Standard of Practice in Cardiology for Pharmacy Services

1 Standard of practice in cardiology for pharmacy services

2 Joanna Pizzi 1, 2 BPharm, GradCertPharmPrac, MClinPharm(Research), Cia Connell 1,3 BPharm(Hons), 3 GradCertPharmPrac, MClinPharm, Adam Hort 1,4 BPharm GradDipClinPharm, Adam Livori 1,5 4 BAppSci(NucMed) B.Pharm(Hons) GradCertPharmPrac, Adaire Prosser 1,6 BPharm(Hons), BPharmSci, 5 AdvPP(I), Catherine Zhang 1,7 B.Pharm, GradDipClinPharm, Kate Ziser 1,8 BPharm, GradDipEd, 6 AdvPP(II), GradCertPharmPrac, Michelle Bunte 9 BPharm, LLB, GradCertClinEpid and Courtney 7 Munro, BPharm, GradCertPharmPrac, MPharmPrac, FSHP, AACPA, PhD 9.

8 9 1 Cardiology Leadership Committee, The Society of Hospital Pharmacists of Australia, Collingwood, 10 Victoria, Australia 11 2 Alfred Health, Melbourne, Australia 12 3 Monash University, Melbourne, Australia

13 4 Fiona Stanley Hospital, Murdoch, Western Australia

14 5 Ballarat Health Services, Ballarat, Victoria 15 6 SA Pharmacy, Flinders Medical Centre, South Australia 16 7 Gold Coast University Hospital, Southport, Queensland 17 8 Royal North Shore Hospital, Sydney, New South Wales 18 9 The Society of Hospital Pharmacists of Australia, Collingwood, Victoria, Australia 19 20 Address for correspondence: 21 Joanna Pizzi,1 Chair, Cardiology Leadership Committee, The Society of Hospital Pharmacists of 22 Australia, Collingwood, Victoria, Australia. Email: [email protected] 23

24 Preface 25 This Standard references and relies upon the SHPA Standards of Practice for Clinical Pharmacy 26 Services1 as the foremost Standard. 27 This Standard may overlap with others and depending on the area of specialty practice it may be 28 advisable to refer to additional Standards of Practice. 29 The use of the word ‘specialisation’ in this standard is in line with the National Competency Standards 30 Framework for Pharmacists in Australia2 where ‘specialisation’ refers to the scope of practice rather 31 than the level of performance. ‘Specialisation’ of itself does not confer additional expertise. 32 This Standard is for professional practice and is not prepared or endorsed by Standards Australia. It is 33 not legally binding. 34

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35 Introduction 36 In Australia, everyone shares a fundamental right to safe and high-quality healthcare. This is defined 37 in the Australian Charter of Healthcare Rights3 which all healthcare systems, including the provision of 38 advanced pharmacy care, must strive to uphold. The Charter summarises the basic rights of patients 39 and consumers when accessing healthcare services including access, safety, respect, communication, 40 participation, privacy, and the ability to provide feedback. The provision of pharmacy services must 41 encompass the Charter to deliver effective, efficient, timely and equitable patient-centred in 42 cardiology pharmacy services. 43 The National Competency Standards Framework for Pharmacists in Australia2 complements the 44 underpinnings of the Charter across five domains of competency for the pharmacy profession, namely: 45 (1) professionalism and ethics; (2) communication and collaboration; (3) medicines management and 46 patient care; (4) leadership and management, and; (5) education and research.

47 Purpose and definitions 48 The Standard describes current best care for the provision of cardiology pharmacy services 49 (summarised in Box 1) by cardiology pharmacists. 50 This Standard is intended to be used across hospital pharmacy services in Australia, regardless of the 51 service type (public or private) or location (metropolitan, regional, or rural). Although this Standard is 52 intended for hospital pharmacy services, the principles and aspects of patient management discussed 53 herein can be applied to broader pharmacy services. It is acknowledged that there are significant 54 variations in pharmacy services that are dependent on organisational capacity, patient population, 55 cardiology and pharmacy department priorities and the availability of cardiology pharmacists; all of 56 these may influence the scope of services. 57 The Standard refers to both the role of the pharmacy service and the pharmacists’ practice in 58 cardiology. It is intended for both pharmacists involved in cardiology and pharmacists whose 59 specialisation is cardiology and, for consistency, refers to both as cardiology pharmacists. The 60 Standard predominantly refers to pharmacists but does not intend to exclude suitably qualified 61 pharmacy technicians where appropriate.1 The SHPA supports both pharmacists and pharmacy 62 technicians to operate at their full scope of practice to achieve optimal patient and pharmacy 63 outcomes. 64 This Standard describes essential and emerging services. Essential services demonstrate the full scope 65 of current pharmacy practice. Emerging services relate to services that are innovative and future- 66 focused and are provided in addition to essential services. The SHPA encourages all pharmacy services 67 to strive to provide emerging services wherever possible, in addition to essential services.

