Clinical Pharmacy Services at a public sector hospital

1. Clinical Pharmacy Services at a public sector hospital The Children’s Hospital & Institute of Child Health, Lahore Zaufishan Rahman

2. The Children Hospital & Institute of Child Health • State of the art - Tertiary care hospital • Centre of Excellence • 45 different specialties in medicine, surgery and diagnostics • 418 beds strength • The hospital OPD operationalized in May 1995 and emergency in October 1996 • In-patient services were first initiated in December 1998

3. Department of Pharmaceutical Services

4. How the Pharmacy Services are different today? In changing times…. • a need for pharmacists to shift their focus • a need to target outcomes that matters • a need to take responsibility for outcomes ....thereby, a need to provide patient centered care

5. Patient Centered Care Pharmaceutical care is: “The cooperative and responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient’s quality of life”

6. Pharmaceutical care plans

7. Key elements • Drug Individualization • All pediatric patients need weight based dosing; hence at increased risk of adverse events • Monitoring of Drug Interactions • Monitoring of In-Vitro and In-vivo drug interactions • Monitoring and Reporting of potential ADRs

8. Pharmaceutical Care Planning

9. Pharmaceutical Care Planning

10. Pharmaceutical Care Planning

11. Pharmaceutical Care Planning

12. Pharmaceutical Care Planning

13. Pharmaceutical Care Planning

14. Extended Scope of clinical pharmacy services • Participation in clinical rounds • Drug information centre services • Poisoning & Drug Overdose management services • Total Parental Nutrition (TPN) • Extemporaneous Preparations • Clinical training program • Hospital Clinical Committees

15. Participation in Rounds 1 • Working in a multidisciplinary team • Interaction with patient’s other healthcare providers • Ensuring best clinical outcomes • Preparation and Implementation of Pharmaceutical Care Plans

16. Drug information Centre Services 2 Provision of unbiased, scientific and up to date information to health care professionals • Concept Paper • Protocol • Tools: • DIC Query Form – A • DIC Query Form – B • DIC Query Referral Form - C

17. Clinical Pharmacist as Information Manger: ….….Assessing the Evidence Where and When you need it! Developing Liaison with other Drug Information Centres and creating a network of knowledge banks, nationally & globally.

18. Poisoning & Drug Overdose Management 3 • 24/7 Presence of Pharmacist in Emergency Department • Availability of antidotes • Backup support from Drug Information Centre • Examples: • Management of Kerosine oil poisoning • Management of patient who has ingested milk with a lizard

19. Total Parental Nutrition (TPN) 4 • First of its kind in any public sector hospital in Punjab • Caters individual needs of patients • Plays a significant role in reducing the morbidity and improving the quality of life of patients • Ensuring aseptic environment with use of Laminar Flow Hoods • Provision of services to other hospitals

20. TPN • During last 1 year i.e. December 2010 to November 2011: • A total of 1202 calls have been received by TPN department • More than 244 pediatric patients benefited • Dispensing an average of 100 calls per month • Dispensing an average of 5 TPN calls per patient

21. Extemporaneous Preparations 5

22. Clinical Training Programs (>400 students/ year) 6 • Clinical Pharmacy Residency Program • Eligibility: Graduates and Awaiting result students • Clinical Pharmacy Projects • Eligibility: 5th Professional Students • Clinical Pharmacy Internship Program • Eligibility: 4th Professional Students

23. Hospital Clinical Committees 7 • Pharmacy & Therapeutics Committee Comprises of all department heads, Assistant and Associate Professors, Pharmacists and administration. • Hospital Infection Control Committee: Pharmacists as key members of team for effective infection control measures

24. “… and if anyone saved a life; it would be as if he saved the life of whole mankind” Case Scenarios Clinical Pharmacy Services

25. Case 1: Thalasemia Major • Patient Name: Sarfaraz • Age : 6 years • Weight: 18 kg • History of present illness: Patient is presented in OPD with generalized body aches, abdominal distention due to massive splenomegaly and significantly darkened skin tone. Pharmacist’s Intervention: Patient’s attendants are counseled for regular and consistent use of agents that treat Iron overdoe (Deferasirox) and regular Serum Ferritin test

26. Case 2: Bronchial Pneumonia • Patient Name: Zihan • Age: 7 months • Weight: 5kg • Current Medication: • Paracetamol, Cefuroxime, Amikacin • Nebulize with Aprint, N/Saline and Clenil Pharmacist’s Intervention: Patient’s mother education and counseling on proper nebulizing technique

27. Case 3: Pericardial Effusion • Patient Name: Minahil • Age: 2 months • Weight: 3.2 kg • Current Medication: • Inj. Ceftrioxone, Inj. Lasix, Inj. Vancomycin Pharmacist’s Intervention: Patient at increased risk of ototoxicity with combination of Ceftrioxone and Furosemide; Close monitoring is recommended after consultation with doctor

28. Case 4: Pneumonia and Sepsis • Patient Name: Iman Fatima • Age: 21 days • Weight: 2.2 kg • Medication: • Inj. Meropenam and Inj. Vancomycin are prescribed to patient after resistance to Ciprofloxacin, Ceftrioxone, Amikacin and Amoxicillin Pharmacist’s Intervention: • Pharmacist ensured that culture sensitivity test is done before prescribing the third line therapy. Culture was positive for Klebsella and Enterobacter • Separate administration of Ceftrioxone and Amikacin was recommended to nurse as these drugs can interact when administered together.

29. Case 5: Nephrotic Syndrome with Acute Renal Failure Suspected Meningococemia • Patient Name: Abdul Malik • Age: 16 months • Weight: 10kg • Medication: • Inj.Benzyl Penicillin, Inj. Solucortif, Inj. Ceftrioxone 500mg IV 12 hourly, SypMucain 1tsf 8 hourly, Inj Ranitidine 5mg IV 6 hourly and others Pharmacist’s Intervention: • Dose of Ceftrioxone and Ranitidine is correct for normal patient but should be reduced to half for patient with severe renal impairment

30. Case 6: Pseudo- Pancreatic Cyst • Patient Name: Zainab • Age: 2.6 years • Body weight: • On 1st day of admission her body weight was 9.2kg. On 24th day of hospital stay on 3 December, 2011 she was NPO since last 31 days and all the required nutrients are being given to her through central and peripheral lines as parental nutrition. • Her last recorded body weight is 10kg. • Patient maintained body weight with significant improvement in clinical outcomes and resumed oral feed

31. What's Next? Way Forward

32. Extension of Clinical Services • Workshop on Identification of potential ADRs monitoring and reporting • Doctors, Pharmacists and Nurses • Workshop on Poisoning and Drug Overdose Management • Drug Utilization Reviews • Utilization review of Meropenam – In Process • Others - In design phase • Impact Assessment Studies • Impact assessment study of TPN in improving quality of life of neonatal patients

33. Access to healthcare is a fundamental human right! “Of all forms of inequality, injustice in health care is the most shocking and inhumane” Martin Luther King, Jr

34. Every Single Life is Valuable….! • UNICEF Missing Mothers a video message on maternal mortality.mp4

35. THINK GLOBAL ….…. ACT LOCAL! Thankyou!