decentralized pharmacy services phcl 471 nouf aloudah

Decentralized Pharmacy ServicesPHCL 471Nouf Aloudah

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Decentralized Pharmacy Services

Hospital pharmacy departments are responsible for the safe and effective use of drugs and drug products within the institution

Pharmacy personnel perform functions that relate to drug distribution and drug information in striving toward this objective

Decentralized pharmacy services have proven over long period of time to be an important action plan to achieve “safe and effective use of drugs” for patients

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Since the mid 1960’s, hospital pharmacy services have evolved to meet these needs, frequently by decentralizing operations and staff in order to provide clinical services and more efficient and less error prone medication system

A decentralized pharmacy is an area located in the patient care parts of a hospital from which pharmacy personnel work and provide pharmacist clinical services and drug distribution service

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Hospital pharmacies historically have been centralized departments

A s hospital increased in size from 100-200 bed facilities to 400-500 bed institutions, there has been a tendency to locate the central pharmacy away from inpatient care areas

Decentralized pharmacies have been an effective method for bringing pharmacy services closer to the patients and professional staff

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The safe and effective use of drugs requires clinically competent pharmacist, system, and services to deal with all patient care areas in cooperation with physician and nurses

A decentralized service component maximize pharmacists’ communications and contributions to the professional staffs and the patient

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A completely decentralized pharmacy staff puts pharmacists and drug close to the end users and facilitates the provision of necessary drugs and drug information in an effective manner

The rationale for providing “proactive” pharmaceutical services is discussed today in conjunction with the alternative centralized and decentralized approaches to providing these services

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Patient needsNurse needsPhysician needsAnd pharmacy needs

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Patient needsHospital medication system have

been reported to have an 8-20 % medication error rate

Medication errors are defined as wrong patient, wrong drug, wrong dose, wrong route and wrong time

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Patient needsComplications in patients resulting from

drug use are1. Adverse drug reaction, 5-30% of

patients2. Prolonged hospitalization from adverse

drug reaction3. Drug modifying laboratory tests4. Drug inducing blood dyspraxia5. Drugs affecting liver function tests6. And drug interaction and teratology

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Patient needsMedication prescribing errors

with regard to safe or effective dosage regimens, ambiguous and incomplete orders, inadequate laboratory test monitoring, and misinterpretation of meaning of serum drug level have been reported

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Patient needsPharmacist dispensing from a central

pharmacy has resulted ◦ in a high rate errors◦Prolonged delays in receiving initial doses◦Significant drug complications◦Extended hospital stays◦ Increased expense

New drugs and drug delivery system technologies will be more complicated and more potent with high risks of toxicity

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Nursing needsPlays a major role in the hospital medication

systemThe nurse may order drugs from the pharmacy,

prepare and reconstitute doses for administration, administer medications, record each drug administered, keep additional records for the controlled drug received and administered, and maintain drug floorstock

Without adequate pharmacy support, the nurse would have to be knowledgeable about drug storage, dosage forms and strengths, the effect of each drug

administered, and the safety of drugs IV administered….. As a result a great deal of nursing time is required for medication related activities!

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Nursing needs Generic drug names, therapeutic interchange of

drug products, variable dosage depending upon the drug’s salt form, more dangerous drugs such

as oncology agents …. just examples of continuing area of confusion and potential errors!

Registered nurse shortage, high staff turnover… make it very difficult to maintain a consistently experienced and a drug knowledgeable nursing staff

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Nursing needsA centralized pharmacy services

frequently leads to many unanswered drug related questions by a busy nurse

A decentralized pharmacy service more readily provides the drug related activities and drug information support to the nurse when needed

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Physician needsThe physician diagnoses the patient

medical problem and then prescribe a plan of therapy

The prescribing of drugs is frequently a critical aspect of inpatient care

Drug complications illustrate the physician’s need for general and specific clinical drug information

Pharmacist can reduce costly drug reactions and quicken the discharge of the patient from a hospital

