Pharmaceutical Care Concept

Pharmaceutical Care goal is to improve clinical outcome of patient by optimization of drug therapy outcome.

The pharmaceutical care task are counseling, pharmacotherapy planing, drug monitoring, home visit and telephone care.

Example
Patients were randomly assigned to a pharmacist-involved group (treatment) or a group with no pharmacist involvement (control). Pre- and post-test BPs, tablet counts, lifestyle modifications, and pharmacists' recommendations were recorded.
Hypertensive patients who received pharmacist input achieved a significantly greater benefit in BP reduction, BP control, and improvement in adherence rate and lifestyle modification.

HYPERTENSION

Pharmacist Involvement in Primary Care Improves Hypertensive Patient Clinical Outcomes

Phayom Sookaneknun, PharmD
The Annals of Pharmacotherapy: Vol. 38, No. 12, pp. 2023-2028. DOI 10.1345/aph.1D605
© 2004 Harvey Whitney Books Company.

How to be a great pharmacist ?

If you want to be a great pharmacist. You shoul be do something to increase your skill and knownlege such as the paper reading, communiction skills and pharmacotherapy knownlege.

The first step of great pharmacist way is learning the Pharmacotherapeutics subject and epidermology or Clinical trial concept.

The next step is learning by doing by used case study from textbook and talk with your patients. The importance thing that pharmacist must keep in mind is " How to make better QOL of patients or more clinical outcome?"

Example
Clinic-based pharmacists offered support to patients with diabetes through direct teaching about diabetes, frequent phone follow-up, medication algorithms, and use of a database that tracked patient outcomes and actively identified opportunities to improve care.
In conclusion, a pharmacist-based diabetes care program integrated into primary care practice significantly reduced HbA1c among patients with diabetes and poor glucose control.

Pharmacist Led, Primary Care-Based Disease Management Improves Hemoglobin Aic in High-Risk Patients With Diabetes

Russell Rothman, MD, MPP

Betsy Bryant, PharmD, CDE

Department of Medicine, University of North Carolina, Chapel Hill, NC

Cheryl Horlen, PharmD

School of Pharmacy, Campbell University, Buies Creek, NC

Michael Pignone, MD, MPH

Division of General Internal Medicine, University of North Carolina, Chapel Hill, NC

American Journal of Medical Quality, Vol. 18, No. 2, 51-58 (2003)
DOI: 10.1177/106286060301800202
© 2003 American College of Medical Quality

Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit

In traditional hospital practice most of the burden of drug therapy decision making falls on the physician. However, studies have shown that physicians sometimes make errors in prescribing drugs.1-2 While most errors are harmless or are intercepted, some result in adverse drug events (ADEs). The pharmacist's role in prescribing is typically reactive: responding to prescription errors long after the decision has been made for patients about whom he or she has little direct clinical knowledge. Thus, the specialized knowledge of the pharmacist is not utilized when it would be most useful: at the time of ordering.

Studies show that pharmacist retrospective review of medication orders prevents errors.3-5 However, the pharmacist's impact might be substantially greater if he or she could provide input earlier, at the time of prescribing. It has been shown that pharmacist consultation with physicians and others in an intensive care unit (ICU) resulted in a net saving from reduced drug use of $10,011 in a 3-month period.6 However, we know of no controlled studies that have evaluated the effect of pharmacist participation on the key outcome measure of error prevention—the rate of ADEs.

For these reasons, we conducted a controlled clinical trial of the efficacy of pharmacist participation in physician rounds in a medical ICU as part of a continuing study of systems changes to prevent ADEs. The ADE rate is higher among patients in ICUs, both because they have pathophysiological abnormalities and often receive many drugs.

We asked the following questions: (1) Is pharmacist participation on rounds associated with a reduction in the rate of preventable ADEs? (2) What types of interventions does the pharmacist make? and (3) Is pharmacist participation on ICU rounds accepted by physicians and nurses?

