Outcomes of a Pilot Contribution Database for the ICU Pharmacy Team at the University Hospitals of Leicester NHS Trust

Introduction It has long been felt that many contributions made by the ICU Pharmacy team, are not well showcased by the yearly regional network multi-speciality contributions audit. Themes specific to ICU are diluted amongst Trust and region wide data, and valuable learning for the multi-disciplinary team (MDT) is subsequently overlooked. Objective(s): The aims of this project were to: * Develop and pilot a MicrosoftTM Access © database for the ICU pharmacy team to record significant contributions. * Enable the production of reports to the ICU Quality & Safety board, to raise awareness, disseminate concerns, and influence future quality improvement projects. * Provide examples to contribute to the training of the whole MDT. * Generate evidence of team effectiveness and encourage further investment. * Provide team members with a means to recall contributions, for revalidation, appraisal, prescribing re-affirmation and framework mapping. Method(s): * A database was built with a user-friendly data-entry form to prevent overwriting. Fields were agreed with peers who would be using the database. * The team were invited to voluntarily enter their contributions which they thought added value and provided useful learning. * The pilot phase ceased with the emergence of the Omicron SARS-CoV-2 variant, due to staffing pressures and surge planning. Result(s): * Between 12/07/2021 and 25/11/2021, a total of 211 contributions were recorded. * Pharmacists entered 88.6% and a single technician entered 11.4% of these. * Independent Prescribing was utilised in 52.13% of contributions, and deprescribing in 25.12%. * Figure 1 demonstrates the contributions by drug group * The top 5 drugs associated with contributions were: ? Dalteparin ? Vancomycin ? Voriconazole ? Meropenem ? Co-trimoxazole * Treatment optimisation was an outcome for 76.3% of all contributions. Figure 2 stratifies these by type. Contributions. * Drug suitability was a cause for intervention in 12.8% of all contributions, encompassing allergies, contraindications, cautions and interactions and routes. * Medicines reconciliation accounted for 17.54% of all contributions, which almost half were Technician led. Admission was the most common stage to intervene (81.08%), followed by transcription. * Of all contributions, 37.91% were classified as patient safety incidents. Reassuringly 76.25% of these were prevented by the Pharmacy team. Themes have been extracted from these incidents and are presented in Table 1. Conclusion(s): PROTECTED-UK1 demonstrated the value pharmacists contribute to the quality and safety of patient care on ICU. Studies of similar quality and scale including Pharmacy Technicians are lacking, but even in this pilot study, it is evident how important their input is. Independent prescribing is a fundamental and well utilised part of our ICU Pharmacist skillset, supporting the GPICS2 recommendation that ICU pharmacists should be encouraged to become prescribers. Compiling a team interventions database is a useful tool to highlight local priority areas for guideline development;training;and ensuring that appropriate decision support is built into electronic prescribing systems. To improve the usefulness of the data, further stratification of contributions according to the Eadon Criteria3 may be worthwhile, to expand its use as a medication safety thermometer for ICU.

Exploring the views of care home staff on the use of antipsychotics for people with dementia amid the COVID-19 pandemic: A qualitative study

