Clinical Pharmacists and Inpatient Medical Care A Systematic Review (original) (raw)
Clinical Effects of a Pharmacist Intervention in Acute Wards- A Randomised, Controlled Trial
Basic & Clinical Pharmacology & Toxicology, 2017
The purpose of the study was to investigate the clinical effect of a clinical pharmacist (CP) intervention upon admission to hospital on inpatient harm and to assess a potential educational bias. Over 16 months, 593 adult patients taking ≥4 medications daily were included from three Danish acute medicine wards. Patients were randomized to either the CP intervention or the usual care (prospective control). To assess a potential educational bias, a retrospective control group was formed by randomization. The CP intervention comprised medication history, medication reconciliation, medication review and entry of proposed prescriptions into the electronic prescribing system. The primary outcome of inpatient harm was identified using triggers from the Institute of Healthcare Improvement Global Trigger Tool. Harms were validated and rated for severity by two independent and blinded outcome panels. Secondary end-points were harms per patient, length of hospital stay, readmissions and 1-year mortality. Harm affected 11% of the patients in the intervention group compared to 17% in the combined control group, odds ratio (OR) 0.57 (CI 0.32-1.02, p = 0.06). The incidence of harm was similar in the intervention and prospective control groups, OR 0.80 (CI 0.40-1.59, p = 0.52) but occurred less frequently in the intervention than in the retrospective control group OR 0.46 (CI 0.25-0.85, p = 0.01). An educational bias from the intervention to the control group might have contributed to this negative outcome. In conclusion, the CP intervention at admission to hospital had no statistically significant effect on inpatient harm. Materials and Methods Study design and setting. This prospective, randomized, controlled trial was approved by the Danish Data Protection Agency (j.nr.2008-58-0020) and Danish Health and Medicines Authority's Supervision and Patient Safety (j.nr. 3-3013-9). Approval from The Scientific Ethics Committee was not required according to Danish legislation because the study included no biomedical research. The trial was registered at Current Controlled Trials Ltd (ID ISRCTN08043800). The setting was the acute medicine wards of three non-university hospitals in Region Zealand, one in five regions of Denmark. Apart
Multifaceted pharmacist-led interventions in the hospital setting - a systematic review
Clinical pharmacy services often comprise complex interventions. In this MiniReview, we conducted a systematic review aiming to evaluate the impact of multifaceted pharmacist-led interventions in a hospital setting. We searched MEDLINE, Embase, Cochrane Library and CINAHL for peer-reviewed articles published from 2006 to 1 March 2018. Controlled trials con- cerning hospitalized patients in any setting receiving patient-related multifaceted pharmacist-led interventions were considered. All types of outcome were accepted. Inclusion and data extraction were performed. Study characteristics were collected, and risk of bias assessment was conducted utilizing the Cochrane Risk of Bias tools. All stages were conducted by at least two indepen- dent reviewers. The review was registered in PROSPERO (CRD42017075808). A total of 11,896 publications were identified, and 28 publications were included. Of these, 17 were conducted in Europe. Six of the included publications were multi-centre studies, and 16 were randomized trials. Usual care was the comparator. Significant results on quality of medication use were reported as positive in eleven studies (n = 18; 61%) and negative in one (n = 18, 6%). Hospital visits were reduced significantly in seven studies (n = 16; 44%). Four studies (n = 12; 33%) reported a positive significant effect on either length of stay or time to revisit, and one study reported a negative effect (n = 12; 6%). All studies investigating mortality (n = 6), patient-reported out- come (n = 7) and cost-effectiveness (n = 1) showed no significant results. This MiniReview indicates that multifaceted pharma- cist-led interventions in a hospital setting may improve the quality of medication use and reduce hospital visits and length of stay, while no effect was seen on mortality, patient-reported outcome and cost-effectiveness.
