Traditionally,
pharmacist in a hospital setting have only been in charge of purchasing and
dispensing drugs to nurses or practitioners, and it has been the role of the prescriber
to monitor therapy. A few decades ago, this began to change. The pharmacists
began reviewing patient records for the appropriateness of medical orders, and
began monitoring the patients’ therapy. Pharmacists became part of the
prescribing system. “The revolutionary feature of these developments was the
presents of the pharmacist on the ward.” (Calvert) Pharmacists were no longer
secluded to the pharmacy, but engaged in patient interaction by participating
in rounds. This idea of clinical pharmacy has evolved rapidly throughout the
years, but there have been plenty of setbacks along the way.
In
1982, D. H. Lawson and R. M. E. Richards
wrote a book about clinical pharmacy in the hospital. The authors are doctors
who were very supportive of the pharmacist taking on a more involved part of
the patient care team. These positive thoughts, however, were not shared by
all. C. F. George, a postgraduate medical student, wrote a review of the book
in the Postgraduate Medical Journal.
“Chapter 7 on monitoring for efficacy and toxicity was less than
convincing. Many pharmacists will not wish or feel competent to undertake the
tasks described therein which, in my view, are or should be an essential part
of the training of doctors. I found myself unconvinced by the arguments
advanced in favor of staff pharmacists tagging along on ward rounds. Obviously,
there are situations where this may be appropriate, but it is hard to believe
that it would be sufficiently cost-effective to be applied universally.”
(George)
This statement encompasses the
entire reason why pharmacists needed to make themselves more apparent. In
Europe, several studies were conducted to see if a pharmacist added to the team
would be cost effective, and every study showed that it would. “Patients who
were treated by teams that included a pharmacist had significantly shorter
length of stay, lower drug cost per admission, but no difference in mortality.”
(Calvert) A few decades after the review mentioned above was published, it was
clear that pharmacists had changed the minds of the doctors with which they
worked. Pharmacists began to show their own style of participation, and changed
their direction from process-oriented to outcomes-oriented. They became part of
the patient care team. In 1999, it was published in the British Journal of
Clinical Pharmacology that “Clinical pharmacists are ideally placed to
influence prescribing by hospital doctors because they have the appropriate
knowledge about therapeutics and are in regular contact with prescribers.”
(Calvert)
Besides
pharmacist actively becoming more involved with patient care during the time
between the review and the publication in the British Journal of Clinical
Pharmacology, pharmacy world was changing to accommodate this new view of
pharmaceutical care. In this time, pharmacy degrees went from a bachelor in
science to a doctor of pharmacy. This provided pharmacists with more in-class
education on therapeutic monitoring and clinical application. Along with that,
more experiences were available to pharmacist during their school curriculum.
The presence of residencies for pharmacy appeared, and became popular very
rapidly. These changes were happening simultaneously in an effort to allow
pharmacy expansion while providing the education needed to do so.
Today,
there are several examples of clinical pharmacy. Some of the most profound are
anticoagulation therapy, diabetic education, and antibiotic monitoring for
inpatient treatment. In anticoagulation therapy, patients that are on warfarin
need to have their INR tested routinely to monitor for efficacy and toxicity.
Instead of meeting with a doctor, they have a short meeting with a pharmacist,
who is authorized to change the patient’s dosage regimen as needed. The
patients don’t have to pay a physician copay, and have easier access and
shorter wait times to meet with the pharmacist. This also frees up the doctor
to deal with more pertinent issues, while the pharmacist can deal with routine
monitoring. In diabetic education, a pharmacist can meet with patients to
discuss their monthly blood sugar logs and adjust their insulin accordingly.
This offers the same benefits as anticoagulation clinic. Since the pharmacist
is the one dispensing the patient’s insulin as well, the pharmacist can monitor
adherence based on the number and timing of refills the patient is picking up.
In antibiotic monitoring, the doctor orders the drug needed and checks the
level of the drug in the patient’s blood. The doctor then reports this back to
the pharmacist and asks for their recommendation on dosage adjustment. The
pharmacist can assess the levels and choose a new regimen for the patient that
is more appropriate, or recommend continuation on the dosage already ordered.
Now
that pharmacy school has changed to a more therapeutic focus, and has
lengthened in education required, pharmacists have more class time reviewing
pharmacokinetics and pharmacology of drugs than doctors. This puts them in a
better position to provide these services, and makes them a pertinent part of the
medical team. Pharmacists are now actively involved in the patients’ drug
therapy.
This
conversion of pharmacists to part of the care team has given pharmacists a more
autonomic position. In cases such as diabetic education and anticoagulation
clinic listed above, pharmacists have the ability to change drug therapy. When
working on rounds in a hospital, they are encouraged to make recommendations,
and they serve as the drug information source for the prescribing doctors.
Because of this increase in responsibility, more management responsibility has
been assigned to the pharmacist. They need to perform routine self-audits and
peer review to make sure that they have all of the information and education
they need to make informed decisions. Most clinical pharmacists in hospitals
still have to report to an overhead in the hospital who attempts to standardize
patient care throughout all of the clinical pharmacists in the hospital.
The
world of pharmacy has been evolving rapidly with the idea that pharmacists
should have a more active role in patient care. Throughout the last few
decades, pharmacists have met with opposition to their changes from the medical
team. However, over time, pharmacists’ medicinal peers have learned how
valuable a pharmacist can be. Pharmacy schooling has expanded to include more
therapeutic-focused classes and more clinical experience for the student
pharmacist. Postgraduate opportunities have also been created to aid the
pharmacist in transitioning into the active role that they now practice. With
more change in the pharmacy world, pharmacists will become more autonomic and
respected throughout the medical field, while claiming more responsibility for
patient care.
Alexis Ireland, PharmD Candidate 2014
References
Calvert, R. T. Clinical Pharmacy – a hospital perspective. Br J Clin Pharmacol 1999; 47, 231-238.
George, C. F.
University of Southampton. Review of Clinical Pharmacy and Hospital Drug
Management. Postgraduate Medical Journal 1982;
58, 803-804.
