Pharmacist independent prescribing in critical care: results of a national questionnaire to establish the 2014 UK position

Assessment of the implementation of pharmacist prescribing: Challenges and pathways for ambulatory practice

BACKGROUND

Prescribing by pharmacists is an increasingly common practice worldwide. In Brazil regulation of this practice began in 2013, and the practice remains unexplored as a research topic.

OBJECTIVE

We aimed to explore and gain insights into pharmacist prescribing practices in Brazil and assessing pharmacist's perceptions of their training and preparedness to prescribe medications.

METHODS

A cross-sectional survey was conducted between October 2022 and March 2023 via convenience sampling. Data were collected using an online questionnaire covering sociodemographic issues, academic training, prescribing practices, and perceptions regarding the provision of pharmacist prescribing in ambulatory care. Exploratory descriptive analysis and Poisson regression were performed to estimate the associations between pharmacist characteristics and their practices in prescribing medicines.

RESULTS

Among the 305 valid responses, 58.7% of the outpatient pharmacists stated that they had not prescribed any medication in the previous three years. Over-the-counter medication prescriptions were most common (42.0%). Only 4.6% of respondents had prescribed prescription-only medicines provided through collaborative agreement, with 2.6% reporting that they had adjusted doses, and 2.3% played a role in prescription renewal. Pharmacists living in Northeast regions tended to be more active prescribers (PR = 1.42; 95%CI 1.03-2.18), whereas those in primary healthcare (PR = 0.61; 95%CI 0.39-0.96) and self-declared Black pharmacists (PR = 0.30; 95%CI 0.10-0.97) prescribed less. Respondents strongly believed in the pharmacist's role as a prescriber, although they remained ambivalent regarding their responsibility for patient outcomes. Progress barriers include infrastructure gaps and strained relationships with physicians.

CONCLUSIONS

This study suggests that pharmacists in Brazil predominantly prescribe over-the-counter medications, and variations in setting, region, and race can influence prescribing by pharmacist in ambulatory care.

Impact of Clinical Pharmacist Intervention in the Intensive Care Unit, Wad Medani, Sudan: A Cross-Sectional, Prospective Study

Purpose

Critical care pharmacists are uniquely qualified to provide a key role within the critical care multi-disciplinary team in managing the aspect of therapy, given their contributions to improved patient outcomes, medication safety, and reduced cost of the drug. Therefore, the purpose of this study was to assess the frequency, type, and impact of clinical pharmacist interventions in the Intensive Care Unit and their physicians' acceptance.

Methods

This was a cross-sectional, prospective study. Data were gathered over six months (15th June 2023 to 15th December 2023) on a daily basis, with a minimum sample size of 384 interventions. All patients admitted to the ICU at Wad Medani Teaching Hospital, Gezira State, Sudan during the study period were included.

Results

In general, a total of 510 interventions were made for 123 patients throughout the six months course of study. Among them, 493 (96.7%) clinical pharmacist interventions were agreed by physicians. Among categories of interventions, most of the recommendations were concerned about safety 34.11% (174/510), in which drug discontinuation due to long duration was the highest one 48.27% (48/174) followed by the renal dose adjustment 30.46% (53/174). Another clinical intervention involving indication accounted for 23.33% (119/510) in second place. Regarding the cost-saving interventions the study showed that, of the total number of interventions, 124 had a costrelated component, accounting for (24.31%) of the total interventions. Among all the interventions, the addition of drug, with a frequency of 103 (20.2%) was the most recurring intervention, followed by dosing at 100 (19.6%), and renal dose adjustment at 53 (10.4%).

Conclusion

This study demonstrated how clinical pharmacists might enhance critical care patients' quality management while reducing the costs associated with medication and care. In addition, it contributes valuable insights into the integration of clinical pharmacists in ICU settings, especially in resource-limited environments.

Economic evaluations of adult critical care pharmacy services: a scoping review

OBJECTIVES

To summarise the extent and type of evidence available regarding economic evaluations of adult critical care pharmacy services in the context of UK practice.

