Clinical Pharmacy

Clinical Pharmacy: Clinical pharmacy is the growing field of pharmacy, where clinical pharmacists are mainly responsible for providing the services for patient care toward the use of medication and promoting health, wellbeing, and prevention of disease. Clinical pharmacy is a more patient-oriented health care service. In this clinical pharmacist associated in taking care of a patient in all health care settings which initially begins inside hospitals and clinics.  The clinical pharmacist often works in collaboration with physicians, physician assistants, nurse practitioners, and other healthcare professionals. 

Clinical pharmacy contains a set of functions that includes promoting the safe, rational, and effective use of medicines for individual patients. The clinical pharmacy practices involved specialized services which include pharmaceutical care of the patient through complete medication history, patient profile review, managing of adverse drug reactions, managing the drug information services, and counseling the discharged patient.

History of Clinical Pharmacy: 

• In 1953 the term clinical pharmacy was first time used.
• The clinical pharmacology concept was initiated in the 1960s with two incidences.
• In 1961 – “Thalidomide Tragedy”, in this, it was found that the birth of babies with a sealed limb is occur due to the consumption of popular sedative thalidomide.
• In 1968, In Australia phenytoin toxicity was reported because of a change in formulation i.e. replacing the calcium sulfate with lactose as an inert excipient in the tablets.
• To investigate bioavailability, pharmacokinetics, and toxicity of different formulations. 

How does a clinical pharmacy differ from a pharmacy? 

Clinical pharmacy differs from the general pharmacy in terms of goals which there is an analysis of population needs concerning medicines, ways of drug administration, the pattern of use, and drug effects on the patients. In clinical pharmacy, attention moves from the drug to the patients receiving the drugs. While the pharmacy mainly deals with synthesis, chemistry, and formulation of medicines. 

The goal of Clinical Pharmacy: 

The primary goal of clinical pharmacy is to promote the rational and appropriate use of medicines. These activities mainly aim at the following:

• Improving the clinical effect of medicines.
• Minimizing the risk of treatment-induced adverse events.
• Minimizing the expenditures for pharmacological treatments. 

Clinical Pharmacist Requirements: 

Clinical pharmacists are specially trained practitioners who deliver comprehensive medication for management and direct patient care services. Clinical pharmacists work directly with physicians, other health professionals, and patients to guarantee that the medications prescribed for patients contribute towards the best possible health outcomes.  Considering the important roles of clinical pharmacists in patient health care services, it is  essential to have the following requirement with the clinical pharmacist:

• Knowledge of drug therapy.
• Knowledge of diseases.
• Knowledge of laboratory and diagnostic skills.
• Should have good communication skills.
• Should possess drug information skills.
• Should have therapeutic planning skills.
• Should know about non-drug therapy.
• Physical assessment skill.
• Patient monitoring skills.

Duties of Clinical Pharmacists 

Clinical pharmacists play an important role at three different levels i.e. before the prescription, during the prescription, and after the writing of prescription in promoting the correct use of medicines. Following are given the key role of clinical pharmacists at a different level:

Before the Prescription: 

• Involved in clinical trials.
• Preparation of formularies.
• Drug information services.
• Designing of drug-related policies.

During the Prescription: 

• Involved in counseling activity.
• Involved in monitoring, detecting, and preventing a medication-related problem.
• Clinical Pharmacist gives special attention to the dosage of drugs that need therapeutic monitoring.

After the Prescription:

• Involved in Patient Counseling.
• Preparation of personalized formulation.
• Involved in the evaluation of the use of the drug.
• Responsible for outcome research.
• Associated in pharmacoeconomic studies. 

Activities or Functions of Clinical Pharmacist: 

The principal activities of a clinical pharmacist include: 

Patient Medication History: 

Patient medication history involves the collection and recording of information on past and present medications used by the patient  It is done during the patient interview and reviewing past medical records.

Profile Patient Review: 

In the patient profile review, the evaluation of the patient and its medical chart is done by the clinical pharmacist. The Components of patient profile review include the patient assessment, profile review, and medication review.

Adverse Drug Reaction Management:

• ADR management involves the prevention, detection, management, and reporting of  Adverse Drug Reactions (ADRs).
• The clinical pharmacist carries out ADRs management with the help of patient counseling, patient profile review, and history of patient medication.

Therapeutic Drug Monitoring (TDM): 

Clinical pharmacist dealing with the application of clinical pharmacokinetic for monitoring drug efficacy and toxicities. The drugs like gentamicin, amikacin, tobramycin, vancomycin,  carbamazepine, phenytoin, valproic acid, lithium, theophylline, cyclosporine, digoxin,  lidocaine, amitriptyline, nortriptyline, and imipramine are commonly monitored.

Drug Information Management: 

A clinical pharmacist is involved in the preparation of appraisal, collection, utilization, and presentation of information relating to the drug.