68 Box 1: Cardiology pharmacy services 69 Cardiology pharmacists provide services across a spectrum of cardiology disease which includes:

70 • Acute and chronic heart failure 71 • Arrhythmias 72 • Ischemic Heart Disease 73 • Structural heart disease 74 • Cardiothoracic Surgery including 75 • Cardiac transplantation

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76 Due to the broad nature of cardiology disease, the cardiology pharmacist will work across many 77 different facets of the healthcare service. This will include in the acute inpatient setting, sub-acute 78 rehabilitation centres, emergency department, critical care units, interventional cardiology units and 79 ambulatory care. 80

81 The burden of cardiovascular disease 82 Cardiovascular disease (CVD) is considered the leading cause of death and disease burden in Australia 83 and worldwide.4 In 2010, the Global Burden of Disease study reported CVD accounted for up to 25% 84 of the burden of all disease.5 This is a number expected to grow due to our aging population and 85 increased prevalence of diseases that are major risk factors of CVD such as obesity and diabetes.6

86 Self-reported data from the Australian Bureau of Statistics 2017-2018 National Health Survey, 87 approximately 1.2 million (6%) Australians reported they had one or more heart or vascular-related 88 conditions.7 The Australian Bureau of Statistics also reported that in 2017, 27% of all deaths in 89 Australia were attributed to circulatory diseases as well as 11% of all admissions which speaks to the 90 level of impact CVD has on the healthcare economy.7, 8

91 The prevalence of CVD has been reported to be higher for men compared to women. The impact of 92 age on CVD has been. An increase in the proportion of people with CVD increases with age. A 2017 93 survey found that of people aged above 75, 25% live with heart disease.7 Globally, the World Health 94 Organisation has stated that cardiovascular disease is the number one cause of death representing up 95 to 31% of all global deaths.9

96 Evidence of pharmacist impact in cardiology 97 There is evidence to suggest that the involvement of the pharmacist as a part of the multidisciplinary 98 team has both direct and indirect benefits on patient care. Although this data is limited and surrogate 99 markers are often used, there is no doubt that in cardiovascular disease, pharmacists can play unique 100 roles in both the acute and ambulatory aspects of patients care.

101 Systematic reviews have shown that the involvement of the clinical pharmacist in the prevention and 102 treatment of cardiovascular diseases including hypertension, dyslipidaemia, diabetes and smoking 103 cessation likely improves the overall outcomes of the patient.9 Acutely, the presence of pharmacists 104 during myocardial infarction presentations has shown to reduce door to balloon times.10

105 In the ambulatory space, pharmacist involvement in heart failure titration clinics whereby they 106 provide education, medication reconciliation and collaborative medication management has shown a 107 reduction in hospital admissions and readmissions as well as achieving target doses of guideline- 108 recommended heart failure therapy.11, 12 Additionally, the HELP-AF study will be pivotal in displaying 109 the potential benefits of a pharmacist-led education initiative for patients with Atrial Fibrillation.13

110

111 Objectives of the Pharmacy Service 112 The objectives of a cardiology pharmacy service are to optimise medication management for patients 113 with acute or chronic heart disease by ensuring the medicines chosen is clinically appropriate, safe, 114 and effective and to improve patient’s quality of life. The cardiology pharmacist must deliver the 115 service as part of interdisciplinary collaboration and with the framework of evidence-based and 116 patient-centred healthcare, to ensure optimal acute management and secondary prevention. Where

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117 possible the pharmaceutical care for patients with heart disease should be manageable with a goal of 118 judicious use of medicine, cost-effectiveness, affordability, and patient engagement.

119

120 Scope 121 This Standard applies to all pharmacists working in cardiology. The service provided by the cardiology 122 pharmacist may be delivered across several settings including both public and private hospitals and 123 in: 124 • The inpatient setting

125 • Ambulatory clinics provided via face to face and telehealth formats inclusive of rural and 126 regional sites

127 • General review clinics

128 • Cardiac rehabilitation (including via telehealth) 129 • Catheter laboratory, angiogram support

130 • Primary prevention 131 The scope of services provided by cardiology pharmacists will depend on a variety of factors including 132 the setting, patient population, the services that the hospital or health service provides, funding 133 models, governance structures for cardiology services, pharmacy department priorities, 134 organisational priorities, and the scope of practice of the individual pharmacist. 135 Although the range of services provided in cardiology is primarily delivered by pharmacists, it may be 136 supported by pharmacy technicians in clinical and non-clinical roles. 137 The types of conditions that patients present requiring cardiology services, inclusive of medical and 138 surgical therapies, include:

139 • Heart failure 140 • Structural heart disease

141 • Arrhythmias

142 • Ischaemic heart disease 143 • Pulmonary HTN

144 • Cardiac transplant. 145 The role of the cardiology pharmacist should include:

146 • delivery of pharmacy services that add value to healthcare systems and improve patient 147 medication outcomes 148 • the development of and input into policies, procedures, guidelines, and resources 149 • comments on medication formulary decisions with relevance to cardiology 150 • the provision of educational programs and training for healthcare professionals and students 151 • quality improvement activities and research related to cardiology.

