In hospitals, pharmacist interventions are vital for correcting prescribing errors, thereby increasing patient therapeutic benefit. To provide an optimal service, adequate pharmacy staffing levels need to be achieved.
Hospital pharmacists’ clinical interventions were audited in October 2009. The results were compared with a previous audit at the North Middlesex University Hospital NHS Trust (NMUH) in November 2008.
Pharmacists were asked to record all clinical interventions made during ward visits, in the dispensary and in the production unit at NMUH. Data were collected using manual or electronic forms over 10 working weekdays during a two-week period. To avoid changes in practice, prescribers were not aware of the audit. Three senior pharmacists reviewed the data independently to resolve any ambiguities, and excluded any interventions that did not result in a clinical change, e.g., a financial intervention. I then obtained a medical perspective on the interventions. One medical registrar and one paediatric registrar reviewed the significance of the intervention only if it was within their specialty area and if sufficient data had been provided. I also examined the impact of pharmacy staffing levels on pharmacists’ clinical interventions.
As Table 1 shows, in the 2009 audit, most clinical interventions were of minor significance, i.e., small adjustments or optimisation to therapy that were not expected to alter hospital stay or patient outcome significantly. Moderate interventions are expected to enhance drug therapy, or improve patient outcome, or reduce hospital stay. Major interventions are expected to prevent or address serious drug-related problems by preventing life-threatening or irreversible situations. Interventions to prevent a potential fatal outcome were termed “catastrophic”. Pharmacists in the 2009 audit skewed more towards minor clinical interventions, whereas in 2008 there were more moderate interventions.
A medical perspective
Of the 232 interventions in the 2009 audit, the significance of 36 interventions was changed during pharmacy peer review. When reviewed by a doctor, the significance of 17 of the 232 interventions was altered. Only one change made by the doctors overlapped with that of the pharmacy reviewing group. Both pharmacists and doctors stated that classifying the significance of each clinical intervention was subjective and dependent upon the information provided.
The doctors highlighted that the indication was not given in some cases and, for example, if it was documented that a patient had septicaemia this would increase the significance further. Most of the doctors’ changes were to increase the significance for sub-therapeutic doses, mainly of anti-infectives. The current audit did not capture any clinical interventions in the catastrophic category. However, one doctor stated that, had more information been provided, the significance could have been changed from major to catastrophic.
Table 2 highlights the change in intervention significance after the doctors’ input. Overall significance was changed from minor to either moderate or major, and from moderate to major. These results suggest that doctors classify clinical interventions as being more significant than pharmacists do. This is a finding that needs exploring in more detail. If pharmacists’ clinical interventions are more significant than the profession realises then steps should be taken to ensure the valuable role of pharmacists is recognised and used appropriately.
Impact of staffing levels
In the 2009 audit, 232 clinical interventions were carried out over 10 working days; 116 when averaged over five working days. In the 2008 audit, 83 interventions were carried out over five working days. In 2008, there were 18 pharmacists with one pharmacist covering multiple wards. During 2009, there were 25 pharmacists. This suggests that the number of pharmacists is likely to have an impact on the number of clinical interventions carried out. It was also noted that 62 per cent of clinical interventions were completed within five minutes, a rise from 32 per cent in the November 2008 audit.
Almost all the clinical interventions in the 2009 audit (99 per cent) were accepted, with 1 per cent not resolved owing to patient ward transfer. This could have been avoided if the intervention had been handed over.
Obtaining a medical perspective on pharmacists’ clinical interventions has shown that their impact may be more significant than the profession realises. This audit also suggests that the number of pharmacists employed is likely to have an impact on the uptake of hospital pharmacy clinical interventions. This highlights the importance of hospital teams filling up vacant posts. ÂWith the increase in hospital bed pressures leading to speedier patient discharges, the role of the clinical pharmacist is crucial in reducing adverse drug events and increasing drug efficacy to maximise patient recovery.
Thanks to Tejal Patel (deputy chief pharmacist, clinical services), Ryhana Haniff (lead pharmacist, education and training), Julian Waung (registrar, diabetes) and Radhalakshmi Senthilkumar (registrar, paediatrics) at NMUH.
About the author
Amena Bhatti is lead pharmacist, women’s health, at North Middlesex University Hospital NHS Trust, London.
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