental in ensuring the appropriate and safe utilization of medications.
6 Given the escalating demands on pharmacists placed alongside the constrained resources, it becomes imperative to devise efficient prioritization mechanisms. To address this, a rigorous two-year study was undertaken at a tertiary pediatric hospital in Australia, leading to the establishment of a pediatric-centric patient prioritization tool.
6 This tool, guided by real-time interventions made by pharmacists, ascertained that a significant 43% of pediatric inpatients did not warrant a routine clinical pharmacist review. The tool was effective in showing the percentage of paediatric hospitalized patients (43%) who did not require a routine clinical pharmacist review. With 98% specificity in finding patients who require a pharmacist intervention.
6
Also, in a retrospective cross-sectional study conducted across four public hospitals in metropolitan Melbourne, Australia, the "High-Needs (HN) pharmacy criteria" were evaluated to determine if they could effectively identify patients at an increased risk of medication-related problems (MRPs), medication incidents, or a 30-day readmission. Out of the 761 patients included from these hospitals, 71% were identified as meeting the HN criteria. The results indicated, those meeting these criteria were generally older (average age of 67), had longer hospital stays, and were more susceptible to being readmitted within 30 days or experiencing MRPs during their admission. Notably, patients under geriatric, general, and specialty medicine units most frequently met the HN criteria. Overall, findings emphasized the utility of the HN criteria in day-to-day hospital settings, suggesting that as electronic healthcare systems continue to evolve, there are opportunities for further refinement and automation of these criteria to better prioritize clinical pharmacy services.
8
In the UK, a survey was conducted to understand the current use of pharmaceutical care prioritization tools in acute hospitals.
15 Out of 130 hospitals, 70 reported using a tool or process to prioritize clinical pharmacy services. These tools usually combine pharmacy service prioritization tasks, such as medication reconciliation, with an aspect that assigns patient prioritization levels.
15 Utilizing set indicators to determine patient priority boosts pharmacist confidence as it ensures they are addressing high-risk patients. Electronic tools are particularly beneficial because they offer real-time data, thus enhancing workflow and maintaining continuity in patient care.
15 However, challenges include a lack of sensitivity of some tools to specific specialties and inefficiencies if not all needed data is readily available. In conclusion, while these tools are beneficial for workload management and timely patient care, there's a need for evidence-based, rigorously evaluated tools to ensure enhanced patient outcomes and more efficient pharmacy services.
15
Lastly, a systematic review was conducted to evaluate existing patient prioritization tools.
7 Using multiple databases, 19 studies were found that detailed 17 risk assessment tools, mostly from Europe, focusing on identifying patients at high risk of medication issues. While 59% of these tools were validated, none demonstrated a direct impact on prescription errors or adverse drug events. However, they had a positive influence on patient care and pharmacy service delivery. Despite the diversity in these tools, they all effectively directed pharmaceutical care where most needed. Yet, more research is essential to gauge their impact on patient outcomes and workforce efficiency.
7
Conclusion and Future Directions
CDRs are instrumental in refining ADE management and ensuring patient safety. The evolving landscape of clinical pharmacy emphasizes the road between advanced decision frameworks and interprofessional collaboration for optimal outcomes. The value of these observational findings, while illuminating, necessitates validation through rigorous randomized controlled trials, especially focusing on the impacts of early medication reviews across varied age groups. In summary, leveraging validated CDRs in hospitals has the potential to revolutionize ADE detection and management. The findings underscore the imperative of a structured, pharmacist-led approach for early and effective ADE interventions.
References
- ActionADE [Internet]. Action ADE; 2022 [cited 2023 Oct 21]. Prevent adverse drug events | Working together for action on ADEs. Available from: actionade.org
- Falconer N, Barras M, Cottrell N. How hospital pharmacists prioritise patients at high-risk for medication harm. Research in Social and Administrative Pharmacy. 2019 Oct;15(10):1266–73.
- Breuker C, Abraham O, di Trapanie L, Mura T, Macioce V, Boegner C, et al. Patients with diabetes are at high risk of serious medication errors at hospital: Interest of clinical pharmacist intervention to improve healthcare. European Journal of Internal Medicine. 2017 Mar;38:38–45.
- Mihajlovic S, Gauthier J, MacDonald E. Patient Characteristics Associated with Adverse Drug Events in Hospital: An Overview of Reviews. CJHP [Internet]. 2016 Aug 31 [cited 2023 Oct 20];69(4). Available from: http://www.cjhp-online.ca/index.php/cjhp/article/view/1583
- Phatak A, Prusi R, Ward B, Hansen LO, Williams MV, Vetter E, et al. Impact of pharmacist involvement in the transitional care of high‐risk patients through medication reconciliation, medication education, and postdischarge call‐backs ( IPITCH Study). Journal of Hospital Medicine. 2016 Jan;11(1):39–44.
- Spencer M, Turner S, Garg A. Development of a pharmacy ‘patient prioritization tool’ for use in a Tertiary Paediatric Hospital. J Clin Pharm Ther. 2021 Apr;46(2):388–94.
- Alshakrah MA, Steinke DT, Lewis PJ. Patient prioritization for pharmaceutical care in hospital: A systematic review of assessment tools. Research in Social and Administrative Pharmacy. 2019 Jun;15(6):767–79.
- Wembridge P, Ngo C, Tran THT, Ivar MP. Evaluating pharmacy high‐needs criteria: a tool for identifying inpatients at risk of medication‐related problems. Pharmacy Practice and Res. 2023 Apr;53(2):91–5.
- Kaufmann CP, Stampfli D, Hersberger KE, Lampert ML. Determination of risk factors for drug-related problems: a multidisciplinary triangulation process. BMJ Open. 2015 Mar 20;5(3):e006376–e006376.
- SHPA B. Position statements, practice updates and fact sheets [Internet]. [cited 2023 Oct 22]. Available from: https://shpa.org.au/news-advocacy/position-statements-practice-updates-fact-sheets?v=638334071119488440
- Hohl CM, Yu E, Hunte GS, Brubacher JR, Hosseini F, Argent CP, et al. Clinical Decision Rules to Improve the Detection of Adverse Drug Events in Emergency Department Patients: CDRs TO IMPROVE DETECTION OF ADEs. Academic Emergency Medicine. 2012 Jun;19(6):640–9.
- Stiell IG, Bennett C. Implementation of Clinical Decision Rules in the Emergency Department. Academic Emergency Medicine. 2007 Nov 1;14(11):955–9.
- Hohl CM, Badke K, Zhao A, Wickham ME, Woo SA, Sivilotti MLA, et al. Prospective Validation of Clinical Criteria to Identify Emergency Department Patients at High Risk for Adverse Drug Events. Griffey RT, editor. Academic Emergency Medicine. 2018 Sep;25(9):1015–26.
- Hohl CM, Partovi N, Ghement I, Wickham ME, McGrail K, Reddekopp LN, et al. Impact of early in-hospital medication review by clinical pharmacists on health services utilization. Marengoni A, editor. PLoS ONE. 2017 Feb 13;12(2):e0170495.
- Abuzour AS, Hoad-Reddick G, Shahid M, Steinke DT, Tully MP, Williams SD, et al. Patient prioritisation for hospital pharmacy services: current approaches in the UK. Eur J Hosp Pharm. 2021 Nov;28(e1):e102–8.