Advertisement

International Journal of Clinical Pharmacy

, Volume 35, Issue 6, pp 1137–1151 | Cite as

Clinical pharmacist service in the acute ward

  • Trine Rune Høgh NielsenEmail author
  • Stig Ejdrup Andersen
  • Mette Rasmussen
  • Per Hartvig Honoré
Research Article

Abstract

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 Acute ward Clinical pharmacy Denmark DRP classification Drug-related problems Electronic prescription template Medication history Medication reconciliation Medication review 

Notes

Acknowledgments

We would like to thank the three wards in Region Zealand who participated in this study. A special thanks to Mie Dyrholm and Karen Søgaard for performing the clinical pharmacist service in the study period. Thank you to the management for support and to the colleagues who have been involved in the study period at Region Zealand Hospital Pharmacy.

Funding

This study was funded by Sygehusapotekernes og Amgros’ Forsknings- og Udviklingspulje, Region Sjællands Sundhedsvidenskabelige Forskningsfond, Region Sjælland Sygehusapoteket and Helsefonden.

Conflicts of interest

None.

References

  1. 1.
    Bergkvist Christensen A, Holmbjer L, Midlöv P, Höglund P, Larsson L, Bondesson Å, et al. The process of identifying, solving and preventing drug related problems in the LIMM-study. Int J Clin Pharm. 2011;33(6):1010–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279(15):1200–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc (Wash). 2001;41(2):192–9.Google Scholar
  4. 4.
    Viktil KK, Blix HS. The impact of clinical pharmacists on drug-related problems and clinical outcomes. Basic Clin Pharmacol Toxicol. 2008;102(3):275–80.PubMedCrossRefGoogle Scholar
  5. 5.
    Viktil KK, Blix HS, Reikvam A, Moger TA, Hjemaas BJ, Walseth EK, et al. Comparison of drug-related problems in different patient groups. Ann Pharmacother. 2004;38(6):942–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Viktil KK, Blix HS, Moger TA, Reikvam A. Interview of patients by pharmacists contributes significantly to the identification of drug-related problems (DRPs). Pharmacoepidemiol Drug Saf. 2006;15(9):667–74.PubMedCrossRefGoogle Scholar
  7. 7.
    Bedouch P, Allenet B, Grass A, Labarére J, Brudieu E, Bosson JL, et al. Drug-related problems in medical wards with a computerized physician order entry system. J Clin Pharm Ther. 2009;34(2):187–95.PubMedCrossRefGoogle Scholar
  8. 8.
    Krähenbühl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krähenbühl S. Drug-related problems in hospitals: a review of the recent literature. Drug Saf. 2007;30(5):379–407.PubMedCrossRefGoogle Scholar
  9. 9.
    Lampert M, Kraehenbuehl S, Hug B. Drug-related problems: evaluation of a classification system in the daily practice of a Swiss University Hospital. Pharm World Sci. 2008;30(6):768–76.PubMedCrossRefGoogle Scholar
  10. 10.
    Blix HS, Viktil KK, Moger TA, Reikvam Å. Characteristics of drug-related problems discussed by hospital pharmacists in multidisciplinary teams. Pharm World Sci. 2006;28(3):152–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Blix HS, Viktil KK, Reikvam A, Moger TA, Hjemaas BJ, Pretsch P, et al. The majority of hospitalised patients have drug-related problems: results from a prospective study in general hospitals. Eur J Clin Pharmacol. 2004;60(9):651–8.PubMedCrossRefGoogle Scholar
  12. 12.
    PCNE. Pharmaceutical Care Network Europe. www.pcne.org. 2013. Available from: URL: http://pcne.org/sig/MedRev/medication-review.php.
  13. 13.
    Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Health Syst Pharm. 1990;47(3):533–43.Google Scholar
  14. 14.
    Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Manno MS, Hayes DD. Best-practice interventions: how medication reconciliation saves lives. Nursing. 2006;36(3):63–4.PubMedCrossRefGoogle Scholar
  16. 16.
    European Society of Clinical Pharmacy. What is Clinical Pharmacy? http://www.escpweb.org/cms/Clinical_pharmacy. 2010 November 12 [cited 2013 Jan 3]. Available from: URL: http://www.escpweb.org/cms/Clinical_pharmacy.
  17. 17.
    Lau HS, Florax C, Porsius AJ, De BA. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. Br J Clin Pharmacol. 2000;49(6):597–603.PubMedCrossRefGoogle Scholar
  18. 18.
