Pharmaceutical Services Offered in Hospitals

Transcription

1 Pharmaceutical Services Offered in Hospitals Product Services Research Services Teaching Services Support Services Clinical Services In-patients (hospitalized) Out-patients (ambulatory) In-patients (hospitalized) Out-patients (ambulatory)

2 Product Services To ensure the quality of the drugs used within the hospital It includes mainly: *Drug storage *Preparation for administration *Distribution to the patient care units

3 Product Services for Hospitalized Patients Medication Distribution Systems Intravenous Admixture System Floor Stock Distribution System Patient Prescription System Combined Stock-Patient Prescription System Unit Dose Distribution System TPN compounding Service Oncology Pharmacy Services Radiopharmacy Service Intravenous Additives Services

4 Medication Distribution Systems (MDS) Floor Stock Distribution System Patient Prescription System Combined Stock-Patient Prescription System Unit Dose Distribution System

5 Floor Stock Distribution System *This system delegates drug order interpretation, drug inventory, and drug preparation on the patient care units to the nurse. *The pharmacist sees only transcribed drug requisitions sent by nursing personnel. *The pharmacist dispenses multiple doses, bulk supplies of drugs which are not labeled for a specific patient

6 Advantages of Floor Stock Distribution System *Availability of required medications *Reduction of drug order transcriptions for the pharmacy *Reduction of number of personnel required Simplicity

7 Disadvantages of Floor Stock Distribution System wrong patient *High incidence of medication errors wrong drug wrong dose wrong route *No clinical role for the pharmacist wrong time Prescription monitoring Patient counseling Drug therapy monitoring *Limited capacity for proper storage facilities in each PCU *Increased danger of unnoticed drug deterioration *Greater chance for pilferage

8 Patient Prescription System *The nurse rather than the pharmacist continued to play the major role in drug preparation and drug order evaluation *The nurse transcribes this order onto a Medication Administration Profile & generates a drug order for pharmacy *The pharmacist dispenses a (2 5) day supply of medication which is labeled for a specific patient

9 Advantages of Patient Prescription System Over Floor Stock System *Reduce medication errors drugs are labeled MAP Limit the supply to prevent continuing treatment without review *Starting clinical role for the pharmacist Prescription monitoring *Facilitate patient billing

10 Disadvantages of Patient Prescription System *Limited clinical role for the pharmacist *Storage problems in patient care units *Applicable only in small hospitals

11 Combined Stock-Patient Prescription System In this system, medicines are supplied as floor stocks for those drugs in more or less frequent use and as prescription dispensed items for all others. The advantages and disadvantages of this combined system are similar to those of the complete floor stock and prescription order systems

12 Unit Dose Distribution System Unit dose is any physical quantity of a drug specified by a physician to be administered to a patient at one time, and not requiring any significant physical or chemical alterations before being administered

13 *The pharmacist has a more active role in the medication cycle *The pharmacist-physician interactive role began to emerge *The nurse returns to the patient care responsibilities The unit dose system is the most cost effective of all pharmacy distribution systems when the entire spectrum of drug delivery activities within a hospital is considered Unit Dose Distribution System

14 The advantages of unit dose systems over alternative distribution systems *A reduction in the incidence of medication errors. *A decrease in the total cost of medication related activities. *A more efficient usage of pharmacy and nursing personnel. *Improved overall drug control and drug use monitoring. *More accurate patient billings for drugs. *The elimination or minimization of drug credits. *Greater control by the pharmacist over pharmacy work load patterns and staff scheduling. *A reduction in the size of drug inventories located in PCU. *Greater adaptability to computerized and automated procedures.

15 Intravenous Admixture System A large percentage of all the drugs administered in hospitals are given in the form of intravenous injections

16 Intravenous Admixture System Intravenous lines peripheral central direct indirect

17 Intravenous Admixture System An intravenous admixture is the combination of two or more parenteral products in one container. Intravenous programs use two systems use of ready to administer premixed products available from manufacturers compounding special solutions for patients with specific medical requirements

18 Steps for intravenous admixture preparation (Parenteral Prescription) 1. Writing the admixture order 2. Checking the order 3. Clerical work (Full detailed Typed label & profile work sheet) 4. Preparation of admixture 5. Checking completed admixture 6. Delivery to patient area 7. Storage in patient area 8. Administration to patient

19 Aseptic preparation in hospitals TPN compounding Oncology pharmacy services Radiopharmacy Service Intravenous Additives

20 Total Parenteral Nutrition TPN Need for nutritional assessment on admission to the hospital

21 Nutritional Requirements macronutrients micronutrients carbohydrates proteins fats trace elements vitamins electrolytes

22 Routes of Nutrition Oral Enteral Parenteral Peripheral Central Direct Indirect

23 Peripheral Parenteral Nutrition (PPN) Given via a peripheral vein Limited duration ( 2 weeks) Central Parenteral Nutrition (CPN) Given via a central vein long term access Limited volume ( 4 liters daily) Larger volumes are possible Isotonicity and osmolarity should be adjusted Require good venous access Risk of phlebitis Greater flexibility of solution formulation Patient comfort No risk of phlebitis

24 Routes of Nutrition

25 Common TPN Complications Line complications such as sepsis (bacterial contamination), thrombosis and catheter malposition. Metabolic complications such as hyperglycemia, Hypoglycemia, fluid overload, electrolytes abnormality, acid-base imbalances, trace mineral deficiency Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia.

26 Common TPN Complications Most of these complications can be avoided By: 1. Placing catheters by experienced physicians. 2. Consistently following strict protocols for aseptic line care. 3. Patient monitoring.