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Physician needs Medical services representatives, Physician Desk Reference,

journal articles, textbooks, drug data, professional conferences

are the usual sources of physician drug information

Theses sources are inadequate in meeting when it relates to complex patients with multiple healthcare problems and multiple drug regimens

Pharmacist who practice in patient care areas can provide clinical drug knowledge and experience to help physician mange their patients’ drug therapy

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Pharmacist needsIn centralized pharmacy the time is devoted to

dispensing duties, professional relationship with the nurse, physician and others are limited

In decentralized environments:◦ the pharmacist is able to relate directly to a patent’s

drug therapy needs as a result of easy access to the patient, nurse, physician

◦ Initial doses for new order can be provided quickly◦ Drug information questions can be answered quickly◦ Pharmacist can develop expertise for particular

patient areas… and more!

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Services And Expected Patient Benefits Of A Decentralized Pharmacy

Pharmacist practicing in hospitals have been active in developing new pharmaceutical services and systems (unit dose distribution system, patient medication profile, drug information services, pharmacist participating in patient care areas, clinical

pharmacokinetics) directed toward reducing the problems associated with drug use

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Characteristic of a pharmacist clinical practice in decentralized pharmacy are:

Patient care roundParticipating in teaching rounds by providing

drug information upon physician request or by pharmacist initiation which usually result in improving in the patient\s treatment plan

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Patient interviewsDrug history information that obtained orallyPrescription and OTC drugs, drug allergy,

attitude about drug as to which worked or did not work

Previous patient drug therapy problems, attitude and misconceptions as to what drugs worked or did not work are identified

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Patient medication therapy monitoringSafe and effective drug therapy is determined

by reviewing medication chartsDrug administered, pertinent laboratory tests,

and patient’s diagnosis and medical condition Changes in drug therapy, actual and potential

drug therapy problems are communicated to the physician

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Physician inquiryPhysician initiated and general drug

information questions are answered by the pharmacist

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Nurse InquiryNurse initiated questions about patient

drug therapy, general drug information, and drug orders are answered by the pharmacist

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Drug InformationThe physician and pharmacist initiate a drug

information questions involving a patient’s drug therapy problems requiring a search of the available literature for information in order to provide a response

The answer should result in safer and more effective drug therapy

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Cardiopulmonary Arrest Emergency Participation

The pharmacist is a member of the hospital’s cardiopulmonary resuscitation team and participates by providing drug therapy assistance and the needed drugs

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Pharmacist regulated drug therapy servicesSpecial services such as anticoagulation,

dosing of drugs in patients with compromised renal status, drugs affecting the blood and liver, amioglycoside dosing, pain control, nutrition support, and aminophyllin therapies

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Clinical pharmacokineticsSchedules the appropriate time for drug

levels to help ensure that test results are usable. Consultation services using the serum drug level and kinetic knowledge can be provided to modify the dose and/or dosing interval to prevent toxicity and ensure therapeutic efficacy

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Drug usage evaluationSpecial drug case studies are conducted and

educational programs provided to the medical, nursing, and pharmacy staff by the pharmacist

Targeted incorrect and inappropriate drug prescription of physician should be corrected via educational programs

Cost and cost reductions of drug therapy can be defined and documented

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Pharmacist performance characteristicsPharmacists who practice in a decentralized

pharmacy environment are able to greatly expand their professional knowledge ad skills in the areas of patient service, teaching, and research bec. Of the greater opportunities for clinical experience

To be successful:Commitment to high standard patient care servicesClinical knowledge and skillsCommitment to lifelong learning Initiative; self accountability and productivitySpecialization or concentration of time and energy

into selected areas of clinical drug use

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What departmental organizational plan or structure is the most effective in providing services to meet patient, nurse, and physical drug related needs?

Drug distribution system that maximize the use of nonpharmacists in the inpatient drug distribution system of the hospital

Unit dose system are more just providing double checks, reducing medication errors and eliminating the drug waste seen in multiple dose systems, it allows the pharmacist to delegate many of the nonprofessional drug distribution tasks to technician and still maintain the necessary responsibility and supervision, that resulted in more pharmacist time for clinical services

Patient drug profiles associated with unit dose system also can provide a record that become the basis for the pharmacist’s patient drug therapy monitoring system

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Advantages and disadvantages of a decentralized pharmacy services?