Introduction: There was an increase in antipsychotic prescribing for people with dementia during the COVID-19 pandemic (1). To explain this increase, the current study was conducted to explore the views of staff working in care homes for the elderly during the pandemic on the use of antipsychotics for residents with Behavioural and Psychological Symptoms of Dementia (BPSD). Aim(s): The aim was to explore the use of antipsychotics for people with BPSD during the COVID-19 pandemic by interviewing staff in care homes about their experiences during that time. Method(s): Semi-structured interviews were conducted online with staff working in ten UK elderly care settings using convenience sampling. Participants mainly onsite care home staff were recruited through online networks, for example, Twitter, and support groups such as CHAIN and NIHR clinical research network. Interviews were conducted between May 2021-March 2022, were audio recorded, transcribed verbatim, and analysed inductively using thematic analysis in NVivo version 12. Result(s): Ten interviews were completed with managers (n=2), care staff (n=6) and nurses (n=2) in nursing homes (n=7) and residential homes (n=3) (all were female). The first theme 'Challenges experienced in care provision' entails challenges experienced in the care environment;residents were confined to their rooms, activities were suspended, staff were absent and stressed, and family visits were barred. The reduced human contact affected residents' sense of self, mental and physical wellbeing, and in turn, their behaviours. The second theme 'Prescribing process' refers to doctors prescribing medicines in response to staff raising concerns. The third theme 'Attitude toward antipsychotics' denotes participants' positive and negative beliefs about antipsychotics. The positive beliefs included antipsychotics being the right choice and beneficial, an increased need and continued use of antipsychotics, use of a combination of medications and weighing the risks and benefits of antipsychotics. The negative beliefs included reports of adverse effects and short-term benefits of antipsychotics, antipsychotics not always beneficial, benefits in deprescribing, dislike for antipsychotics and belief antipsychotics are the last resort. Some expressed the need for antipsychotics had not increased but been driven by health professionals involved. The fourth theme 'Other psychotropic medication' alluded to other commonly used psychotropic medications and associated risks and benefits. The fifth theme 'Measures implemented within care settings' represented strategies implemented to avert the initiation or bolster antipsychotic deprescribing such as non-pharmacological approaches, nurses' assessment of residents before requesting antipsychotics, multidisciplinary consultation, and medication review. Conclusion(s): This is the first study that reports care home staff views on antipsychotic use for residents with dementia during the pandemic. The limitations include that only views of female respondents were obtained and the limited sample size. Care homes faced enormous challenges in the provision of care services to residents with dementia during the pandemic. The multitude of difficulties experienced in care homes due to lack of preparedness may have influenced staff to have positive views of antipsychotics and their use as an option during the pandemic. It's important to acknowledge and address these difficulties for example through education and training interventions to help with future preparedness.

Patient perspectives of safe and routine deprescribing for older people living with polypharmacy: an interview study

Introduction: Stopping medicines where harms outweigh benefits (deprescribing) (1) can reduce adverse events from inappropriate polypharmacy. Deprescribing should be undertaken in a patient-centred way with shared decision-making. However, there is a lack of evidence about the patient perspective on how deprescribing should be safely and routinely implemented in UK primary care. Such evidence is needed to enhance the implementation of deprescribing in primary care. Aim(s): * To identify optimal methods of introducing and actioning deprescribing from the patient's perspective * To understand the nature of support patients require during deprescribing * To identify patient views on the involvement of different healthcare professionals in deprescribing. Method(s): UK patients aged >=65 years taking >=5 medicines and living in their own homes were recruited through social media, service user groups and NIHR People in Research. An interview guide was developed using deprescribing literature, patient and public involvement input, and informed by the theoretical implementation framework Normalisation Process Theory (2). Interviews were conducted online (Microsoft Teams) or via telephone, audio recorded and transcribed verbatim. Data were analysed using the Framework method. Result(s): Twenty patients, diverse in age and gender, were recruited and three main themes developed: 1. 'Why deprescribe now?' focused on the importance of communicating the deprescribing rationale;2. 'Monitoring and follow-up' in which safety netting around deprescribing and patients' motivations to self-monitor after deprescribing interventions were highlighted;3. 'Roles and relationships' focused on patient views of different healthcare professionals involved in deprescribing and the interpersonal skills needed to develop therapeutic relationships. Conclusion(s): Optimal methods of introducing deprescribing from the patient's perspective included communication of a convincing and well-communicated rationale for stopping medicines. Patients required support from a range of healthcare professionals with whom they had an existing therapeutic relationship. Whilst patients were motivated to self-monitor any unwanted/unexpected effects post-deprescribing, this was under the condition that timely support would be available when needed. These findings provide a deeper understanding of patients' needs for the implementation of safe and routine deprescribing in primary care, and these should be considered when designing medication review and deprescribing services. A strength of this study was the overall diversity in age and gender of the patients interviewed. However, although multiple recruitment pathways were utilised, due to the COVID-19 pandemic, recruitment was mainly online which will have excluded patients who did not have access to the internet.

