DISCUSSION
The present study on pharmaceutical analysis in a geriatric care unit at
a teaching hospital reports that clinical pharmacists detected a higher
number of DRPs within prescriptions during the first wave of the
COVID-19 pandemic than beforehand. Associated therapeutic advice focused
on the use of drugs specific to the management of COVID-19 infected
patients rather than geriatric routine treatments. The needs for
clinical pharmacists were strengthened during the pandemic. With the
persistence of hospitalizations for COVID-19, this work may be used to
improve practices and provide better adapted PIs to support patient
care.
To date, several articles on the roles of pharmacists during the
COVID-19 pandemic have been published [18,19]. These articles
emphasize the importance of pharmacists in managing stocks of health
products but also their support role for the medical staff in the proper
use of these treatments. This optimization of therapeutics is part of
the routine job for clinical pharmacists, but has increased due to the
health context [20]. Previous reports on PIs during this pandemic
focused specifically on the management of COVID+ patients, whether via
pharmaceutical teleconsultations in a tertiary care centre [21] or
in hospitalised patients in a community teaching hospital [22,23].
We provide here, to the best of our knowledge, the first review of
pharmaceutical analysis activity in a population of frail, elderly
inpatients - regardless of their COVID status, and the first comparative
review of the pharmaceutical analysis practices prior to and during the
first wave of this pandemic.
The main result of our study is that, during the COVID-19 pandemic,
pharmacists released significantly more PIs per stay, per patient and
also per line of treatment than prior to the pandemic.
During the first wave of COVID-19, 6.0% of PIs were performed out of
the total number of treatment lines analysed, 53.4% of hospital
inpatients’ prescriptions were subject to a PI and the total number of
PIs per patient was 0.94. This rate is higher than those presented by
two other studies in French geriatric acute care units [24,25] and
whose results were similar to ours prior to the pandemic. On the other
hand, the works of Collins et al. [22] and Perez et al. [23]
have shown higher rates of PIs than ours, up to 8 PIs per patient. These
higher figures might be explained by the greater number of staff in the
clinical pharmacy team; nevertheless these studies suggest that the
medical management of COVID+ patients is particularly at risk of
medication errors.
This can be explained in different ways. Firstly, the mean length of
stay for patients was shorter during the COVID-19 pandemic than
beforehand. We therefore analysed more first-prescriptions that were
more at risk of DRPs. Indeed, previous works have shown that
approximately 50% of prescriptions on admission in a hospital unit
include a DRP [26,27]. Secondly, the number of treatment lines per
patient is higher among those hospitalized during the first wave and
thus increases their risk of exposure to an iatrogenic event and
potential DRP identified by the pharmacists. Thirdly, during the
pandemic there were significantly more PIs on anti-infectious drugs than
before. Their high prescription rate in the pandemic context is likely
explained by the recommendation of their probabilistic prescription for
suspicious or infected COVID-19 patients. These drugs are frequently
cited as a cause of DRPs, due to their prescription in acute illness and
their specificities of use in elderly patients (dosage adjustment,
biological monitoring) which reinforced the pharmacists’ vigilance
during the analysis [28,29].
Our results showed a significant difference in the types of the PIs
achieved over the two periods.
During the first-wave of the pandemic there was a focus on drugs that
are part of the medical management protocol of COVID+ patients: the
drugs with the higher number of PIs were anti-infectious ones (20.3%),
acetaminophen (17.5%) and anticoagulant ones (9.6%).
The DRPs found in anti-infectious drug prescriptions were mostly an
improper administration (e.g. an injectable form prescribed when the
oral route is possible, a prescription with no duration of treatment) or
a supratherapeutic dosage.
There were no significant differences in the number of DRPs in the
prescription of acetaminophen and anticoagulants drugs. Acetaminophen is
the most frequently prescribed molecule during hospitalisation in France
[30] and particular attention is paid to its correct prescription in
geriatric care (respecting the maximum dosage for older adults and
according to the patients’ weight, adapted route of administration or
verification of the absence of double prescription lines).
