Clinical Pharmacy Services

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Clinical Pharmacy Services

CLINICAL PHARMACY SERVICES

Anantha Naik Nagappa and Uday Venkat Mateti

Manipal College of Pharmaceutical Sciences, Manipal University, Manipal-576104

Define and enumerate the Clinical Pharmacy services?

The pharmacy services can be broadly classified as clinical, hospital and community pharmacy services based on the point of service. The clinical pharmacy services are rendered in a clinic for inpatients and OPD patients. The inpatient services comprise of entire patient care and supplies regarding the aspects involving drugs. For example the activities like ward rounds, ward pharmacy, prevention of ADRs, DDIs, management of patient safety, drug information services, poison centre, pharmacovigilance services, development and management of hospital formulary, patient counseling and education along with discharge medication. However the drug store management and preparation of medications are extensive functions hospital pharmacy.

What is role and responsibility of Clinical Pharmacists in Pharmaceutical and Therapeutic committee (PTC)?

The objective of PTC is to streamline the decisions regarding selection of medicines to be used in the hospitals. The constitution of PTC comprises of Medical superintend, medical, nursing, and pharmacy staff. The PTC prepares and administers the hospital formulary which determines the godliness principle for prescription and utilization of drugs in the hospital. The PTC decides on list of medicines to be order in in-house pharmacy and sat light pharmacy including OPD pharmacy. The pharmacist is an important professional who has to guide and helps in decision making of issues pertaining to drugs to be included in the hospital list.

What is the value of Clinical Pharmacy services in therapeutics?

The goal of therapeutics is to optimize the clinical, economic and humanistic outcomes. The drugs are having variety of pharmacological manifestations leading to drug induced injury, drug induced disease and increased cost of treatments by careful observation and monitoring one can identify the signals of above mentioned trends. He can alert the fellow clinicians like doctors, nurses and suggest the team to take appropriate preventive measures. The evidence available in the literature clearly demonstrates that the healthcare delivery without clinical pharmacy is risky and dangerous.

Describe the accepted protocol of different CPS?

The CPSs are rendered by pharmacy practice department located in the hospital. The different types of services demand the pharmacists should be a part and parcel of therapeutic team like ward rounds. In ward rounds the doctors, nurses and pharmacists go to the inpatient and observe the patient condition to assess the prognosis and prescribe the course of treatment. In this process the pharmacists makes observation by documenting the prescription. This prescription is checked for patient safety, ADRs, and DDIs. He also observes any deviation in patient condition due to drugs in order to inform the doctors.

How the CPS can be integrated in the current clinical practice?

Following the ward rounds the pharmacists administers Subjective, Objective, Assessment and Planning analysis (SOAP). In SOAP analysis the patient data is integrated with clinical pharmacy knowledge in a systematic approach highlighting the patient's present condition, drug therapy and important issues like pharmacokinetics and possible events regarding Drug-drug and drug food interactions.

What are the areas of conflict for CPS?

The common goal of therapeutics is to achieve excellence in therapeutic outcomes with minimum cost and good quality of life. The doctors are focused on clinical outcomes are likely to give secondary importance to economic outcomes. The other areas of conflict may arise due to differences in background of training and the style of administration of therapeutics. For example, Doctors specialize in skills regarding diagnosis and prescribing are usually the lead persons of a therapeutic team. The Pharmacist experts in matter of drugs, Nurses experts in patient care are following the instructions of doctors. In case any disagreement regarding the practice due to professional guidelines can lead to conflict.

What is the role of communication in delivery of CPS?

The co-ordination among healthcare team with an aim to achieve best results there is no room for miss communication or inadequate communication in a clinical practice. The patients are in critical or serious conditions usually admitted as in patients. In such situations the timely communication is vital among healthcare team as it would lead to assess and administer the healthcare in the model of evidenced based medicines, practice of rational use of drugs and best patient safety practice.

Describe the role of clinical pharmacists in health care team

The clinical pharmacists are expected to cater the need of information regarding drugs and doses. Healthcare team is totally dependent on clinical pharmacists in the matters of DDI, Drug-Food interactions and ADRs. The Pharmacists should be ready to cater the demands of doctor, nurses and patients in the matters of drugs.

Discuss the significance of ethical conduct while delivering CPS

Ethics are code of conduct which is beyond rules and regulations. The ethical practice is the foundation of professional practice. The trust and mutual respect can be built on practice of goodness and consideration for fellow beings. The Dharma prescribes the guidelines for dos and don'ts for each profession. The professional and respect and recognition should be earned by ethical conduct and practice. For example in clinical practice a pharmacists may come across a blatant error happened due to a prominent practitioner under whom he has to report. In such situations the pharmacists should alert the practitioner in the interest of patient risking his future perspectives. It is very easy to remain ignorant and behave blind to such situations considering the self interest. However, the pharmacists who stand for patient cause do boost professional image and carrier prospective in a long run.

