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Published on 2 March 2009

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The future of hospital pharmacy global conference report

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Opening the conference, Andy Gray (FIP hospital section president) asked the delegates to reflect upon the nature of hospital pharmacy practice in their countries and work together with colleagues from around the world to develop a vision for what that practice should look like in the future.

The results of a recent survey of hospital pharmacy practice undertaken by the Hospital Pharmacy Section of FIP showed that in 45% of respondent countries there are vacancies that cannot be filled due to lack of qualified pharmacists, according to Lee Vermeulen (University of Wisconsin, USA). The survey evaluated the activities undertaken by pharmacies (scope of practice) and the extent to which they were implemented (breadth of practice) in each of the 85 UN-member countries that responded.

The results showed that in Europe, in contrast to other parts of the world, pharmacists are predominantly female and that technicians are used extensively. Medicines supply problems for hospitals were common in countries with low human development indices (HDIs). A high proportion of low-HDI nations have  implemented unit dose dispensing, but routine compounding of intravenous doses for all patients was uncommon overall.

Review of medicines orders by pharmacists and the provision of cognitive services by pharmacists appeared to be common across the globe, but documentation of pharmacists interventions and prescribing by pharmacists are uncommon activities.

Pharmacy now faces an unprecedented opportunity to advance patient care, Malebona Precious Matsoso (director of public health innovation and intellectual property, WHO) told the audience. “Communication of information about products is where the pharmacist’s expertise lies”, she said.

The number of pharmacists per hospital bed varies considerably between countries, and only in Belgium is there a standard (one full-time pharmacist for every 150 weighted hospital beds). One useful outcome of the global conference would be to recommend an international standard figure for this ratio, she
suggested.

Another important initiative would be task shifting which could result in a greater clinical role for pharmacists, including prescribing. It would also offer wider roles for pharmacy technicians. The recent UN report on task shifting (see resources) had specifically mentioned pharmacists and pharmacy technicians, she noted. It was recognised that certain functions might be beyond the scope of some cadres of staff,
but shortages were likely to drive task shifting.

In some areas, the situation is complex, for example, in Europe there are only three groups of staff (pharmacists, technicians and assistants), whereas in the African region there are 17. It is important to consider solutions for local situations, Ms Matsoso
emphasised. For example, task shifting might not be required if a dispensing robot were to be installed.

The pharmaceutical supply system also poses a challenge. In some countries, such as Kenya and Burundi, the supply system involves multiple players and a variety of different distribution networks. Pharmaceutical expertise is needed to streamline procurement, facilitate coordination and promote good
procurement practices, she said.

Published studies from around the world have shown that pharmacy services can reduce costs and improve patient safety. Studies from the USA that showed reductions in hospital mortality associated with clinical pharmacy services provided compelling evidence, and more people should be made aware of
it, said Ms Matsoso.

Key challenges in the implementation of new services were the lack of financial resources and the need for champions. In conclusion she said that changes should be incremental and systematic, and that it would require commitment and dedication.

Six workshop themes were then introduced by international experts.

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Medicines procurement
Medicines represent 5-12% of healthcare costs in high-income countries, but can be up to 40% of costs in low-income countries, explained Eva Ombaka (coordinator, Ecumenical Pharmaceutical Network, Kenya). Describing the medicines procurement process she said that it demands technical ability but is prone to bad practices.

Purchasing products that are designed for safe use is important but quality issues, such as substandard and counterfeit products, continue to pose problems. Information the bloodline of procurement is often not available. The global survey had shown that only 20% of pharmacies had computers and only 10% had access to the Internet. More than 60% of hospitals had formularies, with pharmacists participating in formulary decisions, but less than half (44%) had policies relating to the use of samples.

Prescribing of medicines
Lisa Nissen (senior lecturer, School of Pharmacy, The University of Queensland, Brisbane, Australia) considering pharmacists influence on the prescribing of medicines reminded participants that linking a formulary to treatment guidelines had a positive impact on patient outcomes. The current focus on cost-effectiveness creates a clear role for pharmacists, she added. Logistics has an influence on prescribing and pharmacists
should oversee the distribution process otherwise medicines end up where they should not be and are used by default. Prescriber education and drug order review also play a part. Participation in patient rounds effectively takes pharmacy activity to the front
line and provides the opportunity to target high-risk drug groups in situ.