Discharge Patient Counseling: 

Clinical pharmacist involves in patient counseling regarding medication use at the time of discharge of patients. 

Responsibilities of Clinical Pharmacist in Drug Therapy Monitoring 

Monitoring of drug therapy or therapeutic drug monitoring (TDM) is a process that involves the monitoring of the drug concentration at specific time intervals to maintain a  drug concentration in a patient’s bloodstream, thereby optimizing the individual dosage regimen. The main goal of TDM is the individualization of drug dosage regimens by monitoring and maintaining plasma or blood drug concentrations within a targeted therapeutic range. The other goals are to achieve a desired and maximal therapeutic effect in the shortest period and decrease the risk of toxicity. 

TDM is mostly useful for drugs with a narrow therapeutic window, is highly bound to protein, the toxic effect of metabolites, and is likely to interact with other drugs. 

In pharmaceutical practice, the clinical pharmacist performs his role by assessing the pharmacokinetic parameters while therapeutic drug monitoring. The role of the clinical pharmacist is very crucial and has to monitor the patient very consciously when the plasma drug concentration is in between minimal effectiveness and the narrow toxicity range. 

Responsibilities: 

The following responsibilities should be carried out by the clinical pharmacist as a part of  clinical pharmacokinetic evaluation or monitoring services: 

• Clinical pharmacists should design the patient-specific drug dosage regimen to improve the drug safety and patient outcome by considering various factors such as the pharmacokinetic and pharmacological properties of the drugs product, rationale of the drug therapy, drug therapy in concurrent disease, and other patient-related factors.
• Measurement of drug concentration in various biological fluids such as plasma,  serum, blood, or tissue to enable the monitoring of the dosage regimen.
• Adjustment of dosage regimen based on the drug concentration in biological fluid or tissue in conjugation with therapeutic responses, signs, and symptoms, or other biochemical parameters.
• Apart from the therapeutic responses, clinical pharmacists should monitor the additional responses to the drug therapy.
• Maintain the records of oral and written communications with the physician, nurses, or other health practitioners regarding information of patient-specific drug therapy and health record.
• Responsible to educate and conduct training programs for pharmacists, physicians,  nurses, and other health care professionals about clinical pharmacokinetic monitoring and estimation of drug concentration cost-effectively.
• Responsible to prepare programs for documentation of patient outcomes and benefits from monitoring of pharmacokinetic parameters in the patients. 

• Clinical pharmacists should promote a collaborative relationship with the persons and the department involved in the monitoring of drug therapy in the patient. 

Role of Clinical Pharmacist in Medication Chart Review 

• Medication chart review is the process that is conducted in a systemic way for all patients who have been prescribed medicines by the health care profession. Thus, it is a primary responsibility of the clinical pharmacist to ensure the correctness of medication ordering,  transcribing, dispensing of medicines, procedure, and way of administration of medicines and monitoring of medication for potential adverse effects and therapeutic effects.
• Medication chart review has been considered the activities as a starting from activities of counseling, TDM, and ADR. The main objectives of medication chart review are to optimize the drug therapy, improve the health outcomes and reduce the medicine-related problems like untreated indications, inappropriate drug selection, drug interaction, an overdose of any medication; and any errors that may occur while prescribing drug therapy and administration. If the pharmacist found any errors or problems in the medication chart then should write annotations on the chart at the appropriate place where the medication order is unclear. 

Procedure: 

• Clinical pharmacists should check and ensure the medication administration as per the record of a patient medical record.
• Consideration of consultation report, treatment plan, and daily progress report while planning for patient care and medication appropriateness.
• Should review all current and recent medication orders.
• Following are given the components of the medication chart review. Clinical pharmacists should ensure patient care.
• Pharmacists should check the medication order is written as per legal and local requirements also ensure the order is understandable and used the appropriate name of the drug. A pharmacist may also review the order for the cost-effectiveness of medication.  If there is an error observed in order then a mark should be provided for clarification.
• Make sure that the medication order is correct concerning the previous order, the specific condition of the patient (such as disease state, gender, pregnancy, age), dose and dosage schedules with considering the patient conditions, dosage form and route and method of medication administration.
• Pharmacists must check the order for duplication of medication, drug interactions as well as the time of drug administration concerning food and along with another drug.
• Check whether there requires an appropriate follow-up for any medication or therapy monitoring is recommended in the given order. 

Role of Clinical Pharmacist in Clinical Review 

Clinical review is a systematic review/relevant information of all examinations done by clinical pharmacists on response and monitoring of drug treatment and safety aspects on daily basis. The main approach of clinical review is to assess the therapeutic outcome of the dosage regimen and its safety. It is one of the integral parts of the medication chart review. 

