CLINICAL PHARMACY SERVICES AT A PUBLIC SECTOR HOSPITAL

Zaufishan Rahman

The Children’s Hospital & Institute of Child Health, Lahore

The Children Hospital & Institute of Child Health

State of the art - Tertiary care hospital Centre of Excellence 45 different specialties in medicine, surgery and

diagnostics 418 beds strength The hospital OPD operationalized in May 1995 and

emergency in October 1996 In-patient services were first initiated in December

1998

Department of Pharmaceutical Services

How the Pharmacy Services are different today?

In changing times…. a need for pharmacists to shift their focus a need to target outcomes that matters a need to take responsibility for outcomes

....thereby, a need to provide patient centered care

Patient Centered Care

Pharmaceutical care is:

“The cooperative and responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient’s quality of life”

PHARMACEUTICAL CARE PLANS

Key elements

Drug Individualization All pediatric patients need weight based dosing;

hence at increased risk of adverse events

Monitoring of Drug Interactions Monitoring of In-Vitro and In-vivo drug

interactions

Monitoring and Reporting of potential ADRs

Pharmaceutical Care Planning

Patient Category Pharmacist’s Role

1. Patients on polypharmacy

To check each drug for indication, effectiveness, safety, and compliance.

To suggest reduction of doses or drugs

To advice on how to minimize adverse effects, and on best timing to take each drug in relation to other drugs, meal times, daily activities, etc

Pharmaceutical Care Planning

Patient Category Pharmacist’s Role

2. Patients with actual orpotential DRPs

To follow a structured process to identify actual or potentialdrug-related problems and

To develop a plan to eliminate or minimize these problems and maximize desired outcomes

Patient Category Pharmacist’s Role

3. Patients who requireeducation to improve theircompliance with drugtherapy

To discuss the issues with patients to gauge the reasons for poor compliance and

Devising plans to improve compliance and concordance

Pharmaceutical Care Planning

Pharmaceutical Care Planning

Patient Category Pharmacist’s Role

4. Patients on medicines which require the use of Devices as- Asthma inhalers- Glucometers

To identify problems with how thepatient use the drug givingdevices and

To train the patient on the properuse of devices to maximizethe benefit of the drugs.

Pharmaceutical Care Planning

Patient Category Pharmacist’s Role

5. Patients on potentiallyharmful drugs which requireeducation and monitoring(warfarin, steroids,chemotherapy)

To educate the patients on theuse of drug with potentialfor serious adverse effectsor for drug-drug or drug foodinteractions, and alsothose drugs which requiremonitoring to avoid harmfuleffects

Pharmaceutical Care Planning

Patient Category Pharmacist’s Role

6. Patients referred by theirclinicians

Clinicians may wish to refer specific patients to the service when they identifyan issue where the pharmacist might haveappropriate input

Extended Scope of clinical pharmacy services

Participation in clinical rounds Drug information centre services Poisoning & Drug Overdose management services Total Parental Nutrition (TPN) Extemporaneous Preparations Clinical training program Hospital Clinical Committees

Participation in Rounds

1 Working in a multidisciplinary team Interaction with patient’s other

healthcare providers Ensuring best clinical outcomes Preparation and Implementation of

Pharmaceutical Care Plans

Drug information Centre Services

2Provision of unbiased, scientific and up to

date information to health care professionals

Concept Paper Protocol Tools:

DIC Query Form – A DIC Query Form – B DIC Query Referral Form - C

Clinical Pharmacist as Information Manger:….….Assessing the Evidence Where and When you need it!

Developing Liaison with other Drug Information Centres and creating a network of knowledge banks, nationally & globally.

Poisoning & Drug Overdose Management

3 24/7 Presence of Pharmacist in Emergency

Department Availability of antidotes Backup support from Drug Information Centre Examples:

Management of Kerosine oil poisoning Management of patient who has ingested milk with

a lizard

Total Parental Nutrition (TPN)

4 First of its kind in any public sector hospital

in Punjab Caters individual needs of patients Plays a significant role in reducing the

morbidity and improving the quality of life of patients

Ensuring aseptic environment with use of Laminar Flow Hoods

Provision of services to other hospitals

TPN During last 1 year i.e. December 2010 to

November 2011: A total of 1202 calls have been received by TPN

department More than 244 pediatric patients benefited

Dispensing an average of 100 calls per month Dispensing an average of 5 TPN calls per patient

Extemporaneous Preparations

5Sr.

