Impacts of a multipurpose outpatient hospital pharmacy in the framework of 3P medicine

Lara González Freire; Ana Belen Veiga Villaverde; Ana Ballester Vieitez; Rosario Olivera Fernández; Carlos Crespo-Diz

doi:10.1007/s13167-023-00346-0

. 2023 Dec 4;15(1):125–134. doi: 10.1007/s13167-023-00346-0

Impacts of a multipurpose outpatient hospital pharmacy in the framework of 3P medicine

Lara González Freire ^1,^2,^3,^✉, Ana Belen Veiga Villaverde ¹, Ana Ballester Vieitez ¹, Rosario Olivera Fernández ¹, Carlos Crespo-Diz ^1,²

PMCID: PMC10923770 PMID: 38463628

Abstract

Challenge in the framework of Predictive, Preventive and Personalised Medicine

In recent years, we have been witnessing a change in the performance of hospital pharmacists, aimed at increasing their participation in the pharmacotherapeutic process of patients. The drug cycle, characterised as multidisciplinary, is very complex. It is essential for the multidisciplinary team to have a broad vision of the medication system in order to guarantee safety and quality.

Considering the challenges of current healthcare systems and paradigm shift from reactive to predictive medicine, a new professional environment should be created to promote the implementation of Predictive, Preventive and Personalised Medicine in healthcare.

Objectives and study design

To optimise care times in multipurpose outpatient hospital both in the preparation of ready-to-use medications and in the dispensing of medications for home treatment.

To increase the confidence and value of hospital pharmacists in the process of patient and family care.

The design of the study was carried out by the following:

-Coordinating the schedules of the multi-pathology day hospital with the software and records of Medication Preparation in the pharmacy service.

-Opening a Pharmacy Outpatient Clinic associated with the multi-pathology day hospital.

-Planning and scheduling patient treatments.

Achievements

With the implementation of this programme, the visibility of hospital pharmacists in the multidisciplinary team was increased.

This Pharmacy Outpatient Clinic allowed the coordination of the pharmaceutical care process in the day hospital.

This project increased the credibility of the Pharmacy Service in the improvement of the integral process of the medicine.

Conclusions and expert recommendations

Predictive approach

The presence of pharmacists in the multi-pathology day hospital has a predictive approach. A change is made in the workflow that allows to generate a speed of intervention by acting before prescribing, dispensing and administering the treatment to the patient.

Targeted prevention

The presence of pharmacists in the multipurpose day hospital unit and their collaboration with other professionals and the patient bring about a selective prevention that decreases the possibility of medication errors occurring.

Personalisation of medical services

With the individualised dispensing of treatments, a step forward is taken in the personalisation of medical services, which avoids medication errors in labelling and administration and improves safety in the overall medication circuit in the hospital.

Keywords: Predictive preventive personalised Medicine (PPPM/3PM), Patient stratification, Individualised services, Improved outcomes, Health policy, Healthcare economy, Pharmacy service, Health services

Introduction

Pharmacy services as the key element for advancing healthcare quality to the population

Hospital pharmacists are uniquely trained in therapy and provide comprehensive medication management to patients and healthcare professionals [1].

Outcomes of pharmacist intervention include economy, health-related quality of life, patient satisfaction, medication appropriateness, medication errors (ME) and adverse drug reactions (ADR) [1].

The quality of care has gradually become the cornerstone of healthcare. In recent years, patient safety has become more important and has positioned itself as one of the key dimensions of quality [1].

Reviews have been published on pharmacy service (PS) in various settings, including outpatient care, geriatrics, psychiatry, intensive care, economic outcomes and health-related quality of life [1].

Two recent reports from the Institute of Medicine recognized that pharmacists are an essential resource in the safe use of medications, that pharmacist participation in the multidisciplinary team improves medication safety and that collaboration between pharmacists, physicians and patients is important [1].

In this new role, hospital pharmacists work directly with professionals and patients to provide services that are not simply associated with the dispensing of medicines [1].

