Care Clinical Pharmacy Research Articles

Exploring the suitability of a ward-based clinical pharmacy activity collection tool for ambulatory care practice: a mixed-methods study.

At a London-based hospital, a validated ward-based clinical pharmacy activity collection tool has been used to monitor activities of clinical pharmacy teams across all settings, including ambulatory care services. No data confirm its representativeness for the full range of ambulatory clinical pharmacy services, and pharmacists share this concern. This study aimed to identify the range of clinical pharmacy activities in ambulatory care, assess the suitability of the existing ward-based tool for capturing these activities, and recommend modifications. Non-participant direct observations were conducted to record pharmacists' clinical activities in ambulatory clinics and multidisciplinary meetings. These observations were compared to the existing ward-based tool to identify discrepancies. Semi-structured interviews with eight ambulatory pharmacists were transcribed verbatim and thematically analysed inductively to explore the tool's representativeness of their routine clinical activities. Twenty-nine clinical pharmacy activities were observed in ambulatory services. Only fifteen were captured by the existing tool, with therapy monitoring and recommending therapeutic changes not accurately captured. Pharmacists agreed that the tool was not fully representative and included irrelevant activities. Four common uncaptured activities were multidisciplinary meeting-specific activities, arranging laboratory tests, monitoring patient outcomes, and liaising with community healthcare professionals. This study identified 33 candidate ambulatory clinical pharmacy activities. The existing ward-based tool does not fully capture the full range of ambulatory care clinical pharmacy activities, highlighting the need for an improved tool. Pharmacists recommended including the uncaptured activities. The candidate activities provide a foundation for standardised measurement of relevant ambulatory care activities to enable effective workforce deployment and improve patient outcomes.

Critical care clinical pharmacy value-based metrics: Time to terminate widget counting

Critical care clinical pharmacy value-based metrics: Time to terminate widget counting

The road less traveled: Developing pharmacist clinician-scientists through divergent training pathways.

Professional organizations have emphasized the growing need for pharmacists to possess advanced research skills; however, there is a scarcity of training programs aimed at nurturing clinician-scientists. This report outlines 3 critical care-focused research programs, each offering a unique approach to training clinician-scientists. Limited resources and formalized programs are available to bridge the gap between the demand for and availability of skilled clinician-scientists. Several programs have stepped forward to share their experiences in establishing and executing training initiatives aimed at cultivating skilled clinician-scientists in the critical care practice space. Enhancing the development of clinician-scientists for clinical and translational research is necessary in the critical care clinical pharmacy community.

Expansion of around the clock critical care and emergency medicine clinical pharmacy services at a large urban academic medical center

AbstractThe impact of a pharmacist as a dedicated member of multidisciplinary intensive care unit (ICU) and emergency department (ED) teams has repeatedly been described in the literature for over 20 years. A 2020 position paper published by the Society of Critical Care Medicine and the American College of Clinical Pharmacy recommended the optimal practice model include critical care pharmacists providing direct patient care 24 h a day, 7 days a week. The objective of this paper is to describe the expansion and evolution of clinical pharmacy services provided in the ICU and ED at a large academic health center, beginning in 2015 and accelerated in the face of a global pandemic. This was made possible through a combination of creating new positions and reallocating existing positions to substantially increase ICU and ED clinical pharmacy coverage. Over a 7 year period, the emergency medicine and critical care clinical pharmacy team expanded from six full time equivalent (FTE) employees in 2015 to 16 FTEs in early 2022. This allowed for reduced pharmacist to patient ratios, the expansion of clinical pharmacy services from primarily weekday hours to a 24 h per day coverage model, 7 days a week, and to better support clinical pharmacy specialists providing these services. Rapid expansion of around the clock clinical pharmacy services was only possible through collaboration between clinical and operations pharmacy managers and feedback from members of the multidisciplinary team.