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152 The pharmacist should be a point of contact for other pharmacists and health professionals, both 153 within and external to the health service, for medicines information enquiries related to cardiology. 154

155 Operation

156 Clinical Pharmacy Services

Inpatient

•Cardiothoracic •Heart failure •Heart transplant •Arrhythmias •ACS •Pulmonary arterial HTN •Rural sites •Same-Day Admissions

Outpatient

•Ambulatory clinics •Cardiac rehab •Primary prevention – management of CV risk factors 157 158 Figure 1 Clinical pharmacy services for inpatients and outpatients of the cardiology service

159

160 The cardiology pharmacy service should be provided by pharmacists whose main area of specialisation 161 is and who can demonstrate competence in cardiology (refer to Error! Reference source not found.). 162 Components of the service may be delegated to non-specialised pharmacists after undergoing training 163 and demonstrating an appropriate level of competence to perform their tasks. Cardiology pharmacists 164 should be supported by pharmacy technical staff in non-clinical and clinical roles. 165 The provision of cardiology pharmacy services will depend on the practice setting and is surmised in 166 Figure 1. The traditional hospital model focuses on providing a clinical service to inpatients. Due to the 167 increasing burden of cardiovascular disease, this could include patients admitted under a cardiology 168 team as well as units where cardiovascular diseases are prevalent (I.e., general medicine, renal, 169 emergency, and intensive care). The cardiology pharmacist will care for patients with ischaemic heart 170 disease, arrhythmias and/or heart failure in standard practice. Specialist centres may also serve 171 patients with cardiothoracic surgery, cardiac transplantation, rheumatic and other valvular diseases, 172 pulmonary arterial hypertension, or congenital heart disease. 173 Emerging services of the cardiovascular pharmacist include patient review and education in the 174 outpatient setting such as ambulatory clinics and GP practices. These services can be provided both in 175 a face-to-face or telehealth environment. The cardiology pharmacist also has value in providing advice 176 regarding the initiation and up-titration of immunosuppressants, anticoagulants or heart failure 177 therapies.

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178 Due to their position within the multi-disciplinary cardiology service, pharmacists are well-positioned 179 to take an active role in ward rounds, nursing and medical education and policy and procedure review 180 and development. 181 As detailed in the introduction, this Standard describes the provision of pharmacy services for best 182 care, with essential services that demonstrate the full scope of pharmacy practice and emerging 183 services that are innovative and future-focused and are provided in addition to essential services. 184 These are listed in Table 1.

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185 Table 1 Essential and emerging cardiology services for pharmacists

Setting Details Essential Emerging Specialist Centre Only All settings TDM including performing and interpreting perhexiline levels X Identification of medications which can increase MI risk +/- worsen cardiac condition X + implementing avoidance plan Antiplatelet/Anticoagulant monitoring + management plan X Partnered pharmacist medication charting X Pharmacist-led warfarin dosing X Pharmacist initiation of NRT and management of nicotine withdrawal X Involvement with IV infusions and inotropes X Inpatient Acute coronary syndromes (ACS) Attendance at Code STEMI callouts X Heart Failure Driving titration of guideline-directed HF therapies X Management of diuretic resistance X Antimicrobial stewardship and monitoring for infective endocarditis X Monitoring of RHD registered patients for prophylactic therapy X Providing titration plan for HF medications on discharge X Arrhythmias Ensuring baseline monitoring requirements completed for amiodarone initiation X Cardiac Surgery Pain management plan on discharge X Participate in pre and post-operative MDT clinic reviews X Monitoring of RHD registered patients for prophylactic therapy X Pulmonary Arterial Hypertension (PAH) Participation in MDT clinics and case meetings X Heart Transplant / VAD Titration and monitoring of immunosuppressants and antimicrobials X Participation in MDT clinics and case meetings X Heart transplant work up assessment X Same Day Admission Provide clinical pharmacy services in areas servicing day procedure patients X

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Outpatient Ambulatory Clinics Medication history X Medication reconciliation and clinical review X Identify medications that may worsen cardiac condition + implementing an avoidance X plan Antiplatelet/Anticoagulant monitoring + management plan X Medication compliance assessment + management plan X DAA facilitation X Provision of patient education X Heart failure up-titration X Cardiac Rehab Participation in approved outpatient cardiology rehabilitation education programs X Providing medication information sessions in an approved rehabilitation program X Primary care/ GP pharmacists Primary prevention – management of CV risk factors X Management and titration of heart failure medications X Operational Provision of medicines information to prescribers, nurses, GPs X Quality use of medicines audits X Education of pharmacy, nursing, medical staff X Policy and procedure development (including formulary review) X 186

