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Clinical Pharmacy in a South Indian Teaching Hospital

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 INTERNATIONAL REPORT

Clinical Pharmacy in a South Indian Teaching Hospital

Gurumurthy Parthasarathi, Madhan Ramesh, Karin Nyfort-Hansen, and Bahubali Gundappa Nagavi

OBJECTIVE: To describe how clinical pharmacy is helping to improve medication use at a South Indian teaching hospital by
addressing medication use problems, which are commonly encountered in India.
SUMMARY: Clinical pharmacy is practiced in many countries and makes a significant contribution to improved drug therapy and
patient care. India is a country with significant problems with medication use, but until recently Indian pharmacists have not been
educated for a patient-care role. Postgraduate pharmacy practice programs have been established at 2 pharmacy colleges in South
India as a result of a joint Indo-Australian program of cooperation. At a teaching hospital associated with the colleges, clinical
pharmacy services such as drug information, medication counseling, drug therapy review, adverse drug reaction reporting, and the
preparation of antibiotic guidelines are assisting clinicians to improve drug therapy and patient care. Seven hundred twenty-seven
requests for drug information were received from July 1997 to February 2001, and 543 suspected adverse drug reactions were
evaluated from November 1997 to February 2001. The most common drug classes causing adverse drug reactions were
antibiotics, nonsteroidal antiinflammatory drugs, and antitubercular agents. Physician opinion and service utilization have also been
surveyed: 82% of respondents had sought drug information from the Clinical Pharmacy Department and 71% of respondents had
sought advice on individual patient management. The success of this program is raising awareness of clinical pharmacy among
pharmacy educators elsewhere in India and has led to the introduction of clinical pharmacy services at other Indian hospitals.
KEY WORDS: clinical pharmacy, India.

Ann Pharmacother 2002;36:927-32.

ver the last 25 years, clinical pharmacy has become an
O established part of patient care in many hospitals, par-
ticularly in the English-speaking world. Although there are
differences in the extent and emphasis of clinical pharmacy
services between countries, a common focus is the promo-
tion of drug therapy that is safe, effective, and economical.1-3
Studies have clearly shown that clinical pharmacy improves
drug therapy and overall patient health outcomes,4-6 reduces
drug-induced illness and the length of hospital stay,5-7 and
reduces both drug costs and total hospital costs.6,8
The health and economic outcomes of clinical pharma-
cy are particularly relevant in India, which is a country
with significant health and medication use problems.9-11
However, Indian pharmacists have not traditionally been
Author information provided at the end of the text.
educated for a patient-care role.12 The government’s policy
of building a self-reliant economy after achieving indepen-
dence has resulted in the establishment and robust growth
of the local pharmaceutical industry. This, in turn, has led
to pharmacy education being oriented toward the techno-
logical needs of industry. As a result, the role of the phar-
macist in almost all hospitals is restricted to the purchas-
ing, manufacturing, and dispensing of drugs. Community
pharmacies, which sometimes operate without the pres-
ence of a pharmacist, do not provide patients with advice
to improve the efficacy and safety of medication use.13,14
Medication Use in India
India’s population has a diverse range of healthcare and
pharmaceutical needs. Diseases related to poverty such as
malnutrition, tuberculosis, and diarrhea coexist with chron-

www.theannals.com The Annals of Pharmacotherapy ■ 2002 May, Volume 36 ■ 927

Downloaded from aop.sagepub.com by guest on October 11, 2013
G Parthasarathi et al.
ic degenerative conditions such as diabetes and cardiovas-
cular disease. Although India has a system of government-
funded primary healthcare centers, it is estimated that be-
tween 60% and 86% of patients in need of ambulatory care
in both rural and urban areas use private healthcare practi-
tioners.15 Within this context, a range of economic, social,
political, occupational, medical, and regulatory factors con-
tribute to India’s medication use problems. These include:
1. Multiple healthcare systems. Many patients may take
allopathic medications together with remedies from
other healthcare providers such as ayurvedic or home-
opathic physicians or traditional healers.16,17
2. A high illiteracy rate. Medication labels with direc-
tions for use and patient information leaflets are not
generally available. Patients must rely on verbal in-
structions from their physicians and on their own
ability to identify medication by appearance.15
3. Poverty. The economic consequences of illness-asso-
ciated unemployment and medical competition pres-
sures physicians to prescribe fast-acting symptomatic
treatment.15 Low income levels force many patients
to purchase only a few days’ supply of medication at
a time.13-15 These practices may result in noncompli-
ance and increased levels of treatment failure, antibi-
otic resistance, and iatrogenic illness.
