Advanced Pharmacy Australia general medicine standards: paving the way for multidisciplinary care and collaboration

General Medicine is the largest provider of acute inpatient care in Victoria, and possibly also in the wider Australia and Aotearoa New Zealand.¹ Clinicians in General Medicine, including pharmacists, are trained to care for patients who are often elderly and frail, with multiple comorbidities, undifferentiated problems, and complex physiological and psychosocial needs. General Medicine services also care for vulnerable and marginalised patient populations, such as First Nations peoples, people experiencing homelessness, migrant and refugee populations, and people who inject drugs. General Medicine is also frequently involved in the care of perioperative patients, especially for those whose surgical issues are managed non-operatively, and patients who are pregnant with medical issues.

Management of general medical patients poses unique challenges. The specialty requires both breadth and depth of knowledge, concerning every organ system and their intricate interactions, and yet, the available best practice evidence-based guidelines are often single organ focused and may not directly apply to general medical patients. This is because patients who have competing comorbidities and are often not included due to highly selective exclusion criteria in major clinical trials. Patient presentations in General Medicine can range widely from being undifferentiated and acutely unwell, to management of stable chronic diseases which impact their lifestyle. There are also added layers of patient complexity such as cognitive, functional, and psychosocial issues which impact on access to care, medicine compliance, and health literacy. Additionally, certain considerations must be given in the management paradigm of some patient groups, for instance, prioritising and optimising quality of life for patients with advanced age and comorbidities, minimising medication adverse effects and related harm and reducing polypharmacy through deprescribing, while ensuring adherence to essential and critical medications. The care delivered must be of high quality and high value, not only based on the best available evidence, but also be holistic and patient-centred to tailor individual needs, circumstances, psychosocial, and physiological vulnerabilities. All clinicians in General Medicine have the obligation to minimise and eliminate low-value care options, that will not make any difference to patient outcomes, and may in fact result in harm, with significant associated economic and environmental costs.

From the systems perspectives, anecdotally, the models of care in General Medicine have been rapidly changing over the last two decades to meet the increasing service demands and to alleviate bed access pressures. While designed to improve patient flow through the hospital systems, evolving models that institute transitions through different care teams at different phases of the patient's journey, such as acute medical units/streaming teams in emergency departments, inpatient teams during hospital admission, early discharges via Hospital in the Home programs or community/outpatient teams, may potentially lead to multiple handovers, compartmentalisation and fragmentation of care, thus creating further vulnerable points in medication prescription and management.

General Medicine is a team sport. The diversity and complexity in General Medicine undoubtedly call for a multidisciplinary approach, with emphasis on shared decision making across the disciplines, to deliver high-value personalised care to achieve the best outcomes for the patients. Hospital pharmacists have always been a major part of multidisciplinary care for general medical patients. A large body of evidence exists to support the role of advanced clinical pharmacist services in caring for medical inpatients, in areas of medication charting, anticoagulation and thromboprophylaxis stewardship, psychotropic stewardship, vaccination, deprescribing, medication safety and adverse drug reactions, glycaemic management, opioids stewardship, and antimicrobial stewardship and allergy delabelling.

Specifically for General Medicine in the local context, medication reconciliation and the Partnered Pharmacist Medication Charting model have been shown to reduce discharge prescription errors and facilitate safer discharges and have now become the standard of care in many major hospitals across Australia.² Pharmacists play a central and critical role in ensuring smooth transitions of care in the patient's journey (e.g. discharge from hospital to community), which pose high risk and vulnerable points for medication errors.³ Pharmacists are also contributing to ongoing care of patients in the community through outpatient services and bed-substitution models of care (e.g. Hospital in the Home). Integrated General Medicine pharmacy services are thus critical to optimise the care of patients.

Additionally, hospital pharmacists play a leading role in clinical governance and innovation, through participation in audit and research activities, as well as mortality and morbidity reviews, and development of novel models of care. Active contribution by pharmacists to the departmental interdisciplinary education activities can further enhance clinical practice through sharing experiences, knowledge, and team development. The multidisciplinary involvement of pharmacists at every step of the patient's journey within wider team structures in General Medicine, can thus improve patient care and outcomes, improve hospital flow, reduce length of stay, reduce readmissions and enable safe transition of patients between care settings, and should strongly be promoted.

The Internal Medicine Society of Australia and New Zealand (IMSANZ) is a society that supports all healthcare professionals, including pharmacists working in General Medicine across Australia and Aotearoa New Zealand and the Pacific.⁴ IMSANZ welcomes and endorses the General Medicine Standards by Advanced Pharmacy Australia (AdPha) published in this issue of the Journal of Pharmacy Practice and Research.⁵ The best practice principles and professional standards outlined in this document clearly defines the importance of pharmacists in the care of General Medicine patients and the roles and responsibilities of pharmacists working within general medical units across both countries, including specialist pharmacists trained in General Medicine. It places high level emphasis on patient-centred approach to medication management and promotes the importance of interdisciplinary shared decision-making in patient care. Additionally, the document provides advocacy and guidance for staffing, training and qualification requirements, as well as workforce development to meet the complex needs of general medical patients. The document highlights areas where opportunities exist for IMSANZ and AdPha to further collaborate on education, research, workforce development, and innovations in models of care.

Translating the General Medicine Standards into practice will not be without due challenges. Currently, there is limited understanding of the workforce distribution, patient mix, scope of work and associated workload in resource-limited regional, rural and remote general medical settings, as well as in private sectors, across Australia to fully inform if certain approaches are feasible, beneficial, or cost effective. Further robust research is needed to provide advocacy at state and federal levels to establish integrated general medical pharmacy services in resource-limited settings. Additionally, hospital pharmacists need to be highly flexible and adaptable to the rapidly changing and diverse landscape of General Medicine, often driven by high service demands. In such high-pressure environments, processes must also be established to safeguard the pharmacists' health and well-being. The evolving roles, responsibilities and workforce structures of pharmacists in General Medicine must thus be informed by continual needs analysis, research, and health economics analysis to ensure the development of sustainable models of care, both economically and environmentally, that provide only high-value care to our patients.

Ak Kar Aung, Michelle Downie, Douglas F. Johnson all hold unpaid positions on the Board of Directors of the Internal Medicine Society of Australia and New Zealand (IMSANZ). Leigh-anne Shannon holds a salaried position at IMSANZ. Michelle Downie has received payment from Novo Nordisk and Boehringer Ingelheim for presentations and/or educational events. The authors declare that they have no additional conflicts of interest.

Ak Kar Aung: conceptualisation, writing – original draft, writing – reviewing and editing. Michelle Downie: conceptualisation, writing – original draft, writing – reviewing and editing. Leigh-anne Shannon: conceptualisation, writing – original draft, writing – reviewing and editing. Douglas F. Johnson: conceptualisation, writing – original draft, writing – reviewing and editing.

Ethics approval was not required for this editorial as it did not contain any human data or participants.

Commissioned, not externally peer reviewed.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.