How a Patient Personalised Clinical Pharmacy Programme Can Secure Therapeutic Care in an Orthogeriatric Care Pathway (5P Project)?

Figures & data

Figure 1 Personalised clinical pharmacy programme integrated into an orthogeriatric care pathway.

Table 1 Clinical Dimension of the CLEO Tool to Assess the Clinical Impact of Pharmaceutical Interventions

Clinical Dimension	Description
Harmful	Negative effect on patient in regard to clinical situation, knowledge, satisfaction, adherence, or quality of life
Null	No effect on patient in regard to clinical situation, knowledge, satisfaction, adherence, or quality of life
Minor	Effect on patient in regard to clinical situation, knowledge, satisfaction, adherence, or quality of life OR damage, which does not necessitate surveillance or treatment
Moderate	Damage necessitates surveillance or treatment and does not lead to hospitalization or prolongation thereof
Major	Damage that leads to hospitalization or prolongation thereof OR Damage that leads to disablement or impairment
Vital	Damage that leads to intensive care treatment or death
Not determined	The available information does not allow to determine the clinical impact

Notes: The clinical impact is evaluated for the patient’s benefit. Harm: alteration of the physical and mental capacities arising from an accident or illness. Quality of life: physical function (autonomy, physical abilities, capacity to perform the tasks of daily life), psychological (anxiety, depression, emotion), social (relative to family environment, friendly or professional, engaging in personal relationships, participation in social and leisure activities) and somatic (symptoms related to the disease). Monitoring: monitoring clinically relevant (physiological or psychological), biological. Treatment: changing therapy or adding a medical/surgical treatment.

Table 2 Clinical Pharmacy Activities and Outcomes in the Orthogeriatric Care Pathway

	Acute Care, n = 455 Patients		Rehabilitation, n = 122 Patients	Total
	At Admission	At Transfer or Discharge
Prescription review	440	NA	112	552
PI	561	NA	61	622
Number of PI per patient, mean ± SD	1.3 ± 1.3	NA	0.5 ± 0.8	NA
Acceptance rate, n/N (%)	348/561 (62%)	NA	40/61 (66%)	388/622 (62%)
Medication reconciliation	213	105	NA	318
Number of medications per patient, mean ± SD	Before admission: 8.0 ± 3.7	At discharge: 7.3 ± 3.7	NA	NA
UID	316	17	NA	333
Number of UID per patient, mean ± SD	1.5 ± 2.2	0.2 ± 0.5	NA	NA
Acceptance rate, n/N (%)	210/316 (66%)	11/17 (65%)	NA	221/333 (66%)

Abbreviations: NA, not applicable; PI, pharmaceutical intervention; SD, standard deviation; UID, unintentional discrepancy.

Table 3 Most Common PI by DRP/Medication Categories Encountered in the Orthogeriatric Care (1–10)

N°	Medication	Drug-Related Problem	Number of PI per DRP/Medication Category^a	Examples	Result of Clinical Impact by Expert Panel
1	Morphine	Absence of corrective medication	66	Association of an osmotic laxative medication with a morphine-type treatment in order to prevent iatrogenic constipation	No consensus: 2 moderate/2 minor
2	Acetaminophen	Supratherapeutic dosage related to the age of the patient	39	Maximal daily dose of acetaminophen recommended is 3g in elder patients	No consensus: 2 moderate/2 minor
3	Acetaminophen	Duplication	21	Duplication of acetaminophen on the prescription (often intravenous and per os, or sometimes 2* intravenous or 2*per os)	Moderate
4	Calciparin	Non-conformity to guidelines	21	Considering the normal renal function of the patient, the utilization of a low molecular weight heparin is recommended as a first line of treatment	Minor
5	Acetaminophen	Intravenous/oral switch	17	A switch from intravenous acetaminophen to an oral form seems possible as the patient is treated with other oral medications	Minor
6	Acetaminophen	Supratherapeutic dosage related to the patient’s renal function	16	Considering the altered renal function of the patient (< 50 mL/min/1.73m^2), the maximal daily dose of acetaminophen recommended is 3g (instead of 4g)	No consensus: 2 moderate/2 minor
7	Antidepressant	Absence of medication for a valid medical indication (omission)	13	Omission of the usual antidepressant taken by the patient (Citalopram, escitalopram, mianserin, mirtazapine, venlafaxine, fluoxetine) ≤ not prescribed on hospital prescription after the operation	Moderate
8	Morphine	Duplication	11	Duplication of morphine on the prescription (often intravenous and per os, or sometimes 2*intravenous or 2*per os)	Moderate
9	Bronchodilators and inhaled corticoids (± in association)	Absence of medication for a valid medical indication (omission)	11	Omission of the usual bronchodilators taken by the patient (for example (Beclometasone 100 mcg + formoterol 6 mcg powder for inhalation) considering nursing home prescription ≤ not prescribed on hospital prescription	No consensus: 2 moderate/2 minor
10	Morphine	Intravenous/oral switch	9	A switch from subcutaneous morphine to an oral form seems possible as the patient is treated with other oral medications	Minor