Current developments of ambulatory pharmaceutical care in Saudi Arabia

AbstractIntroductionThe evolving specialty of ambulatory care pharmacy practice under the clinical pharmacy profession in the Kingdom of Saudi Arabia (KSA) has blossomed recently. It has provided patient‐centered care in multiple areas such as medication therapy management, anticoagulation, diabetes management, and immunization that advanced over the past two decades. In light of the Saudi Vision 2030, the ambulatory care pharmacy practice awaits tremendous opportunities with expected challenges that require consequential efforts and vigilant planning by clinical pharmacists and concerned governmental and non‐governmental bodies.ObjectivesDescribe the current and future development of ambulatory care pharmacy services in KSA and propose a scheme for collaborative practice agreement (CPA).MethodsThis is a review written by a group of experts under the umbrella of the Saudi Society of Clinical Pharmacy (SSCP) to propose a structured strategy for building an ambulatory care pharmacy practice in KSA, describe the currently available services and training requirements, and suggest a scheme for CPA.Results and ConclusionThe experts' vision support the ambulatory care pharmacy practice in KSA, recommends a framework and constructed elements for a unified and comprehensive CPA in the region. It emphasizes on the training and set requirements for pharmacists to be eligible to provide ambulatory care clinical pharmacy services in a defined care setting.

The Home Care Clinical Pharmacy Practice in Saudi Arabia

The Home Care Clinical Pharmacy Practice in Saudi Arabia

Addressing healthcare inequity experienced by Native Hawaiians with type 2 diabetes: Advancements in an interdisciplinary ambulatory care clinical pharmacy service

Addressing healthcare inequity experienced by Native Hawaiians with type 2 diabetes: Advancements in an interdisciplinary ambulatory care clinical pharmacy service

Impact of Palliative Care Clinical Pharmacists in an Inpatient Care Setting on Total Health Care Expenditures.

Background: Inpatient palliative care clinical pharmacy specialists (IPCPS) on multidisciplinary palliative care (PC) teams have expanding roles in the treatment of pain, nausea, and other symptoms for patients with serious illnesses. Objectives: The aim of this study was to assess the clinical and financial outcomes associated with an IPCPS on an inpatient PC team. Setting and Design: This was a retrospective cohort study conducted in Colorado. Adult patients with an inpatient stay and a PC consult between October 1, 2016 and February 28, 2019 were included. Patients were assigned to the observation group if they received PC from a clinical pharmacist and control group if they received usual PC. The primary outcome was the 180-day change in daily total cost-of-care expenditures. Secondary outcomes included length of index hospitalization and 180-day change in daily morphine milligram equivalents (MME), health care utilization, and opioid adverse effects (AE). Results: A total of 1543 patients were included with 228 and 1315 in the IPCPS and usual care groups, respectively. After adjustment, the IPCPS group had a greater median decrease in daily expenditures (-$22 vs. $6, p = 0.003), higher median increase in daily MME (16.5 vs. 9.7 mg, p = 0.007), and fewer patients with a subsequent hospitalization (34.2% vs. 39.2%, p = 0.010) or urgent care visit (10.5% vs. 14.6%, p = 0.024) but longer mean index hospitalization (9.3 vs. 7.7 days, p = 0.003) and no differences in AE during follow-up (all p > 0.05). Conclusion: IPCPS participation on the PC team can be a component of health care cost reduction while contributing to patient-centered quality care.

Expert consensus on clinical application of multi-chamber bag for parenteral nutrition (2022)

