The value of blood medication analysis to medication verification and reconciliation in older adults at the emergency department

One in four older adults is prescribed more than five medications (1, 2). In
the emergency department setting, this percentage increases up to 61% (3).
However, actual medication use among older adults presenting at the ED is often
unclear, including prescribed, over-the-counter, and recreational drug use (4,
5). Even if complete prescription lists are available, this does not prove the
actual intake of medication as non-compliance occurs in almost 50% of older
adults with chronic illnesses (5-7). To tackle this problem, current policy
consists of medication verification and reconciliation by a physician or
pharmacist (8). Results of this analysis are at risk of being incomplete due to
inaccuracy of patient recall and incomplete or delayed access to pharmacy
records (9). In patients with cognitive deficits or loss of con-sciousness,
medication verification is even more challenging and merely based on recent
pharmacist give-outs and caretaker*s knowledge, if available (10). Unclear
medication use may lead to errors in medication prescription by doctors, which
could decrease the effective-ness of treatment and cause serious harm (11, 12).
One in seven ED visits of older adults are medication related, of which
three-quarters are preventable due to underuse, noncompliance or adverse drug
events (13). Consequences we hypothesize could partially be prevented if
doctors had a more accurate display of the patient*s actual medication use.

Currently, the ED does not use pharmacological analysis techniques, like the
liquid chromatography tandem mass spectrometry (LC/MS/MS), to assess medication
use. This technique is mainly used in toxicology, endocrine system, proteins
and newborn screening (14). For an ED, it has mainly been applied to determine
the detect recreational drugs in pa-tients presenting with intoxication (15).
Additionally, the LC/MS/MS could be used to deter-mine medications in patients*
blood (14). A previous study with LC/MS/MS demonstrated that 63.0% of patients
have a discrepancy between the actual intake and the medication verifica-tion.
They found that opioids and diazepam were the most common medications detected
in the blood without prescription (16). This extra information could provide
more insights into patients* compliance and optimize the diagnostic process and
treatment policy, beyond the standard care practice of medication
verification.

This study will investigate the value and applicability of LC/MS/MS to assess
medication use to medication verification and reconciliation in older adults
with polypharmacy visiting the ED. Discrepancies between LC/MS/MS and
medication verification and reconciliation will be described and analysed
including the potential impact it could have had on the diagnostic process and
treatment policy. We hypothesize that LC/MS/MS will provide additional insights
to the medication verification and reconciliation which will alter the
treatment policy.

This observational study will be conducted in the ED of Amsterdam UMC, location
AMC. During the study, a questionnaire concerning demographic characteristics
and medication use will be conducted at baseline by the researcher at the ED
with the patient or their caretaker/family. One blood sample will be taken,
either by intravenous cannula or a venepuncture, and collected in a 6 ml EDTA
tube. Blood samples will be analysed at a later stage as the LC/MS/MS is
located at the Clinical Pharmaceutical and Toxicology laboratory at OLVG,
location West. The value of the results of the LC/MS/MS to the medication will
be determined retrospectively by a five point scale for the diagnostic process
and treatment policy by the research team. After the analysis, patients might
be contacted by phone if additional questions arise regarding medication use
due to the results.

There are risks associated with venipuncture. There is a risk of pain,
haematoma formation and vasovagal reaction. There is also a risk of needlestick
injury, where a person comes into contact with another person's blood or body
fluids. Contamination is dangerous for disease carriers, but also for those
being cared for, such as patients. The chances of this happening during a
venipuncture are very low.

Venipuncture is avoided as much as possible by using a venipuncture in the
first place. If a venipuncture is needed, the chances of complications are low.
Venipunctures are carried out by trained healthcare professionals where
venipunctures are part of routine care.