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187 Policies, Procedures, and Governance 188 Pharmacists must have knowledge of the following documents which provide a framework within 189 which the pharmacist should practice:

190 • Australian Charter of Healthcare Rights3 191 • National Safety and Quality Health Service Standards14 including the National Model Clinical 192 Governance Framework 15

193 • Pharmacy Board of Australia Code of Conduct16 194 • SHPA Code of Ethics17

195 • National Competency Standards Framework for Pharmacists in Australia2 196 • Professional Practice Standards18

197 • Clinical Governance Principles for Pharmacy Services 19 198 • Legislation, specifically State and Territory Acts and Regulations. 199 Cardiology pharmacists should regularly utilise the following Australian guidelines:

200 • National Heart Foundation of Australia / Cardiac Society of Australia and New Zealand Clinical 201 Guidelines 202 o Heart Failure (2018)20 203 o Atrial Fibrillation (2018)21 204 o Acute Coronary Syndrome (2016) 22 205 • Rheumatic Heart Disease Australia guidelines 23 206 o Acute rheumatic fever and rheumatic heart disease

207 Cardiology pharmacists should also be familiar with relevant international clinical guidelines from the:

208 • European Society of Cardiology 209 • American Heart Association

210 Additional policies, procedures and guidelines that may be considered at the level of individual 211 services include:

212 • International Society on Thrombosis and Haemostasis Clinical Guidelines 213 • International Society for Heart and Lung Transplantation guidelines and consensus documents

214

215 Recommended Staffing 216 As per the Clinical Pharmacy Standards1 there are three major factors that driving staffing levels for 217 clinical pharmacy services including; the range of clinical pharmacy services, the complexity of care 218 required and hospital throughput. 219 Recommended cardiology pharmacist staffing levels for pharmacy services are presented in Table 2. 220 This should be interpreted with consideration for the health service, activities performed by the 221 cardiology pharmacist and those that are undertaken by other pharmacists and pharmacy technicians. 222 The roles of cardiology pharmacists are varied and dependent on the model of care and size of the 223 health service and recommended staffing levels are, therefore, a reflection of this. Whereas the

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224 traditional model has been that ward-based pharmacists are wholly responsible for an individual 225 patient, pharmacists are increasingly practising in team-based models and with specialisation, in 226 consultant-type roles. As the models change and roles grow, the provision of advanced pharmacy care 227 for an individual patient may be shared between pharmacists. An example is a cardiology pharmacist 228 working in cardiothoracic surgery IPU for complex patients, although those patients are under a 229 surgical unit. Given the complexity of these patients and high dependence on medicines, a ratio of 12 230 beds to 1 FTE may be more appropriate in cardiothoracic surgery IPU and coronary care unit based on 231 expert advice. 232 There should be at least one senior clinical pharmacist being responsible for the coordination of all 233 aspects of the cardiology pharmacy service. Components of this may be delegated to other 234 pharmacists and support staff. Intern and early career pharmacists should be supported by a senior 235 pharmacist who is preferably based in the cardiology department.

236 Table 2 Recommended pharmacist: patient ratios for cardiology services

Category Description of service Patients to 1 FTE a pharmacist for clinical pharmacy services 5 days/week b,c 1 Coronary care unit (CCU) 12 Specialist units, high Cardiothoracic surgery IPU dependence medicines 2 Cardiology IPU 15 Medical bed type 11 Interventional cardiology 20 Same-day admission Cardiac catheter suite Procedural patients + Angiographic, Cardiac catheter suite support, alcohol ablation 9 Pharmacists providing review 8 and advice on medicine usage Review and advice on in Allied Health and/or Clinical medicine usage – pharmacist- Nurse Specialist Interventions led or MDT clinic clinics e.g. cardiac rehab and heart failure clinic and pre- admission clinic – Tier 2 Non- admitted Service 40.04

a FTE = Full Time Equivalent b The proposed recommendations cover a 5-day/week service, and a weekend service or discharges over the weekend would require increased pharmacist services. For increases in surgical throughput and potential resultant admissions, there should be a discussion at an executive level and consideration of pharmacy resources required.

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C The recommended ratio for Cardiology IPU accounts for a shorter median length of stay, and consequently higher turn over of a critically unwell cohort, often on many medicines. A ratio of 15 beds (not patients as traditionally recommended) may be more appropriate based on expert advice 237

238 Training and Education 239 It is essential to develop the pharmacy workforce through the training and education of pharmacists 240 and technicians to enable the delivery of advanced pharmacy care in cardiology Pharmacists 241 commencing practice in cardiology should undertake relevant orientation and training. Another 242 avenue for specialisation is a cardiology Advanced Training Residency. 243 Cardiology pharmacists should have a scope of practice competency profile with a continuing 244 professional development (CPD) plan that covers the five domains of professional performance as per 245 the National Competency Standards Framework for Pharmacists in Australia 2016.2 Although the 246 framework itself is not tied to any area of specialisation, for cardiology pharmacists, there are 247 qualifications, educational activities, knowledge, and skills that are recommended in addition to those 248 of a clinical pharmacist. These have been informed by the SHPA cardiology Leadership Committee.