METHODS

A literature search was conducted in eight electronic databases and hand searching of full-text reference lists. Of 2409 journal articles initially identified, 38 were included in the final review. Independent literature review was undertaken by two investigators in a two-step process against the inclusion and exclusion criteria; title and abstract screening were followed by full-text screening. Included studies were taken from high-income economy countries that contained economic data evaluating any key aspect of adult critical care pharmacy services. Grey literature and studies that could not be translated into the English language were excluded.

RESULTS

The majority were before-and-after studies (18, 47%) or other observational studies (17, 45%), and conducted in North America (25, 66%). None of the included studies were undertaken in the UK. Seven studies (18%) included cost-benefit analysis; all demonstrated positive cost-benefit values for clinical pharmacist activities.

CONCLUSIONS

Further high-quality primary research focussing on the economic evaluation of UK adult critical care pharmacy services is needed, before undertaking a future systematic review. There is an indication of a cost-benefit value for critical care pharmacist activities. The lack of UK-based economic evaluations is a limitation to further development and standardisation of critical care pharmacy services nationally.

Critical care pharmacy workforce: a 2020 re-evaluation of the UK deployment and characteristics

INTRODUCTION

Critical care pharmacists improve the quality and efficiency of medication therapy whilst reducing treatment costs where they are available. UK critical care pharmacist deployment was described in 2015, highlighting a deficit in numbers, experience level, and critical care access to pharmacy services over the 7-day week. Since then, national workforce standards have been emphasised, quality indicators published, and service commissioning documents produced, reinforced by care quality assessments. Whether these initiatives have resulted in further development of the UK critical care pharmacy workforce is unknown. This evaluation provides a 2020 status update.

METHODS

The 2015 electronic data entry tool was updated and circulated for completion by UK critical care pharmacists. The tool captured workforce data disposition as it was just prior to the COVID-19 pandemic, at critical care unit level.

MAIN FINDINGS

Data were received for 334 critical care units from 203 organisations (96% of UK critical care units). Overall, 98.2% of UK critical care units had specific clinical pharmacist time dedicated to the unit. The median weekday pharmacist input to each level 3 equivalent bed was 0.066 (0.043-0.088) whole time equivalents, a significant increase from the median position in 2015 (+ 0.021, p < 0.0001). Despite this progress, pharmacist availability remains below national minimum standards (0.1/level 3 equivalent bed). Most units (71.9%) had access to prescribing pharmacists. Geographical variation in pharmacist staffing levels were evident, and weekend services remain extremely limited.

CONCLUSIONS

Availability of clinical pharmacists in UK adult critical care units is improving. However, national standards are not routinely met despite widely publicised quality indicators, commissioning specifications, and assessments. Additional measures are needed to address persistent deficits and realise gains in organisational and patient-level outcomes. These measures must include promotion of cross-professional collaborative working, adjusted funding models, and a nationally recognised training pathway for critical care pharmacists.

Pharmacist-Managed Therapeutic Drug Monitoring Programs within Australian Hospital and Health Services—A National Survey of Current Practice

Pharmacist-managed therapeutic drug monitoring (TDM) services have demonstrated positive outcomes in the literature, including reduced duration of therapy and decreased incidence of the adverse effects of drug therapy. Although the evidence has demonstrated the benefits of these TDM services, this has predominately been within international healthcare systems. The extent to which pharmacist-managed TDM services exist within Australia, and the roles and responsibilities of the pharmacists involved compared to their counterparts in other countries, remains largely unknown. A cross-sectional online survey was conducted evaluating pharmacist-managed TDM programs within Australian hospital and healthcare settings. Pharmacist perceptions were also explored about the strengths, weaknesses, opportunities, and barriers associated with implementing a pharmacist-managed TDM service. A total of 92 surveys were returned, which represents a response rate of 38%. Pharmacist-managed TDM programs were present in 15% of respondents. It is only in the minority of hospitals where there is a pharmacist-managed service, with pharmacists involved in recommending pathology and medication doses. The programs highlighted improved patient outcomes but had difficulty maintaining the educational packages and training. For hospitals without a service, a lack of funding and time were highlighted as barriers. Based on the findings of this survey, there is minimal evidence of pharmacist-managed TDM models within Australian hospital and health services. A standardized national approach to pharmacist-managed TDM services and recognition of this specialist area for pharmacists could be a potential solution to this.

