Authors (including presenting author) :
Lam WL(1), Chung KY(1), Miu HS(1), Chu HM(1),
Wong WL(1), Chan CL(1), Tam KF(2), Chan SK(3)
Affiliation :
(1)Department of Pharmacy, Hong Kong Buddhist Hospital
(2)Department of Medicine, Hong Kong Buddhist Hospital
(3)Department of Nursing, Hong Kong Buddhist Hospital
Introduction :
Geriatric patients are prone to adverse effects from medication due to the presence of poly-pharmacy and multiple comorbidities. The course of hospitalization for geriatric patients involve treatment for underlying medical disease in acute hospital and rehabilitation in a sub-acute hospital. There are robust data on pharmacist’s role in medication management in acute care setting. However, the potential roles of pharmacist in a sub-acute setting are yet to be determined.
Objectives :
To investigate the types and prevalence of drug related problems (DRPs) at an in-patient sub-acute hospital and to explore the role of pharmacist in assisting doctors on comprehensive medication management of geriatric patients in sub-acute setting.
Methodology :
This project was conducted in a medical & geriatric ward in HKBH. All patients transferred to this ward from acute hospital (Queen Elizabeth Hospital) during August 2020 to December 2020 were included. Pharmacist performed (i) Medication reconciliation on admission and upon discharge, (ii) Onsite drug orders verification, (iii) Clinical review, and (iv) Patient counselling on a daily basis. Clinical review by pharmacists include renal/geriatric dosage adjustment, drug-drug/food interaction checking, administration of drugs via enteral feeding tubes, laboratory monitoring & monitoring for specific high risk medications. Verbal and written interventions are proposed to doctors and the results of interventions are recorded using PCNE classification (Version 8.03).
Result & Outcome :
942 cases were reviewed during the study period. A total of 99 DRPs (10%) were identified by pharmacist during medication review. Common DRPs identified include (i) Omission of chronic medications during previous hospitalization in acute ward (37 cases); (ii) Wrong duration of medication therapy (27 cases) and (iii) Inappropriate medication regimen prescribed (8 cases). A total of 138 interventions were proposed to the prescriber on regimen modification; in which 125 (91%) of the proposed interventions were accepted and fully implemented by doctor. The results show that pharmacist’s involvement in comprehensive pharmaceutical care plan help identify drug related problems and enhance medication safety in this setting.
In future, the service can be extended to other sub-acute hospitals with different specialties to further explore pharmacist’s role.