Highlight the etiquettes need to be practiced inter professional communications by clinical pharmacists

The impulsive response behavior should be curtailed in clinical pharmacy practice. The errors are bound to happen in clinical setting due to various causes and reasons. For example the psychological stress, over workload and fatigue. On notice of error it is the responsibility to correct the mistake in a diplomatic manner without hurting the sentiment of the healthcare professionals responsible for error. He must not make gestures or remarks in front of the patients or relatives so that the patient gets scared and becomes suspicious about the practitioner or the quality of care is receiving. He must communicate in passive voice to the practitioners regarding the error or omissions and possible impact on outcome. He must do this in private communication. He should never outburst or make open criticism in front of the patients

How the CPS can be pro patient centric care?

The CPS is a part of protocol of healthcare delivery which integrates the physician and nursing services by acting as a link between the patients and professionals in the matters of drug disease and life style modification. The Clinical pharmacist is supposed to reinforce the care details by explaining and resolving the queries and doubts of the patients. In doing so clinical pharmacists also learns about patient's ignorance and tries to resolve in shared empathetic manner. For example the doctors might have prescribed medicine bid or tid. The patients are likely to miss understand and use medicines without considering the pharmacokinetics. The clinical pharmacists makes it very clear, regarding bid means the dose should be spaced to 12 hours gap and similarly tid means every 8 hourly.

What are the evidences supporting the significance of CPS?

There are several systematic reviews, Meta analysis and RCTs which highlights the value of CPS in clinical practice.

Table1: Evidences supporting the significance of CPS

Randomized Controlled Trials Conducted in an Outpatient Setting Using a Pharmacist Collaborative Model for Patients with Diabetes Mellitus

Randomized Controlled Trials Conducted in a Community Setting Using a Pharmacist Collaborative Model for Patients with Diabetes Mellitus

Randomized Controlled Trials Conducted in an Outpatient Setting Using a Pharmacist Collaborative Model for Patients with Hypertension

Randomized Controlled Trials Conducted in a Community Setting Using a Pharmacist Collaborative Model for Patients with Hypertension

Randomized Controlled Trials Conducted in an Outpatient Setting Using a Pharmacist-Led Intervention Model for Patients with Hyperlipidemia

Randomized Controlled Trial Conducted in a Community Setting Using a Pharmacist Collaborative Model for Patients with Hyperlipidemia

Randomized Controlled Trial Conducted in a Community Setting Using a Pharmacist-Led Intervention Model for Smokers

Randomized Controlled Trial Conducted in an Outpatient Setting Using a Pharmacist-Led Intervention Model for Patients with Coronary Artery Disease

Randomized Controlled Trial Conducted in a Community Setting Using a Pharmacist Collaborative Model for Patients with Coronary Artery Disease

Randomized Controlled Trial Conducted in an Inpatient Setting Using a Pharmacist Collaborative Model for Patients with Heart Failure

How the quality of life is related to CPS?

The CPS is aimed at providing pharmaceutical care for the patients in a care cycle. Where in the detail issues of knowledge attitude and practice of patients get updated due to patient education and counseling. The patients become knowledge able in the areas of drug, disease and life style modifications. Which he adopts the practice of appropriate habits leads to improved quality of life.

What are the quality measures for CPS?

The Asheville Project was a multisite, community-based MTM program that focused on

improving outcomes in patients with the chronic disease states of diabetes, asthma, hypertension, and dyslipidemia. The clinical and economic outcomes of this project were evaluated using a quasi-experimental, longitudinal, pre-post study design. The important tenants of quality measures should explore Comprehensive, Accountable, Feasible, Scientifically sound, and Usable. There are various examples in the literature regarding quality measures in given table 2.

Table 2: Pharmaceutical Quality Measures

Measure Type

Measure Description

Proportion of days covered

The % of patients who were dispensed a drug within the targeted drug class who met the proportion of days covered threshold of 80%.

Gap in therapy

The % of prevalent users of a medication within the targeted drug class who had a significant gap (> 30 days) in medication therapy.

Diabetes medication dosing

The % of patients who were dispensed a dose higher than the FDA-indicated maximal dose for the following 3 therapeutic categories of oral antihyperglycemic agents: biguanides, sulfonylureas, and thiazolidinediones, as well as a combination score of the 3.

Suboptimal treatment diabetes

The % of patients receiving a medication for diabetes and hypertension who are not receiving an ACE or ARB medication

Compare the CPS with integrated hospital systems?

The major difference between the CPS and integrated hospital systems (IHS) is whether Clinical pharmacist is service provider or on request of clinician and nursing or is he an interventionist in health care. The CPS is passive compared to IHS. The pharmacists participating in therapeutic decisions in CPS model are accountable as consultants whereas IHS as service providers. IHS can bring in the elevation of quality of services provided by pharmacy practice.