Barriers to a full scope of pharmacy practice in primary care: A systematic review of pharmacists' access to laboratory testing

Objectives

To describe primary care pharmacists' current scope of practice in relation to laboratory testing.

Method

A 2-tiered search of key databases (PubMed, EMBASE, MEDLINE) and grey literature with the following MeSH headings: prescribing, pharmacist/pharmacy, laboratory test, collaborative practice, protocols/guidelines. We focused on Canada, the United States, the United Kingdom, New Zealand and Australia for this review.

Results

There is limited literature exploring primary care pharmacists' scope of practice in relation to laboratory testing. The majority of literature is from the United States and Canada, with some from the United Kingdom and New Zealand and none from Australia. Overall, there is a difference in regulations between and within these countries, with the key difference being whether pharmacists access and/or order laboratory testing dependently or independently. Canadian pharmacists can access and/or order laboratory tests independently or dependently, depending on the province they practise in. US pharmacists can access and/or order laboratory tests dependently within collaborative practice agreements. In the United Kingdom, laboratory testing can be performed by independent prescribing pharmacists or dependently by supplementary prescribing pharmacists. New Zealand prescribing pharmacists can order laboratory testing independently. Most publications do not report on the types of laboratory tests used by pharmacists, but those that do predominantly resulted in positive patient outcomes.

Discussion/Conclusion

Primary care pharmacists' scope of practice in laboratory testing is presently limited to certain jurisdictions and is often performed in a dependent fashion. As such, a full scope of pharmacy services is almost entirely unavailable to patients in the United States, the United Kingdom, New Zealand and Australia. Just as in the case for pharmacists prescribing, evidence indicates better patient outcomes when pharmacists can access/order laboratory tests, but more research needs to be done alongside the implementation of local guidelines and practice standards for pharmacists who practise in that realm. Patients around the world deserve to receive a full scope of pharmacists' practice, and lack of access to laboratory testing is one of the major obstacles to this. Can Pharm J (Ott) 2019;152:xx-xx.

CAPABLE: Calgary zone usage of Additional Prescribing Authorization By pharmacists in an inpatient setting: review of the prescribing Landscape and Environment

BACKGROUND

In Alberta, Canada, pharmacists have been granted the ability to prescribe most medications independently after completing an additional authorization process. While there are data to support the use of pharmacists' prescribing in the community setting, little is known about its use in the inpatient hospital setting.

OBJECTIVES

To describe the prescribing patterns of pharmacists in an inpatient setting including the percentage of pharmacists using their prescribing authority, the care areas where prescribing occurred, and the frequency of prescribing. Secondary objectives included describing the medications prescribed, and to determine if pharmacists are documenting their prescribing interventions.

METHODS

A descriptive, retrospective, cross-sectional study of medications ordered by pharmacists through the electronic order entry system in Calgary, Alberta, Canada. Prescriptions were examined in the context of how often each pharmacist prescribed, the medications prescribed, and an audit of documentation practices was performed using patient charts.

RESULTS

A total of 64,293 orders from 172 pharmacists were included in the analysis, of which 51% (n = 32,681) were discontinuation orders. It was found that 90% of pharmacists used their prescribing authority, ordering a median of 11.3 prescriptions monthly (interquartile range 4.3-32.8). Clinical areas with the most overall prescribing included critical care (854.8), oncology and palliative care (463.0), and surgery (409.3) prescriptions per pharmacist Full-Time Equivalent per year.

CONCLUSIONS

This study demonstrates a broad range of prescribing from pharmacists within acute care practice and a wide variety of medication prescribed. Future areas for research include barriers and enablers to pharmacist prescribing and examination of where prescribing pharmacists have the greatest value.

Characterizing pharmacist prescribers in Alberta using cluster analysis

Objectives

Legislative and regulatory bodies in Canada have authorized pharmacists to prescribe in different provinces. Albertan pharmacists have the broadest prescribing scope. Our objective was to cluster Albertan pharmacists into different prescriber groups based on their self-reported prescribing practice and to compare the groups according to practice settings, the proportion of Additional Prescribing Authority (APA) pharmacists and support experiences.

