Evaluation of the implementation of a clinical pharmacy service on an acute internal medicine ward in Italy

Clinical pharmacy is a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention [1]. Clinical pharmacy services developed at the end of 1960 in the United Kingdom and United States of America [2, 3] and they are now playing an important role in hospitals aiming to reduce medication errors and Adverse Drug Reactions (ADRs).

Appropriateness of prescribing is defined as the outcome of a process of decision-making that maximises net individual health gains within society’s available resources [4]. Inappropriate medication prescribing in the elderly is rising because of increase of ageing population, number of chronic conditions and number of drugs prescribed. A cohort study has found that 25.8% of elderly receive at least one potentially inappropriate medication [5]. Previous evidence has shown that drug histories taken at admission by a clinical pharmacist and participation of a clinical pharmacist in medical rounds reduce medication errors respectively by 51% and 29% [6]. It has also been shown that clinical pharmacists participating in medical rounds and taking drug histories at admission reduce the number of ADRs [7]. Reduction in medication errors and ADRs following the introduction of clinical pharmacists in hospitals has been shown to have a positive impact on reducing length of hospital stay and mortality rate [8].

A meta-analysis looking at the association of medication use and falling found that the use of sedatives, hypnotics, antidepressants and benzodiazepines had a significant association with falls in elderly patients [9]. Input of the clinical pharmacist in providing information for drug changes that might reduce fall risk has been shown to reduce falls by up to 70% [10, 11].

Acceptance rate of interventions made by clinical pharmacists is key as only those interventions accepted by the healthcare team will have an impact on patient care and might produce cost savings. Ward pharmacy services with a high acceptance rate of interventions made by clinical pharmacists are deemed to be cost-effective by policy-makers. However, evidence shows that acceptance rate of clinical pharmacist interventions can be as low as 53% [12]. Assuming pharmacists with appropriate training and knowledge of pharmacotherapy are employed at ward level a possible cause for the low acceptance rate of pharmacist interventions is lack of communication between the pharmacist and the medical team [12].

There is an assumption that if pharmacists provide evidence base advice on medications, doctors, in turn, will implement them. However, this is not always the case and there is a need to foster active collaboration between the two professions applying models of communication from areas outside healthcare [13].

Several studies report on the introduction of ward based clinical pharmacy services with a satisfactory (> 80%) acceptance rate of interventions made by clinical pharmacists [14–17]. However, description of the reason behind the high acceptance rate of interventions is not reported.

Given there is no evidence on strategies adopted to enhance acceptance rate of interventions made by ward based clinical pharmacists the aim of the study was to assess the effect of a tailored communication strategy on the acceptance rate of interventions made by a clinical pharmacist implementing a ward based clinical pharmacy service targeting patients at high risk of drug-related problems. Characteristics of interventions made are described, their clinical importance is assessed and acceptance rate by doctors is measured.

A total of 143 interventions of major clinical significance were made over a period of 4 months by a clinical pharmacist in an internal medicine ward. That is equivalent to 35 potential major drug-related problems avoided per month. To our knowledge, this is the first study evaluating the effect of a structured communication strategy on acceptance rate of pharmacist interventions. Pharmaceutical care delivered by the clinical pharmacist is likely to have improved appropriateness of prescribing. The majority of interventions made in our study were either of moderate or major clinical significance.

Both the high acceptance of the pharmacist’s interventions (93.2%) and their clinical significance mean that potential harm to patients was avoided and patients care was improved during their stay in the hospital. Other studies using a similar definition of intervention and similar ways of recording them report an acceptance rate of 76%, 88.4% and 87.8% respectively [14, 16, 17]. The acceptance rate of interventions recorded in our study is higher. Driving forces that have contributed for the high acceptance rate of interventions are: aim of the study clearly stated and communicated to healthcare professionals, direct contact with the medical team, nurses and patients, regular presence of the pharmacist on the ward (0.9 full-time equivalent) and pharmacist with appropriate training in clinical pharmacy/pharmacotherapy in the elderly population.

General advice on the use of newer antidiabetics, monitoring of last generation antibiotics and side effects of psycholeptics were frequently asked to the pharmacist. These advices were classified as interventions in the absence of a specific problem (15.9%), were not related to a specific patient and were triggered by physicians highlighting how the pharmacist was fully integrated within the healthcare team.

Collaboration between nurses/medical staff and clinical pharmacists in providing patient care is a relatively new concept in Italy. Currently hospital pharmacists are not ward based and their role is mainly limited to drug dispensing with provision of limited medicine information. This has represented a key challenge emphasizing the need to increase awareness of the new service implemented and build trust with the ward team in order to promote and show potential benefits of pharmaceutical care.

It is expected that the nature and extent of physician-pharmacist collaboration can vary and it can be both episodic and informal rather than as part of a continuum of care. Research looking at interprofessional collaboration between doctors and pharmacists has found that doctors are reluctant to accept the fact that quality and safety of medicine use can improve using the expertise of pharmacists [13]. In our study we have overcome this significant cultural barrier applying models of communication from the commercial world to a healthcare setting in order to foster trust, active collaboration and team working between the two professions with the ultimate aim of enhancing acceptance rate of interventions.