Clinical pharmacist service in the acute ward
International Journal of Clinical Pharmacy, 2013
Background The majority of hospitalised patients have drug-related problems. Clinical pharmacist services including medication history, medication reconciliation and medication review may reduce the number of drug-related problems. Acute and emergency hospital services have changed considerably during the past decade in Denmark, and the new fast-paced workflows pose new challenges for the provision of clinical pharmacist service. Objective To describe and evaluate a method for a clinical pharmacist service that is relevant and fit the workflow of the medical care in the acute ward. Setting Acute wards at three Danish hospitals. Methods The clinical pharmacist intervention comprised medication history, medication reconciliation, medication review, medical record entries and entry of prescription templates into the electronic medication module. Drug-related problems were categorised using The PCNE Classification V6.2. Inter-rater agreement analysis was used to validate the tool. Acceptance rates were measured as the physicians' approval of prescription templates and according to outcome in the PCNE classification. Main outcome measure Acceptance rate of the clinical pharmacists' interventions through the described method and inter-rater agreement using the PCNE classification for drug-related problems. Results During 17 months, 188 patients were included in this study (average age 72 years and 55 % women). The clinical pharmacists found drug-related problems in 85 % of the patients. In the 1,724 prescriptions, 538 drug-related problems were identified. The overall acceptance rate by the physicians for the proposed interventions was 76 % (95 % CI 74-78 %). There was a substantial inter-rater agreement when using the PCNE classification system. Conclusion The methods for a clinical pharmacist service in the acute ward in this study have been demonstrated to be relevant and timely. The method received a high acceptance rate, regardless of no need for oral communication, and a substantial inter-rater agreement when classifying the drug-related problems. Keywords Acceptance rate Á Acute ward Á Clinical pharmacy Á Denmark Á DRP classification Á Drugrelated problems Á Electronic prescription template Á Medication history Á Medication reconciliation Á Medication review Impacts on practice • Clinical pharmacist services in the acute ward need to fit the high-paced workflow to benefit the health care professional teams and thereby the patients. • The method for a clinical pharmacist service in the acute ward described here fits an intensive workflow, identifies multiple drug-related problems and yields a
Hospital pharmacist interventions in a central hospital
European Journal of Hospital Pharmacy: Science and Practice, 2014
Objective The aim of this study is to describe and categorise pharmacist interventions (PIs) in a central hospital and report acceptance rates by physicians. Methods A retrospective study was carried out in a 350-bed central hospital between January and June 2013. Eleven pharmacists screened the pharmacotherapy charts for drug-related problems leading to PIs. The recommendations resulting from this analysis were entered in the electronic prescribing system. All the PIs registered on the electronic medical record system during the study period were eligible for inclusion. Interventions were quantified and characterised. Computer records were consulted to assess acceptance rate by physicians. Results A total of 1249 PIs were made by 11 pharmacists, and covered 147 drugs, with the most common being antibacterial (25%) and for the central nervous system (24%) and cardiovascular system (18%). Of the 1249 PIs, 18% concerned acetaminophen, 13% enoxaparin and 10% amoxicillin/clavulanic acid. The PIs were classified into three main categories: drug, dosage and administration related. When we analysed the most relevant PI type (n>20), the highest acceptance rate was for dosage adjustment according to therapeutic indication (58.1%) and renal function (57.4%). The global rate of acceptance was 53%. Conclusions Pharmacists' recommendations entered in the electronic prescribing system with a short explanation, as well as the pharmacotherapy recommendation, are immediately available to the doctor; however, the relatively low acceptance rate suggests that a further study also evaluating verbal interventions is needed, since the most urgent recommendations are made verbally, and this would likely increase the acceptance rate.
Self reported clinical pharmacist interventions under-estimate their input to patient care
Pharmacy world & science : PWS, 2001
Pharmacists' impact on individual patient care is difficult to measure especially the contribution made by clinical pharmacy ward visits. This study set out to determine what activities pharmacists actually undertook on a clinical pharmacy ward visit and compare this with the usual method of measuring clinical pharmacist performance, self-reported pharmacist interventions. Observational analysis was carried out on 16 pharmacists providing a ward clinical pharmacy service in four acute hospitals. Percentage of pharmacist interventions recorded. A total of 34 wards were visited during the study which included both medical and surgical specialties. Average time spent per patient was less than two minutes for most pharmacists and three-quarters of the pharmacists checked over 80% of patient drug charts. Interventions represented 68% of pharmacist activities on the wards but on questioning the pharmacists reported that they would record only 31% of those interventions. Comparison of ...
