Monday 18 April 2022

Lupine Publishers| Emergency Pharmaceutical Care in ED and ICU: Toxicology, Infectious Disease, Life Saving Drugs Management, Pharmacoeconomy as Synergic Knowledge Instrument to Reduce Mortality Rate and Healthcare Cost 2019

 Lupine Publishers| Journal of Pharmacology & Clinical Research


Ward Clinical pharmacy, pharmaceutical care, and consultant pharmacist service can be considered interesting instruments in the world of cognitive service to improve global clinical/ economical results in multi-disciplinary medical team. This pharmacist field of working can be considered as an opportunity in this time in with a great number of new drugs molecules, medical - diagnostic procedure added to the more complexity of cure, politherapy and more necessity to containment cost for drugs and medical devices than past. Reduction of medication therapy errors is needed and actively requested by patients and health organization institution and government. Multi-professional healthcare team is the right keywords in today health- care systems. Clinical pharmacist contributes today in many disciplines like oncology, toxicology, emergencies medicine, ICU, nuclear medicine, infectious disease, nephrology, nutrition service and other. To be developed pharmacist competence in field of Emergency medicine, ICU, toxicology ,imaging , medicine laboratory , biochemistry molecular biology, genetic, immune-histochemistry for relationship in pharmacological therapy and in new biological agents. Management of new innovative pharmacological- therapies and the necessity of cost containment represent a key to make the difference in medical TEAM. At the same time clinical service as consultant out of hospital settings is a great opportunity for patients and their needs. A consultant pharmacist for patient in the complex world of drugs therapies can be referent point in the different medical speciality and in the complex health care world. The specific pharmaceutical chemist and pharmacology competence conjugated with clinical activity can give an improving in clinical some outcomes , in patient health and quality of life. A reduction in mortality rate is an undeniable fact. Also, economic monitoring of therapies costs receive benefit in this approach. Emergency department and ICT are setting with high complexity of patient and the clinical pharmacist can add specific professionality to improve also clinical outcomes.

Materials and Methods

In this work we observed and analyze some relevant biomedical literature involved in clinical pharmacist presence in some medical team and the results obtained from an practical experience in order to produce a global conclusion.


From Literature

[1] in 2007clinical pharmacy service , pharmacy staffing , and hospital mortality rates. : “ in 7 hospital, clinical pharmacy service reduces mortality rates.” In a significant way [2] in “Pharmacist’s effect as team members on patient care: A systematic review and meta-analyses”: “Pharmacists provided direct patient care has favorable effects across various patient outcomes, health care settings, and disease states. (significant p< 0,005)” [3]. This paper wants to improve the pharmaceutical care application in countries with advanced healthcare system in order to provide a more rational drug therapy to patients. When this is not possible, it would be a good idea using the pharmaceutical care, in determinate populations such as: severe disease, critically ill, patients with multiple illnesses, transplants, immunosuppression, oncology or other serious conditions, at least when the treatments are very expensive.” And “In these studies, we observe a general positive influence of pharmacist’s presence in the medical equips also in different clinical outcomes” [3].

The relevance of pharmaceutical care to diagnostic imaging can be considered from 2 approaches. Diagnostic imaging modalities either are based upon or employ drugs. radio-pharmaceuticals are the key to nuclear medicine procedures and radiopaque contrast agents are essential in many radiographic studies. The principles and practice functions touted for therapeutic medications and therapeutic patient- management apply to drugs employed in diagnostic imaging, as well. Diagnostic imaging modalities are also intimately involved in determining the disease state in many patients. diagnostic imaging is utilized to follow the course of therapy; i.e., determining therapeutic outcomes. Pharmacists, not only specialists, must be knowledgeable of the role diagnostic imaging plays in pharmaceutical care and be prepared to provide the pharm. care in diagnostic imaging [4-5]. The intent of this work is to provide pharmacists with an introduction to the clinical pathology laboratory discipline. As clinical pharmacy services expand, interactions between pharmacists and the laboratory will increase. Laboratory results are an essential tool for pharmacists involved in monitoring the drug therapy and adjusting dosing regimens. Laboratory medicine is a complex and rapidly changing field with new analytical techniques - instruments and continually being developed. methodologies vary greatly from one lab. to another and even within the same laboratory from time to time. Quality control QC are necessary to ensure accurate and reliable results. The medical technologists who staff clinical laboratories are highly trained professionals. Pharmacists should utilize the medical technologist as a consultant on the interpretation / limitations of laboratory tests. there are many areas, such as therapeutic drug monitoring TDM , in which the pharmacist can serve as a consultant to the laboratory. Pharmacists involved in patient care will benefit from a greater understanding of the clinical laboratory and may also find new opportunities for the clinical pharmacy practice and interaction with other health care professionals [5].

