What Is the Impact of a Pharmacist in Cardiac Surgery - Essay Example

Though economic concerns have been the major drivers towards carving a new role for pharmacists in community healthcare and specialty wards, pharmacists can make an important contribution towards containing prescription errors especially antibiotic errors and in the management of crucial drugs like warfarin in intensive therapy units. (Boddy, 2001) Pharmacists are now regarded as the Nation's hitherto untapped knowledge base and they are gradually taking the place of junior doctors in multidisciplinary teams in hospitals and other healthcare centres. The aim of this research is to study the feasibility of this approach of replacing junior doctors with pharmacists in ward rounds and whether it effectively reduces the cost of treatment and enhances treatment quality. The research was conducted at the St. Thomas Hospital and literature review and study of secondary data were the major tools for drawing inferences and arriving at conclusions. Pharmacist intervention monitoring (PIM) sheets from St. Thomas hospital were collected and analysed, for a three month period in both 2007 and 2008. The interventions made by pharmacists during their daily cardiac surgery rounds during the above period were studied and analysed. Though there was not enough evidence from the materials collected, to conclude that pharmacist interventions have helped significantly to reduce costs, minimize clinical errors or enhanced the quality of treatment, study of the data collected revealed that they can contribute significantly towards these targets. In order to properly audit and assess the impact made by pharmacists in a cardiac surgery ward, the PIM sheets must be better developed and interventions properly recorded and judged against a control data. This will enable us to quantify the contributions made by pharmacists in a cardiac surgery ward and enable us to reach a definite conclusion about the effect of their contributions. 2.0 Introduction Our general idea of a pharmacist is someone who dispenses prescription drugs to patients. However, pharmacy involves more than just giving out drugs. In fact, dispensing drugs is only of the jobs of a pharmacist. The duties of a pharmacist vary greatly and include areas of medicine and pharmacy that we do not generally associate with their duties. Pharmacists carry out an important service in community health centres; they also help achieve lifestyle changes by giving up smoking and excessive drinking. (Medical News Today 2008) 2.1 Training of a Pharmacist As undergraduates, pharmacists are trained in the different aspects of drug therapy. In order to work in the National Health Service (NHS), pharmacists are required to obtain a degree in pharmacy. There are twenty two schools of pharmacy approved by the Royal Pharmaceutical Society of Great Britain (RPSGB) that offer a degree in pharmacy. (NhsCareers, 2009) All qualifying courses in pharmacy are five year courses and at Master's level. After obtaining a degree in pharmacy, which lasts for five years, a year long pre-registration period in a pharmacy at the end of the pre-registration year is a registration examination together a competency assessment. (NhsCareers, 2009) The disciplines in which they are educated include pharmaceutical chemistry, pharmaceutics, and pharmacology and pharmacy practice. (NHS Careers 2008) 2.2 Services Provided by a Pharmacist Compounding of drugs is not the most important function of a pharmacist, since most drugs are manufactured by pharmaceutical companies in a standard dosage and delivery form. Pharmacists now, mostly work in a community setting, they are specialists who possess the necessary knowledge and skills to advise health practitioners and patients on the selection of drugs, their dosage, actions and possible side effects. They can monitor patients for progress in health and ensure safe medication. (United States Department of Labor, 2007) Pharmacists represent a huge resource for drug safety and proper medication, which has been left untapped until recently. (PubMed Central, 2007) Pharmacists when qualified may work in a variety of areas, some of which include community, hospital and industry. Services provided by ward pharmacists were first introduced in the 1960's to ensure the safe and correct use of medicines. The term 'clinical pharmacy' became a widely used term as pharmacy services became more patient focused and the pharmacists' knowledge came to be better utilized through their greater involvement in the medical profession. Research by Morgall et al has shown the requirement for new establishments in relationships between pharmacists and other health professionals. (Morgall et al 1999) 2.3 A New Outlook A major thrust in the direction of involving more pharmacists in clinical practices was given this year when pharmacists were employed for cardiac surgery ward rounds instead of junior doctors. A novel service is being provided by pharmacists in such rounds, where they help with prescribing and dispensing drugs and perform medicine-related roles previously undertaken by junior doctors in cardiac surgery. The pharmacist's role is being redefined from someone who merely compounds or dispenses prescription drugs to a specialist with a thorough knowledge of drugs who can form an important part of the multidisciplinary team working in an intensive therapy unit like the cardiothoracic unit of a hospital. (PubMed Central, 2007) Cardiothoracic units are wards where patients are retained before undergoing surgery and where patients who are stable are shifted before being released from hospital. Though HDU or High Dependency units provide a step down care for patients they also provide for some measure of close monitoring and have telemetry monitors to monitor patient conditions round the clock. 