MODULE 1: INTRODUCTION TO INSTITUTIONAL AND HOSPITAL PHARMACY PRACTICE

Institutional Pharmacies

refers to pharmacies of institutions, organization and/or corporations that provide a range of pharmaceutical service, given exclusively to the employee and/or their qualified dependents.

Institutional Pharmacies

includes the provision of distributional and clinical pharmacy services at a broad range of institutional settings including hospitals, long-term care, hospice, correctional facilities, and others.

- Typically, the institutions that pharmacists serve are linked together formally or informally into integrated health systems.

Health System

collection of organizations and institutions whose mission is to positively impact health outcomes.

Health Care

the product of a complex adaptive system of people, equipment, processes, and institutions working together.

Integrated Health System

integrate all care under the umbrella of a central organization, and often include inpatient/acute care, primary care/outpatient care, long-term care, and home care.

True

True of False

Although health systems are made up of independent entities, they are systems because the entities are interdependent and unified.

Integrated Health System

The integrated model creates the potential to provide enhanced levels of patient-care continuity through access to medical records and patient care providers.

Medication Use Process

The multistep process in which a drug travels from the pharmacy to the patient.

1. Prescribing

2. Transcribing

3. Dispening

4. Administration

5. Monitoring

Medication Use Process (5)

to lead and influence the safety, and quality of all aspects of the medication-use process.

• pharmacists should be involved in controlling or influencing any step of the medication-use process that can impact patient health outcomes or costs.

Role of Pharmacists in Medication Use Process

1. Recognition / Assessment

2. Diagnosis / Cause Identification

3. Selecting Intervention / Delivering Care

4. Monitoring

What are the Care Delivery Process (4)

Prescribing, Transcribing / Documenting, Dispensing, Administering

What Medication Use Process involved in Selecting Intervention / Delivering Care?

Monitoring

What Medication Use Process involved in Monitoring?

Prescribing

often viewed as something that only physicians are authorized to do.

Privileging

Many other health-care professionals are authorized to prescribe by state law or through a formalized process in hospitals known as ___________.

the pharmacist’s duty to influence the prescribing of other health professionals.

A more common role for pharmacists beyond actually prescribing?

Privileging

the process by which an oversight body of a health care organization or other appropriate provider body, having reviewed an individual health care provider's credentials and performance and found them satisfactory, authorizes that individual to perform a specific scope of patient care services within that setting.

1. Acting as information resources about medication

2. Providing feedback about the quality of prescribing

3. Developing prescribing protocols through the formulary system

PHARMACISTS INDIRECTLY INFLUENCE PRESCRIBING BY: (3)

Transcribing

Refers to the process by which a prescriber's written order is copied and either manually or electronically entered into pharmacy records.

Transcribing

represents an opportunity for error, especially when done manually.

pharmacists must understand potential breakdowns in the transcribing process and help find ways to minimize errors.

Role of pharmacists in Transcribing

Computerized Physician Order Entry

way or movement to diminish transcription process.

Computerized Physician Order Entry

CPOE means?

Dispensing

Refers to the act of physically transferring the drug product following review and approval of the prescription to the area responsible for administering the medication to the patient.

Dispensing

An area where medication errors can occur, including, but not limited to wrong drug, wrong dose, or wrong dosage form errors.

Administration

Typically managed by nurses and the last step before patients are given their medications, and errors at this point cannot be corrected.

medication error

1 hour with no medication intake =?

1. Clearly labeling medication

2. Using bar-coding system & unit dose packaging

3. Reducing the time & effort involved in accessing drugs

4. Using technology that reduces administration errors (smart pumps, machines)

PHARMACISTS HELP IMPROVE THE SAFETY OF MEDICATION ADMINISTRATION BY: (4)

Monitoring

Includes reviewing laboratory values that are correlated with the expected medication-therapy outcomes, as well as other objective and subjective factors that indicate whether the therapy is effective or may be having a toxic effect.

Monitoring

A critical phase where pharmacists play a vital role.

Patient Care Process

is a fundamental series of actions that guide the activities of health professionals.

process of care

All health professionals who provide direct patient care should use a systematically and consistently applied _______ __ ____ in their practice.

patient-centered approach

Pharmacists use a _______-________ _______ in collaboration with other providers on the health care team to optimize patient health and medication outcomes.

