Clinical Services
Jean-Francois Bussières

Clinical pharmacy services represent one of the five major categories of pharmacy practice. Many pharmacists regard clinical services as the heart and the future of the profession, however, distribution, teaching, research and non-patient care services still account for more than 60% of the pharmacist’s practice time. (See Table F-3 in Human Resources section.)

In 2001/2002, the respondents reported that the average time spent by pharmacists in clinical services was 39%, compared to 38% in 1999/2000, and 9% higher than the 30% reported in the US.¹ The average of reported percentage of time spent by pharmacists in clinical activities was shown to vary according to teaching status (45% in teaching versus 35% in non-teaching hospitals) and region (47% in the Prairies, 42% in Quebec, 37% in Ontario and British Columbia, 31% in the Atlantic provinces). Although it is difficult to establish a link between the systems of distribution and the practice of clinical pharmacy, respondents providing unit dose distribution systems and IV admixture services to = 90% of patients, reported a higher average percentage of time spent by pharmacists in clinical services (n = 29, 47%) versus hospitals with traditional drug distribution (n = 32, 37%).

Even though reported pharmacy staffing has increased by nearly 30% over the past four years, (from 0.57 paid hours/acute patient day in 1997/98, to 0.68 in 1999/2000 and to 0.74 in 2001/2002), the proportion of time spent in clinical activities only increased from 33% in 1997/98 to 39% in 2001/2002. It does not appear that delegation to technicians, and utilization of automation, have been implemented to the full potential and the reported shortage of pharmacists may continue to limit the growth of clinical activities in the future.

Profile of outpatient clinical pharmacy services

In 2001/2002, outpatient clinical pharmacy services were reported in at least one sector by 76% of respondents, compared to 78% in 1999/2000. For the respondents reporting the implementation of outpatient clinical pharmacy services, an average of four outpatient clinical pharmacy services were offered (range 1-10) with an average of 2.32 FTE compared to 1.66 FTE in 1999/2000. The number of outpatient clinical pharmacy services varied across the regions with 3.3 in the Prairies and the Atlantic provinces, 4 in Ontario, 4.1 in British Columbia and 4.5 in Quebec. The number of respondents reporting FTEs for each individual service ranged from 5 to 56, with the services most commonly reported being haematology-oncology, emergency room, DVT/anticoagulant, diabetes, renal/dialysis and infectious disease/aids. It is difficult to identify trends from 1999/2000, as the sample size varies, with a very low number of respondents in some sectors. The number of outpatient clinical pharmacy services and resources allocated (FTE) in 2001/2002 are reported in Table B-1. The average of number of FTE is calculated on the base of respondents reporting at least 0.01 FTE.

Clinical pharmacy resources should be allocated based on established criteria such as patient need, volume of activities, type of drugs used, etc. Based on the annual number of patient visits reported by respondents, a ratio of FTE pharmacists/10,000 visits for each sector was explored, when both volumes of activities and FTE were reported. Results demonstrate a large variance that might be explained by several factors; for example, clinical pharmacists would not be required to see every patient in an ambulatory clinic. The ratios calculated were based on a small number of respondents in many cases and further information of the level of resources required based on volume of activities would enhance internal benchmarking and resource planning. Medians were preferred to means. The median ratio of FTE/10,000 visits was 0.11 ± 0.08 for all sectors. Ratios were in decreasing order (n, median FTE ± SD) : DVT/anticoagulant (n = 7, 7.19 ± 20.99), cardiovascular/lipid clinical services (n = 6, 3.29 ± 4.23), infectious disease /AIDS (n = 5, 3.4 ± 3.64), asthma /allergy (n = 3, 1.39 ± 57.18), mental health (n = 7, 1.28 ± 0.75), geriatric day care (n=4,1.22 ± 1.6), haematology-oncology (n =17, 1.21 ± 14.89), transplantation (n = 3, 0.39 ± 0.23), diabetes (n = 10, 0.38 ± 1.68), emergency room (n = 51, 0.03 ± 0.08).

