Providing the right medicine: hospital pharmacy in the 21st century

pharmacist holding script, medicine

In the second of a two-part series, Ron Batagol looks at the changes in hospital pharmacy practice since the 1970s

In the first of these articles, I provided a short summary of the changes and evolution of hospital pharmacy practice from its beginnings, through to the formation of the Society of Hospital Pharmacists of Australia.

In this article, I will discuss some of the major developments and profound changes that took place in hospital pharmacy practice during my hospital pharmacy career from the early 1970s to 2019.

I will also discuss some of the specific collaborative group projects which I had the privilege of being involved with during this period. Also, by illustrating some of the “endurance tests” required to complete projects in a timely fashion, before and during the infancy of the computer age, how, as we approached the 21st century, emerging computer technology systems revolutionised the process of evaluation techniques, reporting and document storage.

I will very briefly summarise the contemporary scope of hospital pharmacist practices, and the role and evolution of the SHPA from its ‘core’ membership of 36 Victorian pharmacists in 1941, to more than 5000 members as it approaches its 80th year, in 2021.

A trailblazing experience

First, let me recount some challenging and interesting experiences from those early days in hospital pharmacy, during the period that we were doing our share of ‘trail blazing’ as we piloted the concept of clinical pharmacy in the wards and clinical units.

On one occasion, at the hospital in which I then worked, we had a patient in the oncology ward, who was in the terminal stages of a rare but insidious form of skin lymphoma called Mycoses Fungoides, which is ultimately fatal. The odour from the lesion of this patient was so pungent that it was distressing for the relatives to visit her and to be in the same room.

After exhausting all other options, the oncology consultant, an ex-military man, suggested during a grand ward round, that “the pharmacy should obtain sterile maggots produced by the CSIRO in Canberra, to assist with the cleansing and deodorising of the wound”.

I made the required arrangements to have the maggots flown down in a refrigerated pack, due to arrive at the hospital at 4pm that day. But somehow the parcel went astray and didn’t arrive on time.
It was finally located, locked up at the airport parcels office, and eventually arrived at the hospital around 9.30pm, and was then refrigerated overnight.

Thank goodness, the maggots hadn’t hatched!

Once the maggots were set to work, the odour from this poor woman’s wound was gone within three days, and she was able to spend some rare quality time with those close to her, during the latter stages of her disease.

The take-home message? There’s a lot to be said for ‘thinking outside the square’ when nothing else has worked.

Challenges at the dawn of the computer age

One of the two toughest assignments that I was involved with occurred in the mid-1980s.

The SHPA Victorian Committee was asked on a Friday, by the then Victorian HIC (Health Insurance Commission), to finalise and present to their office a therapeutic list of drug codes for Victorian hospitals, based on the MIMS therapeutic classification of drug products, which our group had been compiling in draft format.

This was to be incorporated into the fledgling state Health Commission computer system, and the completed document had to be delivered to the HIC on the following Monday—three days later.

Myself and Ron Harper, the then director of pharmacy at Maroondah Hospital, worked right through the weekend, day and night, collating and laboriously entering data into a recently-acquired desktop computer, then printing out and collating the new set of drug codes, which was completed and delivered to the HIC offices at 8.30am Monday morning!

The final result was to be the ‘1700’ series of hospital drug codes, which were subsequently used universally in Victorian hospitals for several years.

My other endurance test took place a little earlier, over the Easter weekend of 1980, when I was oo-ordinator of the Obstetric Drug Information Centre, and deputy pharmacy director at the Royal Womens Hospital (RWH).

I hired an electric typewriter (before the availability of any sort of personal computers) and, with the assistance of my late wife as typist and proof-reader, spent that entire long weekend shaping a variety of research notes—including obstetrician peer reviews and many references—into a booklet.

This arose from a research grant to produce and publish the first Australian reference guide on drugs and pregnancy, The 3AW Reference Guide on Drugs and Pregnancy (sponsored by the 3AW Foundation).
It included an appendix on neonatal drug dosages written by the hospital’s neonatal department.

In 1983, we produced and published an updated version of the book, called The Royal Women’s Hospital Reference Guide on Drugs and Pregnancy.

These publications were widely used by medical practitioners, pharmacists and other health professionals, both in Australia and overseas.

I specifically mention these particular projects, as we fast-forward to the late 20th and early 21st centuries, with extraordinary developments in computer and database technology, allowing for projects to be completed in a tenth of the time, without the expenditure of tears, tribulations and feats of endurance.
Working collaboratively

These projects are also examples of multi-disciplinary collaborative projects. As the ‘Johnny-on-the-spot’ at the Royal Women’s, I was involved with other such projects involving O&G and other medical colleagues.

One, in 1981, involved researching old guides and identifying the trade names of products from bygone years which contained the second generation teratogen/carcinogen Stilboestrol (DES), used for 30 years, in contrast to the non-toxic, non-DES containing products, also used over the same period, to “sustain an early ‘at-risk’ pregnancy”. The result was the publication of these two contrasting product lists for the hospital’s gynaecology DES-follow-up clinic.

These lists were used as reference for the Victorian Health Department to distribute to medical practitioners, pharmacists, and other health professionals.

In 1985, I collaborated with an epidemiologist/geneticist, Dr Les Sheffield, to publish in the Medical Journal of Australia the first meta-analysis to assess whether a doxylamine/pyridoxine product (Debendox), was a teratogenic risk in early pregnancy.

We demonstrated that this drug combination was not teratogenic and, the day after publication, Dr Sheffield and I found ourselves engaged in media interviews on our “breakthrough” research on television news and current affairs programs.

