Purpose Two to seven percent of the German adult population has a renal impairment (RI) with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m². This often remains unrecognized and adjustment of drug therapy is lacking. To determine renal function in clinical routine, the CKD-EPI equation is used to calculate an indexed eGFR (ml/min/1.73m²). For drug dosing, it has to be individualized to a non-indexed eGFR (ml/min) by the patient’s body surface area. Here, we investigated the number of patients admitted to urological wards of a teaching hospital with RI between July and December 2016. Additionally, we correctly used the eGFR_non-indexed for drug and dosage adjustments and to analyse the use of renal risk drugs (RRD) and renal drug-related problems (rDRP). Methods In a retrospective observational study, urological patients with pharmacist-led medication reconciliation at hospital admission and eGFR_indexed (CKD-EPI) of 15–59 ml/min/1.73m² were identified. Indexed eGFR (ml/min/1.73m²) was recalculated with body surface area to non-indexed eGFR (ml/min) for correct drug dosing. Medication at admission was reviewed for RRD and based on the eGFR_non-indexed for rDRP, e.g. inappropriate dose or contraindication. Results Of 1320 screened patients, 270 (20.5%) presented with an eGFR_indexed of 15–59 ml/min/1.73m². After readjustment, 203 (15.4%) patients had an eGFR_non-indexed of 15–59 ml/min. Of these, 190 (93.6%) used ≥ 1 drugs at admission with 660 of 1209 (54.7%) drugs classified as RRD. At least one rDRP was identified in 115 (60.5%) patients concerning 264 (21.8%) drugs. Conclusion Renal impairment is a common risk factor for medication safety in urologic patients admitted to a hospital. Considerable shifts were seen in eGFR-categories when correctly calculating eGFR_non-indexed for drug dosing purposes. The fact that more than half of the study patients showed rDRP at hospital admission underlines the need to consider this risk factor appropriately.

A 'renal pharmacist consultant service' (RPCS) reviewing patients' charts with renal impairment (RI) for drug-related problems (DRP) can foster patient safety. However, the benefit of this service in the new setting of a computerized physician order entry (CPOE)-system with a clinical decision support (CDS)-system is unknown. The aim of our study was to evaluate the general need for an RPCS on wards with a CPOE-CDS-system already in use and its effectiveness on prescription changes to ensure in-hospital patient safety. Over a period of 3 months (02-04/2021), elective orthopaedic and trauma patients with eGFR_absolute /CrCl <60 ml/min at a German University Hospital received a medication review by a renal pharmacist for all medication entered into the CPOE-system (Meona®) by the treating physicians. Written consultations explaining identified DRP and recommending interventions to solve them, for example, dose or drug adaptation, were shared with the physicians directly in the drug chart tab of Meona®. In complex cases, DRP were additionally discussed via phone. The prescription changes were evaluated retrospectively. During 53 working days, 712 (30.5%) of 2331 screened patients were included with an eGFR_non-indexed /CrCl <60 ml/min and a pharmacist-led medication review was performed for all medication presented in the CPOE-system (Meona®). In 79 of 712 (11.1%) patients, one or more DRP were detected (median 1 DRP (1-3) per patient) and written recommendations concerning 106 of 1090 (9.7%) drugs were shared via Meona®. In total, 104 DRP were identified, mostly caused by 'dosage too high' (n = 55, 52.9%), 'dosage regime wrong' (n = 13, 12.5%), and 'contraindication' (n = 9, 8.7%). Acceptance rate of recommendations was 74.0% (n = 77/104). In nine cases (8.7%), despite of specific recommendations, no adjustment of drugs was made because of lack of alternatives. In 11 (10.6%) cases, prescription remained unchanged for unknown reasons and in seven (6.7%) cases, the result was unknown due to discharge. In the setting of prescribing in a CPOE-CDS-system, that provides physicians with advice for drug or dose adaption, the pharmacist-led medication reviews still identified DRP in orthopaedic and trauma patients with RI. A RPCS forwarding recommendations to solve DRP via the electronic medical record increased appropriate prescribing by physicians and, thus, may further improve patient safety.

Purpose Postoperative delirium (POD) is a common complication in older adult patients after surgery. A patient’s preoperative anticholinergic (AC) burden is a potentially modifiable risk factor for POD. As the influence of the drug dose remains unknown, we aimed to compare three AC burden scores in relation to POD, two of which were dose-related. Methods This retrospective cohort study (03/22–10/22) included orthopaedic and trauma surgery patients > 65 years. POD was assessed using the four A’s test (4AT), delirium diagnosis, and chart review. The AC burden was determined using the non-dose-related German Anticholinergic Burden score (GerACB), an extension of the dose-related Muscarinic Acetylcholinergic Receptor ANTagonist Exposure scale (extMARANTE), and the dose-related German Drug Burden Index (GerDBI). Multivariable logistic regression analysis determined the association between the preoperative AC burden and POD. Scores were compared using kappa statistics, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results POD was observed in 71 of 385 patients (18.4%). For all three scores, a high AC burden was significantly associated with POD after adjusting for age, sex, dementia, preoperative physical status, and number of prescribed drugs (p < 0.001). The overall agreement among the burden classifications was substantial (no POD: κ = 0.645, POD: κ = 0.632). The GerACB had the lowest sensitivity with 23.9% (extMARANTE: 42.3%, GerDBI: 40.8%), but the highest PPV with 48.6% (extMARANTE: 38.5%, GerDBI: 43.3%). Conclusion Both dose-related and non-dose-related AC burden scores have limited sensitivity and modest PPV for screening a patient’s medication for POD. However, given the additional effort required for dose consideration, the non-dose-related GerACB remains sufficient in clinical practice, with the lowest sensitivity but highest PPV.

Background: Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients. Methods: Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A’s test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established. Results: POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66–75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m², 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively. Conclusion: The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.

Background/Objectives: QTc prolongation can result in lethal arrhythmia. Risk scores like the Tisdale score can be used for risk stratification for targeted pharmaceutical interventions. However, the practical usability across different medical specialties has not been sufficiently investigated. The aim of this study was to compare relevant risk factors for QTc prolongation and to investigate the use of the Tisdale score in cardiology and gastroenterology patients. Methods: For patients on a cardiology and a gastroenterology ward receiving a weekly pharmaceutical electronic chart review, risk factors for QTc prolongation, QTc-prolonging drugs, and electrocardiograms (ECGs) were retrospectively collected for a four-month period (07-10/2023), and the Tisdale score and its sensitivity and specificity were calculated. Results: A total of 627 chart reviews (cases) (335 cardiology, 292 gastroenterology) were performed. The median age was 66 (range 20–94) years, and 39% (245) of patients were female. The presence of established risk factors (hypokalemia, renal impairment, age ≥ 68 years, cardiac diseases) differed significantly between the specialties. A median of 2 (range 0–5) QTc-prolonging drugs were prescribed in both groups. Baseline and follow-up ECG were recorded in 166 (50%) cardiology cases, of which prolonged QTc intervals were detected in 38 (23%) cases. In the 27 (9%) gastroenterology cases with baseline and follow-up ECG, no QTc prolongations were detected. Across both specialties, the Tisdale score achieved a sensitivity of 74% and a specificity of 30%. Conclusions: The presence of established risk factors for QTc prolongation differed significantly between cardiology and gastroenterology cases. The Tisdale score showed acceptable sensitivity for risk stratification; however, the limited availability of ECGs for gastroenterology cases was a limiting factor.