249 Credentialing and Qualificationsi 250 Desirable certification, credentialing and qualifications for cardiology pharmacists include:

251 • a postgraduate qualification in clinical pharmacy or public health for example 252 o Master of Clinical Pharmacy 253 o Master of Public Health 254 • Credentialing as an Advancing or Advanced Practice Pharmacist provided by Pharmacy 255 Development Australia 24

256 • Other educational 257 o There is also formalised certification offered by the US Board of Pharmaceutical 258 Specialties (BPS) – in Cardiology Pharmacy or Pharmacotherapy which may relate to 259 the practice of cardiology pharmacy. 260 Further to the Pharmacy Board of Australia Guidelines on Continuing Professional Development 25, it 261 is recommended that cardiology pharmacists have a significant proportion of their continuing 262 professional development per year tailored to cardiology services. Recommended continuing 263 education activities for cardiology pharmacists include the following: 264 Attendance at local or national courses or online activities such as:

265 • SHPA Seminars and CPD activities. 266 • Cardiac Society of Australia and New Zealand (CSANZ) annual scientific meeting 267 • The annual Sydney Cardiovascular Symposium (hosted by the Victor Chang Cardiac Research 268 Institute and Heart Research Institute) 269 • The American Society of Health-System Pharmacists (ASHP) Cardiology Pharmacy Specialty 270 Review Course

i This is a limited list offered for general information and does not represent endorsement of any provider; new providers may emerge, and this is list is current as of February 2021.

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271 • In-house journal clubs

272 Subscribing to the following journals:

273 • Journal of the American College of Cardiology 274 • Circulation 275 • JAMA cardiology 276 • New England Journal of Medicine 277 Joining professional organisations:

278 • Cardiac Society of Australia and New Zealand 279 • Australian Cardiovascular Health and Rehabilitation Association 280 • European Society of Cardiology 281 • American Heart Association

282 The leadership committee considers the ability to undertake preceptorships and/or site visits to 283 health services in either geographically diverse areas or areas of diverse practice to be a useful way 284 of expanding knowledge and skills, particularly for those cardiology pharmacists practising alone or 285 at smaller sites.

286 Educational material and resources are also provided on the SHPA cardiology stream home page on 287 the SHPA eCPD website. For cardiology pharmacists, joining and actively participating in the SHPA 288 Specialty Practice Cardiology stream at the practice group level is strongly recommended. 289 Attendance at specialist conferences and educational meetings should be supported to maintain and 290 update specialist knowledge in emergency medicine. Relevant domestic conferences include those 291 organised by SHPA, Cardiac Society of Australia and New Zealand (CSANZ) and The Australian & New 292 Zealand Society of Cardiac & Thoracic Surgeons (ANZSCTS) Annual Scientific Meeting. International 293 conferences in cardiology include annual conferences of the European Society of Cardiology and the 294 American Heart Association.

295 Knowledge, Skills and Experiential Learning 296 The role of a cardiology pharmacist, like any clinician with specialised expertise, is based on a high 297 level of skill in general pharmacy with the later addition of specialty-specific experience. Pharmacists 298 working in this area should have high levels of interpersonal skills, including confidence, empathy, and 299 effective patient communication skills, to provide personalised care. Underpinning knowledge related 300 to key areas of pharmacy practice in cardiology is the skills and application of clinical pharmacy, which 301 may be advanced by experiential learning (Table 3). This Standard does not list the competencies that 302 the individual cardiology pharmacist should address as this will be dependent upon their scope of 303 practice.

304 Table 3 Essential and desirable knowledge and skills and experiential learning for cardiology pharmacists

Essential Desirable Knowledge Knowledge of management of Where applicable, the acute coronary syndromes, specialist knowledge of cardiac arrhythmias, pharmacotherapeutics to support comprehensive cardiothoracic surgery, and medicine use in cardiac

acute and chronic heart failure transplantation

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Knowledge of the The specialist knowledge of management and prioritisation pharmacotherapeutics to of issues within the cardiac support comprehensive medicine use in cardiac ambulatory and cardiac rehab transplantation setting In-depth understanding of risk factors for medicine non- adherence and strategies to address them Skills Effective communication to Motivational interviewing to deliver and engage patients on support changes in medication discharge or in cardiac adherence for cardiac patients rehabilitation etc. including techniques such as motivational interviewing Ability to work as part of a Ability to promote and support multidisciplinary team with the the skills development of capacity to apply negotiation cardiology pharmacists skills to obtain optimal patient outcomes Provision of education to other Mentorship for early-career health professionals, pharmacists, those newly concerning medicines in working in cardiology and cardiac disease those caring for patients with cardiac comorbidities requiring specialist input Teaching to increase advanced capability e.g., training and education of healthcare professionals regarding cardiology. Research in areas of cardiology Engagement in national health and community policy e.g. Therapeutic Guidelines, National Prescribing Service Experiential Learning (includes Undertaking quality training) improvement projects within all facets of cardiac g disease and the transplant setting

