Hospital Pharmacy and Public Health

Hospital Pharmacy

• Organizes health professionals, diagnostic and treatment facilities, equipment, and physical facilities for public health care delivery
• American Hospital Association standards state a minimum of six inpatient beds are required for a facility to be considered a hospital

Clinic

• Facility/area where ambulatory patients are seen
• Provides specialized study, diagnosis, and treatment by a group of physicians
• Patients are not confined in clinics

Four Fundamental Functions of Hospitals

• Patient care: From diagnosis to convalescence
• Wellness/Public Health: Includes disease prevention and mitigation in the community
• Education: For patients and healthcare professionals
• Research: Includes advancement of medical knowledge

Levels of Prevention

Primordial Prevention

• Targets the general population
• Aims to mitigate social, economic, and cultural patterns contributing to evaluated risks
• Example: comprehensive policies for smoking cessation

Primary Prevention

• Targets specific persons or the general population to prevent disease in healthy individuals
• Examples include general health promotion techniques like good nutrition, adequate clothing, and shelter
• Also includes specific protective measures like protection against occupational hazards, immunization, and environmental sanitation

Secondary Prevention

• Focuses on early disease detection and prompt treatment
• Example: screening tests

Tertiary Prevention

• Aims to limit disability and promote rehabilitation
• Example: early physiotherapy to restore normal motion of affected limbs

Classification of Hospitals by Type of Service

General Hospitals

• Provide services for a wide range of illnesses, diseases, injuries, or deformities
• Example: Philippine General Hospital (PGH)

Special Hospitals

• Specialize in a particular disease, condition, or patient type

Examples of Special Hospitals

• Fabella Memorial Hospital: Focuses on OB, maternal, and newborn care
• Philippine Orthopedic Center: Specializes in orthopedic and neuromuscular conditions
• San Lazaro Hospital: Specializes in infectious/communicable diseases

Categories of General Hospitals by Functional Capacity

• Different levels depend on the range of services provided

Level I

• Includes consulting specialists in medicine, pediatrics, OB-GYNE, and surgery
• Offers emergency and out-patient services, isolation facilities, surgical/maternity facilities, and a dental clinic

Level 2

• Level 1 services plus departmentalized clinical services, respiratory unit, general ICU, high-risk pregnancy unit, and NICU
• Secondary clinical laboratory and a blood station
• Includes 1st level X-ray, and pharmacy

Level 3

• Level 2 services plus teaching/training programs with accredited residency training
• Provides physical medicine and rehabilitation unit, ambulatory surgical clinic, and dialysis clinic
• Tertiary clinical laboratory with histopathology, blood bank, 3rd level X-ray, and pharmacy

Chronic & Rehabilitation Centers

• Focus on adjustive and restorative services for the disabled/handicapped

Psychiatric Facilities

• Specialize in treating mental disorders
• Example: SPMC (Southern Philippines Medical Center) in Davao City

Length of Stay

Short-Term

• Less than 30 days
• Generally, general hospitals are short-term facilities

Long-Term/Custodial

• More than 30 days
• Special hospitals are often long-term facilities
• Examples: those specializing in leprosy, TB, psychiatric care, and AIDS
• Exceptions: maternity, pediatric, ophthalmology, and gynecology

Ownership of Hospitals

Governmental Hospitals

• National hospitals are supported by the national government
• Example: PGH
• Federal hospitals are operated by various branches of the federal government, like the VMMC
• City/municipal hospitals are supported by local governments or with national government counterpart funding

Non-Governmental Hospitals

Non-Profit Oriented

• Church-operated
• Fraternal order-operated
• Community hospitals
• Company hospitals

Profit Oriented

• Individual ownership
• Partnership
• Corporation

Bed Capacity

• Less than 50 beds
• 50-99 beds
• 100-199 beds
• 200-299 beds
• 300-399 beds
• 400-499 beds
• 500 beds & over

Tertiary Hospitals

• 300-399 beds
• 400-499 beds
• 500 beds & over
• Minimum of six beds are needed to qualify as a hospital

Classification of Other Health Care Facilities

Category A: Primary Care Facilities

• Infirmary
• Birthing home
• Medical out-patient clinic, dental clinic

Category B: Custodial Care Facilities

• Psychiatric care facility
• Rehabilitation center
• Sanitarium/ Leprosarium
• Nursing home