Comments

In previous studies, we demonstrated that nearly half of preventable ADEs resulted from errors in the prescribing process.1 Prescribing errors frequently have a cascade effect, causing errors downstream in dispensing or administration. The major cause of prescribing errors was physicians' lack of essential drug and patient information at the time of ordering.2

One method of providing such information is computerized physician order entry, which has been shown to reduce the rate of serious medication errors by more than half.9 Evans et al10 have demonstrated that a computer-assisted management program for antibiotics can substantially reduce excessive use and misuse of antibiotics as well as reduce length of hospital stay and costs. However, most hospitals do not yet have computerized ordering by physicians, so incorporation of the pharmacist into the patient care team is a more feasible alternative at present, especially in units with high medication use.

We estimated the financial impact of the 66% reduction in ADEs. The cost of an ADE has been estimated at $2000 to $2500 per event in 1993.11-12 However, the cost of a preventable ADE, one due to an error, was estimated at $4685.9 For the year 1995 , we estimate that 58 ADEs were prevented. At $4685 each, the cost reduction in this single unit would be approximately $270,000 per year. The intervention required no additional resources and represented a different use of the existing pharmacist's time. Rather than spending time checking and correcting orders after they had been sent to the pharmacy, the pharmacist was involved at the time the order was written. While participating in rounds as a member of the patient care team, the pharmacist reduced ADEs both by preventing errors and by intercepting them. He prevented errors by providing information about doses, interactions, indications, and drug alternatives to physicians at the time of ordering. He intercepted errors by immediately reviewing all orders and correcting deficiencies before the orders were transmitted to the pharmacy. In addition, the pharmacist prevented nursing medication errors by providing ready consultation to the nursing staff and teaching drug safety.

Finally, the on-site pharmacist took overall responsibility for medication safety, spotting unsafe conditions and identifying needs for process improvement. For example, during the study period the pharmacist identified 12 systems errors in pharmacy function and 6 ADEs that probably would not have otherwise been discovered.

The presence of the pharmacist on rounds was well accepted by physicians, as evidenced by the fact that 99% of the recommendations were accepted. While staff perceptions were not evaluated systematically, in our experience, nurses also accepted this role easily, appreciating the reduction in extra work, such as telephoning physicians to have orders corrected. The pharmacist in this study had to overcome the traditional impression of the medical staff that pharmacists may be primarily concerned with costs. This academic medical ICU environment had the added challenge of dealing with a new group of house staff, fellows, and attending physicians every few weeks. In ICUs where the attending physicians are permanent and fellows are assigned for many months, acceptance might be enhanced.

Our study has several limitations. We studied only 1 ICU in 1 teaching hospital. Adverse drug events are more common in teaching hospitals than in community hospitals13 and occur more frequently in ICUs,1 so these findings are not generalizable to all types of units or all types of hospitals. However, the magnitude of the impact of the pharmacist's presence was so great that a substantial effect would probably be found in ICUs in other hospitals. Second, our results do not represent the full extent of preventable ADEs, since record review does not capture all events, nor does it capture most potential ADEs, the "near misses," because they are seldom recorded in patient charts. Third, physicians and nurses in this ICU function as a team and make rounds together. Pharmacist participation would be more difficult to arrange in units where multiple physicians make rounds at different times. Finally, the success of the pharmacist intervention depends on interpersonal relationships. Thus, the personality and cooperativeness of the pharmacist and the medical staff are critical factors in making this system work, especially at the beginning. Similar prevention of ADEs prompted by a designated ICU pharmacist probably would be less likely to occur in ICUs in which staff are not part of a multidisciplinary team and when ICU staff are not open to the important role that the pharmacist can play in optimizing ICU management.

We conclude that participation of a pharmacist on medical rounds can be a powerful means of reducing the risk of ADEs.

