Prescribing and medication management

Introduction

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073 – 1082.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.

Introduction The aim of this study was to examine the prevalence of vitamin D deficiency in elderly patients with fragility fractures of the hip by estimating 25-hydroxyvitamin D levels, whether low levels of Vitamin D at the time of admission affects the functional outcomes and mortality at 28 day and one year. Methods A retrospective study of all the patients admitted with a fracture neck of femur from Jan 2018 to March 2021 was carried out. The data was obtained from NHFD (National Hip Fracture Database) and Medway software. A total of 1221 patients were admitted during this period. Patient demographics including age, sex, fracture pattern, Vitamin D levels at the time of admission, function at 120 days, mortality at one month and one year were calculated. Results Of the 1221 patients, 106 patients did not have the Vit D levels checked at the time of admission. The average age was 81.91 (range-60 to 108). There were 845(70%) females and 376(30%) males. The serum Vit D levels were low in 611(55.3%) patients. The mobility in patients with Vit D deficiency 261(40.9%) has dropped significantly in the 3 months after surgery for fractures of proximal femurs. The 28 day and one year mortality was 6.74% and 30.3% compared to 4.7% and 27.3% for those with low and normal levels of vitamin D respectively. Patients with low Vit D levels at the time of admission with proximal femur fractures has got higher 28 day and one year mortality rates compared to those with normal levels. Conclusion Our study showed that low levels of Vitamin D at the time of admission with proximal femur fractures are associated with poor functional mobility, higher perioperative and one year mortality

Introduction. Pharmacists have traditionally worked in primary care, in the community, and with GPs. However, the role of the clinical pharmacist in primary care is evolving and there are plans to employ more clinical pharmacists in the NHS. With an ageing UK population, there is an increase in the number of people living with multiple long-term conditions, accompanied by polypharmacy, posing numerous challenges to healthcare systems. This review investigates the evidence about the varied roles and services delivered by clinical pharmacists in primary care, capturing the perspectives of health and care professionals, older adults, and their carers.

Method. Our scoping review followed the framework for scoping reviews in accordance with the Joanna Briggs Institute (JBI) methodology. A broad search was conducted in 2023 in CINAHL, Cochrane, Medline, SCOPUS, and Web of Science. We included articles that explored the landscape of clinical pharmacy services for older people in the UK, focusing on roles and services delivered, perceptions, and experiences.

Results. A total of 23 articles was included. These shed light on the multifaceted responsibilities of clinical pharmacists for older people. Stakeholder perspectives, including healthcare professionals and care home staff, emphasise the positive outcomes of clinical pharmacist involvement, from reducing other practitioners’ workloads to improving patient safety. However, communication gaps amongst the primary care team and those living with dementia, concerns about competence, and the need for clear role definitions of clinical pharmacists emerge as challenges.

Conclusions and implications. The review enhances our understanding of the clinical pharmacist service in the UK and identifies gaps in research evidence, emphasising the need for empirical studies on the experiences of older people with cognitive impairment and those from minority ethnic backgrounds. The findings can be used for policymaking, workforce planning, and healthcare provision to improve the services for older people in the UK.

Introduction

Recent trials like ASCEND, ASPREE, and ARRIVE emphasise the limited efficacy of aspirin in primary cardiovascular prevention and its associated increased bleeding risk, particularly in the elderly. Consequently, the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria does not recommend aspirin treatment for primary cardiovascular prevention in any case. This study aimed to determine the prevalence of inappropriate aspirin use among elderly patients admitted within our department and our ability to correctly identify and discontinue its use.

Methods

Patients aged over 65 years admitted under our team between August-October 2023 were identified retrospectively from our electronic medical record. Inclusion criteria were those admitted on aspirin, while exclusion criteria were incomplete records or in-hospital deaths. Discharge summaries were reviewed to determine if aspirin prescribed for primary prevention was stopped or flagged to GP for review. The secondary outcome assessed statin prescriptions for primary cardiovascular prevention. Data concerning age, sex, and cardiovascular history was extracted.

Results

67 patients were admitted under our team. The mean age was 81.4 years (SD 9.3). There were 27 males (40.3%) and 40 females (59.7%). 18 (26.9%) patients were diagnosed with ischaemic heart disease; 11 (16.4%) had a previous myocardial infarction; 19 (28.3%) had a prior transient ischaemic attack or stroke and 8 (11.9%) patients had previously undergone coronary revascularization. 14 (20.9%) patients were taking aspirin, in which 5 (35.7%) were prescribed for primary prevention, yet none were discontinued or flagged to GP for review.10 patients (14.9%) received statins for primary prevention, with a 90% adherence to the STOPP criteria.