Collection

The pharmacist assures the collection of the necessary subjective and objective information about the patient in order to understand the relevant medical/medication history and clinical status of the patient.

Assess

The pharmacist assesses the information collected and analyzes the clinical effects of the patient’s therapy in the context of the patient’s overall health goals in order to identify and prioritize problems and achieve optimal care.

Plan

The pharmacist develops an individualized patient-centered care plan, in collaboration with other health care professionals and the patient or caregiver that is evidence-based and cost-effective.

Implement

The pharmacist implements the care plan in collaboration with other health care professionals and the patient or caregiver.

Follow-up, Monitor, & Evaluate

The pharmacist monitors and evaluates the effectiveness of the care plan and modifies the plan.

Practice Models

Operational structure that defines how and where pharmacists practice, including the type of drug distribution system used, the layout and design of the department, how pharmacists spend their time, practice functions, and practice priorities

Practice Models

The most important factor determining the role and effectiveness of the pharmacy department.

Practice Models

It sets the stage and defines the roles.

Practice Models

describes how pharmacists, pharmacy technicians and automation interrelate to provide pharmacy services.

1. Hospital type;

2. Institution type;

3. Patient population;

4. Philosophy of pharmacy services.

Practice Models may vary based on (4)

1. DRUG-DISTRIBUTION CENTERED MODEL

2. CLINICAL PHARMACIST CENTERED MODEL

3. PATIENT-CENTERED INTEGRATED MODEL

THREE MAJOR PHARMACY PRACTICE MODELS

True

True or False

The three models are generalizations of what might be seen in practice, but they do describe the tension between clinical and distributional roles of pharmacists.

1. its leadership

2. the relationships it develops with medicine, nursing, and the hospital administration

3. its involvement with colleges of pharmacy

4. the drug distribution model

5. variations in regional practice and work force

6. the presence or absence of pharmacy residency training programs

7. department culture

The degree to which an institutional pharmacy resembles any model depends on a variety of factors including the following: (7)

1. Practice will need to be interdisciplinary and team based. Education and training of pharmacists will need to be also.

2. Medication preparation and distribution will need to be made more efficient with automation, centralization, and the use of trained technicians.

3. Pharmacists' contributions to the medication-use process will be increasingly in direct patient care and less in medication distribution.

4. Health information technology will give pharmacists much greater ability to positively influence the medication-use process.

5. Pharmacists will need to justify their value because allocation of health care resources will be heavily driven by metrics. The benefits of pharmacy services will need to be justified against their costs. The value of services in terms of medication therapy out-comes, medication safety, and total care costs related to medication therapy will need to be defended.

6. A pharmacotherapy plan should be developed for every patient. That plan should be comprehensive, multidisciplinary, accessible, and transferable to any provider or location. Primary responsibility for this plan should rest with the pharmacist.

7. Pharmacists will need continuous training to practice pharmacy. Credentialing and privileging of pharmacists may be requirements for practice in general and specialty practice areas.

8. Institutional pharmacists will need to collaborate better with community pharmacists to coordinate care as patients transition from one practice setting to the next.

Whatever the model of pharmacy practice, several common features are likely to emerge as key: (8)

Drug-Distribution Centered Model

Pharmacists primarily distribute drugs and process new medication orders.

Drug-Distribution Centered Model

Role is reactive: responds to requests of physicians and nurses but rarely initiates major changes in therapy.

Drug-Distribution Centered Model

Pharmacists are not actively involved with the health care team or in development of therapeutic plans for the patient.

Drug-Distribution Centered Model

Pharmacists are not accountable for the health outcomes of patients and exert little leadership in influencing the medication-use process.

• in the traditional role

1. Clinical Pharmacists

2. Dispensing Pharmacists

Two primary types of pharmacists in pharmacy departments utilizing Clinical Pharmacists Centered Model

Clinical Pharmacists

are chiefly involved in clinical activities associated with medical teams on the nursing units.