4. Lack of independent, unbiased drug information.9,18
Package inserts and promotional material from the
pharmaceutical industry are the only sources of drug
information for most physicians.
5. Availability of nonessential or unproven drugs and
irrational combinations.19 Examples of such agents
include formulations such as nimesulide/Serratiopep-
tidase, chlorzoxazone/acetaminophen/diclofenac, and
theophylline/ephedrine/phenobarbital. There are an
estimated 85 000 formulations on the Indian market.
6. The sale of prescription drugs without prescription
by community pharmacies.13,14,20 Competitive eco-
nomic pressures on medicine shops and their often
unqualified staff result in this practice being almost
universal.
7. Ineffective regulatory control of drug production,
registration, and marketing.19 Advertising and pro-
motional claims by the pharmaceutical industry are
not strictly regulated.19,21
8. A national drug policy with its focus on industry rather
than health.19 Government involvement in drug poli-
cy has largely been confined to technical and com-
mercial matters such as price control and licensing of
manufacturers. Efforts to introduce a national phar-
macovigilance system were initiated in 1986, but
widespread voluntary reporting of adverse drug reac-
tions (ADRs), with prescriber feedback, remains to
be established.22
Clinical Pharmacy Education
India has a 2-tiered system of pharmacy education.
Diploma pharmacists complete a 2-year course of study
928 ■ The Annals of Pharmacotherapy ■ 2002 May, Volume 36
and find employment in either community pharmacies or
hospital dispensaries.12 Pharmacists with university de-
grees complete 4 years of study, and the majority of these
graduates find work in the pharmaceutical industry, mainly
in marketing.12 Other pharmacists with degrees continue
on to higher studies; these postgraduates find employment
in teaching or industry. Three hundred forty-three institu-
tions offer pharmacy education at the diploma level and
143 offer academic degrees; approximately 60 of these
also have postgraduate programs. Approximately 7600 de-
gree (BPharm)-qualified pharmacists graduate from these
institutions each year.
A joint program of cooperation between institutions in
India and Australia was established in 1996 to assist the
development of clinical pharmacy practice and education
in India.23 Four academic pharmacists from the 2 JSS Col-
leges of Pharmacy in Mysore and Ootacamund in South
India completed 9- to 12-month clinical pharmacy fellow-
ships at the Repatriation General Hospital in Adelaide,
Australia, and attended postgraduate lectures in clinical
pharmacy at the University of South Australia. In 1997,
these pharmacists introduced clinical pharmacy education
in their respective colleges and established clinical phar-
macy teaching departments at the JSS Hospital, Mysore,
Karnataka, and the Ootacamund Government District
Hospital in Tamil Nadu, India.24 These hospitals now act as
training sites for pharmacists undertaking postgraduate
studies in pharmacy practice. Practice-based education al-
lows students to directly observe the effects of drug thera-
py in patients and to develop an understanding of how a
pharmacist can contribute to patient care. It also helps
them to develop the communication skills required for ef-
fective interaction with other healthcare professionals and
patients.