Parenteral nutrition has become a routine clinical nutritional treatment. The guidelines at home and abroad unanimously recommend and standardize the application of "all in one" parenteral nutrition."Multi-chamber bag" parenteral nutrition encapsulates nutrients such as fat emulsion, amino acid and glucose in a non polyvinyl chloride soft bag composed of two or three cavities. When in use, the inner cavity separator is opened. The multi-chamber bag preparation has a variety of specifications and has the characteristics of reasonable prescription, strict quality standards, ready-to-use, and other characteristics, which can reduce prescription and configuration errors, reduce bloodstream infections, and meet the clinical nutritional needs of most patients. In view of the non-standard application of multi-chamber bag, the Chinese Society for Parenteral and Enteral Nutrition organized domestic experts in general surgery, critical care medicine, gastroenterology, geriatrics, nutrition, clinical pharmacy, and evidence-based medicine to write this expert consensus in accordance with the latest guidelines, expert consensus, and the latest clinical evidence. According to the improved Delphi method, 43 experts discussed and modified 23 recommendations one by one in the first round, and 219 experts voted and put forward modification suggestions in the second round. Each recommendation shall be established only when the approval rate of ≥ 90%. It is hoped that this consensus can promote the rational application of multi-chamber bag for parenteral nutrition.

Critical Care Pharmacy Program Accreditation Standards Framework and Core Competencies in Saudi Arabia

Clinical pharmacy services in Saudi Arabia are expanding steadily, particularly with notable developments in critical care pharmacy services and training programs, including four critical care residency programs localized in Riyadh and one program in Jeddah. The Scientific Council of Pharmacy leads extensive efforts to advance clinical pharmacy practice and training under the Saudi Commission for Health Specialties (SCFHS), the accrediting body for critical care training programs and all other specialties. Despite launching critical care pharmacy programs in 2013, currently available accreditation standards and competency assessments for specialized residency programs in critical care were established in 2020. These accreditation standards and competency assessment modalities have been found to have significant areas of improvement based on the feedback of practicing critical care pharmacy residency program directors and trainees over the past few years. This is an opinion paper based on a consensus of critical care and emergency medicine pharmacy experts which recommends updating the current accreditation standards framework and competency assessment blueprint for specialized critical care pharmacy programs. Additionally, it highlights the need to modify the accreditation standards framework for critical care pharmacy programs. Further evaluation of these modalities can be revised as deemed reasonable by governmental authorities by recruiting practicing critical care clinical pharmacy experts.

Role of advanced practice pharmacists in general practice

Advanced practice pharmacists working in general practice represent the next step in the evolution of primary care clinical pharmacy. This article outlines the role of the advanced practice pharmacist and the various routes pharmacists can take to become one. It also provides examples of some of the roles they can take on in general practice.

Pharmacy practice in hospital settings in GCC countries: Prescribing and transcribing

PurposeTo outline hospital pharmacy practices across the Gulf Cooperation Councils (GCC) countries’ hospitals. MethodsA modified survey questionnaire was prepared from the original 2019 American Society of Health-System Pharmacist (ASHP) survey questions. Survey details were discussed with some pharmacy directors for clarity and relevance. A list of hospitals were obtained from the Ministry of Health of each of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly. ResultsSixty four hospitals responded to this survey. The overall response rate was 52%. About 47% of the surveyed hospitals considered their drug formularies as closed, and strict. Additionally, only 44% of hospitals compare the effectiveness of products, when taking formulary decisions for drug inclusion. Forty-four percent of hospitals have computerized prescriber order entry (CPOE / EHR) system functionality for formulary system management. At about 39.1% hospitals, pharmacists have the responsibility for managing medication therapies, majority were engaged in providing anticoagulation therapies. About 61% of hospital pharmacies in GCC countries receive medication orders electronically, through CPOE/EHR. Majority (66%) of the hospitals in GCC countries have an active Antimicrobial Stewardship Program (ASP) while only 40% of pharmacists have a key role in providing clinical support. About 57.8% of hospital pharmacy directors reported that pharmacists do not provide ambulatory care clinical pharmacy servicesin their hospitals. ConclusionIn GCC countries’ hospitals, there are major areas for improvement to patient care of which pharmacists are uniquely qualified as the medication experts to have the most meaningful outcomes in all of the domains of safe medication use, medication therapy management, antimicrobial stewardship program and participation in outpatient clinics.

