Prioritising recommendations to advance community pharmacy practice

Introduction

The nature of community pharmacy in many countries has changed. Despite the significant efforts made to change practice, there is a paucity of literature that highlights consensus on the approaches that should be prioritised for advancing practice particularly in the context of developing countries.

Inability to justify a part-time clinical pharmacist in a community hospital intensive-care unit.

The potential for justifying the cost of a part-time clinical pharmacist position was evaluated. Patients in the medical and surgical intensive-care units of a community hospital were monitored two hours per day for 32 weekdays by a part-time staff pharmacist. The pharmacist completed an initial review of the charts of all patients newly admitted to the units and further evaluated each medical record for at least five minutes each day to determine the need for drug therapy interventions. The pharmacist contacted physicians to make any recommendations for changes in therapy. At the end of the study, the pharmacist calculated the difference in the costs of the original and recommended drug regimens for all recommendations accepted by physicians. A total of 147 patients were monitored during the 32-day period. There were 122 recommended interventions for 60 patients, and 101 (83%) of these recommendations were accepted. Estimated drug cost savings totaled $1651.35, but the cost of the pharmacist, $2599.35, resulted in a net cost to the hospital of $948. There was no significant difference in drug cost savings with respect to the day of the week when the monitoring was performed, the time of day, or the interaction of day with time. A part-time clinical pharmacist in the intensive-care unit of a community hospital reduced the costs associated with drug therapy, but the savings realized were not sufficient to offset the cost of the position.     

二级医院临床药学实践在社区药学服务中的延伸

日前,越来越多的二级医院临床药师进入临床,参与查房、病例讨论和会诊,开展治疗药物和药物不良反应（ADRs）监测、处方点评干预等工作,     

Cost-benefit analysis of clinical pharmacy services in a community hospital.

A cost-benefit analysis of clinical pharmacy services in a 250-bed, acute-care hospital is described. Over a 3-year period, the total net benefit to the hospital and patients has totaled $125,648.     

Collaborative clinical pharmacokinetics service in a community hospital

A clinical pharmacokinetics service (CPS) operated through the collaborative efforts of the pharmacy and laboratory in a community hospital is described. Pharmacokinetic interpretations of aminoglycoside, vancomycin, chloramphenicol, digoxin, and theophylline concentrations are provided routinely by the CPS; other drug assays are interpreted upon physician request. The CPS is operated by two pharmacokinetics pharmacists and a clinical pharmacy coordinator during the week; pharmacy residents and staff pharmacists in decentralized areas assist on the weekends. Pharmacists assign sampling times to all assay requests unless otherwise specified by the physician. Pharmacy, nursing, laboratory, and medical staffs are involved in an ongoing quality-assurance monitoring program. During a recent one-year period, more than 100 pharmacokinetic consultations each were provided monthly for theophylline, digoxin, and antibiotic assays. Through the cooperation of the pharmacy and laboratory departments, the clinical pharmacokinetics service in this community hospital provides a valuable service to patients and serves as an educational forum for pharmacy and medical staffs.     

以临床路径为契机实行主要住院指标考核

目的 探索以实施临床路径为契机,实行主要住院指标考核的方法.方法 根据2008-2010年3年的基线资料,参考省（自治区）内同级医院的数据,设定基准值,制定考核标准,对临床科室实行平均住院日、次均住院费用、药品比例三项指标的考核,并采取分项奖励措施,根据较基准值下降的比率每月给予相应奖励.结果 全院和临床科室的平均住院日、次均住院费用、药品比例三项指标较上年同期均下降,且差异有统计学意义（内科系统：t=27.479、14.462、11.362,均P＜0.01;外科系统：t=18.944、16.029、12.071,均P＜0.01）.结论 实行主要住院指标考核,与实施临床路径相结合,可有效缩短平均住院日,降低次均住院费用和药品比例,减轻患者经济负担.     

Benefits of clinical pharmacy services in a community hospital

The purpose of this analysis was to itemize the long term cost-avoidance and benefits of the Clinical Pharmacy Program at York Hospital and compare them to the cost of the program. It was assumed that the major actual reduction in drug cost would occur within the first year of clinical activities. Therefore, to determine the long term benefits, the hypothetical cost-avoidance of drug expenditures were calculated for the subsequent years after the clinical programs were instituted. For fiscal year 1991 these significant benefits amounted to an estimated monetary cost-avoidance of $416,000, a reduction in numerous hours in preparations and administration of 39,000 IVs, and numerous non-quantifiable benefits. The cost of the program in fiscal year 1991 for the pharmacist and administrative salaries related to the Pharmacy Clinical Program was approximately $140,000. Thus, the Clinical Pharmacy Program was cost-effective at York Hospital.     