Ten students per year are admitted to the Master of
Pharmacy Practice program at JSS College of Pharmacy
— Mysore. During their first year, students study pharma-
cy practice, pharmacology and applied therapeutics, bio-
pharmaceutics, pharmacokinetics, and pharmaceutical
analysis, and are introduced to the department’s patient
care activities. These activities include five 6-week rota-
tions through medical, pediatric, and psychiatric units, dur-
ing which the students attend ward rounds, review drug
therapy, and provide patient counseling and drug informa-
tion. This is the first time these students have visited a hos-
pital ward or interacted with patients, as the education of
degree pharmacists is not practice based. In the second
year, the students complete a thesis, continue to attend
ward rounds, and act as mentors for first-year students. In
2001, the Department of Clinical Pharmacy at JSS Hospi-
tal — Mysore was recognized as a teaching site for the
University of South Australia. Indian pharmacists who en-
roll in the University’s own postgraduate clinical pharma-
cy programs complete a 6-month bridging program in
Mysore before commencing study in Australia. This devel-
opment is another reflection of the increasing interest in
clinical pharmacy among Indian pharmacy students and
graduates.
www.theannals.com

Clinical Pharmacy at JSS Hospital
The JSS Hospital is a 1000-bed, private, acute-care gen-
eral hospital and is the teaching site for both pharmacy
practice students and medical students from JSS Medical
College. The Clinical Pharmacy Department was estab-
lished in 1997, and clinical pharmacy services were intro-
duced into the hospital in consultation with medical staff
and the hospital’s administration.
Patient-care services are provided by postgraduate phar-
macy students under the direct supervision of 3 experi-
enced academic clinical pharmacy practitioners and one
PhD research scholar. Two faculty members have trained
in Australia and have postgraduate qualifications in clini-
cal pharmacy and pharmacology; the third is a postgradu-
ate pharmacist from the department. These faculty spend
90% of their time teaching and supervising student research
and practice activities at the hospital, and the remainder
teaching undergraduate students at the JSS Pharmacy Col-
lege campus. Many students choose thesis projects that
contribute to the development of clinical pharmacy ser-
vices at the hospital. These have included the development
of an adverse drug reaction reporting system and parenter-
al drug administration guidelines, a protocol for atropine
infusion in insecticide poisoning, and guidelines for the
use of benzodiazepines in the psychiatry unit.
Medical staff and patients at the hospital commonly en-
counter the medication use problems mentioned earlier.
Patient-care activities that are helping to address some of
these problems are summarized below.
WARD ROUND PARTICIPATION
Twelve pharmacists, including faculty and students, at-
tend ward rounds with physicians on a daily basis. This
service is provided for approximately 300 patients in all
medical, pediatric, and psychiatric units. This allows medi-
cal staff to ask the pharmacist for information and advice
on drug therapy at the time prescribing decisions are made.
It also assists the pharmacist in identifying patients in need
of medication counseling, and allows a full understanding
of therapy objectives and the patient’s progress.
PATIENT MEDICATION COUNSELING
Patient medication counseling is an important element
of clinical pharmacy practice as many hospital patients are
illiterate. Particular attention is paid to patients on complex
drug therapy such as antitubercular therapy and patients
using metered-dose aerosols and rotohalers. Patient infor-
mation leaflets in the local language of Kannada have been
developed and are used to reinforce verbal medication
counseling where appropriate.
DRUG INFORMATION
Drug information is provided to all units and prescribers
of the hospital.25 Apart from standard texts and references
www.theannals.com The Annals of Pharmacotherapy
Clinical Pharmacy in a South Indian Teaching Hospital
and MEDLINE, the Iowa Drug Information Service and
Internet facilities are used when searching for information.
From July 1997 to February 2001, a total of 727 drug in-
formation requests were received, the majority (65%) from
consultants. A summary of drug information requests ap-
pears in Figure 1.
TREATMENT CHART REVIEW
The treatment charts of patients are reviewed daily, and
any problems related to drug prescription or administration
are brought to the attention of medical or nursing staff.
These problems may include drug interactions, adverse re-
actions, drug duplications or omissions, subtherapeutic
dosage or overdose, inappropriate administration route or
duration of therapy, and failure to receive drugs. In a study
over a 6-month period, 103 drug-related problems were
identified in medical wards. Following discussion with
medical staff, this resulted in a change in therapy in 81%
of the cases. In the remaining 19% of the cases, the practi-
tioners decided that no change in therapy was indicated at
that time.
