Maintaining standards in hospital pharmacy

There are now more than 2000 pharmacists in the UK who have undertaken additional training and qualified as independent prescribers, and many pharmacist-led clinics are in operation, Anthony Sinclair (Director of Pharmacy, Birmingham Children’s Hospital) told the audience. Recently, the role of pharmacists in emergency departments has come under discussion. One project in the West Midlands set out to investigate the potential for enhanced clinical roles for pharmacists working as members of multidisciplinary teams. In the first phase, three sites (two adult, one paediatric) were enlisted and activities involved pre-discharge medicines optimisation and working in clinical decision teams. In the second phase, patients attending the emergency department were assessed to determine the level of professional competence required to manage them. Patients were assigned to one of four ‘professional ability to manage’ (PAM) categories  (see box below).

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The results showed that approximately 40% of patients could be managed by an pharmacist independent prescriber with advanced skills training and about 45% of patients should be managed by a doctor. An advanced clinical practice training programme has now been established at Warwick University. It includes modules on clinical examination and diagnostic clinical investigations. A national project involving 53 sites across the UK, designed to assess 20,000 patient presentations, has also been conducted.

The pilot study has indicated that a new role could exist for advanced clinical practice pharmacists in emergency departments. “This takes clinical pharmacists to a new level of autonomous working”, concluded Professor Sinclair. The consensus view is that about 40% of the case-load in emergency departments could be managed by advanced clinical practice pharmacists, he added.

The use of sedation for ventilated patients dates back to the introduction of mechanical ventilation. Speaking at a satellite meeting, sponsored by Orion Pharma, David Sapsford (Critical Care Pharmacist, West Suffolk Hospital NHS Foundation Trust, UK) explained that early ventilators relied on positive pressure and required the patient to synchronise breathing with the machine. The net effect was an increase in the work of breathing. Sedatives were introduced to make the process less taxing.

Opioids are commonly used to decrease respiratory drive but other agents have also been used. Morphine and midazolam take too long to wear off, propofol tends to cause hypotension and benzodiazepines increase the risk of delirium, although some centres still use lorazepam, he noted. Alpha-2 agonists such as clonidine and dexmedetomidine have also been used. ‘Sedation’ tends to be a ‘catch-all’ term embracing everything from mild anxiolysis to deep sedation. In practice it is used to achieve a number of effects including alleviation of pain, minimisation of discomfort during procedures, reduction of anxiety or agitation and amnesia during neuro-muscular blockade.

A survey of intensive care units (ICUs) in 1981 showed that the majority of units aimed to keep patients “well sedated and detached from the ICU environment”, and neuromuscular blockers were used extensively. By 1998, concerns were being expressed that keeping patients heavily sedated might increase the risks of neuropathy, pulmonary embolism, sepsis and delirium. Since then there has been a growing realisation that most sedative drugs can themselves cause delirium. A recent review of best practice for analgesia and sedation in intensive care concluded that optimally sedated patients should be awake, calm and cooperative, and that measures such as minimisation of night-time noise should be used to reduce stress and anxiety. In addition, pain should be treated first, sedation should be titrated to a pre-defined target and sedation breaks should be used.

A poor understanding of the relevant physiology and pharmacology leads to poor outcomes for patients, according to Scott Brudney (Associate Professor of Anaesthesiology, Duke University Medical Centre, North Carolina, USA). A change in the sedation paradigm has occurred and it is here to stay; benzodiazepines are disappearing, he continued. Sedation involves a combination of amnesia, hypnosis and anxiolysis. Opioids can also have an anxiolytic effect in addition to their analgesic effects. Alpha-2 agonists can have hypnotic, anxiolytic and analgesic effects but have minimal amnesic effects. Patients treated with dexmedetomidine remember 80% of what happens, he noted. Clonidine is a selective alpha-2 agonist with an alpha-2:alpha-1 selectivity ratio of 200:1, whereas dexmedetomidine has a selectivity ratio of 1620:1. Dexmedetomidine has a short half-life and has to be given intravenously. Both opioids and dexmedetomidine work at all levels of pain perception and control and their effects are additive, and so opioid doses must be reduced when alpha-2 agonists are used.

This can be an advantage for opioid-intolerant patients, commented Professor Brudney. Because alpha-2 receptors are found in many tissues, the effects of alpha-2 agonists can be wide ranging. They include bradycardia, a pro-diuretic effect and an anti-shivering effect. The effects on the central nervous system are exerted through the locus coeruleus, like natural sleep, but unlike propofol, alcohol or benzodiazepines that have GABA-ergic effects.

Dexmedetomidine is useful in patients who require prolonged sedation, in the morbidly obese and in patients undergoing alcohol withdrawal. Its use permits early mobilisation and faster extubation and therefore earlier departure from the ICU. A recent meta-analysis comparing dexmedetomidine with propofol showed that dexmedetomidine reduced the length of stay in ICU by one day and reduced the incidence of delirium but increased the risk of hypertension. Professor Brudney concluded that dexmedetomidine is now a front-line drug for ICU sedation in the USA, Canada and Australia. It is also finding a role in perioperative multimodal analgesia and complex monitored anaesthesia care.

