Table3 Acceptance rate and effectiveness rate of the consultations
4 Discussion
4.1 Improvement of anti-infection consultation quality
From 2018 to 2020, the number of consultations increased significantly,
and anti-infection consultations were still dominant. On the one hand,
health administrative authorities in China attached great importance to
the rational use of antibacterial drugs, which was included in hospital
management and performance evaluation indicators. On the other hand,
Chinese clinical pharmacists vigorously invested in anti-infection
consultation work, which dramatically improved the consultation effect
and expanded their influence in the management of antibacterial drugs[22-24]. The main purpose of anti-infection
consultations in our hospital was to adjust the anti-infection scheme,
and the main working mode was to adjust the scheme when the bacterial
culture result was not available or negative, or screen the scheme if it
was available. As a result, how to improve the ability of anti-infection
treatment is a crucial problem that clinical pharmacists should always
pay attention to.
The top three clinical departments applying for pharmaceutical
consultations were Department of Spinal Surgery (99 cases, 18.3%),
Department of Urology (68 cases, 12.5%) and Central Intensive Care Unit
(CICUs) (55 cases, 10.1%). In our hospital, the amount of spinal
surgery is large, so is the number of patients with fever after
operation. Surgeons lack experience in using antibiotics, especially the
choice of drugs for anti-tuberculosis treatment, which should attract
clinical pharmacists’ attention. In terms of Department of Urology, the
patients’ characters are more distinct. They tend to be elder with liver
and kidney dysfunction and multiple chronic disease, so more needs are
for adjusting dosage and identifying drug interactions. Consultations in
Intensive Care Units (ICUs) mainly focus on multidisciplinary difficult
cases. Our main concern is the individualized medication of patients
with multi-drug resistant bacteria or rare pathogenic bacteria
infection. In order to provide better pharmacy services for ICUs
patients, senior clinical pharmacists regularly hold consultation case
discussions and literature reading reports in 4 ICUs. The topics mainly
include high-quality anti-infection literature, the rational use of
special grade antibiotics such as ceftazidime、avermectin and polymyxin
B, and individualized medication experience analysis, which provide a
learning and communication platform for physicians.
It is worth noting that with the rapid increase in the incidence of
fungal infections [25], there is a corresponding
increase in need for the rational use of anti-fungal drugs. Such
consultations are often difficult to give recommendations due to the
long course of broad-spectrum antibiotics treatment for patients. On the
premise of evaluating risk factors with WVUH deep fungal infection
score, clinical pharmacists strictly controlled the abuse of antifungal
drugs and achieved good therapeutic effects.
4.2 Discussion on the consultation mode of multidisciplinary
individualized medication
Pharmacists should take initiative to pay attention to all the
medication of patients. Only in this way can we broaden the breadth and
depth of clinical pharmacists’ consultations. To create
multidisciplinary pharmaceutical consultation is the purpose of
developing the mode of multidisciplinary individualized medication
consultation in our hospital. According to the data above, there are 11
non-anti-infection consultation cases in 2018, 20 cases in 2019 and 30
cases in 2020, demonstrating an increasing trend year by year. The total
number of non-anti-infection consultations in three years accounts for
11.3%, which is equivalent to the average proportion of tertiary
hospitals in other regions of China [7]. Among
them, anticoagulation consultations accounted for 9 cases (14.8%), and
nutrition consultations accounted for 8 cases (13.1%). There is still a
certain gap between the breadth of drug selection and the difficulty of
consultations, by comparison to national clinical pharmacy specialty
hospitals [26-27].
Department of Cardiology is characterized by radiofrequency ablation of
heart failure, arrhythmia and atrial fibrillation. It has a high
reputation in Shanghai, China. In addition, the Department of
Respiration is a rapidly developing specialty in recent years, in which
anticoagulant outpatient service is badly in need. The anticoagulant
pharmacy services our hospital have carried out are embodied in pharmacy
rounds and the support of physician-pharmacist joint anticoagulation
outpatient clinics. The addition of anticoagulant recommendations in
pharmacists’ consultations is another attempt of pharmaceutical
intervention. First, during the intervention process, we found that the
both physicians and nursing staffs have established a relatively
standardized evaluation process and medication habits for postoperative
anticoagulation management. However,for elderly patients with renal
insufficiency,physicians are often confused about the choice of
medication and dosage; Secondly, for the non-surgical patients,
physicians tend to ignore whether they are at high risk of embolism,
which leads to inaccurate application timing of anticoagulant drugs.