Factors Influencing Deprescribing Activities in the Management of Hospitalized Patients in Polytherapy

Objectives: To investigate the factors influencing the clinical choice to change the current patients' therapies, and the impact of potential support of digital innovation and other knowledge assets, such as INTERCheckWEB information technology and/or guidelines, to optimize the prescription decision-making process in older and frailer patients, in polytherapy. Method(s): A narrative literature review was firstly conducted to define the main clinical and non-clinical factors, impacting on the propensity of the clinicians to change the patients' current therapies. Secondly, an observational study was developed involving 35 clinicians referring to the Internal Medicine wards, of five Italian medium size hospitals. Each clinician completed a questionnaire, aimed at evaluating 15 clinical cases of patients in polypharmacy and suffering from multiple diseases, thus defining if in case of specific information, they would have changed the patient's current therapy, during an Internal Medicine hospitalization. A hierarchical sequential linear regression model was implemented to define the predictors of the clinicians' choice to change the current therapy. Result(s): Inferential analysis demonstrated that younger patient's age (beta=-0.073, p-value=0.048), autonomy (beta=0.303, p-value=0.000) and body-max index (beta=0.505, p-value=0.000), as well as clinician's perception with regard to INTERCheckWEB ease of use (beta=0.298, p-value=0.043) and seniority (beta=0.087, p-value=0.009), number of drugs assumed by the patients (beta=0.541, p-value=0.000) and number of concomitant diseases (beta=0.302, p-value=0.000) are factors influencing a potential change in the current therapy. The above aspects explained the 53.7% of the clinician's choice variance, to modify the prescription, reducing the number of treatments to be administered to the patients. Conclusion(s): The findings provide insight into factors influencing clinical assessment decisions, that could highly be replicable in the COVID-19 era, since hospitalized COVID-19 patients are frequently older with comorbidities and receiving polypharmacy, thus strengthening the need for the clinicians to modify the therapy. Copyright © 2022

Cperc 2022

The proceedings contain 102 papers. The topics discussed include: stepwise approach to a competency-based curriculum development of a new undergraduate doctor of pharmacy program (PharmD) at the University of Ottawa;an approach to promote student wellbeing in the faculty of pharmaceutical sciences at UBC;assessing the effectiveness of a novel wellness check-in activity among third-year pharmacy students;let it go: a novel way to facilitate professional identity formation as students transition to practice;integration of online virtual simulation to support the acquisition of patient assessment skills during the COVID-19 pandemic;a curricular framework for an interprofessional approach to deprescribing;two for one: merging continuing professional development and faculty development for pharmacy preceptors);beyond the stigmas: preparing graduates to address heteronormativity and systemic discrimination towards 2SLGBTQ+ people in pharmacy settings;predicting which applicants will most likely succeed in a PharmD program: challenges and realistic expectations;and supporting patient-centered practice: a workshop for pharmacy students to provide strategies for empowering patient self-efficacy and health behavior change.

