Participação na 1ª Edição do Prémio de Investigação Científica Professora Doutora Maria Odette Santos-Ferreira
CANDIDATURA AO PRÉMIO DE INVESTIGAÇÃO CIENTÍFICAPROFESSORA DOUTORA MARIA ODETTE SANTOS-FERREIRA Does a full-time ward- based clinicalpharmacist increase the quality of care and improve the value for money in Paediatrics? Redesigning, monitoring and evaluation of health services Sílvia Figueiredo
Title of ProjectRedesigning, monitoring and evaluation of health servicesDoes a full-time ward-based clinical pharmacist increase the quality of care andimprove the value for money in Paediatrics? Project InvestigatorSílvia Maria dos Reis Figueiredo - Farmacêutica licenciada pela Faculdade de Farmácia daUniversidade de Coimbra; Inscrita na Ordem dos Farmacêuticos na Secção Regional de Lisboacom Carteira Profissional 15173 e Sócia L-10420Contact962404597silviamrfigueiredo@gmail.com Project TeamSílvia Figueiredo – Farmacêutica licenciada pela Faculdade de Farmácia da Universidade deCoimbraCarolina Brinca – Farmacêutica licenciada pela Faculdade de Farmácia da Universidade deCoimbraAcademic and Clinical SupervisorCatherine Duggan – Director of Professional Development and Support at the RoyalPharmaceutical Society of Great Britain; Associate Director for Clinical Pharmacy, Developmentand Evaluation for East and South East England Specialist Services (NHS); Director of AcademicDepartment of Pharmacy, Barts and The London NHS Trust; Senior Clinical Lecturer, School ofPharmacy, University of London;(United Kingdom)ContactTelephone: 020 7572 2358E-mail: firstname.lastname@example.orgClinical Co-supervisorMonica Kan – Senior Directorate Pharmacist, Women´s and Children´s Services at Barts andThe London NHS Trust (United Kingdom)Hetal Kushwaha – Senior Pharmacist, Bailey Ambulatory and Connaught Wards, Women´s andChildren´s Services at Barts and The London NHS Trust (United Kingdom)
Start DateOctober 2005 Completion DateJuly 2006 Project undertaken as part of an academic qualificationErasmus Internship Project;Master Degree in Pharmaceutical Sciences;Master´s Thesis in Clinical Pharmacy Funded byErasmus Scholarship Higher Education Institutes involvedDepartment of Practice and Policy, School of Pharmacy, University of LondonAcademic Department of Pharmacy, Barts and The London NHS TrustDepartamento de Farmacologia e Farmacoterapia, Faculdade de Farmácia Universidade deCoimbra Non-academic project partnerWomen’s and Children’s Services, Royal London Hospital, Barts and The London Trust NHSTrust AcknowledgementsThe author acknowledges all the staff in the academic pharmacy department at Barts and theLondon NHS Trust, especially Catherine Duggan, Monica Kan and Hetal Kushwaha, for theirassistance, guidance and support. The author also acknowledges her colleague Carolina Brincafor her hard work during all stages of the project.
Conflict of Interest StatementThe author certifies there is no conflict of interests. The project was undertaken as part of anacademic 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 servicesDoes a full-time ward-based clinical pharmacist increase thequality of care and improve the value for money in Paediatrics?BACKGROUND AND RATIONALESAs demographic change and financial pressures combine to create challenging timesfor health care system, many aspects of the service have been looked in order toinduce 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 andcost-effectiveness.Redesigning Health Services: Pharmacists as a Means of Cost ContainmentMedicines are a central component of healthcare. The use of medicines is the mostcommon and the most important therapeutic intervention carried out in the NHS.As the patient medications represent one of the single large expense categories forNHS Trust´s and foundation trusts’, this is the area where efficiency savings are needto be made, finding cost reduction opportunities, without compromising patient care orclinical quality.Significant quality improvements for patients and reduced costs can be achieved ifmedicines are managed across the whole health economy.The evidence suggests there is the potential to make significant efficiency savings andimprovements by optimizing the medicines management services and making betteruse of hospital pharmacy staff.As the medicines becomes more powerful (and potentially dangerous), and thepharmacists are experts in medicines, professional practice guidelines recommendedthat pharmacists need to be integrated into the clinical team, closer to the patientcentered care.