Preparation and distribution of medicines
The global survey showed that in many cases physicians and nurses prepare chemotherapy doses without the involvement of pharmacy services, according to Ryozo Oishi (Kyushu University Hospital, Japan). This is part of a wider picture in which more than one third of hospitals did not use laminar flow hoods for
compounding of sterile products or provide pharmacybased cytotoxic compounding services. In addition, in the majority of hospitals, pharmacists are not involved in reviewing medicines orders in emergency departments or operating theatres. The survey also showed that unit dose distribution systems were not widely implemented and automated picking of medicines was uncommon. Dr Oishi concluded that the implementation of automation and computer systems was inadequate.

Administration of medicines
More than 50% of errors that are associated with severe harm or death occur at the administration step, and we do not think enough about medicines administration, said Rita Shane (director, Pharmacy Services, Cedars-Sinai Medical Centre, USA). A number of key initiatives have been shown to reduce adverse events and these include unit dose distribution systems, accurate documentation of drug allergies and the presence
of pharmacists in patient care areas. Nurse competence in pharmaceutical calculations is critical and one study had shown that nurses calculations were incorrect on 90% of occasions. There is no standardised nurse education about pharmaceutical calculations, Dr Shane added.

Intravenous doses are a particular cause for concern because they account for the majority of serious and life-threatening errors. They also figure highly in wrong route errors, eg, when intravenous doses are given by the intrathecal route or when oral liquids are given intravenously. High-risk medicines such as concentrated electrolytes and chemotherapeutic agents pose risks in administration, as do high-risk patient groups such as intensive care patients or neonates. Pharmacists need to have ownership of medicines administration because it is extremely problem-prone and complex, concluded Dr Shane.

Monitoring of medication therapy
Monitoring medication practice involves the use of indicators for safety, effectiveness and economy, explained David Cousins (Head of Safe Medication Practice, National Patient Safety Agency, England). Outcome indicators, such as mortality, cost or the frequency of a clinical event are useful, but they are the hardest to develop and measure in practice. Process indicators measure the impact of systems and policies and it is assumed that improved performance results in improved health outcomes. Examples include dispensing error logs and clinical pharmacy intervention records. Structural indicators provide
an environmental snapshot. They are usually based on published standards and can be conducted by professional peers or on a self-assessment basis.

All three types of indicator might be used to monitor a specific service. For example, an anticoagulation service could be monitored using outcome indicators such as mortality rates and bleeding complications, process indicators such as INR levels and time within therapeutic range and structural indicators such
as policies and procedures.

Human resources and training for hospital pharmacy
Inadequate human resources for health, including pharmacists and pharmacy technicians, threatens to undermine all efforts to strengthen health systems and improve healthcare, according to a 2006 United Nations report, Tana Wuliji (project manager, International Pharmaceutical Federation) told the audience.
The global survey showed that 48% of hospitals had policies and procedures to describe the medication use process and this would be a good starting point for development, suggested Professor Cousins.

The situation is further complicated by the fact that pharmacy personnel are unevenly distributed around the world, with relatively large numbers in North America and Europe and few in sub-Saharan Africa.

In the UK, there is one pharmacist per 1,300 people, whilst in Uganda there is one pharmacist per 140,000 people.

Hospital pharmacists account for 10-15% of the total pharmacist workforce. Most pharmacists education is of five to six years duration. However, there is a global shortage of pharmacists and pharmacy technicians. The shortage of technicians is likely to limit the development of services in hospitals, noted Ms Wuliji.

Three critical dimensions are helpful in integrating human resources and training: service level, coverage and scope. The level of service is linked to workforce competency, training and continuing professional development. Service coverage is related to workforce size and is influenced by supply, recruitment and
retention. Service scope is linked to workforce capacity and is related to skill mix, environment and support systems.

Following these introductions, the six simultaneous workshop sessions allowed delegates to debate the issues raised by the international experts and to formulate a total of 74 consensus statements. In a plenary session that followed, a delegate from each country voted electronically on each statement. All statements were adopted. (See Resources)

Commenting on the voting, Andy Gray said that the figures could be disaggregated by HDI, geographical region and other parameters, so that where reservations had been expressed about some statements the data can be teased out to provide a more detailed analysis. Pharmacy leaders now have the opportunity to take the 74 statements and conduct surveys in their own countries, he said.

Resources
http://data.unaids.org/pub/Manual/2007/ttr_taskshifting_en.pdf
International Pharmaceutical Federation consensus statements www.fip.org/CONGRESS/globalhosp2008/?id=767



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