Interventions by pharmacists in out-patient pharmaceutical care
Saudi Pharmaceutical Journal, 2014
Interventions by the pharmacists have always been considered as a valuable input by the health care community in the patient care process by reducing the medication errors, rationalizing the therapy and reducing the cost of therapy. The primary objective of this study was to determine the number and types of medication errors intervened by the dispensing pharmacists at OPD pharmacy in the Khoula Hospital during 2009 retrospectively. The interventions filed by the pharmacists and assistant pharmacists in OPD pharmacy were collected. Then they were categorized and analyzed after a detailed review. The results show that 72.3% of the interventions were minor of which 40.5% were about change medication order. Comparatively more numbers of prescriptions were intervened in female patients than male patients. 98.2% of the interventions were accepted by the prescribers reflecting the awareness of the doctors about the importance of the pharmacy practice. In this study only 688 interventions were due to prescribing errors of which 40.5% interventions were done in changing the medication order of clarifying the medicine. 14.9% of the interventions were related to administrative issues, 8.7% of the interventions were related to selection of medications as well as errors due to ignorance of history of patients. 8.2% of the interventions were to address the overdose of medications. Moderately significant interventions were observed in 19.4% and 7.5% of them were having the impact on major medication errors. Pharmacists have intervened 20.8% of the prescriptions to prevent complications, 25.1% were to rationalize the treatment, 7.9% of them were to improve compliance. Based on the results we conclude that the role of pharmacist in improving the health care system is vital. We recommend more number of such research based studies to bring awareness among health care professionals, provide solution
Pharmaceutical care: pharmacy involvement in prescribing in an acute‐care hospital
Pharmacy World & Science, 2003
Background: Pharmaceutical care implies reaching a consensus with physicians on prescriptions in cases that call for the substitution of one active ingredient for another, a modification in dose, frequency, route of administration, etc., through the unit‐dose distribution system. The goal of pharmacist interventions in the hospital should be to achieve a rational use of drugs; to ensure this, a daily review of patient prescriptions by a pharmacist is necessary. Most of the incidence of drug‐related morbidity and mortality is predictable and can be avoided, thus reducing the overall cost of health care and the duration of hospitalization while improving the quality of care. The optimum quality of physician or pharmacist care to be achieved would be one that which maximizes benefits and minimizes risks and costs.Objective: The goal of this study was to evaluate pharmacist interventions at the Hospital of Barcelona over a six‐month period and their clinical and economic repercussions and the degree of compliance. Method: The interventions were recorded on a card and classified by type: antibiotic or thromboembolic prophylaxis; substitution of an active principle not included in the hospital's Pharmacotherapeutic Guide; change in dose or route of administration; therapeutic duplication; dose adjustment of aminoglycosides and vancomycin; and inappropriate treatment duration. The economic evaluation considered the average cost of a hospital stay and of the procedures and diagnostics in 1998 and applied data on published probability rates and drug costs.Results: A total of 3,136 interventions were analyzed prospectively during the study period. The interventions represented savings of 129,058.31 euros. Those that contributed most to these savings were recommendations for antibiotic prophylaxis, thromboembolic prophylaxis and pharmacokinetics studies: 49.4, 47 and 5.7% of interventions, respectively, and 79, 3.6 and 15% of total savings, respectively. Conclusion: In general, the degree of acceptance of the interventions was high (88.8%), as a result of the growing compliance by physicians with the hospital's established protocols. It can be concluded that pharmacist interventions have been useful to improve patient care and have been important to help educate physicians on the quality of drug therapy.
The Impact of Clinical Pharmacists on Drug-Related Problems and Clinical Outcomes
Basic & Clinical Pharmacology & Toxicology, 2008
Drug-related problems are frequent and may result in reduced quality of life, and even morbidity and mortality. Many studies have shown that clinical pharmacists can effectively identify and prevent clinically significant drug-related problems and that physicians acknowledge and act on the clinical pharmacist's suggestions for interventions to the drug-related problems. A pro-active rather than a reactive approach on the part of the pharmacists seems prudent for obtaining most benefit. This includes participation of pharmacists in the multidisciplinary team discussions -at the stage of ordering and prescribing -where all types of drug-related problems, including also potential problems, should be discussed. In addition, counselling by pharmacists about medication on discharge and follow-up after discharge resulted in better outcomes. Furthermore, clinical pharmacists can positively influence other outcomes, such as improvement of levels of markers for drug use (e.g. optimization of lipid levels, anticoagulation levels and blood pressure). Some studies have reported positive effects on hard clinical outcomes, such as reduced length of stay, fewer re-admissions and fewer disease events (e.g. heart failure events and thromboembolism). However, more studies should be undertaken with larger patient populations, including patients from multiple sites. More knowledge about patient-specific factors that predict improved care is also needed. In conclusion, there is increasing evidence that participation and interventions of clinical pharmacists in health care positively influence clinical practice.