References

  1. Mateti UV, Rajesh, V, Laddha A, Sharma S, Anantha NN. Activities of Pharm D students in Indian Hospital. Pharma Rev 2011;7:133-4.
  2. Al Mazroui NR, Kamal MM, Ghabash NM, Yacout TA, Kole PL, McElnay JC. Influence of pharmaceutical care on health outcomes in patients with Type 2 diabetes mellitus. Br J Clin Pharmacol. 2009;67(5):547-57.
  3. Clifford R, Batty K, Davis T, et al. A randomized controlled trial of a pharmaceutical care programme in high-risk diabetic patients in an outpatient clinic. Int J Pharm Pract. 2002;10(2):85-89.
  4. Phumipamorn S, Pongwecharak J, Soorapan S, Pattharachayakul S. Effects of the pharmacist's input on glycaemic control and cardiovascular risks in Muslim diabetes. Prim Care Diabetes. 2008;2(1):31-37.
  5. Tobari H, Arimoto T, Shimojo N, et al. Physician-pharmacist cooperation program for blood pressure control in patients with hypertension: a randomized-controlled trial. Am J Hypertens. 2010;23(10):1144-52.
  6. Taveira TH, Friedmann PD, Cohen LB, et al. Pharmacist-led group medical appointment model in type 2 diabetes. Diabetes Educ. 2010;36(1):109-17.
  7. Sarkadi A, Rosenqvist U. Experience-based group education in type 2 diabetes: a randomised controlled trial. Patient Educ Couns. 2004;53(3):291-98.
  8. Scott DM, Boyd ST, Stephan M, et al. Outcomes of pharmacist-managed diabetes care services in a community health center. Am J Health Syst Pharm. 2006;63(21):2116-22.
  9. Clifford RM, Davis WA, Batty KT, Davis TME. Effect of a pharmaceutical care program on vascular risk factors in type 2 diabetes. Diabetes Care. 2005;28(4):771-76.
  10. Sinclair H, Silcock J, Bond C, et al. The cost-effectiveness of intensive pharmaceutical intervention in assisting people to stop smoking. Int J Pharm Pract. 1999;7(2):107-12.
  11. Lowey A, Moore S, Norris C, et al. The cost-effectiveness of pharmacist led treatment of cardiac risk in patients with type 2 diabetes. Pharm World Sci. 2007;29(5):541-45.
  12. Pillittere-Dugan D, Nau DP, McDonough K, Pierre Z. Development and testing of performance measures for pharmacy services. J Am Pharm Assoc (2003) 2009;49:212-9.
  13. Tenets for Developing Quality Measures for Ambulatory Clinical Pharmacy Services: Available from: http://www.accp.com/docs/positions/whitePapers/Pharm3107e_ACCP-QualAmb.pdf

About the Author

Anantha Naik Nagappa's picture

I am professor, intrested in developing the community pharmacy services in India, We have an association called ASSOCIATION OF COMMUNITY PHARMACISITS OF iNDIA. CHECK AT www.acpi.in for further detials

Comments

Albert Ana-Maria's picture

Pharmacists have different jobs on hospital or pharmacy? What are the differences for them ?

Anantha Naik Nagappa's picture

In hospital the pharmacists are catering the needs of healthcare team to provide all the information demanded by the physician or nurses and also managing the issues like patient safety, dosage adjustments for an inpatients. Where in the Pharmacists are in the community setup are engaged with dispensing, prescription scrutinizing and also updating the patent knowledge regarding drug, disease and life style.

Prof Anantha Naik Nagappa

My Page : http://www.pharmainfo.net/ananthanaik

Ph. Bhagavan P S RPh's picture

Sir, Let us be honest in projecting the scenario in present tense.

What has been said is not at all happening or existing in INDIA because:

1. Pharmacists in hospital are just working as HELPERS than as professional pharmacists.

2. They dont have professional identity, professional freedom, professional discretion

3 They are their for their livlihood.

This doesn't mean that they are incapable. They has not been duly empowered.

They have to put forth irrational purchase indent and receive irrational supplies on the diktat of the boss who is invariably a non-professional wrt pharmacy.

They have to dispense silently many time against their consciousness

Class room and stage talks have been futile since over 6 decades.

Law is only on the books and is un-supportive to the professional service rather it counters the professional look and attitude and performance.and growth of pharmacy

One complaint from any doctor , Lo the entire regulatory joins to snub the pharmacist.

Let us be honest and desist from projecting pseudo claims as it is being done in pharmacy class rooms.

The professional pharmacy and pharmacy activity simply do not exist in India.

Bhagavan P.S. B Pharm

Rtd. Dy Dir.(Pharmacy),Govt of Karnataka, India
Srinivas's picture

what are the parameters to assess the quality of services provided by a clinical pharmacist?

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