were made from 21 September 2020 until 22 February 2021 . Of these , 104 were undertaken during remote pharmacy medication review and a further 151 on ward rounds . The average age of the patients needing an intervention was 73.57 (± 1.64 ) years . Female patients accounted for 145 ( 56.9 %; 145 / 255 ) of 255 interventions , 110 ( 43.2 %; 110 / 255 ) interventions were undertaken for male patients .
The total number of patients was not recorded for the complete set of 255 interventions . However , a subset of 159 patients was further reviewed and it was determined that 95 met the criteria ( polypharmacy , age , high-risk drugs ). There were 140 interventions made in these 95 patients . It could therefore be hypothesised that 59.8 % ( 98 / 159 ) of the patients in the medical ward need clinical pharmacy input , requiring on average 1.5 interventions per patient .
Of all interventions undertaken , prompt acceptance rate by the physicians involved was 59.6 % ( 152 / 255 ). In 39.2 % ( 100 / 255 ) of all cases a change was considered by the physician , but in the course of this pilot study it was not followed up further by the pharmacist as to whether the intervention led to a change subsequently ( Figure 1 ) due to a lack of resources and time . None of the suggested clinical pharmacy interventions were declined . In some cases , a discussion between the pharmacist and the ward round physician led to a different change than the pharmacist had initially suggested , which was then classified as “ intervention considered by physician ”.
Figure 2 shows which types of clinical pharmaceutical interventions were made . One intervention could be rated as multiple types of interventions .
Significance of interventions The overall average score for all 255 clinical
FIGURE 1
Responses of ward round doctors concerning the pharmacist ’ s clinical interventions
39.2 %
59.6 %
Intervention led to change Intervention considered by physician Intervention declined Medication stopped
Of all interventions undertaken , prompt acceptance rate by the physicians involved was 59.6 %
1.2 % pharmaceutical interventions taken was 2.18 . Figure 3 shows the distribution of these scores . Of all interventions , 94.9 % ( 242 / 255 ) were rated “ 2 ”; that is , a significant pharmaceutical intervention , or higher . This indicates clinical pharmacy interventions in Tauernklinikum in Zell am See enhance patient welfare and – according to the Hatoum scale 14 – could potentially eliminate organ failure caused by medication errors or potentially fatal outcomes .
Interventions were rated for significance by the clinical pharmacist . To show IRR , 30 interventions were chosen randomly for rating by four consultant doctors on the medical ward as illustrated in Figure 4 . The clinical pharmacist rated the 30 interventions with a mean of 2.43 . Three of the consultants rated with a mean of 2.73 , whilst one had a lower rating with a mean of 2.03 .
ICC average measurement of the four consultant coders was 0.725 with a lower confidence interval of 0.519 and an upper confidence interval of 0.856 . For absolute agreement the average measurement was 0.672 , with a lower confidence interval of 0.429 and an upper confidence interval of 0.828 . The calculated ICC values both indicate “ good ” agreement between the four coders . 15 Single measures were low , namely 0.397 and 0.339 for consistency and absolute agreement , respectively .
When those numbers were correlated with the pharmacist ’ s scores , ICC for consistency was 0.660 and 0.622 for absolute agreement , thus both can be considered as “ good ”. 15
Figure 5 depicts the potential for cost reduction associated with the recommended pharmaceutical changes , namely with medication being stopped ( 84 / 255 ; 32.8 %), a dose reduction ( 73 / 255 ; 28.9 %) and the remaining 98 / 255 ( 38.3 %) of interventions not yielding cost reductions .
Discussion Total number of pharmaceutical interventions Research across Europe and the UK has shown that acceptance rates for clinical pharmacy interventions vary widely . 16 – 21 Around 59.8 % ( 98 / 159 ) of the sample of patients at Tauernklinikum Zell am See need clinical pharmaceutical interventions , thus it is apparent that more patients require medicines reconciliation and medicines review . Due to staffing constraints this is an issue in most Austrian hospitals . The clinical pharmacist is a missing link in the multidisciplinary ward team , for optimising medicine use , reducing adverse drug reactions and improving patient safety . The Chief Executive of the Society of Hospital Pharmacists of Australia stated in 2018 that the maximum number of patients that one hospital pharmacist should have as a case load is 30 . 22 For a 360-bed hospital , as in this study , this equates to 12 full-time clinical pharmacists but , in fact , there are only 0.7 WTE .
Types of clinical pharmacy interventions Non-compliance with guidelines was the main intervention type . The interventions related to expanding the scope of the individual patient treatment , unfamiliarity with guidelines and failing to dose modify in organ dysfunction . The second largest category was inappropriate drug administration .
The third category was DRP with missing specific information or lack of patient counselling . Consultants and registrars were open to , and accepting of , DRP discussions with the pharmacist . This underpins the statement work undertaken in Northern Ireland that concludes that the pharmacist has a complementary role in the ward multidisciplinary team . 23
12 | Issue 99 | 2021 | hospitalpharmacyeurope . com