ADMISSION OR DISCHARGE MEDICATION RECONCILIATION

Medication review and reconciliation was the primary target of 11 studies.28-38 In the 2 admission interventions, Nester and Hale28 found that medication histories taken by pharmacists, as opposed to nurses, resulted in more accurate medication and allergy information, identified allergy history errors more frequently, and entered allergy information into the computer more quickly, with no difference in drug interactions or ADRs. In a study from Australia, Stowasser et al29 implemented a medication liaison service to improve communication between outpatient physicians and pharmacists and the inpatient team at admission and discharge. The intervention group was more likely to have a pharmacist intervene or change at least 1 medication during hospitalization, with no effect on LOS or mortality. At 30 days, the intervention group had fewer health care visits, nonsignificant reduction in readmissions, and no overall change in health status.

Another 9 studies focused on discharge counseling. Smith et al30 performed home visits and assessed pharmacist discharge counseling on patient medication-taking behavior and found significantly better levels of medication adherence (P<.01), although 75% of patients in the intervention group and 96% of patients in the control group were not taking medications as prescribed. Bolas et al31 compared standard discharge planning with pharmacist discharge counseling coupled with a discharge letter from the inpatient physician to the patient's general practitioner. Significant improvement was noted in the correlation between discharge and home medications 10 to 14 days after discharge, as well as knowledge of drug name, dosage, and frequency, with no difference in readmission rates. In a Veterans Administration hospital discharge counseling intervention, Williford and Johnson32 reported that patients were no more knowledgeable or compliant at the 6-week follow-up.

In a study by Lipton and Bird,33 pharmacists reviewed hospital records, consulted with physicians, provided discharge counseling, and made 4 follow-up telephone calls after discharge. At 2 months, patient medication knowledge was higher in the intervention group. At 3 months, patients in the intervention group compared with those in the control group received fewer medications (5.16 vs 6.75; P<.001) and fewer daily doses (8.30 vs 12.04; P<.001), and reported fewer missed doses (8% vs 22%; P<.001); resource use was not affected. From the same study, Lipton et al34 evaluated a 236-patient sample in 6 domains of medication appropriateness. Patients in the intervention group were less likely to have one or more prescribing problems in any category, in appropriateness or in dosage.
Johnston et al35 evaluated the role of pharmacist discharge counseling on medication knowledge in older patients. An evaluation immediately before discharge and a recall questionnaire found that the percentage of critical items correct for the pharmacist-counseled group was 93% compared with 77% in the control group (P = .02). Nazareth et al36 reported no differences in hospital readmissions, outpatient visits, or mortality at 3 or 6 months for a discharge pharmacist intervention to coordinate care with outpatient pharmacists and providers in patients older than 75 years. In a similar study, Al-Rashed et al37 enrolled 83 elderly patients at discharge and reported improvements in knowledge, compliance, outpatient visits, and hospital readmissions. In the most recent study of pharmacist counseling at discharge with telephone follow-up after 3 to 5 days, Schnipper et al reported fewer
preventable ADEs (1% vs 11%; P = .01) and fewer preventable medication-related emergency department visits or hospital readmissions (1% vs 8%; P = .03) at 30 days in the intervention group compared with the control group, with no difference in medication compliance.

Clinical Pharmacists and Inpatient Care

Clinical pharmacists are uniquely trained in therapeutics and provide comprehensive drug management to patients and providers (includes physicians and additional members of the care team). Pharmacist intervention outcomes include economics, health-related quality of life, patient satisfaction, medication appropriateness, adverse drug events (ADEs), and adverse drug reactions (ADRs). An ADE is defined as "an injury resulting from medical intervention related to a drug," and an ADR is defined as "an effect that is noxious and unintended and which occurs at doses used in man for prophylaxis, diagnosis, or therapy." Reviews have been published about clinical pharmacy services in various settings, including ambulatory care, geriatrics, psychiatry, critical care, economic outcomes, and health-related quality of life, and a comprehensive review was published in 1986. To our knowledge, no previous reviews have focused specifically on clinical pharmacist interventions in the inpatient setting. This type of review is of particular importance because most studies reporting medication errors and ADEs were in hospitalized patients, and with the growth of hospital medicine,13 there is increased focus on interventions to improve the care of hospitalized patients. Benefits of clinical pharmacists have also been used to support expansion of their scope of practice.