Pilot of a pharmacist‐integrated interprofessional team to optimize prescribing in a telemedicine palliative care clinic

AbstractIntroductionThe rapidly growing number of frail elderly patients is leading to a greater need for palliative care services. Palliative care clinical pharmacy specialists (CPSs) can improve quality of care through comprehensive symptom and medication management. Incorporating pharmacists into palliative care through telemedicine meets complex pharmacotherapy needs of Veterans who have difficulty accessing care due to advanced illness.ObjectivesThe primary objective of this quality improvement project was to pilot a pharmacist‐integrated palliative care team clinic utilizing telemedicine to optimize palliative prescribing for Veterans and to describe CPS outcomes related to pharmacotherapy changes implemented. A secondary outcome was to assess Veteran satisfaction with assessments completed via telephone post visit.MethodsA CPS was integrated into the existing palliative care team beginning December 1, 2019 with video and audio telemedicine clinic appointments offered through May 31, 2020. The CPS completed comprehensive medication regimen reviews, assessed symptoms, and addressed medication‐related concerns during the visit. Recommendations for deprescribing opportunities and symptomatic management were provided to the consulting provider and/or primary treatment team. Recommendations made and those implemented within 30 days of the appointment were documented. Veteran satisfaction assessments were completed via telephone 14‐30 days after the clinic visit.ResultsThe palliative care team integrated a CPS and completed 25 consults via telemedicine technology between December 2019 and May 2020. The pharmacotherapy implementation rate was 60% (119/200) including a deprescribing rate of 57% (72/126), decreasing polypharmacy and potentially resulting in a decrease in adverse drug events. Veterans were on average very satisfied with their visit, with an assessment response rate of 56% (14/25).ConclusionPharmacist involvement with the palliative care team decreased polypharmacy, optimized symptom management, and increased use of telemedicine technology. Veterans were overall satisfied with the care received by the palliative care team via telemedicine technology.

Development of a process map for the delivery of virtual clinical pharmacy services at Odette Cancer Centre during the COVID-19 pandemic.

Virtual methods have been innovatively utilized to provide clinical and supportive care to patients with cancer. Oncology pharmacists have been actively involved in this movement, in order to minimize patient contact and decrease the risk of viral transmission for this high-risk group. In response to COVID-19 restrictions, the Odette Cancer Centre pharmacy modified the delivery of clinical pharmacy services (CPS), including medication histories and patient education/counseling, to a remote telephone-based model. Process maps were created to visualize workflow before and after the pandemic. Process metrics were tracked over a 6-week period. From March 25th to May 1st, 2020, 202 best-possible medication histories and baseline assessments were completed; 149 of these (74%) were completed remotely. For medication therapy counsels, 72 of 199 were completed remotely (36%). Despite workflow disruptions caused by the pandemic, these results demonstrate that clinical pharmacy service levels could be maintained by incorporating remote delivery approaches without significant investment in resources. Challenges included acceptance by patients and lack of technology to support system-level processes. Further research to develop, refine, and individualize virtual clinical pharmacy care models will help to consolidate the role of these approaches in the post-COVID-19 era.

Prescribing and documentation by critical care clinical pharmacy specialists with around‐the‐clock staffing: A single‐center evaluation

