National Survey of Clinical Pharmacy Practice in Saudi Arabia-2017-2018: Workload Documentation

Yousef Ahmed Alomi*, BSc. Pharm, MSc. Clin Pharm, BCPS, BCNSP, DiBA, CDE, Critical Care Clinical Pharmacists, TPN Clinical Pharmacist, Freelancer Business Planner, Content Editor and Data Analyst, Riyadh, Saudi Arabia. Fatimah Al-Doughan, PharmD, Lecturer College of Pharmacy, Pharmacy Practice Department King Faisal University, Alahssa, Saudi Arabia. Sultan Mohammed Al-Jarallah, Head, Ambulatory Care Pharmacy, Oncology and Hematology Clinical Pharmacist, Pharmaceutical Care Department, Security Forces Hospital, Riyadh, Saudi Araia. Yasir Ahmed Ibrahim, PharmD, Head of Pharmacy Practice Department Pharmacy Practice Department College of Clinical Pharmacy, King Faisal University, Alahssa, Saudi Arabia. Adel Mehmas Alragas, Bsc. Pharm, Staff Pharmacist Pharmacy Department Medical City King Saud University, Riyadh, Saudi Arabia. Norah Omar Bin Haidarah, PharmD, Pharmacy Staff Outpatient pharmacy Dr Sulaiman Al-habib Hopsital, Riyadh, Saudi Arabia.


INTRODUCTION
Clinical pharmacists provide a wide range of clinical services in collaboration with other healthcare providers as a team. All these services are aimed to improve the clinical outcome of the patient. 1,2 Documentation of the clinical activity (workload), clinical interventions and cost avoidance is essential especially with the New Pharmacy Vision 2030 of Saudi Arabia to advocate future growth of resources. [3][4][5][6] Having a clear vision, mission and goals requires consistent documentation of the services to ensure that we are in the right path. 7,8 Various methods of documentation of clinical pharmacy services has been implemented throughout local and national pharmacy practice programs in the KSA. [9][10][11][12][13] Documentation and analysis of workload helps to identify obstacles with scheduling, interruptions, priorities and pharmacists' knowledge of clinical pharmacy practice. By knowing and understanding the problems that can reduce documentation, we can overcome such issues in the future. 14 Previous studies conducted globally have focused on the documentation of workload and analyzing the factors that can reduce or influence the documentation process. [15][16][17][18][19] To the best of our knowledge, this is the first study to discuss and explore the documentation and analysis of workload of clinical pharmacy services in KSA. 4,5 We explored the national survey of clinical pharmacy practice in Saudi Arabia during 2017-2018 with an emphasis on the workload analysis and documentation.

METHODS
This is a 4-month cross-sectional national survey of clinical pharmacy practice in Saudi Arabia. The survey consists of two parts: The first part collects demographic information and the second part comprises of 51 questions divided into four domains. The questionnaire is adopted from the American Society of Health-System Pharmacists (ASHP) and Saudi Pharmaceutical Society (SPS) survey, the international standards of Joint Commission of Hospital Accreditation, in addition to the local standards of Saudi Center of Healthcare Accreditation. 15,16,[20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] The domains were clinical pharmacy administration and management, performances and activities, education and training and workload documentation. We used a 5-point Likert response scale system with Alomi YA, et al.: Clinical Pharmacy Practice Workload Documentation in Saudi Arabia close-ended questions to obtain responses. The questionnaire was distributed in an electronic format to 31 directors of pharmacies at various hospitals in Saudi Arabia. The patients were followed-up by an email and telephone after every 1-2 weeks. All primary healthcare centers and regional pharmacy administration at MOH were excluded from this study. In this study, we discussed and analyzed the national survey of clinical pharmacy practice at hospitals in Saudi Arabia with a focus on workload analysis and documentation. All data were analyzed through the Survey Monkey system and analyzed using Statistical Package of Social Sciences (SPSS) version 20. The data were validated via three methods of validation and more than two authors reviewed the data independently. The pilot study was conducted and then the survey data were cleaned. Finally, we calculated the Cronbach's alpha value for internal validity. This survey was exempted from the international guidelines of institutional review boards (IRB). 37