Category C: Diagnostic/ Therapeutic Facility

Category D: Specialized Out-Patient Facility

• Dialysis clinic
• Ambulatory clinic

Special Types of Health Care Institutions

Long Term Health Care Facility

• Provides medical, comprehensive, preventive, rehabilitative, social, spiritual, and emotional in-patient care

Resident Treatment Facility

• Provides safe, hygienic and living arrangements for residents

Health Maintenance Organizations

• Public or private organization providing comprehensive health services to enrolled individuals on a per capita pre-payment basis

Organization of a Hospital

Board of Directors, Trustees, Regents

• Provides mission and vision
• Policy makers

Hospital/ Medical Director

• Manages overall operation

Chief Executive Officer (Liaison Officer)

• Responsible for the hospital's day-to-day operation
• Reports to the Board

Chief Operating Officer

• Responsible for the hospital's day-to-day operation
• Reports to the CEO

Chief Financial Officer

• In charge of finances

Director of Nursing

Department Heads

Supporting Staff

Medical Staff

• Most important part of the hospital organization

Types of Medical Staff

Open Staff

• Allows certain physicians not on the attending or active medical staff to use private room facilities if they comply with all rules
• These physicians are termed members of the courtesy medical staff

Closed Staff

• Utilizes only its attending or active medical staff for all professional services, both private and charity

Groups of Medical Staff

Attending Medical Staff

• "Active medical staff"
• Provides direct patient care

Consulting Medical Staff

• Medical staff of recognized professional ability
• Specialists: pass specialty board, member of a specialty organization

Honorary Medical Staff

• Former members, retired or emeritus
• Given to a former member whom medical staff choose to honor due to outstanding contribution

Associate Medical Staff

• "Junior medical staff"
• Considered for advancement to attending medical staff

Courtesy Medical Staff

• Not a member but allowed to attend a private patient

Resident Medical Staff

• Full time employee
• Patient services in exchange for training experience

Supporting Services

Nursing Service

• Nursing care
• Administration of medication

Dietary Service

• Procurement, planning & preparation of food for the patient and hospital staff

Central Supply Service

• Sterile linen, OR packs and other medical surgical supplies

Medical Record Service

• Serves as basis for planning & continuity of patient care
• Provide data for use in research education of the care rendered to the patient

Medical Social Service

• Important liaison between the hospital, the patient, and the community

Blood Bank

• Generally, under the supervision of a licensed physician who has a basic interest in hematology

Pathology

• Cytological & gross anatomical analysis
• Clinical laboratories

Radiology

• Diagnostic & therapeutic application of radiant energy

Anesthesia

• Anesthesia care

Hospital Pharmacy

• Practice of pharmacy in a hospital setting and related facilities/services
• A department or division of hospital responsible for procurement, storage, compounding, manufacturing, packaging, controlling, assaying, dispensing, distribution and monitoring of medications
• Manages drug therapy for hospitalized and ambulatory patients
• Activities performed by legally qualified, professionally competent pharmacists

Clinical Trial Phases

Phase I

• Assesses safety in 20-25 healthy participants
• Non-blinded

Phase II

• Assesses efficacy and proper dosage in 100-200 participants with the disease
• Single-Blinded

Phase III

• Compares new treatment to the current standard of care in 200-1000 participants with the disease
• Double-Blinded

Phase IV

• Post-marketing survelliance
• Pharmacovigilance

More on Blinding

• Blinded: patient does not know what treatment they received
• Double blinded: Neither the patient nor the researcherknows what treatment the patient receives
• Cons:costly, time-intensive, ethical considerations

Meta-analysis

• Systematic review using quantitative methods to summarize results
• The unit of analysis is the variable common to the studies, rather than the individual patient

Systematic Review

• Comprehensive summary of the best available evidence addressing a defined question

Essential Drug List

• Core/minimum list: caters to most health care needs
• Complementary list: provides alternatives

Formulary List

• Identical to the essential drug list, but tailored to a specific setting
• Includes the Philippine National Formulary (PNF), 8th Edition

National Formulary List (PNF) Volumes

• Contains a list of drugs
• Provides drug monographs
• Indexes generic and brand names

Formulary Manual

• Drug-centered
• Summary of pharmacological information

Standard Treatment Guidelines

• Disease-centered
• Assists with prescribing

Drug Management Cycle: Procurement

Inventory Management

• Routine ordering processes
• Heart of drug supply system

Types of Stock

• Cycle stock: most active portion
• Safety stock: buffer, protects against fluctuations in demand

