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Pharmacist Chat Eases Discharge Worries

PHILADELPHIA  –  Providing patients with pharmacy consults prior to hospital discharge resulted in valuable medication recommendations without adding significant time, researchers found in a pilot study.

Nearly three-quarters of pharmacist consults contained medication recommendations related to the principal hospital problem, according to Liz Meichsner, MD, of the University of Minnesota Family Medicine Residency Program at Methodist Hospital in St. Louis, Minn., and colleagues.

The top class of drugs recommended was cardiovascular (24), which included ACE inhibitors, ARBs, calcium channel blockers, and beta-blockers, among others, Meichsner reported here at the American Academy of Family Physicians annual meeting.

Other drugs recommended by the pharmacist included antidepressants (12), and 10 each of cholesterol-lowering drugs, inhalers, and proton pump inhibitors, narcotics (seven), anticoagulants (three), and benzodiazepines (two).

Meichsner told MedPage Today that there were enough recommendations for cholesterol-lowering drugs for them to separate it from the cardiovascular category.

The average time the pharmacist spent with the patient was 20 minutes, with a total time of 30 minutes to complete the task.

“The consult time might have been a bit skewed because there was a pharmacy student along with the pharmacist,” Meichsner said.

Meichsner noted that the Joint Commission singled out medication-related errors in its top ten sentinel events from 2008 to 2010. The group said that 63% of these errors occur during transitions of care.

“This pilot program is an attempt to address those medication-related errors at discharge, as well as a way to reduce the increasing number of Medicare patients readmitted to the hospital non-electively within 30 days of discharge,” she said.

Researchers recruited 211 patients, of whom 170 were eligible, meaning they met one or more of these criteria:

  • Admitted non-electively in past 30 days
  • Have one or more chronic disease
  • Have five or more chronic medications
  • Have three or more new medications at anticipated discharge

Thirty -seven patients consented to be in the study and 35 of them completed the consults. The mean age of patients was 65.

The pharmacist, who was accompanied by a pharmacy student, reviewed the patients medical and medication history, discussed recommendations with the physician, provided patient education about medications, and documented the consult in the patients chart.

In this 427-bed facility, there are usually two to three clinical pharmacists per floor, Meichsner said.

Of the nine patients who completed a survey, nearly all said they would want to have a similar consult in future hospital admissions. They also were glad to be able to ask questions and have the importance of medications clarified.

The residents noted the value of being able to simplify the medication regimen, flag medication interactions, and provide medication reconciliation.

Meichsner said that bringing the physician and pharmacists together was “easily achieved” and that physicians did not express concern for the extra time. In fact, “they enjoyed the help with medication reconciliation,” she said.

As the study period progressed, the consults became more streamlined, with shorter and clearer recommendations, she said.

Meichsner said that discharge summaries need to point out potential changes left to the primary clinician, as this will close the loop of communication.

The study was limited by its small sample size, the limited availability of consults (only 2 days a week), lack of nursing involvement, and little patient feedback.

The researchers plan is to follow-up these patients to determine if the consults make a difference in outcomes.

Source: Med Page Today at

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