Profile of inpatient clinical pharmacy services

In 2001/2002, 73% of respondents reported FTE for inpatient clinical pharmacy services compared to 92% in 1999/2000. The apparent reduction could be explained by the pharmacist shortage and/or the unavailability of data for some respondents. Also, due to differences in the questionnaire design, the results may not be completely comparable. Respondents reporting FTEs for inpatient clinical pharmacy services reported an average of 5.7 inpatient clinical pharmacy services offered (range 1-13) with an average of 6.66 FTE compared to 4.46 FTE in 1999/2000. The number of inpatients clinical pharmacy services varied across the regions with 4.6 in Quebec, 5.1 in the Atlantic Provinces, 5.4 in the Prairies, 6 in British Columbia and 7.4 in Ontario. The number of inpatient clinical pharmacy services and resources allocated (FTE) in 2001/2002 are reported in Table B-2. The average of number of FTE is calculated on the base of respondents reporting at least 0.01 FTE. It is difficult to identify trends when comparisons are made to 1999/2000 survey results, as the mix and number of respondents varies. The specific services for which FTE’s were most commonly reported were adult general medical units, adult surgical units, adult intensive care units, geriatrics/LTC units, adult mental health units, pediatric general medical units, and adult haematology-oncology units.

As with outpatient services, inpatient clinical pharmacy resources should be allocated based on established criteria. Based on the annual number of patient days reported by respondents, a ratio of FTE pharmacists/10,000 patient days for each service was calculated, when both volumes of activities and FTE were reported. Results demonstrate a large variance and the median ratio of FTE/10,000 patient-days was 0.49 ± 0.38 for all services. Ratios were in decreasing order (n, median FTE ± SD) : pediatric intensive care units (n = 5, 2.93 ± 0.65), pediatric haematology-oncology units (n = 4, 2.56 ± 1.09), adult intensive care units (n =36, 1.57 ± 0.31), pediatric surgical units (n = 5, 1.4 ± 2.1), adult haematology-oncology units (n = 11, 1.29 ± 0.68), pediatric mental health units (n= 4, 0.99 ± 0.28), general medical units (n = 19, 0.83 ± 0.5), adult general medical units (n = 43, 0.53 ± 0.34), adult mental health units (n = 29, 0.52 ± 0.37),adult rehab units (n = 15, 0.48 ± 0.57), adult surgical units (n = 38, 0.45 ± 0.31), ob-gyn units (n = 18, 0.25 ± 0.2), geriatrics/LTC units (n = 24, 0.26 ± 0.72).

Pharmacist staffing, distribution systems and clinical pharmacy practice models

The reported average pharmacist staffing for clinical services was 2.32 FTE for outpatient areas and 6.64 FTE for inpatient areas, giving a combined total of the averages of reported inpatient and outpatient staffing for clinical services of 8.96 FTE per hospital. The figures vary according to bed size (3.24 FTE in 100-200 beds, 7.19 FTE in 201-500 beds and 17.28 in >500 beds), teaching status (12.95 FTE in teaching hospitals vs. 5.21 FTE in non-teaching hospitals) and the presence of pharmaceutical care model (9.04 FTE if implemented vs. 4.28 if not implemented).

Upon review of the relationship between clinical pharmacist staffing and drug distribution systems, the average of reported clinical pharmacist FTE was higher in hospitals with unit dose systems (2.65 FTE in outpatient and 8.61 FTE in inpatient) than in hospitals with a traditional drug distribution system (2.27 FTE in outpatient and 4.12 FTE in inpatient). Further statistical analysis could be conducted to identify the relative importance of each element affecting clinical pharmacist staffing.

Participation of pharmacists in clinical activities

Table B-3 provides information on clinical pharmacy activities and documentation. Respondents reported on average a higher percentage of regular rounds with nurses (62% in 2001/2002 compared to 45% in 1999/2000). The difference could be explained by this years’ lower weight of respondents from Quebec, where rounds with nurses were reported less frequently (17%, 6/36). There was an increase in the average of respondents reporting admission histories (64 % in 2001/2002 compared to 53% in 1999/2000), regular rounds with physicians (61% compared to 55%) and pharmacokinetic dosing (88% compared to 84%).

