Community & Hospital Pharmacy Operations and Ward Participation

Community Pharmacy Practice

Importance and Scope of Community Pharmacy

• Definition: Provision of pharmaceutical care by pharmacists in primary healthcare settings. A drug store or medicine shop meeting public’s medicine and healthcare needs.
• Accessibility: Community pharmacists are often the most accessible healthcare professionals to the public, frequently serving as the first point of contact due to easy access and free advice.
• Potential Role: Enormous potential to play a positive and useful role in the public healthcare system.
• Global Context:
  • United States (USA): Pharmacist responsibility for safe and effective drug therapy, conducting prescription reviews, maintaining patient records, and providing counselling (established by OBRA-90, 1990).
  • Canada: Involved in professional dispensing, patient counselling, medication management review for seniors, and care for specific conditions (diabetes, hypertension, smoking cessation).
  • Australia: Professional dispensing, patient counselling, health screening, drug information, and Home Medicines Review (HMR) services. Pharmacy ownership is restricted to pharmacists, and location rules protect established pharmacies. The Pharmaceutical Benefits Scheme (PBS) subsidises essential medicines, acting as a de facto national formulary.
• Indian Scenario:
  • Historically, community pharmacies were seen predominantly as traders.
  • Over 500,000 retail medical stores exist, often managed by D Pharm qualified pharmacists.
  • Many pharmacists consider it a trade rather than a profession due to poor knowledge base, lack of training, confidence, and financial benefits.
  • Changing Landscape: With new Pharm D and M Pharm (Pharmacy Practice) graduates, a shift towards professional and pharmaceutical care services is expected.
  • Medical staff in pioneering institutions have shown enthusiastic support for clinical pharmacy services, including drug information and patient counselling.

Medication Use Problems in India

• India faces significant drug-related problems due to:
  • Polypharmacy.
  • Drug duplication.
  • Underdosing.
  • Potential drug interactions.
  • Illiteracy and inadequate information about medication use.
• Prescriber Issues: High patient load leads to short consultation times (5-10 minutes), difficulty in clear diagnosis, and reliance on pharmaceutical company promotions for drug information. Tendency to prescribe by brand names (risk of duplication) and empirically treat infections.
• Pharmacist Issues: Traditionally limited professional services (counselling, labelling, doctor interaction) due to lack of knowledge, training, confidence, and financial benefits. Pharmacies may be managed by non-pharmacists.
• Government Policies: Main focus on industry (price control, licensing) rather than wise medicine use. Poor regulation of advertising and promotional claims. Lack of functional national ADR reporting system.
• Patient Issues: Majority of literate Indians cannot read English labels, leading to non-adherence.

Professional Responsibilities of Community Pharmacists

• Core Services:
  • Processing prescriptions.
  • Dispensing prescription and over-the-counter (OTC) medicines.
  • Making extemporaneous preparations and small-scale manufacturing.
  • Supplying traditional/alternative medicines.
• Patient-Oriented Services:
  • Patient Counselling: About medications, diet, lifestyle, administration technique, storage, side effects, interactions, and strategies to overcome problems. A widely accepted responsibility in developed countries.
  • Responding to Minor Ailments: Providing advice and referring patients to doctors when necessary.
  • Medication Reviews: Assessing appropriateness of medicines, identifying drug-related problems (DRPs), and optimizing therapy.
  • Medication Adherence: Identifying determinants, detecting non-adherence, and implementing intervention strategies.
  • Drug Information: Providing unbiased information to healthcare professionals and the public.
  • Pharmacovigilance: Monitoring and reporting Adverse Drug Reactions (ADRs).
  • Health Promotion & Education: Immunisation, vaccination programmes, disease prevention, and public health awareness (e.g., safe sexual practices, chronic disease prevention, poison prevention, smoking cessation).
  • Health Screening Services: Blood pressure, blood glucose, cholesterol, diabetes detection.
  • Maintaining Patient Medication Records: Helps identify DRPs like non-adherence, interactions, and ADRs.
  • Domiciliary Services: Home visits for medication reviews (e.g., Australia’s HMRs).
• Collaboration: Working with patients and other healthcare providers (e.g., doctors).
• Research: Participation in community pharmacy practice research to provide evidence for new initiatives in patient care.

