Clinical pharmacy services

Scope, and outcomes

Mohamed Shahen

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 Contents

1. Definition of Clinical Pharmacy

2. Clinical Pharmacy Services
3. The impact of clinical pharmacy services on economic outcomes
4. The impact of clinical pharmacy services on clinical outcomes

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 1- Definition of Clinical Pharmacy

Clinical pharmacy is defined as that area of pharmacy concerned with the

science and practice of rational medication use.
Clinical pharmacy is a health science discipline in which pharmacists provide
patient care that optimizes medication therapy and promotes health, wellness,
and disease prevention.
Clinical Pharmacists are experts in the therapeutic use of medications.
Clinical pharmacists are a primary source of scientifically valid information and
advice regarding the safe, appropriate, and cost-effective use of medications.
Pharmacy AC of C, Key. The Definition of Clinical Pharmacy. Pharmacotherapy. 2008;28(6):816-817. doi:10.1592/phco.28.6.816.

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 2- Clinical Pharmacy Services

1- Medical rounds participation

Pharmacist attends rounds with medical team,
providing advice
The advice given can include help with choice of
medicine, dose, method of administration, side-
effects, interactions, monitoring requirements and
many other aspects of medicines use

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 2- Clinical Pharmacy Services(cont.)

1- Medical rounds participation

pharmacists patient care process
A. Collect
Subjective and objective information.
Information from existing patient records, the patient, and other health care
professionals. This process includes collecting:
A current medication list and medication use history for prescription and
nonprescription medications, herbal products, and other dietary supplements
Relevant health data that may include medical history, health and wellness
information, biometric test results.
Patient lifestyle habits, preferences and beliefs, and socioeconomic factors that
affect access to medications and other aspects of care
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 2- Clinical Pharmacy Services(cont.)

1- Medical rounds participation

pharmacists patient care process
B. Assess
Assesses the information collected and analyzes the clinical effects of the patients
therapy to identify and prioritize problems. This process includes assessing:
Each medication for appropriateness, effectiveness, safety, and patient adherence
Health and functional status, risk factors, health data, cultural factors, health
literacy, and access to medications or other aspects of care
Immunization status and the need for preventive care and other health care
services, where appropriate

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 2- Clinical Pharmacy Services(cont.)

1- Medical rounds participation

pharmacists patient care process
C. Plan
Develops an individualized patient-centered care plan, with other health care
professionals and the patient or caregiver that is evidence-based and cost-
effective. This process includes establishing a care plan that:
Addresses medication-related problems and optimizes medication therapy
Sets goals of therapy for achieving clinical outcomes
Engages the patient through education, and self-management
Supports care continuity, including follow-up
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 2- Clinical Pharmacy Services(cont.)

1- Medical rounds participation

pharmacists patient care process
D. Implement
Implements the care plan with other health care professionals and the patient or
caregiver. the pharmacist:
Addresses medication- and health-related problems and engages in preventive care
strategies, including vaccine administration
Initiates, modifies, discontinues, or administers medication therapy as authorized
Provides education and self-management training to the patient or caregiver
Contributes to coordination of care, including the referral or transition of the patient
to another health care professional
Schedules follow-up care as needed to achieve goals of therapy 8
 2- Clinical Pharmacy Services(cont.)

1- Medical rounds participation

pharmacists patient care process
E. Follow-up: Monitor and Evaluate
The pharmacist monitors and evaluates the effectiveness of the care
plan and modifies the plan with other health care professionals and the
patient or caregiver as needed. This process includes the continuous
monitoring and evaluation of:
Medication appropriateness, effectiveness, and safety and patient
adherence through available health data, biometric test results, and
patient feedback
Clinical endpoints that contribute to the patients overall health
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 2- Clinical Pharmacy Services(cont.)

2- Drug-use evaluation:
Assess the actual process of administration or dispensing of a medication (indications,
drug selection, doses prescribed, dosage form, route of administration, duration of
therapy, costs, therapeutic duplication, quantity dispensed, contraindications, therapeutic
outcome, adverse drug reactions, and drug interactions) and also the outcomes of
treatment (e.g. cured disease conditions or decreased levels of a clinical parameter).

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 2- Clinical Pharmacy Services(cont.)

3- In-service education
pharmacist presents continuing education to fellow
employees on a scheduled basis at least 4 times a year

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 2- Clinical Pharmacy Services(cont.)

4- Drug information
provided only if a formal drug information service with
specifically assigned pharmacist is available for questions.
Does not require a physical location called drug information
center

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 2- Clinical Pharmacy Services(cont.)

5- Poison information:
provided only if a pharmacist is available to answer toxicity and
overdose questions on a routine basis with appropriate
resources.