'Following surgery, all patients will undergo initial inpatient cardiovascular rehabilitation and be enrolled into the preventive cardiology programme. They will then progress to outpatient cardiac rehabilitation after discharge.' (National Heart Centre Singapore 2008) While the importance of a pharmacist in a cardiothoracic surgery unit cannot be overemphasized, questions can be raised about the practicability of replacing junior doctors with pharmacists. The National Health System (NHS) has moved forward in the direction of replacing junior doctors with pharmacists because it believes that this step will definitely help reduce costs and help to financially ease out the treatment process. (Findarticles.com, 2008) 2.4 The background of investigation During the 1960s and early 1970s, pharmacist role started expanding, from 'chemists' performing the traditional function of drug distribution to more important clinical roles which included participation in cardiac arrest management teams. Their new roles as part of this team included dispensing drugs, providing supportive information, maintaining records of administration of drugs, and restocking supplies. As treatment became more complex and management options increased with the variety of intervention approaches and drug options, a greater need was felt for harnessing the knowledge of pharmacists in the treatment of cardiac and thoracic conditions. Lately, the pharmacists working in the cardiac arrest teams have started involving them in several businesses like provision of information about drugs, manufacturing of drugs and documentation of all the utmost necessary elements and inventions during a cardiac arrest of a patient. 2.5 Pharmacists in Treatment Centres Pharmacists have an important function in treatment centres (TCs). Pharmacy services in the shape of providing medicines are already part of some early centres, but TCs are now making greater use of the services that can be provided by pharmacists. (The Pharmaceutical Journal, 2005) Some of the services provided by pharmacists in TCs include their participation in preoperative assessment clinics, formulating protocols for discharge medicines, pharmaceutical care in different wards, determining patient group directions or PGDs and providing knowledge support to the nursing staff on different medicine issues. Typically, the job of a pharmacist in such TCs include taking the medication history of the patient, sorting out any problem related with drugs, arranging for discharge medicines and advising doctors and patients on medicines that need to be discontinued before surgery. Another important job of the pharmacist is monitoring and managing prescribed medicines in wards. Keeping in mind the brisk patient throughput, one of the major requirements of TC's is the need for a well planned and effective patient discharge preparation. Well thought out procedures are therefore required to make sure that patients get the medicines they need when they are ready to be discharged. In fact, pharmacists in several centres are involved in training and in developing protocols to help the nursing staff on different medicine issues. (The Pharmaceutical Journal, 2005) 2.6 The Expanding Role of the Pharmacist The need to set up a multidisciplinary team of technicians, doctors and pharmacists has been felt for quite a long time. 'Since the work of a TC is carried out to defined care pathways, it can be helpful for pharmacists to be part of the multidisciplinary team setting up these systems to ensure that appropriate pharmaceutical input is included. Much of the medicine supply, e.g. postoperative antibiotics and analgesics, is protocol-driven.' (Lumb, 2005) Licensed pharmacists in the UK are able to offer advice to patients and guide them on a range of health care problems. These include: 'the authority to measure, evaluate and monitor blood pressure and cholesterol; the right to counsel patients on smoking cessation, weight loss and diabetes management; even the authority, after proper training, to prescribe drugs for minor ailments.' (Business Network 2008) The real reason behind this new decision on utilizing pharmacists for taking care of health problems lies in the fact that England cannot afford to provide its citizens an acceptable degree of traditional health care that it has been providing till so long. (Business Network 2008) The government has decided that the answer in easing out the financial burden facing the nation's health care system lies in involving pharmacists who can, after receiving the proper training, advice and even sometimes prescribe medicines for treating different illnesses (Business Network 2008). The pharmacist's role has therefore seen a significant evolvement from being one of dispensing drugs to one of consulting. (Bell et al. 1999) The acceptance of this new role of pharmacists has not been sudden. To encourage patients to consult with pharmacists, they routinely initiate discussions with customers at the drug store where they work. (Anysubject.com, 2009) Pharmacists are well grounded in drugs and their effects. A brief idea of their training has already been provided above towards the beginning of this research work. It is therefore being reasonably argued that pharmacists should also be considered as health care professionals. One of the obvious advantages is that this increases the chances of diagnosing and treating an illness in its early stage and preventing future complications. In order to add meaningful value to this advantage, pharmacists in the UK now undergo training to prescribe drugs for routine illnesses. There are two factors that can make this new system a viable practice. Pharmacists need to receive a meticulous and systematic training to be able to diagnose problems and prescribe treatment. It also requires a change in the patient's perspective which is no less important. 2.8 A New Step Forward In the UK, the clinical pharmacy service embraces functions like prescription monitoring, recording medication histories, providing drug information and counseling patients. They maintain regular liaison with the healthcare team and are in direct contact with the patient. This has been observed to improve the quality of patient care. 