LESS ISMORE: DEPRESCRIBING PPIS IN A RESIDENT PRIMARY CARE CLINIC DURING THE COVID-19 PANDEMIC

BACKGROUND: Medication reconciliation is a important part of primary care, yet good prescribing practices are not often a focus of residency training. This study aims to raise awareness among resident physicians around polypharmacy and deprescribing by targeting a common class of medications, proton pump inhibitors (PPIs). PPIs are often continued longer than appropriate and can have side effects when used long-term. We present a quality improvement (QI) project aimed at deprescribing non-indicated PPIs in a resident clinic. As residency education has increasingly relied on teleconferencing to adapt to the COVID-19 pandemic, this study is the first to describe the use of virtual education sessions to reduce rates of inappropriate PPI use. METHODS: We implemented an IRB-approved QI project at a federally qualified health center that serves as the continuity clinic site for 46 internal medicine residents. From 9/2021 to 10/2021, residents participated in a 10-minute virtual education presentation on an evidence-based PPI deprescribing algorithmat the beginning of a clinic “huddle” session. Pre-and post-education surveys were administered to assess resident knowledge of and comfort level around deprescribing PPIs. Data were collected from our electronic medical record from 7/1/21 (start of academic year) through 1/1/22. RESULTS: Comparison of pre-and post-education surveys showed improvement in resident knowledge of PPI side effects (27% correct on pre-education survey vs 98% post), indications for long-term PPI use (7% vs 62%) and guidelines around re-assessment of PPI use in patients with GERD (49% vs 78%). After the education session, residents reported increased comfort with deprescribing PPIs (5.8 out of 10 pre-education vs 7.9 post). PPI utilization decreased by 13% across all ages from 9/1/21 to 1/1/22. Residents deprescribed PPIs for 56 patiens;there were 14 new PPI prescriptions. Rates of PPI deprescribing were higher in adults under 65-years-old (14%) compared to adults 65-years-old and older (11%). CONCLUSIONS: Deprescribing can be effectively incorporated into the residency curriculum during the COVID-19 pandemic through brief, virtual teaching sessions. The sessions increased resident knowledge and comfort around deprescribing PPIs, as demonstrated by a reduction in PPI utilization over a short period of time.

Implementation of targeted deprescribing of potentially inappropriate medications in patients on hemodialysis.

PURPOSE: Patients on hemodialysis have a high risk of medication-related problems. Studies using deprescribing algorithms to reduce the number of inappropriate medications in this population have been published, but none have used a patient-partnership approach. Our study evaluated the impact of a similar intervention with a patient-partnership approach. METHODS: The objective was to describe the implementation of a pharmacist-led intervention with a patient-partnership approach using deprescribing algorithms and its impact on the reduction of inappropriate medications in patients on hemodialysis. Eight algorithms were developed by pharmacists and nephrologists to assess the appropriateness of medications. Pharmacists identified patients taking targeted medications. Following patient enrollment, pharmacists assessed medications with patients and applied the algorithms. With patient consent, deprescription was suggested to nephrologists if applicable. Specific data on each targeted medication were collected at 4 and 16 weeks. Descriptive statistics were used to examine the effects of the deprescribing intervention. RESULTS: Of 270 patients, 256 were taking at least one targeted medication. Of the 122 patients taking at least one targeted medication who were approached to participate, 66 were included in the study. At enrollment, these patients were taking 252 targeted medications, of which 59 (23.4%) were determined to be inappropriate. Deprescription was initiated for 35 of these 59 medications (59.3%). At 4 weeks, 33 of the 59 medications (55.9%) were still deprescribed, while, at 16 weeks, 27 of the 59 medications (45.8%) were still deprescribed. Proton pump inhibitors and benzodiazepines or Z-drugs were the most common inappropriate medications, and allopurinol was the most deprescribed medication. CONCLUSION: A pharmacist-led intervention with a patient-partnership approach and using deprescribing algorithms reduced the number of inappropriate medications in patients on hemodialysis.

Health Services Research and Pharmacy Practice Conference Abstracts: Delivering Impact for Patients and Other Stakeholders

The proceedings contain 66 papers. The topics discussed include: exploring elderly patients? perspectives on deprescribing: a qualitative study interim analysis;supporting safe and gradual reduction of long-term benzodiazepine receptor agonist use: development of the safeguarding-BZRAs toolkit using a co-design approach;a feasibility study of a pharmacist led proton pump inhibitor deprescribing intervention in older patients in an Irish hospital;using risk prediction to case-find frail older people at risk of anticholinergic burden for structured medication reviews: a qualitative study exploring the views and perspectives of primary care professionals;routinely implementing safe deprescribing in primary care: a scoping review;and antimicrobial consumption in hospitalized COVID-19 patients: a systematic review and meta-analysis.