Goals of Clinical Review: 

Following are the primary goals of the clinical review:

• Evaluate the response and safety of drug treatment.
• Assess the improvement in the patient’s condition and the need to change in drug therapy.
• Evaluate the need for therapeutic drug monitoring.
• Check for patient compliance to therapy.

Criteria for Effective Pharmacist Clinical Review: 

Pharmacists have the expertise and advanced training in the effective and appropriate use of medications. Following are some important criteria for effective clinical review:

• Ensure adequate training is given to persons involved in clinical review.
• Main the good working relationship with all practitioners, other health care staff to permit clinical review of patient, assess the clinical report and for effective communication.
• Identify the expert to discuss any problems and options.
• Implements systematic approach for the clinical review and always involve the patient in interrogation.
• Decide the most reliable therapeutic intervention for the individual patients.
• Before any recommendation to patients or practitioners, a pharmacist must see the medical notes for any sensible issue related to recommendations. 

Role of Clinical Pharmacist

• Ensure to take approval and request for clinical review of any treatment and facilitation of appropriate patient care.
• Take approval with the clinicians regarding the treatment plan and if modification needs, any financial coverage, and for coordination with any authority. Ensure the approvals notes are documented in the electronic medical record/general record of the patient.
• Ensure the prescribed medication contributes to the best therapeutic outcomes.
• Assess the effectiveness of the treatment regimen, status of the patient health as well as determine the prescribed medications are optimally meet the patient need and care.
• Identify any untreated health problems of patients and could be resolved by using appropriate medication therapy after approval from respective authorities. 

Pharmacist Intervention 

Pharmacist intervention covers a wide range of medication-related issues. Pharmacist intervention must detect any problem with the medication therapy. In patient care services, there recognize various untreated health issues and this can be resolved by choosing an appropriate therapeutic regimen. Pharmacists follow the progress of therapeutic outcomes. Pharmacists involved in the review of prescription and if needed suggest the appropriate therapeutic regimen to improve the safety, efficacy as well as cost of medications. Method of pharmacist intervention considered has great inputs in the patient care system. In this, the pharmacist’s role is to reduce medication errors, justify the use of therapeutic regimens in a particular patient, and reduce the cost of medications.

There has the diversified role of pharmacist including the dispensing of medication, patient monitoring, patient counseling, health education, community services, and clinical practices.  It is recommended that all the prescriptions must be reviewed by the pharmacist before dispensing medications to avoid medication errors. 

Importance of Pharmacist Intervention: 

Medication errors may cause consequences that may range from minor to serious and sometimes may require hospitalization or death of a patient. Pharmacist intervention may reduce this happen. Following are some objectives of pharmacist intervention.

• To review the prescription order before dispensing o the drugs.
• To prevent the development of complications and morbidity.
• To improve patient compliance.
• To reduce the cost and to improve the safety and effectiveness of medications.

Role of Clinical Pharmacist in Ward Round Participation 

Ward round is nothing but the routine rounds by the health care provider to meet/visit the patient for a normal check up on daily basis to check the progress of health of patients.  Mostly physician is the leading person along with their team who may be assistant, nurse, and pharmacist in the ward round to observe the patient condition and routine checkup and decide further therapeutic regimen for their patient. 

Goals and Objectives of the Ward Round Participation:

• Monitors the patient’s condition and take immediate decision on medication to improve the patient’s condition and avoid death.
• To check the case history of patients and accordingly change the approaches of treatments.
• To ensure a safe and cost-effective treatment plan for the patients. 

Role of Pharmacist: 

Pharmacists should always associate as team members of health care professionals during ward round participation. A pharmacist is an expert person in the decision-making process in matters of dosage regimens, monitoring of adverse drug reactions, interaction with medications, and interpretation of prescription as well as associated with drug and poison information services. 

• A pharmacist has a great role in the enrichment of treatment accuracy and uses several pharmaceutical services considering the patient safety and efficacy of treatment.
• A pharmacist is a qualified person in a hospital and should participate with the team to promote healthcare practice in the management of a disease.
• Pharmacists should prevent negative perspectives of therapeutic outcomes due to medication errors and incorporation of incorrect dosage regimens.

Responsibilities of the Pharmacists: 

Pharmacists should participate with a physician during the ward round as well as they should do visit alone to provide information related to medication and its administration and necessity care to concerned patients.

• During ward rounds with a physician, the pharmacist should follow the treatment given by the physician as well as check the prescribed dose by referring to the formulary.
• A pharmacist may also think about the prescribed medication and assess the possible risk to the patients while drug administration and will report or alert the health care team to prevent further causality.
• A pharmacist must target the patients before discharge while his ward round and advice regarding the practice of drug administration which is necessary to take after discharge of the patient. Pharmacists should also motivate the patient while discharging regarding taking proper diet and exercise for disease management. 

