Discharge dispense dilemma

pharmacist hospital

A roundup of research from the recent SHPA Medicines Management 2017 conference, including evidence of poor discharge prescribing of opioids   

Guidelines are being developed by a local health district to reduce inappropriate analgesic prescribing to patients on discharge from hospitals.  

Data collected by researchers from the Illawarra Shoalhaven Local Health District, NSW, showed that of 468 patients who were reviewed, one-third received an analgesic on discharge.

The majority received an opioid, mostly oxycodone immediate-release. Almost half of these (42%) received more than one opioid. Pregabalin was supplied to 17% at discharge, despite no prior use.

Less than one in four also received a laxative.

The authors said their findings backed “pharmacist observations of poor use of adjuvant analgesics and laxatives, increasing and sustained use of pregabalin”.

“It takes time to dispense an opioid and 70% of these remain unused after discharge,” they added. 

Among the guideline initiatives they propose are:

  • Dosage guidance for pregabalin and restrictions for discharge supply
  • Automatic supply of laxatives for patients receiving opioids
  •  Paracetamol supply to all patients, and NSAIDs for those without contrindications
  • Advice for de-escalation of opioids or cessation at discharge.

Other posters presented at the conference include:

– A study from Cabrini Hospital, Victoria that showed pharmacy technicians could obtain best practice medication histories from patients with “the same accuracy and completeness as a pharmacist”.

The researchers analysed medication histories from 227 patients – 112 completed by PTs and 115 by pharmacists.

“Defined referral criteria ensured pharmacist review of clinical or medical information where necessary”, the authors added, saying the findings were important for allowing a possible expansion of hte PT role, freeing up pharmacists to dedicate more time to “complex clinical tasks”.

A review of discharge summaries found that this communication channel “continues to suffer, as information is often missing from the medication list or inaccurate, despite training and educating doctors”.

Analysis of 37 discharge summaries by a team from Western Sydney Local Health District found only 46% had a medication list that was “current, accurate and comprehensive”, and only 60% had all ongoing medications listed. Two patients had at least one medication listed that should not have been  continued on discharge.

“Discussions are underway for a stronger presence of hospital pharmacists at the time of discharge”, the authors said, recommending stndardisation of the medication list template in the discharge summary.

Continuing uncertainty among healthcare providers over the risks, doses, monitoring and pharmacotherapeutic issues with non-vitamin K antagonist oral anticoagulants (NOACs).

Hospital pharmacists in particular were heavy enquirers to a Medicines Information service on different issues relating to these medicines, in particular rivaroxaban. A number of enquiries relating to ‘off-label’ use of these medicines may reflect their “perceived convenience” compared to other oral anticoagulants, the authors said.

The research team were from the Hunter Drug Information Service, Calvary Mater Hospital, NSW.

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