Predictive factors for clinically significant pharmacist interventions at hospital admission
Medicine, 2018
Pharmaceutical care activities at hospital admission have a significant impact on patient safety. The objective of this study was to identify predictive factors for clinically significant pharmacist interventions (PIs) performed during medication reconciliation and medication review at patient hospital admission.A 4-week prospective study was conducted in 4 medicine wards. At hospital admission, medication reconciliation and medication review were conducted and PIs were performed by the pharmaceutical team. The clinical impact of PIs was determined using the clinical economic and organizational (CLEO) tool. Clinical characteristics, laboratory results, and medication data for each patient were collected and analyzed as potential predictive factors of clinically significant PIs. Univariate and multivariate binary logistic regression were subsequently used to identify independent predictive factors for clinically relevant PIs.Among 265 patients admitted, 150 patients were included. Am...
Role of Clinical Pharmacists in Intensive Care Units
Cureus, 2021
The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.
Evaluation of patient care interventions and recommendations by a transitional care pharmacist
Abstract: A “transitional care pharmacist” (TCP) was deployed within an acute care setting to identify opportunities for improved continuity of care. The provision of medication reconciliation services, drug consultation, patient counseling and planning for after-hospital care was time consuming but also fruitful, resulting in roughly nine interventions per patient. Areas with the greatest potential for morbidity reduction were the resumption of home medications during the acute stay and at discharge. Allergy identification was a key contribution at admission, as was the provision of a detailed follow-up plan at discharge. Targeting high-risk patients and spreading portions of the work to other disciplines could achieve added efficiency in this service. Results have value to hospitals implementing medication reconciliation programs.
Background: To prevent adverse drug events and promote patient safety, medication reconciliation is critical in all patient care settings. The purpose of this study was to identify medication discrepancies occurring in an inpatient medicine unit and to analyze the clinical and economic benefit of clinical pharmacist and physician team collaboration. Methods: A prospective cohort study in which pharmacist attended daily team rounds and assisted with medication management and medication reconciliation on admission and discharge in an academic hospital with internal medicine residents. All interventions related to medication management were categorized based on error type, severity of harm, preventable, non-preventable and potential adverse drug events. The economic outcome associated with these medication errors was analyzed. Results: There were 160 admissions and 179 pharmacist recommendations with a 91% acceptance rate from physicians. There were 145 discharges during the study period of which 104 medication discrepancies were identified. Eighty nine of the medication discrepancies were corrected by the pharmacist within 72 hours of discharge. Pharmacist identified 11 actual adverse drug events. Cost savings from pharmacist interventions during the study period was 11,652andcostavoidancefrominterceptingpotentialandactualadversedrugeventswas11,652 and cost avoidance from intercepting potential and actual adverse drug events was 11,652andcostavoidancefrominterceptingpotentialandactualadversedrugeventswas256,806. Conclusion: Collaboration of pharmacist with a physician team improved medication safety and led to significant cost savings and cost avoidance.
