Table 2 Description of pharmacist interventions
Author (year) | Pharmacist intervention | Focus of the intervention | Recipients | Mode of contact | Methods of communication | Settings | Pharmacy contact (frequency) | Data source | Source guide for intervention | Supporting materials |
|---|---|---|---|---|---|---|---|---|---|---|
AbuRuz et al. [33] | ▪ Attending and discussing during medical rounds ▪ Follow-up of patient daily to resolve or prevent DRPs ▪ Discharge medication counselling | N/A | Patients | Contact with group (medical staff and patients) | ▪ Face to face | ▪ Hospital bedside | On or during patient admission, on discharge (continuous) | EMR | Up-to-date guidelines | None |
Bansal et al. [38] | ESMOS services ▪ Patients are reviewed in a virtual pharmacist clinic whereby patients’ pre‐existing medical comorbidities are recorded along with any high‐risk medication the patient is taking ▪ In the postoperative phase, close monitoring on the ward with the focus being on medicines optimization to minimize the incidence of any postoperative complications occurring ▪ Collaboratively work in multidisciplinary teams | N/A | Patients | One on one | ▪ Preadmission telephone ▪ Postadmission face to face | ▪ Preadmission recipient home ▪ Postadmission Hospital bedside | One time before admission and throughout the admission (continuous) | EMR | Always events toolkit by the NHS | None |
Chen et al. [39] | ▪ Quarterly lecture on rational use of PPIs to medical staff ▪ Rounds attendance and medication recommendations ▪ Interception of irrational PPI use ▪ Daily prescription audits and communicated with doctors and provides feedback ▪ Enlisting all essential monitoring drugs and checked medical records every month ▪ Monitoring of PPI-related ADR | PPI | Patients, medical staff | One on one (patient), contact with group (surgical team) | ▪ Face to face, written | ▪ Hospital bedside | On or during patient admission (continuous) | EMR | The PPIs Review Guidelines of the Second Affiliated Hospital of Fujian Medical University | None |
Falconer et al. [40] | ▪ Patient identification by surgery team ▪ Consultation to pharmacy (medication history documentation, documentation of patient preferred pharmacy, reconciliation of home and inpatient medications for hospital admission, recommend changes for medications as indicated, and provide patient education regarding proposed changes) ▪ Assigned clinical pharmacist to perform face-to-face inpatient consultation ▪ Standardized documentation and communication of recommendations with surgery team | N/A | Patients | Contact with group (medical staff and patients) | ▪ Face to face | ▪ Hospital bedside | On or during patient admission, on discharge (continuous) | EMR | Primary literature review, institutional expert opinion, drug information from databases | None |
Fitzpatrick et al. [28] | ▪ Review of electronic notes ▪ Phone call with patients to confirm history, demographics, answer patient’s questions, and involve patient in shared decision-making ▪ Discussion with the surgical team to highlight or resolve perioperative medical issues ▪ Individualized discharge prescription written, emailed, dispensed, and supplied to wards before patient admission | VTE prophylaxis, NSIADs, QTc prolonging medications | Patients | One on one (patient), contact with group (surgical team) | ▪ Face to face, telephone, written | ▪ Recipient home | 1–2 weeks before admission, 7–10 days post discharge (twice) | NHS (VPN), (ARISE) dataset in Scotland | Evidence-based guideline produced in collaboration with surgical MDT team, health board guidance for VTE risk assessment and procedures | None |
Hale et al. [34] | ▪ Usual pharmacy care in addition to prescribing (continuing, discontinuing, and initiating medications with co-signature of physician | N/A | Patients and physicians | One on one | Face to face | Hospital (bedside and outpatient clinic) | Pre-operative (once) | Medication chart | Clinical guidelines and hospital VTE prophylaxis guidelines | None |
Han et al. [41] | ▪ A clinical pharmacist integration into the bariatric surgery clinic (as part of every patient’s preoperative clinic evaluation) ▪ A onetime 30- to 60-min meeting with the pharmacist prior to meeting with the surgeon ▪ Obtained medication histories and provided recommendations to patients and the team on perioperative medication management ▪ Resolved any potential DRP (e.g., medication absorption after bariatric surgery) ▪ Provided medication education to the patient | N/A | Patients | One on one | Face to face | Hospital (clinic) | Before admission (only once) | NR | NR | None |
