Hospital Pharmacy

Polypharmacy, often defined as taking five or more medications at the same time, has been associated with a variety of adverse health outcomes. Therapy with a medication is initiated when the patient and care team conclude that the benefits of taking the medication outweigh the risks of not starting therapy. However, over time, patients and their conditions or goals of care change, new evidence is discovered, and other factors can tip the balance, such that the benefits no longer outweigh the risks or burdens of continued treatment. Few, if any, medications should be continued on a lifelong basis. Patients and caregivers should be made aware of the planned duration of therapy and the outcomes desired, and should feel empowered to follow up with providers to ensure that the benefits of therapy continue to outweigh the risks. The performance of medication reconciliation and transitions of care—such as admission to or discharge from a hospital—may serve as critical activities for deciding whether to continue therapy or create a plan to safely stop a medication.

Sources:

Barnsteiner JH. Medication Reconciliation: Transfer of medication information across settings-keeping it free from error. Am J Nursing. 2005 Mar; 105(3 Suppl):31-36.

Bootsma N, et al. Deprescribing: Managing Medications to Reduce Polypharmacy. Institute for Safe Medication Practice Canada. [Internet]. 28 Mar 2018. [Accessed 17 Jul 2018].

Cipolle RJ, et al. Pharmaceutical care practice: the patient-centred approach to medication management services. 3rd ed. New York: McGraw-Hill; 2012.

De Vries, TPGM, et al. “Step 6: Monitor (and stop?) the treatment”. Guide to good prescribing: a practical manual. Geneva: World Health Organization. 1994:79-83. [Internet].

Garfinkel D, et al. Routine deprescribing of chronic medications to combat polypharmacy. Ther Adv Drug Saf. 2015 Dec;6(6):212-233. PMID:26668713.

Halapy H, et al. Ascertaining Problems with Medication Histories. Can J Hosp Pharm. 2012 Sep;65(5):360-367. PMID:23129864.

ISMP Canada. Five Questions to Ask about your Medications. [Internet]. [Accessed 20 Dec 2018].

The “time to benefit” is the period between initiation of an intervention (in this case, a medication) and the point when the patient begins to experience a benefit. This period varies from one medication to another. Treatment with a medication is usually not indicated unless the “time to benefit” is clearly shorter than the patient’s life expectancy and any potential adverse effects are deemed manageable. These factors are particularly relevant for older adults and those receiving palliative care.

 Sources:

Holmes HM, et al. Rationalizing Prescribing for Older Patients with Multimorbidity: Considering Time to Benefit. Drugs Aging. 2013 Sep;30(9):655-666. PMID:23749475.

In many cases, a proton pump inhibitor (PPI) is initiated for a valid indication, in cases where the benefits outweigh the risks. During a hospital stay, PPIs may be started for stress ulcer prophylaxis or for patients who will receive certain treatments that increase the likelihood of high-risk gastrointestinal conditions. After the patient’s risk for stress ulcer returns to baseline the PPI should be stopped. In addition, patients who did not require a PPI before their hospital admission typically will not need to continue taking one of these drugs after the underlying reason for PPI therapy has been addressed.

Long-term adverse effects associated with the acid inhibition caused by PPIs are now emerging. Patients should talk to their healthcare team and only continue taking PPIs if the benefits truly outweigh the risks and to obtain advice on how to taper the dose towards discontinuation if warranted.

 Sources:

Boghossian TA, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017 Mar 16;3:CD011969. PMID:28301676.

Cochrane. Stopping or reducing vs continuing long-term proton-pump inhibitor use in adults. [Internet]. 2017 Mar 16. [Accessed 20 Dec 2018].

Deprescribing Guidelines and Algorithms. [Internet]. [Accessed 20 Dec 2018].

Kinoshita Y, et al. Advantages and Disadvantages of Long-term Proton Pump Inhibitor Use. J Neurogastroenterol Motil. 2018 Apr 30;24(2):182–196. PMID:29605975.

Therapeutics Initiative: Independent Healthcare Evidence. Deprescribing Proton Pump Inhibitors. [Internet]. 26 Jun 2018. [Accessed 20 Dec 2018].

Broad-spectrum antibiotics are effective in treating bacterial infections, particularly life-threating infections such as sepsis or febrile neutropenia. In certain high-risk situations, these drugs may be clinically indicated and started at the first signs or symptoms of an infection. Broad-spectrum antibiotics should be stopped as soon as the causative pathogen is known or suspected. Targeted antibiotic therapy should begin as soon as possible. When a broad-spectrum antibiotic is deemed necessary, it should be used for the shortest possible duration, according to guideline recommendations and the patient’s clinical response.