Conclusion

Despite limited evidence, our analysis found a large proportion of patients from our team were discharged on aspirin for primary prevention. However, adherence to STOPP criteria for statin prescriptions was high. Consequently, we are developing a proforma to assist physicians in discerning inappropriate aspirin prescriptions.

Introduction:

A Clinical Audit was recommended by the ME following identification of potential safety signal because of possible non-compliance with guidelines on Anticoagulation in AF. The audit data collection tool was developed in discussion with the Chief Pharmacist and took account of up-to-date prescribing guidance from the Integrated Commissioning Board (ICB). Aim of the audit was to identify if, as per NICE guidelines patients had: o Risk for stroke (CHA2DS2-VASc) and bleeding (ORBIT) is assessed upon new diagnosis of AF? o Made aware of their risk assessments and involved in discussion regarding risk -vs-benefit of anticoagulation o Anticoagulation prescribed as per national recommendations.

Objectives:

To ensure that patients with new diagnosis of atrial fibrillation are assessed for stroke and bleeding and involved in discussion regarding anticoagulation which is prescribed as per national recommendations.

Methodology:

This local audit was carried out by analysis of both electronic and paper-based patient records using an Excel spreadsheet for analysis. Data was then analyzed with the help of the Senior Clinical Effectiveness Advisor. Results and highlighted risks: It was observed that in most cases (82%), patients were not made aware about the condition and associated risk of stroke due to underlying AF. They were also not involved in discussion regarding commencing lifelong anticoagulation, and not explained the benefits and risks of anticoagulation. Omittance/Ignorance of anticoagulation upon new diagnosis of AF hence increasing the risk of stroke with lethal consequences of preventable death in 21% of patients.

Recommendations & Conclusion:

Formulation of “AF Anticoagulation Checklist” (based on NICE guidelines) ensuring every patient with a new diagnosis of AF has a repeat ECG for confirmation of diagnosis, CHA2DS2-VASc and ORBIT scores for risk assessment, their renal functions and coagulation profile checked, followed by discussion with patient regarding results of risk assessment and risk vs benefit of anticoagulation.

Introduction:

Polypharmacy is commonly defined as the concomitant use of five or more medications. This is a common problem in frail elderly patients and more so on the surgical inpatients where it is not regularly reviewed by the surgical team.

Methods:

We reviewed retrospectively the data on vascular inpatients from 2015-2016 and after the set-up of the perioperative services in 2022-23. Patients above 65 years of age with a clinical frailty score of 4 or more or with two or more co-morbidities were selected from both groups. In total 130 patients were selected from each group and their notes were reviewed in terms of polypharmacy review, before and after the introduction of the perioperative service in the trust.

Results:

Average age of the patients in both groups combined was 75 years. Average polypharmacy number per patient before and after the perioperative service were 6.8 and 10.7, respectively. In 2022-23, all the 130 patients had a polypharmacy review by a Consultant Geriatrician. In 2015-16, polypharmacy was reviewed only if there was an adverse effect to the drug, for example bradycardia caused by beta blockers. There was no routine review of polypharmacy. 0.06 Medications were stopped per patient in 2015-16, in contrast to 1.7 per patient in 2022-23. Most common causes of discontinuation of medications were falls, confusion, postural hypotension, drowsiness, electrolyte imbalance or medication no longer needed.

Conclusions:

Polypharmacy optimisation should routinely be practised in frail vascular surgical patients as it leads to avoidance of undesirable side-effects, improves patient compliance to medications, and has a huge financial benefit from deprescribing.

Introduction

It is estimated that by 2030, 1 in 5 people undergoing surgery will be over the age of 75. These patients are often frail with a higher risk of post-operative complications including delirium. They are also more likely to have multiple co-morbidities and an increased anticholinergic burden due to polypharmacy. Anticholinergics are often linked with an increased risk of dementia, delirium, and falls.

Methods

This retrospective cohort study analysed anonymised data from 50 emergency general surgery patients the POPS team reviewed between December 2023 and February 2024 at the University Hospital of Wales. Objectives included measuring ACB (anticholinergic burden) scores on admission and discharge and evaluating subgroup analysis such as the relationship between CFS (clinical frailty score), known or new cognitive impairment and ACB score.

