Hospital Pharmacy in Europe The EAHP survey 2010 Dr. Roberto Frontini, President EAHP president@eahp.eu
Outline EAHP Methodology of the survey Results General frame, staffing Procurement Production & Quality assurance Clinical services Patient safety Education & Research 2
European Association of Hospital Pharmacists (EAHP) Created in 1972 in The Hague (NL) Federation of National Associations of Pharmacists Members of the Council of Europe 31 countries: 24 EU + 7 outside EU More than 21,000 Hospital Pharmacists working in hospitals and other healthcare facilities in Europe 3
EAHP Members Austria Bosnia Herzegovina Croatia Denmark Finland Germany Hungary Italy Lithuania FYROM Norway Portugal Slovakia Spain Switzerland United Kingdom 31 members Belgium Bulgaria Czech Republic Estonia France Greece Ireland Latvia Luxembourg Netherlands Poland Serbia Slovenia Sweden Turkey 4
Methodology 4 th pan-european survey (1995/2000/2005/2010) 87 questions on hospital pharmacy practice Direct approach through national coordinators of every Head of Pharmacy of the member states (4,747 in total) Data collection Oct.2010 -Jan. 2011 Total number of answers 1,238 = 26.1% 5
Methodology: Response rate green = > 20 (30)% yellow = 10-20% orange = < 10% red = no answer grey = no member Max % = 100% (Fyrom) Max # = 130 (Germany) 6
Methodology By insufficient response rate (<25%) check by national coordinators Decision on inclusion in national reports based on the national distribution of hospital types and the distribution of answering hospitals Rates (%) always in relation to the total number of answers to the question Response rate for each question ranges between 5.0% and 91.0% 7
Limitations by bias The response rate varies substantially from country to country and does not reflect the weight of the population of that country in Europe Language barriers might have created a bias of answering pharmacists Some of the questions might have been misunderstood by non native English speakers Enlargement of EU to eastern countries might have created a bias in relation to past survey 8
General frame Staffing 9
Austria Belgium BiH Bulgaria Croatia Czech Republic Denmark Estonia Finland France FYROM Germany Great Britain Greece Hungary Ireland Italy Latvia Lithuania Luxemburg Netherlands Norway Poland Portugal Serbia Slovakia Slovenia Spain Sweden Switzerland General Frame: Number of beds served 3500 3000 2500 2000 1500 1000 500 0 2010 2005 2000 10
General Frame: Number of beds served 800 Hospitalisation 700 600 500 400 300 Sum 2010 2005 2000 Average 708 703 648 Median 427 200 100 0 2000 2005 2010 Sum Complete Partial 11
General Frame: Ownership Hospital ownership in 2010 (n= 1102) Church affiliated hospital 4% Private hospital 10% Public hospital (i.e. owned by the government) 81% Other 5% 12
Question to audience The biggest group of staff in European Hospital Pharmacies is Green Blue Yellow Red = Bachelor of Pharmacy = Qualified Technician = Unqualified Technician = Pharmacist 13
Staffing: Qualification of Staff in Pharmacies (FTE) Trainee pharmacists (interns) 4% Others 5% Nurses 3% Cleaning personnel 3% Pharmacy students 3% Prescriptionists (Bachelor of Pharmacy) 1% Qualified pharmacy assistants / technicians 32% Administrative Staff 8% Non qualified pharmacy assistants 14% Pharmacists 27% 14
Great Britain Switzerland Portugal Ireland Norway BiH Spain Luxemburg Sweden Italy Estonia Belgium Denmark Finland Czech Republic Slovenia Bulgaria Latvia Netherlands Greece France Serbia FYROM Poland Slovakia Austria Lithuania Hungary Croatia Germany Staffing: Pharmacists/100 beds (complete + partial hospitalisation) 0.33 2010 2005 2000 Average 1.0 0.9 0.7 Median 0.7 3.47 0,00 0,50 1,00 1,50 2,00 2,50 3,00 3,50 4,00 15
Great Britain Switzerland Spain Portugal Netherlands France Denmark Norway Belgium Italy Luxemburg Ireland Finland Czech Republic Poland Slovenia Sweden BiH Greece Serbia Slovakia FYROM Bulgaria Estonia Latvia Hungary Austria Lithuania Germany Croatia Pharmacy staff / 100 beds (complete + partial hospitalisation) 1.4 2010 2005 2000 Average 3.1 3.6 2.9 Median 2.6 10.6 0 2 4 6 8 10 12 16