These data show that hospital pharmacists continue to work in collaboration with nurses and physicians to provide direct patient care from patient admission through to discharge in a majority of hospitals across the country. The data reported captures the prevalence of clinical activities but not their level. The total impact of the pharmacist shortage in Canada cannot be measured in this section, as respondents shared the tendency was to reduce services rather than not provide them. Larger hospitals, teaching hospitals and hospitals that provide pharmaceutical care to at least some of their patients reported a higher proportion of clinical activities in select areas.

Eighty percent of respondents reported documentation of interventions. Partial documentation was reported by 54% (67/123) of respondents and documentation for more than 90% of the cases was reported by 26% (32/123). For hospitals reporting the documentation of their interventions, it occurred in medical records (81%), manual pharmacy records (56%), and computerised pharmacy records (53%).

Respondents continued to report a higher number of interventions/year, increasing from an average 2,749 in 1992/93 to 8973 (SD ± 12 534 – range from 0 to 60,000) in 2001/2002. This trend could be related to mergers and regionalization, as the average number of acute and non acute care beds increased from 333 in 1995/96 to 453 in 2001/2002. The rate of intervention documentation increased from 0.44 interventions (both pharmacokinetic or therapeutic) per admission in 1997/98 to 0.53 in 1999/2000 and 0.60 in 2001/2002. This ratio does not appear to be influenced by teaching status or bed size.

The average of reported number of interventions/pharmacist FTE was 571 (SD ± 568) in 2001/2002 compared to 418 in 1999/2000. There are large variations of interventions/pharmacist FTE among regions in the country (British Columbia – 221, Prairies - 446, Ontario – 760, Quebec - 749, Atlantic - 382). This does not seem to be explained by the pharmacist shortage, which is similar between regions, or by staffing, as Quebec had a low 0.68 paid hours/acute patient day compared to Ontario (0.82), Prairies (0.78) or British Columbia (0.75).

Clinical Practice models

Clinical pharmacy practice has evolved through a combination of practice models. Pharmaceutical care is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes. The process of pharmaceutical care includes designing, implementing and monitoring a therapeutic plan that involves the identification of potential or actual drug-related problems, their prevention and resolution. Traditional clinical pharmacy services are defined as a variety of clinical pharmacy services related to a specific drug, a specific pharmaceutical expertise or a targeted approach that will maximise a specific outcome for a patient (e.g. pharmacokinetic services, total parenteral nutrition (TPN) services).

Traditional clinical pharmacy services were reported to be utilized to fulfil the needs of some patient populations by 89% of respondents (Table B-4), a rate similar to that reported in 1995/96. The provision of pharmaceutical care was reported by 75 % of respondents, up from 66% in 1999/2000. Coexistence of both models, with the current pharmacist resource situation, is inevitable. The resources required to provide pharmaceutical care are extensive and only 2 % of respondents who used the pharmaceutical care model (two hospitals) reported that the pharmaceutical care model was offered to more than 90% of patients.

Respondents from hospitals reporting traditional clinical pharmacy services reported that an average of 57% of beds (SD ± 27, range 2% to 100 %) were covered utilizing this model in 2001/2002 versus 52% in 1999/2000. For hospitals reporting pharmaceutical care services, respondents reported that an average of 33% (SD ± 23 – range 1% to 100%) of beds were covered using this model Sixty-eight percent of all respondents reported that some patients did not receive any patient oriented clinical services in their institution (for 31% of their beds – SD ± 23 – range 1% to 100%) a decrease from 83% reported in 1999/2000.

Seamless care

Seamless care is defined as the desirable continuity of care delivered to a patient in the health care system across the spectrum of caregivers and their environments. Pharmacy care is carried out without interruption such that when one pharmacist ceases to be responsible for the patient's care, another pharmacist or health care professional accepts responsibility for the patient's care. In 2001/2002 31% of all respondents had established a policy for seamless care, a response similar to the percentage reported in 1999/2000.