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Completion of an evaluation of MiniCEX or MiniPAT clinical skills using the ClinCAT (version 3) Completion of an SHPA Foundation Residency or Advanced Training Residency program 305 Training and education will predominately be work-based education and should follow adult learning 306 principles. Further information can be found in Chapter 10 of the SHPA Standards of Practice for 307 Clinical Pharmacy Services 1. 308

309 Quality Improvement 310 The practice of cardiology spans a multi-disciplinary team involving not only pharmacists, but also 311 cardiologist, intensivists, cardiothoracic surgeons, nurses, and allied health professionals. Therefore, 312 quality indicators for practice need to extend beyond standard Quality Improvement (QI) indicators 313 specified in Chapter 14 of SHPA Standards of Practice for Clinical Pharmacy Services.1 314 QI activities specific to cardiology pharmacies include: 315 Australian Commission on Safety and Quality in Health Care Acute Coronary Syndrome Care Standard 316 2019 indicators: 317 • The proportion of patients with Acute Coronary Syndrome (ACS) provided with individualised 318 care plan (6a) 319 • The proportion of patients with acute coronary syndrome (ACS) on aspirin or dual antiplatelet 320 therapy on separation from hospital (6b) 321 • The proportion of patients with acute coronary syndrome (ACS) prescribed lipid-lowering 322 therapy on separation from hospital (6c) 323 • The proportion of patients with reduced left ventricular ejection fraction (LVEF) prescribed a 324 beta-blocker and angiotensin-converting enzyme (ACE) inhibitor on separation from hospital. 325 (6e) 326 Quality improvement activities should demonstrate improvements in patient care through advanced 327 pharmacy care in cardiology by targeting and achieving the best outcomes for all patient groups, 328 including those at greatest risk of medication misadventure. 329 Baseline and yearly reports of the number of staff education sessions provided, conference 330 presentations and manuscripts published by pharmacists. 331 Governance indicators also include the presence of pharmacists on cardiology advisory groups within 332 the health service/district and the presence of pharmacist oversight on clinical practice guidelines and 333 mortality/morbidity committees in cardiology. 334 Further information on quality improvement can be found in Chapter 14 of SHPA Standards of 335 Practice for Clinical Pharmacy Services.1

336

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337 Research 338 Research is vital for developing the pharmacy profession and may inform a pharmacy services’ current 339 level of, and future contributions to, advancing pharmacy and patient care. Cardiology pharmacists 340 should initiate, conduct, and supervise research that contributes to the body of knowledge providing 341 evidence of impact in support of optimal use of medicines and advanced pharmacy care in cardiology. 342 Cross-sector, inter-sectoral and interdisciplinary research is advocated to ensure the input of key 343 stakeholders and that research is relevant to the Australian community. Collaborations with research 344 institutes and groups are also advocated, for example, The Heart Foundation, National Prescribing 345 Services (NPS), State and Territory based Cardiovascular Research Alliances and Networks. 346 The research question must be of benefit to patients and interest to multidisciplinary health care 347 professionals working in cardiology, with a feasible study design. 348 Examples of cardiology pharmacist research have included: 349 • the role of a cardiology ward-based pharmacy technician and a telehealth technician in 350 specialist cardiology outpatient clinics 26, 27 351 • the sustainability of a telehealth cardiology pharmacist in regional practice 28and a novel role 352 working with Aboriginal & Torres Strait Islander cardiac patients 29 353 • evaluation of the management of type 2 diabetes mellitus in established atherosclerotic 354 cardiovascular disease 30 and of asymptomatic hypertension 31 355 • initiation and monitoring of amiodarone in a tertiary setting 32 356 • adherence studies, such as to dual antiplatelet therapy following percutaneous coronary 357 intervention 33 358 • case studies on the use of medicines such as Entresto in heart failure 34 359 Data collection for any research should be achievable promptly. There should be clearly defined 360 outcomes with objective measures where possible. 361 External funding enables larger and feasibly multi-centre studies to be conducted. Research grants, 362 practitioner grants and educational grants to develop research capacity may also be available from 363 SHPA and other organisations including CSANZ, the Heart Foundation, Cardiovascular Health Mission. 364 Presentation and publication of studies by Australian cardiology pharmacists are imperative to aid 365 others in the implementation of desirable cardiology services (such as telehealth services) and to 366 illustrate how cardiology pharmacists are demonstrating improvements in patient care. 367 Presentation of research at relevant conferences and seminars as referenced in Training and 368 Education, such as those organised by XX is highly recommended. The Journal of Pharmacy Practice 369 and Research (JPPR) has a readership of primarily Australian pharmacists. Journals specific to 370 cardiology that may be appropriate are listed in Appendix 1. Resources.

