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Pharmaceutical Services
In Hospitals
Nirmal K. Gurbani
1
& Abhishek Dadhich
2
Introduction
The pharmacy profession comprising the industry and practice
sectors is undergoing a rapid change. While Indian Pharma industry
has registered a spectacular progress ranking 3
rd
in volume and
13th in value in the global pharmaceutical market, the visibility
and recognition of pharmacists in health sector has still a long
way to go. The pharmacist in healthcare sector has to evolve from
a mere dispenser of medicines to a more crucial role in medicine
management and as overall health care programmer. While
community pharmacy is largely dominated by mere dispensing
of medicines without paying any attention to patient information
while dispensing, the hospital pharmacy offers an emerging
opportunity for the pharmacists to demonstrate their capabilities
in view of the proliferation of corporate hospitals along with private
hospitals aspiring for accreditation from National Accreditation
Board for Hospitals & Healthcare (NABH) or JSI and by many
accreditation boards in other countries. Among many stipulated
requirements for the accreditation, medication management
through a functional Drug and Therapeutics Committee (DTC)
which is also referred to as Pharmacy & Therapeutics Committee
(PTC), can provide an effective structure and tool to bring together
all the relevant people to work jointly for promoting more effcient
and rational use of medicines. Besides, playing a pivotal under
the functioning of DTCs, pharmacists can also provide relevant
patient information related to medicines being dispensed in the
hospitals as a service. This would defnitely lead to his recognition
by the society as competent health professional.
Pharmaceuticals/medicines have always remained and would
continue to remain as core in the healthcare. It constitute second
highest item of expenditure after the manpower in any given
health facility/hospital. Medicines save lives and improve quality
of life, but can be dangerous with adverse drug reactions (ADR)
and medication errors which would be expensive. Medicines have
often been misused and abused. Irrational use of medicines is
prevalent at all levels of health care leading to wastage of scarce
resources as well as reduced medication safety in patients.
Emergence of antimicrobial resistance continues to pose a global
problem in handling the management of infections. Common
drug related problems encountered in most hospitals are:
Selection of medicines is not evidence based
Quantifcation of demand of medicines is not scientifc
Supply is not regular
Standard Treatment Guidelines (STGs) are not developed
or used
Over enthusiasm in using newer & expensive medicines
Rampant use of combination product
Over use of antimicrobials
No system for monitoring use of medicines
Majority of hospitals do not have system / committee to tackle
these problems. Pharmaceutical management in hospitals can
be one of the most cost effective measures for appropriate use of
scarce health care resources. Medication safety in patients can
be best ensured if rational and appropriate uses of medicines
are practiced. The effcacy and therapeutic benefts of medicines
is often not grasped during the treatment which happens due
to problems with medicine selection and dosages, improper
administration of medicines and lack of adherence by patients
to prescribed treatment, medicinemedicine and medicinefood
interactions, and adverse medicine events. To reduce these
healthcare burdens, the following pharmaceutical services in
hospitals can contribute towards health improvement and to help
patients:
Formulary management
Quality assurance of medicines
Medicines safety & Pharmacovigilence
Preventing, identifying, and resolving medication errors
Patient education and counseling
Prescription audit
Monitoring medicines use
Supply Chain Management of Pharmaceuticals including
stock management and inventory control
1
Professor,
2
Asstt. Professor Pharmaceutical Management, Institute of health Management Research, Jaipur.