For hospitals providing seamless care, respondents reported that the service was provided to an average of 15% of patients (range 1 to 60) in 2001/2002, compared to 11% reported in 1999/2000. Eighty-two percent provided seamless care on a prospective basis and 66 % on request. Respondents reported that the information provided was directed towards community pharmacists (92%), family physicians (68%), home care providers (58%) or home care centres (50%). The information provided included medications at discharge (97%), relevant drug monitoring parameters and lab values (79%), medications discontinued during hospital stay (71%), care plan information (58%) diagnosis (58%). Thirty four percent of respondents indicated that the seamless care documentation form could also serve as a prescription. A higher percentage of respondents who had adopted the pharmaceutical care model reported the development of a seamless care policy, compared to respondents with traditional clinical services (38% vs. 6%).

Hand-held devices

Fifty-two percent of respondents reported the use of hand-held devices in their clinical practice (Table B-5). The technology appeared to be more popular in larger institutions, where 68% of respondents reported use of these devices. For the respondents reporting the use of hand-held devices, the main uses indicated were to consult clinical databases and to manage mail, agenda and tasks. Unfortunately, there were few cases (n = 6) reported where the devices were interfaced with pharmacy software.

Evaluation of clinical pharmacy services

As pharmacy practice evolves, prospective evaluation of clinical pharmacy services should be conducted, not only at a research level, but also on an operational level. Twenty percent of respondents evaluated the provision of direct patient care services through an audit of clinical activities (Table B-6), a rise from 13% reported in 1999/2000. Evaluation of clinical pharmacy services is conducted more often in teaching hospitals (29 %) than non-teaching hospitals (13%).

For hospitals conducting evaluation of clinical pharmacy services (n = 24), respondents reported that the evaluation was performed by peers/other pharmacists (75%), others (50%) and physicians (21%). The methods of evaluation included retrospective chart review (67%), direct observation (50%) and self-evaluation by pharmacists (42%). The aspects that were evaluated included documentation (79%), competency assessment (58%), implementation of objectives and monitoring plan (54%), patient assessment (46%), and patient counselling and understanding of information (46%). No significant changes from 1999/2000 data were observed. The respondents who evaluated services reported that the percentage of pharmacists evaluated was 41% (SD ± 33 %) and that results of the evaluation were shared with pharmacists (79%), professional practice/quality of care committee (21%), multidisciplinary care team (4%) or others (33%).

A recent quantitative evaluation of randomised trials on counselling, education and other clinical services was published The American Society of Health System Pharmacists has published²³ for reference a useful handbook on job skills and evaluation, and provides annual updates.⁴

Prescribing rights

In 2001, the Canadian Society of Hospital Pharmacists (CSHP) adopted a Statement on Pharmacist Prescribing,⁵ based on a collaborative prescribing model. The statement supports a co-operative practice relationship between pharmacists and physicians and suggests that “ In an ideal collaborative practice, the physician will diagnose and make initial treatment decisions for the patient and then the pharmacist will select, initiate, monitor, modify, continue and discontinue pharmacotherapy, as appropriate, in order to achieve the desired patient outcomes. In this collaborative practice model, both the physician and the pharmacist share in the risk and responsibility for the patient outcomes achieved.”

At the same time, CSHP also released An Information Paper on Pharmacist Prescribing within a Health Care Facility.⁶ This information paper observes that “In the traditional model of health care, physicians have the authority to prescribe medications, order laboratory tests and conduct or supervise procedures consistent with a patient’s diagnosis. More recently, prescribing privileges have been extended to other health care professionals...... Various levels of prescribing authority for pharmacists are being examined and implemented in a number of provinces (e.g. specially instructed and certified pharmacists prescribing post-coital contraception).”

Fifty-four percent of respondents reported that professionals, other than physicians and dentists, had authority to prescribe drugs (independent and dependent) in the hospital. (Table B-7) Approval of prescribing rights for other professionals was most common in teaching hospitals (69%) vs non teaching hospitals (42 %), and hospitals with more than 500 beds (75%).