There is evidence that through the implementation of clinical pharmacy programs thatincludes standards and guidelines for best practices and the identification of medicationtargets of opportunity to reduce costs (from product procurement to medicationadministration and all areas between), the clinical pharmacy service contributes to helporganizations meet the twin challenges of providing high quality care to patients andthe public while also saving money and resources.The objective of clinical pharmacy practice is to optimize patient outcomes, making themost effective, efficient and economical use of medicines.Hospital pharmacists have shown clearly their benefit in patient care by intervening toimprove the cost-effective use of medicines.But despite the growing evidence supporting the pharmacist’s contribution to patientcare, many hospital services have not taken full advantage of this vital resource.Monitoring, Evaluation and Research of Health ServicesIn this era of cost containment, hospital administrators are likely to fund only thoseprograms and services that clearly improve patient care, reduce costs and thatrepresent 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 ofa cost-savings report is essential.Pharmacy Practice ResearchPharmacy leaders are constantly under pressure to justify both existing and expandedclinical pharmacy services. The research and the published evidence of the value ofclinical pharmacy services are important resources that pharmacy leaders can use tojustify pharmacist led programs that improve clinical outcomes while also improving netrevenue by reducing overall expenses or augmenting gross revenue.The Kings Fund defines pharmacy practice research as "research which attempts toinform and understand pharmacy and the way in which it is practiced, in order tosupport the objectives of pharmacy practice and to ensure that pharmacists knowledgeand skills are used to best effect in solving the problems of the health service andmeeting the health needs of the population".Health Service EvaluationThe decisions about resource allocation to health care services will increasingly bebased on Service Evaluation.Health Service Evaluation is “A set of procedures to judge a services merit by providinga systematic assessment of its aims, objectives, activities, outputs, outcomes andcosts.” (NHS Executive, 1997)
Service Evaluation is a key component of any strategy to develop resources to improvehealth. It can ensure that resources are being used on the most cost-effectiveinterventions, thereby maximising the available resources to achieve the most benefit.Evaluation can also indicate where changes may need to be made to a service, inorder to improve its effectiveness. For this reason, evaluation is usually considered atthe planning stage of any activity aimed at improving health.Service Evaluation can demonstrate which services are effective and efficient, how toachieves maximum effects for minimum costs.A well-designed evaluation will provide valuable evidence both of successful outcomesand of good project management, or will indicate the opposite. Demonstratingacceptable outcomes and/or management action will make it easier to obtain additionalresources from the funders to develop or change the service. Findings will alsodemonstrate to potential new funders or partners that the service is a good investment.Monitoring, Service Evaluation and Research are important aspects of Pharmacy andessential in providing evidence that pharmacy delivers services that are effective, highquality and value for money.AIM AND OBJECTIVESThe overall aim of the project was to monitor, evaluate and research the impact of theproposal of a new pharmacy service model implemented – a full-time ward-basedclinical pharmacy service in Paediatrics.To achieve this, the objective set was: to compare the pharmacist’s performancebetween 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 itsoutcomes.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 RECOMMENDATIONSKey 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.ConclusionsThe study concluded that re-designing the pharmacy services around the patientthrough having a full-time ward-based pharmacist on Paediatrics has not only benefitedthe patient through a reduction in drug related incidents and faster dischargeprescriptions, but also, the drug budget by saving drug costs through improvedmedicines management.Therefore, it was concluded that a full-time ward-based pharmacist is an important andcost-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 PHARMACYPRACTICE AND FUTURE DIRECTIONSBecause of the findings, conclusions and recommendations of this study, the pharmacyand hospital administration agreed to provide a full-time ward-based clinical pharmacistto round in Paediatrics on a regular basis. This approach is considered to be more costeffective than using a one hour a day clinical pharmacist for daily rounds.
Moreover, the new implemented service made evidence of a better use of thepharmacist’s skills and by all the characteristics that presents, Paediatrics proved to bean exceptional area where the investment in clinical pharmacy services should be apriority.This project may also be used to educate other health providers, administrators, anddevelopers of health care policy on the role of pharmacists and pharmacy services inthe health care system.HOW DOES THE PROJECT ACHIEVE THE OVERALL AIM OF THE PROFESSORADOUTORA MARIA ODETTE SANTOS-FERREIRA SCIENTIFIC RESEARCH PRIZE?A good way to improve performance is to share knowledge and replicatesuccesses from one place to another.This study generated new knowledge and points to innovation, good pharmacypractice, promising practice, lessons learned and success stories in the full cycle ofmedicines management and in the pharmacy profession.Therefore, the project can contribute as a catalyst for change. The application ofthis data and the collation of the generated evidences enables ultimately informpolicy and practice relating to pharmacy and pharmaceutical services. It alsoallows the sharing and showcasing of good pharmacy practice and the increasedknowledge exchange and learning in pharmacy and pharmaceutical sciences.Increasingly inputs and studies such as this are needed, whether these are casestudies, audit data, service development, service evaluation or research findings, forthe 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 additionto clinical and humanistic outcomes is absolutely vital for ensuring the implementationand the sustainability of a clinical pharmacy service. Economic analysis of clinicalpharmacy services is necessary to ensure that health care administrators and payersunderstand the savings or benefits that can be achieved through the implementation ofthese services. Moreover, this may significantly improve the ability of other pharmaciststo implement similar services in other health care venues.Valuable conclusions and recommendations emerged from the study for pharmacyprofessional development and support that can also be extrapolated to PortuguesePharmacy Practice in the current context of our Health Care System.Pharmacists are in a unique position to be able to identify clinical situations wherethere is lack of evidence for a specific practice.Furthermore, by evaluating their services, pharmacists will be able to provide evidencethat their priorities for service development and patient care are justified. The
importance of dissemination of any evaluation work cannot be over emphasised. It isonly by sharing our learning that we can improve services.The success of the implementation of a new pharmacy service model such as thisdepends on pharmacists understanding the importance of documenting theirinterventions and of contributing to the pursuit of evidence-based practice. Whenintervening as part of their clinical pharmacy services, pharmacists did not necessarilysave lives but did bring about changes, which directly increased the quality of patientcare and contributed to a significant financial gain. By undertaking this study, the valueof 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