    Andersen SE, Pedersen AB, Bach KF. Medication history on internal medicine wards: assessment of extra information collected from second drug interviews and GP lists. Pharmacoepidemiol Drug Saf. 2003;12(6):491–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057–69.PubMedCrossRefGoogle Scholar
  20. 20.
    Hellstrom LM, Bondesson Å, Höglund P, Midlöv P, Holmdahl L, Rickhag E, et al. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol. 2011;67(7):741–52.PubMedCrossRefGoogle Scholar
  21. 21.
    Scullin C, Scott MG, Hogg A, McElnay JC. An innovative approach to integrated medicines management. J Eval Clin Pract. 2007;13(5):781–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894–900.PubMedCrossRefGoogle Scholar
  23. 23.
    Lisby M, Thomsen A, Nielsen LP, Lyhne NM, Breum-Leer C, Fredberg U, et al. The effect of systematic medication review in elderly patients admitted to an acute ward of internal medicine. Basic Clin Pharmacol Toxicol. 2010;106(5):422–7.PubMedGoogle Scholar
  24. 24.
    Kjeldsen LJ, Nielsen GS. Implementation of clinical pharmacy in Danish hospital-pharmacies: winning the championship or the wooden spoon? Eur J Hosp Pharm Sci Pract. 2012;19(6):539–40.CrossRefGoogle Scholar
  25. 25.
    Olesen C. Ordination af vanlig medicin ved farmaceut. 2008 Oct.Google Scholar
  26. 26.
    Buck T, Brandstrup L, Brandslund I, Kampmann J. The effects of introducing a clinical pharmacist on orthopaedic wards in Denmark. Pharm World Sci. 2007;29(1):12–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Taegtmeyer AB, Curkovic I, Rufibach K, Corti N, Battegay E, Kullak-Ublick GA. Electronic prescribing increases uptake of clinical pharmacologists’ recommendations in the hospital setting. Br J Clin Pharmacol. 2011;72(6):958–64.PubMedCrossRefGoogle Scholar
  28. 28.
    Kuperman GJ, Bobb A, Payne TH, Avery AJ, Gandhi TK, Burns G, et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc. 2007;14(1):29–40.PubMedCrossRefGoogle Scholar
  29. 29.
    Bondesson Å, Holmdahl L, Midlöv P, Höglund P, Andersson E, Eriksson T. Acceptance and importance of clinical pharmacists LIMM-based recommendations. Int J Clin Pharm. 2012;34(2):272–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Chen T, Almeida Neto A. Exploring elements of interprofessional collaboration between pharmacists and physicians in medication review. Pharm World Sci. 2007;29(6):574–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173–84.PubMedCrossRefGoogle Scholar
  32. 32.
    Bladh L, Ottosson E, Karlsson J, Klintberg L, Wallerstedt SM. Effects of a clinical pharmacist service on health-related quality of life and prescribing of drugs: a randomised controlled trial. BMJ Qual Saf. 2011;20(9):738–46.PubMedCrossRefGoogle Scholar
  33. 33.
    Fertleman M, Barnett N, Patel T. Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds. Qual Saf Health Care. 2005;14(3):207–11.PubMedCrossRefGoogle Scholar
  34. 34.
    Mortimer C, Emmerton L, Lum E. The impact of an aged care pharmacist in a department of emergency medicine. J Eval Clin Pract. 2011;17(3):478–85.PubMedCrossRefGoogle Scholar
  35. 35.
    Mutnick AH, Sterba KJ, Peroutka JA, Sloan NE, Beltz EA, Sorenson MK. Cost savings and avoidance from clinical interventions. Am J Health Syst Pharm. 1997;54(4):392–6.PubMedGoogle Scholar
  36. 36.
    Nesbit TW, Shermock KM, Bobek MB, Capozzi DL, Flores PA, Leonard MC, et al. Implementation and pharmacoeconomic analysis of a clinical staff pharmacist practice model. Am J Health Syst Pharm. 2001;58(9):784–90.PubMedGoogle Scholar
  37. 37.
    O’Dell KM, Kucukarslan SN. Impact of the clinical pharmacist on readmission in patients with acute coronary syndrome. Ann Pharmacother. 2005;39(9):1423–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Kjeldsen L, Olesen C, Truelshøj T, Nielsen L. Physicians’ evaluation of clinical pharmacy revealed increased focus on quality improvement and cost savings. Eur J Hosp Pharm Sci Pract. 2011;17:31–4.Google Scholar
  39. 39.
    Vand S, Hermansen I. How can clinical pharmacy profession be used at the emergency wards? Scand J Trauma Resusc Emerg Med. 2012;20(2):1.Google Scholar
  40. 40.
    van Mil JW, Westerlund LO, Hersberger KE, Schaefer MA. Drug-related problem classification systems. Ann Pharmacother. 2004;38(5):859–67.PubMedCrossRefGoogle Scholar
