ESCP best practice: development, implementation and evaluation of sick day guidance in primary care in the Netherlands

Introduction: To prevent acute kidney injury, guidelines recommend temporary adjustment of high-risk medications in patients with impaired renal function during so-called ‘sick days’. Sick days are periods with increased risk of dehydration, such as diarrhoea, fever or vomiting. Currently, awareness of sick day guidance among patients and healthcare professionals is low, which hampers implementation in daily practice. Aim: To develop, implement and evaluate sick day guidance for patients with pre-existing impaired renal function on maintenance treatment with high-risk medication. Setting: Over a 12 month study period, community pharmacies collaborated with at least one affiliated general practitioner (GP) to implement sick day guidance in primary care. Development: Training materials, including an E-learning module for healthcare professionals and patient information materials were developed. Implementation: In total, 21 community pharmacies completed the 12 month study period, in which 373 patients received oral and written instructions to report sick days to the GP or pharmacist. The median age of included patients was 78 years (IQR 73–83), 42% were male, and 68% used ≥ 2 high-risk medications. The implementation process of sick day guidance was evaluated with the Consolidated Framework for Implementation Research (CFIR), including a start interview in every pharmacy, registration of agreements, monthly telephone evaluations and an end-evaluation interview. Evaluation: Successful implementation was facilitated by adequate training, strong team engagement and support, and making pharmacy technicians responsible for information provision as well as providing in-person counselling to patients. Implementation barriers related to a lack of support from the information system, a lack of reimbursement and a low number of reported sick days. Patients reported 8 sick days, although a telephone survey amongst 188 patients showed that 12 more sick days had occurred. Conclusion: While training healthcare professionals supports appropriate medication adjustments when sick days are reported, patient education alone does not consistently lead to reporting. Additional implementation efforts, such as involving informal caregivers, may be needed to support patients in signalling and managing sick days.