SUMMER VOLUNTEERSHIP PROGRAMME AT JOHN HOPKINS ARAMCO HEALTHCARE IN SAUDI ARABIA

15^thAugust to 15^th September 2014

Marry Raju Mathew, Pharm.D 5^th Year

This vacation I got a chance to participate in a summer volunteership programme for a month at the John Hopkins Saudi Aramco Healthcare in Saudi Arabia. It was quite an experience and this is a brief overview of what I could learn during the programme.

INPATIENT PHARMACY

The inpatient pharmacy at John Hopkins follows an automated unit dose dispensing and distribution system. Medicines that are entered by a physician in the patient chart are faxed to the pharmacist (called the decentralised pharmacist) who is available on each level; the pharmacist reviews the medical orders, does medication reconciliation and enters the medications in the electronic medical record. Any errors are clarified with the physician before the entry is made. Once entered, a medicine label for each individual drug for each patient is printed automatically in the inpatient pharmacy and the drugs are dispensed as unit doses with a label for each drug from the pharmacy.

Most of the drugs are already available on the patient’s floor. They are stored in an automated vendor machine called the Pyxis Medstation ™. It is an automated dispensing system that supports decentralised medication management (picture 1). The nurse assigned to a particular patient can alone access the medicine for a patient. By using a unique access code and biometric finger printing the nurse can open the particular pocket or bin having the patient’s drug. Well, if a nurse wants to access a controlled substance like narcotic analgesics, it’s a little more procedural, it requires two witnesses to verify before accessing. Each time an access is made the drug remaining is recounted and entered in the Pyxis Medstation ™ as verification. This has benefits like improved medication safety during dispensing and administration. As all the Pyxis Medstation ™ machine are connected to a master unit in the pharmacy, the current status of availability and use of drug on each floor can be monitored. Not all medicines can be stored on the floor but common medicines and patients who have a medicine that is specific to them, is stored in a patient specific bin.

Any medicine not on the machine is printed as a label automatically in the pharmacy and they can be replenished every 24 hours into the Pyxis Medstation ™ from the pharmacy. A printed label has the patient details, direction for use, expiry date and batch number. It’s important that each unit drug whether a tablet or other formulation has a label showing its expiry date.

CLINICAL DECISION SUPPORT SYSTEM

The electronic medical record and computerised prescriber order entry (CPOE) are  helpful technology aids but a Clinical Decision Support System (CDSS), has the above two components with an interactive intelligent component that can detect drug interaction, dose range, duplication and allergies which are given as alerts immediately when a wrong drug is entered. The Epic™ system is the most advanced CDSS available and is highly efficient as it can assist the healthcare professionals with various decision making tasks like correlating diagnosis with the choice of drug therapy.

CLINICAL PHARMACY SERVICE

Clinical rounds are often multidisciplinary. Every morning the physician is accompanied by a clinical pharmacist, dietician, nurse and other medical personnel like the respiratory therapist. When I asked a doctor whether they prefer a multidisciplinary ward round or not, he said they do prefer it, as a multidisciplinary ward round facilitates the delivery of safer medications and also enables the team to plan for a patient’s healthcare jointly. During the programme, I had an opportunity to join clinical rounds in the chemotherapy, cardiology and medical intensive care unit.

 Some of the clinical pharmacist does the vancomycin dosing for each patient. They also do anticoagulation monitoring service, Total Parenteral Nutrition calculations and antibiotic dosing for renal impairment as well as medication reconciliation. In medication reconciliation the patient’s home medication is reconciled over the active inpatient drugs during admission, at transfer and at discharge. Medication history interview and discharge medication counselling are part of medication reconciliation.

COMPOUNDING UNIT PHARMACISTS

Drugs for the paediatrics and geriatrics patients who have difficulty in ingestion are prepared as syrups in the pharmacy especially for those dose strengths that are not available commercially. A separate area is allotted in the pharmacy for manufacturing. All kinds of formulations which are widely used within the hospital are prepared here. Tablets are grinded into syrups or sometimes syrups are made from pure raw materials. The oral medications are then aspirated as unit dose in syringes for oral use and labelled for each patient.

OUTPATIENT PHARMACY

Usually outpatient pharmacies are quite busy, well in this hospital they have a ticketing system. This system keeps the patient in a queue based on the priority for their prescription and also gives a limited time framework for each pharmacist to fill the prescription orders. To make things smoother for the pharmacist and the patient at the counter they have brought in the Parata™ (picture 2), an automated dispensing system loaded with up to 100 tablets and capsules. The machine dispenses in less than a minute, yes, it saves the time that takes in counting out tablets/capsules and keeps the prescription filling process an error free one too.

The outpatient pharmacy also has a medication management clinic which deals with counselling outpatients who are on long term care or with more than ten medications.

Drug information service department is also a live and actively functioning service the pharmacy provides.  Journal clubs are organised for the pharmacy interns. It was a good experience to understand how an article is critically evaluated in a practical setting, while attending the journal club with the Pharm.D interns. They also have knowledge sharing sessions and case presentations.

As technology is evolving at a faster pace, most of the works like unit packaging can be done easily with advanced automated solutions. One such solution is the Pillpick™ robot; it automates packing and dispensing within the inpatient pharmacy. And how does it help a pharmacist? Most obviously, gives you more time as a pharmacist to focus on the clinical arena with patients and deal efficiently in matters regarding to their medications.

IV PHARMACY

Most of the IV formulations are prepared in-house. They prepare bulk preparation for the most frequently used drugs in the hospital as well as patient specific IV formulations and concentrated liquid allergens for the allergy clinic. Total Parenteral Nutrition preparations are made for each patient separately, using an automated TPN filling machine (picture 3). Chemo drugs are reconstituted in a separate room facilitated with negative pressure and under a vertical flow hood.

PHARMACY INFORMATICS

That’s an emerging field within the pharmacy domain. As the name suggests, pharmacy informatics backs the many technologically supported medical services. Here, a pharmacist deals with the number figures that’s statistics, data mining, linguistics, CDDS programming and CDDS system trouble shooting. It’s a wide and novel arena. Some of the universities have now included informatics as an optional subject for their Pharm.D programme. The pharmacists in pharmacy informatics department work close with the pharmacy and therapeutic committee. If a change is made in the drug formulary, the same is programmed into the CDDS by the informatics pharmacist.

CONCLUSION

Many hospitals elsewhere in the world, like the John Hopkins Saudi Aramco Healthcare have incorporated much advancement both clinically and technologically to ensure the patient an eventually error free medication therapy. It was contemplating to see how clinical and hospital pharmacy services in many other parts of the world have evolved over the years. I could learn and understand how clinical pharmacy services are being practised well in a real hospital setting. This programme gave me an experience that has really boosted my confidence on becoming a clinical pharmacist and I feel really happy on choosing doctor of pharmacy as my career.