Pharmaceutical Interventions on Hospital Discharge Prescriptions: Prospective Observational Study Highlighting Challenges for Community Pharmacists.

BACKGROUND: Transition between hospital and ambulatory care is a delicate step involving several healthcare professionals and presenting a considerable risk of drug-related problems. OBJECTIVE: To investigate pharmaceutical interventions made on hospital discharge prescriptions by community pharmacists. METHOD: This observational, prospective study took place in 14 community pharmacies around a Swiss acute care hospital. We recruited patients with discharge prescriptions (minimum three drugs) from the internal medicine ward of the hospital. The main outcome measures were: number and type of pharmaceutical interventions made by community pharmacists, time spent on discharge prescriptions, number of medication changes during the transition of care. RESULTS: The study included 64 patients discharged from the hospital. Community pharmacists made a total of 439 interventions; a mean of 6.9 ± 3.5 (range 1-16) interventions per patient. All of the discharge prescriptions required pharmaceutical intervention, and 61 (95%) necessitated a telephone call to the patients' hospital physician for clarifications. The most frequent interventions were: confirming voluntary omission of a drug (31.7%), treatment substitution (20.5%), dose adjustment (16.9%), and substitution for reimbursement issues (8.8%). Roughly half (52%) of all discharge prescriptions required 10-20 min for pharmaceutical validation. The mean number of medication changes per patient was 16.4: 9.6 changes between hospital admission and discharge, 2.6 between hospital discharge and community pharmacy, and 4.2 between community pharmacy and a general practitioner's appointment. CONCLUSION: Hospital discharge prescriptions are complex and present a significant risk of medication errors. Community pharmacists play a key role in preventing and identifying drug-related problems.

[POCUS (Point-of-Care Ultrasonography) in internal general medicine: applications scope and training]. / POCUS (Point-of-care ultrasonography) en médecine interne générale†: champ d'application et formation.

POCUS is a valuable tool for the internist. Its field of application in internal medicine is multisystemic and requires rigorous training. This training includes an initiation phase, followed by a practical training phase for the acquisition of images from patients or simulators. Supervision by experts is vital for mastering the necessary skills for the safe use of POCUS. Although, supervisors are available in French speaking Switzerland, there are too few to meet training needs. Several associations provide training courses to obtain POCUS certification, the content of which has been established since 2018 in Switzerland. In order to maintain a high level of proficiency and to identify tomorrow's supervisors, it is essential to provide the necessary means to allow more internists to obtain POCUS certification.

Le POCUS (Point-of-care ultrasonography) est précieux dans la pratique de l'interniste. Son champ d'application en médecine interne est multisystémique et requiert une formation rigoureuse qui comporte une phase d'initiation et une phase de formation pratique pour l'acquisition des images sur patients ou simulateurs. La supervision par des experts est primordiale pour l'acquisition des compétences nécessaires à l'emploi sûr du POCUS. Les superviseurs existent en Romandie, mais sont trop peu nombreux pour répondre à la demande. Plusieurs associations offrent des formations pour l'obtention du certificat POCUS dont le contenu est établi depuis 2018 en Suisse. Il est essentiel d'engager les moyens nécessaires pour permettre à plus d'internistes d'obtenir cette certification POCUS, pour maintenir un niveau élevé de compétences et identifier les superviseurs de demain.

SIADH and water intoxication related to ecstasy.

Recreational drug use is a significant societal issue and remains a clinical challenge in emergency and critical care departments. We report on a 19-year-old woman admitted to hospital semiconscious and with severe hyponatraemia. Urinalysis was positive for methamphetamine and supported a diagnosis of hyponatraemia related to ecstasy use together with a syndrome of inappropriate antidiuretic hormone secretion (SIADH). The woman was transferred to an intensive care unit, where a hypertonic saline infusion was started. Three hours postadmission she developed polyuria. Follow-up urinalysis at this point was consistent with water intoxication. This case is a reminder that hyponatraemia is a potentially fatal complication after the ingestion of 3,4-methylenedioxymethamphetamine, illustrates the sequential nature of an SIADH and water intoxication and highlights the importance of considering the sequence of onset of hyponatraemia, as the patient may be admitted at any stage.

Prescription of Sedative Drugs During Hospital Stay: A Swiss Prospective Study.

