María del Pilar García Rodríguez
Raquel Silgado Arellano
Susana Cortijo Cascajares
Mercedes Campo Angora
Olga Serrano Garrote
Alberto Herreros de Tejada y López Coterilla
Head of the Pharmacy Service
“12 de Octubre” University Hospital
In Spain, the National Specialty Pharmacy Programme establishes that fourth-year pharmacy residents (Y4PRs) must perform the regular clinical activities carried out by pharmacists in hospital in- and outpatient departments, and must do so through integration in the clinical team.(1,2)
This results from the ever-increasing orientation of the pharmacist to pharmaceutical assistance, which leads, in practice, to an individualised pharmaco‑therapeutic follow-up, which allows for the detection, prevention and resolution of medicine-related problems (MRPs).(3) The purpose is to ensure correct drug usage, which means achieving the highest effectiveness with minimal unwanted effects and use of resources.(4–6)
However, pharmacist interventions do not necessarily have to be associated with an MRP. They can also help to improve the quality of prescription, with the pharmacist suggesting alternatives oriented to simplify dosage, make administration and compliance easier and reduce treatment cost, or just remind of the need to adhere to the hospital formulary.(7)
The Pharmacy Service of “12 de Octubre” University Hospital (Madrid, Spain) selected the following hospital in- and outpatient units for the rotations during the PGY4 residency: medical oncology unit (2.5 months), internal medicine department (1.5 months) and multipathology unit (4 months) as medical areas; urology unit (1 month) as surgical area; and HIV services (1 month) as outpatient department.
Selection of these units was based on the already existing good relationship with the staff at these units, as well as an already implemented unit-dose drug distribution system, to make patients’ pharmacotherapeutic monitoring easier.
A Pharmaceutical Assistance Programme was implemented in these units during residents’ stay in the wards. Thus, the resident became integrated into the clinical team and performed the following activities:
- Review medical records and accompany physicians on their daily ward rounds.
- Interview patients at admission to obtain information on their treatment at home, their lifestyle and their personal history.
- Conduct a pharmacotherapeutic follow-up of patients while in hospital, to detect and solve potential medication errors (MEs) and MRPs and to participate actively in drug therapy evaluations.
- Carry out active bibliographic searches and answer queries raised by other members of the team.
- Provide patients with information, both oral and written, about the treatment they must follow at discharge (with the help of the Infowin® application).
- Assess, through an interview for discharged patients, their perception of the usefulness of the information received.
- Assess the extent to which pharmacists are accepted on wards by other members of staff.
The functions to be fulfilled by pharmacists in the outpatient services focused on the following:
- Assess antiretroviral treatments and other therapies used to treat comorbidities.
- Actively contribute to the detection of the patients’ lack of adherence to treatment and to the studies of resistance to antiretroviral drugs.
- Work with nurses to provide patients with health education and pharmacotherapeutic information, stressing the fact that patients must follow their treatments as prescribed.
During the period of rotation at the different hospital clinic units, 283 patients were clinically followed up, with 204 interviews made at the time of admission and 129 reports at discharge (see Table 1). There were 514 interventions by pharmacists associated with 585 potential MRPs, 457 of which were related to MEs. The information provided by the pharmacist when a patient was discharged turned out to be very useful, according to most patients. The acceptance of the pharmacist’s interventions by the clinical team was very high: 100% of the staff thought that the pharmacist’s presence on wards, either full- or part-time, was needed. The experience in each of these clinical units is described below.
Surgical unit: urology
During rotation at this unit, the Pharmaceutical Assistance Programme was barely developed. The main reasons were: the insufficient number of physicians (surgeons) on this ward (operation theatre timetables were not compatible with scheduled ward rounds); the high rate of rotation of patients; and the large number of hospital beds allocated for follow-up (45 beds). The pharmacist’s task in this ward was just to interview patients at admission, to monitor drug administration. In fact, most potential MRPs detected were associated with the treatment followed at home by the patient.
