The hospital pharmacist’s role in delirium
The HPAI Annual Conference 2023 featured a range of high-quality short oral presentations that encompassed a range of topics of interest to hospital pharmacists. The conference heard from Ms Helen Heery, who discussed the issue of delirium in patients and the role of the hospital pharmacist in a presentation titled, ‘Stop! Think Delirium’. “This is a really serious problem in hospitals and one in which I believe pharmacists can play a key role in its management,” she said.
Ms Heery provided an overview of the instance, nature and definition of delirium and explained: “Delirium is defined as an acute cognitive decline and it also affects sensory perception, so a person with delirium might have visual or auditory hallucinations,” she said. “But it can also affect them physically. A person with delirium may move differently, they may become slower in their movements, or conversely, they may also become restless and may be wandering up and down the corridor.”
The onset of delirium may happen quickly, possibly over one or two days, but is usually reversible, Ms Heery explained. It is relatively common, and figures show that approximately one-in-three older adults in hospital will develop delirium, with some studies suggesting this could be a rate of one-in-two older hospital patients. This rate, however, can increase to more than 50 per cent if the patient is severely ill or in the ICU, or if they suffer a hip fracture.
“Having delirium has stark consequences,” Ms Heery continued. “It means that there’s a higher chance that you will stay in hospital longer and you will have a higher-risk stay as an inpatient, with a greater risk of developing pressure sores or suffering falls or incontinence. If you have delirium, you may not return to baseline and there is also a higher risk of being moved to a nursing home, with a higher risk of dementia and overall mortality. It’s also quite a frightening and stressful experience for the patient and everyone involved.”
Ms Heery outlined the potential causes of delirium, which can be synopsised with the abbreviation ‘PINCH ME’: P is the person in pain, and has urinary retention been excluded?; IN, infection — is there a possible infection?; C, constipation — when was the patient’s last bowel movement?; H, hydration/nutrition — Is there a major electrolyte imbalance and have hypoxia, hypotension, hypoglycaemia been considered?; M, medication — has there been omission of regular medication or addition of new ones?; and E, environment — has a change of environment, noise or activity levels been affecting sleep or rest?
“Delirium is common and it is usually reversible,” she told the attendees. “But screening is key and we really need to be on the lookout for it. The earlier it is identified, the easier it is to treat, and established delirium that has been there for a day or two or a few days is harder to reverse and harder to manage. Our focus should be on treating the cause of the delirium, rather than the symptoms… there is room for improvement in how we treat these patients, and I think hospital pharmacists have a key role in that.”
Some of the key ways hospital pharmacists can be instrumental in helping these patients is through medication reviews; medical reconciliation on admission; providing support and guidance to clinicians on the use of antipsychotics in delirium; providing support and information to patients, carers and family members; and conducting medication reconciliation on discharge.
The attendees were treated to a number of other Oral Presentations delivered by experienced hospital pharmacists who are specialists in their areas.
The attendees heard from Ms Mariosa Kieran of the Mater Misericordiae University Hospital, who delivered a presentation on ‘Introducing Pharmacy Key Performance Indicators in a Level 4 Academic Teaching Hospital’. Ms Sarah Fenton of Cork University Hospital delivered a talk titled ‘Standardisation of Preterm Parenteral Nutrition in Ireland’, which was followed by a presentation titled ‘Incorporation of Pharmacy Technicians into the Medication Administration Process in a Single Paediatric Cancer Inpatient Service: An Implementation Study’, by Ms Michelle Beirne of CHI, Crumlin.
The final oral presentation of the day was delivered by Ms Caroline Gallagher of St Vincent’s University Hospital in Dublin, who spoke on the topic, ‘Designing A Future-Proofed Pharmacy Department at St Vincent’s University Hospital’.
Each presentation was followed by enthusiastic participation in lively interactive Q&A sessions, and the organisers commended the speakers on the quality and practical value of their oral presentations.
CAT clinics — hospital pharmacists at the forefront
Attendees at the HPAI Annual Conference 2023 heard a presentation by Mr Kieron Power, Lead Pharmacist for Thrombosis and Anticoagulation at Singleton Hospital, NHS Wales, who delivered a talk titled ‘The Future of Pharmacy-Led Cancer-Associated Thrombosis (CAT) Clinics — A Real-Life Case Study’. The presentation was sponsored by Leo Pharma, which had no input into the content of the meeting.