In recent years, we have witnessed a change in the actions of hospital pharmacists, aimed at increasing their participation in the pharmacotherapeutic process of patients, favouring their outreach to hospitalisation units. This trend has been highlighted by the publication of several studies on pharmaceutical care, following the US model, where pharmacists play an important role in clinical activities [2–7].

Multi-professional expertise is essential in the framework of 3P medicine

The drug cycles administered in hospitals are often very complex and can comprise several different processes. Indeed, it is estimated that between 20 and 60 different stages are involved in the processes of prescription, dispensing and administration of medicines. Thus, the participation of so many professionals in this process characterises these cycles as multidisciplinary, which can favour the occurrence of ME and medication administration and dispensing delays, therefore promoting a lack of trust between professionals and patients [8].

In this sense, it is essential that multidisciplinary teams have an expanded view of the medication system and each of its processes, thereby allowing them to guarantee the safety and quality of the processes they are responsible for. This can include seeking information on the flow of different activities and already known problems with the environment, human resources, knowledge of different drugs and their possible interactions and the correct preparation of medications, their administration routes and administration techniques [8].

Predictive, Preventive and Personalised Medicine (PPPM) is emerging as the focal point of efforts in healthcare. Integrative approach by PPPM is considered as the medicine of the future. Being at the forefront of the global efforts, the European Association for Predictive, Preventive and Personalised Medicine (EPMA) promotes the integrative concept of PPPM among healthcare stakeholders, governmental institutions, educators, funding bodies, patient organisations and the public domain [9, 10].

For the paradigm shift from delayed reactive to PPPM, a new culture should be created in communication between individual professional domains, between doctor and patient and pharmacist and patient. Optimal clinical and pharmaceutical decisions result from a multidisciplinary approach performed by specialists with expertise [9, 10].

However, for their daily communication, different professional groups currently utilise different professional languages. This frequently leads to misunderstandings and delays in the implementation across diverse areas in PPPM. Breaking such communication barriers is a great challenge which can be solved only by international and multidisciplinary networking providing the necessary environment for a creation of a new culture of communication of PPPM stakeholders [9, 10].

Working hypothesis and innovation in the framework of 3P medicine

Predictive approach

One of the most important factors related to quality of care is patient satisfaction with the services provided. Any organisation aiming to improve its quality must orient its services towards patient satisfaction [11].

Complaints are a key element for understanding patient expectations while they serve as an indicator of perceived quality and patient satisfaction [11].

The analysis of the information provided by complaints and suggestions is one of the indirect methods that can be used to ascertain the degree of patient satisfaction. A study focused on these can help us detect problems related to the activity in our centres, by promoting improvements in order to provide the best service to patients [11].

b)
Targeted prevention

In hospitals, the medicine cycle is very complex and is composed of several processes. Thus, the involvement of various professionals characterises this cycle as multidisciplinary, which may encourage the occurrence of errors [8].

Errors can occur due to active faults in the practices of the different professionals involved or to latent faults in the system of medicines use, whether during the prescription, dispensing or administration [8].

ME are widespread in hospitals and include “any preventable event that may cause or lead to inappropriate use of medication or harm to the patient”. Examples of ME include omission of medication, administration of the wrong medication, administration to the wrong patient or dosing errors [12].

ME can occur due to gaps in knowledge, non-compliance with rules or the use of inappropriate rules for use and the presence of slips, technical errors and memory lapses during the use of these medicines [12, 13].

These ME can cause harm to the patient. The prevalence of ME deaths in the USA during the period 1983–1993 was 3000–7000. This trend has continued in recent years [12, 13].

The main causes of these ME are related to poor multidisciplinary collaboration and poor communication among healthcare professionals [12, 13].

Therefore, by focusing on strategies aimed at improving communication between health professionals, there is the potential to reduce ME, particularly those that cause harm [12, 13].