Pharmacy departments are usually referred to as either “centralized” or “decentralized” this is oversimplification, because most decentralized pharmacy departments are a mix of centralized and decentralized functions

Decentralized pharmacies frequently differ considerably in exactly what is decentralized and how

The way services are provided may also vary from shift to shift, from weekday to weekend

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Functions are New order review by the pharmacist First dose preparation Unit dose preparation of ongoing orders Unit dose checking by the pharmacist or trained technician IV order review by the pharmacist IV order preparation including admixture and total parenteral

nutrition IV piggy back (PB) order reconstitution IVPB order review by the pharmacist IVPB order distribution to the patient Prescription filing for discharge and special inpatients Unit dose packaging

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Functions are (cont’) PK consults by the pharmacist Drug level order/or scheduling by the pharmacist Drug information questions directed to the pharmacist Responses to drug information questions Nonformulary drug request follow-up by the pharmacist Pharmacist –patient interviewing as needed Drug therapy regulation by the pharmacist Drug therapy monitoring by the pharmacist ADR monitoring by the pharmacist Pharmacy charge processing

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These functions: some must be done by the pharmacist, others by technician or clerk

Some requires the pharmacist to be outside the pharmacy

Some nonpharmacist activities requires immediate supervision others not

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What is the scope of the pharmacy services? What and when?

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Advantages of a decentralized pharmacy services

1. Drugs are immediately available for administration to the patient

2. Drug control and accountability are greater3. Pharmacist communicate directly to the nurse

and physician4. There is more space for the pharmacy as a

whole and flexibility in reallocating or designing existing space in the central pharmacy

5. Unique drug distribution systems are implemented to issue drugs to the nurse

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Advantages of a decentralized pharmacy services 6. Pharmacist review of the chart or talk with the patient

is efficient7. Drug information from the pharmacist is readily

available to physician and nurses8. Nursing time is reduced in drug distribution bec. More

tasks are being performed by pharmacy personnel9. Pharmacist drug therapy specialization by patient care

area is accomplished more effectively as a result of focused clinical experience

10. Specialized pharmacist clinical services can be developed and efficiently provided

11. Pharmacists more readily perform clinical drug research and patient drug therapy quality assessment studies

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disadvantages of a decentralized pharmacy services 1. All clinical practice pharmacies must become proficient

as supervision to work effectively with technicians2. Pharmacist are usually responsible for both drug

distribution and clinical services3. Staffing flexibility id reduced when only one pharmacist

with or without a technician is providing all inpatient pharmacy services for a specific patient car area when census level are significantly above or below normal

4. Unrealistic expectation from nursing and physician and excessive interruptions off the pharmacist and /or technician can reduce efficiency

5. Drug inventory control within the department is more complex because of multiple pharmacy location for the same drug, particularity infrequently prescribed drugs

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disadvantages of a decentralized pharmacy services

6. Communications within the pharmacy department are more difficult bec. the staff member practice in multiple physical location

7. More equipment is required8. Patient acuity and resulting drug distribution

work load may exceed the capacity of space and personnel in the small decentralized pharmacy units

9. Use of technology to automate and mechanize the drug distribution system component of pharmacy service will require more hardware and software

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Relative cost of a decentralized and decentralized pharmacy service

Cost is very impartment part in hospital decision

Cost is either patient benefits such as reduction in mortality, morbidity, and hospital patient days

Also it is the equipment, facilities, and personnel

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Relative cost of a decentralized and decentralized pharmacy service

Equipment and facilitiesSpace, size, computer systemPersonnelComparisons such as Centralized

pharmacy services personnel cost per patient day and decentralized pharmacy services personnel cost per patient day and other can help

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Forces that interfere with decentralized pharmacy service

Attitude ad behavior Pharmacy department Pharmacy time for information

functions Legal requirements

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Any volunteers !AssignmentsDermal fillers (previous lecture)Medication therapy management

(MTM) programs

Best Wishes!