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Milestones and new horizons for hospital pharmacy


Laurence A Goldberg FRPharmS
Editorial Consultant

Irene Krämer, President of the German Society of Hospital Pharmacists (ADKA), paid tribute to the work of the organisation over the past century and emphasised that ADKA now needs to prepare for the next 100 years and consider how pharmaceutical expertise will be channelled and professional excellence maintained and developed. As part of this approach, the conference organisers invited speakers from the UK and France to give their perspectives on milestones and new aspirations in hospital pharmacy.

Hospital pharmacy in the UK
In the UK hospital pharmacists have demonstrated their competence in managing drug therapy and, more recently, as prescribers and this will equip them for further developments in the future, Christine Clark (Independent Pharmacy Consultant and Editor, HPE) told the audience. Describing the past, present and future of hospital pharmacy, Dr Clark focused on the development of clinical pharmacy services, as this has been the driving force for many other developments. Over the past 30 years, hospital pharmacy has moved from being a largely product-oriented service to a patient-oriented service and this has gone hand-in-hand with a shift from reactive to proactive services. Dr Clark took up her appointment as the first clinical pharmacist in the UK in 1977 and immediately became involved in reshaping undergraduate and postgraduate teaching at Manchester University to include clinical elements. Training programmes for hospital pharmacists quickly followed and in time these were opened to pharmacists from mainland Europe.

During the 1980s and 1990s there were numerous developments – pharmacists experimented and developed services. “We tried to find niches where we had something unique and valuable to offer,” she said. Many pharmacists started their clinical work with pharmacokinetic services, because they alone in the healthcare team had the required expertise. Dr Clark herself worked in a clinical nutrition team. At the time, pharmaceutical expertise – knowledge of formulation and compatibilities – was much in demand because of the launch of 3-litre total parenteral nutrition bags and a growing understanding of ‘intestinal failure’.

Pharmacists commonly attended ward rounds and provided on-the-spot information. They also became involved in patient safety initiatives through medication error monitoring and reporting.

Gradually, a portfolio of activities was built up including taking drug histories, educating patients about treatment, and preparing and managing discharge prescriptions.

Turning to the present situation, Dr Clark said that there are now mature clinical pharmacy services in most hospitals with medicines’ reconciliation, intensive patient monitoring and education and discharge prescription management. There are also well-established practice interest groups, in areas such as surgery, critical care, gastroenterology and many others. Compulsory continuing professional development (CPD) has become an important aspect of everyday life. Professional development activities have to be recorded and can be called in for assessment. Moreover, CPD is essential for re-registration. Most importantly, there are now prescribing pharmacists and consultant pharmacists.

Prescribing pharmacists
Prescribing for pharmacists has been introduced in several stages, and since 2006 it has been possible for pharmacists to qualify as independent prescribers, who can prescribe any medicine (except controlled drugs) for any disease provided they work within their sphere of competence.  Prescribing is not for everyone, Dr Clark emphasised. To qualify as a prescriber, a minimum of 26 days of additional training must be undertaken. This covers consultation skills, basic clinical examination skills (e.g. blood pressure measurement, spirometry, auscultation (use of stethoscope)), basic diagnostic skills and legal and ethical aspects of prescribing, as well as additional therapeutics and evidence-based medicine. It also includes 12 days of practice training under the supervision of a designated medical practitioner. Trained prescribers must then be registered with the General Pharmaceutical Council as prescribers, before they can prescribe as part of their routine work.

Dr Clark said that she was proud of this development because she had long believed that pharmacists were better trained for the prescribing role than junior doctors.

Turning to the future, Dr Clark predicted that there would be more prescribing pharmacists because they have already demonstrated their competence and value in patient care. There will also be competence assessment for revalidation for pharmacists. There will be continued growth in patient safety activities, pharmacists will take on a bigger role in the management of drug therapy for long-term conditions and there should be closer working with patient support groups. Other developments will include ward-based clinical pharmacists, and further development of the pharmacy technician’s role. Underpinning these changes will be increased implementation of robotic dispensing, greater use of industry-produced ready-to-use injections and wider use of dose-banding (also known as dose-rounding).

In conclusion, she said that come what may, hospital pharmacists will continue to concern themselves with safe and effective drug therapy.

Hospital pharmacy in France
It takes 12 years to qualify as a hospital pharmacist in France, according to Alain Astier (Chief Pharmacist, Henri Mondor Hospital, Creteil, France).  This gives hospital practitioners the same status as doctors, he continued.

The training includes a number of mandatory modules including drug, dispensing, medical devices, clinical trials and magistral preparations (preparations for individual patients). Other modules include aseptic dispensing, the preparation of cytostatic drugs and compounding of parenteral nutrition.
Hospital pharmacists in France are responsible for the supply and distribution of medical devices and a typical pharmacy budget is almost evenly split between medicines and medical devices. Hospital pharmacists are also responsible for managing the central sterile supply departments.

One of the challenges for the future will be to ensure the best and most economical use of medical devices, said Professor Astier. This is particularly challenging because the current university course only offers 20 hours of tuition relating to medical devices. Clinical pharmacists will also be required to ensure that medicines are used most effectively. Finally, he predicted the development of robotics for the aseptic preparation of injections.

Swiss army knife
A poster from Jacqueline Menchini, Peter Buchal and Stephan Paul in Konstanz, Germany described how a smart phone with suitable apps could be so versatile and useful that it could be thought of as being the ‘Swiss army knife’ of the clinical pharmacist. The authors claim that a significant proportion of the clinical questions that are likely to arise at the bedside can be answered using a suitably equipped smart phone. Their poster gave examples of four types of questions and corresponding apps that could provide the answers. One question concerned clinical teaching query, the second related to product availability, the third concerned laboratory values and the final question was about antibiotic treatment for chronic osteomyelitis

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