Ying-Ling Liu, Li-Ling Chu, Pei-Chuan Wu, Ming-Cheng Hsu, Kang-Ting Tsai, Pei-Hsin Kao, Chien-Chin Hsu, Hung-Jung Lin, Chien-Cheng Huang, Hui-Chen Su

Background: Major polypharmacy (MP, ≥10 medications) and potentially inappropriate medications (PIMs) will increase the risk of adverse drug events in older patients. However, there has not been a “computer-assisted screening” and “dedicated clinical pharmacist leadership” medication integration initiated in the emergency department (ED), and therefore we conducted this implementation to clarify it.

Method: From February 2018 to December 2018, we recruited older ED patients waiting for bed at the Chi Mei Medical Center for the study. Through the cooperation by multi-disciplainary team, we adopted computer screening and pharmacist leadership to carry out medication integration. We compared MP, PIMs, and average chronic medications when patients are discharged from the hospital before, during and after the implementation, and evaluate the cost savings due to reduced adverse drug events after implementation. We also participated in various national quality improvement competitions.

Results: The rate of PM at discharge decreased from 34.71% before implementation (December 2017 to February 2018) to 22.22% (June 2018), 27.08% (July 2018), 14.78% (August 2018), 26.39% (September 2018) and 19.33% (October 2018) after implementation; the rate of PIMs has reduced from 50.87% before implementation (December 2017 to February 2018) to 26.83% (June 2018), 35.71% (July 2018), 32.05% (August 2018), and 32.00% (September 2018) and 34.04% (October 2018) after implementation. From June 2018 to November 2020, the average total number of chronic medications discharged from the hospital decreased from 12.40±2.70 to 7.21±2.93 (p<0.05). During the period from June 2018 to April 2019, it was estimated that the cost of reducing the occurrence of preventable drug adverse events was 4,116,000 New Taiwan Dollars and the benefit-cost ratio was 5.6. Our results have also won the 2019 National Health Quality Gold Award, the 2019 Taiwan Continuous Improvement Golden Tower Award, the 2019 Taiwan Healthcare Quality Association Gold Award, and the 2020 Taiwan College of Healthcare Executives Gold Award.

Conclusion: Through multi-disciplinary teamwork, we implemented computer-assisted screening and pharmacist-led medication integration in the older ED patients. The implementation reduced MP, PIMs, and total chronic medications, prevented adverse drug events, and reduced related costs. The result has also won national recognition in Taiwan. In the future, we hope that the model we built can be apllied to outpatients, hospitalized patients, and other institutions. Further analyses about the impact of medication reduction on the outcomes of patients are also warranted.

劉盈伶，朱麗鈴，吳佩娟，許明正，蔡岡廷， 高霈馨，許建清，林宏榮，黃建程，蘇慧真

目的：「嚴重多重用藥」及「潛在不適當用藥」會增加高齡病人發生藥物不良事件的機會。 然而，目前尚未有提早於急診進行「電腦輔助篩檢」及「專責臨床藥師領導」之藥物整合，因 此本團隊計畫來釐清此問題。

方法：我們在 2018 年 2 月至 2018 年 12 月期間，以奇美醫學中心「高齡急診待床病人」為 介入目標，藉由跨領域團隊合作，運用品管圈之改善手法，以電腦篩檢為基礎及藥師領導來進 行藥物整合。我們比較改善前、中、後期病人出院時的嚴重多重用藥、潛在不適當用藥及平均 慢性用藥品項數，並評估介入後，因減少之藥物不良事件所節省的成本。我們並將成果參與國 內各種品質提升競賽。

結果：出院時嚴重多重用藥的比率由改善前的 34.71%（2017 年 12 月～ 2018 年 2 月），降 低到改善中的 22.22%（2018 年 6 月）、27.08%（2018 年 7 月）、14.78%（2018 年 8 月），以及 改善後的 26.39%（2018 年 9 月）及 19.33%（2018 年 10 月）；潛在不適當用藥比率由從改善前 的 50.87%（2017 年 12 ～ 2018 年 2 月），降低到改善中的 26.83%（2018 年 6 月）、35.71%（2018 年 7 月）、32.05%（2018 年 8 月），以及改善後的 32.00%（2018 年 9 月）及 34.04%（2018 年 10 月）。在 2018 年 6 月至 2020 年 11 月期間，出院平均慢性總用藥數從 12.40±2.70 種降低至 7.21±2.93 種（p ＜ 0.05）。在 2018 年 6 月至 2019 年 4 月期間，估計減少可預防藥物不良事件 發生之成本共 4,116,000 元，效益成本比率為 5.6。我們的成果也獲得了 2019 年醫策會國家醫 療品質獎金獎、2019 年中衛競賽金塔獎、2019 年台灣醫療品質協會競賽金品獎及 2020 年台灣 醫務管理學會競賽金獎。

結論：我們經由跨領域團隊合作，從急診開始以電腦篩檢為輔助及藥師領導之高齡急診病 人藥物整合，降低了嚴重多重用藥、潛在不適當用藥及總用藥數，預防了藥物不良事件發生及 減少相關成本的支出。本成果也榮獲國家級的肯定。未來希望能推廣到門診及住院，以及其他 機構，並進一步分析減藥後對病人預後的影響。