RESULTS
The survey was distributed to 31 hospitals. Of them, 7 (22.58%) hospitals consisted of 200-299 beds, whereas 6 (19.35%) hospitals had 300-299 beds followed by 5 (16.13%) hospitals with 50-99 beds and 5 (16.13%) hospitals with 400-499 beds. Of the total 31 hospitals, 19 (67.86%) were accredited by CBAHI, 5 (17.86%) were accredited by the Saudi Commission of Health Specialties and 4 (14.29%) were accredited by the Joint Commission. Majority of the hospitals (23 (74.19%)) covered <25% of the patients through health insurance. Most of the responders had Bachelor of Science in Pharmacy degree (13 (41.94%)), whereas only 9 pharmacists had a Doctor of Pharmacy degree (29.03%). However, all pharmacists (100%) were not certified by the BPS. Most of the responders had 1-3 years (32.26%) of experience, whereas 22.58% of the responders had 4-6 years of experience ( Table 1). The total number of patients followed up through clinical pharmacy services were 27.88 daily, 836.29 monthly, with 10.82 patients daily followed up per hospital. While the total number of prescriptions reviewed by the clinical pharmacists were 184.86 daily, 1294.05 monthly, with 68.77 prescriptions followed up daily per hospital ( Table 2). Most of the clinical pharmacy services that were documented were for medication errors (80.65%) followed by ADRs (77.42%) and drug quality reporting (70.97%). The hospitals documented clinical pharmacy services either manually or electronically. A total of 18 (58.06%) medication errors were documented manually and 11 (35.48%) were documented electronically; 18 (58.06%) ADRs were documented manually and 9 (29.03%) ADRs were documented electronically. Next, 16 (51.61%) reports of drug quality were documented manually and 9 (29.03%) reports were documented electronically ( Table 3). The most documented clinical pharmacy services of clinical impact and cost avoidance were recorded for drug information inquiries (61.29%), medication errors (58.06%) and ADRs (58.06%). In the case of adult patients, the most common documented clinical pharmacy services of clinical impact and cost avoidance was for drug information inquiries (19 (61.29%)), medication errors (18 (58.06%)) and ADRs (18 (58.06%)), whereas in the case of pediatric patients, 13 (41.94%) medication errors, 12 (38.71%) drug information inquiries and 10 (33.33%) pharmacist intervention were recorded. In the case of neonate patients, drug information inquiries was the most recorded category (10 (32.26%)) followed by medication errors (8 (25.81%)) and poisoning information inquiries (7 (25.81%)) ( Table 4). The monthly workload of clinical pharmacy services of clinical activities was recorded for prescriptions (80.65%), number of medication errors (70.97%) and ADRs (67.74%). The most documented clinical pharmacy monthly workload analysis of clinical activities in adult patients is the number of prescriptions (24 (77.42%)) followed by the medication errors (21 (67.74%)) and ADRs (21 (67.74%)), whereas in the case of pediatric patients, the number of prescriptions (18 (58.06%)) was the most commonly documented clinical activity followed by the number of medication errors (14 (45.16%)) and the number of ADRs (14 (45.16%)). In the case of neonate patients, the number of prescriptions (13 (41.94%)) was the most commonly documented clinical activity, followed by the number of patients (11 (36.67%)) and the number of medication errors (9 (29.03%)) ( Table 5). Cronbach's alpha value was found to be 0.765.

DISCUSSION
The analysis of workload documentation is very important for all healthcare professionals. Clinical pharmacy services measure the current level of patient care and its analysis helps to plan for the future expansion as it serves as an evidence of the progress done by pharmacists on the impact of patient care outcome and cost. In our study, medication errors was the most documented clinical service as it is one of the common intervention pharmacists provide. 38 The majority of the documentation was done manually despite that electronic documentation is available. This result can raise many questions. Why did pharmacists not use the electronic documentation? Is it complicated? What are the factors that withhold pharmacists from using electronic documentation? Manual documentation is considered as one of the obstacles for pharmacists as it is a timeconsuming process and it is at greater risk as the documents might be lost and be left incomplete. 7 Many studies have shown the benefit of using a computerized system to document the clinical services as it makes the process easier and saves time in addition to that using a computerized system can make the documented data very useful by the ability to generate different analysis in order to provide useful reports that increased cost avoidance. 7,19,39,40 However, drug information inquiries were found to be the most documented clinical service in this study that has a clinical impact and cost avoidance role to it, especially for adult and neonate patients. 4,5 The previous study has shown that documentation of drug information inquiries helps to calculate the increase in cost avoidance and measures the impact of pharmacists. 41 In previous study, workload documentation analysis did not yield positive results and some of the participants considered it as not necessary and may lead to deprived pharmacist's time for patient care. 42 In this study, we obtained 50% as the average percentage of workload analysis. Compared to the other clinical activities, the number of prescriptions was the most documented clinical activity in the monthly workload analysis in all patient groups. This might be because the number of prescriptions and dispensing were the most comfortable and most accurate clinical activity to be measured especially with the use of a computerized dispensing system. 42 The documentation of clinical pharmacy services workload is meager especially with respect to two essential points: clinical outcomes and cost avoidance. Without documentation, we cannot attain the required information needed for determining the clinical outcomes and cost avoidance. We need to study the factors that prohibited pharmacists from taking up documentation. Many factors mentioned in previous studies show that pharmacists get discouraged from the process of documentation. First, documentation is a time-consuming process especially if it is done manually and requires tabulation of the data. Inaccuracy, duplication of the data and inconsistency were also mentioned. 7,42,43 However, many factors found to influence the documentation process. The pharmacist who has a positive professional attitude along with high clinical knowledge and a high level of training on the use of electronic documentation tend to have a high intervention rate. 38

CONCLUSION
The documentation of workload of clinical pharmacy services was found to be inadequate in this study, especially in the cost avoidance and clinical outcome impact. There is a need to study the factors that can discourage pharmacists from documentation in order to improve the workload

CONFLICT OF INTEREST
The authors declare conflict of interest.