In his talk, Mr Power addressed cancer-associated thrombosis, followed by a clinical discussion on the condition itself and treatments, as well as the role of pharmacists in CAT clinics, and the pharmacist’s role in managing treatments. “What we are starting to see now is pharmacists being involved further forward in the ‘queue’, with pharmacists now involved in what I would term ‘primary’ prescribing, or primary initiation of therapies from day one,” Mr Power told the conference. “We are actually starting to see pharmacists more involved in the diagnostic roles too — these are some of the ways in which we have seen evolution in pharmacy practice.”
He defined CAT as “any thrombotic event in active cancer. When we talk about VTE, what we are fundamentally talking about is primarily deep-vein thrombosis, which of course would usually affect the legs, but in active patients, we would see a reasonable number of clots in other locations such as extremities, abdominal vein thrombi, and various other forms of thrombosis.” The presentation was interactive, with Mr Power asking the attendees a number of clinical questions throughout the talk.
“CAT is actually a common complication in cancer,” Mr Power told the meeting. “I think it’s fair to say it is under-appreciated — in cancer, we tend to think of all the other complications, but what we are not very good at is warning patients that they are at risk of having a clot… around 20 per cent of cancer patients will have a VTE at some time during their cancer journey.”
He pointed out that second most-common cause of death in cancer patients after the tumour itself is VTE, and presented studies on the use of DOACs in this patient cohort. He described the various complications and high level of risk for VTE, not only in cancer patients, but across the board. Cancer treatments and hospitalisation, in themselves, provide their own additional risks, he said, adding that every cancer patient is different, with their own clinical nuances.
Mr Power also described the first CAT clinic consultation, which is focused on patient education and reassurance. This means explaining what CAT is and the link between cancer and thrombosis. The patient also hears how CAT will be treated and what expectations the patient can have, and he explained that each of these factors involves a certain degree of anxiety for these patients. “A standard clinic consultation appointment slot is generally not enough to adequately address these issues,” he added. The PELICAN study, said Mr Power, showed that these patients have a high degree of anxiety and a strong desire for information.
On how pharmacists can improve the management of patients with CAT, he told the conference: “Pharmacists are a really great resource for these patients… not least in the area of drug interactions. The potential for interactions with DOACs is huge and we can evaluate whether a treatment is acceptable. Pharmacists can also help with pharmacokinetic considerations, and there is a huge amount of patient [treatment] counselling required, and again, this is something that we can offer to patients.”
He concluded: “I hope everyone would agree that CAT is a quite common but complex condition and cancer patients are at a higher risk of thrombosis and bleeding on anticoagulation versus patients without cancer. However, strategies aimed at preventing VTE in cancer are becoming more commonplace and while treatment of CAT was historically with LMWH [low molecular weight heparin], we are now seeing more DOACs being used. This is great for patients but comes with its own challenges, and that is a great opportunity for pharmacists to become involved.”
Mr Power cautioned that careful patient assessment is required to choose between a DOAC of LMWH, and the patient should be involved in this decision process. “CAT services are paramount to ensuring that these challenges are addressed effectively,” he said. “These services are becoming far more commonplace, and models are now available that can be adopted, and to support AHPs with an interest in CAT management, a training programme has been developed and will be available soon.”
Excellent standard at 2023 poster presentations
The HPAI Annual Conference 2023 hosted a number of poster presentations covering a wide range of topics relevant to hospital pharmacy.
First prize in the Research category, which was kindly sponsored by Pfizer, was won by Ms Eileen Whittle of St Vincent’s University Hospital, who presented on the topic ‘The Role of Medicines Information Services in Ireland in the Education and Development of Early Career Clinical Pharmacists — A Qualitative Interview Study’. The judges, led by Mr Stephen Byrne of UCC and team, commented that the presentation was “a really important piece of work which has national implications for education and training”.
Second prize in the category was awarded to Ms Dzana Hadzic of the Mater Misericordiae University Hospital in Dublin, for her work on the theme ‘Pharmacist-led Medicines Reconciliation: An Observational Study to Evaluate Information Sources as a Quality Indicator of the Service’. The judges remarked that the work was an “important evaluation with key findings regarding the accuracy of information sources”.
A number of posters were highly commended by the judging panel, including a presentation by Ms Moninne Howlett, titled ‘Efficiencies on Implementation of an Automatic Dispensing Cabinet into a Paediatric Emergency Department – An Observational Study’ at Children’s Health Ireland, Crumlin. Also highly commended was the presentation by Ms Christine McAuliffe, titled ‘Polypharmacy in Atrial Fibrillation – Potential for Clinical Pharmacy Input’, and Mrs Barbara Nicolaou-Ghekas, who presented on ‘Exploring Intern Doctors’ Views and Experiences of Prescribing at Hospital Discharge: A Qualitative Interview Study’.