'In 2001, the Audit Commission reported that the pharmacy service was 'absolutely vital' to the quality of patient care, and that inclusion of pharmacists into multi-disciplinary teams would reduce the workload of doctors in training, improve prescribing and save money.' (Weller and Jamieson 2004) 'Full-time ward-based clinical pharmacists are an effective intervention in reducing serious medication errors in the intensive care unit. They will likely prove to be extremely cost-effective and an important adjunct to technology based interventions.' (NLM Gateway 2008) With the publication of its White Paper on pharmacy on 3rd April, 2008, titled "Pharmacy in England - Building on Strengths, Delivering the Future," the Government has taken a major step forward in expanding the role of pharmacists in community health care as well as in specialized units. (Department of Health 2008). Pharmacists now perform a very important function as a core member of the multi-disciplinary team in intensive therapy units and critical care. Specialist pharmacists in hospitals in the UK cover critical care and cardiac treatment areas including transplants, RSSC and cystic fibrosis. Most hospitals have a medicines management pharmacist who is responsible for information regarding medicines. They also collect detailed drug and drug related allergies history from patients at the cardiac surgery and thoracic pre-admission clinics. Specialist pharmacists also carry out transplant assessments and annual review of detailed cystic fibrosis drug histories from patients. Many pharmacy technicians have received training in warfarin and discharge counselling and they talk with patients before they are discharged to explain and review the medication that has been prescribed to them. (Papworth Hospital 2008) 2.9 The healthcare concern Though cost is one of the driving factors in the UK government's decision to include the services of pharmacists in treatment of ailments that include critical care, this decision is also expected to boost the quality of treatment that patients receive in hospitals in the UK. [PubMed Central, 2007] However, in the previous two years no junior doctors have been employed in the cardiac surgery units. Instead, a novel service is provided by a pharmacist who attends the cardiac surgery ward round, helps with prescribing and discharges and performs some medicine-related roles previously performed by junior doctors in cardiac surgery. Junior doctors in their 'early postgraduate years are considered to be simultaneously responsible health professionals, subjugate learners and human resource'. (McDougal, 2008:268-270) However, they often face many 'ethical challenges' in their roles. They spend most of their time in the wards, are involved in prescribing drugs and maintaining medical records. They are in effect 'responsible clinicians' somewhat similar to pharmacists in the ward. However, it is expected and emphasised that they 'remain students, with a body of knowledge and skills to be learnt'. (McDougall 2007) As a result it more likely those junior doctors are susceptible to committing more errors especially in the first few days of their training year. Since pharmacists are better equipped to provide drug information and implement drug safety measures and they can be employed with lesser pay their participation in ward rounds would be beneficial. The superior drug knowledge of pharmacists is expected to reduce drug related errors and also shorten treatment periods and hospital stay (Fertleman et al, 2005:207-211) However, having pharmacists in ward rounds instead of junior doctors can severely comprise junior doctors training and the result can be alarming. 'Unemployment has become a serious threat to junior doctors, the British Medical Association has warned'. (BBC News 2005) This move to replace posts earlier held by junior doctors by pharmacists this year may result in further unemployment problems. As has been mentioned earlier, shortage of funds has been one of the major factors in support of this move. Employing pharmacists in place of doctors will ease out a part of the expenses, the government believes. (Findarticles.com, 2008) Junior doctors earn a basic salary and will usually be paid a supplement. This supplement is based on the extra hours worked above a 40 hour standard working week and the intensity of the work. The most common banding supplement is 50% of basic salary. In the most junior hospital doctor post (foundation year 1) a doctor on a 50% supplement would earn 32,793. This increases in the second year (foundation year 2) to 40,674. A doctor in specialist training on a 50% supplement could earn from 43464 to 68,343. (NHS Careers 2008) The government has also ordered a cut in the junior doctor's hours from this year onwards. So from August 2008 junior doctors will work 48 hours a week instead of 56 hours. This has resulted in angry retorts from several quarters. (Medical News Today 2008) The chairman of the British Medical Association (BMA) Junior Doctors Committee, Mr Simon Eccles, said in reference to the growing unemployment among junior doctors, "It makes no sense that at a time when the country is short of fully trained medical staff, we're pushing doctors into unemployment. It costs around a quarter of a million pounds to train a doctor to this level. A lot of talent and taxpayers' money is going to waste." [http://news.bbc.co.uk/1/hi/health/4720905.stm] However, the government is keeping the issue under close scrutiny. It needs to be understood that including pharmacists in the multidisciplinary team need not be done at the expense of junior doctors, since that will not only result in compromised training of junior doctors but may also adversely affect the quality of care and the total hours of medical supervision a patient receives in a cardio thoracic ward. Though cost is one of