No

Preparations Used in/ for

1. Zinc Sulphate Sachets Zinc deficiency with diarrhea

2. Zinc Acetate Sachets Wilsons Disease

3. Jouli’s Solution Hypo-phosphatemia Rickets

4. Hydrosol, Eusol Solution Wet dressings (Irrigation Solution)

5. Sodium Benzoate Solution Urea cycle defect and hyperammonemia

6. Dexinal Mouthwash Oncology Patients

7. Morphine Suspension Oncology Patients

8. Shohl’s Solution (Polycitra, Polycitra-K, Bicitra)

Renal tubular acidosis

9. Tablet dilutions of Digoxin, Sildenafil, Indomethacin, Spiromide

Pediatric Cardiology Unit

Clinical Training Programs (>400 students/ year)

6 Clinical Pharmacy Residency Program

Eligibility: Graduates and Awaiting result students

Clinical Pharmacy Projects Eligibility: 5th Professional Students

Clinical Pharmacy Internship Program Eligibility: 4th Professional Students

Hospital Clinical Committees

7 Pharmacy & Therapeutics Committee

Comprises of all department heads, Assistant and Associate Professors, Pharmacists and administration.

Hospital Infection Control Committee:Pharmacists as key members of team for effective infection control measures

Clinical Pharmacy Services

CASE SCENARIOS

“… and if anyone saved a life; it would be as if he saved the life of whole mankind”

Case 1: Thalasemia Major Patient Name: Sarfaraz Age : 6 years Weight: 18 kg History of present illness:Patient is presented in OPD with generalized body aches,

abdominal distention due to massive splenomegaly and significantly darkened skin tone.

Pharmacist’s Intervention:Patient’s attendants are counseled for regular and consistent use

of agents that treat Iron overdoe (Deferasirox) and regular Serum Ferritin test

Case 2: Bronchial Pneumonia Patient Name: Zihan Age: 7 months Weight: 5kg Current Medication:

Paracetamol, Cefuroxime, Amikacin Nebulize with Aprint, N/Saline and

Clenil

Pharmacist’s Intervention:Patient’s mother education and

counseling on proper nebulizing technique

Case 3: Pericardial Effusion Patient Name: Minahil Age: 2 months Weight: 3.2 kg Current Medication:

Inj. Ceftrioxone, Inj. Lasix, Inj. Vancomycin

Pharmacist’s Intervention:Patient at increased risk of ototoxicity with combination

of Ceftrioxone and Furosemide; Close monitoring is recommended after consultation with doctor

Case 4: Pneumonia and Sepsis Patient Name: Iman Fatima Age: 21 days Weight: 2.2 kg Medication:

Inj. Meropenam and Inj. Vancomycin are prescribed to patient after resistance to Ciprofloxacin, Ceftrioxone, Amikacin and Amoxicillin

Pharmacist’s Intervention: Pharmacist ensured that culture sensitivity test is done before prescribing

the third line therapy. Culture was positive for Klebsella and Enterobacter Separate administration of Ceftrioxone and Amikacin was recommended

to nurse as these drugs can interact when administered together.

Case 5: Nephrotic Syndrome with Acute Renal Failure

Suspected Meningococemia Patient Name: Abdul Malik Age: 16 months Weight: 10kg Medication:

Inj.Benzyl Penicillin, Inj. Solucortif, Inj. Ceftrioxone 500mg IV 12 hourly, Syp Mucain 1tsf 8 hourly, Inj Ranitidine 5mg IV 6 hourly and others

Pharmacist’s Intervention:- Dose of Ceftrioxone and Ranitidine is correct for normal patient

but should be reduced to half for patient with severe renal impairment

Case 6: Pseudo- Pancreatic Cyst

Patient Name: Zainab Age: 2.6 years Body weight:

On 1st day of admission her body weight was 9.2kg. On 24th day of hospital stay on 3 December, 2011 she was NPO since last 31 days and all the required nutrients are being given to her through central and peripheral lines as parental nutrition.

Her last recorded body weight is 10kg.

Patient maintained body weight with significant improvement in clinical outcomes and resumed oral feed

Way Forward

WHAT'S NEXT?

Extension of Clinical Services Workshop on Identification of potential ADRs monitoring and reporting

Doctors, Pharmacists and Nurses

Workshop on Poisoning and Drug Overdose Management

Drug Utilization Reviews Utilization review of Meropenam – In Process Others - In design phase

Impact Assessment Studies Impact assessment study of TPN in improving quality of life of neonatal

patients

Access to healthcare is a fundamental human right!

“Of all forms of inequality, injustice in health care is the most shocking and inhumane”

Martin Luther King, Jr

Every Single Life is Valuable….!

UNICEF Missing Mothers a video message on maternal mortality.mp4

THINK GLOBAL ….…. ACT LOCAL!Thankyou!