According Clinical Pharmaceutical Care: A New Management Health Care Discipline in 2016 UKJPB “The development of clinical pharmacy in 1960-70s and pharm. care in 1990 has represented an interesting innovation in pharmacy field. clinical pharmacy and Pharm. care showed some practice critical limits:

(a) clinical pharmacy approach is more oriented to the clinical population needs or pathology but is not strictly request to manage at the level of every single clinical patient case.

(b) In hospital setting Pharmaceutical care can not to be applied to the entire patient for economic reason (limited number of pharmacist applied).

To give a more rationale priority of actions and to select the patient to be seen in priority way we think a good solution to apply the principle of pharmaceutical care with the instrument of clinical pharmacy into a new management system [6].

According article Infectious Disease Pharmaceutical Care:

Analyzing the article reported in this work we can see a relevant role of clinical pharmacist in field of the infectious disease [7]. Infectious clinical pharmacist provides direct patient care in different inpatient settings (internal medicine a, critical care hemology/ oncology, solid organ transplant with other, as well as outpatient settings such as HIV clinics). Antibiotic stewardship/surveillance programs can be considered efficacy instruments available today as well as a guideline of protocols, procedure, EBM criteria and many others. Clinical pharmacokinetic consultant service, microbiologic and laboratory assay and assessment, scientific drug information, toxicity management, ADR, interactions, medicinal chemistry competences are the core curriculum of clinical pharmacist course and for this reason the permanent presence of clinical pharmacists results in general positive outcome in many clinical equip”[7,8]. To review the effects of pharmaceutical care on hospitalizations, mortality and clinical outcomes in patients. “Systematic searches were conducted in biomedical database like MEDLINE, EMBASE and International Pharmaceutical Abstracts (IPA) databases to identify studies that were published between 2004 and January 2017. Studies included in this review were randomized controlled trials (RCTs) that spanned across both community and hospital settings. Using strict inclusion/exclusion criteria studies were included if they reported level 1 or 2 outcomes in the hierarchy of outcome measure i.e. clinical and surrogate outcomes (e.g. blood pressure (BP) control, blood glucose level, cholesterol BMI).

54 RCTs were included in the present review. 46 of these studies ranked high- quality according to the Jadad scoring system. Studies were categorized into their general condition groups. Interventions in patients with diabetes, depression, respiratory disorders, cardiovascular disorders, epilepsy, osteoporosis, and interventions in older adults were identified. In the majority of studies pharmaceutical care was found to lead to significant improvements in clinical outcomes and/or hospitalizations when compared with the non-intervention group. Some conditions had a large number of RCTs, for example for cardiovascular conditions and in diabetes. Statistically significant improvements were seen in the majority of the studies included for both of these conditions, with studies indicating positive clinical outcomes and/ or hospitalizations rates. Within the cardiovascular CV condition, a subset of studies, focusing on cardiac heart failure and coronary heart disease, had more mixed results. In other conditions the number of RCTs conducted was small ,the evidence did not show improvements after pharmaceutical care, Example in depression, osteoporosis, and epilepsy. The majority of interventions were face to face interactions with patients, whilst a smaller number were conducted via phone and one with a web-based system. Patient education was a key component of most interventions, verbal and/ or written. Longitudinal data, post intervention cessation, was not collected in the majority of cases.

RCTs conducted to evaluate pharm. care appear to be effective in improving patient short-term outcomes for a number of conditions including diabetes and CV conditions, other conditions such as depression are less well researched” [8,9]. “Pharmacists were consulted by the physicians to correct any drug-related issues that they suspected may cause or contribute to a fatal outcome in the cardiology ward. A total of 1,541 interventions were suggested by the clinical pharmacist in the study group; 1,416 (92.0%) of them were accepted by the cardiology team, and violation of incompatibilities had the highest percentage of acceptance by the cardiology team. All-cause mortality was 1.5% during Phase I (pre-intervention) and was reduced to 0.9% during Phase II (post-intervention), and the difference was statistically significant (P=0.0005). After PS matching, all-cause mortality changed from 1.7% during Phase I down to 1.0% during Phase II, and the difference was also statistically significant (P=0.0074)” [9,10]. Clinical pharmacists did not perform any interventions during the phase 1 (pre-intervention) and consulted with physicians to address drug related problems (DRPs) during phase 2 (postintervention). The main outcome was a decrease in mortality from AMI. The 2 phases were compared using propensity score matching (PSM).