ADVERSE REACTION REPORTING AND MONITORING
A hospital-wide ADR reporting system was introduced
in 1997 after wide publicity and education. Reporting is
encouraged using either suspected ADR notification forms
or via personal or telephone contact. From November 1997
to February 2001, 543 suspected reactions were reported
and evaluated by the Department of Clinical Pharmacy. A
summary of these reports appears in Figures 2 and 3. Ad-
vice regarding the management of individual ADRs is pro-
vided to medical staff caring for the patient. Feedback to
prescribers is provided via the Clinical Pharmacy newslet-
ter, which is published quarterly, where risk factors for re-
ported reactions are summarized as an educational service.
Figure 1. Category of different drug information queries received from July
1997 to February 2001.
■ 2002 May, Volume 36 ■ 929
G Parthasarathi et al.
ADR reporting from other hospitals in the local area is en-
couraged and is raising awareness of iatrogenic illness in
these institutions. This work has attracted the attention of
national and international funding agencies, including the
government of India and the World Health Organization.
ANTIBIOTIC GUIDELINES
Drug utilization evaluation (DUE) studies are used to
compare prescribing practices within an institution with
predetermined standards, and are a means to improve the
quality use of medicines. In 1999, the Department of Clini-
cal Pharmacy in collaboration with medical staff conduct-
ed DUE studies on the use of antibiotics in respiratory and
urinary tract infections at JSS Hospital. These studies re-
sulted in the development of antibiotic guidelines in con-
sultation with medical and surgical consultants and the De-
partment of Microbiology. These guidelines were pub-
lished in booklet format and are used by medical staff
throughout the hospital. Another DUE examined the use of
aminoglycosides in pediatric patients; based on the results
of this study, guidelines were prepared in consultation with
pediatricians and the Department of Microbiology. A fol-
low-up DUE showed that there was 80% adherence to the
guidelines that reflected the improved quality use of amino-
glycosides in pediatric patients.
OTHER GUIDELINES AND PROTOCOLS
Protocols for the administration of drugs commonly
used in the intensive care setting have been prepared.
These provide medical and nursing staff with information
on how individual drugs should be diluted for infusion,
rates of administration, compatibilities and incompatibili-
ties, ADRs, and nursing responsibilities.26
Insecticide poisoning in India is usually deliberate and,
as a consequence, is associated with a high mortality rate.27
During 1996, 165 patients with deliberate agrochemical
poisoning were admitted to JSS Hospital; 121 were sus-
pected to be organophosphate poisoning, with a mortality
rate of 21.5%.28 In the Emergency Department and Inten-
Figure 2. Reported adverse reactions by reaction type from November 1997
to February 2001.
930 ■ The Annals of Pharmacotherapy ■ 2002 May, Volume 36
sive Care Unit, medical staff have been provided with a
classification summary of common insecticides, their trade
and generic names, and guidelines to assist them with the
selection of appropriate drug therapy in organophosphate,
carbamate, and pyrethrin poisoning.
EDUCATIONAL ACTIVITIES
The department publishes Clinical Pharmacy, providing
drug and prescribing information for medical staff and stu-
dents. Evaluations of new drugs and recent developments
in therapeutics are featured regularly. Staff and students of
the department have contributed to workshops on rational
drug use and the essential drug concept for house surgeons
and postgraduate pharmacy students, and have provided
training programs for community and hospital pharmacists
on patient counseling for selected common diseases and
drugs.
Physician Opinions
A questionnaire survey of consultants at JSS Hospital
was conducted in 1999 to gauge physician opinions of the
services provided by the Department of Clinical Pharmacy
and determine how these can be improved. One hundred
ten consultants completed the questionnaire, a response
rate of 72%. Eighty-eight percent of consultants had visit-
ed the department, 30% had frequently sought clinical
pharmacy services, 50% had sought services on several
occasions, and 20% had rarely used the services. Seventy-
one percent of the consultants had sought advice on patient
management in relation to ADRs (37%), choice of antibi-
otics (23%), dose adjustment in renal/hepatic/elderly pa-
tients (15%), drug interactions (13%), choice of therapy
(12%), and patient counseling (9%). Eighty-two percent of
consultants had sought drug information from the depart-
ment. All found Clinical Pharmacy to be informative and
useful and postgraduate students to be a useful resource
during ward rounds.
