Introduction
Methods
Study design
Identifying review questions
Criteria | Element(s) | Description |
---|---|---|
P- Population | Patients | Individuals at risk of developing AKI on the background of CKD |
Healthcare workers | Healthcare providers such as doctors, nurses, and pharmacists who are involved in CKD care at some stage along the healthcare continuum | |
C- Concept | Development and usability of sick day rules | Interventions targeted at facilitating the provision of sick day management i.e., the temporary discontinuation of certain medications, commonly referred to as SADMANS medications, that are implicated in AKI and thus need to be withheld upon acute illness to prevent disease deterioration |
Current Practice | Current knowledge, awareness, understanding and attitudes of patients and relevant health professionals towards advice to withhold medications during acute illness | |
Current Guidance | Current guidance provided to healthcare professionals on the management of medications during acute illness | |
Clinical outcomes | Outcomes that resulted from the use of SADMANS medications or from temporarily withholding/discontinuing them | |
C- Context | Primary care | Services or interventions developed or implemented in primary care settings |
Any geographical context | Studies from any geographical context that dealt with sick day rules or temporary discontinuation of medications in the context of AKI on top of CKD is considered |
Identifying studies
Study selection
Data charting and extraction
Data summary and presentation of results
Results
Description of studies
Characteristics of included studies
Characteristics | Number of studies (%) | Author |
---|---|---|
Publication year | ||
2022 | 1 (10) | Fink et al. [25] |
2020 | 4 (40) | |
2019 | 2 (20) | |
2017 | 2 (20) | |
2016 | 1 (10) | Morris et al. [19] |
Study by country/region | ||
United States | 3 (30) | |
United Kingdom | 3 (30) | |
Netherlands | 1 (10) | Faber et al. [22] |
New Zealand | 3 (30) | |
Types of articles | ||
Original articles | 8 (80) | |
Letter to the editor* | 1 (10) | Doerfler et al. [24] |
Systematic review | 1 (10) | Whiting et al. [23] |
Study designs | ||
Quantitative | 2 (20) | |
Qualitative | 2 (20) | |
Mixed methods research | 4 (40) | |
Systematic review | 1 (10) | Whiting et al. [23] |
Randomised controlled trial | 1 (10) | Fink et al. [25] |
Perspectives explored** | ||
Patients | 6 (67) | |
Pharmacists | 3 (33) | |
General practitioner | 4 (44) | |
Practice nurses | 2 (22) | |
Key concepts*** | ||
Development, usability, or implementation of “sick day” guidance | 5 (50) | |
Current practice | 3 (30) | |
Outcomes | 2 (20) |
Development/usability testing and implementation of sick day management
Key concept | Evidence | Exemplary findings |
---|---|---|
Development, usability testing and implementation of sick day guidance | ||
Limited number of interventions explored | Vicary et al. [26] | • Pharmacists were effective educators and well placed in the community to provide sick day advice during acute illness • 58% (n = 54) participants interviewed on follow up recall receiving the intervention and 55% (n = 42) had retained the guidance sheet provided |
Morris et al. [19] | • Patient handouts alone were seen as insufficient and unlikely to improve outcomes. The implementation of sick day interventions likely requires more resources in the form of remuneration and overall health infrastructure | |
Bowman et al. [20] | • Majority of participants found a digital tool easy to use, helpful and would recommend it to others • Participants identified story examples and guiding audio as important components to aid in understanding of sick day management • Digital education tools may be effective in educating CKD patients with low health literacy and/or older age | |
Doerfler et al. [24] | • The use of index cards containing information on sick day management did not appear effective and raised concerns regarding consequences of incorrect activation leading to harm | |
Fink et al. [25] | • The use of a sick day protocol coupled with an interactive voice response system to enable event reporting was associated with high engagement with participants, although this did not translate into better clinical outcomes | |
Martindale et al. [21] | • As a stand-alone intervention, sick day guidance cards may have little benefit • Guidance cards should be used to supplement patient education, but HCPs reported this did not regularly occur | |
Barriers to implementation of sick day management protocol | Vicary et al. [17] | • Whilst half of patients who recalled receiving sick day management advice indicated they would discontinue medications when they were sick, less than 20% of patients who recalled the advice would correctly discontinue medications if they had “excessive vomiting and/or diarrhoea.” |
Vicary et al. [26] | • Around half of participants would discontinue medications during acute illness but may not cease the correct medications • More than half of participants were comfortable that they knew when to restart their medications but only 16% would restart medications after being symptom-free for 48 h per recommendations | |
Vicary et al. [18] | • Pharmacists and GPs highlighted that whilst instructions seemed straightforward, they require a high level of knowledge by patients | |
Doerfler et al. [24] | • Whilst most participants were able to correctly identify an index scenario where the “sick day” guidance should be applied, many patients activated the “sick day” guidance for scenarios where it was inappropriate to do so • Most participants (95%) made errors when selecting appropriate medications to discontinue during acute illness | |