the major concerns of the government, the inclusion of pharmacists in specialty and critical care wards have also been triggered by several occurrences of errors associated with medication, both in prescribing and dispensing. The most disturbing fact remains that, despite their training, doctors commit errors in prescribing drugs resulting to an increase in the number of cases of 'adverse drug reactions' (ADR). (PubMed Central, 2007) It was realized that besides doctors and other trained healthcare professionals, hospitals should also employ the knowledge of pharmacists for the benefit of patients. "The scope of pharmaceutical interventions in critical care is broad. Issues such as impaired organ function, dialysis, haemofiltration, impaired circulation and impaired respiration can alter drug handling significantly." (Hill Haley, 2005) Errors not only occur due to lack of proper knowledge of drugs, but also due to the lack of proper recording of drug history. As part of clinical governance, these errors need to be prevented. (Bellingham, 2002) It is this lack of information at the 'point of prescribing' which is the most important cause of errors, accentuating the vital advantage of including a pharmacist as part of the clinical team to help minimise the number of errors and 'optimise drug therapeutics'. (Deshmukh et al, 1995) As the Pharmacy White Paper emphasizes mentioned earlier, pharmacists, with their clinical expertise in the promotion of the safe use of medicines, have an important role to play in reducing the number of times patients have to be re-admitted. (DOH 2008) Fertleman et al conducted a research to understand the effect of a pharmacist on post admission ward rounds. Relevant abstracts from their research article "Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds" published in Qual Saf Health Care, 2005, are being reproduced below to help our understanding of the crucial role that is played by pharmacists in ward rounds. In the study by a pharmacist was asked to participate in the post-take ward round that reviewed medical patients within 24 hours preceding their admission. These patients continued to receive medical care from a ward based pharmacist. "Patient notes were analysed for cost of drugs on admission and discharge, discrepancies between admission drug history and pharmacist history, number of admission drugs stopped before discharge, and pharmacist recommendations. Pharmacist recommendations and actions were classified using a National Patient Safety Agency risk matrix." (Quality and Safety in Health Care, 2005) This approach produced startling results: "Discrepancies between the admission and the pharmacist derived drug history were noted in 26 of 50 in the pre-intervention group and 52 of 53 in the intervention group." "Five pre-admission drugs were stopped in three pre-intervention patients saving 276 per annum, while the 42 drugs stopped in 19 intervention patients saved 4699 per annum." "58 minor, 48 moderate and four major risks to patients were potentially avoided." (Quality and Safety in Health Care, 2005) It was apparent that the presence of a pharmacist on a post-take ward round can improve the "accuracy of drug history documentation", reduce the cost of prescription drugs, and of course reduce the number of potential risks to patients. (REF) Mr. C. Booth (MPhil, MRPharmS), has offered a very clear picture of the pharmacist's role in cardiac surgery. His article "The role of the pharmacist in cardiac surgery" published in the Hospital Pharmacist, February 2000, provides an important insight into the very significant role played by pharmacists in cardiac operation and cardiac care. 2.10 Clinical governance Clinical governance is a framework that aims to 'create an environment in which excellence in clinical care will flourish'. This can be accomplished by NHS organisations ensuring that services are continuously being improved and maintaining a high standard. Safety, quality and efficacy provided in health by all healthcare professionals are the centre point focus of clinical governance. (Scott, A.; Poole, P. J. and Jayathissa, S. 2007) 'Clinical databases and audit systems that allow prospective collecting and reporting of clinical performance data remain severely underdeveloped.' (Scott, A.; Poole, P. J. and Jayathissa, S. 2007) It is suggested that the data collated may show poor performance of the staff. However data collected on administration of medicines for predicting the time till discharge and relevant costs could also provide beneficial information associated with errors. It has also been proposed that up to thirty percent of treatments have shown no improvements in many complicated cases, of which includes coronary vascularisation. It stated that pharmacists should be involved in ward rounds; to take part in every medicine related process, from educating to discharge to prohibit errors associated with medicines. (Scott, A.; Poole, P. J. and Jayathissa, S. 2007) Added References: Nhscareers (2009). Training as a Pharmacist [Online] available from [accessed 1 February 2009] United States Department of Labor (2007). Pharmacists [online] available from [accessed 1 February 2009] PubMed Central (2007). This is What Your Pharmacists Can Do for You and Your Patients - Let Them Help [online] available from [accessed 1 February 2009] Findarticles.com (2008). Pharmacists Take on Expanded Role in U.K.[online] available from [accessed 1 February 2009] The Pharmaceutical Journal (2005). What role will there be for pharmacists in the treatment centre programme [online] available from [accessed 1 February 2009] Anysubject.com (2009). Pharmacist Career - An Inside Look [online] available from [accessed 1 February 2009] McDougal, Ms. R (2008) 'The Junior Doctor as Ethically Unique.' Journal of Medical Ethics, (34) 268-270 Fertleman, M, N Barnett, T Patel (2005) 'Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds'. Quality and Safety in Health Care, (14) 207-211 Read More