CANDIDATURA AO PRÉMIO DE INVESTIGAÇÃO CIENTÍFICA

PROFESSORA DOUTORA MARIA ODETTE SANTOS-FERREIRA

Does a full-time ward-based clinical

pharmacist increase the quality of care and

improve the value for money in Paediatrics?

Redesigning, monitoring and evaluation of health services

Sílvia Figueiredo

Title of Project

Redesigning, monitoring and evaluation of health services

Does a full-time ward-based clinical pharmacist increase the quality of care and improve the value for money in Paediatrics?

Project Investigator Sílvia Maria dos Reis Figueiredo - Farmacêutica licenciada pela Faculdade de Farmácia da Universidade de Coimbra; Inscrita na Ordem dos Farmacêuticos na Secção Regional de Lisboa com Carteira Profissional 15173 e Sócia L-10420 Contact 962404597 silviamrfigueiredo@gmail.com

Project Team Sílvia Figueiredo – Farmacêutica licenciada pela Faculdade de Farmácia da Universidade de Coimbra Carolina Brinca – Farmacêutica licenciada pela Faculdade de Farmácia da Universidade de Coimbra

Academic and Clinical Supervisor Catherine Duggan – Director of Professional Development and Support at the Royal Pharmaceutical Society of Great Britain; Associate Director for Clinical Pharmacy, Development and Evaluation for East and South East England Specialist Services (NHS); Director of Academic Department of Pharmacy, Barts and The London NHS Trust; Senior Clinical Lecturer, School of Pharmacy, University of London; (United Kingdom) Contact Telephone: 020 7572 2358 E-mail: catherine.duggan@rpsgb.org

Clinical Co-supervisor Monica Kan – Senior Directorate Pharmacist, Women´s and Children´s Services at Barts and The London NHS Trust (United Kingdom) Hetal Kushwaha – Senior Pharmacist, Bailey Ambulatory and Connaught Wards, Women´s and Children´s Services at Barts and The London NHS Trust (United Kingdom)

Start Date October 2005

Completion Date July 2006

Project undertaken as part of an academic qualification Erasmus Internship Project; Master Degree in Pharmaceutical Sciences; Master´s Thesis in Clinical Pharmacy

Funded by Erasmus Scholarship

Higher Education Institutes involved

Department of Practice and Policy, School of Pharmacy, University of London Academic Department of Pharmacy, Barts and The London NHS Trust Departamento de Farmacologia e Farmacoterapia, Faculdade de Farmácia Universidade de Coimbra

Non-academic project partner Women’s and Children’s Services, Royal London Hospital, Barts and The London Trust NHS Trust

Acknowledgements

The author acknowledges all the staff in the academic pharmacy department at Barts and the London NHS Trust, especially Catherine Duggan, Monica Kan and Hetal Kushwaha, for their assistance, guidance and support. The author also acknowledges her colleague Carolina Brinca for her hard work during all stages of the project.

Conflict of Interest Statement The author certifies there is no conflict of interests. The project was undertaken as part of an academic qualification and entirely funded by an Erasmus Scholarship.

Research, Development and Innovation - Challenges, opportunities, a chance to

make a difference

“Is it possible to increase the quality of health care provided against a backdrop of tightening budgets?” (National Institute for Health and Clinical Excellence)

Redesigning, monitoring and evaluation of health services

Does a full-time ward-based clinical pharmacist increase the

quality of care and improve the value for money in Paediatrics?

BACKGROUND AND RATIONALES

As demographic change and financial pressures combine to create challenging times

for health care system, many aspects of the service have been looked in order to

induce a more rational use of resources, services and control of expenditures,

providing better and more efficient services.

In doing so it is required explicitly to take into account both clinical effectiveness and

cost-effectiveness.

Redesigning Health Services: Pharmacists as a Means of Cost Containment

Medicines are a central component of healthcare. The use of medicines is the most

common and the most important therapeutic intervention carried out in the NHS.

As the patient medications represent one of the single large expense categories for

NHS Trust´s and foundation trusts’, this is the area where efficiency savings are need

to be made, finding cost reduction opportunities, without compromising patient care or

clinical quality.

Significant quality improvements for patients and reduced costs can be achieved if

medicines are managed across the whole health economy.

The evidence suggests there is the potential to make significant efficiency savings and

improvements by optimizing the medicines management services and making better

use of hospital pharmacy staff.

As the medicines becomes more powerful (and potentially dangerous), and the

pharmacists are experts in medicines, professional practice guidelines recommended

that pharmacists need to be integrated into the clinical team, closer to the patient

centered care.

There is evidence that through the implementation of clinical pharmacy programs that

includes standards and guidelines for best practices and the identification of medication

targets of opportunity to reduce costs (from product procurement to medication

administration and all areas between), the clinical pharmacy service contributes to help

organizations meet the twin challenges of providing high quality care to patients and

the public while also saving money and resources.

The objective of clinical pharmacy practice is to optimize patient outcomes, making the

most effective, efficient and economical use of medicines.