Home healthcare services' clinical pharmacists0 patient-centered interventions during the COVID-19 outbreak

Background: Home Health Care Services is a non-residential long-term care facility, part of Hamad Medical Corporation. It serves around 2,700 patients, the majority of which are elderly, with multiple co-morbidities and polypharmacy, and subsequently, an increased risk of drug-related problems and inappropriate medication use.1 The clinical pharmacists' ultimate focus is to provide effective pharmaceutical care to improve health outcomes and quality of life for these patients. Methods: As most clinical and medical services were delivered via telephone consultations, pharmacists were visiting elderly patients at home for Medication Therapy Management2,3 taking appropriate measures to protect everyone. Their interventions included;medication reconciliation with appropriate identification of medication discrepancies, assessing compliance to prescribed medications ensuring safe and effective medication use;educating patients/families/caregivers about appropriate indication, dose, frequency, safe handling, and disposal, considering deprescribing of some medications that could negatively impact health outcomes using shared decision making in a very simple and raw language free from medical jargons, and recognizing any medications related problems (Figure 1). Results: Between January 2020 and December 2020, around 1,000 home visits were conducted, and 865 phone call consultations took place. The main challenges that were encountered were the language barriers of some caregivers as well as difficulty tracking some medications that have no clear indication. As a result, this work has created a long-term vision for aspirational and forward-thinking pharmacy practice models that resulted in improved clinical outcomes as well as increased patients' and their caregiver's satisfaction about the clinical pharmacy services in Qatar (Figure 2). Conclusion: Clinical pharmacists played a major role during the COVID-19 pandemic as part of the multidisciplinary team providing unique, patient-centered, and high-quality pharmaceutical care. Through their visits and elderly patient and caregivers education, clinical pharmacists contributed significantly to keeping home healthcare elderly patients safe and well looked after despite the pandemic.

Opioid deprescribing in thoracic surgical patients at Nottingham University Hospitals

Opioid prescriptions have been increasing in England;it is postulated that the use of peri-operative opioids can contribute to prolonged community use [1, 2]. We conducted a quality-improvement project to assess opioid use within our thoracic surgical population. Subsequently, we have introduced several changes in the patient pathway to optimise opioid prescriptions, which have been adopted at a Trust level. Methods Using digital health records, we conducted a retrospective analysis of 74 patients undergoing thoracic procedures between December 2018 and February 2019. We recorded opioid requirements in the 24 h before discharge and details of prescriptions on discharge, including type, dose and length. Results Out of 74 patients, 21 had no short-acting opioid requirements and 16 had no long-acting opioid requirements in the 24 h before discharge yet 67 patients were discharged on opioids. There was a wide range in short-acting opioid requirements 24 h before discharge: 5-200 mg of Shortec and 5-400 mg of Oramorph. Only 12 patients had their long-acting opioids weaned before discharge. Maximal length of discharge prescription was 14 days. Patients did not receive opioid deprescribing advice. Discussion Opioids are one of the most effective acute pain analgesics [1, 2]. As anaesthetists, we have a responsibility to manage acute post-surgical pain whilst ensuring we do not contribute to long-term misuse of opioids. This project highlights that a considerable proportion of patients with no opioid requirement are receiving potentially unnecessary prescriptions on discharge. We discussed our findings with thoracic surgeons at governance meetings. We redesigned the Trust opioid patient leaflet alongside pharmacists to improve patient understanding and delivered targeted teaching sessions to doctors responsible for discharge prescriptions. Teaching aimed to increase their confidence in assessment and weaning of opioids. COVID-19 has necessitated an increase in the duration of discharge prescriptions to avoid unnecessary further contact for vulnerable patients. Therefore, it is imperative that patients are also fully informed regarding appropriate use and tapering of opioids. It is the failure to educate regarding the cessation of opioids, rather than the necessary use of opioids in the immediate postoperative period, which contributes to chronic abuse in the community. We plan to review opioid prescriptions again in 6 months.