Marvin Vanessa, Ward Emily, Jubraj Barry, Bower Mark, Bovill Iñaki
Department of Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, UK.
Medicines Optimisation, NIHR CLAHRC NW London, London SW10 9NH, UK.
Pharmacy (Basel). 2018 Apr 16;6(2):32. doi: 10.3390/pharmacy6020032.
In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Generalised guidance for reviewing older adults' medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily "hold" medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital.
在急性医院环境中，采用多学科方法进行用药评估可改善体弱患者的处方开具和药物选择。需要清楚了解药剂师的角色和职责，以确保干预措施对患者护理产生最大影响。采用共识建立过程为药剂师制定指导方针，以支持识别有药物风险的患者，并阐明预期行动和升级流程。进行了文献检索，并依据证据确定了住院患者常遇到的一组十种情况，每种情况有六种或更多可能的行动。四位顾问医师和四位资深药剂师对列出的行动的认同程度进行了排序。该流程经过重新起草和重复，直至达成共识并确定干预措施。制定了针对老年人用药评估的通用指导方针，以及在特定临床情况下应遵循的升级流程。小组一致认为，药剂师和医师在用药评估中都应发挥积极作用，面对面沟通始终更有利于促进明智的决策。只有开处方者才能减少用药量，然而，未接受开处方培训的药剂师在有适当文件记录并与开处方团队进行后续讨论的情况下，可为了患者的最大利益暂时“停用”药物。达成的共识是，年龄、复杂的多重用药问题以及与药物相关问题的存在，是识别最能从全面用药评估中受益的患者的最重要因素。已制定了关于识别使用不当药物的患者以及随后由药剂师主导的干预措施以促使和推动减少用药量的指导方针，以便在急性医院实施。