Methods

A cross-sectional survey was administered among a sample of 700 Albertan practicing registered pharmacists in 2013 to identify their involvement in different types of prescribing activities. Cluster analysis was used to group participants based on their reported prescribing practices. Chi-squared test was used to compare prescriber groups by practice settings and the proportion of APA pharmacists. One-way analysis of variance was used to compare the groups by their support experiences.

Key findings

Three major groups of pharmacist prescriber were identified – ‘renewal prescriber’ (74%), ‘Modifier’ (17%) and ‘Wide ranged prescriber’ (9%). Prevalence of ‘renewal prescriber’ in the community setting was 85.8% whereas ‘Modifier’ was predominant (66.7%) in the collaborative setting. Higher support experience facilitated the wide range prescribing. Pharmacists with APA were most likely to be classified into ‘Modifier’ (17.6%) or ‘Wide ranged prescriber’ (13.8%) groups than the ‘renewal prescriber’ group (3.1%).

Conclusions

Although legislation allowed Albertan pharmacists to have the broadest scope of prescribing authority, few are practicing with the fullest scope. Prescribing practice varies based on practice setting and support experience. Future research could explore factors influencing the types of adoption and measure the shifting of prescribing type over time.

Stakeholders' views and experiences of pharmacist prescribing: a systematic review

AIMS

The aims of this systematic review were to: (1) critically appraise, synthesize and present the available evidence on the views and experiences of stakeholders on pharmacist prescribing and; (2) present the perceived facilitators and barriers for its global implementation.

METHODS

Medline, CINAHL, International Pharmaceutical Abstracts, PsychArticles and Google Scholar databases were searched. Study selection, quality assessment and data extraction were conducted independently by two reviewers. A narrative approach to data synthesis was undertaken due to heterogeneity, the nature of study types and outcome measures.

RESULTS

Sixty-five studies were identified, mostly from the UK (n = 34), followed by Australia (n = 13), Canada (n = 6) and USA (n = 5). Twenty-seven studies reported pharmacists' perspectives, with fewer studies focusing on patients' (n = 12), doctors' (n = 6), the general public's (n = 4), nurses' (n = 1), policymakers' (n = 1) and multiple stakeholders' (n = 14) perspectives. Most reported positive experiences and views, regardless of stage of implementation. The main benefits described were: ease of patient access to healthcare services, improved patient outcomes, better use of pharmacists' skills and knowledge, improved pharmacist job satisfaction, and reduced physician workload. Any lack of support for pharmacist prescribing was largely in relation to: accountability for prescribing, limited pharmacist diagnosis skills, lack of access to patient clinical records, and issues concerning organizational and financial support.

CONCLUSION

There is an accumulation of global evidence of the positive views and experiences of diverse stakeholder groups and their perceptions of facilitators and barriers to pharmacist prescribing. There are, however, organizational issues to be tackled which may otherwise impede the implementation and sustainability of pharmacist prescribing.

The role of the pharmacist in the intensive care unit

The use of medication to support patients and optimise outcomes is a fundamental strand of care. Pharmacists provide a key role managing medication within the complexity of various routes of administration, severe and rapidly shifting pharmacokinetic and dynamic parameters, and extremes of physiology in critical illness. Pharmacists intercept and resolve medication errors, optimise medication therapy and undertake broader professional activities within the job role that contribute to the smooth running of ICU. These activities are associated with improved quality, reduced mortality and reduced costs.

Pharmacist prescribing in critical care: an evaluation of the introduction of pharmacist prescribing in a single large UK teaching hospital

OBJECTIVES

To evaluate the introduction of pharmacist independent prescribing activity across three general critical care units within a single large UK teaching hospital. To identify the prescribing demographics including total of all prescriptions, number prescribed by pharmacists, reason for pharmacist prescription, range of medications prescribed, pharmacist prescribing error rate and the extent of pharmacist second 'clinical check'.

METHODS

Retrospective evaluation of e-prescribing across all general critical care units of a single large UK teaching hospital. All prescribing data were downloaded over a 1-month period (May to June 2016) with analysis of pharmacist prescribing activity including rate, indication, therapeutic class and error rate.

