HOSPITAL AND CLINICAL
PHARMACIST PRESENT AND
FUTURE ROLES
Antnio Melo Gouveia
Hospital Pharmacist
Instituto Portugus de Oncologia de Lisboa, Portugal
Member of the Scientific Committee of the EAHP
What is a HOSPITAL PHARMACIST ?
(EAHP)
Hospital pharmacy is the health care service, which comprises the art, practice, and
profession of choosing, preparing, storing, compounding, and dispensing medicines and
medical devices, advising healthcare professionals and patients on their safe, effective and
efficient use.
Hospital pharmacy is a specialised field of pharmacy which forms an integrated part of
patient health care in a health facility.
Hospital pharmacy is the profession that strives to continuously maintain and improve the
medication management and pharmaceutical care of patients to the highest standards in a
hospital setting.
Hospital pharmacists provide services to patients and health care professionals in hospitals.
The missions of the hospital pharmacist
to be part of the medication management in hospitals, which encompasses the entire way
in which medicines are selected, procured, delivered, prescribed, administered and
reviewed to optimise the contribution that medicines make to producing informed and
desired outcomes
to enhance the safety and quality of all medicine related processes affecting patients of the
hospital
to ensure the 7 rights are respected: right patient, right dose, right route, right time, right
drug with the right information and documentation
What is a CLINICAL PHARMACIST ?
ESCP
Clinical Pharmacy - a Definition
Clinical Pharmacy () is a health specialty, which describes the activities and services of the
clinical pharmacist to develop and promote the rational and appropriate use of medicinal
products and devices.
Clinical Pharmacy includes all the services performed by pharmacists practising in hospitals,
community pharmacies, nursing homes, home-based care services, clinics and any other
setting where medicines are prescribed and used.
The term clinical does not necessarily imply an activity implemented in a hospital setting. A
community pharmacist may perform clinical activities as well as a hospital practitioner.
How does clinical pharmacy differ from pharmacy?
the discipline of pharmacy embraces the knowledge on synthesis, chemistry and preparation
of drugs
clinical pharmacy is more oriented to the analysis of population needs with regards to
medicines, ways of administration, patterns of use and drugs effects on the patients.
The focus () moves from the drug to the single patient or population receiving drugs.
Clinical Pharmacy - Overall Goal
The () goal of clinical pharmacy activities is to promote the correct and appropriate use of
medicinal products and devices. () maximising the clinical effect of medicines, i.e., using the
most effective treatment for each type of patient ; minimising the risk of treatment-induced
adverse events, i.e., monitoring the therapy course and the patients compliance with therapy
() minimising the expenditures for pharmacological treatments () trying to provide the
best treatment alternative for the greatest number of patients.
So, where are the differences?
Specific to Hospital Pharmacy: buying and
compounding (is it totally outside clinical
pharmacy or not ?)
Specific to Clinical Pharmacy: outside the
hospital setting
What about REAL LIFE ? (of the Hospital
Pharmacist )
Getting the drugs the patients need
Compounding what we cannot get
Small scale manufacturing
Storing medication
Therapeutic drug monitoring
Preparing Cytotoxics and other IV drugs
Dispensing Drugs to Patients
Working within the therapeutic team
Getting the drugs the patients
need
No logistic operator to support us.
Choosing therapeutic equivalents (the me toos - which one is
better, cheaper, more likely to have generics.) and the market
find the lowest price always.
Finding the hard to find drug:
Too new (I need defibrotide for my bone marrow transplant patient by
Monday back in 2003)
Too old (it is uthinkable that you dont have liotironin for my patient- can
you at least suggest a replacement drug?)
Drug shortages at a hospital pharmacy in Germany, EJHP, Year: 2007; Nr: 6; Pages: 44- 48; Author: Walter Deutschmann
Compounding what we cannot get
Compounding may be like factory work, but
often in HP it is very patient oriented.
Even small scale production is often a direct answer to patients needs (or
economic/market concerns)
The very young children in the Bone Marrow Transplant unit
need tacrolimus oral suspension can you do it? (2004)
The radiotherapy patients often have anal fissures that dont
heal. Ive read something about l-arginine
The GVH reaction is impairing the sight of this patient could
we try ciclosporin eyedrops or autologous serum eyedrops ?
Storing medication
Doesnt seem very patient oriented.
However
In the hospital (and elsewhere), nobody cares
about the very informative pharmacist who
doesnt have the drug for the patient.
The way we reduce the weight of tasks in
stock management is the way towards the
patient.
Therapeutic drug monitoring
Analytics its pharmacy
Result interpretation and dosage schedule
suggestion its clinical pharmacy
Again, the weight of pharmacy work can
hinder the ability to look at the patient.
Preparing Cytotoxics and other IV
drugs
GMP (even in a light HP version) is a MUST.
Hospital pharmacists must ensure GMP
compliance but
Error control in cytotoxics is a major problem.
Patient by patient prescription validation is
fundamental.
Process design is also fundamental
Preparing Cytotoxics and other IV
drugs
Some validation topics:
Strict use of pre-approved protocols (P?)
Patient data: diagnosis, weight/body surface (CP)
Check adequate dosing for patient/disease/drug (CP)
Check for variations to previous cycles (CP)
Recalculate body surface, eventually correction for renal
function data may be adequate (CP)
Check dilution, solvents, stability , light sensitivity, etc.(P)
In the same process you must use typical pharmacy skills and
perform clinical pharmacy activity.