In the Audit category, first prize was awarded to Ms Sinead O’Mahony of St Vincent’s University Hospital in Dublin, who presented on the theme ‘An Audit of the Management of Drug-Drug Interactions Associated with Paxlovid at a Tertiary Dublin Hospital’. Second prize went to Mr Aaron Daunt of St James’s Hospital in Dublin, who presented on the topic ‘A Retrospective Audit of Timing and Appropriateness of Antimicrobial Prescribing in Presentations of Suspected Meningitis/Encephalitis at an Irish Teaching Hospital’.
The judges, Ms Aisling O'Leary, Ms Fionnuala Brady and Ms Carmel Darcy, commented that “the judging panel was delighted with the standard and obvious enthusiasm for audit”. Highly-commended poster presentations in this category included ‘Clinical Audit of Analgesia and Associated Prescribing on Our Lady of Lourdes Orthopaedic Ward’ by Ms Marie Richardson; and ‘An Audit of Pharmacist Discharge Prescription Review on Orthopaedic Rehabilitation Wards’ by Ms Lydia Duggan of South Infirmary Victoria University Hospital, Cork.
In the Service Development category, first prize was awarded to Ms Rebecca Clarke, who presented on the theme ‘A Study to Assess and Enhance Clinical Prioritisation Within the Clinical Pharmacy Service at St James’s Hospital Dublin’. The judges commented that they “hope to see it in a published paper — useful to many hospital environments”.
Second prize went to Ms Emer O Mahony of Tallaght University Hospital, who presented a poster on ‘Design Implementation and Evaluation of a Medication Counselling Service Provided by Pharmacists Using Teach Back at Hospital Discharge’. The judges remarked that the work is “applicable across many sectors and areas – integrate into teaching”.
Highly-commended presentations included ‘Clinical Pharmacist Interventions and Severity Rating Project at Mayo University Hospital’ by Ms Selena Gill of Mayo University Hospital; ‘A Time-Saving Analysis of Benchtop Preparation of Subcutaneous Monoclonal Antibodies’ by Mr Eoin Tabb of University Hospital Waterford; and ‘Evaluation of the Decisions Made by Clinical Pharmacists When Charting Medication Following Medication Reconciliation in a Tertiary Hospital’ by Ms Sinead O’Mahony of St Vincent’s University Hospital.
In the Innovation category, the first prize went to Ms Maria Mulrooney of Cork University Hospital, who presented on the subject of ‘Improving the Clinical Pharmacist Handover Process Using an Adapted ISBAR Communication Tool when Transferring Patients from CUMH to an ICU within Cork University Hospital’. The judges, led by Mr Stephen Byrne of UCC and team, commented that this is “an excellent body of work with national applicability”.
Second prize was awarded to Ms Roisin O’Connor of St James’s Hospital, who presented on the topic ‘Intervention to Improve Vancomycin Sampling Time at St James’s Hospital’. The judges added that this work is an “excellent patient safety initiative”. Highly-commended posters were by Ms Sandra Lauhoff, who presented on ‘Successful Implementation of a Focused Antimicrobial Stewardship Intervention for the Treatment of Cellulitis, Bon Secours Hospital, Cork’; and Ms Marie Ronan, who presented on ‘Antimicrobial Stewardship in the Digital Era, Mayo University Hospital’.
Doing the right research in the right way
Attendees at the HPAI Annual Conference 2023 heard a presentation by Mr Patrick Dicker of the Department of Epidemiology and Public Health Medicine at the RCSI, who delivered a talk titled ‘Critical Appraisal and Research Integrity Evaluation of Randomised Controlled Trials’. Mr Dicker provided guidance on how to ethically conduct research to the best quality possible, while highlighting some of the common pitfalls, such as ethics matters and potential plagiarism.
Mr Dicker has spent 15 years as a trial statistician and currently lectures in the RCSI, teaching evidence-based health to medical students, and is research Integrity Editor for a leading medical journal. Mr Dicker discussed some of the common pitfalls that may lead a researcher to retract their paper. For example, “we know that there are a lot of dodgy Covid-19 trials that have been retracted,” he said. “There have been 300 papers looking at Covid that have been retracted. That’s probably quite a small figure, as approximately 30,000 papers have been published in the first six months of the pandemic. Retractions have become a major concern, and that’s why research integrity has become so important. Nobody wants to have a paper retracted, and that can make it difficult to get published again or to obtain research funding.”