Sources:

Centers for Disease Control and Prevention. Antibiotic Prescribing and Use in Hospitals and Long-Term Care. [Internet]. Updated 11 Apr 2017. [Accessed 29 Jan 2019].

Government of Canada. Antibiotic (antimicrobial) resistance: Protecting yourself and your family. [Internet]. Updated 13 Nov 2018. [Accessed 20 Dec 2018].

Hildreth CJ, et al. Inappropriate Use of Antibiotics. JAMA. 2009 Aug 19;302(7):816.

Isturiz RE. Optimizing Antimicrobial Prescribing. Int J Antimicrob Agents. 2010 Nov;36 Suppl 3:S19-22. PMID:21129628.

Zalmanovici Trestioreanu A, et al. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev. 2015 Apr 8;4:CD009534. PMID: 25851268.

Non-pharmacologic options to treat insomnia, such as sleep hygiene and cognitive behavioural therapy, are less harmful than drugs, and should be first line therapy.

Sources:

Canadian Agency for Drugs and Technologies in Health. Sleep Medications for Adults Diagnosed with Insomnia: Clinical Evidence and Harm. [Internet]. 29 Apr 2013. [Accessed 20 Dec 2018].

Canadian Agency for Drugs and Technologies in Health. Current Practice Analysis: Interventions for Insomnia Disorder. [Internet].  June 2017. [Accessed 20 Dec 2018].

Fick DM, et al. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015 Nov;63(11):2227-2246. PMID:26446832.

Soong C, et al. Less Sedatives for Your Older Relative: A toolkit for reducing inappropriate use of benzodiazepines and sedative-hypnotics among older adults in hospitals. [Internet] July 2017. [Accessed 20 Dec 2018].

Evidence shows that opioids are not more effective than other analgesics for certain chronic pain conditions. Furthermore, evidence is mounting that the risks of opioid treatment, including opioid use disorder, overdose, and other previously under-recognized side effects (e.g., hyperalgesia, psychomotor impairment [which can increase the risk of fractures], myocardial infarction, sexual dysfunction) support the use of non-opioid therapy.

Thorough patient-centred discussion about risks, benefits, and expectations is essential.

Sources:

Busse JW, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666; PMID:28483845.

Busse JW, et al. Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis. JAMA. 2018 Dec 18;320(23):2448-2460. PMID:30561481.

Canadian Agency for Drugs and Technology in Health. Evidence Bundles: Alternatives to Opioids. [Internet]. [Accessed 20 Dec 2018].

Canada Agency for Drugs and Technology in Health. Opioids for the Treatment of Pain. [Internet]. September 2018. [Accessed 20 Dec 2018].

The Institute for Safe Medication Practices Canada. Opioid Pain Medicines Information for Patients and Families. [Internet]. March 2017. [Accessed 20 Dec 2018].

Krebs EE, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872-882. PMID:29509867.

Before prescribing or recommending inhalers, providers should ensure a confirmed objective diagnosis of asthma and/ or COPD exists to reduce unnecessary inhaler use and patient exposure. When inhalers are indicated, consider patient-specific factors and preferences to determine if lower carbon intensive inhaler device(s) (Dry Powder Inhalers (DPIs), or soft-mist inhalers (SMIs)) is clinically appropriate as both are often preferred by patients and are as effective as MDIs. Once a device has been selected, ensure the patient is trained on proper inhaler device technique, and technique is reviewed intermittently, as inhaler education programs have shown to reduce exacerbation rates. Additionally, non-pharmacologic strategies (e.g. education, trigger avoidance, action plans) should also be included in airway management, as they not only improve patient outcomes, but can also reduce rescue inhaler use.
MDIs which contain hydrofluoroalkane (HFA) propellants known to contribute to climate change, account for 0.03% of global gas emissions annually. Thus prescribing low carbon footprint inhalers when medically indicated, ensuring adequate patient inhaler technique and incorporating nonpharmacologic strategies into airway management, can lead to better patient outcomes with environmental co-benefits.

Sources:

Canadian Thoracic Society. Respiratory Medicine: Seven Tests and Treatments to Question. Choosing Wisely Canada, last updated December 2022.

Gupta, S, Couillard S, Digby G, Tse SM, Green S, Aceron R, Carlsten C, Hubick J, Penz E. Canadian Thoracic Society Position Statement on Climate Change and Choice of Inhalers for Patients with Respiratory Disease. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine. 2023. doi: 10.1080/24745332.2023.2254283.

