Treatment of patients is, in most cases, a combined effort of several individuals and it is recognised that the outcome of a procedure is optimal when the professionals do indeed work together as a team.
Obviously, pharmacists are part of treatment teams in healthcare establishments. With expertise of product and processes, they improve the therapeutic outcome and the quality of work flow. Although it seems obvious that a pharmacist form part of a team, do we know the exact added value of their contribution?
The answer to this question is even more important in times of economic constraints, a factor that pharmacists themselves have to keep in mind. Through examples described by several colleagues, we would like to inspire you to think about your role in a team.
The Netherlands
Paul PH LeBrun
PharmD PhD
Hospital Pharmacist and Clinical Pharmacologist
Central Hospital Pharmacy, The Hague, The Netherlands
Email: [email protected]
In The Netherlands, a hospital pharmacist has always been a member of therapeutic and antibiotic committees. Lately, however, he is confronted with a role that has evolved from background advisor to frontline patient care provider, continuously requiring different skills.
A hospital pharmacist can at any one moment be a member of several teams of professionals, all with different goals and perspectives. The added value is obvious and has resulted – and still results – in best practice described in formularies. The input is mostly based on thorough knowledge and review of the literature.
The new tasks evolving from the roles in these committees are challenging. A particular example is antibiotic stewardship (see previous issue of HPE).
Another example is the role of the hospital pharmacist in the intensive care unit. His consulting role is increasingly recognised as being indispensable and, as such, as in several other countries, being formalised by his recognition as an intensive care pharmacist.
The examples above are based on product knowledge. Another value of the pharmacist, however, is process knowledge. Based on FMEA principles, the hospital pharmacist can introduce risk assessments on several subjects.
For example, a team of nurses, pharmacy personnel and doctors can evaluate the process from prescription to administration. By recognising and ranking risks, the team can define proper measurements in order to control risks.
A future challenge will be home care treatment. Length of stay in hospital is diminishing and pharmacists play a key role in the transfer of patients.
A key example is the use of antibiotics in the case of a patient being treated at home. In a team effort requiring the doctor, the outpatient pharmacist, the community pharmacist, nurses and a logistic service, the preparation, delivery and control of the medication of the leaving patient has to be organised.
A successful example of this coordination can be seen in the treatment at home of 200 cystic fibrosis patients by a team from the Haga Teaching Hospital in The Hague.
Belgium
Tiene Bauters
PharmD PhD
Clinical Pharmacist, Paediatric Haematology, Oncology and Stem Cell Transplantation Pharmacy
Ghent University Hospital, Belgium
Email: [email protected]
The concept of clinical pharmacy, in which pharmacists act as part of a multidisciplinary team, has existed in Belgium since the early 2000s.
At the time the position was created, there was often limited understanding on the part of physicians and clinical staff with regard to the role of the pharmacist as a member of a multidisciplinary team. Initially, much time was spent educating providers and staff about the qualifications of the pharmacist to operate in their unique role.
Pharmacists’ contributions now mainly include reducing prescription-related errors, drug-drug interactions and contraindications, and monitoring therapeutic responses. In addition, enhancing patients’ pharmacotherapy by recommending the addition of necessary drugs or discontinuation of unnecessary drug therapy, modification due to adverse effects or drug-disease interactions, and optimising patient adherence are now well established.
Their activities mainly focus on high-risk patient groups and disease states (for example, intensive care, paediatrics, oncology, stem cell transplantation, geriatrics and HIV patients) or focus on optimising adherence in patients on oral cancer therapy. They also play an active role as part of general hospital established teams, such as a nutrition team or a multidisciplinary infection team, where antibiotic treatments are daily discussed with infectious disease experts, microbiologists and physicians.
Another role involves their participation in chronic disease management (for example, diabetes and chronic pain), including anamnesis of medication, documenting medication management plans and providing patient education.
By being a member of a multidisciplinary team, pharmacists can significantly improve appropriate prescribing and expand patient care. They can provide services themselves, liaise with other health settings and bridge the gap between the hospital and the patients’ local community pharmacies for services available there (for example, home medicines reviews).
