The aim of this study is to evaluate the impact of an enhanced collaboration between a hospital pharmacist and a community pharmacist during hospital discharge. For patients taking multiple medications, hospitalization often involves numerous changes to their treatment regimen. For community pharmacies, discharge prescriptions are often complex, and they sometimes lack the information that pharmacists need to deliver the treatment as safely as possible. As a result, there is a risk of medication errors, and a risk for patients. We aim to evaluate the benefits of this collaboration for adult patients admitted to the internal medicine ward of a regional hospital who are taking seven or more drugs and are being discharged to home.
The main question it aims to answer is : Does the enhanced collaboration reduce the number of drug-related problems encountered by community pharmacists with discharge prescriptions ? Researchers will compare patients when a hospital pharmacist is involved during the discharge process and when he or she is not involved, which corresponds to normal care.
The hospital pharmacist will not perform the intervention directly on the patient, but only with the community pharmacy. Once they agree to participate in the study, patients will only have to go to their usual community pharmacy after discharge and accept that the hospital transmits medical information to their usual pharmacy.
Patients admitted to the internal medicine ward for more than 48 hours
Patients prescribed seven or more drugs at the time of screening
Patients discharged to home
Patients able to give informed consent as documented by signature
Patient discharged to another hospital, nursing home or rehabilitation clinic
Refusal of the community pharmacy to participate
Inability to sign consent and follow the procedures of the study, due to language problems, psychological disorders, dementia, alterations of consciousness and lack of judgement
Parallel
Support of the hospital pharmacist for the medication management at hospital discharge
Other intervention1\) The hospital pharmacist calls the community pharmacy the day before discharge to order unusual or specific medications 2) The day of discharge, the hospital pharmacist performs a medication reconciliation in collaboration with the hospital physician 3) Once completed, the discharge prescription is sent to the community pharmacy before the patient is discharged. 4) The hospital pharmacist calls the community pharmacy to provide additional information about the patient and the prescription and to answer any questions. Additional information will help the community pharmacist to understand the prescription : administrative data, clinical data, medication-related information, patient follow-up and patient concerns.
Number of drug-related problems on the hospital discharge prescription
Community pharmacists will assess the number of drug-related problems (DRP) on the discharge that they faced when preparing the discharge medication. They will have to use the PharmDISC system, which is a validated tool for referencing drug-related problems faced in the community which was adapted from the drug-related problems classification system of the Pharmaceutical Care Network Europe (PCNE). Community pharmacists will also document the intervention performed for each DRP, and the resolution (yes/no) of the DRP.
Patient's satisfaction
Patients' satisfaction related to their visit at the pharmacy after hospital discharge will be assessed using a questionnaire. Patients will be contacted via email or telephone
Community pharmacists' satisfaction
The satisfaction of community pharmacists with the service provided by the hospital pharmacist at patient discharge will be evaluated
30 day readmission rate
Number of participants with hospital emergency department visits and hospital readmission in the same hospital within 30 days of discharge
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