Hospital pharmacists have shown clearly their benefit in patient care by intervening to

improve the cost-effective use of medicines.

But despite the growing evidence supporting the pharmacist’s contribution to patient

care, many hospital services have not taken full advantage of this vital resource.

Monitoring, Evaluation and Research of Health Services

In this era of cost containment, hospital administrators are likely to fund only those

programs and services that clearly improve patient care, reduce costs and that

represent a cost-effective use of public money and staff time invested.

To demonstrate the impact on a hospital budget and to justify a position or service,

research, monitoring, evaluation and documentation of improvement and generation of

a cost-savings report is essential.

Pharmacy Practice Research

Pharmacy leaders are constantly under pressure to justify both existing and expanded

clinical pharmacy services. The research and the published evidence of the value of

clinical pharmacy services are important resources that pharmacy leaders can use to

justify pharmacist led programs that improve clinical outcomes while also improving net

revenue by reducing overall expenses or augmenting gross revenue.

The King's Fund defines pharmacy practice research as "research which attempts to

inform and understand pharmacy and the way in which it is practiced, in order to

support the objectives of pharmacy practice and to ensure that pharmacists' knowledge

and skills are used to best effect in solving the problems of the health service and

meeting the health needs of the population".

Health Service Evaluation

The decisions about resource allocation to health care services will increasingly be

based on Service Evaluation.

Health Service Evaluation is “A set of procedures to judge a services merit by providing

a systematic assessment of its aims, objectives, activities, outputs, outcomes and

costs.” (NHS Executive, 1997)

Service Evaluation is a key component of any strategy to develop resources to improve

health. It can ensure that resources are being used on the most cost-effective

interventions, thereby maximising the available resources to achieve the most benefit.

Evaluation can also indicate where changes may need to be made to a service, in

order to improve its effectiveness. For this reason, evaluation is usually considered at

the planning stage of any activity aimed at improving health.

Service Evaluation can demonstrate which services are effective and efficient, how to

achieves maximum effects for minimum costs.

A well-designed evaluation will provide valuable evidence both of successful outcomes

and of good project management, or will indicate the opposite. Demonstrating

acceptable outcomes and/or management action will make it easier to obtain additional

resources from the funders to develop or change the service. Findings will also

demonstrate to potential new funders or partners that the service is a good investment.

Monitoring, Service Evaluation and Research are important aspects of Pharmacy and

essential in providing evidence that pharmacy delivers services that are effective, high

quality and value for money.

AIM AND OBJECTIVES

The overall aim of the project was to monitor, evaluate and research the impact of the

proposal of a new pharmacy service model implemented – a full-time ward-based

clinical pharmacy service in Paediatrics.

To achieve this, the objective set was: to compare the pharmacist’s performance

between two levels of clinical pharmacy services – 1 hour a day service (control group)

and a full-time service (study sample) by measuring clinical pharmacy activities and its

outcomes.

METHODS AND MATERIALS

1. Literature review of national recommendations and local guidelines for each

stage of patient’s journey;

2. Development of a data collection form;

3. Pilot study;

4. Data collection;

5. Statistical Package for the Social Sciences (SPSS) version 13 was used for

data entry and analysis.

6. A final report was written for dissemination of the findings and

recommendations

KEY FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

Key Findings

The full-time ward–based pharmacy service provided an opportunity for several

clinical pharmacy interventions.

Pharmacist activities and interventions included: accurate medication history;

clinical prescription review (endorsements and amendments in Inpatient

Prescription); correcting/clarifying orders; providing medicines information;

suggesting alternative therapies; detection and prevention of drug reactions and

interactions; prevention of potential medication errors; therapeutic drug

monitoring; participation in multidisciplinary ward rounds; supporting

prescription decision making; therapeutic discussion with medical and nursing

staff; participation in discharge planning; information for ongoing care

(communication to the 1st care and patient education about their current

medication and medication to take home); review problems arising from

dispensing; liaise with the pharmacy compounding service or CIVAS for items

required; liaise with Drug Information Service for any information not readily

resourced; liaise with pharmacy dispensing services for timely dispensing of

discharge medication; ensuring the use of PODs during patient stay; supporting

the medical and nursing staff in the use of unlicensed medicines.

As a result of these clinical pharmacy interventions, preventable adverse drug

reactions, prescribing errors, length of hospital stay and drug-related re-

admissions were reduced, thereby yielding savings related to cost avoidance.

Cost-savings interventions comprised a small percentage of clinical pharmacy

interventions, but they generated substantial savings. Interventions relating to

CIVAS (Centralised Intravenous Additive Service) medication lowered costs of

care without adversely affecting clinical outcomes. During 10 days of the study

period, the pharmacist ordered CIVAS medication twice, which represented a

therapy cost savings of £957.03.

Conclusions

The study concluded that re-designing the pharmacy services around the patient

through having a full-time ward-based pharmacist on Paediatrics has not only benefited

the patient through a reduction in drug related incidents and faster discharge

prescriptions, but also, the drug budget by saving drug costs through improved

medicines management.