THE ROLE OF THE PHARMACIST IN PATIENT CARE
Handbook for the Hospital and Community Pharmacists, 2020
® The book solely focuses on job responsibilities of patient care pharmacists, separated from those of doctors and nurses, with the most recent information. ® Various aspects of pharmacist-led patient care services are incorporated in a single book. ® Career-focused discussions in every chapter with structured guidelines provided for the pharmacists. ® Content is mostly based on recent pharmacists’ activities in the healthcare arena of developed countries. ® Chapter outline, abbreviations, synopsis, learning outcomes, cases, key terms and further references are added like a textbook. ® Possible errors during the patient dealing and measures to be taken in all aspects are thoroughly discussed. ® The future prospect of patient care pharmacists in different areas of health care elaborately discussed. ® Discusses patient relationship management with a caring and compassionate touch which is a very demanding approach to many high-profile healthcare settings. ® Along with professionals, undergraduate students can utilize this book as a reference for their courses like hospital and community pharmacy and pharmaceutics. ® Scholars from countries around the world are giving their recommendation about the book. PubMed: https://www.ncbi.nlm.nih.gov/nlmcatalog/101766397 Sample Copy: http://www.bookpump.com/upb/pdf-b/7343083b.pdf
ASHP–SHM Joint Statement on Hospitalist–Pharmacist Collaboration
American Journal of Health-System Pharmacy, 2008
The American Society of Health-System Pharmacists (ASHP) and the Society for Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists (hereinafter, "pharmacists"), and other health care providers. The emerging model of care allows for deeper professional relationships among health care providers and promotes a shared interest in and responsibility for direct patient care, indirect patient care, and service activities. ASHP and SHM encourage hospitalists, pharmacists, and health care executives to seek out ways to foster collaboration between hospitalists and pharmacists. The purpose of this consensus statement is to promote an understanding of the ways hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals, examine opportunities for improving hospitalist-pharmacist alliances that enhance patient care, suggest future directions for collaboration, and identify aspects of such collaboration that warrant further research.
Pharmacist-led medication review in an acute admissions unit: a systematic procedure description
European Journal of Hospital Pharmacy, 2015
Objectives Over the last decades, several papers have evaluated clinical pharmacy interventions in hospital settings with conflicting findings as results. Medication reviews are frequently a central component of these interventions. However, the term 'medication review' covers a plethora of principles and methodologies, and the practical procedure is seldom described in detail, which makes reproducing study findings difficult. The objective of this paper is to provide a detailed description of a procedure developed and used for pharmacist-led medication review in acute admissions units. Methods A procedure was developed based on clinical experience and inspiration from previous studies and literature on medication review models. The procedure was developed to fit the busy workflow in acute admissions units. Results The procedure consists of five steps: (1) collection of clinical patient data, (2) collection of information about the patient's medical treatment, (3) patient interview, (4) critical examination of the patient's medications and (5) recommendations for the hospital physician. Conclusions We have provided a detailed description of a procedure for pharmacist-led medication review. We do so, not to provide or advocate a single one-size-fitsall solution, but in an attempt to inspire a debate of the practical approach on how to execute a systematic medication review in order to develop and expand clinical pharmacy and achieve better patient outcomes.
Quality and Safety in Health Care, 2005
Medication management in the NHS has been highlighted by the UK Department of Health as an area for improvement. Pharmacist participation on post-take (post-admission) ward rounds was shown to reduce medication errors and reduced prescribing costs in the USA and in UK teaching hospitals, which can contribute to improved medication management. We sought to demonstrate the problem in our hospital by collecting data on prescribing practice from three consecutive general medical post-take ward rounds. Setting: Northwick Park Hospital, a district general hospital in northwest London, which provides acute medical services to a population of 300 000. Strategy for change: A pharmacist was invited to become a member of the post-take ward round team that reviewed medical patients admitted within the preceding 24 hours. Patients also continued to receive care from a ward based pharmacist. Patient notes were analysed for cost of drugs on admission and discharge, discrepancies between admission drug history and pharmacist history, number of admission drugs stopped before discharge, and pharmacist recommendations. Pharmacist recommendations and actions were classified using a National Patient Safety Agency risk matrix. Effects of change: Discrepancies between the admission and the pharmacist derived drug history were noted in 26 of 50 in the pre-intervention group and 52 of 53 in the intervention group. The annual drug cost per patient following discharge increased by £181 in the pre-intervention group and by £122 in the intervention group. Five pre-admission drugs were stopped in three pre-intervention patients saving £276 per annum, while the 42 drugs stopped in 19 intervention patients saved £4699 per annum. No ward based pharmacist recommendations were recorded in the pre-intervention group. Recommendations regarding drug choice, dose, and need for drug treatment were most common; 58 minor, 48 moderate and four major risks to patients were potentially avoided. Lessons learnt: The presence of a pharmacist on a post-take ward round improved the accuracy of drug history documentation, reduced prescribing costs, and decreased the potential risk to patients in our hospital. As a result of this work a full time pharmacist has now been funded to attend daily post-take ward rounds on a permanent basis.