Greece Serbia BiH Hungary Great Britain Italy Slovenia FYROM Slovakia Ireland Portugal Czech Republic Poland Switzerland Bulgaria Belgium Croatia Netherlands Spain Luxemburg Finland Austria Denmark Latvia France Norway Germany Sweden Estonia Lithuania Staffing: Shortages Have you experienced any shortages of pharmacists (n=939) or Technicians (n=936) in your hospital pharmacy in the past 2 years? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pharmacist Technicians 17
Staffing: Specialisation in Hospital Pharmacy Ireland Belgium France Italy Spain Netherlands Germany Hungary Portugal Serbia Luxemburg BiH Switzerland Austria Greece Bulgaria Slovenia Great Britain Czech Republic Poland Norway Finland Croatia Latvia Sweden Denmark Slovakia Lithuania FYROM Estonia % 2010 Average 49.5 Median 33.3 0 10 20 30 40 50 60 70 80 90 100 18
Staffing: % of pharmacies with internal CPD 60,0 50.1 50,0 40.2 * Target Group 40,0 30,0 20.8 Pharmacists Technicians Others 20,0 10,0 0,0 * Total >100% as partially more than 1 target group 19
Staffing: Financial support of CPD 80,0 70,0 75.6 * 60,0 50,0 38.7 Time off Full reimbursement 40,0 30,0 20,0 16.4 Partial reimbursement 10,0 0,0 * Total >100% as partially more than 1 system 20
General frame / Staffing The average number of bed served by one pharmacy did not change since 2005 but there is a decrease of complete and an increase of partial hospitalisation Pharmacists (27%) and qualified technicians (32%) cover 60% of the total staff The number of pharmacists/100 beds varies from 0.33 (Germany) to 3.47 (UK) Only few countries did not experience shortages for pharmacists and technicians 49% of the pharmacists are specialised in Hospital Pharmacy 21
Procurement 22
Purchasing groups National multi hospital alliance 15% Multiple answers 7% Regional group 17% No group purchasing 55% Local group 6% 23
Question to audience The major source of procurement in European hospital pharmacies is Green Blue Yellow Red = Industry = Wholesalers = Own production = Other pharmacies 24
Procurement s source Other hospital 1% Own production 2% Industry 46% Wholesaler 51% 25
Purchasing: Responsibility for medical devices 100 Selection 2010 2005 2000 % 55.8 77.8 84.6 90 80 70 60 50 55.8 47.2 56.2 48.7 Selection Evaluation Purchasing Vigilance 40 30 20 10 0 26
Formularies 2010 2005 2000 % Hospitals with 77.1 82.4 85.3 Great Britain Austria Slovenia Ireland Netherlands Sweden Greece Switzerland France Germany Croatia Portugal Belgium Spain Luxemburg Czech Republic Serbia Finland Poland Slovakia Bulgaria Lithuania Latvia Italy Hungary Denmark Norway Estonia BiH Number of Products in formulary 246 1,982 2010 2005 2000 Average 1,006 1,031 700 Median 960 0 500 1000 1500 2000 2500 27
Formularies: Information content 100 90 * 80 70 60 52.1 56.8 Price Dosage Hospital drug policy 50 40 43.6 28.9 29.9 Local antibiotics sensitivity Antibiotics surgical prophylaxis Antibiotics guideline 30 20 14.4 10 0 * Total >100% as partially more than 1 information 28
Distribution 100 94.2 90 80 70 60 50 40 * 2010 2005 Total robotic % 10.1 3.3 Manual picking Stock robotic Unit picking automat Unit dose (patient supply) Automated cabinets 30 20 10 6.3 7.3 2.4 10.9 0 * Total >100% as partially more than 1 system 29
Procurement 45% of pharmacies are purchasing in groups Industry (46%) and wholesalers (51%) are the most important suppliers 55.8% of the pharmacies are responsible also for medical devices Formularies have an average of 1,006 products with a broad range from 246 to 1982 and an increase since 2000 by 43.7% 94.2% of the pharmacies distribute by manual picking and the total of automation is still only 10.1% 30
Production & Quality assurance 31
Batch production 100 90 80 70 60 50 % 2010 2005 2000 Sterile 29.9 54.9 66.8 Non sterile 48.4 92.3 92.1 Reagents 16.3 30.1 33.6 48.4 Sterile pharmaceuticals Non sterile pharmaceuticals Laboratory reagents 40 30 29.9 16.3 20 10 0 32
Question to audience Sterile production of individual preparations is performed by Green Blue Yellow Red = 10% of Pharmacies = 80% of Pharmacies = 30% of Pharmacies = 50% of Pharmacies 33