Therefore, it was concluded that a full-time ward-based pharmacist is an important and

cost-effective member of a Paediatric health care team.

Recommendations

1. Clinical pharmacist interventions in the Pediatric wards resulted in significant

effect on clinical and economic measures and can therefore be suggested as a

routine practice. The participation of a clinical pharmacist on a multidisciplinary

care team should be a standard of care.

i. Pharmacist’s presence and participation in multidisciplinary ward rounds

and meetings is the most effective method of contributing to the quality

of patient care. The presence and participation at multidisciplinary ward

rounds and meetings provides an opportunity for a pharmacist to have a

current knowledge of patient clinical situation and about the latest

evidence regarding disease and medicine state management, which

leads to valuable clinical interventions with positive impact in clinical

results and on economic outcomes.

ii. The complexity of the medication use system necessitates a

comprehensive and specialized knowledge base, and pharmacists are

best suited to have the knowledge, skills, and abilities required for the

proficient medicines management at all levels.

iii. In collaboration with other members of the patient care team, pharmacist

share the responsibility for patient care outcomes and for saving money

and resources, not just by providing basic dispensing functions and drug

information services, but by solving patient drug-related problems and

by making decisions regarding drug prescribing, monitoring, and drug

regimen adjustments.

2. Pharmacists need to continue to generate evidence for the impact they have on

the quality and cost-effectiveness of patient care and publish findings on the

effectiveness of their roles.

i. Documentation of clinical interventions can provide evidence of the

impact of clinical pharmacy services on patient care.

ii. Thus, all the activities that potentially improve the quality of patient care

or result in clinical and/or economic outcomes should be documented.

IMPLICATIONS OF THE FINDINGS AND CONCLUSIONS FOR PHARMACY

PRACTICE AND FUTURE DIRECTIONS

Because of the findings, conclusions and recommendations of this study, the pharmacy

and hospital administration agreed to provide a full-time ward-based clinical pharmacist

to round in Paediatrics on a regular basis. This approach is considered to be more cost

effective than using a one hour a day clinical pharmacist for daily rounds.

Moreover, the new implemented service made evidence of a better use of the

pharmacist’s skills and by all the characteristics that presents, Paediatrics proved to be

an exceptional area where the investment in clinical pharmacy services should be a

priority.

This project may also be used to educate other health providers, administrators, and

developers of health care policy on the role of pharmacists and pharmacy services in

the health care system.

HOW DOES THE PROJECT ACHIEVE THE OVERALL AIM OF THE PROFESSORA

DOUTORA MARIA ODETTE SANTOS-FERREIRA SCIENTIFIC RESEARCH PRIZE?

A good way to improve performance is to share knowledge and replicate

successes from one place to another.

This study generated new knowledge and points to innovation, good pharmacy

practice, promising practice, lessons learned and success stories in the full cycle of

medicines management and in the pharmacy profession.

Therefore, the project can contribute as a catalyst for change. The application of

this data and the collation of the generated evidences enables ultimately inform

policy and practice relating to pharmacy and pharmaceutical services. It also

allows the sharing and showcasing of good pharmacy practice and the increased

knowledge exchange and learning in pharmacy and pharmaceutical sciences.

Increasingly inputs and studies such as this are needed, whether these are case

studies, audit data, service development, service evaluation or research findings, for

the delivery of professional advice and support as well as professional development,

science and research strategies.

The documentation of the economic value of clinical pharmacy interventions in addition

to clinical and humanistic outcomes is absolutely vital for ensuring the implementation

and the sustainability of a clinical pharmacy service. Economic analysis of clinical

pharmacy services is necessary to ensure that health care administrators and payers

understand the savings or benefits that can be achieved through the implementation of

these services. Moreover, this may significantly improve the ability of other pharmacists

to implement similar services in other health care venues.

Valuable conclusions and recommendations emerged from the study for pharmacy

professional development and support that can also be extrapolated to Portuguese

Pharmacy Practice in the current context of our Health Care System.

Pharmacists are in a unique position to be able to identify clinical situations where

there is lack of evidence for a specific practice.

Furthermore, by evaluating their services, pharmacists will be able to provide evidence

that their priorities for service development and patient care are justified. The

importance of dissemination of any evaluation work cannot be over emphasised. It is

only by sharing our learning that we can improve services.

The success of the implementation of a new pharmacy service model such as this

depends on pharmacists understanding the importance of documenting their

interventions and of contributing to the pursuit of evidence-based practice. When

intervening as part of their clinical pharmacy services, pharmacists did not necessarily

save lives but did bring about changes, which directly increased the quality of patient

care and contributed to a significant financial gain. By undertaking this study, the value

of pharmacists’ clinical expertise in Paediatrics has been established.

“The future success of pharmaceutical care models is increasingly dependent on

our ability to provide compelling evidence of the value of clinical pharmacy

services and to articulate that value to financial decision makers.” 2002 Task Force

on Economic Evaluation of Clinical Pharmacy Services of the ACCP