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Mekonnen AB, Yesuf EA, Odegard PS, Wega SS. Implementing ward based clinical pharmacy services in an
Ethiopian University Hospital. Pharmacy Practice 2013 Jan-Mar;11(1):51-57.
Original Research
Implementing ward based clinical pharmacy
services in an Ethiopian University Hospital
Alemayehu B. MEKONNEN, Elias A. YESUF, Peggy S. ODEGARD, Sultan S. WEGA.
Received (first version): 25-Sep-2012 Accepted: 8-Mar-2013
*
ABSTRACT be generalized to other health care settings in the
Background: Clinical pharmacy practice has country to improve medication outcomes.
developed internationally to expand the role of a
pharmacist well beyond the traditional roles of Keywords: Medication Errors; Inpatients;
compounding, dispensing and supplying drugs to Pharmaceutical Services; Professional Practice;
roles more directly in caring for patients. Studies on Ethiopia
the activities of the clinical pharmacist in an
inpatient ward in resource constrained settings are IMPLANTACIÓN DE SERVICIOS DE
scarce, however. FARMACIA CLÍNICA EN LOS
Objective: To assess ward based clinical pharmacy DEPARTAMENTOS DE UN HOSPITAL
services in an internal medicine ward of Jimma UNIVERSITARIO ETÍOPE
University Specialized Hospital.
Methods: The study was carried out in the internal RESUMEN
medicine ward from March to April, 2011 at Jimma Antecedentes: El ejercicio de la farmacia clínica se
University Specialized Hospital. The study design ha desarrollado internacionalmente para expandir el
was a prospective observational study where papel del farmacéutico más allá de los papeles
pharmaceutical care services provided by clinical tradicionales de formulación, dispensación y
pharmacists for inpatients were documented over a distribución de medicamentos a papeles más
period of two months. Interventions like optimization directamente relacionados con los cuidados de los
of rational drug use and physician acceptance of pacientes. Sin embargo, son escasos los estudios de
these recommendations were documented. Clinical las actividades del farmacéutico clínico en los
significance of interventions was evaluated by an departamentos en establecimientos de recursos
independent team (1 internist, 1 clinical escasos.
pharmacologist) using a standardized method for Objetivo: Evaluar los servicios de farmacia clínica
categorizing drug related problems (DRPs). en un departamento de medicina interna del
Results: A total of 149 drug related interventions hospital universitario especializado de Jimma.
conducted for 48 patients were documented; among Métodos: El estudio fue realizado en el
which 133(89.3%) were clinical pharmacists initiated departamento de medicina interna desde marzo a
interventions and 16(10.7%) interventions were abril de 2011 en el hospital Universitario
initiated by other health care professionals. The especializado de Jimma. El diseño del estudio fue
most frequent DRPs underlying interventions were observacional prospectivo donde se documentaron
unnecessary drug therapy, 36(24.2%); needs los servicios de atención farmacéutica
additional drug therapy, 34(22.8%) and proporcionados por un farmacéutico clínico a
noncompliance, 29(19.5%). The most frequent pacientes internados durante un periodo de dos
intervention type was change of dosage/instruction meses. Se documentaron intervenciones como la
for use, 23(15.4%). Acceptance rate by physicians optimización del uso racional y la aceptación de los
was 68.4%. Among the interventions that were médicos de estas recomendaciones. Un equipo
rated as clinically significant, 46(48.9%) and independiente (1 internista y 1 farmacólogo clínico)
25(26.6%) had major and moderate clinical evaluó la significación clínica de estas
importance respectively. intervenciones usando un método estandarizado de
Conclusion: Involving trained clinical pharmacists clasificar los problemas relacionados con
in the healthcare team leads to clinically relevant medicamentos (PRM).
and well accepted optimization of medicine use in a Resultados: Se realizó un otal de 149
resource limited settings. This approach can likely intervenciones para 48 pacientes.; de ellos, 133
(83,9%) fueron intervenciones iniciadas por el
farmacéutico clínico y 16 (10,7%) fueron iniciadas
*Alemayehu B. MEKONNEN. BPharm, MSc. Lecturer of por otros profesionales de la salud. Los PRM más
Pharmacotherapy. School of Pharmacy, University of frecuentes subyacentes a cada intervención fueron
Gondar. Gondar (Ethiopia). medicación innecesaria 36 (24,2%); necesidad de
Elias A. YESUF. MD. Department of Health Services medicación adicional 34 (22,8%); e incumplimiento
Planning and Management, Jimma University. Jimma 29 (19,5%). El tipo de intervención más frecuente
(Ethiopia). fue el cambio de dosis/instrucciones de uso
Peggy S. ODEGARD. PharmD, CDE. Professor of 23(15.4%). La tasa de aceptación por médicos fue
Pharmacy. School of Pharmacy, University of Washington. del 68,4%. Entre las intervenciones que fueron
Seattle, WA (United States). calificadas de clínicamente significativas, 46
Sultan S. WEGA. MSc, PhD fellow. School of Pharmacy,
Jimma University. Jimma (Ethiopia).
www.pharmacypractice.org (ISSN: 1886-3655) 51
Mekonnen AB, Yesuf EA, Odegard PS, Wega SS. Implementing ward based clinical pharmacy services in an
Ethiopian University Hospital. Pharmacy Practice 2013 Jan-Mar;11(1):51-57.
(48,9%) y 25 (26,6%) tuvieron grande y moderada revised national curricula of the country in March
importancia clínica, respectivamente. 2009. Jimma University took the lead in clinical
Conclusión: Envolver a un farmacéutico clínico en pharmacy in Ethiopia because of its unique
el equipo de salud lleva a la optimización experiential learning practice sites and its
clínicamente relevante y aceptada del uso de community-based approach to learning, which
medicamentos en un establecimiento de recursos allows students to train in the university’s teaching
limitados. Este abordaje puede, probablemente, hospital and local training health centers. The
generalizarse a otros establecimientos en el país graduate program is accompanied by a one year
para mejorar los resultados de la medicación. clinical internship program for which ward based
clinical pharmacy services are the primary focus.
Palabras clave: Errores de Medicación; Pacientes Therefore, the purpose of this study was to assess
Internos; Servicios Farmacéuticos; Práctica the development, implementation and initial
Profesional; Etiopia outcomes of ward based clinical pharmacy service
in the internal medicine ward of Jimma University
Specialized Hospital (JUSH).
INTRODUCTION
The role of pharmacists as members of the health METHODS
care team has expanded beyond conventional This prospective observational study was conducted
medication dispensing. Recently, pharmacists at JUSH, located in Jimma city of Oromia regional
entered doctor’s clinics as clinical pharmacists to state which is located at a distance of 350 Km
perform direct patient care services.1 According to southwest of Addis Ababa. It provides specialized
Barber2, clinical pharmacy services (CPS) are health services through its 9 medical and other
patient oriented services developed to promote the clinical and diagnostic departments for
rational use of medicines and more specifically to approximately 9000 inpatients and 80,000
maximize therapeutic effect, minimize risk, minimize outpatients each year with bed capacity of 450 and
cost and respect patient choice.1 To achieve this, a total of more than 550 staff. The study was carried
clinical pharmacists are trained in therapeutics and out at the internal medicine ward of JUSH over a
provide comprehensive drug management to period of 2 months from March 1 to April 30, 2011.
patients and health care providers (clinical The internal medicine ward has three subsections:
pharmacists). Interacting with the health care team medical A, B, and C with total bed occupancy of 60.
in patient rounds, interviewing patients and Three hundred patients were admitted during the
conducting medication histories; providing study observation period. All in-patients in the
recommendations on drug selection and follow-up internal medicine ward whose medicine chart or
all resulted in improved outcomes2,3 Murray et al.4 prescription led to an intervention were enrolled in
reported the effect of pharmacist interventions in the study based on their consent. Critically ill
outpatients with cardiovascular disease reduced the patients requiring intensive care unit (ICU)
risk of adverse drug events by 34% compared with admission and patients with length of stay less than
the control group. . The positive impact of CPS (or 48 hours were excluded from the study.
pharmaceutical care services) on clinical, economic Data Collection Procedure
and humanistic outcomes has been demonstrated
in numerous studies in the North America and Normally, patients are under the care of one
United Kingdom (UK).5-8 Despite this, there is much attending physician and two internal medicine
inter-country and intra-country variability in the residents in each ward of internal medicine, JUSH.
practice and implementation of clinical pharmacy Standard practice at the ward includes daily medical
(CP) and CP is still in its early stages, even in most rounds by the resident in charge. Students and
European countries.9 CP is new to many developing interns also participate in daily clinical rounds. The
countries including Ethiopia. internist/resident assessed the patients and made
The importance of pharmaceutical care services in recommendations and the resident/intern would
saving lives and protecting public health is made changes to the prescriptions respectively.
particularly relevant in resource-limited settings with In this study, the graduate level clinical pharmacists
a high prevalence of major medicine-treatable completing their one year internship and training of
diseases.10 Ethiopia is an Eastern African country of trainers pharmaceutical care course were involved
approximately 80 million persons with a gross in ward rounds in the internal medicine inpatient
domestic product of USD900 per capita, classifying settings to give pharmaceutical care services
it as a low-income country.11 In addition to policy according to the standards of practice. This practice
and resource related challenges, the effect of process involves three major steps including
limited number and quality of pharmacy personnel assessment, development of a care plan and follow-
on the provision of health care in Ethiopia is up evaluation. Specifically, eight clinical
prominent.12,13 To tackle these and similar problems pharmacists, two for two weeks, were assigned in
in the country, the School of Pharmacy of Jimma the internal medicine ward for 2 months and
University launched the country’s first graduate participated in medical and multidisciplinary team
program in clinical pharmacy with an objective of two days per week. Ward rounds usually took place
training patient centered pharmacy practitioners as from 10:00 am to 12:00 am. At each visit, the
well as training faculty members for the new clinical pharmacist used all relevant information
undergraduate clinical pharmacy courses in the new about each patient which was systematically
www.pharmacypractice.org (ISSN: 1886-3655) 52
Mekonnen AB, Yesuf EA, Odegard PS, Wega SS. Implementing ward based clinical pharmacy services in an
Ethiopian University Hospital. Pharmacy Practice 2013 Jan-Mar;11(1):51-57.
collected in the medical record: the results of pharmaceutical care patient record. Data were
examinations and laboratory results, the medical checked for completeness daily with appropriate
history, clinical factors, diseases, symptoms and follow-up and editing if needed. Data were then
medication history. We recognized that undertaking cleaned and analyzed, using SPSS version-16. The
this activity for as many patients as possible data were summarized and described using cross
represents a significant use of time and needs tabulation. Descriptive statistics was used to
commitment. Likewise, recording all interventions to characterize interventions, drug related problems
treatment takes time. So, for the sake of this study; and physicians acceptance of interventions.
pharmaceutical care interventions were The following operational definitions were used:
documented in only those patients with DRPs.
Participation with a multidisciplinary team was part Acceptance of pharmaceutical care
of the project. Interventions made were interventions: the doctor approves the proposal
communicated with the concerned health care made by the pharmacist for the prevention or
professionals. All clinical pharmacists’ interventions resolution of the DRP.
were documented in the pharmaceutical care Clinical importance of interventions: a rating of
patient record, which was already incorporated as the intervention’s significance or impact with
patient care in the patient chart. With the data regard to patent’s outcomes. Significance was
collected, the pharmacist evaluated appropriateness classified as extreme - life saving, deleterious;
of medical therapy, identified any other DRPs and major - intervention may prevent serious
communicated interventions to the internist/resident. morbidity, including readmission, serious organ
Written information to support the need for the dysfunction, serious adverse drug event;
intervention was then provided by the clinical moderate - no benefit or minor benefit,
pharmacist to the provider and the intervention depending on professional interpretation; mild -
documented. At discharge, the clinical pharmacists recommendation that brings care to a more
provided treatment update information to the patient acceptable and appropriate level of practice or
or caregiver and the general practitioner for that may prevent an adverse drug event of
continuity of care and communication. A written plan moderate importance.
(including names of drugs, indications, dosages and
forms, frequency and time of administration, Ethical Consideration
modalities of administration, list of drugs
discontinued and reason) was given to the patient Letter of ethical clearance was obtained from the
or caregiver, together with oral explanations. The Ethical Review Board of Jimma University. Privacy
further follow-up of the decisions on subsequent and confidentiality was ensured during the
days or after the patient’s discharge from the pharmaceutical care services. Thus, name and
hospital was not a part of the study. address of the patient was not recorded in the DRP
Drug related problems (DRPs) identified, resolved data collectionformat. From the pharmaceutical care
and prevented were recorded through DRP service, DRPs were identified and
registration format. A drug-related problem is resolved/prevented so that health and economic
defined by Strand et al.14 as ‘an undesirable patient outcome was ensured.
experience that involves drug therapy and that
actually or potentially interferes with the desired RESULTS
patient outcome’. Different pharmaceutical care Clinical pharmacists were present in the internal
researchers have employed different kinds of DRP medicine ward for 16 days during the study period.
classification categories. However, many of the A total of 149 drug related interventions were
DRP categories are adapted from the Cipolle-
Morley-Strand classification.15-17 In our study, DRPs documented for 48 of the 300 patients admitted
were categorized according to this classification during the study period. Among them, 133 (89.3%)
scheme.18 It consisted of seven DRP categories: interventions were initiated by the clinical
unnecessary drug therapy, needs additional drug pharmacists and 16 (10.7%) by another health care
therapy, ineffective drug therapy, dosage too low, professional (i.e. interventions were already handled
adverse drug reaction, dosage too high and by another health care professional). Mean average
noncompliance. A definition for each DRP is age of the patients was 38 (SD=17.6) (range 18-
available which is adapted from Cipolle et al.18 80), majority of patients 32 (66.7%) were females
Thus, clinical pharmacists identified and and mean average DRPs identified per patient was
documented DRPs accordingly. DRPs documented 3.83 (SD=2.43).
were validated by a senior pharmacist. Types of Medication use for all patients was evaluated for
interventions made and their acceptance were potential DRPs. DRPs identified were documented.
recorded from the pharmaceutical care patient These are summarized in Table 1. Unnecessary
record. To judge the relevance of interventions, an dug therapy was the most common drug related
independent panel comprised of one internist and problem identified accounting for a quarter of all
one clinical pharmacologist rated DRPs according documented drug related interventions. Of the 36
to their significance. Disagreements between the DRPs classified as unnecessary, 18 (50%) were
ratings were provided for discussion to the clinical because there was no valid medical indication at
pharmacist adjudication team for deliberation and that time, 9 (25%) were due to alcohol use or
confirmation of the DRP. Data collection was smoking and 7 (19.4%) were due to duplication of
completed by junior pharmacists that were properly therapy. “Needs additional drug therapy” was also a
trained on the extraction of data from
www.pharmacypractice.org (ISSN: 1886-3655) 53
Mekonnen AB, Yesuf EA, Odegard PS, Wega SS. Implementing ward based clinical pharmacy services in an
Ethiopian University Hospital. Pharmacy Practice 2013 Jan-Mar;11(1):51-57.
Table 1. Characteristics of interventions documented by (14.3%) and drug discontinuation 16 (12%) (Table
clinical pharmacists, JUSH, Ethiopia, March-April 2011. 3).
Drug related problem category* Interventions, A total of 68.4% of the interventions were fully
n (%)
Unnecessary drug therapy 36(24.2%) accepted and 2.3% were partially accepted by
Additional drug therapy 34(22.8%) physicians. All of the health education interventions
Ineffective drug 4(2.7%) that were made were accepted by the patients and
Dosage too low 18(12.1%) implemented by the multidisciplinary team. An
Adverse drug reaction 16(10.7%) independent clinical panel assessed the clinical
Dosage too high 12(8%) significance of 94 interventions made by clinical
Noncompliance 29(19.5%)
pharmacists. The panel reviewed only those
Total 149(100%)
*A classification scheme by Cipolle et al, 2004 interventions which were considered fully and
partially accepted. The panel and the intervening
common problem identified 34 (22.8%). For 17 pharmacist were deemed to be in agreement if both
(50%) of the subjects, a medical condition indicated assessed the same change (increase/decrease)
the need for initiation of drug therapy, with 12 and the same magnitude of change. Individual
(35.3%) requiring preventive drug therapy to ratings were different for some of the interventions
prevent development of a new condition. The third and level of agreement was determined between
most frequently identified drug related problem was the independent panels and the intervening clinical
noncompliance, 29 (19.5%) including unavailability pharmacists after discussion and consensus was
of drug product 18 (62.1%) and the patient prefers reached. On the basis of clinical importance, 46
not to take the medications 9 (31%). (48.9%); 25 (26.6%); 18 (19.2%) and 5 (5.3%)
Analysis of drug classes involved in interventions of interventions were rated as major, moderate, mild,
all types showed iron, calcium, vitamins and other and extreme respectively.
