CSHP Professional Practice Conference 2016: Poster Abstracts / Conférence sur la pratique professionnelle 2016 de la SCPH : Résumés des affiches
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Background: Twelve months of dual antiplatelet therapy (DAPT) is recommended after percutaneous coronary intervention with drug-eluting stent implantation (PCI-DES). However, certain clinical scenarios may require premature discontinuation of therapy (e.g., urgent surgical procedures, major bleeding).
Objective: To investigate clinically relevant efficacy and safety outcomes associated with a shorter duration of DAPT, compared to 12 months, after PCI-DES.
Methods: A systematic search of Medline and Embase (inception to April 2015) was conducted. Included were randomized controlled trials that compared 6 months (or less) to 12 months of DAPT in patients who underwent PCI-DES. DAPT was defined as acetylsalicylic acid 75–200 mg daily and clopidogrel 75 mg daily. Outcomes of interest included death, myocardial infarction (MI), definite or probable stent thrombosis, major bleeding, and any bleeding. An odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome using a Mantel-Haenszel random effects model (Review Manager, version 5.3).
Results: Five studies (4 open-label, 1 double-blind) were included constituting 12,078 patients. Three studies investigated 6 months of DAPT, and 2 studies investigated 3 months. Outcomes were reported at 12 months in 4 trials and 15 months in 1 trial. Efficacy outcomes were not statistically significantly different between groups including death (OR 0.85, 95% CI 0.61–1.18), MI (1.14, 0.85–1.55), and stent thrombosis (1.20, 0.67–2.15). There was no significant difference in major bleeding (0.61, 0.35–1.03); however, any bleeding was reduced by a relative 41% with shorter-term DAPT (0.59, 0.44–0.79).
Conclusion: Shorter duration (3–6 months) of DAPT was not associated with a higher risk of death, MI, or stent thrombosis compared to 12 months. Furthermore, it was associated with a lower rate of overall bleeding, but not major bleeding. Though limited by low event rates and study methodology, these data support that DAPT could be safely discontinued before 12 months if required.
Background: It has been estimated that 30% of all hospital discharges are delayed for non-medical reasons including poor organization of post-discharge health, poor knowledge of social circumstances, and poor communication between the hospital and community pharmacy. Studies have shown that patients are at greater risk for medication errors during transitions of care. A pharmacy discharge planning service has the potential to decrease length of stay, readmission rates due to medication errors, and inappropriate prescribing.
Description: The pharmacy department, at our hospital, implemented a pilot project to offer pharmacy discharge services on two units from July 13, 2015 to September 11, 2015. The objectives were to: 1) improve patient flow by reducing medication-related discharge delays, and 2) improve patient safety through education and medication reconciliation at discharge. Patients eligible for the service were “at risk” for: 1) low medication literacy; 2) discharge delays; 3) financial barriers, and 4) non-adherence.
Action: The medication reconciliation technician’s role was to identify patients eligible for the service. Interventions by the discharge pharmacist included education, illustrated medication calendars, suggesting medication changes to physicians, completing application forms for drug coverage, preparing discharge prescriptions, communicating with the community pharmacy, requesting social work consultation, and providing compassionate drugs.
Evaluation: A total of 308 patients were admitted during the pilot phase. Fifty patients were referred to the pharmacy discharge service, the most common reason for referring patients was “complex medication regimens” (36.7%). A total of 73 interventions were made, with the most common being the preparation of discharge prescriptions with communication with the community pharmacy to ensure drug availability (n=32).
Implications: Pharmacy technicians and pharmacists play an important role in discharge planning with nearly 1 pharmacist intervention for every 4 patients admitted. Future evaluation will focus on readmission rates, patient and physician satisfaction, drug adherence and patient health literacy.
Background: Most intravenous medication errors occur during administration. Smart pumps can reduce the incidence of dose or rate errors using soft and hard limits. But industry standard dose error reduction software misses errors that occur during titration. The dose change alert was developed to detect errors during titration.
Objective: To evaluate the safety implications of the dose change alert in the SIGMA Spectrum Infusion System on the administration of high alert medications.