Although responses to questionnaires of this type may
be subject to bias, the results of this survey confirm im-
pressions formed from interaction with medical staff and
Figure 3. Reported adverse reactions by drug class from November 1997 to
February 2001. NSAIDs = nonsteroidal antiinflammatory drugs.
www.theannals.com

students during routine clinical practice. Suggestions for
improving clinical pharmacy services included the provi-
sion of seminars on new drugs, more frequent publication
of the newsletter, and the development of therapeutic
guidelines for specific diseases/infections.
The Future of Clinical Pharmacy
Based on the enthusiastic response of the medical staff
at JSS Hospital and other hospitals, clinical pharmacy has
the potential to play a significant role in helping to im-
prove medication use in India. Pharmacists who are gradu-
ates from the pharmacy practice programs at the JSS Col-
leges in Mysore and Ootacamund have introduced clinical
pharmacy services in hospitals in Chennai, Hyderabad,
Kochi, Coimbatore, Belgaum, and Manipal. These pro-
grams are funded by private pharmacy colleges and ser-
vices are provided by teacher–practitioners and their stu-
dents. Financial support from tuition fees is expected to
sustain the further expansion of clinical pharmacy in other
hospitals.
For the benefits of clinical pharmacy to extend more
widely, undergraduate pharmacy students are required to
receive patient-oriented training in pathophysiology, ap-
plied therapeutics, clinical pharmacokinetics, and drug in-
formation.29 To achieve this, India needs more academi-
cians with clinical pharmacy experience and training who
can pass on the knowledge and skills required for effective
clinical pharmacy practice. The profession needs to inform
the government, hospital clinicians, and administrators
about the health and economic benefits of clinical pharmacy
so that pharmacists will have new opportunities to practice
their clinical skills. In the community sector, the economic
realities of the pharmaceutical marketplace discourage
pharmacists from applying rational drug use principles in
their daily practice. Clinical pharmacists can assist here by
educating the community about the appropriate use of
medications, so that pharmacies providing pharmaceutical
care will be rewarded economically by continued customer
patronage. In time, it is hoped that government regulation
will limit the distance between pharmacies and introduce a
professional-service dispensing fee that offers further fi-
nancial support for community pharmacists providing
pharmaceutical care.
Gurumurthy Parthasarathi MPharm PhD Grad Dip Clin Pharm,
Professor, JSS College of Pharmacy — Mysore, Karnataka, India
Madhan Ramesh MPharm Dip Clin Pharm, Lecturer, JSS College
of Pharmacy — Mysore
Karin Nyfort-Hansen BPharm Grad Dip Ed (Health) CGP, Clini-
cal Pharmacist, Repatriation General Hospital, Adelaide, South Aus-
tralia
Bahubali Gundappa Nagavi BSc MPharm PhD, Professor and
Principal, JSS College of Pharmacy — Mysore
Reprints: Gurumurthy Parthasarathi MPharm PhD Grad Dip Clin
Pharm, Clinical Pharmacy Department, JSS Hospital, Ramanuja Rd.
Mysore 570 004, Karnataka, India, FAX 91-821-564 195, E-mail
partha18@eth.net
We thank the medical staff of JSS Hospital for their support and encouragement,
and faculty and students of the Department of Clinical Pharmacy for their contribu-
www.theannals.com
Clinical Pharmacy in a South Indian Teaching Hospital
tion to the department’s activities. The assistance of staff of the Pharmacy Depart-
ment at the Repatriation General Hospital, Adelaide, South Australia, is also grate-
fully acknowledged.
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EXTRACTO
OBJECTIVO: Describir el impacto de los servicios de farmacia clínica en
el mejoramiento del uso de los medicamentos en un hospital del sur de
India, a traves de la identificación y solución de los problemas
relacionados a los medicamentos.