Kwan et al. [35] | Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) ▪ Conducted a standardized comprehensive medication history interview and assessment focusing on the patient’s current home medication regimen in the preadmission clinic ▪ Description of any issue was written in the medical record to be considered by the surgeon ▪ Conducted telephone interviews with patients they were unable to see in the clinic ▪ After postoperative admission, verified with the patient if any medication changes had been made since the clinic assessment | N/A | Patients | One on one | Face to face or telephone if patient did not attend the clinic | Hospital (clinic), recipient home (by telephone) if patient did not attend the clinic | Before admission and postoperative admission, if possible (once or twice) | Patient history taking, if needed the pharmacist contacted community pharmacy or family physician | Not reported | Preprinted postoperative medication order form, EMR |
Léguillon et al. [29] | ▪ Medication’s review (within 72 h of admission) ▪ Pharmaceutical synthesis (summarized pharmaceutical plan with proposals) ▪ Dedicated meetings with geriatricians | N/A | Patients, geriatrician | One on one (patient, geriatrician) | Face to face | Hospital bedside | On or during patient admission (continuous) | EMR | STOPP/START, Medication appropriateness Index, French guideline | None |
Luo et al. [30] | ▪ Provide educational sessions and handouts about SUP for medical teams ▪ Collect information about the patient from the EMR and HIS ▪ Judge appropriateness of prophylactic acid suppressant use on: indication, selection, dose, duration of prophylaxis, combination, and replacement depending on the criteria ▪ Communicates immediately with the prescriber with their recommendation if any ▪ Report to the hospital administration every week | Omeprazole, lansoprazole | Physicians | One on one | Face to face | Hospital | On or during patient admission (as needed) | EMR | Hospital protocol | None |
Marotti et al. [25] | ▪ Document medication history or document medication history and prescribe | Beta-blockers, statins, antiplatelets, anticoagulant | Patients | One on one | EMR, telephone, fax | Hospital | Pre-operative (once) | EMR | Hospital protocol | None |
Nguyen et al. [27] | ▪ PREP pharmacist contacted patients via telephone 1 week prior to surgery to obtain BPMH and reconcile medications ▪ After surgery, a surgical pharmacist was provided with a handover from the PREP pharmacist for continuation of care ▪ The surgical pharmacist would verify the BPMH ▪ Confirmed MRF is generated by the pharmacist ▪ At discharge, the PREP pharmacist prepared discharge prescriptions for the patients, which is then checked and signed by the doctor | OTC products, cardiovascular medications, and analgesics | Patients | One on one | Telephone | ▪ First contact: recipient home ▪ Second and third contact: hospital bedside | Before admission by the PREP pharmacist, on admission, and before discharge by the surgical pharmacist (three times) | NR | NR | Medication reconciliation form, EMR, handover form |
SUREPILL Study Group [26] | ▪ Medication reconciliation ▪ Consultation with the patient using a standard questionnaire ▪ Reviewing medication chart and optimizing medications when needed ▪ Performing interventions with liaison with the physician ▪ Weekly patient meetings (when possible) ▪ Reviewing discharge medications ▪ Patient counselling about the medications | N/A | Patients and physicians | One on one | Face to face | ▪ Hospital | On or during patient admission, on discharge (continuous) | EMR & patient history taking | Hospital protocol | None |
Van Prooyen et al. [36] | ▪ Completion and documentation of a medication history ▪ Review of the home medication list for needed postsurgical medication changes ▪ Creation of a discharge medication plan based on a defined protocol ▪ Documentation of the recommended discharge medication plan in a consult note ▪ Patient education outlining the discharge medication plan | Extended release or other noncrushable formulations, NSAIDs, loop diuretics | Patients, surgeons | One on one (patient, Doctor) | Face to face, written, telephone | Hospital bedside | Post-operative day 1 (once, patient and as needed for physicians) | EMR | Institutional protocol based on guideline recommendation, primary literature review, drug information databases, and the team’s expertise | None |
Yang et al. [42] | ▪ Direct patient care and medication management during hospitalization ▪ Reviewing medication regimens, resolving DRPs and medication reconciliation ▪ Answering drug information questions ▪ Therapeutic drug monitoring (TDM) ▪ Making therapeutic recommendations ▪ Patient education | N/A | Patients | One on one (patient), contact with group (medical team) | Face to face | Hospital bedside | On or during patient admission (continuous) | Not reported | Not reported | None |
Zhang et al. [37] | ▪ Participation in daily medical rounds and clinical duties ▪ Targeted educational interventions for medical staff | PPI | Patients, medical staff | Contact with group (medical staff and patients) | Face to face | Hospital bedside | On or during patient admission (continuous) | EMR | Martindale: The Complete Drug Reference (39th), New Materia Medica, drug instructions, American Society of Health-System Pharmacists criteria and Expert consensus on the application of PPIs | None |