83 Medication use evaluations and clinical pathways to standardize patient care for hospitalized patients under medicine department: A pharmacy-general internal medicine department’s collaborative work

Background Clinical Pharmacists (CPs) play a vital role in multidisciplinary teams, offering pharmaceutical care and ensuring safe medication use.^{1 2} They often identify inappropriate prescribing during patient reviews, prompting the expansion of medication use evaluations (MUEs) beyond new formulary medications to address other concerns. MUEs analyse the medication process to enhance safety and effectiveness. Additionally, CPs recognize the lack of standardized disease management protocols, leading to collaboration with General Internal Medicine (GIM) physicians to update existing pathways and introduce new ones.³ This Quality Improvement project aimed to standardize clinical practices for common admissions reasons (e.g., electrolyte imbalances, infectious diseases) and optimize medication use through CP-GIM collaboration. The goals included updating 14 existing pathways, creating five new ones, and conducting 10 MUEs by December 2022.

Methods This involved educating internal medicine pharmacists on conducting MUEs, applying the Institute for Healthcare Improvement model for improvement to perform MUEs, reviewing and updating existing pathways, prioritizing medications for evaluation, and using improvement models for MUEs and pathway development (figure 1).

Results Seventeen conducted MUEs exceeded the target. The findings were shared with Internal Medicine leaders and presented during morning reports. Actions taken included raising tickets to add specific order comments, fire alerts on significant drug interactions, and modifying digoxin-level units reported on Cerner® to match the international references. Twenty-three new pathways were developed and submitted for approval (figure 2).

Conclusion Enhanced collaboration between CPs and GIM improves patient safety through interventions based on MUE findings and standardized practices. Continued MUEs and pathway compliance monitoring will sustain standardized practices.

References

1. Kimura T, Fujita M, Shimizu M, Sumiyoshi K, Bansho S, Yamamoto K, OmuraT, Yano I. Effectiveness of pharmacist intervention for deprescribing potentially inappropriate medications: a prospective observational study. Journal of Pharmaceutical Health Care and Sciences 2022 Dec;8(1):1–0. https://doi.org/10.1186/s40780-022-00243-0

2. FanikosJ, Jenkins KL, Piazza G, Connors J, Goldhaber SZ. Medication use evaluation: pharmacist rubric for performance improvement. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy 2014 Dec;34(S1):5S–13S. https://doi.org/10.1002/phar.1506

3. Afanasjeva J, Burk M, Cunningham F, FanikosJ, Gabay M, Hayes G, Masters PL, Rodriguez R, Sinnett MJ. ASHP guidelines on medication-use evaluation. American Journal of Health-System Pharmacy 2021 Jan 15;78(2):168–75. https://doi.org/10.1093/ajhp/zxaa393

Ethical Approval/IRB Statement This internal audit of the service was approved by the head of Hamad General Hospital’s (HGH) internal medicine and pharmacy departments for conducting and publication.

Disclosures and Acknowledgments The authors would like to thank the Internal Medicine Department clinical pharmacy team for their efforts in conducting Medication Use Evaluations and clinical pathways.