ABSTRACT
Background: Medication-related problems (MRPs) occur across the continuum of emergency department (ED) care: they may contribute to ED presentation, occur in the ED/short-stay unit (SSU), at hospital admission, or shortly after discharge to the community. This project aimed to determine predictors for MRPs across the continuum of ED care and incorporate these into screening tools (one for use at ED presentation and one at ED/SSU discharge), to identify patients at greatest risk, who could be targeted by ED pharmacists. Methods: A prospective, observational, multicenter study was undertaken in nine EDs, between July 2016 and August 2017. Blocks of ten consecutive adult patients presenting at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine a medication history, patient understanding of treatment, risk factors for MRPs and to manage the MRPs. Logistic regression was undertaken to determine predictor variables. Multivariable regression beta coefficients were used to develop a scoring system for the two screening tools. Results: Of 1,238 patients meeting all inclusion criteria, 904 were recruited. Characteristics predicting MRPs related to ED presentation were: patient self-administers regular medications (OR = 7.95, 95%CI = 3.79-16.65), carer assists with medication administration (OR = 15.46, 95%CI = 6.52-36.67), or health-professional administers (OR = 5.01, 95%CI = 1.77-14.19); medication-related ED presentation (OR = 9.95, 95%CI = 4.92-20.10); age ≥80 years (OR = 3.63, 95%CI = 1.96-6.71), or age 65-79 years (OR = 2.01, 95%CI = 1.17-3.46); potential medication adherence issue (OR = 2.27, 95%CI = 1.38-3.73); medical specialist seen in past 6-months (OR = 2.02, 95%CI = 1.42-2.85); pharmaceutical benefit/pension/concession cardholder (OR = 1.89, 95%CI = 1.28-2.78); inpatient in previous 4-weeks (OR = 1.60, 95%CI = 1.02-2.52); being male (OR = 1.48, 95%CI = 1.05-2.10); and difficulties reading labels (OR = 0.63, 95%CI = 0.40-0.99). Characteristics predicting MRPs related to ED discharge were: potential medication adherence issue (OR = 6.80, 95%CI = 3.97-11.64); stay in ED > 8 h (OR = 3.23, 95%CI = 1.47-7.78); difficulties reading labels (OR = 2.33, 95%CI = 1.30-4.16); and medication regimen changed in ED (OR = 3.91, 95%CI = 2.43-6.30). For ED presentation, the model had a C-statistic of 0.84 (95% CI 0.81-0.86) (sensitivity = 80%, specificity = 70%). For ED discharge, the model had a C-statistic of 0.78 (95% CI 0.73-0.83) (sensitivity = 82%, specificity = 57%). Conclusion: Predictors of MRPs are readily available at the bedside and may be used to screen for patients at greatest risk upon ED presentation and upon ED/SSU discharge to the community. These screening tools now require external validation and implementation studies to evaluate the impact of using such tools on patient care outcomes.
ABSTRACT
OBJECTIVE: To study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients' characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management. METHODS: A prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: patients, demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, χ2 association, and regression models. RESULTS: Among the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years (SD=11.1). Gastrointestinal tract bleeding was the most common (n=48, 33.3%), followed by epistaxis (n=32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy (n=65, 45.1%). Warfarin was commonly used (n=74, 51.4%), followed by aspirin (n=29, 20.1%), rivaroxaban (n=26, 18.1%), and apixaban (n=12, 8.3%). The majority had increased blood urea nitrogen (n=67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above their condition's target range despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal (B= -1.7, P=<.001), and with a shorter LoS (B= -4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy. CONCLUSION: Warfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood of receiving reversal and a shorter LoS than warfarin, LMWH, which might support a broader application of DOACs into community practice.
ABSTRACT
OBJECTIVE: Patients present to EDs with various medication-related problems (MRPs). MRPs are also associated with ED care, occurring during ED presentation or shortly afterwards. The aim of the present study is to describe the prevalence and nature of MRPs that occur prior to, during or shortly after leaving ED. METHODS: We undertook a prospective, observational study in nine Australian EDs. Blocks of 10 consecutive adult patients who were not seen by a pharmacist in ED and who presented at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine their medication history, patients' understanding of treatment, potential MRP risk factors and manage any identified MRPs. RESULTS: A total of 904 patients were recruited: 14.8% aged ≥80 years, 18.9% taking more than eight regular medications; 581 MRPs were identified; 287 (49.4%, 95% confidence interval [CI] 45.3-53.5%) of moderate-high significance. Most highly significant MRPs involved high-risk medications, particularly strong opioids, insulin and anti-coagulants. The most common types of MRPs were prescribing errors (46.8%), patient adherence/knowledge issues (31.2%) and adverse drug reactions (7.4%). Of all patients, 381 (42.1%, 95% CI 38.9-45.5%) had at least one MRP; 31.4% (95% CI 28.4-34.6%) had MRPs that could be identified or managed by screening at ED presentation and 12.4% (95% CI 10.4-14.8%) had MRPs that could be identified or managed by screening at ED discharge. CONCLUSIONS: Patients experienced a range of MRPs throughout the ED continuum of care. From these data, screening tools will be developed so that ED clinicians may identify patients at greatest risk of MRPs.