Mr Dicker explained that when a retraction is due to an honest error, some studies have shown there is little evidence of differential stigma. He also talked about the blog ‘Retraction Watch’, which reports on retractions of scientific papers, with its parent organisation being the Centre for Scientific Integrity. “Retraction Watch allows flagging of cases where the authors have owned-up to errors and have taken steps to correct them,” Mr Dicker said. “Everybody makes mistakes, and the scientific community can be forgiving when researchers own up to their mistakes.”
There are a series of key questions around critical appraisal and research integrity that authors should ask themselves before and during the course of their study, he told the conference. “These include, is there a valid rationale for conducting the trial in the first place?” he said. “Also, are the objectives clearly described? Are REC approval, prospective registration and informed consent described? What is the PICO, and is the chosen outcome appropriate? Does the trial have key features, such as control, randomisation and blinding? What were the primary results, their uncertainty, and are they realistic? Was there adequate safety assessment? These are all key questions.”
The acronym PICO, he explained, stands for the ‘Population’ of the study, for example infants with spinal muscular atrophy; ‘Intervention’ with a therapy or treatment; ‘Comparisons’, for example with placebo; and the ‘Outcome’, such as motor-milestone response or event-free survival. “PICO is useful when you are looking at a large number of clinical trials, for example, as they might be different in terms of comparative treatment or the outcomes used, and for an initial systematic review, you might want to make note of what the PICO is for the study,” he said.
“Most healthcare professionals are committed to life-long learning,” Mr Dicker concluded. “Many of you are involved in research, and research integrity is an essential ingredient for publishing trustworthy research. Everyone relies on published evidence, and critical appraisal is an essential skill to understanding the literature that’s out there.”
From frail older adults to aseptic pharmacy
The HPAI Annual Educational Conference 2023 featured a range of six workshops that covered practical learning opportunities for hospital pharmacists, which ranged from ‘Care of the Elderly’, to ‘Aseptic Pharmacy Practise’, to Medication-Related Hospitalisations’, and more.
One of the workshops, facilitated by Mr Kieran Dalton and Mr Eoin Hurley of UCC, was titled ‘Patient-Centered Pharmacotherapy Optimisation in Frail Older Adults with Limited Life Expectancy’. The workshop was focused on recognising frailty in older adults, rationalising medications using validated tools and clinical judgement, as well as managing the prescribing process and evaluating outcomes.
Participants were challenged to evaluate factors that should be considered when aiming to optimise pharmacology in frail older adults, such as their remaining life expectancy, the goals of the treatment, the medications’ time to benefit, as well as withdrawal complications and administration issues. It included feedback on case studies based on real-life patients, and participants were invited to discuss proposed treatment plans.
Participants gained a better understanding of the patient-centered approach to medication optimisation and managing opportunities for de-prescribing. The attendees were also challenged to use validated screening tools, such as STOPPFrail, to identify medication-related issues and potential de-prescribing opportunities. Complex patient cases were discussed and participants collaborated to develop medications recommendations and monitoring requirements, as well as assessing drug withdrawal effects and overall outcomes.
Another useful practical workshop was facilitated by Ms Olivia Flynn, Chief II Pharmacist in Cancer Services at University Hospital Limerick, and Mr Tadhg Reddan, Chief II Pharmacist in Cancer Clinical Services at St Vincent’s University Hospital in Dublin. They hosted a workshop titled ‘Aseptic Pharmacy Practice’ and provided an overview of the role of a pharmacist in the Aseptic Compounding Unit.
The learning objectives also included raising awareness of health and safety considerations in the aseptic compounding unit, and the steps involved in the supervising of the compounding of systemic anti-cancer treatment, as well as highlighting the quality management systems in place in an aseptic compounding unit.
Perfecting your hiring skills
The HPAI Annual Educational Conference 2023 also featured a workshop designed to provide essential skills to people managers to improve their confidence and competence in the recruitment and interview process. Facilitated by Ms Jo Irwin of i4trainingservices.com, the workshop was titled ‘Interviewing Skills: The Key to Hiring’ and was kindly sponsored by United Drug, which had no input into the content of the workshop.
Through interactive discussion, the group drew on their own experiences of being on both sides of the interview process and they were invited to enhance their own existing skills in this Management Workshop. One of the several objectives of this workshop was to better understand the aspects of a HSE interview process, particularly the need to be objective, fair and consistent with each candidate. Proper preparation was also covered, including reviewing paperwork and planning the right questions.