Describing the implications of the National Health Service (NHS) five-year forward view for pharmacy, Sue Ambler (Head of Education and Training, Health Education England) said that there could be a £30 billion shortfall in NHS funding unless radical changes are made, including upgrading prevention and public health, patients controlling their own care and breaking down barriers in healthcare provision. The integration of social and healthcare budgets would demand “doing things differently, closing the gap and improving service productivity”, she added.

Specific service productivity improvements would include reducing errors that cause harm and re-admissions and reducing medicines wastage, smoking cessation and obesity, improving adherence and maximising value through innovation. Medicines optimisation would play an important part here because sometimes “spending more money on the right medicines leads to an overall saving’’, said Dr Ambler. Staffing accounts for the biggest expenditure – currently about £43 billion – and so this provides the biggest scope for savings and improved productivity. There will be a strong focus on urgent and emergency care services and primary and community care services because shortages in these areas have become apparent. This will include a critical examination of skill mix and who can provide services most effectively. It will also involve reviews of the roles of pharmacist and pharmacy technicians and the use of technology, she said.

Hospital pharmacy medicines optimisation is one component of the NHS procurement and efficiency programme. Andrew Davies (Director of Pharmacy, North Bristol NHS Trust, UK), a member of the core project team, described how the development of a pharmacy dashboard is a central plank of the work. The dashboard will show how the hospital is performing in four key areas – medicines quality and safety, medicines cost effectiveness, pharmacy systems and processes and pharmacy workforce. The first phase of work involves examining the scale and scope of current hospital pharmacy services. So far this has included 132 acute and community trusts, 549 questions and more than 1200 innovative practice examples.

At the recent EAHP summit conference on hospital pharmacy, there was almost complete agreement that the overarching goal of the hospital pharmacy service was to optimise patients’ outcomes through collaborative work in multidisciplinary teams to achieve responsible use of medicines, Roberto Frontini (Immediate Past President, European Association of Hospital Pharmacists) told the audience. The participants comprised 31 European hospital pharmacists, 12 patient groups and seven healthcare professionals who reviewed 44 statements about best practice that had previously been developed and refined. There were some areas of disagreement; for example, only 63% of patients and healthcare professionals agreed that the pharmacist should have access to patients’ health records in order to record interventions. All patients strongly agreed that pharmacists should ensure that information for safe use of medicines is available at the point of care but only 64% of healthcare professionals strongly agreed. EAHP is now collecting examples of good practice initiatives to help hospitals across Europe to implement the best practices.

In the humanitarian aid setting many agencies have failed to identify the need for a pharmaceutical expertise although many of the problems of managing medicines in disaster situations call for just this type of input, according to Trudi Hilton. Ms Hilton, a pharmacist working with humanitarian aid projects, described some of her experiences. Humanitarian aid is needed when a disaster strikes and there are typically three phases – the immediate response, which is typically two weeks of intensive work, the recovery phase over the next three to six months, and the rehabilitation and reconstruction phase.

During the monsoon disaster in Pakistan, an efficient system for drug distribution was set up by developing computer software to track all medicines and use on a ’first expiry, first out’ basis. In this way they were able to reduce wastage to a level of 2% over seven years – a sharp contrast with the 25–40% levels of wastage seen in other disasters, according to the World Health Organization (WHO). Often this is not because of local mismanagement but because the wrong medicines are sent, or they are labelled in the wrong language, have already expired or are inappropriate for use in the country concerned, said Ms Hilton. Expired medicines can be a particular problem in developing countries that do not always have the facilities or funds to destroy them, she noted. An important principle here is that the recipient country can always “say no”. Do not donate unless a medicine requested – “it is not a donation, it is a burden”, she said. The software that was developed is now freely available from the WHO.

After the typhoon in the Philippines in 2013, Ms Hilton hoped to replicate the distribution system that had been so successful in Pakistan. However, she discovered that the Department of Health in the Philippines had no supply chain information regarding medicines in the affected region other than the total expenditure on medicines. All medicines were purchased by a doctor and pharmacists were only responsible for distribution. As a result of Ms Hilton’s work, the profile of pharmacy has been raised and a new law has been enacted requiring a pharmacist to be present wherever medicines are held.

Turning to medicines’ donation, Ms Hilton said that the WHO guideline should be followed. It is important to start with the local formulary, respond to the list of specific needs and comply with the country’s language and shelf-life requirements. “What is taken in cannot be taken back”, she emphasised, so “something is not necessarily better than nothing”.

Pharmacists who travel to overseas countries must work within the local rules. For example, an independent prescribing pharmacist from the UK could not work as such in countries that do not recognise role or qualification. Individuals need to be flexible, creative and able to “deliver something from nothing”. The important thing is to listen and learn from the local context.

Ms Hilton suggests that pharmacists who are interested in this type of work should visit the Humanitarian Aid and Response Network on the Royal Pharmaceutical Society website:

www.rpharms.com/sector-groups/humanitarian-aid-and-response-network.asp.