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Conclusion and relevance DOAC use increased notably in our PC area during the SARS-CoV-2 pandemic. We found that 40.2% of patients treated with DOAC had at least one contraindication for the treatment. Interventions should be done to improve DOAC prescription and ensure patient safety.

BackgroundMedication reconciliation (MR) is one of the measures with greater impact on safety in the use of the drug. Reconciliation errors appear frequently in the transitions between the different levels of care, especially at hospital discharge.PurposeEvaluate the impact of a MR project performed by pharmacists on medical discharge summaries.Material and methodsA protocol was performed to support the MR at discharge by the pharmacy service in a 350-bed hospital and developed over 4 weeks. The pharmacist went to the hospitalisation area from Monday to Friday at the end of the morning and he made the MR prior to discharge. He conducted a structured pharmacotherapeutic interview with the patient to know the home medication prior to admission and later discussed with the physician the new medication that would be added and if there was any modification of the previous medication. A report with active principle, dosage/posology and pharmacotherapeutic recommendations was elaborated. Subsequently, the medical discharge summaries were reviewed and a database was developed in which were included demographic variables (sex, age, no pre-admission drugs) and as a primary endpoint if the physician included in his summary all medication of the patient (complete summary), as well as whether there was any treatment with a finite duration and if this was included in the instructions to the patient. We also selected a sample of discharged patients before the pharmacist’s intervention to compare both groups. Bivariate analysis and logistic regression analysis was used using SPSS software.ResultsTwenty-eight patients were recruited in the pre-intervention group and 27 in the post-intervention group: median age (IQR) 65.2 years (50.4–71.6) vs 77.9.(61.1–84.2) (p=0.004), sex 66.7% males vs. 51.7% (p=0.653) respectively. Median number of drugs prior to admission (IQR) was four drugs (0–10) vs eight (5–12) (p=0.028), respectively. Regardless of the age of patients in the post-intervention group, they are about four times more likely to have a complete medical discharge summary (OR: 3.97, 95% CI: 1.18 to 13.3) (p=0.026). The percentages of medical reports with duration specified in the pre- and post-groups were, respectively, 0% vs. 18.5% (p=0.023).ConclusionThe participation of the pharmacist improves the process of MR at discharge, favouring that it is performed in a greater number of patients and that information provided at discharge is more complete.References and/or AcknowledgementsWe thank the research team for their supportNo conflict of interest

HSA prescriptions, duration of treatment, previous serum albumin, previous infection, HSA indication and level of evidence of the indications. The classification was based on the scale established by the American Society of Apheresis, which categorises four groups according to the degree of evidence:. High priority (grade I): paracentesis induced circulatory dysfunction (PICD) after large volume paracentesis (>5 L); hepatorenal syndrome, renal failure after spontaneous bacterial peritonitis (SBP) and plasmapheresis.. Reasonable evidence, but with available alternatives (grade II): resuscitation in critically ill patients with septic shock when crystalloids are insufficient.. Weak evidence (grade III): hypervolaemic hyponatraemia in decompensated cirrhosis, awaiting liver transplantation, non-SBP bacterial infections in cirrhotic patients, prevention of PICD <5 L.. Treatment not recommended (grade IV): other indications. Results The study included 142 patients, 41% women, mean age 66±11 years. The main admission diagnoses were: decompensated cirrhosis (32%), septic shock (31%), haemorrhagic shock (5%) and respiratory infection (4%). They received a total of 223 batches of HSA. The median duration of prescription was 3 days (IQR 2-4). The mean basal plasma albumin was 2.5±0.5 mg/dL. 48% had a previous active infection. The major indications of HSA were: anasarca and hypoalbuminaemia (32%), prevention of PICD >5 L (17%), resuscitation in shock septic (13%) and protein malnutrition (9%). 26% of the indications had grade I evidence, 13% grade II, 9% grade III and 53% grade IV. Conclusion and relevance There is an important use for HSA in hospitals with a low level of evidence. It is necessary to train prescribing doctors to optimise the use of HSA in hospital.