Lee Fidler, Samantha Green and Kimberly Wintemute. Pressurized meter-dose inhalers and their impact on climate change. CMAJ March 28, 2022 194 (12) E460; DOI: https://doi.org/10.1503/cmaj.211747. PMID: 35347049.

Tiago Maricoto, Luís Monteiro, Jorge M.R. Gama, Jaime Correia-de-Sousa, and Luís Taborda-Barata. Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta-Analysis. J Am Geriatr Soc 67:57–66, 2019. https://doi.org/10.1111/jgs.15602. PMID: 30291745.

Optimizing medication usage yields positive clinical outcomes for patients. In 2021, 25% of Canadian older adults were prescribed 10 or more medication classes, leading to polypharmacy and increased healthcare costs, adverse reactions, and potential interactions. Re-evaluating prescriptions to discontinue unnecessary medications can reduce adverse events, healthcare burdens, and enhance quality of patient care. Addressing polypharmacy enhances individual and healthcare system efficiency and sustainability. Furthermore, optimizing medication use reduces pharmaceutical waste and environmental impact. Close to 100000 million tonnes of CO2 emissions are released from unused medications and pharmaceutical waste every year. Medications account for a quarter of carbon emissions within the healthcare sector. By avoiding the prescribing of unnecessary or unindicated prescriptions healthcare providers may contribute to reducing the overall demand for raw materials and energy-intensive processes involved in pharmaceutical production.

Sources:

Canadian Institute for Health Information. Changes in drug prescribing to seniors in Canada. Accessed February 12, 2024.

Duncan P, Duerden M, Payne RA. Deprescribing: a primary care perspective. Eur J Hosp Pharm. 2017;24(1):37-42. doi:10.1136/ejhpharm-2016-000967. PMID: 31156896.

Mangoni AA, Walker LE. Avoiding harm from overprescribing: What are the challenges and how do we overcome them? Br. J. Clin. Pharmacol. Published December 17, 2020. doi:10.1111/bcp.14696. PMID: 33336507.

Richie C. Environmental sustainability and the carbon emissions of pharmaceuticals. J Med Ethics. Published April 14, 2021. doi:10.1136/medethics-2020-106842. PMID: 33853877.

Ensuring proper medication disposal is crucial to minimize health risks, preventing misuse and adverse effects. Less than 1% of patients return unused medication, increasing the likelihood of accidental ingestion by children and pets. Flushing medications down the toilet, a prevalent disposal method, poses risks of antibiotic resistance and water contamination. The improper disposal introduces pharmaceutical residue into water systems, threatening aquatic life. Education on safe disposal and encouraging return to designated collection sites can reduce these risks. Regulatory measures, such as those implemented in British Columbia, aim to address pharmaceutical waste through recycling regulations, highlighting the importance of comprehensive strategies to minimize environmental harm.

Sources:

Afanasjeva J, Gruenberg K. Pharmacists as environmental stewards: Strategies for minimizing and managing drug waste. Sustainable Chemistry and Pharmacy. 2019;13:100164. doi:10.1016/j.scp.2019.100164. ISSN 2352-5541.

Haas C. Environmental Paper Organization. Ending 90 Billion Sheets: The Environmental Impact of Pharmaceutical Paper Waste. 2023; September.

Insani WN, Qonita NA, Jannah SS, et al. Improper disposal practice of unused and expired pharmaceutical products in Indonesian households. Heliyon. 2020;6(7):e04551. Published 2020 Jul 29. doi:10.1016/j.heliyon.2020.e04551. PMID: 32760838.

Owens L, Anand S. MEDICATION DISPOSAL SURVEY Final Report. December 2009. University of Illinois Survey Research Laboratory.

Qadar SMZ, Thane G, Haworth-Brockman M. A Call to Action: An Evidence Review on Pharmaceutical Disposal in the Context of Antimicrobial Resistance in Canada. National Collaborating Centre for Infectious Diseases; January 2021. ISBN: 978-1-927988-68-8.

Reducing paper usage has been shown to minimize the risk of prescription errors. Decreasing paper prevents waste and recycling needs, hence is environmentally beneficial.

Sources:

Haas C. Environmental Paper Organization. Ending 90 Billion Sheets: The Environmental Impact of Pharmaceutical Paper Waste. 2023; September.

Osmani F, Arab-Zozani M, Shahali Z, Lotfi F. Evaluation of the effectiveness of electronic prescription in reducing medical and medical errors (systematic review study). Ann Pharm Fr. 2023;81(3):433-445. doi:10.1016/j.pharma.2022.12.002. PMID: 36513154.