Clinical Pharmacists

Primary responsibility is assisting physicians and other health professionals in avoiding and solving clinical problems exclusive of the distribution process.

Dispensing Pharmacists

are those who spend most of their time in drug distribution, reviewing orders and verifying the accuracy of medication preparation by technician.

Clinical Pharmacist Centered Model

Little or no collaboration occurs between clinical and distributive pharmacists in the extreme of this model, so these pharmacists are selectively accountable for the medication-use process.

Patient-Centered Integrated Model

All pharmacists in the department accept responsibility for all elements of the medication-use process and therefore spend their time on both clinical and distributive functions.

Patient-Centered Integrated Model

Pharmacists' roles in drug distribution are often limited, because many distribution tasks are delegated to well-trained pharmacy technicians.

Patient-Centered Integrated Model

Pharmacists can expand their clinical roles to more active engagement in medication selection and drug use as part of an interdisciplinary team. - Pharmacists exhibit a high degree of ownership of and accountability for the entire medication-use process.

1. efficiency

2. accuracy

Pharmacy automation serves to increase efficiency and accuracy of dispensing.

Automation and Technology INSIDE THE PHARMACY

Important to the practice model because utilization of many of the available technologies can influence what the pharmacist and pharmacy technician do in support of medication dispensing.

full use of automation can re-direct staff time away from routine technical tasks and towards more direct patient care activities.

Advantage of Automation and Technology INSIDE THE PHARMACY

1. Unit-Based Cabinet (Pyxis®, Omnicell®)

2. Pharmacy Robot (McKesson Robot-Rx®)

3. Sterile Compounding Automation

Examples of Automation and Technology INSIDE THE PHARMACY (3)

safety

Medication-related technology used outside of the pharmacy is usually focused on ______.

Automation and Technology OUTSIDE PHARMACY

These systems have a direct impact on the pharmacy and require active involvement by the pharmacy in making sure that systems are designed and used optimally to realize their safety benefits.

1. Bar coded medication administration (BCMA) systems

2. Computerized prescriber order entry systems (CPOE)

3. Smart pumps

Examples of Automation and Technology OUTSIDE THE PHARMACY (3)

1. Most institutional care is provided to inpatients. Since health care reimbursement models changed in the 1980s, there has been a shift to treat patients in the home or non-hospital setting whenever possible.

2. These shifts have moved healthier patients to outpatient settings while focusing hospital care on treating only the sickest patients.

UNIQUENESS OF THE HOSPITAL PHARMACY PRACTICE (2)

Inpatient Care

Admitted within the floors of a hospital.

Critical Care

Patients are of a higher acuity level, meaning that they have greater needs for care.

Critical Care

Patients are, by definition, critically ill and therefore their clinical status is constantly changing.

Critical Care

They must be monitored closely and their drug therapy is often changed or adjusted and typically, these patients are on multiple intravenous medications, thereby creating a high potential for incompatibilities, drug interactions, and errors.

Critical Care

Patients also may have declining organ function, such as kidneys or liver, which affects drug dosing.

1. surgical,

2. medical,

3. neurosurgery,

4. pediatrics,

5. coronary care,

6. neonatal,

7. burn, and others.

Examples of critical care units include (7)

1. Making sure that patients are receiving the right drugs, in the dose that is appropriate for their condition, and without error.

2. Participates in medical rounds with the rest of the healthcare team, providing advice and information on drug therapy

ROLE OF PHARMACISTS IN CRITICAL CARE (2)

General Care Units

The acuity of patients is less.

General Care Units

Drug therapy is more likely to be stable, and many times is a combination of oral and intravenous medications, depending on the patient's treatment regimen.

Medication Reconciliation

is the process of comparing a patient's medication orders to all of the medications that the patient has been taking.

Medication Reconciliation

Compare all the medications, transfer of care, and upon discharge.

1. Assuring that the patient orders upon admission accurately reflect those medications being taken at home, making sure that the discharge orders are appropriate, & that patients are going to be able to continue their medications upon arriving home.

2. Attends medical rounds with a health-care team, depending on the nature of the hospital.

3. General care units include medical, surgical, pediatrics, cardiology, orthopedics, post-partum, obstetrics and gynecology, oncology, and others.