An important characteristic of communication involves multidisciplinary collaboration, whereby different professionals work together to solve patient care problems. Teamwork involves the design and monitoring of the patient’s pharmacotherapeutic plan in order to identify, prevent and resolve ME [12, 13].

Several studies have shown a decrease in ME when pharmacists work in collaboration with other healthcare professionals from different medical services and nursing units [12].

c)
Personalisation of medical services

Over the years, medical and pharmaceutical care has become increasingly patient-centred [14].

The main idea of the person-centred medicine is to promote health and, therefore, reduce disease burden. In this concept, any health condition is considered an individual state of physical, mental, social and spiritual well-being. Humanistic interpretation of medicine is characteristic including the articulation of science, enhanced understanding of positive health versus illness, emphasised personalisation of all medical services and strong patient empowerment and essential responsibility of every person, at individual and community levels [14].

Patient stratification is one step towards individualised patient treatments and so-called personalised medicine [14].

The American Society of Hospital Pharmacist (ASHP) and the ASHP Foundation have a long history of fostering the advancement of pharmacy practice in hospitals and health systems by building consensus about a vision for the future, expressing specific goals for practice change designed to achieve the vision and developing tools to help practitioners move in the desired direction [15, 16].

The most recent iteration of this approach to change leadership has been the ASHP Practice Advancement Initiative (PAI), launched in 2015 as a successor to the ASHP Pharmacy Practice Model Initiative (PPMI), which began in 2010 [15, 16].

The objective of PAI has been “to significantly advance the health and well-being of patients in hospitals and health systems by developing and disseminating optimal pharmacy practice models that are based on the effective use of pharmacists as direct patient-care providers” [15, 16].

The PAI 2030 initiatives aim to change the way pharmacists look after patients by empowering the pharmacy team to take responsibility for the outcomes of medicines use and to promote the optimal, safe and effective use [15, 16].

The paradigm shift from reactive medical services to predictive approach, targeted prevention and personalisation of treatments has been proposed by the EPMA to reverse above documented trends and to improve overall quality of medical services [17].

This project arises within the framework of continuous improvement and clinical safety of the pharmaceutical care process in the multipurpose outpatient hospital (MOH), to minimise complaints from patients and relatives due to delays in response times for the administration and dispensing of medicines, caused by a lack of coordination and planning between the MOH and the PS, which leads to dissatisfaction, uncertainty and loss of trust on the part of patients and their relatives.

It was considered necessary to cover the need for pharmaceutical care by incorporating the Specialist Pharmacist into the interdisciplinary care team in the MOH, to integrate them into the process and provide pharmaceutical care in situ.

We aimed to reengineer the pharmaceutical care process in a MOH in which care for patients with different pathologies is provided by various medical services with the support of the PS and one nursing unit.

Thus, pharmaceutical care was reorganised from being off-site to on-site, with the following objectives:

Optimise service times in the MOH, where the PS plays a key role in the process, both in the preparation of ready-to-use medications and in the dispensing of medications for home treatment.
Increase the confidence and value placed in the care process managed by hospital pharmacists, patients and their relatives, achieving this by providing pharmaceutical care as another clinical activity in the care environment in which the prescription and administration of medications are conducted.

Study design

For the implementation of this programme, previous suggestions from patients and relatives regarding the pharmaceutical care provided at the Pharmacy Outpatient Clinic (POC) and MOH were taken into account.

The project was designed through the hospital’s continuous improvement process and met the requirements of the PS quality management system.

Beginning of the process:

The process begins with the request for treatment by medical prescription for a specific patient and ends with the individualised dispensing, follow-up and registration of the corresponding treatment for the patient in the MOH or in the POC.

Phase 1: Coordination of the MOH agendas with the computer software and medication preparation registers in the PS.

Phase 2: Creation and operation of the POC associated to MOH for the dispensing of medicines with pharmaceutical intervention and the provision of active information to patients and/or relatives.

Phase 3: Planning and scheduling of patient treatments in MOH and POC, in collaboration with the medical services and nursing units involved.