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Antibiotic stewardship and infection control
Drug & Therapeutics Committee
Drug & Therapeutics Committee signifcantly improve drug use
and reduce costs in hospitals. In many developed countries, a
well functioning DTC has shown to be one of the most effective
structures to address drug problems. Concept of DTC is well
accepted in developed world. As early as 1935, frst DTC was
founded in USA. During 1940s, DTCs were established in
UK. In some developing countries (African countries), DTC
concept has been adopted. In India there are a few DTCs at
certain places but their functioning is yet to catch up with the
requirements of the National Accreditation Board for Hospitals
& Healthcare Providers (NABH). The DTC is an advisory group
that recommends policies related to drug therapy to the medical
board. Every hospital, especially a teaching hospital must have
a Therapeutic Committee. The goals and objectives of the DTC
are to ensure that patients are provided with best possible cost
effective care, and this could be achieved by providing treatment
with quality essential medicines as per evidence based standard
treatment guidelines and adverse drug reaction monitoring.
Structure and Organization
The committee should have suffcient members to represent
all stakeholders, viz.; clinical departments, administration and
pharmacy. Members should have technical competence with no
confict of interest and should have defned terms of reference.
It should include clinicians from each major specialty, a clinical
pharmacologist, a nurse (infection control section), pharmacist,
microbiologist, fnance person. Dedicated and committed
persons as Chairperson (preferably Medical Superintendent/
Chief of the hospital) and Member Secretary (preferably a clinical
pharmacologist/pharmacist) are crucial to its success. The
committee may perform major roles like:
1. Advisory Functions
The DTC can advise to medical, administrative, and pharmacy
departments on all issues, policies and guidelines concerning
the selection, distribution and use of medicines and participate
in other hospital committees and departments on all matters
concerning drugs.
2. Development of Drug Policies
The review and development of drug policies within a hospital
is taken care by DTC, since the committee members have the
expertise and training in drug therapy and supply. These policies
are concern with:
Criteria for inclusion of medicines on the formulary list
(essential medicines list (EML)
New, non-formulary, restricted, investigational drugs
Generic substitution and therapeutic interchange
Standard treatment guidelines (and other interventions)
Meeting Drug representatives and reviewing promotional
literature
The drug policies are to be periodically reviewed because of
changing costs and indications, new information on safety, and
availability of new medicines. The documents review process
includes reputable textbooks, published treatment guidelines and
formularies, newsletters and primary drug literature.
3. Evaluation and Selection of Drugs For The Formulary
DTC perform the evaluation and selection of the drug on the
basis of the standard treatment guidelines or protocols that
have been developed or adapted for use in the hospital. The
consideration for inclusion of medicine in formulary list is carried
out by DTC which is followed by evidence based documentation
of the effcacy, safety, quality and cost-effectiveness of drugs. The
evaluating and selecting drugs should be through a consistent
decision making on evidence, local context and transparency-
driven.
4. Developing Standard Treatment Guidelines
To promote rational use of medicines in hospitals standard
treatment guideline (STGs) or protocols are developed by DTC in
a participatory way involving end-users. STG are develop in such
a way that they are easy to read and up to date. STGs provide a
benchmark of optimum treatment in the monitoring and audit of
drug use.
5. Assessing Drug Use Problems
DTC may identify the priority problems and make appropriate
recommendations for drug use. Common drug use problems
include:
Drug procurement and availability
Drug prescribing
Administration / Use
Adverse drug reactions reports
Medication error reports
Antimicrobial resistance surveillance reports
Unsafe injections
6. Improving Drug Use
DTC in hospital have a major responsibility to ensure that drug
information is provided to health staff and patients by conducting
educational interventions. Managerial interventions are also need
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to be ensured by the DTC through Drug use evaluation program
and Clinical pharmacy programs, besides, structured order forms
and automatic stop orders, etc. Regulatory interventions are
also performed by the DTC during drug selection (essential &
non-essential medicines list) and also regulating visits of drug
representatives.
7. Managing Adverse Drug Reactions
Adverse drug reactions (ADRs) are serious problems in terms of
patient harm (morbidity and mortality) and avoidable economic
costs. These adverse drug reactions may be due to the unknown
effects of new or older drugs, unknown drug combinations
and interactions, or poor drug quality. DTC can plan effective
ADR monitoring, assessment and reporting under National
Pharmacovigilence program, besides initiating preventive
measures to minimize adverse drug reaction.