Respondents identified pharmacists (34% of all respondents), nurse practitioners (24%), midwives (23%) and other professionals (9%) as groups having prescribing rights. Only 6% (7/123) of respondents (in 4 provinces) reported that pharmacists’ prescribing rights had been authorized by legislation. Seventeen percent of all respondents indicated nurses prescribing rights had been authorized by legislation.

The Boards and committees involved in the hospital-specific approval process to grant other professionals with a right to prescribe drugs were identified as the medical advisory board (88%), the P & T Committee (68%), the hospital board of directors (27%) and the affiliated universities (5%).

Independent prescribing usually implies that the prescribing practitioner is solely and legally responsible for patient outcomes. Dependent prescribing suggests that the prescribing practitioner has obtained a delegation of authority from an independent prescribing professional. In most cases, dependent prescribing refers to prescribing according to a protocol. Of hospitals where professionals other than physicians and dentists prescribed drugs, pharmacists were reported to have dependent prescribing authority for new therapies by 20%, dependent prescribing for dosage adjustments by 56% (mainly for antiemetics and chemotherapy) independent prescribing for new therapy by 6%, independent prescribing for dosage adjustment by 15% (mainly for aminoglycosides and anticoagulants) and independent prescribing for lab tests by 20%.The situation varies across the country with the most similarities in practice reported among the teaching hospitals.

A short-term plan, to address pharmacists’ prescribing rights, might be accomplished through the establishment of a process to recognise specialization in pharmacy practice. The National Association of Pharmacy Regulatory Authorities’ (NAPRA) 2002 spring newsletter reported that the Council supports the concept of establishing a process for pharmacists to become a “Registered Pharmacist Specialist”.⁷ The National Advisory Committee on Pharmacy Practice (NACPP) continues to develop the framework for recognition and certification of pharmacist specialists in Canada.

Other readings

A recent position paper of the American College of Physicians-American Society of Internal Medicine (ACP-SIM), on pharmacist scope of practice has been at the heart of a recent debate. Zed PJ, Loewen PS and Jewesson P have provided a positive and well balanced response to the argument evoked in that position paper, from the Canadian perspective.⁹ The “Suggested readings” provided below provide further comparisons of clinical pharmacy services in Canada with the United States and other countries.

Conclusion

Even though the 2001/2002 survey results indicate that the majority of the pharmacists’ time is not spent on clinical activities, it is important to remember that a pharmacist uses his/her knowledge and clinical expertise when carrying out all professional duties.

The 2001/2002 data illustrates that clinical pharmacy services have continued to grow based on the absolute paid hours dedicated to clinical services and the variety and complexity of clinical services provided. Changes to health care professionals’ regulations, the emergence of drugs prescribing rights for pharmacists and the trend towards specialization will be key challenges in the years ahead.

Suggested Readings

Ringold DJ, Santell JP, Schneider PJ. ASHP national survey of pharmacy practice in acute care settings: dispensing and administration – 1999. Am J Health Syst Pharm 2000; 57: 1759-75.

Pedersen CA, Schneider PJ, Santell JP. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing--2001. Am J Health Syst Pharm 2001 Dec 1;58 (23):2251-66

Bond CA, Raehl CL, Franke T. Clinical pharmacy services, pharmacy staffing and the total cost of care in the United states hospitals. Pharmacotherapy 2000; 20 (6): 609-21.

Bond CA, Raehl CL, Franke T. Clinical pharmacy services and hospital mortality rates. Pharmacotherapy 1999; 19 (5): 556-64.

Raehl Cynthia L, Bond CA. 1998 National clinical pharmacy services study. Pharmacotherapy 2000; 20 (4): 436-60.

ACCP White Paper. A vision of pharmacy’s future roles, responsibilities and manpower needs in the US. Pharmacotherapy 2000; 20 (8): 991-1020.

Carter BL, Helling DK. Ambulatory care pharmacy services: has the agenda changed± Ann Pharmacother 2000; 34: 772-87.

Various authors. Special issue on hospital pharmacy practice around the world. International Pharmaceutical Federation. 2002; summer issue.

References