27 Nutrition Support Team *To reduce the morbidity & mortality from nutrition support *To ensure its application in a safe & effective manner

28 Nutrition Support Team Physician Pharmacist Nurse Dietitian Team manager -formula design -compatibilities -evaluation of interactions -solution compounding -metabolic monitoring -catheter care -patient education -metabolic monitoring Enteral nutrition Social worker Physical therapist

29 TPN Monitoring Parameters *Temperature *Weight *Nitrogen Balance *Plasma Proteins *Lab tests *Clinical status

30 TPN Monitoring Parameters *Nitrogen Balance = nitrogen input nitrogen output Healthy adults excrete the same amount as is ingested (They are in N equilibrium) positive value negative value growth tissue repair pregnancy Burns & injuries fever fasting

31 TPN Monitoring Parameters *Nitrogen Balance = nitrogen input nitrogen output 1. Determine nitrogen intake by dividing the daily protein intake by Determine nitrogen lost in urine by a 24 h urinary urea nitrogen test (UUN). 3. Add 4* to the UUN to account for non-urinary losses of nitrogen

32 TPN Monitoring Parameters *Nitrogen Balance = nitrogen input nitrogen output Example: Protein intake: 90 gm, 24 hr UUN: 20 gm N intake = 90/6.25 = 14.4 gm N N total output = = 24 gm N N-balance = = -9.6 gm N This person is losing 9.6 X 6.25=62.5 gm protein per day protein intake should be increased by a factor = nitrogen balance X 6.25

33 TPN Monitoring Parameters *Nitrogen Balance = nitrogen input nitrogen output Example: Protein intake: 95gm, 24 hr UUN: 15gm -24 g protein/day

34 TPN Monitoring Parameters *Nitrogen Balance = nitrogen input nitrogen output Example: Protein intake: 100gm, 24 hr UUN: 12gm 0 g protein/day

35 TPN Monitoring Parameters *Nitrogen Balance = nitrogen input nitrogen output Example: Protein intake: 80gm, 24 hr UUN: 3gm +6 g protein/day

36 TPN Monitoring Parameters *Temperature *Weight *Nitrogen Balance *Plasma Proteins *Lab tests *Clinical status

37 *Lab tests Blood: TPN Monitoring Parameters daily for electrolytes (Na +, K +, Cl - ), Glucose and acid-base status. 3 times/week for BUN, Ca +,, P and plasma transaminases Twice/week for ammonia, Mg and plasma transaminases Weekly for Hgb, prothrombin time, Zn, Cu and triglycerides Urine: 4-6/day for glucose and ketones 2-4/day for specific gravity or osmolarity Weekly for urinary urea nitrogen

38 Intravenous Additives It is the administration of combined intravenous drugs

39 Intravenous Additives *Dilution, reconstitution & transfer to a device (e.g., syringe) for administration to the patient *Subcutaneous infusions of drug combinations used in palliative care *Prefilled syringes *Drugs addition to infusions on the ward, e.g: antibiotics, electrolytes, vitamins, heparin & aminophylline

40 Advantages of Intravenous Additives *Convenience and time saving *Reduction in the number of injections necessary *Treatment of several conditions simultaneously *Giving the drugs in controlled increments

41 Radiopharmacy Service Responsibilities of the pharmacist : *Procurement, storage and dispensing of radioisotopes used in clinical practice *Perform quantitative analysis and determine the isotopic purity of all radiopharmaceuticals dispensed *Formulate sterile and non-sterile radioactive dosage forms to meet the current needs of the medical staff *Prescribe and schedule doses, which is often complex

42 Oncology pharmacy services Cytotoxic drugs are therapeutic agents intended primarily for the treatment of cancer. They affect cell reproduction. They have been known to be non-selective. Many have proved to be carcinogens, mutagens or teratogens

43 Sources of Hazardous Drug Exposure (workplaces) Hospital settings Pharmacies (hospital and community) Analytical or research laboratories Doctor s surgeries Ambulatory clinics Patients and their homes Veterinary clinics Waste disposal facilities Ambulance vehicles

44 People at risk Nurses Medical officers Pharmacy staff Technicians Laboratory staff Research staff Ambulance officers Couriers & porters Pharmacy delivery personnel Veterinarians and veterinary nurses Cleaning and waste disposal staff Stores and warehouse workers Patients, family and friends

45 Symptoms reported amongst people dealing with cytotoxic drugs Contact dermatitis Liver damage Abdominal pain Abdominal pain Hair loss Nasal sores Vomiting Excretion of the drugs or metabolites in the urine local toxic or allergic reaction Foetal loss & malformations of the offspring. Alterations to normal blood cell counts

46 Safe Handling Methods The manipulation of cytotoxic drugs requires: -Critical aseptic technique -Signs and labels -Protective clothing -Certain work techniques -Emergency procedures for spillage management -Trained personnel During Preparation During administration During storage and distribution

47 Cytotoxic signs and labels Purple is the recognized colour denoting the presence of cytotoxic substance or waste

48 Cytotoxic signs and labels A purple label with labels should be used on: IV solution flasks Syringes spill kits pump cartridges laundry bags transport containers for drugs plastic bags sharps containers storage areas for cytotoxic substances containers of oral and topical materials containers used for storing &transporting waste

49 Protective clothes 6.Hooded coveralls or caps 1.Gown: Made of low permeability fabric with a solid front long sleeves Elastic or knit cuffs 5.Eye protection: Goggles or glasses with side shields transparent full face chemical splash shield 2.Surgical Gloves: Unpowdered Latex made long enough Of acceptable thickness & tactile sensation 4.Boots or overshoes: Impermeable High enough Sturdy soles Skid resistant 3.Respiratory protection: