25th EAHP Congress 2021

The Congress also heard from Prof Isabel Spriet, Head of the Clinical Pharmacy Department at University Hospitals Leuven in Belgium, and Mr Sotiris Antoniou, Head of Pharmacy at St Bartholomew’s Hospital in London, who both spoke on the topic of ‘Combining Centralised and Bedside Clinical Pharmacy’.

Clinical errors are the third-leading cause of deaths in the US, according to one estimate published in the BMJ in 2016, which also concluded that the key element to improve quality of care is the optimisation of patients’ pharmacotherapy, said Prof Spriet. “As we all know, we are confronted with a large ageing population characterised by often complex polypharmacy,” she told the congress. “Also, the new drugs that are entering the market are often complex, such as the NOACs and the oral anti-cancer drugs. In Belgium, we have had the initiation of a fixed drug budget for hospitalised patients, so pharmacoeconomics is also becoming increasingly important.

“We also see a shift towards an overall shorter length of stay,” she continued. “So due to all these elements, we have seen over the past 10 years a shift in the role of hospital pharmacy, from more drug-oriented services to more patient-oriented services. The development of bedside hospital pharmacy has already been implemented since the 1980s and 1990s in the US, Canada, Australia and the UK, but we have only seen the development of clinical pharmacy services in Belgium since early 2000.”

Belgian hospital pharmacists contribute on different levels, she explained, such as in the development of clinical decision support systems (CDSS), including the installment of drug-drug interaction modules and maximum doses, modules on drug use during pregnancy/lactation, therapeutic duplication, and drug allergy, said Prof Spriet. “We have also developed what we call ‘front-office’ clinical pharmacy services… at the bedside, we contribute in the classical clinical pharmacy tasks, we attend ward rounds, we do medication reconciliation and review, counselling patients at discharge, and we also do a lot of projects focused on high-risk drug-drug interactions and antibiotic stewardship,” she said, adding that the ‘front-office’ initiatives were aided by structural funding from the Belgian government.

Teams of front-office pharmacists are present in Prof Spriet’s hospital on the geriatrics, haematology, trauma, hypertension, and paediatric oncology wards, as well as the emergency department, for example. KPIs show that the involvement of clinical pharmacists contributes significantly to improved outcomes for patients, she told the attendees, “and our advice is highly appreciated and implemented, as illustrated by high acceptance rates”.

However, the number of clinical pharmacists in Europe per 100 beds is significantly lower than in the US, at 0.9 vs 17.9 respectively, she pointed out. This led to the development of ‘back-office’ clinical pharmacy services, which involves clinical validation, checks of medication appropriateness, and screening of patients at risk for potentially inappropriate prescriptions.

“More than 60 per cent of clinical pharmacists in Belgium are now investing in back-office clinical pharmacy services, vs 30 or 40 per cent front-office investment in clinical pharmacy services,” she said.

Mr Antoniou told the attendees about the challenges to be faced: “We know that when a patient is admitted, around 60 per cent have three or more medicines changed during their hospital stay and adverse drug events occur in up to 20 per cent of patients after discharge,” he said. “It is estimated that 11-to-22 per cent of hospital admissions for exacerbations of chronic disease are a direct result of non-compliance with medication.” Mr Antoniou pointed out the real focus of the hospital pharmacist’s day is spent in the dispensary in the supply of medicines.

“When they go to the ward, there is a focus on discharge prescription validation and on high-risk medicines,” he said. Mr Antoniou also provided an overview of the development of clinical pharmacy since the 1990s and the emergence of pharmacy technician-led dispensaries.

He stressed the need to continue the evolution of clinical services and moving clinical pharmacy “from the basement to the bedside”, and to have a greater presence for clinical pharmacists, and Mr Antoniou also described the path followed by his hospital in achieving these aims. One aspect of this was the need for a seven-day clinical pharmacy service across three sites following the Heart Centre Merger of 2015, which saw the merger of three cardiac specialist centres into one.

He told the congress: “Pharmacy service is integral to patient care; I firmly believe that,” he said. “And yet we know that when a patient is admitted to hospital, medicines are the number-one intervention that we provide — I’m not aware of any patient who is admitted that doesn’t receive some form of medication. But in order to make us integral, we need to utilise the whole, with the right role for the right person and if we really feel that we are integral, we need to be accountable for our actions.

Hence the argument for writing discharge medicines, with the opportunity to communicate effectively with our primary care colleagues as to the changes to the medicines, as well as counselling the patient and providing guidance for further optimisation.”