Implementation of an emergency department-based clinical pharmacist transitions-of-care program.

PURPOSE: The implementation of an emergency department (ED)-based clinical pharmacist transitions-of-care (TOC) program is described. SUMMARY: The intervention program consisted of collaboration between ED and ambulatory care pharmacists to provide patient-specific comprehensive medication review and education in the ED setting and to help ensure a coordinated transition to the ambulatory care setting by scheduling an ambulatory pharmacy clinic or home-based visit. Patients who sought care at an adult ED for an exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) were assessed for issues with medication adherence or administration technique, patient-specific concerns regarding medication use, access to medications at discharge, the need for modification of chronic therapy, contraindicated medications, and vaccination status, if applicable. The pharmacist then referred the patient to follow up in an ambulatory care pharmacy clinic or with the home-based medication management (HBMM) program. Of the 18 program participants who were referred to follow-up care, 5 successfully followed up with a pharmacist after ED discharge. The mean time from the ED visit to follow-up for these 5 patients was 16.6 ± 8.6 days. In addition, 5 patients followed up with their primary care provider within 30 days of the initial ED visit; 2 of these patients also followed up with a pharmacist. Within 30 days of the initial ED encounter, 4 patients had ED revisits. CONCLUSION: A TOC pharmacist-led program targeting patients who arrived at the ED with the chief complaint of asthma exacerbation, COPD, or CHF provided interventions from an ED or ambulatory care pharmacist as well as follow-up opportunities at outpatient clinics or an HBMM program.

Medication management for left ventricular assist device thrombosis.

PURPOSE: Current strategies for prevention and treatment of "pump thrombosis" associated with the use of left ventricular assist devices (LVADs) are discussed. SUMMARY: LVADs provide morbidity, mortality, and quality-of-life benefits in patients with advanced heart failure. Since continuous-flow LVADs came into wide use, there have been increased reports of pump thrombosis (clot formation in the LVAD system that can lead to pump dysfunction and clinical complications). Anticoagulation and antiplatelet therapies are important for preventing pump thrombosis, although the optimal antithrombotic regimen remains unclear. International Normalized Ratio goals should be determined according to specific device characteristics and patient risk factors. Medication therapy for pump thrombosis provides a less invasive option than surgical pump exchange or heart transplantation but is associated with high risks of bleeding events, recurrent pump thrombosis, and mortality. Decisions regarding medical versus surgical management should be based on clinical status and surgical candidacy. Management of pump thrombosis may include intensified i.v. anticoagulation, i.v. or intraventricular thrombolytics, or glycoprotein IIb/IIIa inhibitors. Optimization and close monitoring of anticoagulation and antiplatelet therapy can help reduce the risk of pump thrombosis. CONCLUSION: Intensive clinical and laboratory monitoring are important in identifying signs and symptoms of LVAD thrombosis. Medical management of LVAD thrombosis can be considered an early treatment strategy before thrombi become too large and unresponsive to pharmacotherapies, but antithrombotic medications carry a high risk of bleeding complications and should be used judiciously. More definitive treatment with pump exchange or heart transplantation in appropriate candidates may be required.