supplements, 30 (20.1%), were the most frequent
classes involved in DRPs, followed by antibiotics, DISCUSSION
22 (14.8%) (Table 2). The frequencies of classes of The clinical pharmacist contributes to the general
drugs with each particular drug therapy problem health outcomes by improvement of the drug
demonstrated; - the most predominant were therapy. This study provided evidence for the
antibiotics as ‘unnecessary drug therapy’ and benefit of a patient to a more appropriate (effective
‘adverse drug reaction’ categories; digoxin from the and safe) medication use as a result of clinical
‘ineffective drug therapy’ category; iron, calcium, pharmacist initiated interventions. A number of
vitamins and other supplements from the ‘needs studies reported that involvement of clinical
additional drug therapy’ and ‘dosage too low’ pharmacists in patient care in the inpatient hospital
categories and anticoagulants, antihyperlipidimics settings resulted in safer and more effective
from the ‘dosage too high’ and ‘noncompliance’ medication use through identification, resolution and
categories. prevention of drug therapy problems.19-24 To our
Clinical pharmacists working in an internal medicine knowledge, this is the first study to report results of
ward during the study period were providers of the ward based clinical pharmacy services in an
pharmaceutical care resulting in 133 initiated African hospital setting. We found that clinical
interventions. Among those interventions they acted pharmacists through the provision of
up on, dosage/instruction for use changed and pharmaceutical care were able to propose a lot of
consulting the health care professionals each interventions to a wide variety of DRPs and drugs.
accounting for 23 (17.3%) were the most common The most common drug related problem in our
interventions made followed by new drug started 19 patients was unnecessary drug therapy (24%) with
Table 2. Classes of drugs involved in interventions of all the most common reason being no valid medical
types, JUSH, Ethiopia, March – April 2011. indication (50%) and much of the share was to
Drug class N (%) antibiotics. A study in Indonesia showed antibiotics
Iron, calcium, vitamins and other are the third most common agents involved in
30 (20.1%) 25
supplements * unnecessary drug therapy but the cost incurred on
them is the highest. . Unnecessary drug use has
Antibiotics 22 (14.8%)
Anticoagulants, antihyperlipidimics 17 (11.4%) two implications according to this result. On the one
Diuretics 16 (10.7%)
hand, antibiotic use without indication and over
Antacids, antiulcers 11 (7.4%) prescription has its own effect on the emergency of
Analgesics 10 (6.7%)
resistance to particular bacterial strains. On the
Antiretrovirals 7 (4.7%)
other hand, in this era of inflation drug therapy costs
ACEIs 6 (4.0%)
are on the rise. This is cumbersome for developing
Digoxine 6 (4.0%)
nations. Prevention of unnecessary drug therapy
Antifungals 5 (3.4%)
will contribute in cost saving among hospitalized
Antituberculars 4 (2.7%)
patients. Numerous US studies have demonstrated
BBs 3 (2.0%)
cost reductions when pharmaceutical care is
Bronchodilators 2 (1.3%)
provided.23,24 In Australia the value of clinical
others† 9 (6.7%)
pharmacists in reducing costs of treatment and
Total 149 (100%) 26
ACEIs=angiotensin converting enzyme inhibitors; BBs=beta- shortened hospital stays has been reported. A
blockers study done in Sweden has showed the addition of
*other supplements include potassium, multivitamins pharmacists to health care teams would lead to
†antihelminthics, antiviral, sedative hypnotics
www.pharmacypractice.org (ISSN: 1886-3655) 54
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