Germany
Martin J Hug
PhD
Director of Pharmacy
University Medical Centre, Freiburg, Germany
Email: [email protected]
All over the world, pharmacists receive an interdisciplinary training before they qualify. This provides an excellent basis for teamwork once they have reached their professional destination.
German hospital pharmacists are often considered to be all-rounders in their field, which is why they are welcome in a number of different multidisciplinary teams both inside and outside their institution. Pharmacists are often the ones who communicate with the treating physician in order to offer the best possible treatment for hospitalised patients.
Clearly, no drug formulary or Pharmacy and Therapeutics Committee could make substantial decisions without the interaction between physicians and hospital pharmacists. Commissions on medical devices or nutrition steering committees are further examples of why institutions cannot do without the work of hospital pharmacists.
Ever since German legislation recognised infection control as a subject of the utmost importance, the participation of hospital pharmacists in respective hygiene commissions is mandatory. In these commissions, they discuss the use of antimicrobial agents with hygienists, microbiologists and physicians involved in the care of patients with infectious diseases.
Most recently, however, pharmacists are being challenged to be involved with yet another relevant group within the hospital: business administration.
In order to keep the budget at bay, pharmacists have to provide solid forecasts on the present and future costs of drugs and communicate these estimates to the hospital’s controlling department. Often this also involves negotiations with insurance providers and the public health administration. In such situations, pharmacists often enter uncharted territory, as their training at university rarely provides insight into cost control.
It is therefore not surprising that the network of the German Society of Hospital Pharmacists receives a large number of inquiries on how to deal with numerous regulations imposed by the healthcare providers.
The fact that most questions are answered within a few hours demonstrates that German hospital pharmacists are perfectly up to that challenge.
Spain
María José Tamés
PhD
Hospital Pharmacy Specialist, Assistant Manager Pharmacy Department
Onkologikoa Foundation, San Sebastian, Spain
Email: [email protected]
Revising current literature, one often comes across the terminology ‘multidisciplinary teamworking’ on many and different activity fields. This concept describes activities that develop professionals, considering their separate but inter-related roles as members of a multidisciplinary team.
Healthcare systems and hospitals (as part of them) are entities where this approach becomes of special interest and where benefits are outstanding.
The traditional role of hospital pharmacists has a long history, but the way this activity has been performed throughout time has evolved dramatically. One of the most important changes has been the integration of the pharmacist into the hospital multidisciplinary team, incorporating a combination of skills, knowledge and values.
This orientation in the profession has been called ‘clinical pharmacy’. Its evolution has also differed from country to country. Hospital pharmacists in the US were pioneers in incorporating this philosophy in the early 1970s, while in Europe the movement came later. This approach has not been easy in many countries, but nowadays it is consolidating and becoming a common practice at least in some clinical areas.
To deal successfully with participation in the multidisciplinary team, it is essential to acquire competence in terms of professional skill, knowledge and expertise. Spanish hospital pharmacy is in a good position to develop the integration of the pharmacist into the multidisciplinary team. Several factors support this strategy.
The first one is our specialisation through a four-year residency program, which is performed completely at the hospital. The introduction of the fourth year (devoted to clinical rotations) in the year 2000 reinforced the clinical approach and integration in the multidisciplinary team. This specialisation programme follows the same criteria as the medical specialists, allowing us to have the same status at the hospital.
Another important contribution is the continuing education activities developed in the country. Here, I would like to highlight the grants’ programme oriented to obtain the BPS (US Board of Pharmaceutical Specialisations) certificates in some areas such as oncology and nutrition. The experience of certified pharmacists is really very positive. They consider that it facilitates clinical approach and strengthens their position in multidisciplinary teams.
As a result of this background, Spanish hospital pharmacists are engaged in providing clinical activity, playing an active role in the hospital multidisciplinary team.
Italy
Anna Carollo
PharmD PhD MS
Hospital Clinical Pharmacist
ISMETT Hospital, Palermo, Italy
Email: [email protected]
The role of the clinical pharmacist could be defined as an umbrella of services aimed at maximising pharmacotherapy effects, minimising the risk for developing adverse drug reactions and reducing medication errors.