Besides, during the process of medication, hemorrhage risk is not easy
to pay attention to, resulting in increased risk of adverse
consequences. Finally, how to balance embolic risk and hemorrhage risk,
and how to carry out physical prevention are also weak links. In
response to the problems above, clinical pharmacists give interventions
in consultations and play a certain effect. After intervention, no
consultation patients have experienced embolism or hemorrhage due to the
unreasonable use of anticoagulants. At present, the participation of
clinical pharmacists in anticoagulant work in China is still in the
initial stage. The work mainly focuses on patient follow-up and
assisting doctors in patient education management. Besides, current
anticoagulant management norms and standardized anticoagulant effect
evaluation system are also in the exploratory stage[28]. We need to find our own way out to catch up
with other countries. In the future, we intend to continue implementing
this mode to improve the quality and quantity of anticoagulation
consultations.
PPIs are widely used in clinical practice. In the previous
pre-prescription review and key monitoring drugs review, we found that
physicians had many irrational PPIs use, including inappropriate timing
of medication, unreasonable choice of dosage and dosage form,
inappropriate use of drugs, etc. After the implementation of the
intervention, we gave individualized suggestions to patients. The
recommendations mainly include reasonable therapeutic and preventive
dose, choice between oral and intravenous drip dosage form and the
incidence of adverse reactions caused by drug interaction, which were
generally welcomed and accepted by physicians. In China, due to the
increasingly serious problems of PPIs abuse, a series of targeted
measures have been implemented and preliminary results have been
achieved [29-30]. The addition of PPIs
recommendations in clinical pharmacists’ consultations is our attempt.
With the continuous promotion of this mode, we hope to further
rationalize PPIs use and reduce unnecessary drug expenditures.
In China, clinical nutrition support is developed late,so is the work
of nutrition pharmacists. Besides, nutrition pharmacists’ work content
overlaps with that of the Department of Nutrition, resulting in the
relatively slow work progress. The nutritional pharmaceutical care in
our hospital is still in its infancy, which does not match the needs of
its tumor specialty characteristics. In fact, nutrition support is
indeed urgently in need. In the face of the needs of a large number of
tumor patients and rapid development of new varieties and dosage forms
of nutritional drugs in the market, oncologists need nutrition
pharmacists’ support.
At present, although the total number of nutrition consultations is
small, we have basically achieved individualized nutritional score
screening for each patient, which is related to the low prevalence of
malnutrition [31].That means we have taken the
first step of nutritional screening at the pharmaceutical level. But it
is far from enough to give recommendations on enteral or parenteral
nutrition based on screening scores. The next step is to publicize our
nutrition support and promote propaganda and education on problems of
nutritional risk screening, early low calorie supply, enteral nutrition
priority, etc. We plan to sort out the classification of enteral and
parenteral preparations in our hospital, and introduce energy density,
sugar fat ratio, preparation characteristics and pharmacoeconomic
evaluation to physicians, so as to let them know our expertise in
nutrition support.
When giving consultation recommendations, it is equally important to
focus on the effect of medication advice, the monitoring of adverse
reactions, and whether they should ask other departments for help. In
the future, we should also pay attention to follow-up monitoring and
multidisciplinary cooperation.
4.3 Evaluation of consultation effects
The ARC of the post-intervention group was not significantly increased,
compared with the pre-intervention group (96.9% vs 95.7%, P = 0.578).
But it was higher than what was reported in domestic literature[8-10]. This was probably due to the frequent
interactions with physicians and the general recognition of ability. The
ERC in the post-intervention group was significantly higher than that in
the pre-intervention group (81.7% vs 70.2%, P < 0.05), but
lower than was reported in the domestic literature. It may attribute to
the fact that our hospital is the leading phase I tumor clinical
research center in China, which attracts large numbers of patients with
advanced malignant tumor. The consultation patients are often
infected seriously and combined with multiple organ failure, which lead
to poor prognosis and affected the effectiveness of consultations.
4.4 Case in point
A 92-year-old female was admitted to our hospital with the diagnosis of
malignant tumor of colon. She had a history of peptic ulcer and heart
failure. After admission, the patient had repeated fever and was treated
with levofloxacin and moxifloxacin hydrochloride injection successively.