Methods: Observational analysis of continuous quality improvement data from all titratable high-alert drug infusions across 1600 large volume pumps between May 1st and October 31st 2014 (inclusive). Outcomes included dose change alert confirmation and cancellations and drug library compliance.
Results: Compliance with using the drug library was 96.8%. The percentage of dose change confirmations and cancellations, within the soft limits were 48.1% and 1.9%, respectively. The titration of vasopressors resulted in the highest percentage (75%) of dose change confirmations. The titration of anticoagulants resulted in the highest percentage (12%) of dose change cancellations.
Conclusions: This study provided insight into the safety implications of the dose change alert on the titration of high alert drugs. The dose change alert allows the hospital to define the percentage dose change limit for individual drugs and plays a large role in potentially preventing medication errors.
Background: Delirium is a recognized post-operative adverse event whose significance has intensified due to effects on morbidity and mortality. Currently, the rate of delirium post cardiac surgery in the cardiovascular intensive care unit (CVICU) at our institution is unknown and the pharmacological treatment modalities are not standardized and vary greatly.
Objective: To determine the rate of delirium, the presence of risk factors that may predict the development of delirium and pharmacological treatment modalities used in post-operative cardiovascular surgery patients admitted to the CVICU.
Methods: In this retrospective chart review, all patients undergoing cardiovascular surgery from April 1 to December 31, 2014 were reviewed. Differences between patients were analyzed using Chi-square analysis.
Results: The review included 420 patients of which 17% (n=73) developed delirium post-cardiovascular surgery in the CVICU. No significant differences were found between groups with respect to pre-operative co-morbidities and the development of delirium. Of those who became delirious, 83.6% (n=61) received a pharmacological agent for the treatment of delirium, with 52.5% (n=32) receiving 1 medication, 31.1% (n=19) receiving 2 and 16.4% (n=10) receiving 3 or more medications. Haloperidol was most commonly used (82%) followed by quetiapine (60.7%) and dexmedetomidine (13.1%). Those who experienced delirium had significantly greater exposure to sedatives including midazolam (57.5 vs 17.3%, p<0.00001), lorazepam (26 vs 1.4%, p<0.00001) and zopiclone (26 vs 6%, p<0.00001). No differences in mortality were found however length of CVICU stay was significantly longer in delirious patients (5.7 vs 1.8 days, p<0.00001).
Conclusions: Delirium can commonly develop post cardiovascular surgery in the CVICU and it is difficult to predict who will develop it based on preoperative comorbidities. Therefore, the development of strategies to prevent delirium and to optimize pharmacological management is warranted.
Background: Pharmacists play a vital role in educating patients on the safe and effective use of medications in a variety of situations. Pharmacists must select and prioritize which patients receive education within hospital and just prior to discharge. In order to balance performance of patient education and other clinical duties, standard criteria for prioritization was necessary.
Description: In order to minimize variation amongst pharmacists in patient selection, the process of standardizing practice for patient education was required to allow all pharmacists to apply a consistent approach.
Action: A formalized literature search was performed as a baseline assessment of existing patient education practices. Clinical pharmacists were surveyed to assess the current methods for patient selection, educational practice and documentation. This data was used to develop criteria for the selection of patients for pharmacist education.
Evaluation: All inpatient pharmacists surveyed participated in the provision of patient education, averaging 2 hours of patient education per week over 6 patients. The majority of patients were self-referred, followed by physician, nurse and nurse practitioner referrals. Pharmacists targeted patients taking on an average 3 new or 9 medications in total. Drug-specific criteria were considered most important for prioritization of patient education, followed by those patients on a high number of medications on discharge. Medication counseling was the most common type of education provided, followed by medication schedule teaching. Therapeutic anticoagulants were the most common targeted drug for discharge education, followed by systemic corticosteroids and insulin.
Implications: Prioritizing patients taking therapeutic anticoagulation was identified as the best criteria to standardize patient education. Standardization enables the discipline to set minimum criteria for when education will be provided by pharmacists to enable a balance of clinical duties.
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