Other practically useful workshops at the conference included ‘Medication-Related Hospitalisations’, facilitated by Dr Tamasine Grimes of Trinity College Dublin, and Dr Ulrike Gillespie of Uppsala University Hospital in Sweden. Another highly useful workshop, ‘Care of the Elderly’, was facilitated by Ms Niamh McMahon, Chief II Pharmacist at St James’s Hospital in Dublin and Adjunct Professor in Practice of Pharmacy at Trinity College Dublin; and Ms Aine O’Reilly, Senior Pharmacist at South Tipperary ICPOP, and Tipperary Enablement Programme for Older Persons.
European hospital pharmacy was also well represented in the line-up of workshops. ‘EAHP Academy Seminar Feedback: Qualitative Research Methods’ was facilitated by Dr Suzanne McCarthy, Senior Lecturer in the School of Pharmacy at UCC and Interim Director of the MSc in Clinical Pharmacy; Dr Virginia Silvari, Chief II Pharmacist at Cork University Hospital and Adjunct Lecturer at UCC and Trinity College Dublin; and Ms Sinead Doyle, Senior Clinical Pharmacist in Portiuncula University Hospital and Clinical Lecturer at Trinity College Dublin.
In 2019, the EAHP held a two-day seminar on ‘Qualitative Research Methods’ designed to address a number of questions around qualitative research, including what, why and how do patients think about their medicines. This workshop was designed to help participants better understand qualitative research and why it should be used; formulate qualitative research questions and prepare topic guidelines; and to apply methods used in qualitative interviews, including focus groups.
98% of hospital pharmacists have struggled with medication shortages in past six months
Attendees at the HPAI Annual Educational Conference 2023 participated in an important poll that asked a series of questions on whether they have had difficulties with shortages of key medications, as well as a range of other questions around the issue. The poll results highlighted how pressing the problem of medicine shortages has become, and the efforts of hospital pharmacists to maintain patient safety. A total of 58 attendees responded to the poll questions.
On the question ‘Have you experienced medication shortages in your hospital in the last six months?’, the responses were stark, with 98% of respondents answering ‘Yes’. This was followed by the question, ‘Were many of these medications for critical medicines or medicines for which there was no alternative available?’ Almost 30 of the respondents said this was the case 10-to-20% of the time, with a little over 25 answering that this happened to them 20-to-40 per cent of the time. More than 20 people answered that there was no alternative available 5-to-10% of the time, while 10 answered that this was the case in 40-to-60 per cent of cases. Five people said there were no alternatives 60-to-80% of the time, with less than 10 respondents saying this was the case less than 5% of the time.
The participants were also asked, ‘How much notice of shortages do you have on average?’ Some 58% of pharmacists said they received no notice at all, with 29% responding ‘1 week’, and 7% answering ‘2 weeks’. Only 2% of respondents said they received notice of three weeks, four weeks or more than four weeks, respectively.
On the question ‘How much of your time is taken up by managing medication shortages in the average week?’, 47% said they spend between one and three hours, while 21 per cent answered three-to-five hours. This was followed by one hour (17%), five-to-10 hours (14%), with 2% saying they spent more than 10 hours per week dealing with shortages.
However, when the question was tweaked to illustrate the impact on a departmental level, the results were striking — 52% of pharmacists said their department spent more than 10 hours per week dealing with shortages, with 29% responding ‘five-to-10 hours’, and 16% answering ‘three-to-five hours’. Only 3% said their department spent one-to-three hours each week dealing with shortages.
On the question ‘Do you know of patients who have received less than optimal treatment or missed out on treatment due to medication shortages?’, 76% answered ‘No’, with 24% responding ‘Yes’.
The attendees were also asked, ‘Who is best placed to strategically manage shortages of critical meds?’ Twenty pharmacists said the AHDMP is best placed, while just under 20 said the HPRA is best placed to handle these situations. Less than 10 said it is the Department of Health, and the remaining responses (less than five each) comprised ‘National clinical programme leads’, ‘marketing authorisation holder’, ‘Local’, ‘Depends on circumstances’, ‘Need separate group’, and ‘Combination of above’.
The final question asked the respondents, ‘Has the HPRA Medicines Shortages Framework improved communication around medicines shortages on the ground?’ Forty-seven pharmacists answered ‘No’, with 36% answering ‘Yes’, and the remaining 17% saying they had ‘No opinion’.