The clinical pharmacist participates in the clinical decision-making process by participating in medical rounds. The presence of clinical pharmacists in a multidisciplinary team provides added value to the treatment of patients. In fact, clinical pharmacists play an important role in drug safety on hospital wards, optimising drug prescriptions and improving surveillance.
Integration of pharmacists into multidisciplinary teams has been shown to have a positive effect in several clinical, pharmaceutical and financial indicators. Literature on this particular field is sparse, and there are few data available on this aspect of the clinical pharmacist’s role. Differences in methods, outcome measures and working frameworks make the available evidence difficult to generalise.
Clinical pharmacists have been recognised as an essential component of the multidisciplinary team by their colleagues, as well as by several governing and professional organisations. The specific education, training and responsibilities of the clinical pharmacist have not been clearly delineated in the literature and there are still various differences across European country.
Many European pharmacists have been called on to serve on multidisciplinary teams, necessitating standardisation of their fundamental and desirable activities.
France
Mikael Daouphars
PharmD PhD
European Society of Oncology Pharmacy Board Chair
Hospital Pharmacist
Cancer Centre Henri Becquerel, Rouen, France
Email: [email protected]
As for other healthcare professionals, the main goal of the pharmacist within the team is to benefit the patient.
To this end, there are many direct and indirect interactions with the patient. In the pharmacy department, the pharmacist performs drug regimen reviews and monitors for medication-related problems and inappropriate therapy.
Thanks to his knowledge of medications, he helps ensure that patients are placed on appropriate therapies and will limit drug-drug interactions.
By having access to medical records and laboratory results, the pharmacist can propose dose modification regarding renal or liver impairments, perform therapeutic drug monitoring and check the appropriateness of antibiotic drugs in relation with microbiological results.
Outside the pharmacy department, the pharmacist works with other health professionals on clinical pharmacy services for individual patients. With the patient, the pharmacist performs admission medication history interviews, drug management review, medication counselling and patient education.
Within the clinical ward, the pharmacist can provide drug information to doctors and nurses, including IV drug compatibilities or physicochemical stability, and train pharmacy students and others.
The pharmacist serves as a member of policy-making committees, including those concerned with drug selection, use of antibiotics, nutrition and pain management and thereby influences the composition of the hospital formulary.
The pharmacist is also involved in management services that also improve patient safety, through the development prescribing policies, quality activities such as drug use evaluation, and standardisation of high-risk medicines.
In cancer care, proper preparation of cytotoxic infusions raises safety in the patient journey. In multidisciplinary meetings dedicated to treatment choice for individual patients, the pharmacist’s participation contributes to choosing the best drug through taking into consideration evidence-based medicine data, off-label use and financial issues.
Finally, the pharmacist also takes part in the planning and implementation of clinical trials within the multidisciplinary team.
The UK
Michael Scott
BSc PhD FPSNI
Head of Pharmacy and Medicines Management
Northern Health and Social Care Trust, Antrim, UK
Email: [email protected]
The role of the pharmacist in the multi-disciplinary team is to bring his particular knowledge and skill sets to this group with the objective of optimising patient care.
The pharmacist is recognised as a medicines expert in terms of the rational selection of medicines for the treatment of patients, taking account of the fact that, in hospital, a significant proportion of patients are over 65 years of age.
The appropriate use of medicines in this age group is complex, given the fact that such patients will be receiving a number of medications in order to manage the range of co-morbidities with which these patients typically present. It is therefore important to be aware of all the potential drug-drug interactions, drug-disease state issues and potential side effects that may occur.
The initial reconciliation of medicines at admission is a critical first step in the process, followed by on-going monitoring during the hospital stay and at discharge to ensure that a fully reconciled list is provided to primary care colleagues.
The participation of pharmacists in the multidisciplinary team ward round is another key component, including specialist rounds, for example, with microbiologists in respect of antimicrobial prescribing. The pharmacist in this setting also has an educational role with regard to both junior medical and nursing staff.
