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Australian Journal of Pharmacy : April 2005
shpa T HE prospective multicentre study undertaken in eight Australian pub- lic hospitals in the 1990s indelibly regis- tered the value of clinical pharmacy ser- vices in the hospital scene.1 The study concluded that for every dollar spent on a pharmacist to initiate changes in drug therapy or drug management, $23 was saved in the areas of length of stay, re- admission, drug costs, laboratory moni- toring and medical procedures. This study confirmed an earlier—and far more modest—study undertaken in 1996 by Lamour and Thompson who, in a letter published in the Australian Journal of Hospital Pharmacy titled ‘Spend more on pharmacists to spend less on drugs’, showed that for every dollar of pharmacy department salary costs spent per bed day, drug costs per bed day decreased by an average of $5.20. There is now no doubt that for both hospital pharmacists and health econo- mists, clinical pharmacy represents a crit- ical facet of pharmacy-based services. However, one of the major impediments to the implementation of clinical phar- macy services has been the impact of the present shortages in appropriately trained and experienced pharmacists to provide such services. A number of studies undertaken by both the Pharmacy Guild of Australia and the Society of Hospital Pharmacists of Australia (SHPA) attempted to quantify the problem and evaluate various solu- tions that may have been applied. The most recent SHPA study by O’Leary and Allinson published in 2004 found that high vacancy rates could be managed downwards where a combination of ini- tiatives based on training, award restruc- turing and workplace restructuring were introduced. In some jurisdictions vacancy rates fell from in excess of 15 per cent to less than 5 per cent. hospital talk John Low, hospital pharmacist Clinical pharmacy practice —accountability and quality While workforce problems remain an issue for clinical pharmacy services, there is a practice prospective review which is being pursued in a few institutions in Aus- tralia. This fundamentally aligns clinical and distributive pharmacy services. Prospective review as outlined by Thorn- ton in a recent editorial in the Journal or Pharmacy Practice and Review aims at under- taking the medication review process, which traditionally occurs some 24 to 48 hours after admission, at the point of pre- scribing rather than as a retrospective review process.2 While it is legitimate to undertake retrospective review, such a process delays any benefit that might accrue to the patient. There is now no doubt that for both hospital pharmacists and health economists, clinical pharmacy represents a critical facet of pharmacy- based services. One factor that has allowed the pre- sent (retrospective review) process to flourish is the existence of comprehen- sive stocks of medicines held in wards and other clinical areas. Such stocks allow the implementation of treatment regimens without reference to clinical review by a pharmacist. Nurses, not unreasonably, have been able to initiate therapy the moment the prescriber puts pen to paper rather than after a review of drug treatment has been undertaken by a pharmacist. If there was no ward stock the action of a clinical pharmacist 244 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.85 APRIL 2004 would have been necessary prior to the first dose being administered. This evolution in clinical pharmacy ser- vices limits ward drug stock to essential emergency items. It also requires the inte- gration of clinical and distributive services to a greater extent that has been evi- denced thus far. The most effective mod- els include the use of technicians working under the supervision of pharmacists where the distribution-delivery and place- ment of dispensed items are the responsi- bility of technicians, where the stock of drugs available in a ward area is rigor- ously managed and where medications remaining from discharged patients and discontinued dispensed items are promptly removed from the ward. In an accompanying editorial, Scott dis- cussed the quality of clinical pharmacy ser- vices and discussed a recent study by Bond et al which used data obtained from 1,000 (US) hospitals in the 1990s.3 The article concluded that the five core clinical phar- macy services that had a significant impact on patient care outcomes were drug infor- mation, adverse drug reaction manage- ment, drug protocol management, med- ical rounds participation and admission drug histories. It is encouraging to note that such services have been the backbone of clinical pharmacy services in this coun- try since the 1980s. 1.Dooley MJ, Allen KM, Doeke CJ, Galbraith KJ, Taylor GR, Bright J et al. A prospective multicentre study of pharmacists initiated changes to drug ther- apy and patient management in acute care gov- ernments funded hospitals. Br J Clin Pharmacol 2004; 57: 513–21. 2.Thornton P. Accountable clinical pharmacy prac- tice. J Pharm Pract Res 2004 ;34: 258–9. 3.Bond CA, Raehl CL, Patry R. Evidence-based core clinical pharmacy services in United Stated hospitals in 2020; services and staffing. Pharma- cotherapy 2004; 24: 427–40. ¦