Colette B Raymond , Lori D Wazny , Amy R Sood
The prevalence of chronic kidney disease (CKD) continues to increase.1 Patients with stage 1 to 5 CKD and those undergoing dialysis are at extremely high risk for drug therapy problems (DTPs).2,3 In controlled trials involving general patient populations, clinical pharmacist interventions have reduced hospital admissions, length of hospital stay, readmissions, and emergency department visits.4–7 The activities of pharmacists most strongly associated with improved patient outcomes include participating on rounds, interviewing patients, performing medication reconciliation, counselling patients on discharge, and conducting postdischarge follow-up.5 A systematic review of 8 controlled trials involving patients with CKD showed that clinical pharmacist interventions improved management of anemia, blood pressure, and lipids, as well as calcium and phosphate parameters.8 In this patient population, clinical pharmacists’ interventions reduced hospital admissions, length of hospital stay, and incidence of end-stage renal disease or death.8
The Manitoba Renal Program (MRP) provides comprehensive renal care throughout the province of Manitoba, Canada (population 1.2 million). The program provides care at 4 urban hospitals and 12 rural hemodialysis units. Health services offered include in-centre and home hemodialysis, peritoneal dialysis, and interprofessional renal health clinics for individuals with stage 1 to 5 CKD who do not require renal replacement therapy. At the time this article was prepared, in mid-2013, the MRP had approximately 1100 hemodialysis patients, 285 peritoneal dialysis patients, and nearly 4500 patients with stage 1 to 5 CKD.
The MRP pharmacists operate within a patient-centred medication therapy management model to provide care for patients with stage 1 to 5 CKD and patients undergoing dialysis within the program.9 The MRP has a unique funding structure, with one full-time equivalent (FTE) clinical pharmacist for every 100 hemodialysis patients, 200 peritoneal dialysis or home hemodialysis patients, or 300 patients with stage 1 to 5 CKD.10 This funding structure provides equitable and consistent patient care across the province and allows the pharmacists to perform patient care, conduct research, and serve as educators. As of 2013, the MRP employed 19 individual pharmacists, whose time devoted to the program ranged from 0.2 to 1.0 FTE, for an overall total of 11.8 FTE clinical pharmacists. On average, these pharmacists spend 90% (range 20%–100%) of their MRP time performing activities related to direct patient care within the program, with the remainder of their time spent performing drug distribution in the hospital inpatient pharmacy. The MRP pharmacists attend all nephrologist clinics. In clinics for patients with stage 1 to 5 CKD, the pharmacists focus on those patients who have stage 4 or 5 CKD, as well as patients with stage 1 to 3 CKD who are receiving pharmacotherapy for glomerulonephritis. In clinics for peritoneal dialysis, home hemodialysis, and rural hemodialysis, the pharmacists see all patients. The pharmacists also staff the in-centre hemodialysis units at each urban hospital and liaise by telephone with the 16 rural hemodialysis units. The MRP pharmacists have a highly diverse practice, working at a variety of institutions that are geographically separate and that have different pharmacy managers, practice patterns, clinic structures, and patient populations; they also interact with different nephrologists within the MRP. However, to ensure consistency in patient care, the MRP pharmacists meet at least every 2 months in person and by teleconference to discuss the clinical and operational issues affecting them. Two of the pharmacists have postbaccalaureate Doctor of Pharmacy training, and they serve as clinical practice leaders for the other MRP pharmacists, focusing on hemodialysis and peritoneal dialysis, respectively.
Working collaboratively with pharmacy managers, MRP pharmacists, and the MRP itself, we sought to develop standards of clinical practice for the MRP pharmacists. The purpose of doing so was to define and prioritize the core activities that these renal pharmacists must perform on a regular weekday with full staffing levels. We evaluated the literature describing the role of renal clinical pharmacists, surveyed MRP pharmacists about existing clinical pharmacist services, met with pharmacy and MRP stakeholders, and evaluated existing pharmacist standards of practice and existing activities and practices of the MRP pharmacists.11 A small working group of MRP pharmacists developed a draft set of standards of clinical practice for renal pharmacists. The draft was distributed to all MRP pharmacists on multiple occasions to obtain feedback. Feedback for priority activities was also obtained from nephrologists. Consensus was achieved, and all MRP pharmacists, pharmacy managers, and nephrologist medical directors have adopted the final version of the standards of clinical practice for renal pharmacists (Box 1). These standards specify that MRP pharmacists should routinely evaluate their patients for the DTPs commonly experienced by people with CKD (listed in Box 2). The standards of clinical practice can be updated to reflect the incorporation of local policies and procedures, patient safety initiatives, and published guidelines.
Box 1. Standards of Clinical Practice for Renal Pharmacists in the Manitoba Renal Program (MRP)
Box 2. Steps in Review of Patients with Chronic Kidney Disease for Drug Therapy Problems (DTPs)
Creation of standards of clinical practice for renal pharmacists across diverse practice environments and numerous pharmacists has allowed for a common method to perform and prioritize clinical pharmacist activities and to aid in the training of new staff. Across the MRP, the pharmacists typically assess patients before the nephrologist does so. Therefore, the pharmacist’s documentation is critical to ensuring that an accurate medication list is included in the chart and that DTPs are identified before the nephrologist’s review. This streamlined approach helps to resolve existing DTPs quickly and prevents additional DTPs from occurring. The use of standards of practice as a common approach to patient assessment provides continuity of pharmacist care across the MRP. For example, the standards of practice have been used to develop a standard template for medication review for patients undergoing hemodialysis or peritoneal dialysis, which becomes part of the medical record (see Appendix 1). Within the MRP, we have used the standards of practice as guidelines and for training purposes. The standards could also be used to develop criteria for competency assessment or to inform performance appraisals.
Others have developed and validated a list of criteria to assess medication safety and use issues in patients with CKD in order to identify DTPs.48 However, that list of DTPs was based on interventions by community pharmacists. The specialized renal pharmacists have the advantage of access to patient care records and have developed trusting relationships with the nephrologists, both of which facilitate optimization of medication therapy. The renal pharmacist standards of practice document describes renal-specific DTPs, as well as processes and priorities for renal pharmacists functioning as members of an interprofessional team.
The standards of practice for renal pharmacists developed within the MRP are a unique set of evidence-based practice guidelines that can serve to educate and train renal pharmacists, students, or trainees completing a renal pharmacy rotation. Furthermore, the standards of practice can serve as a tool to standardize patient care, set priorities, develop criteria for competency assessment, and inform performance appraisals for renal pharmacists. Additionally, centres without renal pharmacists on staff could use the standards of practice to justify the funding needed to hire such specialized practitioners.
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The efforts of all of the Manitoba Renal Program pharmacists who contributed to developing the standards of clinical practice are greatly appreciated. The contributions of Nick Honcharik, who spearheaded development of the original Winnipeg Regional Health Authority’s clinical practice expectations for pharmacists, are acknowledged. This work was funded by the Winnipeg Regional Health Authority and the Manitoba Renal Program.
Competing interests: Colette Raymond is a member of the Canadian Hospital Pharmacy Residency Board and has received grants for work unrelated to this article from the Canadian Institutes of Health Research and Health Canada. No competing interests declared by Lori Wazny or Amy Sood.
Canadian Journal of Hospital Pharmacy , VOLUME 66 , NUMBER 6 , November-December 2013
