PharmVisit: Reducing medication-related problems through an interprofessional ward round process in acute geriatric care – a quality improvement project

STUDY AIMS: Older adult patients admitted to hospital are often multimorbid, polymedicated and thus more susceptible to medication-related problems. To improve medication safety for this patient population, the University Hospital of Bern’s Department of Geriatrics hosts clinical pharmacists on its ward rounds as part of an interprofessional collaboration project called PharmVisit. This study aimed to describe the interventions recommended by those clinical pharmacists and their rates of acceptance by physicians. METHODS: The PharmVisit pilot project involved geriatricians and clinical pharmacists separately preparing for weekly ward rounds. Pharmacists used a checklist for medication reviews and the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA) classification tool for characterisation of recommendations. All patients residing on the ward during the study period were included. Outside the patient’s room, clinicians and pharmacists, accompanied by a nurse, discussed the ongoing drug therapy and recommended beneficial medication adjustments resulting from the re-evaluation of treatment indications, potential drug-drug interactions, dose adjustments, optimised dosages and forms of administration, and medication omissions. Afterwards, all the parties, including the patient, discussed the medication changes at the bedside. Type and number of recommendations by clinical pharmacists were tabulated as primary outcomes. Acceptance rate as a secondary outcome was calculated based on the number of pharmacists’ recommendations compared to the number of prescriptions adapted directly during ward rounds. RESULTS: From July 2023 to April 2024, 46 ward rounds were documented, resulting in 480 recommended interventions for 221 patients. The top reasons for recommending interventions, categorised according to the GSASA tool, were dosing issues (17%), medication omissions (15%) and no apparent indication (13%). Clinical pharmacists made the most recommendations on issues involving pain medication (analgesics and opioids, 4% and 2%, respectively), laxative drugs (4%), proton-pump inhibitors (4%), hypnotics and sedatives (2%), and drugs for obstructive airway diseases (2%), reflecting the most problematic drugs identified in studies nationally and internationally. The overall acceptance rate of PharmVisit recommendations was 54%. An additional 33% of recommended interventions were referred to a senior physician for a decision or to the primary care provider in the discharge letter. The most frequently and directly accepted intervention recommendations were optimising administration modalities (77%), medication exchange or substitution (71%) and medication discontinuation (62%). CONCLUSION: This project emphasised how including clinical pharmacists in interprofessional ward round teams enabled the integration and consideration of more viewpoints on different aspects of drug therapies, facilitating a more critical debate on medication therapy decisions. Because older adult patients are at an elevated risk of medication-related problems, especially the high acceptance rate of deprescribing, recommendations suggest that PharmVisit is a meaningful means of reducing potentially inappropriate medications.