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Applying the Evidence for Clinical Pharmacy Services to Pharmacy Practice . Provided by: Michael G. Liebl, BS, PharmD, BCPS Clinical Manager, Pharmacy Services The Methodist Hospital Houston, TX 77030 Pager: 281-735-5815 Phone: 713-441-6973 Email: firstname.lastname@example.org.
Michael G. Liebl, BS, PharmD, BCPS
Clinical Manager, Pharmacy Services
The Methodist Hospital
Houston, TX 77030
At the completion of this program, the participant will be able to:
W. Arthur Purdum
...within the new minimum standard lies the key to our first objective: improving and extending the usefulness of the hospital pharmacist.
…Today we are still recognized as a complementary service department and we must continue our efforts until pharmacy is regarded asessential.
So, where to begin…Is there an essential, established need for advanced clinical pharmacy service?...what is the problem or the void in healthcare?
Heart disease 743,460 dead
Cancer 529,904 dead
Stroke 150,108 dead
Medications 137,000 dead
Pulmonary disease 101,077 dead
Accidents 90,523 dead
Pneumonia 75,719 dead
Lazarou, et al. JAMA 1998;279:1200-5
# of Events
(1000 pt days)
% of Patients with ADRs
Cornish P. Arch Int Med 2005; 165: 424-429. – Admission
% of Patients with error: 53%
38% with moderate to severe adverse event potential
Weiner B, Venarske JL, Yu M & Mathis K. Spine 2008;
% of meds with error pre: 62%
% of meds with error post: 39%
42% with moderate to severe adverse event potential
Bowman L. Can J of Hosp Pharm 1994; 5: 209-216. (Wishard, IN)
LOS 6.6 days; ~70% type ”A” Events
JAMA. 1997; 277: 301-6
Mortality 2%, LOS 2 days at a cost of $2,000/event
Br J Clin Pharmacol 1998; 3: 301-8.
LOS 8.5 days;
7.6% of all hosp days
Lazarou J. JAMA 1998; 279: 1200.
(Meta-analysis of ADRs)
Estimated as the 4th - 6th leading cause of death
Vargas E. CCM 2003; 31: 694-98.
LOS 3.9 days
Cullen D. CCM 1997; 25: 1289-97.
Holdsworth M. Arch Pediatr Adolesc Med 2003; 157: 60-65.
LOS 15.3 days
Chaudhry S, Olofinboba K, J Gen Intern Med 2003; 18: 595-600.
1.9% of ADRs attributed to increased morbidity
Forester A. Ann Intern Med 2003; 138: 161-167.
Hospital readmissions due to medication events
Annual Cost: Lives Lost
Source: Roger Resar, MD (Mayo Clinic) IHI Symposium 2001
“…After studying the Institute of Medicine’s To Err Is Human, a suggestion for improving might be that there should be a person who has expert knowledge about drugs and drug therapy to review the entire drug selection and monitoring aspects of patient care. In a world where there were no such people as pharmacists, they would have to be invented. Perhaps, on that planet, they would be called “medicationists”.
Well, our world does have drug experts. They are
called pharmacists, so there is no need to create
a new professional to fill that void.”
*Two phases reported for this evaluation: Pre-intervention & post-intervention
RRR: Relative Risk Reduction
ARR: Absolute Risk Reduction
NNT: Number needed to treat = [(1/ARR)x100]
…The time needed for clinical activities can be gained from better utilization of pharmacy technicians, bar coding, automation and a well-designed, fully integrated CPOE. For some facilities, all of this will still not be enough to substantially reduce the error problem and more pharmacists will have to be hired.
…Institutions will have to attract and retain pharmacists…
Junior high and high school students must be exposed to the
benefits of pharmacy as a career choice to ensure that there
is an adequate pool of bright and motivated students.
...We see today that there are stirrings of a more objective approach towards sound drug therapy and…the pharmacist plays an increasingly important role.
…It seems to me that this trend which is gaining momentum constantly, offers great opportunities for pharmacists to increase our professional responsibilities through cooperative efforts with colleagues in the medical profession, we can increase our value as professionals benefiting not only to pharmacy but also to medicine, our hospital and patients. These are indeed goals to which we should strive.
…I am confident that the hospital pharmacist will…occupy an increasingly important position not only in the selection and procurement of pharmaceuticals but also as a valued consultant to the physician.
…We are beginning a new era…more medical cases will increase the volume of drugs dispensed and paid for by a third party who will want prices to reflect costs. Hospital revenue must equal expenditures…so unnecessary expenditures must be curtailed.
...It is the pharmacist’s major duty to maintain rational therapeutics in his hospital. He must keep himself well informed about drugs so that he can withstand the flood of unsubstantiated claims often made for new products.
…To challenge scientifically, one needs an equality of knowledge. The doctor, so skilled in the basic sciences, is still vulnerable to the high pressured salesmanship of even nonpharmacists.
Am J Hosp Pharm. 1991 Oct;48(10):2154-7
# of Pharmacy Admin. / 100 Occupied Beds
# of Clinical Pharmacist / 100 Occupied BedsPharmacy Staffing Associations and total costs of care in US Hospitals
Please write down a number
…Let me summarize this recommendation for an entry level residency program in hospital pharmacy. 1st training in clinical (general) practice becomes the focus of the program. 2nd a Pharm.D. degree should be a prerequisite for entry into the program. 3rd the training program should provide meaningful experience in the other important services and in the overall management of the department. 4th this generalist entry-level residency should be a prerequisite for advanced specialized residency programs. It is this level of training that we should set our sights on for all pharmacists who are preparing for a future in hospital pharmacy practice.
…Beyond this entry-level training program, there is a growing need for highly specialized clinical training programs. I believe that there is now a much greater demand for highly specialized clinicians than we can supply, and the demand will likely increase.
…The leaders of a clinical profession must be committed to, almost obsessed with, the idea of clinical practice. And, most important, they will need to project that idea into images that create excitement in other people about that activity.
Increase to 7,500 residency slots up from 1,250 offered today in mostly general practice (PGY-1)
PGY2 offerings should increase similarly
Medication History Accuracy Improvements
Internal Data: Sirimaturos M, Venarske J & Yu M.
Example: Patient identified with a platelet count decrease of greater than 50% from baseline & was maintained on heparin therapy. Pharmacist recommended antibody screen & treatment. Subsequent testing demonstrated patient was positive for Heparin antibodies and diagnosed with HIT.
*Cost avoided values derived from internal benchmarking, published pharmacoeconomic & ADE avoidance literature & medical malpractice claims higher in patients with preventable ADEs.
*Based Upon Consult Orders Received per Month
?A Pharmacoeconomic Estimation of Clinical Pharmacy Services:
ROI Range Estimate: 2.5 – 4
…pharmacists who are not in constant face-to-face contact with physicians, nurses & particularly patients where they are being treated & who are unable to see exactly how drugs work…are destined to know little more than a myriad of unorganized details.
…The pattern most idealized of a professional pharmacist would be one who has a close association with patients; a comprehensive awareness of previous medication habits; knows allergies, sensitivities, & idiosyncrasies; extracts information about them from charts, laboratory, x-ray, and other data; has access to drug-oriented information; is able to correlate that information with knowledge about the patient’s physiology & disease; & recommends to physicians, nurses, & others the proper course to follow where drugs are indicated. He emphasizes and insures safety and effectiveness of drugs.
…The hypothetical professional pharmacist would serve as a counselor, advisor, teacher… & patient care team member
…The model which comes closest to conformance with this professional ideal is the clinical pharmacist.