Request for treatment

The request for treatment is made by prescribing the medicine to the specific patient.

The prescription is made on different computer media depending on the type of treatment and the service/unit where it is generated.

First consultation and treatment changes

The first consultation is considered to be the one that takes place with new patients. It is also considered to be that which is carried out with patients who have already been seen but who follow a change in treatment.

If necessary, and at the pharmacist’s discretion, the necessary medication is dispensed.

Subsequent consultations

Subsequent consultations are defined as complementary and follow-up consultations after a first consultation. Two types of consultations are distinguished according to whether a pharmacist is present or not:

Face-to-face consultation

Patients come to the consultation, by appointment, following the appointment procedure established in accordance with the Admissions Service.

Pharmacists plan the interventions to be carried out according to the workload foreseen for the following day, which is analysed using the patient records in the CLINICA® software and in the SILICON® pharmacy software application.

The dispensing order is generated specifying the date of the next appointment.

In the case of intravenous mixtures for day hospital administration, the corresponding elaboration orders are issued.

Non-face-to-face consultation with informed medicine dispensing

The selection of patients to be assisted by telephone consultation is carried out by pharmacists according to the following criteria:

Patients with chronic pathologies.
Patients with good adherence to treatment.
Patients whose place of residence allows the implementation of the home dispensing programme.

Pharmacists get in contact with the patient. The procedure to be followed in the telephone POC is presented and explained. The patient’s details are confirmed, and the patient is informed about the quick communication channel for resolving incidents and questions related to the treatment (e-mail, telephone).

In both consultations, the patient interview is structured in three parts:

Data collection and assessment: the pharmacotherapeutic profile is established by recording the data related to medicines, doses and posology in the medical history created in the computer software.
Analysis of the pharmacotherapeutic profile and information related to it is given to the patient in order to encourage adherence to treatment, promote the correct conservation of the medication, provide the patient with knowledge about the treatment, detect incidents and drug-related problems (DRP), avoid errors in the use of medications and decide the follow-up method and the frequency of visits.
Intervention in response to the DRP detected. It should be oriented towards the following:

The patient: to clarify all aspects needed for the understanding of the treatment, by emphasising the problem detected.
The doctor: when there are significant clinical repercussions or when a DRP is detected repeatedly.

Pharmaceutical validation

Pharmaceutical validation includes the monitoring of the prescribed treatment, confirmation of dosage and frequency of administration and the identification of DRP and/or ME, by carrying out the following actions:

Review of administrative data: all requests must include the patient’s name and surname and Clinical History Number (CHN).
Review of clinical data: diagnosis, indication, dose, frequency, allergies, analytical data.
Registration and configuration of the pharmacotherapeutic profile in the corresponding pharmaceutical software.
Reassessment of treatment, if applicable.
Suitability (Yes/No):

If it is suitable and the elaboration of the medicinal product is necessary: the elaboration order is issued in the corresponding software and the procedure of elaboration and quality control of the medicine in question continues.

If it is suitable and no elaboration is necessary: the dispensing order is issued from the outpatient dispensing software.

If it is not suitable: the person responsible for prescribing the treatment is contacted in order to verify and/or rectify the deficiencies detected.

Medicine dispensing

The dispensing of medicines is carried out on an individualised basis for each patient at the MOH where the medicine is to be administered or at the POC.

The patient is given verbal or written information, if necessary, including at least the following elements: storage and handling, characteristics of the administration, relevant interactions, possible adverse reactions.

Resources available

Space and equipment for POC associated with MOH.
Pharmacist specialised in hospital pharmacy.
Computer software of the PS:
- Management, prescription and dispensing to outpatients’ software: SILICON®
- Electronic software for the preparation of intravenous mixtures: PHARMASUITE®
- Electronic software for the prescription, validation and administration of antineoplastic treatments: FARMIS-ONCOFARM®
- System for the preparation and traceability of cytotoxic preparations: BD-CATO®
- Electronic medical record: IANUS®

Results and data interpretation

The pharmacy service as part of the MOH multidisciplinary team

The implementation of this programme increased the visibility of hospital pharmacists in the multidisciplinary team in collaboration with the prescribing physicians and nursing staff of the MOH in order to achieve the proposed objectives.

