Background: Missed doses have been associated with adverse outcomes and directly correlate to time off the floor. Pharmacist-assisted administration has decreased omitted doses. At Eskenazi Health, most patients requiring intermittent hemodialysis move to the dialysis unit for hemodialysis which occurs during standard medication administration times. As it relates to antihypertensives, some patients benefit from holding antihypertensive medications immediately prior to hemodialysis. Intradialytic hypotension is a frequent complication of hemodialysis and associated with adverse cardiovascular events, inadequate dialysis, loss of vascular access, and death. If antimicrobials, anticoagulants, and antiepileptics are not given or given at an inappropriate time as it relates to dialysis, patients could experience adverse outcomes.

Methods: We performed a retrospective pre- (July-September 2019), post- (July-September 2021) analysis of a pharmacist driven process improvement aimed at reducing delayed or missed doses and improving clinical outcomes for inpatients receiving hemodialysis. The pharmacist driven process improvement included a task list fire when hemodialysis is ordered coupled with documentation templates, creation of standard dialysis medication administration times (MAT) in the electronic medical record, and pharmacist education on optimal MAT based on dialyzability. We included inpatients who received hemodialysis and who were prescribed at least one of the following: antihypertensives, antiepileptics, anticoagulant (specifically apixaban), or antimicrobials. The primary endpoint was percentage of missed or delayed doses. Secondary endpoints included percentage of missed doses, percentage of delayed doses, incidence of interdialytic hypotension, intervention for interdialytic hypotension (such as stopping hemodialysis or giving fluid boluses), incidence of interdialytic hypertension, seizure events, and clotting events.

Results: We included 25 patients receiving 126 hemodialysis sessions and 29 patients receiving 80 hemodialysis sessions in the pre vs. post group. For the primary endpoint, 118 (17.9%) vs. 57 (9.3%) of doses were missed or delayed in the pre vs. post group (p< 0.001). Forty (6.1%) vs. 32 (11.95) doses were missed, and 78 (5.2%) vs. 25 (4.1%) doses were delayed in the pre vs. post group (p=0.489 and p=< 0.001.) For antihypertensives, 84 (24.3%) vs. 44 (10.5%) of doses were missed or delayed (p< 0.001.) Fourteen (5.5%) vs. 1 (0.9%) antimicrobial doses were administered at inappropriate times relative to hemodialysis in the pre vs. post group (p= 0.044). For clinical outcomes, there were 21 (16.7%) vs 10 (12.5%) hypotensive events in patients prescribed antihypertensives in the pre vs. post group (p=0.062). During those hypotensive events an intervention occurred in 8 (38%) vs. 1 (10%) of the hypotensive events (p=0.037). Hypertensive events occurred in 17 (13.4%) vs. 26 (32.5%) of dialysis sessions in patients prescribed antihypertensives (p=0.037). No patients prescribed an antiepileptic or anticoagulant experienced a seizure of clotting event.

Conclusions: Implementation of pharmacist driven standard medication administration times for patients receiving hemodialysis resulted in more patients receiving medication doses and receiving them on time, fewer hypotensive events and fewer interventions for hypotension in patients prescribed antihypertensives, and more hypertensive events in patients prescribed antihypertensives.

IMAGE 1: Table 1: Missed and Delayed Doses Results

IMAGE 2: Figure 1: Missed or Delayed Doses Results