Success of DTC
Experience shows that it is easy to establish DTC, but diffcult
to ensure its functioning. The success depends on strong
support from senior hospital management and administration,
careful selection of members who are willing and committed to
take on responsibility, besides, having regular meetings of DTC
(monthly or quarterly) with regular attendance by the members,
dissemination of recommendation, document operating
guidelines, policies and decisions of DTC to all concerned.
Objective relationship with other hospital committees, especially
Antimicrobial Subcommittee and Infection Control Committee can
strengthen linkages within the system. Accreditation of hospitals,
only if they have functional DTC can contribute further in the
success of the DTCs. Pharmaceutical manufacturers can be
very infuential on this committee and the committee must remain
unbiased and transparent at all times to maintain credibility. There
should be no relationship with a manufacturer or supplier other
than the exchange of unbiased drug information. Well functioning
DTCs have improved use of medicines leading to savings &
improved patient care and DTCs are considered as agents and
vehicles for improving rational use of medicines.
Pharmaceuticals Purchasing And Stock
Management
In hospitals medical stores or material management
departments manages all hospital purchasing which includes
pharmaceuticals, medical supplies and equipment etc. A separate
designated committee or the DTC manages the purchasing of
pharmaceuticals which is reviewed and approved by all committee
members. Medicines and health products have its own shelf life
and therefore, maintaining of optimum stocks would be the key
feature under the stock management. Expiration of products is
fnancial loss and stock outs leads to local purchases which are
expensive. Therefore, Standard Operating Procedures (SOPs) for
drug procurement, proper quantifcation, inventory management
and written manuals, including security measures approved by
the hospital administration and the appropriate committees can
ensure optimum availability of medicines and health products
stocks with least stock-out and expiry situations.
Inpatient Medication Services In Hospital
Inpatient services in hospital settings includes dispensing,
patient education and medication counseling, besides, regular
stock registers updating for periodic medicines purchasing
and inventory management are also important tasks which are
performed under pharmaceutical services.
Medication Distribution System In Hospital
Medication distribution is a primary function of pharmaceutical
services in hospital and depending on hospital structure;
medication distribution is categorized into four types, namely:
Bulk wards stock replenishment, Individual medication order
system, Unit-dose system and Automated medication system. All
these four system may be used in same facility depending on the
strategy developed.
Bulk Ward Stock
In this system, the pharmacy unit works as a warehouse and
dispenses bulk container on requisition. The main advantage of
this system is shorter turnaround time between prescribing and
administering the medication. This is appropriate and desirable
system for life-threatening emergency situation where medication
need to kept near patient care areas as a time saving measure.
Ward stock maintain high volume, low-cost medicine if the patient
safety risk is low.
Individual Medication Order System
The individual medication order system performs dispensing
to outpatients. The pharmacist reviews the appropriatness of
medication order and dispenses a course of therapy according
to a written prescription for an individual patient with proper drug
related patient information. A patient-specifc medication profle
can be maintained and optimum control of inventory is possible.
Unit-Dose Distribution System
This system is more preferable from a patient care perspective
which has lower possibility for medication error. Medications
are dispensed in unit-dose packages (each dose is separately
packaged) in separate bins or drawers for each patient. Commonly,
a twenty-four-hour supply is provided. Initially this system needs
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large capital investment for establishing the repackaging machine
and system. The cost per delivered dose is higher than with bulk
packaging, but these increased expenses may be offset by
reduced wastage and easier detection of leakage.
Automated Medication Dispensing
Technology based intervention is made in medication distribution
in which medication errors are minimized and it helps in improving
medication safety within the hospital. This system works on a
computer interface between the hospital pharmacy computer
terminals and the dispensing machines at the clinical ward. This
system electronically controls and tracks the dispensing of unit
doses for each patient based on individual medication profle. The
dispensing machines allow medicines to be stored on the ward
and to be more conveniently accessed by the clinical staff.