  41. 41.
    Nathan A, Goodyer L, Lovejoy A, Rashid A. “Brown bag” medication reviews as a means of optimizing patients’ use of medication and of identifying potential clinical problems. Fam Pract. 1999;16(3):278–82.PubMedCrossRefGoogle Scholar
  42. 42.
    Larrat EP, Taubman AH, Willey C. Compliance-related problems in the ambulatory population. Am Pharm. 1990;NS30(2):18–23.PubMedGoogle Scholar
  43. 43.
    Nielsen TRH, Kruse MG, Andersen SE, Rasmussen M, Honoré PH. The quality and quantity of patients’ own drugs brought to hospital during admission. Eur J Hosp Pharm. doi: 10.1136/ejhpharm-2013-000277.
  44. 44.
    Gracious B, Abe N, Sundberg J. The importance of taking a history of over-the-counter medication use: a brief review and case illustration of ‘‘PRN’’ antihistamine dependence in a hospitalized adolescent. J Child Adolesc Psychopharmacol. 2010;20(6):521–4.PubMedCrossRefGoogle Scholar
  45. 45.
  46. 46.
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.PubMedCrossRefGoogle Scholar
  47. 47.
    Urbaniak GC, Plous S. Research randomizer (version 3.0) [computer software]. http://www.randomizer.org/. 2013 [cited 2011 Jul 14]. Available from: URL: http://www.randomizer.org/.
  48. 48.
    WHO Collaborating Centre for Drug Statistics Methodology. The Anatomical Therapeutic Chemical (ATC) classification system. http://www.whocc.no/atc/structure_and_principles/. 2012 May 4. Available from: URL: http://www.whocc.no/atc/structure_and_principles/.
  49. 49.
    Galindo C, Olive M, Lacasa C, Martinez J, Roure C, Llado M, et al. Pharmaceutical care: pharmacy involvement in prescribing in an acute − care hospital. Pharm World Sci. 2003;25(2):56–64.PubMedCrossRefGoogle Scholar
  50. 50.
    Munk CL, Bendixen HB, Kjeldsen LJ. Medication review with a focus on fracture prophylaxis among patients suffering collum femoris fractures. Eur J Hosp Pharm Sci Pract. 2011;2:26–30.Google Scholar
  51. 51.
    Ghazanfar M, Honoré PH, Nielsen TRH, Andersen SE, Rasmussen M. Hospital admission interviews are time-consuming with several interruptions. Dan Med J. 2012;59(12):A4534.PubMedGoogle Scholar
  52. 52.
    Lummis H, Sketris I, van Veldhuyzen ZS. Systematic review of the use of patients’ own medications in acute care institutions. J Clin Pharm Ther. 2006;31(6):541–63.PubMedCrossRefGoogle Scholar
  53. 53.
    Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414–22.PubMedCrossRefGoogle Scholar
  54. 54.
    Barry PJ, Gallagher P, Ryan C, O’mahony D. START (screening tool to alert doctors to the right treatment) an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36(6):632–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Gallagher P, Ryan C, Byrne S, Kennedy J, O’mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.PubMedCrossRefGoogle Scholar
  56. 56.
    Mannheimer B, Ulfvarson J, Eklöf S, Bergqvist M, Andersén-Karlsson E, Pettersson H, et al. Drug-related problems and pharmacotherapeutic advisory intervention at a medicine clinic. Eur J Clin Pharmacol. 2006;62(12):1075–81.PubMedCrossRefGoogle Scholar
  57. 57.
    Chan DC, Chen JH, Kuo HK, We CJ, Lu IS, Chiu LS, et al. Drug-related problems (DRPs) identified from geriatric medication safety review clinics. Arch Gerontol Geriatr. 2012;54(1):168–74.PubMedCrossRefGoogle Scholar
  58. 58.
    Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam GD. Drug-related problems: their structure and function. Ann Pharmacother. 1990;24(11):1093–7.Google Scholar
  59. 59.
    Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, et al. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial. J Am Geriatr Soc. 2007;55(5):658–65.PubMedCrossRefGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013

Authors and Affiliations

  • Trine Rune Høgh Nielsen
    • 1
    • 2
    Email author
  • Stig Ejdrup Andersen
    • 3
  • Mette Rasmussen
    • 4
  • Per Hartvig Honoré
    • 2
  1. 1.Region Zealand Hospital PharmacyNæstved HospitalNæstvedDenmark
  2. 2.Department of Drug Design and Pharmacology, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
  3. 3.Department of Clinical PharmacologyBispebjerg HospitalCopenhagen NVDenmark
  4. 4.HolteDenmark

Personalised recommendations