371 Further research information can be found in Chapter 11 of SHPA Standards of Practice for Clinical 372 Pharmacy Services.1

373 374 Acknowledgements 375 376 Conflict of interest statement 377 The authors declare that they have no conflicts of interest.

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378

379 References 380 1. SHPA Committee of Specialty Practice in Clinical Pharmacy. SHPA Standards of Practice for 381 Clinical Pharmacy Services. Journal of Pharmacy Practice and Research. June 2013 382 2013;43(No. 2 Supplement):S1-69. 383 2. Pharmaceutical Society of Australia. National Competency Standards Framework for 384 Pharmacists in Australia. Deakin West: PSA; 2016. 385 3. The Australian Commission on Safety and Quality in Health Care. Australian Charter of 386 Healthcare Rights. 1st ed; 2008. 387 4. World Health Organization. Cardiovascular Diseases (CVDs). WHO. Available at: 388 https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). 389 Accessed 30 May 2020, 2020. 390 5. Moran AE, Forouzanfar MH, Roth GA, et al. The global burden of ischemic heart disease in 391 1990 and 2010: the Global Burden of Disease 2010 study. Circulation. Apr 8 392 2014;129(14):1493-1501. 393 6. Australian Institute of Health and Welfare. Australian health expenditure — demographics 394 and diseases. Hospital admitted patient expenditure 2004–05 to 2012–13. Canberra 2017. 395 7. Australian Bureau of Statistics. National Health Survey: First Results, 2017-18. Canberra: ABS; 396 2017. 397 8. Australian Bureau of Statistics. Causes of Death, Australia, 2017. Canberra: ABS; 2018. 398 9. Omboni S, Caserini M. Effectiveness of pharmacist's intervention in the management of 399 cardiovascular diseases. Open Heart. 2018;5(1):e000687. 400 10. Acquisto NM, Hays DP, Fairbanks RJ, et al. The outcomes of emergency pharmacist 401 participation during acute myocardial infarction. J Emerg Med. Apr 2012;42(4):371-378. 402 11. Cheng JW. Current perspectives on the role of the pharmacist in heart failure management. 403 Integr Pharm Res Pract. 2017;7:1-11. 404 12. Jain A, Mills P, Nunn LM, et al. Success of a multidisciplinary heart failure clinic for initiation 405 and up-titration of key therapeutic agents. Eur J Heart Fail. Mar 16 2005;7(3):405-410. 406 13. Hendriks JM, Brooks AG, Rowett D, et al. Home-Based Education and Learning Program for 407 Atrial Fibrillation: Rationale and Design of the HELP-AF Study. Can J Cardiol. Jul 408 2019;35(7):846-854. 409 14. Australian Commission on Safety and Quality in Health Care. National Safety and Quality 410 Health Service Standards. Medication Safety. Sydney: ACSQHC; 2017:86. 411 15. Australian Commission on Safety and Quality in Health Care. National Model Clinical 412 Governance Framework. Sydney: ACSQHC; 2017. 413 16. Pharmacy Board of Australia. For Pharmacists Code of Conduct. March 2014 ed: PBA; 2014. 414 17. The Society of Hospital Pharmacists Australia. SHPA Code of Ethics. Collingwood: SHPA; 415 2016. 416 18. Pharmaceutical Society of Australia. Professional Practice Standards Version 5. Deakin West: 417 PSA; 2017. 418 19. Pharmaceutical Society of Australia. Clinical Governance Principles for Pharmacy Services 419 2018. Deakin West: PSA; 2018. 420 20. Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and 421 Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and 422 Management of Heart Failure in Australia 2018. Heart, Lung and Circulation. 423 2018;27(10):1123-1208. 424 21. Brieger D, Amerena J, Attia J, et al. National Heart Foundation of Australia and the Cardiac 425 Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and 426 Management of Atrial Fibrillation 2018. Heart, Lung and Circulation. 2018;27(10):1209-1266.