Notes: ^aAll PI were exclusively made in acute care, except “DRP and medication categories” number 2, 4, and 5 in which one to three PI were formulated in rehabilitation unit.

Abbreviations: DRP, drug-related problem; PI, pharmaceutical intervention.

Table 4 Most Common PI by DRP/Medication Categories Encountered in the Orthogeriatric Care (11–20)

N°	Medication	Drug-Related Problem	Number of PI Per DRP/Medication Category^a	Examples	Result of Clinical Impact by Expert Panel
11	Tiapride	Contraindication	9	The association of tiapride and escitalopram (or citalopram or hydroxyzine) is contraindicated because of the increased risk of torsades de pointes	Moderate
12	Infusion fluids with electrolytes	Unjustified medications	9	Considering that the patient has an hyperkalemia (> 5.5 mmol/L), revaluation of the administration of Glucidion containing potassium supplementation: switch with another hydration if still necessary	No consensus: 4 different ratings, minor/ moderate/major/vital
13	Acetaminophen	Supratherapeutic dosage related to the patient’s weight	8	Considering the patient’s weight of 40 kg (<50 kg), the maximal daily dose of acetaminophen recommended is 3g (instead of 4g/day)	No consensus: 2 moderate/2 minor
14	Benzodiazepines and Z drugs	Supratherapeutic dosage	8	In older patients, it is recommended to prescribed zopiclone at half-dose	Moderate
15	Benzodiazepines and Z drugs	Not recommended in older patients	8	As bromazepam is a benzodiazepine with a long half-life, its prescription is not recommended in elder patients. Switch to benzodiazepine with shorter half-life such as oxazepam	No consensus: 2 moderate/2 minor
16	Tiapride	Drug-drug interaction other than contraindication	8	The association of tiapride and amiodarone is contraindicated because of the increased risk of torsades de pointes (5 not recommended, 3 precautions for use)	No consensus: 2 major /2 moderate
17	Enoxaparin	Infratherapeutic dosage	8	Actual prescription of enoxaparin is unclear, in between a prophylactic and a curative dosage (patient of 58 kg with a prescription of 4000 UI twice a day).	Moderate
18	Nefopam	Not recommended in older patients	7	As nefopam is a central analgesic with anticholinergic properties, its prescription in elder patients is not recommended. Nota bene: the patient has already other analgesic treatments (acetaminophen + morphine)	Major
19	Calcium ± vitamin D	Absence of medications for a valid medical indication (omission)	7	The patient takes an oral chronic calcium + vitamin D supplementation ≤ not prescribed on hospital prescription	Minor
20	Morphine	Therapeutic optimization	6	Morphine is systematically prescribed whereas acetaminophen is prescribed only if needed.	Minor

Notes: ^aAll PI were exclusively made in acute care, except “DRP and medication categories” number 15, 17, 19 and 20 in which one to three PI were formulated in rehabilitation unit.

Abbreviations: DRP, drug-related problem; PI, pharmaceutical intervention.

Figure 2 Flowchart of inclusion of PI and categories of PI for clinical impact evaluation by the pluriprofessional expert panel.

Abbreviations: DRP, drug-related problem; PI, pharmaceutical intervention.