Two recent Institute of Medicine reports recognized that pharmacists are an essential resource in safe medication use, that participation of pharmacists on rounds improves medication safety, and that pharmacist-physician-patient collaboration is important.15-16 In a recent survey, 30% of hospitals (74% of hospitals with >400 beds) reported that pharmacists attend rounds, and the rate is increasing.17 The role of clinical pharmacists differs from that of traditional pharmacists in that they work directly with providers and patients to provide services not simply associated with dispensing of drugs. Many clinical pharmacists have completed residencies and are board certified in specialty areas such as pharmacotherapy, oncology, nutrition, and psychiatry. This qualitative systematic review evaluates the published literature on the effects of pharmacist interventions in controlled trials in hospitalized patients.

PATIENT CARE UNIT PHARMACIST PARTICIPATION ON ROUNDS

Two studies involved the intensive care unit (ICU). Leape et al18 implemented a trial of pharmacist participation in a medical ICU, comparing ADE rates before and after intervention and with a control ICU. Preventable ADEs decreased by 66%, from 10.4 per 1000 patient-days before the intervention to 3.5 patient-days after the intervention (P<.001), with no change in the control ICU, from 10.9 per 1000 patient-days before the intervention to 12.4 per 1000 patient-days after the intervention (P = .76). Actual ADEs also decreased in the study ICU, from 33.0 to 11.6 per 1000 patient-days (P<.001), with an increase in the control ICU, from 34.7 to 46.6 per 1000 patient-days (P<.001). In a medical progressive care unit, Smythe et al19 implemented a clinical pharmacist–structured evaluation of 131 patients during 8 weeks and reported fewer ADRs compared with baseline (1 vs 8 events; P = .03); ICU transfer, readmission rate, and hospital length of stay (LOS) did not differ between baseline and intervention.

Eight studies20-27 assessed clinical pharmacists on general medicine, surgery and psychiatry services. Bjornson et al20 evaluated a clinical pharmacist intervention involving medication reconciliation, drug therapy plans, and discharge counseling. Intervention teams had fewer patients transferred for more intensive care and their patients had shorter LOS, but hospital readmissions and mortality did not differ. There were more ADRs in the intervention group (1.7%) compared with the control group (0.5%), but no P value was reported. The authors attribute this to a higher propensity for pharmacists to document ADRs. Scarsi et al21 compared results in patients when a pharmacist participated on rounds with an inpatient medicine team compared with patients who received pharmacist services only on the first day of hospitalization or when requested. These authors reported reductions in medication errors, number of patients without a medication error during hospitalization, and duration that an error persisted once it occurred.

One of the first intervention trials of clinical pharmacists on patient care units by Clapham et al22 involved regular interaction with physicians, patients, and nurses compared with the more traditional role of centralized pharmacy drug monitoring. The intervention reduced total average cost ($1293; P<.05) and produced nonsignificant reductions in LOS and drug costs, and pharmacists found working on the patient care area more professionally rewarding. In similar studies by Haig and Kiser23 and Boyko et al,24 inclusion of pharmacists on general medical teams resulted in reductions in LOS and in hospital and pharmacy costs. Kucukarslan et al25 found that a clinical pharmacist on the medicine team reduced preventable ADEs by 78%, but the number of events was small (2 vs 9; P = .02). The intervention was well accepted by physicians, with 98% of pharmacist recommendations accepted.

Owens et al26 assessed a geriatric team pharmacist and found that the intervention resulted in fewer medications by day 3 (P<.05), with the greatest reduction in patients in nursing homes. Medication use was increased by day 3 in 40% of subjects in the control group vs 18% of patients in the intervention group (P<.005), and control subjects received more medications without indications (19% vs 11%; P<.025) and inappropriate medications (37% vs 20%; P<.005), with no difference in number of medications at 6 weeks and 3 months. In the 1 inpatient psychiatry study, Canales et al27 showed significant improvements in clinical response (measured by psychiatric scales) and extrapyramidal symptoms, with no difference in medication costs and LOS.

The commitment of great pharmacist.

1 To save the life of people.
2 To develope the quality of life of people.
3 To reduce the morbility rate in people.