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427 22. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of 428 Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute 429 Coronary Syndromes 2016. Heart, Lung and Circulation. Sep 2016;25(9):895-951. 430 23. RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, 431 diagnosis and management of acute rheumatic fever and rheumatic heart disease. 3rd ed: 432 Menzies School of Health Research; 2020. 433 24. Pharmacy Development Australia. Advancing Practice Background and Guiding Principles: 434 Pharmacy Development Australia; 2018. 435 25. Pharmacy Board of Australia. Guidelines on Continuing Professional Development: PBA; 436 2015. 437 26. Dening K, Livori A, Dimond R, Kong D, Fitzpatrick A. Technician in Specialist Outpatient Clinics 438 – The Telehealth Cardiology Pharmacist Clinic Technician! 2020 SHPA Virtual Congress. 439 Virtual: SHPA; 2020. 440 27. Hattersley L, Faint A, Peters N. Cardiology Ward Based Technician: Positive Impact on Patient 441 Outcomes In An Acute Chronic Disease Setting. Medicines Management 2019. Gold Coast, 442 Australia: SHPA; 2019. 443 28. Bishop J, Livori A, Dimond R, et al. A Sustainable Telehealth Cardiology Pharmacist Clinic At A 444 Regional Hospital. Medicines Management 2019. Gold Coast, Australia: SHPA; 2019. 445 29. Mitchell S, Yong H, Michael H, et al. A Novel Hospital Pharmacist Role Working With 446 Aboriginal & Torres Strait Islander Cardiac Patients. Medicines Management 2018. Brisbane, 447 Australia: SHPA; 2018. 448 30. Nguyen J. Management of type 2 diabetes mellitus in patients with established 449 atherosclerotic cardiovascular disease. 2020 SHPA Virtual Congress. Virtual: SHPA; 2020. 450 31. Koo S, Burrows J, Nye E. An Evaluation Of The Managment Of Asymptomatic Hypertension 451 Focusing On The Use Of Glyceryl-Trinitrate Patches. Medicines Management 2018. Brisbane, 452 Australia: SHPA; 2018. 453 32. Coddo J, Shepley M, Potts C. Amiodarone Initiation And Baseline Monitoring At A Large 454 Tertiary Institution. Medicines Management 2018. Brisbane, Australia: SHPA; 2018. 455 33. Weeks G, Cheung J, Birdsey G, Amerena J, George J. Adherence to dual antiplatelet therapy 456 following percutaneous coronary intervention. 2020 SHPA Virtual Congress. Virtual: SHPA; 457 2020. 458 34. Kumarage R, Clarke C, Tran M. In Your Best Entrests?: A Case Study On The Use Of Entresto 459 In Heart Failure. Medicines Management 2018. Brisbane, Australia: SHPA; 2018. 460 461

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462 Appendices

463 Appendix 1. Resources

Useful journals specific to cardiology

Heart, Lung, Circulation

New England Journal of Medicine

European Heart Journal

Circulation

Journal of the American College of Cardiology

JAMA Cardiology

Heart

American Journal of Cardiology

Consider subscribing to cardiology research reviews for acute coronary syndromes, atrial fibrillation, general cardiology, interventional cardiology and/or heart failure – researchreviews.com.au/au/Clinical- Area/Internal-Medicine/Cardiology.aspx [Clinical] Guidelines and Standards Please ensure the latest version of the guideline is accessed Australian:

• Australian Clinical Guidelines for the Management of Acute Coronary Syndromes • Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia • Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation European

• Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation (Management of) Guidelines • ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation • Guidelines for Management of Atrial Fibrillation • Acute and Chronic Heart Failure Guidelines American • ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction • AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes • AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation • ACCF/AHA Guideline for the Management of Heart Failure

For other specialty or focussed guidelines, please search the society websites listed below Cardiology professional societies and other useful websites

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Society Website Cardiac Society of Australia and New www.csanz.org.au Zealand (CSANZ) Australian and New Zealand Society of www.anzscts.org Cardiac & Thoracic Surgeons European Society of Cardiology (ESC) www.escardio.org American College of Cardiology www.acc.org American Heart Association (AHA) www.heart.org Australian Cardiovascular Health and www.acra.net.au Rehabilitation Association The heart foundation www.heartfoundation.org.au Rheumatic Heart Disease Australia www.rhdaustralia.org The International Society for Heart & Lung www.ishlt.org Transplantation Pulmonary Hypertension Society of www.phsanz.org Australia and New Zealand (PHSANZ) Australian Amyloidosis Network www.amyloidosis.net.au Heart Online – Heart Education Assessment www.heartonline.org.au Rehabilitation Toolkit Application Developer ESC Pocket Guidelines European Society of Cardiology HF Smart Heart Guidelines Heart Foundation TreatHF American College of Cardiology ACC Clinical Guideline App American College of Cardiology Journal Club: Medicine Peripheral Brain, LLC HeartEvidence Pro/Lite JoongHeum Park MDCalc Medical Calculator MD Aware, LLC Cardiology podcasts ESC Cardio Talk Purple Pen Podcast(selected)

ESC Cardio Talk • What’s new in atrial fibrillation – 2 June 2019 ACC Podcasts • Heart Failure – 20 April 2017 Heart podcast – The BMJ • Controversies about lipid-lowering Cardionerds therapies – 19 Feb 2017 • QT Prolongation – 8 Jan 2017 Research Review (selected) • Management of Fabry Disease

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• Is it Fabry Disease? • Cardiomyopathies and Fabry Disease • Genetic Cardiomyopathies • CMR for myocardial disease • Cardiology Watch Edition 1 • Cardiology Watch 2 – Sacubitril/Valsartan in Chronic Heart Failure, How does it work? 464

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