Hart Kristin M, Gennari Amelia S, Ruby Christine M
Sr Care Pharm. 2020 Mar 1;35(3):136-144. doi: 10.4140/TCP.n.2020.136.
To describe and gather further details about the clinical and educational activities that were documented by the geriatric pharmacist resident during both weekly interprofessional Acute Care for the Elderly (ACE) rounds as well as bedside patient counseling. Retrospective chart review (quality improvement project). Inpatient geriatric service at University of Pittsburgh Medical Center (UPMC). Medical learners selected one complex patient from the geriatric service for ACE rounds each week. The geriatric pharmacist resident provided clinical information and medication education to the interprofessional team and to the patient and/or family at their bedside. Activities were documented in a newly developed template. Patient demographics, medication categories, discrepancies and dosing changes, time-in-rounds, and team members. De-identified data from 18 patients (72.2% female, average age 82.5 ± 9.18 years) over a 6-month period were collected and analyzed. The geriatric pharmacist resident provided most education to the team on antibiotics, antidepressants, over-thecounters (OTCs), and prescription pain medications during ACE rounds. They provided most education to the patient/family on prescription pain medications, antidepressants, OTCs, and anticoagulants. The pharmacist resident identified 38 medication discrepancies (72.2% of patients had ≥ 1 discrepancy, range 0-7) and clinically significant drug-drug interactions in 15 patients. The pharmacist resident recommended dosing changes in 12 patients and therapeutic alternatives in 11 patients. The ACE rounds lasted on average 26.6 [± 6.42] minutes and included medicine, pharmacy, social work, nurse case management, nursing, and nutrition and rehabilitative services when necessary. The results provide insight into both the clinical and educational activities of the geriatric pharmacist resident in support of interprofessional rounds.
描述并收集更多关于老年药剂师住院医师在每周跨专业的老年急性护理（ACE）查房以及床边患者咨询中记录的临床和教育活动的详细信息。回顾性病历审查（质量改进项目）。匹兹堡大学医学中心（UPMC）的住院老年服务部。医学实习生每周从老年服务部挑选一名复杂患者进行ACE查房。老年药剂师住院医师在床边向跨专业团队以及患者和/或家属提供临床信息和用药教育。活动记录在一个新开发的模板中。内容包括患者人口统计学信息、药物类别、差异和剂量变化、查房时间以及团队成员。收集并分析了6个月期间18名患者（72.2%为女性，平均年龄82.5±9.18岁）的去识别化数据。在ACE查房期间，老年药剂师住院医师向团队提供的关于抗生素、抗抑郁药、非处方药（OTC）和处方止痛药的教育最多。他们向患者/家属提供的关于处方止痛药、抗抑郁药、OTC和抗凝剂的教育最多。药剂师住院医师识别出38处用药差异（72.2%的患者有≥1处差异，范围为0 - 7）以及15名患者存在具有临床意义的药物相互作用。药剂师住院医师建议12名患者调整剂量，11名患者更换治疗方案。ACE查房平均持续26.6[±6.42]分钟，必要时包括医学、药学、社会工作、护士病例管理、护理以及营养和康复服务。这些结果为老年药剂师住院医师支持跨专业查房的临床和教育活动提供了见解。