AbstractIntroductionEvidence supports pharmacists as essential team members in the intensive care unit (ICU). Data are limited for pharmacist prescribing and documentation, ideal pharmacist staffing, and timing of clinical pharmacy activities in the ICU.ObjectiveThe purpose of this evaluation was to assess the frequency, timing, and most common areas of prescribing and documentation for critical care clinical pharmacy specialists (CPSs) in a single medical center with around‐the‐clock staffing.MethodsA Veterans Affairs (VA) medical center implemented a collaborative practice model in which CPSs provide direct ICU patient care around the clock. Direct patient care activities are provided for two ICUs with three multidisciplinary teams (medical, surgical, and cardiovascular), the nutrition support team, and emergency response teams. Documentation through an electronic health record progress note is required any time a CPS performs a patient encounter and uses prescriptive authority. A retrospective evaluation was performed to evaluate critical care CPS patient encounters and clinical interventions from October 1, 2016 through September 30, 2020.ResultsCumulatively, 78 622 CPS clinical interventions requiring prescriptive authority were made during 17 938 documented encounters. For clinical interventions, 40 897 (52.0%) were during daytime hours and 37 725 (48.0%) were after‐hours. Of the documented encounters, 10 461 (58.3%) were during daytime hours compared with 7477 (41.7%) after‐hours. Medication‐related prescribing interventions accounted for 57 400 (73.0%) of the interventions, while 6931 (8.8%) were nonpharmacologic and 14 291 (18.2%) were additional interventions. The most common disease states for prescribing interventions included Anticoagulation (13.8%), Infectious Diseases (13.1%), Cardiovascular (10.5%), Nutrition/Gastrointestinal (6.6%), Neuropsychiatric (5.3%), Endocrine (4.3%), Nephrology (3.5%), and Pulmonary (1%).ConclusionThis evaluation provides details of prescribing and documentation by critical care CPSs with an around‐the‐clock staffing model. This may be useful for ICU clinicians and administrators considering expanding critical care pharmacy services.

Outpatient clinical pharmacy practice in the face of COVID-19 at a cancer center in New York City.

With the rapid spread of COVID-19 in New York City since early March 2020, innovative measures were needed for clinical pharmacy specialists to provide direct clinical care safely to cancer patients. Allocating the workforce was necessary to meet the surging needs of the inpatient services due to the COVID-19 outbreak, which had the potential to compromise outpatient services. We present here our approach of restructuring clinical pharmacy services and providing direct patient care in outpatient clinics during the pandemic. We conducted a retrospective review of electronic clinical documentation involving clinical pharmacy specialist patient encounters in 9 outpatient clinics from March 1, 2020 to May 31, 2020. The analysis of the clinical pharmacy specialist interventions and the impact of the interventions was descriptive. As hospital services were modified to handle the surge due to COVID-19, select clinical pharmacy specialists were redeployed from the outpatient clinics or research blocks to COVID-19 inpatient teams. During these 3 months, clinical pharmacy specialists were involved in 2535 patient visits from 9 outpatient clinics and contributed a total of 4022 interventions, the majority of which utilized telemedicine. The interventions provided critical clinical pharmacy care during the pandemic and omitted 199 in-person visits for medical care. The swift transition to telemedicine allowed the provision of direct clinical pharmacy services to patients with cancer during the COVID-19 pandemic.

Implementation of primary care clinical pharmacy services for adults experiencing homelessness

BackgroundIt is estimated that on any given night in the United States, more than half a million individuals experience homelessness. Within the homeless population, chronic conditions such as diabetes, heart disease, and human immunodeficiency virus are found at rates 3-6 times higher than in the general population. Despite this, access to appropriate treatment and preventive care remains difficult for those experiencing homelessness, and many barriers exist to achieving positive health outcomes. ObjectiveThe primary objective of this study was to determine the clinical impact and sustainability of implementing clinical pharmacy services in a clinic for adults experiencing homelessness. Practice descriptionAs a pilot service, a postgraduate year 2 ambulatory care pharmacy resident attended the Pedigo clinic for adults experiencing homelessness 1 half-day per week to provide independent cardiovascular risk reduction (CVRR) disease state management under a collaborative practice agreement. Practice innovationThe existing CVRR model was applied at a clinic location that did not previously have clinical pharmacy services. The provision of these services was adapted to meet the unique health needs of the homeless population. Evaluation methodsThe outcomes from having a clinical pharmacist in this clinic setting were retrospectively reviewed from September 2019 to March 2020. ResultsDuring the pilot period, the pharmacist conducted 28 encounters for 14 unique patients and made a mean of 4 clinical interventions per patient encounter. A total of 124 interventions occurred, including comprehensive medication review (n = 23; 82.1%), patient education (n = 21; 75%), medication regimen optimization (n = 18; 64.3%), and tobacco cessation (n = 18; 64.3%), among several others. Clinical outcomes (glycosylated hemoglobin level, blood pressure, and weight) remained stable with pharmacist management throughout the pilot period. ConclusionThe addition of a clinical pharmacist to the interdisciplinary care team for patients experiencing homelessness addresses a health care disparity and enhances the care provided to this vulnerable population.