ROLE OF PHARMACISTS IN GENERAL CARE UNITS (3)

Outpatient Dispensing Pharmacy

Most common and perhaps most visible, similar to community pharmacies without general merchandise.

Outpatient Dispensing Pharmacy

Many hospitals have at least one outpatient dispensing pharmacy which cater to clinic patients, patients being discharged from inpatient settings, and patients with prescriptions written in emergency departments.

1. Drug therapy consultation with providers

2. Error prevention & patient safety

3. Monitoring adherence to practice guidelines

4. Medication counseling

5. Reviewing patient profile ○

6. Participating in resuscitation efforts

The pharmacist’s role in the emergency department usually includes: (6)

Ambulatory Care Clinics

Clinics may be general in nature (e.g., primary care, medication adherence) or specialized (e.g., anticoagulation, palliative care).

Ambulatory Care Clinics

In these settings, medication therapy is managed by a pharmacist and usually patients see the pharmacist one-on-one by appointment.

Ambulatory Care Clinics

Pharmacists have great potential to improve medication-therapy outcomes, reduce errors, and reduce readmissions in outpatient clinic settings.

Home Health Care

most specifically home infusion services, have evolved as a way for patients to be treated in a non-hospital setting, usually their home.

Home Health Care

These pharmacy services are unique in that they provide infusion therapy for both short term and long-term chronic conditions.

1. Antimicrobial therapy

2. Pain management

3. Parental nutrition

4. Chemotherapy administration

Common therapies in Home Health Care include: (4)

1. training,

2. storage,

3. labeling,

4. administration,

5. disposal of medications.

Considerations in Home Health Care (5)

True

True or False

In Home Health Care, pharmacists play an important role in making sure that patients receive their medications appropriately under these less controlled conditions.

1. Increased interaction with prescribers and other health professionals.

2. Greater input in prescribing decisions about drugs and administration.

3. Larger team of pharmacists working together in the same institution.

4. Better access to medical records of patients.

5. Patient contact for hospital pharmacists is often much less when compared to a pharmacist working in the community.

6. Hospital pharmacies also usually stock a large variety of medications, including those for specialized purposes that may only be indicated in a controlled medical setting.

Differences between Hospital Pharmacy and Community Pharmacy (6)

Accreditation and Standards of Practice

Institutional pharmacy practice is governed by a variety of requirements and guidance including, respectively, accreditation and practice standards.

Accreditation

is a voluntary process by which the quality of care provided by a hospital is assessed by an outside accrediting body on a routine basis.

Accreditation Organizations

• are different from regulatory bodies in that their primary purpose is to assess and improve the quality of patient care (i.e., when they identify a quality of care problem they work with the hospital to make improvements).

• have no authority to impose fines or bring forth legal action.

Regulatory Bodies

are law enforcement bodies whose purpose is public protection, and are therefore tasked with imposing fines and taking other legal actions.

Practice Standards or Practice Guidelines

are those practices that a profession develops and imposes on itself.

○ Practice standards should be based on the best scientific evidence, and should ideally strive to surpass minimum requirements established by law or regulation.

Licensure

a process by which a governmental authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession.

protect basic public health and safety.

Purpose of Licensure

Certification

● a process by which an authorized body, either a governmental or non-governmental organization, evaluates and recognizes either an individual or an organization as meeting pre-determined requirements or criteria.

1. Possessing good leadership skills and providing leadership is important for virtually all pharmacist roles, but it is especially crucial for those individuals responsible for the oversight of pharmacy services.

   • This includes the primary pharmacist in charge and other pharmacy managers who have responsibility for specific aspects of pharmacy services.

2. The primary pharmacist in charge, usually referred to as the Director of Pharmacy, has ultimate responsibility and accountability for all aspects of the pharmacy service.

   • This includes the safety of medication use, quality of drug information provided, financial budgeting and management, human resources, drug procurement, technology implementation, education and qualifications of their staff, regulatory compliance and adherence to accreditation standards.

3. The quality of services depends on strong leadership in these types of positions, as well as the advancement of pharmacy practice.

IMPORTANCE OF PHARMACY LEADERSHIP (3)