Het Nederlands Platform voor Farmaceutisch Onderzoek (NPFO) presenteert onderzoek in de farmaceutische wetenschappen. De nadruk ligt op klinische toepassing zoals medicatieveiligheid, patiëntenzorg, formulering, analyse, farmacologie en casuïstiek.
Additional medication reconciliation by telephone to indicate discrepancies after preoperative screening
BACKGROUND
Medication reconciliation (MR) as part of the preoperative screening (POS) is widely used for identifying current medication use and potential medication related problems in patients who are scheduled for surgery. Since the POS is carried out up to three months before hospitalisation, discrepancies in the medication use may be introduced after the POS. Therefore, an additional medication reconciliation was introduced for patients who had visited the POS more than seven days ago. Patients were interviewed by telephone two to three days before hospitalisation.
OBJECTIVE
To study whether an additional medication reconciliation by telephone two to three days before hospitalisation is effective in identifying recent discrepancies in the medication use. Secondary objectives were to define the relevance of each discrepancy and to investigate the time needed for the additional MR by phone.
DESIGN and METHODS
In this retrospective, observational study, we included all patients who were interviewed by phone in January 2018. Any mutation in medication profile following the interview was defined as a discrepancy. Both the type and the relevance of each discrepancy were recorded. The relevance of each discrepancy was independently scored by two separate pharmacists. Also, the time investment of 73 additional MRs by phone in June 2018 was assessed.
RESULTS
A total of 142 patients were included. In 39% of the patients at least one discrepancy was found during MR by phone. 101 discrepancies were found, of which 49 were moderately to very relevant. An MR by phone took approximately 8.1 minutes per patient.
CONCLUSION
An additional medication reconciliation by phone two to three days before hospitalisation is effective in identifying discrepancies and leads to a more accurate medication overview.
The effect of a therapeutic guideline on the percentage of patiënts with supratherapeutic clozapine blood levels during hospital admission
BACKGROUND
Hospitalized patients on clozapine are at risk for dysregulation of their clozapine blood concentration due to smoking cessation, (pre-existing) infections and the use of drugs which influence the metabolism of clozapine. In July 2017 a therapeutic guideline was implemented in the Haga Teaching Hospital and Haaglanden Medical Centre to monitor patients during hospital admission to prevent clozapine toxicity.
OBJECTIVE
Primary objective was to study the effect of the guideline by comparing the percentage of hospitalized patients with one or more serum clozapine levels > 0,80 mg/L and/or > 50% increase of their serum clozapine level during admission, before and after implementation of the guideline.
DESIGN
We conducted a non-interventional retrospective study.
METHODS
In a period of ten months before and after the implementation of the guideline, data from all hospitalized patients ≥ 18 years using clozapine for schizophrenia were collected from electronic patient files.
RESULTS
In 90% of all patients an intervention was necessary according to the guideline. There was no significant difference between the percentage of patients with supratherapeutic clozapine levels before and after the implementation of the guideline (P = 0,695). The involvement of the hospital pharmacist improved significantly after implementation of the therapeutic guideline (number of interventions; P < 0,001). The hospital pharmacist recommended the involvement/consultation of the psychiatrist in 39% of the admissions after implementation of the guideline.
CONCLUSION
The therapeutic guideline did not reduce the number of patients with supratherapeutic clozapine levels. However, the involvement of the hospital pharmacist resulted in earlier involvement of the psychiatrist. According to the guideline an intervention was necessary in most patients (90%). All patients with supratherapeutic clozapine levels (n = 28) had an infection and/or an elevated CRP which suggests early dose reductions are required.