Medication History 

Patient medication history interview is a practice associated with collection and recording of information by reviewing/interviewing of patient-related to his/her past and present medications used. Clinical pharmacists are mainly dealing with such types of activity. Clinical pharmacist collects detailed, accurate, and complete information on all prescribed and non-prescribed medications which patients have taken previously or are currently underused. 

Patient medication history provides valuable information on the patient’s allergic tendency, patient compliance, and self-medications. Such type of information of medication history helps the pharmacist to establish with a patient, commencing of patient counseling and designing of a pharmaceutical care plan. 

The goal of medication history is to acquire information on aspects of drug use by patients. So, such information may help pharmacists for improvement in the overall care of the patient. The collected information can be helpful to achieve the following goals:

• Helps to investigate the medication discrepancies by comparing the medication profile with the medication administration record.
• Other staff verify the collected history of the patient and can provide additional information wherever require appropriately.
• Helps to document the allergies and drug-related adverse reactions.
• Helps to evaluate the rationale for prescribing drugs.
• Helps to assess indications of drug abuse.
• Helps to check the drug interactions.
• Helps to access drug administration techniques.
• Helps to examine the requirement of assistance in medication.

Importance of Accurate Medication History:

• Helps in the prevention of prescription errors and subsequent risks to the patients.
• Helpful in finding drug-related pathology and any clinical signs due to results of drug therapy.
• Considering all accurate medication history information helps to establish a better care plan for the patients. 

Details information about the medication history in terms of questions asked by the pharmacist while interviewing the patients, type of information recorded in medical history,  stages of medication history, etc. are given in chapter 9 of patient medication history interview.

Pharmaceutical Care 

Pharmaceutical care is a practice of pharmacists to contribute to optimizing the rational therapy towards improvement in the health status of patients. The major goal and outputs of pharmaceutical care are elimination/prevention of the disease symptoms, cure or slowing of a disease condition. 

The pharmaceutical care plan is prepared based on the clearly defined therapeutic goal.  The pharmaceutical care plan is made in the form of written, individualized, and comprehensive medication therapy. The responsibility of the pharmaceutical care plan is delivered to pharmacists who are involved in direct patient care and are updated with each major change in patient status. The physician should give any important instruction as well as to achieve the common goals by the pharmacist about the pharmaceutical care plan. Patients should also be informed regarding the content of the pharmaceutical care plan for gaining compliance with the patient to medication therapy. 

Functions of Pharmaceutical Care Plan: 

Following are the three main functions of a pharmaceutical care plan:

• Identification of actual and potential drug-related problems in a patient.
• Resolve the patient’s actual drug-related problems.
• Prevention of the patient’s potential drug-related problems. 

Development of Pharmaceutical Care Plan: 

Following are some steps involved in the formation of a pharmaceutical care plan:

• Creation of a comprehensive database for the respective patient.
• Evaluate the actual and potential drug-related problems.
• Establish therapeutic goals.
• Specify the parameters for the monitoring with end points and frequency.
• Documentation of the progress of the patient health status towards therapeutic goals.

Create Patient Database: 

In this step, the comprehensive database is created for the respective patient and may include the following information.

• Patient demographics.
• Past medical history and diagnosis.
• Present medications status.
• Any medication allergies or intolerances.
• History of smoking/alcohol/caffeine/drug use.
• Results of abnormal laboratory and physical examination.
• Renal and liver function test examination report. 

Assess Drug-related Problems: 

In this step, the pharmacist should evaluate the drug therapy given to the patient and  include the following points:

• Assess the patient for drug-related problems.
• Examine whether drug-related problems are being treated.
• Determine the appropriateness of the current drug therapy.
• Check whether there requires any additional drug therapy.
• Assess for any drug-related problems that may have been caused due to the medication. 

There are so many reasons for drug-related problems which include not receiving an indicated/prescribed drug by patients, receiving the wrong drug or drug which does not have a valid medical indication, administration of too little or too much of the drug,  experiencing an adverse drug reaction, drug interaction. 

Establish Therapeutic Goals: 

There must establish the therapeutic goals for each drug-related problem so that the pharmaceutical care planning process can be effective. The therapeutic goals should be definite, accurate and, if possible, measurable. Examples for most of the therapeutic goals are normalization of blood pressure, relief of pain symptoms, slowdown of progression of cancer, prevent medication cost, etc. 

Specify Monitoring Parameters: 

In pharmaceutical care plan monitoring parameters must be specified so that the progression of patient health status can be followed and recorded. In the parameters list, there must also include the potential adverse effects. Determination of desired end points for each parameter must be done.

Document Patient’s Progress: 

The evaluation and documentation of the progress of the patient’s health status are done to achieve the desired therapeutic goals. Documentation of progress also helps in the avoidance of potential adverse effects. The pharmaceutical care plan is a review of each major change in patient status.

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