BackgroundMedication discrepancies between actual and documented therapy often arise at patient transfer between wards. Intensive care unit(ICU) patients are particularly prone because of polymedication, frequent therapy changes and impaired consciousness, with also an increased risk for drug related problems (DRPs).PurposeTo determine the type and frequency of medication discrepancies and DRPs on admission, during ICU stay and on transfer to the ward, and the clinical pharmacist’s role in prevention.Material and methodsThis was a prospective before and after study on adult patients after informed consent, in two ICU units (general and cardiology; 12 beds) in a tertiary care university hospital. During an 8 week observation period (October 2015 to January 2016) a clinical pharmacist conducted a standardised drug reconciliation on ICU admission, twice weekly drug review and review on patient transfer. These data were compared with physicians’ notes and prescriptions. Discrepancies and potential DRPs were classified using a standardised flow chart. During a subsequent 16 week intervention period (January–May 2016), the pharmacist additionally entered compiled drug histories in the patient files, participated in clinical rounds and proactively provided feedback.Results111 patients were included (observation 50; intervention 61). On ICU admission, we found a significant difference in the number of drugs found after medication reconciliation by the physician compared with the pharmacist (observation 5.5 vs 8.5/patient; intervention 6 vs 8/patient; both p<0.0001). Furthermore, during the intervention period we saw a reduction in DRPs during ICU stay (5 vs 3/patient; p=0.06) and a reduction in median number of discrepancies (1 vs 0/patient; p=0.0067) and DRPs (3 vs 1/patient; p=0.0009) at patient transfer. The proportion of transfer discrepancies due to incomplete drug reconciliation showed a similar reduction (17.9% vs 5.1%; p=0.0061). Most frequent DRPs at patient transfer were incomplete reconciliation (26.2%), missing therapy duration (22.7%) and inadequate administration route (20.6%). Main transfer discrepancies were omission (59%), frequency (12%), addition (11%) and dose (11%). During the intervention period, the pharmacist proposed a total of 683 interventions with an 92.7% acceptance rate.ConclusionA clinical pharmacist, integrated in a multidisciplinary ICU team, can make a significant contribution to medication safety by preventing drug discrepancies on admission, by identification of DRPs during ICU stay and by reducing discrepancies on transfer to a normal ward.No conflict of interest
Background & aims: Parenteral Nutrition (PN) has been shown to cause glycemic deregulation, whether patients have type 2 diabetes (T2DM) or not, causing elevated mortality, despite intensive insulin treatment. Long-term effects, however, are unclear. Methods: A retrospective observational study was performed. 226 patients of the UZ Brussel, both T2DM patients and non-diabetics, who received PN in 2013 or 2014, were analyzed on the presence of hyperglycemia and hypoglycemia, as well as mortality inhospital and after 6 months. Results: Here we show that T2DM patients displaying either hyperor hypoglycemia, had a significant higher mortality. This was the case both in-hospital and after 6 months. Non-diabetics undergoing hyperglycemia had a similar fate, but not when these patients had hypoglycemic events. Conclusion: Whether PN-receiving patients had T2DM or were non-diabetic, hyperglycemia was related to mortality, both in-List of abbreviations: PN, parenteral nutrition; T2DM, type 2 diabetes; T1DM, type 1 diabetes.
BackgroundTotal Parenteral Nutrition (TPN) isn’t always prescribed according to international guidelines: nutritional screening is frequently lacking, the prescribed therapy is not always adapted accordingly and subsequent monitoring is often absent. Our objective was to assess the potential benefit of a clinical pharmacist reviewing prescribed TPN.PurposeEvaluation of the appropriateness of prescribed TPN.Material and methodsSetting: A prospective pre-post intervention study in a tertiary care teaching hospital with a high percentage of cancer and critically ill patients.Method: Adult hospitalised patients on TPN were included. The presence of a Nutritional Risk Screening-2002 and the calculation of energy requirements, the indication, the therapy appropriateness and the therapy duration were assessed by a clinical pharmacist. During the intervention period feedback was provided to the physician and dietician in multidisciplinary collaboration. The ESPEN guidelines were taken as golden standard. All data were obtained from the electronic patients files.ResultsWe assessed 272 hospitalisations, 152 pre-interventional (10/2013–01/2014) and 120 post-interventional (02/2014–04/2014). During the latter period an intervention was needed in 83.7% (176 interventions) of the cases. Prevalence of nutritional screening increased from 25.0% to 61.7% (p < 0.001) as did energy requirement calculation (30.9% vs. 67.5%; p < 0.001). Therapy appropriateness increased from 58.8% to 75.8% (p < 0.05). The median duration (6.0 vs. 7.0 days) of the therapy was not significantly reduced (p = 0.36). We avoided the production of at least 81 TPNs on a total of 1172. During the 3 month intervention period an estimated total saving of 20756€ could be obtained.ConclusionThe additional monitoring of the appropriateness of TPN by a clinical pharmacist has a positive influence on therapy quality and healthcare costs.References and/or acknowledgementsESPEN guidelines ()Nutrition support teamNo conflict of interest.
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