Dispensing Drugs to Patients
In some countries, some drugs for ambulatory use must be dispensed by
hospital pharmacy. Typical of these are HIV drugs and Cancer oral drugs
(cytotoxics but also hormonal drugs)
Compliance, advice, connection to the
therapeutic team, easy access to hospital
resources
The (HP?) pharmacist works with the patient.
Should provide a clinic environment.
Uncontrolled info (www) vs Technically sound
info
Working within the therapeutic
team
The key issue !
Doctors and Nurses are all around us.
And nutritionists, and psychologists, and social
workers and
Decisions can have immediate and serious
consequences. Must be right! Must be fast!
Advice is expected to be correct and swift,
otherwise credibility is lost
Education: the EAHP data
This brings us to education issues:
What makes a hospital pharmacist?
In Europe!
The EAHP has made a SURVEY!
The problem with surveys is that not
everybody answers, and when answers, they
are not all very clear.
EAHP
Specialisation in HP in Europe
Austria
Croatia
Denmark
Finland
FYROM
Greece
Ireland
Latvia
Luxembourg
Norway
Portugal
Slovakia
Spain
Switzerland
United Kingdom
Belgium
Czech Rep.
Estonia
France
Germany
Hungary
Italy
Lithuania
Netherlands
Poland
Serbia
Slovenia
Sweden
Turkey
29 EAHP members
No specialisation
Specialisation
Not member of EAHP
Country
Specialization
Inclusion criteria
Years
AT
BE
YES
YES
M Sc Pharm
M Sc Pharm
3
1
CH
CR
CZ
YES
NO
YES
M Sc Pharm
M Sc Pharm
DE
YES
Stadtsexam in Pharmacy
DK
YES
M Sc Pharm
ES
YES
M Sc Pham + exam
EST
FI
NO
YES
M Sc Pharm
FR
YES
M Sc Pharm
GR
HU
IE
IT
NO
YES
YES
YES
M Sc Pharm
M Sc Pharm
M Sc Pham + exam
LA
LIT
LUX
NL
NO
NO
NO
YES
NO
PL
Title
Hospital Pharmacist
Responsible Association/University
Apotekarkammar
All University work together /Flemish), Leuven and
Liege/Brussels (French)
Swiss Society of Hospital Pharmacy
Pharmacist with
specialisation in hospital
pharmacy
Fachapotekar for (clinical
pharmacy etc)
Ministry of health/Institute of further education for staff in health
care
Specialist in Hospital
Pharmacy
Specialist in Hospital
Pharmacy
Pharmacy Faculty Copenhagen/Hospital Pharmacy Managers
Specialist in Health Care
Pharmacy
Specialist in Hospital
Pharmacy
Faculty of Pharmacy Kuopio
3
2
4
Hospital pharmacist
M Sc Hosp Pham
Specialist in Hospital
Pharmacy
Four different Faculty of Pharmacy
Trinity College Dublin or Cork University
Dep of Pharm Sci/School of Specialization in Hospital
Pharmacy
M Sc Pharm
Hospital Pharmacist
(registerd specialisation)
Dutch National Assos of Pharm
NO
YES
M Sc Pharm
center for education after the study work with ministry of health
POR
YES
M Sc Pharm
SE
YES
M Sc Pharm
SK
SL
YES
YES
M Sc Pharm
M Sc Pharm
3
3
Specialist in Hospital
Pharmacy
Specialist in Hospital
Pharmacy
Specialist in Health Care
Pharmacy
Specialist in.
Specialist in Pharmacy
UK
YES
M Sc Pharm
M Sc Clin Pharm
Chamber of Pharmacy/Regional
Ministry of Health/Spanish Hospital Pharmacy Association
Faculty of pharmacy/University
Order of Pharmacist-College of Hospital Pharmacy
Swedish Pharmaceutical Association
Pharmacy Faculty Ljubliana
Ministry of health/University/Institute of further education for
staff in health care
University
What makes a Hospital Pharmacist ?
EAHP concept!
Pharmacy education, obviously, because HP is
pharmacy in a nutshell from
manufacturing to patient counseling, you have
to do it all.
Specialization: the responsibility and the
specific demands of hospital environment
multidisciplinary work require a specialist in
Hospital Pharmacy
What is a Specialist in Hospital
Pharmacy
Should be a pharmacist who, through a mix of practice and
formal education, is given a degree - which means a level of
responsibility.
Can further specialize in clinical areas of interest oncology,
nutrition, infections diseases, cardiovascular
Is the guy who is working within the hospital therapeutic
team, and can take for responsibility for:
Suggesting a new dosage schedule
Stopping a dangerous prescription
Designing and testing a new formulation
Prescribing according to protocol
How to create this Specialist
In Europe there are many ways to achieve the
same goals thus, some degree of
harmonization could be welcome.
- Internship plus final examination by competent entity
- Formal education in university, with a practical component
(MSc in Hospital Pharmacy)
- Etc.
The EAHP believes that specialisation in hospital
pharmacy should be recognised on the European
level: this is hopefully the outcome of the Pharmine
project lead by EAFP where EAHP is a partner.
What about the future ?
The way towards the patient.
The tasks of Hospital Pharmacy already require that the focus
is the patient.
The shift of focus towards the patient should intensify in the
coming years
In the near future, the development of genomic and
proteomic medicines will imply more and more tailored made
treatments requiring specific clinical pharmacy skills.
The number of pharmacists and the weight of basic pharmacy
tasks can block the process.
There is a two sided relationship between clinical pharmacy
activities in hospitals and number of pharmacists
Its a question of balance!
The balance for the hospital pharmacist is
between the
buying/storing/compounding/dispensing
and the increased focus on the patient in all
activities.
Its not what we do, but how we
do it.
.
Thank You
