The Effects of an Intervention to Optimise Quality Use Of Medicines In Older People in Hospital

A multifaceted tool bundle including computerised decision support to measure exposure to medications with anticholinergic and sedative effects (Drug Burden Index [DBI]) in the electronic medical record (EMR) was developed to guide patient-centred medication review in older patients in hospital. The intervention is the combination of a DBI stewardship program with the multifaceted tool bundle that is available for use by the multidisciplinary team. The intervention includes: 1. Prioritise patients for medication review based on Drug Burden Index score (DBI>0). The DBI Calculator in the EMR presents the patient’s DBI score on the patient’s EMR MPage and in the pharmacist’s patient list on the Pharmacy Care Organiser; 2. Support and guide medication review in hospital using: (i) The DBI EMR MPage, which provides detailed information on the patient’s DBI throughout the admission; (ii) Education and guides for clinicians and consumers (an eleven minute online video Health Education and Training Institute [HETI] Polypharmacy Module available to NSW Health staff via https://www.heti.nsw.gov.au/education-and-training/my-health-learning, online pdf clinician deprescribing guides and consumer deprescribing leaflets, developed in related project and available from https://www.nswtag.org.au/deprescribing-tools/); and (iii) Monitoring and feedback using NSW Therapeutic Advisory Group [TAG] Polypharmacy Quality Indicators developed in related project and available from https://www.nswtag.org.au/polypharmacy-qum-indicators-and-resources/ The Steward is a research pharmacist who will provide education on the bundle through usual professional development channels (departmental and hospital clinical meetings and continuing education meetings) for doctors, nurses and pharmacists at each site. The Steward will flag potential drugs to consider deprescribing in eligible patients to clinicians and provide support for clinicians when using the intervention materials (for example, twice weekly to daily telephone calls with the doctors, attendance at wards rounds and/or meetings related to patient care, and documentation of deprescribing recommendations in the hospital electronic medical record). The Steward’s workflow may vary slightly between sites as clinician input (including through Hospital Working Groups) on how to best integrate the Stewardship and the multifaceted bundle into their usual workflow will be sought, primarily in the last week of the control period and first week of the intervention period for each hospital site. Hospital Work Group membership will vary depending on each site, however, it is envisaged that each Group will consist of an Executive Sponsor, the Site Principal Investigator, the Director of Pharmacy (or delegate senior clinical pharmacist), the Steward and nominee senior and junior clinicians, clinical pharmacist and nursing staff from each target ward. The Steward may shadow Working Group members and/or their delegates to observe the workflow processes in target services and make notes on his/her observations. Prior to implementation of the bundle, all hospitals will receive standard pharmaceutical care in hospital. This should include medication reconciliation and medication review of patients perceived to be at high risk using local risk assessment strategies. Electronic medical record data will be collected for 12 weeks as pre-trial baseline data. After the 12 week pre-trial data period, the hospital sites will be randomised to commencing the DBI stewardship program at different times, with one hospital transitioning from the control (bundle only) to the intervention (DBI stewardship program and bundle) every 6 weeks in the stepped wedge trial period. The DBI Stewardship will begin as an intensive program for the first 12-week time block at each hospital site and then transition to a less intensive program to capture the sustainability of the DBI Stewardship in the remaining period of the stepped wedge trial period (12 to 42 weeks depending on when the hospital was randomised to start the DBI Stewardship Program). In the less intensive program, the Steward will shift focus from provision of patient-specific deprescribing recommendations to reminders about using the bundle. A purposely chosen cohort of participants who are representative of the variety of patients/carers, hospital clinicians and general practitioners will be recruited to participate in the mixed methods analysis (self-administered questionnaire and interview or focus group) to evaluate the enablers and barriers of the intervention.