Individual prescriptions % 2010 2005 2000 100 Sterile 48.5 66.2 71.0 Non sterile 64.9 91.6 92.5 90 80 70 60 50 48.5 64.9 Sterile prescriptions Non sterile prescriptions 40 30 20 10 0 34
GMP Sweden Great Britain Finland Denmark Netherlands Norway Switzerland France Czech Republic Spain Ireland Croatia Portugal Hungary Italy BiH Poland Luxemburg Slovenia Germany Belgium FYROM Serbia Austria Greece Bulgaria Latvia Estonia Lithuania Slovakia % 2010 Average 58.5 0 10 20 30 40 50 60 70 80 90 100 35
External quality certification 100 90 % 2010 External certification 46.8 80 70 60 50 ISO 9001 ISO 14001 Others 40 30 27.7 16.6 20 10 2.4 0 36
Production & Quality assurance The batch as well as the individual production of sterile and non sterile medicines decreased significantly since 2000 In average 58.5% of pharmacies follow GMP guidelines with a broad range between countries from 0% to 100% There is a need for more resources in the field of quality assurance especially in the eastern part of Europe 46.6% of the pharmacies are certified by external bodies 37
Clinical services 38
Question to audience Pharmacists are working at the ward in Green Blue Yellow Red = 10% of Hospitals = 80% of Hospitals = 25% of Hospitals = 95% of Hospitals 39
Presence of pharmacists at ward 16% 77% 23% 4% 3% no yes occasionally yes daily yes decentralised* * pharmacists at least 50% of time at ward 40
Clinical services by technicians 75% 25% % of yes yes no 100 90 80 84.32 * ward stock drug information 70 60 patient counselling 50 40 30 41.2 22.6 25.1 25.1 20.2 member of committees member of audit 20 other 10 * Total >100% as partially more than 1 activity 0 41
Outpatients services No 34% Both 9% Yes, through a separately licensed outpatient pharmacy 8% Yes, through the hospital in inpatient pharmacy department 49% 42
Clinical consultations 100 90 Anticoagulants 80 Lipids drugs 70 60 Antibiotic therapy 50 41.3 Cytotoxic induced nausea 40 30 20 10 14.9 6.0 21.1 11.7 15.4 Immunosuppresive therapy Others 0 43
Clinical services nutrition 10% No 58% Yes 42% 32% Participation in TPN team only Participation in TPN/Enteral nutrition team Not involved in decisions about nutrition prescription 44
Clinical services pharmacokinetic inpatients 0.2% No 81.1% Yes 18.9% outpatients 13.5% Both 5.3% 45
Drug information by pharmacist Yes 2010 2005 2000 % 29.0 29.5 29.2 71% 29% yes no 46
Documentation of services No 76% Yes* 24% inpatients 14% Both 8% outpatients 2% * At least 80% of interventions 47
Clinical services Only 23% of pharmacies offer clinical services at the ward and only 7% do it on regular base Clinical services for outpatients are common (67%) The major field of consultations are antibiotics, cytotoxic induced nausea and nutrition. Drug information by pharmacists is implemented only in 29% of the hospitals and constant since 2000 Only 24% of the pharmacies document at least 80% of their interventions 48
Patient safety 49
Policy of hospital in safe medication 26% 74% At least 1 None % of at least 1 100 90 * policy on safe medication practice 80 70 60 50 40 51.1 38.1 35.2 55.1 committee for safe medication practice dedicated team doctor/pharmacist/nurse 30 20 clinical incident reporting system (CIRS) 10 ** Total >100% as partially more than 1 activity 0 50
Patient safety system implemented in hospital Luxemburg Denmark Sweden Great Britain Belgium Norway Netherlands Switzerland Spain Finland Ireland Czech Republic Portugal France Serbia Poland Hungary Italy Germany Slovenia Bulgaria Austria Slovakia Latvia Croatia Estonia BiH FYROM Lithuania Greece % 2010 Average 55.0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 51
Question to audience The most common activity for save medication in European hospitals is Green Blue Yellow = Therapeutic drug monitoring = Drug information = Unite dose dispensing Red = Centralized cytotoxics reconstitution 52
Implemented activities in safe medication practice* 80% 20% At least 1 None % of at least 1 100 ** unit dose dispensing 90 80 70 60 50 44.1 54.6 centralized cytotoxic reconstitution centralized intravenous administration service therapeutic drug monitoring drug information 40 30 20 10 22.1 9.2 25.5 22.7 17.6 3.8 patient visits at admission patient counselling at discharge other 0 * At least 50% of activities on regular base ** Total >100% as partially more than 1 activity 53