BACKGROUND: In recent years, the number of prescriptions for sedative drugs has increased significantly, as has their long-term use. Moreover, sedative use is frequently initiated during hospital stays. OBJECTIVES: This study aimed to describe new prescriptions of sedative drugs during hospital stays and evaluate their maintenance as discharge medication. METHODS: This observational prospective study took place in an internal medicine ward of a Swiss hospital over a period of 3 months in 2014. Demographic (age, sex, diagnosis, comorbidities) and medication data [long-term use of sedative drugs, new regular or pro re nata ('as needed') prescriptions of sedative drugs, drug-related problems] were collected. Sedative medications included: benzodiazepines, Z-drugs, antihistamines, antidepressants, neuroleptics, herbal drugs, and clomethiazole. McNemar's test was used for comparison. RESULTS: Of 290 patients included, 212 (73%) were over 65 years old and 169 (58%) were women; 34% (n = 98) were using sedative drugs long term before their hospital stay, and 44% (n = 128) had a prescription for sedative drugs at discharge-a 10% increase (p < 0.05). Sedative drugs were newly prescribed to 37% (n = 108) of patients during their stay. Among these, 37% (n = 40) received a repeat prescription at discharge. Over half of the sedative drugs were prescribed within 24 h of admission. Drug-related problems were detected in 76% of new prescriptions, of which 90% were drug-drug interactions. CONCLUSION: This study showed that hospital stays increased the proportion of patients who were prescribed a sedative drug at discharge by 10% (absolute increase). These prescriptions may generate long-term use and expose patients to drug-related problems. Promoting alternative approaches for managing insomnia are recommended.

Transition of care: A set of pharmaceutical interventions improves hospital discharge prescriptions from an internal medicine ward.

BACKGROUND: Continuity of care between hospitals and community pharmacies needs to be improved to ensure medication safety. This study aimed to evaluate whether a set of pharmaceutical interventions to prepare hospital discharge facilitates the transition of care. METHODS: This study took place in the internal medicine ward and in surrounding community pharmacies. The intervention group's patients underwent a set of pharmaceutical interventions during their hospital stay: medication reconciliation at admission, medication review, and discharge planning. The two groups were compared with regards to: number of community pharmacist interventions, time spent on discharge prescriptions, and number of treatment changes. RESULTS: Comparison between the groups showed a much lower (77% lower) number of community pharmacist interventions per discharge prescription in the intervention (n=54 patients) compared to the control group (n=64 patients): 6.9 versus 1.6 interventions, respectively (p<0.0001); less time working on discharge prescriptions; less interventions requiring a telephone call to a hospital physician. The number of medication changes at different steps was also significantly lower in the intervention group: 40% fewer (p<0.0001) changes between hospital admission and discharge, 66% fewer (p<0.0001) between hospital discharge and community pharmacy care, and 25% fewer (p=0.002) between community pharmacy care and care by a general practitioner. CONCLUSION: An intervention group underwent significantly fewer medication changes in subsequent steps in the transition of care after a set of interventions performed during their hospital stay. Community pharmacists had to perform fewer interventions on discharge prescriptions. Altogether, this improves continuity of care.

Unintentional baclofen intoxication in the management of alcohol use disorder.

In recent years, there has been a growing interest in using baclofen for the management of alcohol use disorder. This off-label indication usually involves high doses of the medication. We report a case of severe baclofen overdose in a 66-year-old man. The patient was found severely agitated, and he presented with delirium and auditory hallucinations. At hospital admission, his daily dose was 180 mg baclofen. He was admitted to the intensive care unit for sedation and supportive care. When sedation was withdrawn, the patient presented with a normal neurological status. In this clinical context, baclofen intoxication was suspected. This was confirmed by measuring blood baclofen levels. This intoxication was probably mediated by a combination of risk factors including a high daily dose of baclofen and acute renal failure, conducive to drug accumulation.

[Implementation of focused ultrasonography in an acute care setting]. / Implémentation de l'ultrasonographie ciblée dans une unité de soins critiques.

The legitimacy of intensivists and emergency physicians to use ultrasound in their daily practice is no longer questioned. This new tool is now considered essential in the acute care setting. After overcoming the technological and political obstacles, the current challenge is to implement technology in units. Here we give some recommendations based on our experience of the last fifteen years.

La légitimité des réanimateurs et des urgentistes à utiliser l'échographie dans leur pratique quotidienne n'est plus remise en question. Ce nouvel outil est actuellement considéré comme indispensable pour l'intensiviste et l'urgentiste. Après avoir surmonté les obstacles technologiques et politiques, le défi actuel est d'implémenter la technique dans les unités de soins. Nous donnons ici quelques recommandations basées sur notre expérience de ces dix dernières années.

Clinical pharmacist's role in implementing a smoking cessation intervention in a Swiss regional hospital: an exploratory study.