It is expected that lack of awareness and knowledge on the importance of ward based clinical pharmacy services on improving appropriateness of prescribing could be one of the reasons for rejection of pharmacist interventions [30]. Involving all key stakeholders is key in service implementation. The use of communication tools such as the SWOT analysis, SMART goals and the AIDA model are likely to have had a positive impact on the acceptance rate of pharmacist interventions. The SWOT analysis had the aim of explaining to doctors and nurses the aim of the new service implemented and forecast potential issues the team would potentially face in future. Suggestions from stakeholders were considered when planning implementation of the service. This in turn led to involvement of doctors and nurses from conception of the project making them more likely to support it.

The use of SMART goals allowed the breakdown of the aim of the study in more simple and measurable objectives which in turn increased awareness of doctors and nurses on the role of the clinical pharmacist at ward level. The AIDA model helped delivering results of the project throughout implementation of the service in a timely and efficient way increasing involvement of doctors and nurses. Communication was delivered, in practice, via power point presentations on key clinical topics tailored for the specific audience and attending meetings to update stakeholders on progress of the service being implemented. Information and concepts delivered using these communication tools were then reinforced via email 1 week after the presentation/meeting. Content of meetings and presentations was further reminded to healthcare staff using face to face communication on a daily basis. A monthly email was sent to staff summarizing key topics discussed in the last 30 days and asking for feedback.

The average number of medication per patient on admission was lower than reported in the literature [14, 31]. This was due to the fact that doctors withhold several drugs when patients were admitted and reintroduced them usually within the following 72 h when the patient’s clinical picture was better defined. The clinical pharmacist spent an important part of his time providing ward-based teaching to healthcare professionals. This is the reason we observed a high number of interventions (20.4%) aiming to educate the healthcare team. A cohort study found that 25.8% of elderly had at least one potentially inappropriate medication prescribed [5]. Our study found that 14.2% of interventions aimed at discontinuing one or more medication suggesting the clinical pharmacist contributed to avoid unnecessary prescribing and generated cost savings. Cost savings were also generated by the pharmacist advising less costly alternative (10%) drugs. In our study it was found that one of the main drug classes involved in interventions was psycholeptics (10.3%). The use of these drugs is associated with falls in elderly patients [9] suggesting interventions made by the clinical pharmacist in addressing DRPs caused by psycholeptics had the potential to reduce falls. Our study found that 9.7% of interventions were made to address DRPs related to errors in medication history. A US study showed that 24.2% medication history discrepancies resulted in discrepancies during hospitalisation [32] highlighting that interventions addressing medication history DRPs might have reduced these discrepancies.

The way interventions are communicated between doctors and pharmacists affects acceptance rates. Research has shown that written communication in the form of paper notes or entries into the medical records result in lower acceptance rate of 39–70% [17]. High acceptance rate of 88.4% has been reported when face-to-face communication has been used [16]. These findings are confirmed in our study where interventions either partially accepted or rejected were communicated attaching a pharmacist intervention note to the drug chart and interventions accepted were communicated and discussed with doctors orally.

To our knowledge this is the first study reporting on the introduction of a clinical pharmacist on an acute care hospital ward in Italy. The trust has been accredited by The Joint Commission (JC) as academic hospital in 2014 and benefits of the clinical pharmacy service introduced are in line with patient safety goals required by JC [33].

Our study has provided evidence to policy makers that a well thought and tailored communication strategy can have a positive impact on acceptance rate of interventions made by pharmacists. The ward-based clinical pharmacy model implemented could have a significant impact on the improvement of healthcare in hospitals. The service could be implemented within the whole trust using the same model and trained clinical pharmacists should be introduced at ward level. Pharmacoeconomy should be a key component in future developments of clinical pharmacy as cost-effective quality improvements are given priority within healthcare settings [8].

The main strength of the study is that clinical assessment of interventions by an external independent panel made results of the study more reliable. Furthermore the substantial level of agreement when coding DRPs and types of interventions highlights the extent to which the data collected in the study are correct representations of the variable measured. Current research shows that ward pharmacy services like the one described can be successfully implemented in countries having low level of clinical pharmacy input within the hospital setting using the correct communication strategy.

The study had a number of limitations. The service was implemented by a single clinical pharmacist on a 30 beds acute internal medicine unit. A multicentre study was not feasible at the time due to funding issues. The results of the study should be interpreted carefully due to lack of generalizability. However, we believe the clinical pharmacy model described can be replicated elsewhere employing trained staff and the communication strategy described as we would expect other hospitals have a similar operating health care system. The study was relevant in our context as aimed at raising awareness of hospital based clinical pharmacy services amongst policy makers nationwide. Lack of control and the employment of one clinical pharmacist in the study potentially limited interpretation of results. However, we used an external independent panel to assess interventions and findings of the study were interpreted and discussed by the whole research team reducing the risk of bias. Previous work has shown that clinical pharmacists providing pharmaceutical care to inpatients might improve their health-related quality of life [34] however this was not measured in our study. Persistence of interventions after discharge was not assessed due to lack of time. As clinical pharmacy is patient oriented, patients’ reported experience of pharmaceutical care should have been measured using a patient satisfaction questionnaire.

We believe the communication strategy adopted has increased both trust and collaboration between doctors and the pharmacist and this has had in turn a positive impact on acceptance rate of interventions. Pharmaceutical care delivered by the clinical pharmacist is likely to have had beneficial outcomes. Clinical pharmacy services like the one described should be implemented widely to increase patient safety. We reckon hospital pharmacy stakeholders should be more proactive and invest in ward-based clinical pharmacy services as the impact on patient safety is likely to be immediate. Introduction of the service is justified by the need to improve appropriateness of prescribing. Clinical pharmacy services like the one described must be evidence based and employ staff with appropriate training.