Establishing a clinical pharmacokinetic service for gentamicin in a community hospital

To assess the feasibility and acceptability of a pharmacy-based clinical pharmacokinetic service for gentamicin, serum gentamicin levels were measured by radioimmunoassay in 44 patients hospitalized during a three-month period in an acute-care general hospital. Serum levels measured pre- and post-infusion were used to estimate pharmacokinetic parameters and optimum dosage regimens for individual patients. Based on serum level measurements of gentamicin, 30% of patients required no dosage adjustment, 23% an increase in dose and 47% a decrease in dose. Of the 30 changes recommended, 83% were implemented by physicians. Monitoring serum levels and adjusting dosage reduced the number of patients with sub-therapeutic and toxic serum levels. Adjusting dosage with the aid of serum levels appeared to be most useful for the elderly patient or the patient with impaired kidney function. Initial choice of dosage regimens for patients would be improved by appropriate use of the Hull and Sarubbi dosing nomogram (with certain modifications) or method of estimating pharmacokinetic parameters. The Hull and Sarubbi method was considered preferable to the dosing recommendation of 1.1 mg/kg at an interval of eight times the serum creatinine value. Excellent physician acceptance of a gentamicin serum level monitoring service was demonstrated in terms of the physician's usage of the service and implementation of the pharmacist's recommendations. A multidisciplinary approach involving medicine, pharmacy, nursing and laboratory staff was essential for successful operation of the pharmacokinetic service. However, the responsibility for the development and overall coordination of the pharmacokinetic service should remain with the pharmacist.     

Implementation of an i.v. morphine infusion program in a community hospital.

Pharmacy departments play a role in helping to design and implement a pain management program in community hospitals. The history, documentation of need, and benefits of the program are presented. Protocol guidelines for the intravenous infusion of morphine are outlined, and specific job functions of the nurse and pharmacist members of the pain management team are defined. In addition, the results of a pain management study are reported, which describe the efficacy of the treatment protocol in 22 patients.     

A quality assurance program for clinical pharmacy services provided to a long-term care unit in a community hospital.

This paper describes the development of a quality assurance program for the clinical pharmacy services being provided to a long term care unit in a community hospital. The functions, standards and criteria of these clinical services are presented and the results and impact of four completed audits are discussed. It is the intent of this article to demonstrate the ease with which a quality assurance program for clinical pharmacy services may be instituted and the potential benefits it may offer.     

Combination therapy for non-Hodgkin's lymphoma: an opportunity for pharmaceutical care in a specialty practice

OBJECTIVE: To describe the application of pharmaceutical care practices in the administration of new therapeutic radiopharmaceuticals used in the treatment of non-Hodgkin's lymphoma (NHL). PRACTICE DESCRIPTION: At the Antibody Labeling Facility at the University of Nebraska Medical Center, the nuclear pharmacist provides support in the formulation, preparation, and quality testing of radiopharmaceuticals. The nuclear pharmacist also provides direct patient care by assisting in the administration of radiopharmaceuticals, monitoring patients during their infusions, and counseling patients on radioimmunotherapy and radiation safety. PRACTICE INNOVATION: Expanding the role of the nuclear pharmacist in treating patients with NHL using radiolabeled monoclonal antibodies (MABs). INTERVENTIONS: The nuclear pharmacist provides specialized pharmaceutical care by being involved in planning patient care, administering diagnostic and therapeutic radiopharmaceuticals, performing individualized patient dose calculations, monitoring patients, and counseling patients. MAIN OUTCOME MEASURES: Number of patients treated with radiolabeled MABs. RESULTS: Since January 1996, 85 patients with NHL have been treated using 131I-tositumomab (Corixa, GlaxoSmithKline), an anti-B1 MAB, under various clinical research protocols requiring specialized pharmaceutical care. The nuclear pharmacist on the team provided direct patient care, assisting with the administration of diagnostic and therapeutic radiopharmaceuticals under a collaborative agreement with a nuclear medicine physician or a radiation oncologist. Other pharmaceutical care activities performed include calculating individual patient doses, obtaining medication histories, counseling patients on their therapy and on radiation safety after early release, and monitoring patients for adverse effects during medication infusion. Patients have responded favorably to nontraditional nuclear pharmacy activities. CONCLUSION: The nuclear pharmacist has become an important member of the health care team that provides a new and unique therapy for patients with NHL. To date, the nuclear pharmacist, in collaboration with the nuclear medicine physician or the radiation oncologist, has successfully administered the tositumomab and 131I-tositumomab combination therapy without significant incident.     

Interdisciplinary diabetic team in a community hospital.

An interdisciplinary diabetic team which provides inpatient and outpatient diabetic instructional services in a 200-bed community hospital is discussed. The team consists of a pharmacist, a dietitian, and a registered nurse, each of whom is assigned to a specific area of diabetic education. Instructional objectives include coordination of teaching efforts by hospital personnel, standardization of education, and development of evaluation procedures. Upon notification of a physician request for diabetic team services, a form which contains competency-based instructional objectives and patient referral questions is placed in the patient's chart. Diabetic instruction may then be initiated by ward personnel or a member of the diabetic team. Outpatient classes are offered for those who desire or require additional or indepth instruction.     

Drug usage review in a community hospital.

A simple and effective manual drug usage review program in a community hospital is described. Fifteen randomly selected charts are screened each month by a drug information pharmacist. Charts demonstrating questionable drug therapy are forwarded to a physician member of the pharmacy and therapeutics committee; those showing questionable drug administration practices are referred to the nurse member of the committee. These committee members screen the questionable charts and refer to the entire committee those cases which require further follow-up. The committee categorizes the problems and communicates its recommendations to the individual practitioners involved. Recommendations focus on the legal ramifications of FDA-unapproved drug usage. During the first two years of the program, 341 charts were screened for drug usage; 62 of these were referred to the pharmacy and therapeutics committee for further review. In 20 cases, the committee sent a letter to the prescribing physician or his department chairman; in 16 cases, letters were sent to nursing administration.