Hospital Antimicrobial Stewardship
Antimicrobials and injectable drugs are amongst the most
expensive of all drugs; often consuming major portion of a
hospitals drug budget. Emergence of Antimicrobial resistance
(AMR) has become a global problem and therefore, in this context
antibiotics stewardship is designed to optimize antimicrobial
therapy administered to hospitalized patients, ensure cost
effective therapy and improve patients' outcome while containing
antimicrobial resistance. Various goals under antimicrobial
stewardship programme are:
Ensure appropriate use of antibiotics at suffcient dose and
duration
Eradicate the pathogen
Prevent recurrence of infection
Prevent resistance
Antimicrobial subcommittee assists the DTC in dealing with the
management of antimicrobials. The subcommittee develops
policies concerning use of antimicrobials for approval by the DTC
and medical staff and the policies should specifcally include
sections on methods to limit and restrict use of antimicrobials in
the hospitals. Periodic drug use evaluations are conducted by
this subcommittee to ensure use of effective antimicrobials of
adequate quality only when clinically indicated, in the correct
dose and for the appropriate length of time. This subcommittee
also assists in evaluating and selecting antimicrobials for the
formulary and standard treatment guidelines.
Infection Control In Hospital
Hospital acquired infections (HAI) are most dangerous and often
diffcult to handle. Therefore, prevention of nosocomial infections
is the responsibility of all individuals and services providing
health care. Everyone must work cooperatively to reduce the
risk of infection for patients and staff in the hospital. An Infection
Control Committee provides a forum to prevent the spread of
infection within the hospital or facilities within its jurisdiction.
This forum involves overseeing the hospitals infection control,
prevention, and monitoring programmes. DTC in hospital
creates a subcommittee that will specifcally deal with all issues
relating to infection control. The infection control committee
in hospital is more concerned with environmental issues such
as food handling, laundry handling, cleaning procedures,
visitation policies, proper biomedical waste disposal practices
and direct patient care practices, including hand washing and
immunizations. An infection control committee carry out active
surveillance of infections and antimicrobial resistance, with data
analysis and feedback (ideally monthly reports) to the appropriate
departments, health-care staff, antimicrobial subcommittee and
the DTC. It develop and recommend policies and procedures
pertaining to infection control, besides also organizing infection
control education and training programmes for all hospital staff.
Conclusion
In context to provide better and effective healthcare services in
hospital premises, pharmaceutical services perform a vital role
under multidisciplinary responsibility that includes selection
and formulary management, prescribing by the physician,
procurement, storage and medication distribution within hospital.
The Drug and Therapeutics Committee (DTC) is responsible
for developing policies and procedures to promote rational
medicine use. Antimicrobial and Infection Control subcommittees
in hospitals perform systematic approaches towards safe and
effective use of antibiotics as well as also focus on strengthening
biomedical waste management under infection control programme
in hospitals to minimize the risk of hospital acquired infections. In
compliance to quality accreditation of hospitals, pharmaceutical
services are integral component under medication management
to ensure patient safety.
References
1. Holloway K., Green T, Drugs and Therapeutics Committees (A Practical Guide),
by WHO and MSH, 2003, France. Website: www.who.int/medicinedocs.
2. Management Support System Part III, Hospital Pharmacy Management,
Pg.45.1-45.15 Website: apps.who.int/medicinedocs/documents.
3. DTC and its Role in Ensuring Drug Quality, Website: http://www.sgnhc.org.np.
4. Bero L, Cho MK (1994) Instruments for assessing the quality of drug studies
published in the medical literature, Journal of American Medical Association
272(2): 101104.
5. Ducel G., Hygie F., Fabry J., et. al., Hospital Acquired Infection (A Practical
Guide) By WHO, 2002, 2nd edition, Website: www.who.int/csr/resources/
publications.

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