In pharmacy settings, when the risk of body fluids exposure and infection transmission is low, maintaining safety standards in most routine healthcare interactions can most often be achieved by using proper hand hygiene without additional precautions. Do not use gloves in place of hand hygiene or when hand hygiene alone is sufficient. The pharmacy staff should reserve the use of gloves to situations in which the safeguard of pharmacy staff is required due to risk of infection, or to comply with infection prevention and control (IPAC) and National Association of Pharmacy Regulatory Authorities (NAPRA) standards and/or guidelines. Refraining from using latex or nitrile gloves when not medically necessary is an important aspect of environmental stewardship to be considered by healthcare professionals. Minimizing the use of gloves can help reduce environmental waste associated with disposable medical supplies, contributing to sustainability efforts in healthcare facilities. Approximately 500 boxes of gloves were found to emit 2 tonnes of CO2 emissions. Limiting the use of gloves is highly effective in promoting environmental sustainability.

Sources:

CASCADES, Campaigns for appropriate glove use, Quebec campaign – Les gants, pas tout le temps!

Lindberg M, Skytt B, Lindberg M. Continued wearing of gloves: a risk behaviour in patient care. Infect Prev Pract. 2020;2(4):100091. Published 2020 Sep 17. doi:10.1016/j.infpip.2020.100091. PMID: 34368725.

While intravenous (iv) may be required for patients who do not or cannot tolerate oral therapy or for certain medical conditions or medications, iv therapy is associated with several complications.  These include: phlebitis, thrombophlebitis, infiltration, extravasation, and catheter-related infections and bacteremia infections, hematoma, thrombosis, pain or discomfort, and fluid overload in fluid-restricted patients, such as some patients with renal or cardiac disease. Switching to oral therapy, when and if clinically appropriate, has other potential benefits for the patient including:  increased ease of mobility, better quality of life (some patients feel less “medicalized”), earlier discharge from the hospital, thereby decreasing the risk of hospital-acquired infections.  Other benefits include reduced length of stay, rate of hospital-acquired infections, lower drug costs and reduced waste (eg. Tubing, expired IV bags).

Although the life cycle analyses of most medications are not widely available, the carbon footprint of intravenous medications is estimated to be higher than oral medications due to primary packaging materials, plastic waste, equipment for administration and their disposal. Switching from IV to oral therapy reduces length of hospital stay and may reduce its associated environmental impacts.

Sources:

Béïque, L. et al. Addressing Concerns about Changing the Route of Antimicrobial Administration from Intravenous to Oral in Adult Inpatients; Can J Hosp Pharm. 2015 Jul-Aug; 68(4): 318–326. doi: 10.4212/cjhp.v68i4.1472; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4552233/. PMID: 26327706.

Dychter, S et al. Intravenous Therapy : A Review of Complications and Economic Considerations of Peripheral Access. Journal of Infusion Nursing 35(2):p 84-91, March/April 2012. DOI: 10.1097/NAN.0b013e31824237ce. PMID: 22382792.

Parvatker, A et al. Cradle-to-Gate Greenhouse Gas Emissions for Twenty Anesthetic Active Pharmaceutical Ingredients Based on Process Scale-Up and Process Design Calculations; ACS Sustainable Chem. Eng. 2019, 7, 6580-6591;

Royal Pharmaceutical Society : RPS Greener Pharmacy Guide for Hospital Pharmacies

Sanchez, V et al. Green hospital pharmacy: A sustainable approach to the medication use process in a tertiary hospital; Facmacia Hospitalaria volume 47, Issue 5, September-October 2023, pages 196-200. PMID: 37451908.

Anesthetic gases possess significant global warming potential (GWP) and contribute approximately 5% of the harmful greenhouse gas emissions of a typical hospital. However, not all anesthetic gases are equally harmful. The anesthetic gas desflurane has the highest GWP at twenty times more than that of sevoflurane. In addition, when both are delivered at equal fresh gas flows, desflurane has approximately 50 times the impact of sevoflurane due to its lower potency. Patient care can be provided safely and efficiently without desflurane; anesthetic alternatives such as sevoflurane, intravenous anesthesia or regional techniques should be considered, depending on clinical and geographical context. The restriction of the use of desflurane is supported by the Canadian Anesthesia Society, American Society of Anesthesiologists and World Federation of Societies of Anaesthesiologists. The elimination of desflurane is an effective change that aligns with the Choosing Wisely environmental practice recommendations.

Sources:

Bansal et al.  A comparative study of desflurane versus sevoflurane in obese patients: Effect on recovery profile.  Anaesthesiolo Clin Pharmacol. 2020 Oct-Dec; 36(4):541-545.doi:10.4103/joacp.JOACP-307-19. PMID: 33840938.