RESUMEN: La Farmacia Clínica es practicada en muchos países del
mundo y ha demostrado que contribuye al mejor uso de los
medicamentos y a un mejor cuidado del paciente. India es un país que
confronta muchos problemas relacionados a los medicamentos. No fue
hasta hace poco que los farmacéuticos en India comenzaron a ser
educados en Atención Farmacéutica. Recientemente, 2 programas de
posgrado en Farmacia Clínica han sido implementados en 2 colegios de
farmacia en el sur de India, como resultado de un programa de
cooperación con un colegio de farmacia en Australia. En un hospital de
India, los servicios de farmacia clinica, como lo son el Centro de
Información de medicamentos: consejo al paciente, evaluación de la
terapia con medicamentos, reporte de reacciones adversas, y desarrollo
de protocolos y guías de uso de los antibioticos, estan mejorando el
cuidado al paciente en el hospital. Un total de 227 consultas de
información de medicamentos fueron recibidas durante el período de
julio de 1997–febrero de 2001, y un total de 543 reacciones adversas
fueron evaluadas de noviembre 1997–febrero 2001. Los antibioticos,
medicamentos anti-inflamatorios, y los agentes antituberculosos fueron
los medicamentos mas envueltos en estas reacciones adversas. En una
encuesta realizada en el hospital un 82% de los medicos indicaron que
ellos utilizaron los servicios de información de medicamentos y otros
servicios clínicos ofrecidos por el departamento de farmacia, y un 71%
ha consultado los farmacéuticos clínicos buscando consejo para el
manejo de la terapia de sus pacientes. El éxito de estos programas
clínicos estan ayudando a incrementar el conocimiento de estos servicios
de farmacia clínica entre los educadores de farmacia en otros lugares de
India.
Magaly Rodríguez de Bittner
932 ■ The Annals of Pharmacotherapy ■ 2002 May, Volume 36
View publication stats
RÉSUMÉ
OBJECTIF: Décrire comment la pharmacie clinique aide à améliorer
l’utilisation des médicaments dans un hôpital d’enseignement du sud de
l’Inde en identifiant des problèmes fréquents reliés à l’utilisation des
médicaments dans ce pays.
RÉSUMÉ: La pratique de la pharmacie clinique est présente dans plusieurs
pays et contribue significativement à améliorer les thérapies
médicamenteuses et les soins aux patients. L’Inde est un pays avec de
nombreux problèmes reliés à l’utilisation des médicaments mais jusqu’à
tout récemment les pharmaciens Indiens n’étaient pas éduqués pour
jouer un rôle dans les soins aux patients. Suite à un programme conjoint
de coopération Indo-Australien, des programmes post-gradués en
pratique de la pharmacie ont été établis dans 2 collèges de pharmacie en
Inde du sud. Des services pharmaceutiques cliniques tels que:
l’information sur les médicaments, les conseils sur les médicaments, la
révision des thérapies médicamenteuses, les rapports d’effets
indésirables, et des procédures dans la préparation des antibiotiques ont
été établis dans un hôpital associé d’enseignement pour aider les
cliniciens à améliorer les thérapies médicamenteuses et les soins aux
patients. Plusieurs demandes d’information furent recues (727) entre
juillet 1997 et février 2001, et 543 réactions médicamenteuses
indésirables suspectées furent évaluées entre novembre 1997 et février
2001. Les classes de médicaments causant le plus d’effets indésirables
étaient les antibiotiques, les anti-inflammatoires non-stéroidiens, et les
agents antituberculeux. Un sondage fut aussi mené sur l’opinion des
médecins et sur l’utilisation du service. Quatre-vingt deux pour cent des
répondants avaient fait une demande d’information médicamenteuse au
département de pharmacie clinique, et 71% avaient demandé de
l’information pour le traitement de patients spécifiques.
CONCLUSIONS: Le succès de ce programme interpelle les éducateurs en
pharmacie ailleurs en Inde au sujet de la pharmacie clinique et a
contribué à l’introduction de services pharmaceutiques cliniques dans
d’autres hôpitaux Indiens.
Pierre Dion
www.theannals.com