Identification of the optimal primary care clinical pharmacy comprehensive medication management practice in the veterans health administration

AbstractClinical pharmacists are well‐positioned as the medication experts on the health care team to work collaboratively with providers and patients to achieve optimal medication use in order to maximize patient benefit and outcome. Comprehensive medication management (CMM) is defined as a patient‐centered approach to optimizing medication use and improving patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health care providers. Lack of fidelity in practice model design and implementation make generalization of results of clinical pharmacy CMM practice difficult. There is currently no organization that evaluates standardized implementation of clinical pharmacists providing CMM in a Patient‐Centered Medical Home (PCMH) leading to wide variability of CMM implementation within the PCMH model. The Veterans Health Administration (VA) is the largest integrated health care system in the United States. Clinical pharmacy specialists (CPS) in the VA work autonomously but collaboratively under a practice area‐based scope of practice with prescriptive authority. The goal of the Clinical Pharmacy Practice Office Platinum Practice Designation was to develop a standardized review process to recognize sites that have achieved core elements of desired primary care pharmacy practice. In this paper, we describe the creation and implementation of this process. The submission process consisted of three rounds ranging from survey, data submission, data review and validation, and a facility interview. A total of 19 submissions were completed with two sites identified as achieving greater than 90% fidelity to the CMM model and were considered best practices. The creation of a rigorous set of implementation tools and measurement metrics creates the necessary fidelity to evaluate programs across different geographic areas. Identified sites provide examples for other facilities to emulate and creates momentum for pharmacy practice advancement throughout the nation.

Diagnosis and treatment pathway for pneumonia in patients with diabetes mellitus: a Chinese experts' consensus

Patients with diabetes mellitus are prone to various infections owing to host immune impairment, especially pneumonia. In China, morbidity of pneumonia in patients with diabetes mellitus is high. And in case of pneumonia, patients with diabetes mellitus were of increased probability of opportunistic infections, low detection rate of pathogens, more severe pneumonia and high mortality, resulting in heavy medical and economic burdens. Therefore, it is urgent for multi-disciplinary experts to explore and formulate standards for diagnosis and treatment of pneumonia in patients with diabetes mellitus to improve the prognosis. Based on domestic and international literatures and clinical experiences of experts in respiratory and critical care medicine, endocrinology, microbiology and clinical pharmacy, a consensus was developed on the diagnosis and treatment of pneumonia in patients with diabetes mellitus.

Ambulatory care practice in the COVID-19 era: Redesigning clinical services and experiential learning.

The coronavirus disease (COVID‐19) has created a variety of challenges for health care professionals, including ambulatory care clinical pharmacists. High‐quality remote and minimal‐contact care has become a necessity. Ambulatory care clinical pharmacists around the nation have adjusted their practice. In many cases, this included implementation of telehealth programs for comprehensive medication management. The redesign of ambulatory care Advanced Pharmacy Practice Experiences (APPE) also required quick adaptation. In this paper, we describe the clinical practice and experiential education challenges encountered by an ambulatory care clinical pharmacist workgroup in a COVID‐19 “hotspot,” with an emphasis on solutions and guidance. We discuss how to adapt ambulatory care clinical pharmacy practices including methods of minimal‐contact care, reimbursement opportunities, tracking outcomes, and restructuring ambulatory care APPE. As ambulatory care clinical pharmacists continue to expand the services they provide in response to COVID‐19, we also describe opportunities to promote pharmacists as providers during times of pandemic and into the future.