What is Clinical Pharmacy?

Clinical pharmacy is the branch of pharmacy in which doctors of pharmacy provide patient care that optimizes the use of medication and promotes health, wellness, and disease, prevention. Clinical pharmacists care for patients in all healthcare settings but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often work in collaboration with physicians, nurse practitioners, and other healthcare professionals.

Education and credentialing:

• Clinical pharmacists have extensive education in the biomedical, pharmaceutical, socio-behavioral, and clinical sciences. Most clinical pharmacists have a Doctor of Pharmacy (Pharm-D.) degree and many have completed one or more years of post-graduate training. (for example, a general and/or specialty pharmacy residency). 
• In the United States, clinical pharmacists can choose to become Board-certified through the Board of Pharmacy Specialties (BPS), which was organized in 1976 as an independent certification agency of the American Pharmacists Association.
• The BPS certifies pharmacists in the following specialties: ambulatory care pharmacy, critical care pharmacy, nuclear pharmacy, nutrition support pharmacy, oncology pharmacy, pediatric pharmacy, geriatric pharmacy, pharmacotherapy, and psychiatric pharmacy. 

Scope of Clinical Pharmacy

1. Preparation of patient medication histories:

• Any hypersensitivity or allergies to specific drugs observed in the past, any particular drug or food habits, drug dependence or intoxication with chemicals due to occupational hazards, all of which are likely to interfere with the therapy. 
• This will help in saving physicians time and effort and thus will result in faster and more accurate selection of drug therapy.

2. Rational prescription: 

• The clinical pharmacist can suggest to the physician and help him in selecting the right drug. Some of the examples of irrational combinations identified by pharmacists are E.g.: Haloperidol + Diazepam + Amitriptyline, and Reserpine + Sintamil. 

3. Bioequivalence and generic equivalence of pharmaceutical formulations: 

• A number of factors influence the bioavailability of drugs from the dosage forms. Selection of proper drug therapy based on bioequivalence studies on different dosage forms of the same drug moiety. 

4. Patient monitoring:

• Observe the signs and symptoms that indicate the need for a reaction to drugs. 
• A clinical pharmacist who knows the correct route of administration, the signs and symptoms of over dosages, contraindications, desired effects, undesired effects, and side effects can help in monitoring the drug therapy for safety and efficiency, a necessity with the increasing applications of potent and toxic chemicals and drugs. 
• Drugs with a narrow therapeutic index, or When drugs are administered in patients, who are critically ill or suffering from chronic diseases. 

5. Adverse drug reactions and drug interaction:

The clinical pharmacist:

• Can compile and process data using computers and make it available to the medical staff.
• May suggest an alternate therapy if applicable.
• Identify drug effect modifications due to interactions with several foods, alcohol, smoking, and environmental chemicals, as well as due to pregnancy. 

6. Drug Information Specialist:

• A clinical pharmacist is an expert on drugs and may operate a drug information service. 
• Through effective utilization and retrieval of clinical drug literature, the pharmacist can actively communicate drug information.
• He can help during medical emergencies, by providing immediate information on antidotes in case of poisoning or overdosing. 

7. Retail pharmacy stores:

• Many OTC drugs have the potential to interact with prescription drugs.
• A clinical pharmacist at retail drug stores can maintain patient drug profiles, family drug profiles and family records based upon which the pharmacist can counsel the patient each time while filling the prescription.
• He can determine the patient’s responses to drug therapy and help him in the selection and use of OTC drugs. 

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8. Discharge counseling and patient compliance:

• Compliance with drug therapy can be improved several times, by educating and counseling the patient at the time of discharge from the hospital or while dispensing the prescription at the retail counter.
• The patient may be made aware of the purpose of the medication, the proper mode of administration, dosage schedule and storage conditions. 
• He may be told of any potential adverse or side effects to expect and any food or activities to be avoided during therapy. 

9. Clinical research and continuing education program:

• The clinical pharmacist can participate in an evaluation program on investigational drugs. 
• He can help in conducting clinical trials based on sound principles of biostatistical methods of evaluation. 
• He can also develop training programs for pharmacists, nurses and interns. 

10. Medical Audit: 

The medical audit is a logical and necessary procedure within organized teamwork. The clinical pharmacist is either the initiator or a very active member of a functioning committee. 