This programme helped to create an environment of trust and security with the patient, facilitating the provision of active information and answering doubts and concerns about their pathology and treatment.

Likewise, it increased the credibility of the PS in the improvement of the integral process of the medicine, from prescription to administration, guaranteeing the traceability of medicines and improving clinical safety and the satisfaction of both patients and professionals.

The implementation of this project is as follows:

Minimised delays in medication administration in the MOH.
Guaranteed an adequate care environment and direct healthcare provision to patients.
Allowed coordination of the pharmaceutical care process within the MOH.
Facilitated interactions with health professionals and communication with patients and families.

Consultations associated with the MOH and patient intake

After its implementation for 18 months (from January 2021 to June 2022), care had been provided in the EPC associated with the MOH to a total of 5.315 patients, with more patients having been taken on over time (Fig. 1).

Fig. 1 — Patients receiving pharmaceutical care in the external pharmacy consultation associated with the multipurpose outpatient hospital

Regarding the type of consultations, 1.60% were to start a treatment regimen and 98.40% were ongoing treatment consultations and/or treatment changes.

The patients came from the following departments: digestive system (48.62%), pneumology (22.9%), internal medicine (3.7%), general and digestive surgery (3.37%), haematology (1.35%), cardiology (1.22%) and other clinical services for the remaining 18.74% (Fig. 2).

Fig. 2 — Distribution of the patients seen by service their treatment was associated with

Patients were progressively incorporated from different clinical services into the new POC. The incorporation of the patients according to their clinical service of origin is summarised in Fig. 3.

Fig. 3 — Evolution of the incorporation of patients to the multipurpose outpatient hospital according to their clinical department of origin

Patient complaints

From the sixth month of implementation of this new system to the present day, complaints about treatment administration delays have reduced by 100% (Fig. 4).

Fig. 4 — Evolution of the number of complaints about treatment administration delays

Difficulties encountered and facilitating elements during the implementation of the new consultation

The difficulties encountered included the following:

Searching for physical spaces and procuring the location for the MOH-associated EPC.
The logistics of requesting treatments, both from the MOH nursing unit and the prescribing physicians.

The facilitating elements were as follows:

Support from the head of healthcare provision.
The credibility of the PS to improve the time taken from prescription to administration, guaranteeing the traceability of treatments to improve clinical safety by minimising medication errors in terms of erroneous medication prescription, preparation or administration operations.
Collaboration with the Medical Services Department.
Collaboration with the Nursing Unit.

Conclusions and expert recommendations in the framework of 3P medicine

Because, to the best of our knowledge, no research articles related to the integration of PSs into MOHs have been published in the academic literature, it is very difficult to compare our results with those from other hospitals.

PPPM is the emerging field considered as the medicine of the future [10].

PPPM is the patient-centred approach meeting healthcare challenges, running treatments efficiently and keeping costs of medical services under control [10].

PPPM objectives promote innovation in science, technologies, education, healthcare, economic and social aspects of the societies in Europe and worldwide [10].

Successful PPPM implementation needs unprecedented level of collaboration among all stakeholders, long-term multidisciplinary professional partnerships, robust juristic platform and smart political regulations [10].

The role of hospital pharmacists is currently moving towards them taking on more clinical activities, therefore favouring their integration into medical teams in different hospitalisation units with the aim of promoting rational, safe and efficient pharmacotherapy [2].

This trend has been revealed with the publication of several studies on pharmaceutical care carried out in our country (Spain), following the model of the USA, where pharmacists play an important role in clinical units [2, 4–7].

These experiences have shown that this way of working has clear benefits, both in terms of the processes involved in using drugs and in preventing their adverse effects and medication errors [2].