Drug-related problems (DRPs) in emergency department (ED) visits and the impact of the pharmacist-initiated analgesia pathway (PIAP) intervention for adult patients of a teaching hospital of Hong Kong

Abstract

Drug-Related Problems (DRPs) are substantial causes of hospital admissions to the Emergency Department (ED). It is estimated that approximately 5 to 35% of hospital admissions are due to DRPs. However, little is known about the incidence, preventability and severity of DRPs resulting in ED visits in Hong Kong. Besides, delayed administration of analgesia is another DRP due to the overcrowding in EDs. Literature reviews have shown that advanced trained pharmacists may support the clinical workload of ED, especially in pain management. Hence, we sought to evaluate the incidence, severity, preventability and types of drug-related visits to ED as well as the impact of pharmacist in acute pain management through multidisciplinary model in the setting of Hong Kong. There are two chapters of this study. For chapter one, a retrospective, observational study was performed by reviewing the electronic patient records of 2,000 samples in a teaching hospital of Hong Kong over eight-month period. An emergency physician and a pharmacist were responsible for assessing and classifying all cases. For chapter two, we undertook a pre-intervention trial (September-October 2016) and post-intervention trial (November- December 2016) in the ED of the Queen Mary Hospital (QMH). The intervention comprised development and implementation of a comprehensive Pharmacist-Initiated Analgesia Pathway (PIAP), in which the pharmacist was authorized to assess and administer paracetamol to eligible patients prior to doctors’ consultations. The primary outcome was patient satisfaction towards ED pain management during their stays in the department. Secondary outcomes were time to analgesia and the reductions in the pain scores at different time points after the dosing of paracetamol. We included 1,849 cases (mean age, 65.9 years; female 57.6%). Of these, 127 cases (6.9%; 95% Cl 5.74-7.28%) were deemed drug-related. 57 cases of these 127 cases (44.9%; 95% Cl 36.25-53.55%) were considered preventable. Severity was classified as mild in 19 cases (15.0%; 95% Cl 8.8-21.2%), moderate in 98 cases (77.2%; 95% Cl 69.9-84.5%) and severe in 6 cases (4.7%; 95% CI 1.03-8.41%). The most common reasons of DRP ED visits were ADRs and nonadherence, whereas the most common inflicting medications were anti-diabetics (21.2%) and cardiovascular agents (44.9%). For chapter two, 55 patients were enrolled in both the pre- and post-intervention periods. Patient sex, mean age and triage pain score did not differ significantly between the groups (p > 0.05). At post-intervention, the proportion of parents who was satisfied or very satisfied with their overall pain management trended upwards was 88.9% vs. 52.8% at pre-intervention periods (p<0.05). The median time to analgesia was significantly reduced (33 min vs 173 min; p < 0.001). A significant portion of ED visits (about 7 in 100 ED visits) was attributed to DRPs of which most 44.9% were preventable. The PIAP significantly reduced waiting the lag time to analgesia, which was also associated with higher levels of patient satisfaction. Strategies should be provided to minimize the occurrence of preventable DRPs and pharmacists may enhance the pain management in the ED in Hong Kong.