The following are the activities, concerning the medical audit:

• Legislation. 
• Contractual obligation. 
• Regulation and registration of pharmacotherapy orders and administration. 
• Regulation of clinical experiments with drugs. 
• Information per subject and per patient. 
• Pharmacotherapy-committee policy. 
• Regulation of information from the pharmaceutical industry. 
• Local or regional micro symposia per patient. 
• Formulary policy.
• Retrospective study of drug use patterns. 
• Medical auditory committee work. 

Legislation:

The pharmacist is responsible for the quality of the medicines he dispenses. 

Contractual obligation:

The authorized pharmacist should be charged with supervision over the maintenance of the organization including the storage, distribution, and registration of drugs, regardless they are in the pharmacy or elsewhere in the institution. 

Regulation and registration of pharmacotherapy orders and administration:

The clinical pharmacy must provide the means for pharmacotherapy. The follow-up should be reviewed by the pharmacist with head nurses and the medical director. Specific problems should be discussed with the concerned members of the healthcare team and regulated. 

Regulation of clinical experiments with drugs: 

Regulation of clinical trials is necessary 

1. To ensure that there are no ethical problems that may harm patients. 
2. To control trials. 
3. To control pharmacotherapy through: 

• Registration and processing of requests for the use of unregistered drugs. 
• Purchasing.
• Control of stock and turnover.
• Quality control.
• Supply.
• Compounding.
• Control of code and key of "blind" experiments. 
• Reporting deviation of standard operating and registration procedures to the directorate.

Information per subject and per patient:

Information per subject and per patient may be provided by the clinical pharmacy. Information is a service and should be given unasked for when deemed necessary.

Pharmacotherapy-committee:

In this information, the specific subject policy is prepared within a multidisciplinary team and produced as advice. Clinical pharmacists can recommend, and motivate, and must ensure the continuity of pharmacotherapy-committee work.

Regulation of information from the pharmaceutical industry:

Promotional activities of the pharmaceutical industry are primarily physician-oriented. Part of their information may be essential. Clinical pharmacists and physicians have different requirements for additional information. Thus, it is possible to select information and representatives from the industry for the discussion of specific subjects with clinical pharmacists and physicians. 

Functions of Clinical Pharmacists:

1. Taking the medical history of the patient.
2. Patient Education.
3. Patient care.
4. Formulation and management of drug policies.
5. Drug information. 
6. Teaching & training to medical and paramedical staff 
7. Research and development. 
8. Participation in drug utilization studies. 
9. Patient counseling. 
10. Therapeutic drug monitoring. 
11. Drug interaction surveillance. 
12. Adverse drug reaction reporting. 
13. Safe use of drugs. 
14. Disease management cases. 
15. Pharmacoeconomics.

Development of clinical practice: 

1. In pharmacy, the emergence of clinical pharmacy as a form of practice has been attributed to the poor medicine control systems that existed in hospitals during the early 1960s (Cousins and Lacombe, 1995).
2. Although provoked by similar hospital-centered problems, the nature of the professional response differed between the USA and the UK. In the USA, the approach was to adopt unit dose dispensing and pursue decentralization of pharmacy services. 
3. In the UK, the unification of the prescription and the administration record meant this document needed to remain on the hospital ward and required the pharmacist to visit the ward to order medicines. 
4. Clinical pharmacy thereby emerged from the presence of pharmacists in these patient areas and their interest in promoting safer medicine use. This was initially termed ‘ward pharmacy’ but participation in medical ward rounds in the late 1970s signaled the transition to clinical pharmacy. 
5. Medication safety may have been the spur but clinical pharmacy in the 1980s grew because of its ability to promote cost-effective medicines used in hospitals. 
6. This role was recognized by the UK government, which, in 1988, endorsed the implementation of clinical pharmacy services to secure value for money from medicines. Awareness that support depended, to an extent, on the quantification of actions and cost savings led several groups to develop ways of measuring pharmacists' clinical interventions. 
7. Coding systems were necessary to aggregate large amounts of data in a reliable manner and many of these drew upon the eight steps of the drug use process (DUP) indicators. 
8. The data collected from these early studies revealed that interventions had very high physician acceptance rates, were made most commonly at the ‘select regimen’ and ‘need for drug’ stages of the DUP, and were influenced by hospital ward type (intensive care and pediatrics having the highest rates), pharmacist grade (rates increasing with grade) and time spent on wards. Despite the level of activity that intervention monitoring revealed, together with evidence of cost containment and a broadly supportive healthcare system, frustrations began to appear. 
9. These, in part, stemmed from a lack of certainty about the fundamental purpose of clinical pharmacy and from tensions between the drive towards specialization in clinical pharmacy and the need to improve services at a more general level in hospitals and other care settings.

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