Patient care of adverse reactions Inpatients 31% No 46% Yes 54% Both 19% Outpatients 4% 54
Activities to avoid medication errors No 47% Yes 53% Inpatients 31% Both 19% Outpatients 3% 55
Documentation of interventions in medical record No 84% Yes 16% Inpatients 11% Both 4% Outpatients 1% * At least 80% of the interventions 56
Education activities in safe medication 24% 76% At least 1 None % of at least 1 100 90 80 70 60 50 * 53.3 49.0 46.6 national congress CPD programmes incidental seminars ** Total >100% as partially more than 1 activity 40 30 20 10 0 24.2 4.4 education included in faculty programme other 57
SOP for withdrawing own products 36% Yes 2010 2005 2000 % 64.1 55.5 61.0 64% yes no 58
Patient safety Patient safety is in focus of hospital pharmacies and 80% of them have implemented activities in safe medication practice There is a broad range between countries from 0% to 100% with some need for improvement especially in the eastern part of Europe There is a lack of documentation with only 16% of interventions registered in medical records 76% of pharmacies have at least 1 education activity in safe medication 64% of pharmacies with production have a SOP for withdrawing own products 59
Education & Research 60
Affiliation with teaching programmes 32% 68% At least 1 None % of at least 1 100 90 80 70 58.1 73.7 60.4 * University Pharmacy School Nursing school 60 50 40 43.9 University Medical School ** Total >100% as partially more than 1 activity 30 20 10 0 College offering pharmacy technician training 61
Training of students 32% 68% At least 1 None 100 90 % of at least 1 81.5 * Pharmacy students 80 70 60 50 40 30 48.2 55.5 post graduate pharmacy training programme Technicians training programme 20 ** Total >100% as partially more than 1 activity 10 0 62
Question to audience How many hospital pharmacies are involved in research Green Blue Yellow Red = 10% of Pharmacies = 90% of Pharmacies = 30% of Pharmacies = 60% of Pharmacies 63
Participation in research 61% 39% None At least 1 field % of at least 1 A) Research (including clinical drug trials) B) Drug use evaluation programmes C) Pharmacoepidemiological studies 100,0 90,0 80,0 70,0 60,0 50,0 40,0 30,0 20,0 61.1% 2.4 17.5 41.2 47.3% 0.7 28.5 * 35.3% 1.4 18.5 Outpatients Inpatients Both 10,0 0,0 18.2 15.4 ** Total >100% as partially more than 1 activity A B C 64
Education & Research Hospital pharmacies are highly involved (68%) in teaching programmes for health professionals including physicians, pharmacists, technicians and nurses 61% of hospital pharmacies are involved in clinical research 65
Take home messages The 4 th pan-european survey on Hospital Pharmacy is based on 1,238 (26.1%) answers out of all European pharmacies (# = 4,747) Despite some unavoidable bias, the survey is a valuable source of information about the status quo of hospital pharmacy in Europe The data from the survey highlight priorities for actions to achieve the state of the art as postulated in the Basel statements of FIP 66
Thanks for great input and dedication! Tajda Miharija Gala University Medical Centre Ljubljana Prof. Juraj Sykora Pharmacy Department SZU National Cancer Institute Bratislava EAHP board members responsible for the survey 67
Thanks to all national coordinators! AUSTRIA Silvia HETZ BELGIUM Raphaël COLLARD Sofie VERBEKE BOLGARIA Nina PURVANOVA Ilko GETOV BIH Enisa SALIHEFENDIĆ Tijana MARINKOVIĆ CROATIA Marijeta DUKARIĆ KURTIĆ Ana CRNKOVIĆ CZECH REP. Helena ROTTEROVA Petr Horak DENMARK Helle McNULTY Gitte NIELSEN ESTONIA Tiia VALS FINLAND Hanna TOLONEN FYROM Maja KOVAČEVA FRANCE André RIEUTORD GERMANY Steffen AMANN GREECE Despina MAKRIDAKI HUNGARY IRELAND ITALY LATVIA LITHUANIA LUXEMBOURG NETHERLANDS NORWAY PORTUGAL POLAND SERBIA SLOVAKIA SLOVENIA SPAIN SWITZERLAND SWEDEN UK Gyöngyver SOOS Joan PEPPARD Ilaria UOMO Valdis PIRSKO Birute VARANAVICIENE Patrick ENGELHARDT Rob MOSS Hans OVERDIEK Frank JORGENSEN Aida BATISTA Dariusz SMOLINSKI Dragana RAJINAC Juraj SYKORA Tajda MIHARIJA GALA María José TAMES Eduardo ECHARRI Susanna KUSSMANN Per Nydert Richard CATELL 68