At present, she was still in fever with liver dysfunction (total
bilirubin 42.4 umol·L-1, direct bilirubin 37.1
umol·L-1, AST 66 U·L-1, r-GT 183
U·L-1) and renal dysfunction (creatinine 233
umol·L-1). The infection index was abnormal (WBC 14.59
× 109 L-1, CRP 126.64
mg·L-1) and the mental response was poor.
Purpose of consultation: To adjust the anti-infection scheme.
Clinical pharmacists suggest that: (1) The patient’s current
inflammatory indicators are progressively elevated with frequent
urination symptoms. Midstream urine culture repeatedly shows
multidrug-resistant Klebsiella pneumoniae (+), which needs to be treated
with another antibiotic. Considering that the patient is at the advanced
age of 92 with abnormal liver and kidney function, polymyxin is not
suitable because of its nephrotoxicity and neurotoxicity, neither is
compound sulfamethoxazole because of its hepatotoxicity and
nephrotoxicity. In addition, the concentration of tigecycline in urinary
tract is low, which should not be the primary choice in treating urinary
tract infections. Considering the conditions above, we recommend to use
ceftazidime avibatam sodium for injection 1.25g q12h ivgtt (creatinine
clearance rate of 32ml·min-1). Blood routine, CRP and
PCT should be reexamined after 3 days of medication. (2) The patient’s
Padua score is 6 points (stay in bed for at least 3 days 3’+advanced age
1’+heart failure 1’+infection 1’), indicating a high risk of embolism.
So it is recommended to use low molecular weight heparin 4000 IU qd. (3)
The patient has a history of peptic ulcer, uncontrolled infection and
liver dysfunction, which are risk factors of stress ulcer. So
pantoprazole 40 mg bid ivgtt is recommended. (4) According to NRS2002
nutritional screening score, the patient gets 3 points (malignant
tumor1’+ recent weight loss1’+decreased food intake1’), which suggests
severe malnutrition. So we suggest to use ENSURE on demand. (5) The
patient is currently using compound amino acid injection (18AA). In view
of the abnormal liver function, we suggest to select branched chain
amino acids preparations. As a result, we suggest to use compound amino
acid injection (20AA) instead.
Follow-up: Physicians accepted the consultation recommendations above.
After 3 days of treatment, the patient’s temperature decreased and the
infection index gradually returned to normal. No thrombosis or upper
gastrointestinal bleeding occurred. The nutritional status improved.
4.5 Conclusion
During the specialty construction of Shanghai clinical pharmacy, we
strengthened the training of clinical pharmacists, and further improved
the pharmaceutical services. In terms of the pharmaceutical consultation
work, we created a multidisciplinary individualized medication
consultation mode. During the implementation of this mode, we added
anticoagulation, PPIs use, nutrition and individualized follow-up
monitoring to the consultation recommendations, which increased the
total number of consultations year by year. In details, the number of
general consultations, multidisciplinary difficult consultations,
departments applying for general consultations, departments applying for
multidisciplinary difficult consultations, anti-infection consultations
and non-anti-infection consultations increased correspondingly. The ARC
continued to be higher than the average level in China and the ERC was
significantly higher than that in the pre-intervention stage, which
reflected clinical pharmacists’ value in rational drug use.
4.6 Limitations
The limitations of this study are listed as follows: 1.This study is a
retrospective study, so the baseline is difficult to be flattened when
the subjects are included in the study. In addition, some of the
consultation subjects are in critical situation and require
multidisciplinary diagnosis and treatment. Their outcomes cannot be
completely attributed to the acceptance or rejection of clinical
pharmacists’ consultations, and the evaluation of effectiveness needs to
be viewed objectively. 2. As the study is a single center study, the
vast majority of patients are only limited in Pudong New Area of
Shanghai, China. In order to further evaluate the impact of the new
consultation mode on the consultation effects, multi-center, large
sample studies should be carried out.
Acknowledgments
This study was supported by Key Specialties Foundation of Clinical
Pharmacy of Shanghai Municipal Health Commission in China
(SWLCYXZX-2018-001) and Research on the Epidemiology of Severe
Drug-induced Diseases of the Chinese Society of Toxicology
(CST2019CT304).
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