6- Clinical research
is performed by pharmacist either as principal investigator or
coinvestigator. Pharmacist is likely to be (co-) author of a
published paper.

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 2- Clinical Pharmacy Services(cont.)

7- ADR management
pharmacist evaluates potential ADR while patient is hospitalized through early
identification and prompt treatment (avoidance or resolution)

8- Pharmacokinetic consultation and therapeutic drug

monitoring (TDM)
For narrow therapeutic index drugs
E.g. aminoglycoside antibiotics, anticonvulsants, immunosuppressant, digoxin,
lithium and theophylline

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 2- Clinical Pharmacy Services(cont.)

9- Drug therapy monitoring

Monitoring is continuing and repeated, often on daily basis
The prescription is reviewed for medication dosing errors, appropriateness of
administration route, drug interactions, inappropriate prescribing and many
other potential problems

10- Drug protocol management

pharmacist, under the order of a prescriber, requests laboratory tests if
necessary and begins drug therapy or adjusts dosage to obtain desired outcome
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2- Clinical Pharmacy Services(cont.)

11- TPN team participation

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 2- Clinical Pharmacy Services(cont.)

12- Patient counseling

Pharmacist provides counseling either during hospitalization or at time of discharge.
Helping patients to understand their medicines and how to take them is a major
feature of clinical pharmacy

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 2- Clinical Pharmacy Services(cont.)

13- Cardiopulmonary resuscitation (CPR) team

participation
pharmacist is active member of the team attending most arrests when the
pharmacist is present in the hospital

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 2- Clinical Pharmacy Services(cont.)

14- Admission drug histories

Pharmacists are able to take more accurate medication histories than medical staff
Patients can be questioned on their medication histories, including allergies and
intolerances, efficacy of prescribed treatment, side-effects and adverse drug reactions
(ADRs)

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 2- Clinical Pharmacy Services(cont.)

15- Medicines formularies

Pharmacists providing clinical services are responsible for ensuring
that prescribers practices comply with formulary recommendations.

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 3- The impact of Clinical Pharmacy Services
on Economic Outcomes
Clinical Pharmacy Services, Pharmacy Staffing, and the Total Cost of Care
in United States Hospitals Pharmacotherapy. 2000;20(6):609-621.
Economic Evaluations of Clinical Pharmacy Services:20062010,
Pharmacotherapy. 2014;34(8):771-793

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 Clinical Pharmacy Services, Pharmacy Staffing, and the
Total Cost of Care in United States Hospitals

1016 hospitals from 1992 to 2000

Results: Six clinical pharmacy services were associated with lower total cost of
care: drug use evaluation (p=0.001), drug information (p=0.003), adverse drug
reaction monitoring (p=0.008), drug protocol management (p=0.001), medical
rounds participation (p=0.0001), and admission drug histories (p=0.017).
Recommendation: Staffing for clinical pharmacists should be as high as
possible, but definitely more than 1.11/100 occupied beds.
improved drug therapy should have a profound impact on the total cost of care
by decreasing lengths of hospital stays, adverse drug reactions, infection rates,
law suits, number of personnel to care for patients, and so on.
Bond C, Raehl CL, Franke T. Clinical pharmacy services, pharmacy staffing, and the total cost of care in United States hospitals. Pharmacotherapy. 2000;20(6):609-621.
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Clinical Pharmacy Services, Pharmacy Staffing, and the
Total Cost of Care in United States Hospitals

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 4- The impact of Clinical Pharmacy Services
on Clinical Outcomes
Clinical Pharmacy Services, Pharmacy Staffing, and Hospital Mortality
Rates. Pharmacotherapy. 2007;27(4):481-493.
Clinical Pharmacy Services, Pharmacy Staffing, and Adverse Drug Reactions
in United States Hospitals Pharmacotherapy. 2006;26(6):735-747.
Clinical Pharmacy Services, Hospital Pharmacy Staffing, and Medication
Errors in United States Hospitals Pharmacotherapy. 2002;22(2):134-147.

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 Clinical Pharmacy Services, Pharmacy Staffing,
and Hospital Mortality Rates

2,836,991 patients in 885 hospitals.

Results: Seven clinical pharmacy services were associated with reduced mortality rates:
pharmacist-provided drug use evaluation (4491 reduced deaths, p=0.016), pharmacist-provided
in-service education (10,660 reduced deaths, p=0.037), pharmacist-provided adverse drug
reaction management (14,518 reduced deaths, p=0.012), pharmacist-provided drug protocol
management (18,401 reduced deaths, p=0.017), pharmacist participation on the
cardiopulmonary resuscitation team (12,880 reduced deaths, p=0.009), pharmacist
participation on medical rounds (11,093 reduced deaths, p=0.021), and pharmacist-provided
admission drug histories (3988 reduced deaths, p=0.001).

Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy. 2007;27(4):481-493. doi:10.1592/phco.27.4.481.

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Clinical Pharmacy Services, Pharmacy Staffing,
and Hospital Mortality Rates

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 Clinical Pharmacy Services, Pharmacy Staffing, and
Adverse Drug Reactions in United States Hospitals

1,960,059 patients in 584 hospitals.

Results: The most significant reductions occurred in hospitals offering: (9 services)
pharmacist-provided in-service education , Drug information
ADR management , drug protocol management
Participation on the total parenteral nutrition team
participation on the cardiopulmonary resuscitation team
Medical round participation, admission drug histories and increased clinical pharmacist
staffing
Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy. 2006;26(6):735-747.
doi:10.1592/phco.26.6.735.

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Clinical Pharmacy Services, Pharmacy Staffing, and
Adverse Drug Reactions in United States Hospitals

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 Clinical Pharmacy Services, Hospital Pharmacy Staffing,
and Medication Errors in United States Hospitals

A total of 429,827 medication errors were evaluated from 1081 hospitals

Results: increased staffing of clinical pharmacists and the presence of a drug
information service, pharmacist-provided adverse drug reaction management,
pharmacist-provided drug protocol management, medical rounds participation, and
pharmacist-provided admission histories are all associated with reduced medication
errors.

Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy.
2002;22(2):134-147. doi:10.1592/phco.22.3.134.33551

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Clinical Pharmacy Services, Hospital Pharmacy Staffing,
and Medication Errors in United States Hospitals

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 References

Pharmacy AC of C, Key. The Definition of Clinical Pharmacy. Pharmacotherapy. 2008;28(6):816-817.

doi:10.1592/phco.28.6.816.
Bond C, Raehl CL, Franke T. Clinical pharmacy services, pharmacy staffing, and the total cost of care in
United States hospitals. Pharmacotherapy. 2000;20(6):609-621.
Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy.
2007;27(4):481-493. doi:10.1592/phco.27.4.481.
Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States
hospitals. Pharmacotherapy. 2006;26(6):735-747. doi:10.1592/phco.26.6.735.
Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United
States hospitals. Pharmacotherapy. 2002;22(2):134-147. doi:10.1592/phco.22.3.134.33551
Bond C, Raehl C, Franke T. Total Cost of Care , and Length of Stay in United States Pharmacy Services and Staffing.
Pharmacotherapy. 2001;21(2):129-141.
Touchette DR, Doloresco F, Suda KJ, et al. Economic evaluations of clinical pharmacy services: 2006-2010.
Pharmacotherapy. 2014;34(8):771-793. doi:10.1002/phar.1414.

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 Interrelationships among Mortality Rates, Drug Costs, Total Cost of Care,
and Length of Stay in United States Hospitals: Summary and
Recommendations for Clinical Pharmacy Services and Staffing

1029 hospitals
Relationships between variables(mortality rates, drug costs, total cost of care, and length
of stay in United States hospitals) and the presence of clinical pharmacy services
Seventeen clinical pharmacy services were associated with improvements in mortality
rates, drug costs, total cost of care, and length of stay in U.S. hospitals.
As clinical pharmacist staffing levels increased from (0.34/100 occupied beds) to the
(3.23/100 occupied beds), hospital deaths declined from 113/1000 to 64/1000
admissions (43% decline). This resulted in a reduction of 395 deaths/hospital/year. This
translated into a reduction of 1.09 deaths/day/hospital having clinical pharmacy staffing
Bond C, Raehl C, Franke T. Total Cost of Care , and Length of Stay in United States Pharmacy Services and Staffing. Pharmacotherapy. 2001;21(2):129-141.

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Interrelationships among Mortality Rates, Drug Costs, Total Cost of Care,
and Length of Stay in United States Hospitals: Summary and
Recommendations for Clinical Pharmacy Services and Staffing

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 Evidence-Based Core Clinical Pharmacy Services in
United States Hospitals in 2020: Services and Staffing

associations between 14 clinical pharmacy services and five health care

outcomes (mortality rate, drug costs, total cost of care, length of hospital stay,
and medication errors).
five clinical pharmacy services should constitute a core set in all U.S. hospitals by
2020 (drug information, adverse drug reaction management, drug protocol
management, medical rounds participation, and admission drug histories). These
five specific clinical pharmacy services offer the best documented likelihood of
improving health care for our patients.
Bond CA, Raehl CL, Patry R. Evidence-based core clinical pharmacy services in United States hospitals in 2020:
services and staffing. Pharmacotherapy. 2004;24(4):427-440. doi:10.1592/phco.24.5.427.33358.

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