Results

66% of patients were female, the median age was 82 and median CFS was 6. 32% had delirium on admission, 40% had a Charlson comorbidity score of 5 or 6 and the median length of stay was 17 days. 74% of patients had no known cognitive impairment while 8% had dementia on admission. Small bowel obstruction (34%) was the commonest diagnosis and emergency laparotomy was the most common surgery type (56%). The median number of medications on admission and discharge was 9. Median ACB score on discharge reduced from 1.5 to 1 and 86% showed a stable or reduced ACB score. There was a positive correlation between frailty and delirium as well as frailty and ACB score. The correlation between delirium and ACB score was unclear. 

Conclusion

CGA by the POPS team reduces the anticholinergic burden of this patient cohort. Increasing frailty appears to be associated with an increased risk of delirium and ACB score on admission, however the relationship between anticholinergic burden and delirium is unclear in this small patient cohort. 

The elderly population ( cut off 65 and over, for this audit) are being increasingly prescribed direct oral anticoagulants(DOAC) for prevention of stroke in atrial fibrillation/ prevention and treatment of DVT/PE.This poses significant difficulties when stopping/ restarting these medications in the peri-operative period , due to the ever changing clinical circumstances in this period. Therefore , we performed an audit( in Glangwili Hospital, Jan-July 2024)  , using the Welsh Frailty Fracture Network guidelines as our standard and found out(during the first cycle) that around 40 percent of patients did not have their DOAC restarted on time post surgery and that poor documentation regarding the circumstances causing delay was prevalent. We intervened by providing teaching , putting up posters and trying to include the guidelines in the trust intranet. In the second cycle, there was significant improvement in the documentation of the circumstance causing delay of restart and higher number of patients with DOACs stopped in correct time in keeping with their renal functions.

Introduction

The Older Persons Assessment and Liaison team at North Manchester General Hospital (NMGH) reviews geriatric patients using a Comprehensive Geriatric Assessment (CGA), as directed by the British Geriatric Society. The Anticholinergic Burden (ACB) score is an integral part of the CGA however it is often overlooked. ACB is the cumulative effect of taking one or more drugs used to block Acetylcholine. A greater ACB score increases the risk of developing adverse drug reactions such as; falls and urinary retention. As such, it is integral that we work to reduce patient ACB scores during hospital admissions.

Aim

To reduce the ACB score of geriatric patients at NMGH.

Method

Several months of retrospective data for 50 patients was analysed. We then carried out teaching on the importance of ACB documentation and its’ implementation. ACB scores were compared before and after this teaching session.

Results

Before the teaching session, 60% of patients had their ACB score calculated, however only 18% had an improvement in their score on discharge. After the teaching session 75% of patients had their ACB score calculated and 32% had an improvement in their score on discharge.

Conclusion

Although the teaching session was a successful intervention, as there has been a reduction in the ACB score of frail patients, there is room for improvement. We are hoping to integrate ACB score calculation into the computer software used throughout the hospital to break down the barriers that clinicians currently face in using it.

Title: Antibiotic Stewardship Audit in Gerontology wards in Princess Royal University Hospital 

Introduction: Misuse of antibiotics leads to the emergence of antimicrobial resistance, which is an important public health and patient safety issue. Infections caused by resistant organisms are associated with poorer clinical outcomes and undesired side effects.

Aim: Assessing compliance with the antimicrobial stewardship package introduced by the UK Department of Health in 2011 and with the trust guidelines.  

Method:

* Spot checks done across all gerontology wards between January and March 2024 to assess the compliance as described above.

* Intervention: Teaching sessions for junior doctors discussing the first cycle’s results, the main lacking areas, and the takeaway messages.

* Second spot checks in May and June. The results were presented in the Adult Medicine Conference at the trust.

Results:

* Improvement in documenting clinical indications to an average of 90%.

* Compliance with local antibiotic guidelines improved to an average of 80%

* Documentation of a reason for continuing IV antibiotics after 48 hours and factors preventing a per-oral switch improved to an average of 80%.

* Areas of improvement identified in documenting CURB65 score for community acquired pneumonia

Conclusion: The audit and the interventions showed marked improvement in antibiotic prescriptions and compliance with the trust guidelines. Despite being a common basic audit, it encourages junior doctors to check the trust policy and prescribe accordingly. This is important in the geriatric population who are at increased risk of side effects due to co- morbidities and drug interactions because of polypharmacy.