RESULTS

In total, 5374 medicines were prescribed in 193 patients during the evaluated period. Prescribing pharmacists were available on the units on 60.4% (58/96) of days, during their working hours and accounted for 576/5374 (10.7%) of medicines prescribed in 65.2% (126/193) of patients. The majority (342/576) of pharmacist prescriptions were for new medicines. Infections, central nervous system, and nutrition/blood were the top three British National Formulary (BNF) therapeutic categories, accounting for 63.4% (349/576) of all pharmacist prescriptions. The critical care pharmacist prescribing error rate was 0.18% (1/550).

CONCLUSIONS

Pharmacist independent prescribers demonstrated a high degree and wide-ranging scope of prescribing activity in general critical care patients. Pharmacists contributed a significant proportion of total prescribing, despite less than full service coverage. Prescribing activity was also safe with a very low error rate recorded.

Pharmacist independent prescribing in secondary care: opportunities and challenges

In recent years a number of countries have extended prescribing rights to pharmacists in a variety of formats. The latter includes independent prescribing, which is a developing area of practice for pharmacists in secondary care. Potential opportunities presented by wide scale implementation of pharmacist prescribing in secondary care include improved prescribing safety, more efficient pharmacist medication reviews, increased scope of practice with greater pharmacist integration into acute patient care pathways and enhanced professional or job satisfaction. However, notable challenges remain and these need to be acknowledged and addressed if a pharmacist prescribing is to develop sufficiently within developing healthcare systems. These barriers can be broadly categorised as lack of support (financial and time resources), medical staff acceptance and the pharmacy profession itself (adoption, implementation strategy, research resources, second pharmacist clinical check). Larger multicentre studies that investigate the contribution of hospital-based pharmacist prescribers to medicines optimisation and patient-related outcomes are still needed. Furthermore, a strategic approach from the pharmacy profession and leadership is required to ensure that pharmacist prescribers are fully integrated into future healthcare service and workforce strategies.

PROTECTED-UK - Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level

PURPOSE

Clinical pharmacist (CP) interventions from the PROTECTED-UK cohort, a multi-site critical care interventions study, were further analysed to assess effects of: time on critical care, number of interventions, CP expertise and days of week, on impact of intervention and ultimately contribution to patient care.

METHODS

Intervention data were collected from 21 adult critical care units over 14 days. Interventions could be error, optimisation or consults, and were blind-coded to ensure consistency, prior to bivariate analysis. Pharmacy service demographics were further collated by investigator survey.

KEY FINDINGS

Of the 20 758 prescriptions reviewed, 3375 interventions were made (intervention rate 16.1%). CPs spent 3.5 h per day (mean, ±SD 1.7) on direct patient care, reviewed 10.3 patients per day (±SD 4.2) and required 22.5 min (±SD 9.5) per review. Intervention rate had a moderate inverse correlation with the time the pharmacist spent on critical care (P = 0.05; r = 0.4). Optimisation rate had a strong inverse association with total number of prescriptions reviewed per day (P = 0.001; r = 0.7). A consultant CP had a moderate inverse correlation with number of errors identified (P = 0.008; r = 0.6). No correlation existed between the presence of electronic prescribing in critical care and any intervention rate. Few centres provided weekend services, although the intervention rate was significantly higher on weekends than weekdays.

CONCLUSIONS

A CP is essential for safe and optimised patient medication therapy; an extended and developed pharmacy service is expected to reduce errors. CP services should be adequately staffed to enable adequate time for prescription review and maximal therapy optimisation.

Developing a Business Plan for Critical Care Pharmacy Services

Critical care medicine has grown from a small group of physicians participating in patient care rounds in surgical and medical intensive care units (ICUs) to a highly technical, interdisciplinary team. Pharmacy's growth in the area of critical care is as exponential. Today's ICU requires a comprehensive pharmaceutical service that includes both operational and clinical services to meet patient medication needs. This article provides the elements for a business plan to justify critical care pharmacy services by describing the pertinent background and benefit of ICU pharmacy services, detailing a current assessment of ICU pharmacy services, listing the essential ICU pharmacy services, describing service metrics, and delineating an appropriate timeline for implementing an ICU pharmacy service. The structure and approach of this business plan can be applied to a variety of pharmacy services. By following the format and information listed in this article, the pharmacy director can move closer to developing patient-centered pharmacy services for ICU patients.