CHAPTER 11

Traditionally, the inpatient or institutional pharmacist performs medication order entry and/or verification. A provider will write an order. Thereafter, the pharmacist reviews the written order and enters it into the pharmacy system so that it may be prepared for dispensing by the pharmacy staff. If the hospital has Computerized Practitioner Order Entry (CPOE), a provider will enter the order directly into the pharmacy system; the pharmacist is then able to review and verify the electronic order, allowing the pharmacy staff to prepare the medication for dispensing. The pharmacist who is entering and/or verifying the medication order goes through a process that ensures the medication is safe and appropriate for the patient. This safety step is especially important in patients on medications for arrhythmias such as AF. In addition to being prescribed antiarrhythmic agents, these patients are often also on anticoagulants, which further complicates their medical regimen. When a pharmacist verifies a prescription, he or she looks at a variety of potential issues, including but not limited to appropriateness of choice, dose, dosage form and schedule, allergy, drug–drug and drug–disease interactions, and risk of side effects. The patient’s medical record is reviewed to verify current medications, allergies, laboratory results that may impact drug choice, dose, route and schedule, past and current medical issues, and any other medical testing that has been done or is scheduled. If there are any concerns or problems, the pharmacist will contact the prescribing provider to rectify the issue. Once the medication order is verified, the pharmacy staff can prepare the drug to be dispensed. Once the drug is prepared, a pharmacist inspects the drug to ensure proper dispensing of oral agents and to ensure proper manufacturing of intravenous medications. Thereafter, it is sent to the patient’s floor to be administered to the patient. As many medications related to AF treatment are high-risk medications, these are only some of many steps that are taken to ensure medication safety.

Antiarrhythmic agents are discussed comprehensively in previous chapters. From the pharmacist’s perspective, certain antiarrhythmic agents, particularly class III antiarrhythmics such as dofetilide and sotalol, commonly used to treat AF, require renal dosing to ensure efficacy and safety. In particular, QT interval prolongation and subsequent polymorphic ventricular tachycardia are potential serious and possibly fatal adverse effects. A small pharmacist-conducted study evaluating proper dosing of sotalol in a community hospital found that pharmacists identified 89% of sotalol orders as improperly dosed by nonpharmacist providers, mostly due to patients’ poor renal function, and almost half of those patients were experiencing signs of toxicity.1 There is an opportunity to use the knowledge base and availability of pharmacists to remedy this situation. Pharmacists are the perfect resource to evaluate patients’ renal function and to determine the need to renally dose medications. Many hospitals currently employ pharmacist-run renal dosing services. Additionally, many medications interact with antiarrhythmics, which may lead to an increase in the risk of adverse effects. A common example is the interaction of antibiotics that prolong the QT interval with class III antiarrhythmics. As a result, the pharmacist may offer a different antibiotic choice for a patient on amiodarone. Similarly, there are agents that are used for agitation that also may prolong the QT interval. Suggesting an alternative agent for agitation in a patient on an antiarrhythmic residing in the ICU is an important safety measure.

Patients with AF may require some form of anticoagulation based on their CHADS₂ or CHA₂DS₂-VASc score, and many hospitals have moved to pharmacist-run anticoagulation services. Current data demonstrates that hospitals with pharmacist-run heparin dosing services report a lower mortality rate, less bleeding complications, shorter length of stay and lower Medicare costs than hospitals without the same pharmacy services.2 Because of the many complicated medication situations that AF patients encounter while hospitalized, pharmacists play a vital role in ensuring their proper care. Further discussion regarding anticoagulation, particularly novel agents, is reserved for another chapter.

Patient Care Team

In the 2010 AHA Scientific Statement regarding Medication Errors in Acute Cardiovascular and Stroke Patients, the AHA specifically recognizes and endorses the involvement of pharmacists in interdisciplinary cardiovascular and intensive care unit patient-care rounds.³ This endorsement is supported by data that describes an increase in recognition and tracking of medication errors when a pharmacist is a member of the interdisciplinary team.^4,5 Additionally, there is a decrease in adverse events caused by medication errors when a pharmacist is involved in direct patient-care in the intensive care unit.⁶ Having a pharmacist function as part of the patient care team along side the physician, nurse, and other healthcare providers allows for direct patient contact and education and real-time medication interventions that can save time and resources; this interaction been shown to improve patient outcomes without causing harm.⁷

Education of Providers and Patients

Not only are pharmacists the medication safety experts, they also are a vital source of education to both the medical team and the patient. Pharmacists are well trained to respond to specific drug information questions in a timely and efficient manner. Additionally, pharmacists often provide physicians and other medical staff members with information services pertaining to new medications. This unbiased form of education is vital to improving medication use especially in patient populations such as those with AF.

As previously mentioned, patients with AF are often placed on complex medication regimens. Early in the hospitalization, a pharmacist can educate the patient on what acute medications have been prescribed and how they may differ from the patient’s home regimen. A 2013 pilot study evaluated the effect of daily medication education by a pharmacist on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.8 HCAHPS can be thought of as a patient satisfaction survey regarding hospital care that has been implemented by the Center for Medicare and Medicaid (CMS) to aid in assessing providers and health-system compliance with reimbursement criteria. Medication education is one main criterion assessed by the HCAHPS survey. The study demonstrated a significant improvement in medication communication, and specifically medication side effect communication, when a pharmacist counseled patients daily during their hospitalization versus once on admission.⁸ This highlights how important patients perceive medication education to be, and that consistent education from a pharmacist during a hospitalization can improve patient understanding and satisfaction. There is also evidence that suggests when pharmacists conduct medication reviews, educate patients at discharge, and follow up with discharged patients via phone, there is a decreased rate of preventable adverse drug events at home.⁹

Medication Reconciliation

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