Medication management at the discharge of hospitalization: Should a co-pilot be in the plane?

Background The clinical pharmacist has proved value of collaboration at admission and during hospitalization to optimize patient drug management. Short hospitalization and changes of treatment, might justify pharmaceutical support at discharge. Purpose Assess the relevance of a future pharmaceutical collaboration to support the discharge and promote the hospital-city link. Methods A 50-day retrospective study at the discharge of patients over 65 years old from a cardiology unit. After analysis of hospital prescriptions, a pharmacist retrospectively analyzed the clinical relevance of the treatments of medication order and discharge letters. The match between information was verified and different criteria were compared with validated indicators. Results A total of 75 patients were included (Median of stay: 2 days [1;15]). Reasons for hospitalization were angiography (30), ACS (11), PCI (9) and preoperative assessment (10). The average number of treatments at discharge was 8. Seventy five hospital discharge letters and 68 orders found were analyzed. Seventy five patients had their chronic treatments adapted and explained in 57% of case. Dual antiplatelet therapy (DAPT) was prescribed for 36 patients. The duration was mentioned in 67% of the discharge letters. Betablockers (BB) and ACE inhibitors were introduced for 13 and 16 patients. The recommendations for doses titration was mentioned in BB = 38% ACE inhibitor = 31%. Lipid profile was performed for 63 patients and when it was appropriated, drug adjustment was realized for 86% of them. Discharge orders were analyzed: 100% were not in accordance with the legislation and 93 Pharmaceutical Interventions (PI) were made. The main PIs concerned the lack of explicit indication of DAPT prescriptionu0027s duration (30), chronic treatments not renewed (27) or overdosages (10) Ccl. This study highlights the potential interest of the pharmacistu0027s collaboration to optimize the patientu0027s medication management and improve the transmission of information to liberal practitioner.