Martindale et al. [21] | • HCPs had concerns about the depth of understanding of symptoms and medications required by patients to proactively discontinue medications during acute illness • HCPs were wary of the subjective nature of guidance, highlighting that patients had different perceptions on what is “severe” illness • Implementing sick day management may be difficult in patients who have cognitive impairments, reduced literacy in English, visual impairments, or elderly housebound patients | |
Morris et al. [19] | • Patients were uncertain if they would be able to distinguish between symptoms of various conditions which may affect their ability to assess the appropriateness of sick day management | |
Current practice | ||
Rate of sick day management advice | Faber et al. [22] | • 91% of GPs did not offer high risk patients advice to discontinue or adjust medication dosages or referred them to hospital during a dehydration risk encounter |
Vicary et al. [18] | • Only 16% of pharmacists and 11% of physicians (GPs) reported that they always provided sick day management advice to patients prescribed an ACEI/ARB/NSAID/diuretic | |
Vicary et al. [17] | • Around 14% of participants taking an ACEI, ARB, diuretic, NSAID and/or metformin indicated that they had been advised by an HCP to stop taking medicines during acute illness | |
Coordination of care and defined roles | Vicary et al. [18] | • There are varied and unclear expectations of the level of patient education that should be provided by pharmacists – over half of GPs expected “sick day” guidance to be provided by pharmacists but pharmacists do not report routinely providing this advice • Barriers identified by pharmacists included time constraints, unclear renumeration and lack of existing GP and pharmacist collaboration • Pharmacists required clear support from GPs – they will only provide advice if GPs view it as best practice • GPs preferred to be contacted to discuss their patients’ condition or at least informed when discontinuation advice was provided |
Morris et al. [19] | • Both patients and HCPs highlighted the need for a consistent message about sick day rules • Patients and HCPs questioned which provider should be providing the sick day management advice • Legal and professional boundaries limited the willingness of nurses and pharmacists to implement sick day rules • A key barrier to pharmacists providing targeted “sick day” guidance is that they had limited access to diagnostic information including patients’ renal function | |
Outcomes | ||
Limited evidence on outcomes associated with medication discontinuation | Whiting et al. [23] | • The systematic review identified no published literature reporting on the impact of temporarily discontinuing medications during acute illness |
Faber et al. [22] | • In 3.1% (n = 25) of episodes of acute illness, a complication occurred in the subsequent 3 months after contacting their GP, most commonly AKI. In 88% of these cases, no discontinuation advice was provided • In three episodes the patients had been advised to discontinue their high-risk medication, but despite this advice AKI (n = 2) or hypotension (n = 1) occurred | |
Fink et al. [25] | • When adjusted for baseline eGFR, there is no statistically significant difference in mean change of eGFR in a 6-month period between patients who received a sick day protocol handout and weekly survey calls from an interactive voice response system (intervention group) and patients who received usual care • There were no statistically significant differences in number of hospitalisations, emergency department or urgent care visits • Only half of sick day events (n = 33) reported through the interactive voice response system were true sick day events • In the instance of a true sick day event, only half of the participants in the intervention group correctly discontinued their medication(s) • There were high rates of engagement reported and high ease of use, ease of comprehension and desire to continue using the program • There was notable error in the use of the digital tool both in the identification of a true sick day event and correctly applying the sick day protocol |
Limited number of sick day interventions
Barriers to implementation of sick day guidance
“I don't think that it should be just put on a counter… I don't think, number one, they’ll read it, number two, they’ll digest what’s on it, or number three, they’ll apply it to themselves…” [21]
“we have quite a lot of different ethnicities here…they’ve got limited English I think they’re not quite sure and it takes quite a while explaining …about what medicines to stop, when to stop it, when to restart it…” [21]
“You’ve got to look at everything else that’s going on…you get patients obviously with multiple medical problems and you must try and remember to include everything in your consultation. It’s sometimes quite hard” [19].
Current practices on the provision of sick day management
Poor uptake of sick day guidance
Lack of evidence and poor information access
“We don’t have enough data or…best practice… if you stop the metformin or whatever medication how long do you stop it for…? Then after a week are you going to restart them again on the ten milligrams or are you going to start them on the 1.5, the 2.5…?” [21]
“I think as pharmacists we could deliver it in a positive way because we’d have the time to sit with the patient, do a medicines review, or even without a medicines review the fact is that when we’re dispensing any medication you’ve got time to really engage with them, probably more so than the GP would… But identifying the patients in the first place would be a big stumbling block for us.” [19]
Importance of coordination of care and defined roles
“GP or nurse…I suppose a GP or the nurse at the GP centre would know more about my history than the pharmacist would, so I would be more likely to take their word for it.” [19]