Introducing the PBS into hospitals

An example of a very significant collaborative pharmacy and medical project with which I was involved was the introduction of publicly funded medicines into the hospital system.

This project, which commenced in 1993, had far-reaching implications on hospital ambulatory medicine supply.

Our Melbourne Teaching Hospitals Drug Usage Group (MTHDUG)—the forerunner to VICTAG—of which I was chairman, prepared two discussion papers on Funding of Pharmaceuticals in Public Hospitals, which included the support of the medical colleagues in our group.

Over time, this would lead to very significant benefits to outpatient and discharged hospital patients, who had, up to that time, only been able to obtain “starter quantities” of their medications (usually a few days’ supply at best), when discharged into the community.

With a little bit of luck and much negotiation, we were able to arrange delivery of these discussion papers directly to the office of the federal Health Minister, with whom we also arranged a subsequent face-to-face meeting, with copies of our discussion papers also delivered to relevant state and territory health ministers.

In addition, we put out a concurrent media release on the significance of this initiative to ongoing patient care.

Arising from this initiative, Geelong Hospital and the Royal Children’s Hospital implemented outpatient PBS pilots during 1994.

However, finalising the agreement between the Commonwealth and Victoria through a variation to the Australian Health Care Agreement was a long and tedious process, not concluding till the end of 2001.
Commencing with three hospitals, the PBS system was then progressively introduced into public hospitals from 2002 to 2003, with appropriate staff training and involvement.

Again, the recurrent theme in all of these ventures is the collaborative work with medical and other health professional colleagues across the professions.

A dedicated recording system

Another important “collaborative development” in the 1990s, was the launch of the Merlin hospital pharmacy dispensing and recording system.

This was introduced in major Victorian hospitals in 1994, with ‘customised’ design and beta-testing undertaken by hospital pharmacists in the field, for the Hospital Pharmacy Computer Users’ Group. Its development and implementation was driven by Brian Donaldson, (former deputy pharmacy director and pharmacy computer software developer), in collaboration with a software development company.

This hospital-based dispensing and recording system is still in use in several Australian hospitals.
Rounding out a career

In my final 20 years of hospital pharmacy, I practiced as a senior pharmacist at Monash Medical Centre, Monash Health, working with the then pharmacy director, my esteemed colleague, the late Dr Ian Larmour, and subsequently with current pharmacy director Associate Professor Sue Kirsa.

In addition, from 2001 to 2008, I was the pharmacist-in-charge of the ambulatory pharmacy services (outpatients/discharges) section of the pharmacy department at Monash Medical Centre, Clayton, initially taking over that role, to assist Monash Health with the preparation and training for the introduction of the PBS in hospitals, and continuing on in the ambulatory services role until 2008.

Hospital pharmacy in the 21st century

In the 21st century, most hospitals have pharmacists working in collaborative clinical roles throughout the wards, emergency, and other inpatient special care and treatment areas.

A 2007 survey reported that, on average, hospital pharmacists spent 47% of their time providing clinical services, drug information services, and training and education, 36% of their time acquiring, manufacturing, and dispensing medicines, and 15% of their time managing the medicines and personal resources of the pharmacy service and performing hospital-wide activities such as institutional drug policy management.

Practising hospital pharmacists in Australia can have generalist roles or can practise within a very narrow specialised field, and are supported in their work by a team of trained and accredited technician support staff.

In many hospitals it is now common to find a large number of clinically-trained hospital pharmacists, working in ward and clinical treatment areas, within multi-disciplinary teams.

The following summarises the clinical pharmacy activities, as described in the SHPA 2016 Clinical Pharmacy Standards:

Medication reconciliation, assessment and review, including providing medicines information, clinical review and documentation of interventions, including TDM and ADRs, facilitating continuity of medication management on transition to external healthcare settings and to ongoing community care, prioritising clinical pharmacy services, including training and education, participation in research, and improving the quality of clinical pharmacy services and peer review.

In addition, the standards have recently had a chapter added focusing on the use of My Health Record in pharmacy practice.

The SHPA today

From its humble beginnings (outlined in the first article), the SHPA has represented and advocated in peak national healthcare management and health planning formats on behalf of pharmacists working in hospitals and other healthcare settings.

As it approaches its 80th year in 2021, the SHPA has a membership of more than 5200, comprising pharmacists, students, technicians and associates, and conducts regular CPD meetings, webinars, and annual federal conferences.

Career reflections

I have been most fortunate to enjoy a fulfilling professional career, working with many dedicated groups of pharmacists as well as many other health and non-health professionals.

And, as I have emphasised continuously in these two articles, it is critically important to work collaboratively with health professional colleagues.

So, my final message to hospital pharmacists and, indeed, to all pharmacists is, in contributing and collaborating with colleagues, bring your acquired therapeutic knowledge and expertise so as to engage in further research into the understanding of optimum medication efficacy and safety.

Use this to assist in educating and enhancing an understanding of improved safety and better management of medication use within the community.

Also, don’t forget-to keep the medical jargon to a minimum where possible when conselling patients. – forget talking about the medication’s cardiac, hepatic or renal efficacy- just tell them about the effects on their heart, liver or kidneys. Plain English works a treat in getting the messages across in a way that they can readily understand. 

The author
Ron Batagol has had 47 years’ experience at all levels of hospital pharmacy practice, in addition to 18 years’ full-time, and 30 years’ part-time practice at all levels of community pharmacy. He has been a prominent voice in specialist, general and consultant pharmacy, author of the first Reference guide on drugs and pregnancy in 1980, several drugs and breastfeeding guides and, more recently in 2013, Taking medicines in pregnancy—what’s safe and what’s not, a plain English guide, as well as contributing to numerous advisory groups and committees.

Go here to see the first of these articles

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