BACKGROUND: Smoking cessation represents one of the best means of preventing smoking-related complications. In recent years, a majority of hospitals have implemented smoke-free policies, making support for smoker patients a necessary and indispensable task. The clinical pharmacist is well-positioned to provide this kind of support, given a good understanding of the medical condition and pharmacotherapy of hospitalized patients and the possibility to acquire specific smoking cessation training. OBJECTIVES: This study aimed to evaluate the impact of a smoking cessation intervention for hospitalized patients by a clinical pharmacist previously trained for smoking cessation counselling. SETTING: Internal medicine department of a Swiss regional hospital. METHOD: Smoker patients hospitalized in this department were included in the study from mid-September 2012 to mid-January 2013, according to the inclusion criteria. Moderate-intensity smoking cessation interventions based on smoking counselling and motivational interviewing techniques were used, and a follow-up telephone call at least 1 month after discharge was made. Patients' pharmacotherapy was analysed with regards to interactions with tobacco smoke. MAIN OUTCOME MEASURES: Motivational stage, abstinence at follow-up, change of readiness to quit between hospital visit and follow-up, patients' evaluation of the programme, pharmacotherapy interventions. RESULTS: One hundred smoker patients were screened, of whom 41 received the intervention and 40 received a follow-up contact. At least 1 month after discharge, the readiness to quit of 53 % of patients improved and 33 % of patients declared themselves abstinent. Even though 35 % of patients declared having mild to moderate withdrawal symptoms in hospital, only 15 % were interested in receiving nicotine replacement therapy. Study participants evaluated the intervention positively. CONCLUSION: A moderate-intensity smoking cessation intervention in hospitalized patients was associated with a higher quit rate than in control groups from other studies, and their readiness to quit generally improved at least 1 month after hospital discharge. A clinical pharmacist trained for smoking cessation counselling can play a key role in providing such interventions, including the assessment of pharmacotherapy interactions with tobacco smoke.

Refractory changes in hyperosmolar diabetic decompensation: when hyperglycaemia improves vision.

Type 2 diabetes is a frequent condition in humans with about 350 million affected people. One of the complications is blindness caused by damage of the blood vessels in retina, cataract or glaucoma. But in an acute developing hyperglycaemia, changes in sugar level in blood modify the refraction in the eye. Thus people complain of blurred vision. We present a case of a patient with hypermetropia who reported quick amelioration of his vision as hyperglycaemia developed, because of myopisation.

[Evaluation of practical skills in echocardiography for intensivists]. / Evaluation des compétences requises pour la pratique de l'echo- cardiographie aux soins intensifs.

In 2009, the Critical Care NetWork of the American College of Chest Physicians (ACCP) in partnership with La Société de réanimation de langue française (SRLF) selected a panel of experts to characterize competence in critical care ultrasonography (CCUS) and suggest a consensus statement on competence in CCUS. CCUS may be divided into general CCUS (thoracic, abdominal, and vascular), and echocardiography (basic and advanced). For each component, the experts defined the specific skills that the intensivist should acquire to be competent in that aspect of CCUS. They, also, defined a reasonable minimum standard statement to serve as a guide for the intensivist in achieving proficiency in the field. The present article focuses on the consensus statement concerning the evaluation of the competences (basic level) in critical care echocardiography.

Dramatic beneficial effects of sildenafil in recurrent massive pulmonary embolism.

OBJECTIVE: Sildenafil has a well established pulmonary vasodilatory effect, but has seldom been used in critically ill patients. We report a case of severe recurrent pulmonary embolism in which sildenafil was used as a rescue therapy. RESULTS: After oral administration of 50 mg of sildenafil, cardiac index increased from 2.11/min/m(2) to 3.21/min/m(2); mean pulmonary artery pressure decreased from 56 mmHg to 46 mmHg, and pulmonary vascular resistance index decreased from 700 dynes/cm(-5)/m(2) to 425 dynes/cm(-5)/m(2), without reduction of arterial systemic pressure. Clinical condition also improved during the following days under treatment of 50 mg sildenafil three times daily. CONCLUSIONS: These observations should stimulate studies with sildenafil in the ICU setting. Sildenafil is easy to administer in every ICU and at any time. If its potential is confirmed, it may be a life-saving drug in some emergency situations caused by severe pulmonary hypertension.

[Pre-hospital management of acute myocardial infarction: weaknesses]. / Prise en charge pré-hospitalière des infarctus myocardiques aigus: les points faibles.

The overall mortality of acute myocardial infarction (AMI) is still high, half of deaths occurring in the prehospital setting. The American Heart Association (AHA) recommendations strongly emphasize the rapid use of "Emergency Medical Services". Despite this guideline, we frequently observe patients with AMI arriving at the hospital without an emergency ambulance service (SMUR). We undertook a retrospective study to quantify this problem with special interest in the mean of transport, in the role of the primary care practitioner and in the influence of the SMUR on the in-hospital delay. We had 125 AMI in 2000 and 2001: 42 reached the hospital by self-transportation, 57 by ambulance with SMUR and 26 by ambulance without SMUR. An out-hospital doctor was first warned by half of the patients 38% of which arrived by ambulance with SMUR, 37% by ambulance without SMUR and 25% by their own means. A thrombolysis was applied in one third of the AMI: the median prehospital and in-hospital delays were 120 and 40 minutes respectively. The in-hospital delay was significantly shorter when the emergency ambulance service was used. Our results confirm a suboptimal utilisation of the emergency ambulance service for AMI, due to patient and out-hospital doctors. This encourages us to go on providing specific information to the population but also to the primary care practitioners.