Seamless care at hospital discharge is an important part of patient care, where a clinical pharmacist with his expertise contributes to safer and more effective drug treatment. Seamless care at discharge has been practiced at URI Soča since 2013 and has become well established over the past 6 years. It focuses on medication reconciliation at discharge, the preparation of medicines, and empowering and educating the patient for treatment with medicines after discharge.
The purpose of the master's thesis was to obtain data on pharmaceutical interventions at discharge, to classify it according to the chosen classification and to analyse it. In addition, the goal was to evaluate (through quality indicators) pharmaceutical services in the context of seamless care at discharge and to propose measures to improve the process. The data source was systematically managed documentation, which is filled out by the pharmacist during the entire patient care.
Between September 1st, 2018 and November 30th, 2018, 98 patients were discharged from two departments of the URI Soča. In further analysis we included 80/96 (83.3%) patients who were treated with medicines and where the pharmacist has been informed of discharge in due time to perform the necessary activities. 78/80 (97.5%) patients underwent medication reconciliation at discharge and 79/80 (98.8%) received a personal medication card. Empowerment and education about medicines were conducted in 75/79 (94.9%) patients with prescription medicines and in 45/47 (95.7%) patients with over-the-counter medicines, nutritional supplements or medical devices. As part of the patient's supply of medicines at discharge, 309 prescriptions were prescribed, of which 277 (89.6%) were dispensed. Pharmaceutical interventions were present in 48/80 (60%) discharged patients with medicines. A total of 126 interventions were recorded and the average of interventions per patient was 2,6. Most commonly these occurred in group N according to ATC classification (40/126; 31.7%), followed by group A (36/126; 28.6%). According to the PharmDISC classification, most interventions (67/126; 53.2%) were performed due to technical/formal intervention problems and in only 23/126 (18.3%) interventions there was a problem with the safety and efficacy of therapy. The main reason for implementing the interventions was logistics (47/126; 37.3%) and the most common interventions were clarifications and addition of information to the patient (43/126; 34.1%) and drug replacement (29/126; 23%). In addition to the pharmacist, the patient was most frequently involved in interventions (102/126; 81%). Based on the actions of the individual pharmacist, 86/126 (68.3%) interventions were accepted and implemented. It was also found out that the classification by the Slovene Chamber of Pharmacies was not appropriate for the purpose of our study, as it was possible to classify only 32 (25.4%) interventions.
The effectiveness of performing seamless care at discharge in selected departments of URI Soča is also confirmed by the quality indicators of the pharmaceutical services that were monitored in the study. The proportion of patients who received counselling and education about medicines at discharge was 76/96 (79.2%). Documentation on past, current medicines and changes in medication treatment was received by 74/96 (77.1%) patients. 70/96 (72.9%) documentation contained changes in medication treatment and explanations for them.
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