Results Obtained

1388 interventions were suggested by clinical pharmacists during phase 2, of which 1239 (89.2%) were accepted. Logistic regression- analysis demonstrated that interventions of clinical pharmacists were significantly associated with a reduced mortality in patients with both ST segment elevation myocardial infarction (STEMI) (OR 0.449; 95% CI 0.296 to 0.680) and non-ST segment elevation myocardial infarction (NSTEMI) (OR 0.268; 95% CI 0.125 to 0.572). Using PSM analysis, mortality reduced from 6.8% to 4.3% in STEMI patients (P=0.0034) and from 3.2% to 0.7% in NSTEMI patients (P=0.0202) after interventions. DRPs that caused or contributed to possible mortality were detected by clinical pharmacists in patients with AMI. Correcting these DRPs after pharmacists’ interventions could result in a significant decrease in mortality” [10,11]. “This research -study was conducted with 13 health-system pharmacists and 5 local health managers that were involved in the CPS implementation. The pharmacists who consented to participate were those who agreed to implement CPS in their respective workplaces. In order to get a comprehensive understanding of the facilitators that influenced the CPS implementation process, the health-system pharmacists were divided into 2 groups:

(i) 7 accredited pharmacists, who fulfilled all steps of the process and implemented CPS in their workplaces; and

(ii) 5 non-accredited pharmacists, who did not complete all steps of the process and did not fulfill implement CPS in their workplaces setting . The local health managers were those who held important positions in the local healthcare network (directors, supervisors, and coordinators) during the implementation of CPS.

Regarding the structure of the local healthcare network, the organization of services, health facilities, and local pharmaceutical services was reported to be a facilitator. Some units presented infrastructure as a facilitator, with adequate - comfortable physical space for pharm. care (private acclimatized room), computer equipment, and clinical devices (tensiometer, glucometer, et other). “Accredited pharmacists reported facilitators related to their attitudes, as willpower, commitment, proactivity to learn and perform clinical activities. The motivation generated by the positive results of CPS boosted the progress of these services. Managers reinforced the availability and intellectual/personal commitment of pharmacists to obtain knowledge that would help the implementation of CPS. “A great facilitator, in the first place, was my willpower to want to do, to learn, despite the difficulties; I think the proactivity of each one was fundamental for this” (Accredited Pharmacy D).

The clinical profile was cited as facilitator. We defined this profile as a set of intrinsic characteristics of a professional who is motivated a, had an affinity for clinical activities, previous knowledge, skills and attitudes. Some pharmacists reported having a previously created clinical profile to act directly with the patient, which was stimulated by the CPS implementation process. lifelong knowledge has helped pharmacists in clinical practice and patient management. “I want to be with the patient, not only as a pharmacist, but like a human who wants to make a difference in the patient’ life, since the time they are diagnosed until the moment they know that it is possible to live with the disease and have a good quality of life” (Accredited Pharmacist G).

The pharmacists’ work process, integrating collaborative practices with other members of the health-care team, in a different setting was pointed out as important facilitator. access to medical records, previous pharmacist-patient interactions. “I have full access to the patients’ medical records, and physicians are accessible. With RT [reference technicians] we can talk about patients, like any healthcare team” (Non-accredited Pharmacist C)

Facilitators Related to Implementation Process of CPS

Participants reported that assistance provided by supporters during the implementation of CPS was an essential facilitator, both in theoretical and practical training, as mentoring activities during pharm. care. The local health- manager also recognized the expertise and contributions of supporters in CPS implementation. the systematization of the pharmacists’ work process through documentation in medical records helped assimilate and incorporate clinical activities into the work routine of the pharmacists.

Strategies to Implement CPS Related to the Local Healthcare Network

 I do not think [local health- management] giving us a glucometer in December is a support. Support is to be together, to attend. (Nonaccredited Pharmacist C).

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