The level of knowledge acquired during this rotation was low, and the contribution made by the pharmacist was insufficient. For this reason, data obtained at this unit are not included in this article.
Special hospital unit: medical oncology
The Pharmaceutical Assistance Programme was very well received in the medical oncology ward (15 beds). There were many opportunities to work with clinical staff, since patients staying there were polymedicated, and many of them were receiving chemotherapy and/or artificial nutrition. The fact that patients stayed for 14 days on average allowed the pharmacist to do a continuous follow-up of each patient and to have a deeper knowledge of their individual problems.The multidisciplinary nature of the clinical team (made up of physicians, nurses and psychologists) favoured a better and faster integration of the pharmacist.
Medical oncology was the ward where more queries were solved and one of the wards where more interventions by the pharmacist were registered (see Table 1).
The level of knowledge acquired by the pharmacy resident was high as far as pharmacological therapy, chemotherapy, palliative care and pain management were concerned. In addition, the resident was able to develop his/her psychological skills to communicate with the patients and their family.
Hospital unit: internal medicine
The Pharmaceutical Assistance Programme was well received in this ward, which is characterised by the presence of older patients (average age: 72 years) and multiple pathologies. Despite the low rate of rotation of patients (average stay: 16 days), the high number of beds (49 beds) where the Programme was implemented hindered good follow-up of patients. However, the number of interviews at admission and of reports at discharge was higher than that in other wards (see Table 1). The level of knowledge acquired by the resident was high.
Short-hospital-stay unit: unit for the integral care of polymedicated, pluripathologic patients
This unit is part of the Internal Medicine Service and is coordinated with primary care centres, so that patients are referred from their primary care centre to the hospital outpatient service or directly admitted to the unit without first going to the crowded emergency services. Patients in this unit are polymedicated and pluripathologic. The ward has a small day hospital, two consultations and 25 hospital beds distributed among four medical teams.
The Pharmaceutical Assistance Programme was implemented in collaboration with two of the four medical teams (14 beds), and it was the ward with the largest number of interventions per patient (see Table 1).
The resident’s integration in this ward and his/her collaboration with the staff was excellent, receiving full support and recognition from both physicians and nurses.
The level of knowledge acquired by the resident pharmacist was very high, thanks to the multiple pathologies of the patients, the extraordinary teaching skills of the physicians and the interest of the clinical sessions based on clinical cases to which the resident attended.
Outpatient HIV service
This rotation turned out to be very interesting and necessary to complete the resident’s training in the field of HIV disease, both at the pharmacological level and in terms of how to communicate better with HIV patients.
The activity performed by the Y4PRs at the clinical units has been positive, both for the residents (training received) and for the clinical team (information contributed). In general, the pharmacists’ presence at hospital departmental level allowed the detection, prevention and solution of many problems, and provided patients’ care with an added value. In addition, the information provided to patients at the time of discharge about their treatment at home possibly contributed to a better administration of the medication prescribed and avoided oversights.
However, pharmaceutical intervention was, to a large extent, influenced by the importance of integration and collaboration with the other members of the team and by the number of patients followed up.
This article was partly presented as a poster at the 50th National Congress of the Spanish Society of Hospital Pharmacy (Sociedad Española de Farmacia Hospitalaria), Oviedo (Spain), in October 2005
- Programa Nacional de la Especialidad. Farmacia Hospitalaria. Available from: http://www.sefh.es/01programa_especialidad.php
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- Grupo de Consenso en Atención Farmacéutica. Madrid. Ministerio de Sanidad y Consumo; 2001.
- Andújar Arias MM, Hermoso Martínez MC, Nieto Pajares JF, et al. Registro, documentación, clasificación y evaluación de las intervenciones farmacéuticas (2003). Aten Farm 2005;7:342-50.
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- Ellis SL, Carter BL, Billups SJ, et al. Types of interventions made by clinical pharmacists in the IMPROVE study. Pharmacotherapy 2000;20:429-35.