Management Aspects & Dispensing Procedures (Community Pharmacy)

• Legal Requirements (India): Qualified person, 120 sq ft practice area, suitable racks for storing all schedule medicines, special storage for biologicals (vaccines, sera).
• Records: Maintenance of retail and wholesale drug store records.
• Staffing (Australia Example): Pharmacist-owned, limited number of pharmacies per owner. At least one registered pharmacist must be present during opening hours. Support staff (assistants, technicians) are integral, with formal training and certification.
• Quality Control (Australia Example): Quality Care Pharmacy Program (QCPP) ensures adherence to professional standards, including cold chain procedures for refrigerated products.
• Dispensing & Labelling (General):
  • Legal requirement for labels with directions, patient name, pharmacy name.
  • Cautionary and advisory labels for side effects or interactions.
  • Dispensing technicians may prepare medications for pharmacist’s final check.
  • Batch numbers and expiry dates for non-prescription or less-used medicines.
• Reimbursement (Australia Example): Government pays dispensing fees and a mark-up on medication cost. Funding for professional services like HMRs and RMMRs is provided by the government.
• Financial, Materials, Staff, Infrastructure Requirements: These are key aspects of community pharmacy management, implicitly covered by the various operational descriptions and directly mentioned in the syllabus.

Hospital Pharmacy Operations

Hospital Classification and Organisation

• Definition: Hospitals are healthcare facilities providing inpatient services.
• Classification (India):
  • Primary: Early management of patients, minor ailments. General physicians. May be called nursing homes in the private sector.
  • Secondary: Manage more complex cases, often referrals from primary care.
  • Tertiary: High-level specialised care, often teaching hospitals affiliated with medical schools.
• Classification based on Clinical and Non-clinical Basis: Syllabus mentions this as a criterion.
• Organisation Structure: Includes various medical and allied health staff.
• Healthcare Team: Comprises medical practitioners (interns, residents, registrars, consultants, professors), nursing staff, and allied health professionals. Varies between teaching/non-teaching and private/government hospitals.

Hospital Pharmacy Definition and Functions

• Definition: The department responsible for managing and distributing medications within a hospital.
• Functions:
  • Drug Distribution: Managing drug inventory and dispensing for inpatients and outpatients.
  • Drug Information Services: Providing relevant information on drug use, pharmacology, pharmacokinetics, availability, cost, interactions, and ADRs.
  • Medication Review: Daily review of patient’s drug therapy to ensure appropriateness, safety, efficacy, and cost-effectiveness.
  • Therapeutic Drug Monitoring (TDM): Providing advice on appropriate use and timing of TDM, and assisting with interpretation of results.
  • Patient Counselling: Educating patients about their medications and treatment regimens.
  • Adverse Drug Reaction (ADR) Monitoring & Reporting: Detecting, assessing, managing, documenting, and preventing ADRs.
  • Ward Round Participation: Contributing to patient care by influencing prescribing decisions and providing drug information at the point of care.
  • Formulary Management: Developing and implementing hospital formulary policies, including drug selection, addition, and deletion.
  • Drug Use Evaluation (DUE): Conducting studies to assure quality of drug use.
  • Education and Training: Participating in and providing training programs for hospital staff (nurses, junior doctors).
  • Research: Supporting clinical research activities.
  • Procurement and Storage: Ensuring good quality, cost-effective medicines, proper inventory control, and storage practices.
• Organisation Structure, Location, Layout, Staff Requirements: Clinical pharmacists need a department for administrative, educational, and professional activities, ideally centrally located for easy access to wards, patients, and staff. Requires office areas, library, drug information resources, teaching areas, and computer resources. Staff must have appropriate education and training, with postgraduate qualifications in clinical pharmacy or pharmacy practice being desirable.