Anticoagulants are a class of drugs that are particularly at risk of
serious adverse effects in older adults [31]; the pharmaceutical
team therefore focused attention on their prescription as they require
reinforced vigilance in their use (duration of treatment, route of
administration, adapted dosage, biological monitoring).
Before the COVID-19 pandemic, the drugs with the highest number of PIs
were laxatives (13.0%), acetaminophen and proton pump inhibitors
(11.1%). These therapeutic classes are frequently found in
prescriptions for older adults, and correspond to standard geriatric
care. We noted significantly more DRPs for a prescription without an
indication and advice on drug discontinuation. This is consistent with
the specificities of routine geriatric care where particular attention
is paid to the reassessment of inappropriate prescriptions (i.e.,
overuse, misuse, underuse). The purpose is to encourage deprescribing
whenever possible in order to limit avoidable iatrogenic risks, the
prevalence of which is particularly high in this population [32,33].
This difference in practices adopted during the pandemic, and
significantly highlighted, can be explained by the notion of emergency
in the management of COVID+ patients on their admission to the unit.
Indeed, PIs on inappropriate administration or dosage adjustments are
more in line with those expected for acute care management as this was
the case during the first wave of the pandemic; whereas PIs on laxatives
or drugs without an indication are more appropriate for routine
management, when the patient stays long enough on the ward to benefit
from geriatric therapeutic optimisation.
Our PIs during the pandemic were similar to the advice for therapeutic
optimisation during COVID-19 proposed by the work of Burgess et al.
[20] and found in the reviews by Surapat et al. [21], Collins et
al. [22] and Perez et al. [23]. Basically, we proposed dosage
adjustments to use the optimal dose for each patient, we insisted on the
optimisation of the administration of drug modalities and advised on
deprescription to ease the treatment regimens for those patients, but we
note, however, a lower proportion of PIs on treatment monitoring in our
results.
Concerning the clinical impact of our PIs, no significant difference was
found between the two periods of analysis. Only 3 studies proposing an
evaluation of the impact of PIs using the CLEO scale were found in the
literature [34-36]. The CLEO scale being a French scale and of
recent implementation, is currently little used.
Other scales have been used in previous works (Hatoum, Pippins) and
these tools have demonstrated that PIs in geriatrics most often have a
clinical impact considered as ”significant” [25,37,38]. This is
similar to our results. As the pharmaceutical team works in partnership
with the medical team, PIs have little major or even vital clinical
impact for patients.
The acceptance rate of our PIs is similar for both analysis periods,
with an average value of 60.2%. This result is lower than those found
in the literature, ranging from 63.3% to 92.0%. The main hypothesis to
explain this lower acceptance rate is the lack of systematic oral
communication of the PI. Indeed, it has been proven that PIs have a
better chance of being accepted if they are discussed with the medical
team [39]. We did not distinguish the mode of transmission of our
PIs to the prescribers in our data collection. Studies that have shown
an acceptance rate of computer-transmitted-only PIs in their results
have similar results to ours [25]. Following the awareness of the
need for oral transmission, proposals to improve our communication were
discussed with the medical team but were not always successful in the
health context of the pandemic which reduced the contact between
pharmacists and the healthcare team. While PIs focusing on compliance
with good prescribing practices, in accordance with protocols or based
on biological elements, may be considered relevant, some advice for
therapeutic optimisation may have been less appropriate for prescribers
during the pandemic.
This study had some limitations. Contrary to other works, we decided to
compare the PIs carried out over two distinct periods of time rather
than between COVID+ and COVID- patients. This may have caused a bias in
our analysis practices. As the clinical pharmacy team has only been
working in the unit since November 2019, its efficiency in analysing
prescriptions was not optimal at the beginning of the data collection.
As the gain in experience through contact with the medical team and the
performance of clinical pharmacy activities is acquired over time, it is
logical to highlight an improvement in the pharmacists’ practices in
this activity during the 2nd period of data collection.
Also, due to the difficulties in determining the proportion of COVID+
patients in our population, the results of our work are more a
reflection on general geriatric management during this pandemic than
specific geriatric management for COVID+ patients.