Inventory Cost Factors

• Acquisition cost: production + markup/discount
• Procurement cost: shipping, restocking
• Carrying cost: holding inventory
• Opportunity cost: potential gain lost from choosing an alternative
• Customer dissatisfaction cost related to stockouts

Managing Inventory Context

Demand Systems management

• Independent: based on historical consumption for finished goods
• Dependent: based on the current demand for raw materials

Logistics Systems

• Push: allocation/forecasting
• Pull: requisition/'just enough'; waste reduction

Stock Records

• Core records of the inventory management systerm
• Manual or computerized

Manual Systems

• Vertical file cards: cards in alphabetical/ numerical order
• Kardex system: visible-edge record ray system
• Bin cards: cards physically kept with stock
• Ledger system: uses ledger sheets

Monitoring and Restocking with ABC Analysis

• A - Tight Inventory control to avoid loss.
• B - Moderate control, depending on closeness of A to C.
• C - Not worth it to closely monitor

VEN System

• Vital - life-saving, critical
• Essential - effective and needed for diseases but is not absolutely vital
• Non-essential - for minor, self-limiting illnesses; has marginal advantages

Drug Distribution Systems

• For dispensing drugs to in-patients

Drug Distribution Systems

Floor Stock/ Bulk Ward System

• Medications in nursing station
• Non-charged or charge

Advantages

• Lesser transcription
• Requires less pharmacy personnel
• Provides readily available supply
• Results in less drug return

Disadvantages

• Increased medication errors
• Added work for nurses
• Increased pilferage
• Increased hazard of drug deterioration
• Greater capital outlay and drug inventory

Individual Prescription Order System (IPOS)

• Used in small or private hospitals

Advantages

• All medication orders can be reviewed by RPh
• Provides interaction between RPh, doctors, nurses, and patients
• Provides clear control of inventory

Disadvantages

• Delayed administration
• Places the patient at a disadvantage if a drug change is needed
• Results in excessive paperwork/documents

Combined Floor Stock & IPOS

• Limited floor stock
• Uses IPOS as the primary means of dispensing
• Possibly the most common system for hospitals

Unit-Dose Delivery System (UDDS)

• Medications are packaged in a single unit
• Ready to administer
• Dispensed within 24 hours
• Maintains a patient medication profile

Advantages

• Cheaper for the patient
• Decreases medication errors
• Frees up more time for nurses to provide patient care
• Eliminates excessive paperwork
• Most common and cost-effective,

Types of Unit-Dose Delivery Systems

Centralized Systems

• The most common and efficient
• Orders are interpreted and doses are picked and placed in patient drawers in a central pharmacy

Decentralized Systems

• They often have satellite pharmacies scattered throughout the hospital that distribute the single unit doses
• Routine packaging of medication is usually carried out

Combined Systems

• Some distribution activities are performed in patient care areas, while others are performed centrally

Partial Systems

• Partially complete due to special circumstances

Drug Utilization Review (DUR)

• A study on frequency and cost of drug use
• Patterns of prescribing, dispensing and patient use can be determined from it

It can

• Identify interactions
• Promote proper prescribing and generic usage
• Monitor compliance and promote quality care

Prospective DUR

• Before medication is dispensed
• Routinely done

Example

• Checking for interactions and altering a prescription to avoid problems

Con:

Time consuming

Concurrent DUR

• During the course of treatment
• Usually done institutionally
• Manages cases in real time

Retrospective DUR

• After the patient has received medication
• Simplest to perform

Example

• Reviewing records to check if STGs were followed

Cons

• No immediate benefit
• Relies on inaccurate record data

Medication Errors

• Preventable event of inappropriate medication use potentially harmful to the patient
• Deviations from prescriber's order
• Significant effect: extended hospital stays, additional treatment, malpractice litigation

Sources of Medication Errors

• Giving unauthorized or unordered drugs
• Extra dose
• Omission
• Incorrect dosage, strength, route, timing, and/or form

National Coordinating Council for Medication Error Reporting & Prevention

• Provides medication error category definitions

Categories

• (A) potential
• (B) not reaching thepPtient
• (C) no harm
• (D) Requires Monitoring
• (E) temporary/reversible harm
• (F) Requires Hospitalization.
• (G) permanent injury
• (H) Require near Death
• (I)Death