Ward Round Participation

Goals and Objectives

• Improved Patient Understanding: Gain understanding of patient’s clinical status, progress, investigations, and therapeutic goals.
• Information Provision: Provide relevant information on drug therapy (pharmacology, pharmacokinetics, availability, cost, interactions, ADRs).
• Optimise Management: Influence drug therapy selection, implementation, monitoring, and follow-up.
• Problem Identification: Investigate unusual orders, doses, detect ADRs and drug interactions.
• Holistic View: Assimilate information on co-morbidities, compliance, and complementary/alternative medicine use.
• Discharge Planning: Participate in patient discharge planning.
• Learning Opportunity: See how medicines are used, prescribed, and their effects on patients; gain new perspectives on therapeutics; identify cases for teaching and publication.
• Strengthen Relationships: Improve inter-professional relationships among healthcare professionals.

Pre-Ward Round Preparation

• Information Gathering: Review medication chart, case records, patient health status, disease management, and medication history (including allergies/hypersensitivities, provisional/final diagnosis, past medical/social history, lab data, other investigations).
• Patient Interviews: Speak to patients/carers to obtain detailed medication history, cross-check information, and identify new relevant data.
• Resource Consultation: Clarify issues using appropriate information resources (e.g., BNF, Drug Information Handbook, AMH, clinical guidelines).
• Prioritisation: Make notes of potential interventions/recommendations in order of priority.
• Patient Profiles: Maintain individual patient profiles summarizing relevant drug therapy information.

General Guidelines and Practical Tips

• Timeliness: Complete preparation ahead of the round; arrange to be notified if no fixed time.
• Prioritisation: If responsible for multiple wards, prioritise rounds where the pharmacist can contribute most.
• Formulary Adherence: Ensure prescriptions align with the hospital formulary or drug list.
• References: Carry appropriate clinical references and up-to-date guidelines.

Types of Interventions

• Direct Impact: Reduce preventable Adverse Drug Events (ADEs) (e.g., by 72% in ICU, 78% in general medicine units).
• Medication Ordering: Address incomplete orders, wrong dose/frequency, inappropriate choice, duplicate therapy, drug allergies.
• Alternative Therapies: Recommend safer, cheaper, or equally effective alternative therapies.
• Drug Information: Provide drug use information to the team.
• Addressing Queries: Respond to drug-related queries on dose, frequency, choice, adverse effects, interactions, formulation, duration, availability, and legal issues.
• Problem-Solving: Recommend solutions/alternatives for identified drug therapy problems.
• Proactive: Make interventions at the time prescribing decisions are made.

Communication Skills

• Inter-professional Communication: Work closely with medical and allied health professionals. Convey views on patient management, focusing on patient welfare.
• Language: Understand “medical language” for effective communication with doctors. Knowledge of regional language is helpful for patient interaction.
• Diplomacy: Avoid giving the impression of a “pharmacy police force”. Approach should be courteous, willing to help, provide reliable information, and be a team player.
• Respect: Acknowledge other staff’s abilities, support their roles, and show respect for physician’s clinical acumen and experience. Avoid open or implied criticism.
• Clarity: Focus on significant issues, avoid trivia.
• Uncertainty: Do not bluff if unsure; acknowledge, retrieve information, and communicate later.
• Patient Presence: Be cautious when discussing drug-related issues in front of patients, avoiding challenges to prescriber’s integrity or patient’s faith.
• Documentation: Case note annotation conveys important information, serves as a legal record, and alerts staff. Entries must be clear, precise, dated, and signed.

Follow-up Activities

• Responding to Enquiries: Address all unanswered queries promptly, using appropriate methods (phone, email, print, in-person) and references.
• Communicating Information: Inform relevant personnel (medical, nursing, pharmacy, dietetics) about changes in drug therapy.
• Documentation: Document recommendations/interventions and identified ADRs (e.g., on alert sheets/patient case records).
• Care Plan Alterations: Update patient’s care plan due to management changes (e.g., monitoring drug levels, dose recommendations after dialysis).
• Discussions with Patients: Discuss therapy issues, reasons for alterations, administration techniques, or adverse effects.
• Performance Evaluation: Documentation is important for justifying service needs, quality assurance, and as key performance indicators.