Campbell M, Pierce T. Atmospheric science, anaesthesia, and the environment. BJA Education, 15 (4): 173–179 (2015)

Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med. 2018 Jul 31;15(7):e1002623. PMID: 30063712.

Gadani H, Vyas A. Anesthetic gases and global warming: Potentials, prevention and future of anesthesia. Anesth Essays Res. 2011 Jan-Jun;5(1):5-10. PMID: 25885293.

Hanna M, Bryson G. A long way to go: minimizing the carbon footprint form anesthetic gases. Can J Anesth/J Can Anesth (2019) 66:838–839. PMID: 30877589.

Özelsel TJ, Sondekoppam RV, Ip VHY, Tsui BCH. Re-defining the 3R’s (reduce, refine, and replace) of sustainability to minimize the environmental impact of inhalational anesthetic agents. Can J Anaesth. 2019 Mar;66(3):249-254. English. doi: 10.1007/s12630-018-01279-3. Epub 2018 Dec 17. PMID:30560410.

Shelton, C, Sutton R., White, S. Desflurane in modern anaesthetic practice: walking on thin ice(caps)?  British Journal of Anaesthesia, 125 (6): 852e856 (2020) doi: 10.1016/j.bja.2020.09.013. PMID: 33039121.

Considerable pharmaceutical waste is generated in hospital settings which can be reduced by appropriately re-dispensing unused medications. A study from three Fraser Health hospitals extrapolated the results to show re-dispensing unused oral solid medications in 21 hospitals could divert ~ 461 000 units of medication from the incinerator with an estimated net value of ~ 415 000 per year. Re-dispensing unused medications will decrease environmental impact associated with unnecessary drug wastage (disposal/incineration).

Sources:

Drummond I, et al. Recycling unused medications in hospitals is financially viable and good for the environment. International Journal of Pharmacy Practice, Volume 31, Issue 5, October 2023, Pages 562–564, https://doi.org/10.1093/ijpp/riad062. PMID: 37566550.

Naeem, A et al. Returned medications management: The way toward reducing medications waste and improve the recycling process, single-center, cross-sectional study. International Journal of Pharmaceutical Research, Apr – Jun 2021, Vol 13, Issue 2; 235-242. https://doi.org/10.31838/ijpr/2021.13.02.055

The continuation of unnecessary medications can lead to potential adverse effects and increase consumption and costs to the patient. The performance of medication reviews at transitions of care within hospitals has been shown to decrease adverse drug event-related hospital revisits, emergency department (ED) visits and hospital readmissions. One study estimated that avoiding in-hospital activity and journeys to and from hospital resulted in a reduction in avoidable medicine-related admissions of 110 tonnes of greenhouse gas emissions, 179 million m3 of fresh water and 13, 300 tonnes of waste. Thus, performing medication reviews throughout a hospital stay and optimizing medications may help reduce the overall use and consumption of health care resources and impacts to the environment.

Sources:

Collin, M. et al. Impact of pharmacist-led discharge medication reconciliation at an Academic Medical Center. First published: 06 April 2023 https://doi.org/10.1002/jac5.1789.

Chiu, P et al. Outcomes of a pharmacist-led medication review programme for hospitalised elderly patients. Hong Kong Med J. 2018 Apr;24(2):98-106. doi: 10.12809/hkmj176871. Epub 2018 Feb. PMID: 29302017.

Mekonnen, A et al. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis: BMJ Open 2016;6:e010003. doi:10.1136/bmjopen-2015-010003. PMID: 26908524.

NICE Environmental impact report: Medicines optimisation Implementing the NICE guideline on medicines optimisation (NG5).

Embedding a planetary health lens when making pharmacy system-level decisions, benefits the health of the population by reducing the associated adverse health impacts. Selecting medications with lower environmental impact to be added to hospital formularies, adopting green purchasing strategies (such as streamline ordering and delivery of medications to reduce carbon emissions) and ensuring medicine procurement policies incorporate and where possible prioritize manufactures, supplier and distributors with commitments to sustainability are a few examples of embedding planetary health lens in pharmacy system-level decisions.

Sources:

Maharaj S, Moonilal M, Jankie S, Dookeram D. Pharmacist Rethink through a Planetary Health Lens. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 2021;58. doi:10.1177/00469580211020885. PMID: 34088229.

Health Canada. Health of Canadians in a Changing Climate Report 2022.

Park JY, Miller FA. Climate Resilient, Low Carbon Sustainable Pharmacy. CASCADES.

Watts, N et al. Health and climate change: policy responses to protect public health. The Lancet. 2015 June 29. https://doi.org/10.1016/S0140-6736(15)60854-6. PMID: 26111439.