hospital discharge

Overall, for the patients in this pilot project, who had complex medical conditions, were taking multiple medications, and had recently been discharged from hospital, many medication-related issues were identified, and many important interventions were carried out to optimize their medication regimens, particularly during the first visit by the pharmacist after discharge from hospital. In addition, both patients and the home care team were extremely positive about the involvement of the pharmacists in home care during this pilot project. The literature published to date has demonstrated that a variety of positive outcomes can be achieved through pharmacist involvement on the health care team. The results from this small pilot project suggest that home visits conducted by a pharmacist during the first month after hospital discharge can facilitate the identification of medication-related issues and the provision of recom­mendations to resolve these issues.

This group of predominantly elderly patients had a variety of medication-related issues, despite their recent stay in hospital. The most common type of medication- related issue was failure to receive a medication (e.g., nonadherence with prescribed therapy, inappropriate inhaler technique). This was not surprising, as previous lit­erature and practice insights suggest that nonadherence can occur for various reasons. The next most common types of medication-related issues were untreated indication (e.g., patient with pain who was not receiving an analgesic) and incorrect dose (i.e., subtherapeutic dose or overdose). Once medication-related issues had been identified, the pharmacist offered various recommenda­tions to optimize patients’ medication regimens. Over 40% of the recommendations were related to altering a specific medication, such as starting a medication (e.g., starting an antiplatelet agent for secondary prevention of a stroke), stopping a medication (e.g., stopping a benzodiazepine that had been started to treat insomnia during the hospital stay for a patient without prior sleep difficulties), changing a medication (e.g., changing from glyburide to repaglinide for an elderly patient with diabetes, reduced renal function, and ongoing episodes of hypoglycemia), or changing a dose or instructions (e.g., decreasing ranitidine dose from twice to once daily for a patient with reduced renal function). One-quarter of the recommendations were related to laboratory or symptom monitoring, which represents a key component of pharmacists’ involvement in ensuring both medication efficacy and tolerability. Examples include recommenda­tions to repeat measurement of hemoglobin A1C if changes were made to oral hypoglycemic or insulin therapy or recommendations to order testing for ferritin, iron, total iron-binding capacity, vitamin B12, and folate for a patient receiving erythropoietin with apparent resistance to the effects of the drug after an initial response. The need for recommendations such as those made during this pilot project may be partially explained by the current constraints on the health care system. Shorter lengths of stay relative to what occurred in the past may contribute to the presence of unresolved medication-related issues at the time of hospital discharge (although this was not iden­tified at the time of patient enrolment in the study). If short hospital stays lead to a focus on urgent medical needs, rendering it difficult to address all medication-related issues, then the need for active participation of pharma­cists on the home care team is clear.
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The importance of the interventions provided by the pharmacist to the patients in this study is highlighted in many ways. For example, 56% (15/27) of patients had more than one reason for referral, which perhaps signals the high number of medication-related needs among this group of patients immediately after hospital discharge. Also, the recommendations made by the pharmacist were rated as having high levels of clinical significance. Most (89%) of the recommendations were rated as significant or very significant, which (according to the scale used) signals that patients’ therapies were brought into line with standards of practice and might have had an impact on major organ dysfunction. It is important to note that this scale was developed for use in an acute care setting and may therefore underestimate the significance of recommendations in the context of a less acute setting, such as home care. For example, the recommendation to start a 6-blocker in a patient with heart failure was ranked as having level 4 significance (in line with standards of practice), rather than level 5 (potential or existing major organ dysfunction) or 6 (life-or-death situation), even though, over the long term, the use of ^-blockers in this setting has been demonstrated to reduce the risk of death and hospital admission among patients with heart failure. These findings suggest that having a pharmacist involved immediately after hospital discharge may represent a wise use of resources. By offering focused suggestions targeted at improving patient outcomes and optimizing patient safety pertaining to medications, pharmacists can work to decrease risks to patients and optimize efficacy outcomes. erectalis