The hospital pharmacist’s role in delirium

The HPAI Annual Conference 2023 featured a range of high-quality short oral presentations that encompassed a range of topics of interest to hospital pharmacists. The conference heard from Ms Helen Heery, who discussed the issue of delirium in patients and the role of the hospital pharmacist in a presentation titled, ‘Stop! Think Delirium’. “This is a really serious problem in hospitals and one in which I believe pharmacists can play a key role in its management,” she said.

Ms Heery provided an overview of the instance, nature and definition of delirium and explained: “Delirium is defined as an acute cognitive decline and it also affects sensory perception, so a person with delirium might have visual or auditory hallucinations,” she said. “But it can also affect them physically. A person with delirium may move differently, they may become slower in their movements, or conversely, they may also become restless and may be wandering up and down the corridor.”

The onset of delirium may happen quickly, possibly over one or two days, but is usually reversible, Ms Heery explained. It is relatively common, and figures show that approximately one-in-three older adults in hospital will develop delirium, with some studies suggesting this could be a rate of one-in-two older hospital patients. This rate, however, can increase to more than 50 per cent if the patient is severely ill or in the ICU, or if they suffer a hip fracture.

“Having delirium has stark consequences,” Ms Heery continued. “It means that there’s a higher chance that you will stay in hospital longer and you will have a higher-risk stay as an inpatient, with a greater risk of developing pressure sores or suffering falls or incontinence. If you have delirium, you may not return to baseline and there is also a higher risk of being moved to a nursing home, with a higher risk of dementia and overall mortality. It’s also quite a frightening and stressful experience for the patient and everyone involved.”

Ms Heery outlined the potential causes of delirium, which can be synopsised with the abbreviation ‘PINCH ME’: P is the person in pain, and has urinary retention been excluded?; IN, infection — is there a possible infection?; C, constipation — when was the patient’s last bowel movement?; H, hydration/nutrition — Is there a major electrolyte imbalance and have hypoxia, hypotension, hypoglycaemia been considered?; M, medication — has there been omission of regular medication or addition of new ones?; and E, environment — has a change of environment, noise or activity levels been affecting sleep or rest?

“Delirium is common and it is usually reversible,” she told the attendees. “But screening is key and we really need to be on the lookout for it. The earlier it is identified, the easier it is to treat, and established delirium that has been there for a day or two or a few days is harder to reverse and harder to manage. Our focus should be on treating the cause of the delirium, rather than the symptoms… there is room for improvement in how we treat these patients, and I think hospital pharmacists have a key role in that.”

Some of the key ways hospital pharmacists can be instrumental in helping these patients is through medication reviews; medical reconciliation on admission; providing support and guidance to clinicians on the use of antipsychotics in delirium; providing support and information to patients, carers and family members; and conducting medication reconciliation on discharge.

The attendees were treated to a number of other Oral Presentations delivered by experienced hospital pharmacists who are specialists in their areas.

The attendees heard from Ms Mariosa Kieran of the Mater Misericordiae University Hospital, who delivered a presentation on ‘Introducing Pharmacy Key Performance Indicators in a Level 4 Academic Teaching Hospital’. Ms Sarah Fenton of Cork University Hospital delivered a talk titled ‘Standardisation of Preterm Parenteral Nutrition in Ireland’, which was followed by a presentation titled ‘Incorporation of Pharmacy Technicians into the Medication Administration Process in a Single Paediatric Cancer Inpatient Service: An Implementation Study’, by Ms Michelle Beirne of CHI, Crumlin.

The final oral presentation of the day was delivered by Ms Caroline Gallagher of St Vincent’s University Hospital in Dublin, who spoke on the topic, ‘Designing A Future-Proofed Pharmacy Department at St Vincent’s University Hospital’.

Each presentation was followed by enthusiastic participation in lively interactive Q&A sessions, and the organisers commended the speakers on the quality and practical value of their oral presentations.

CAT clinics — hospital pharmacists at the forefront

Attendees at the HPAI Annual Conference 2023 heard a presentation by Mr Kieron Power, Lead Pharmacist for Thrombosis and Anticoagulation at Singleton Hospital, NHS Wales, who delivered a talk titled ‘The Future of Pharmacy-Led Cancer-Associated Thrombosis (CAT) Clinics — A Real-Life Case Study’. The presentation was sponsored by Leo Pharma, which had no input into the content of the meeting.

In his talk, Mr Power addressed cancer-associated thrombosis, followed by a clinical discussion on the condition itself and treatments, as well as the role of pharmacists in CAT clinics, and the pharmacist’s role in managing treatments. “What we are starting to see now is pharmacists being involved further forward in the ‘queue’, with pharmacists now involved in what I would term ‘primary’ prescribing, or primary initiation of therapies from day one,” Mr Power told the conference. “We are actually starting to see pharmacists more involved in the diagnostic roles too — these are some of the ways in which we have seen evolution in pharmacy practice.”

He defined CAT as “any thrombotic event in active cancer. When we talk about VTE, what we are fundamentally talking about is primarily deep-vein thrombosis, which of course would usually affect the legs, but in active patients, we would see a reasonable number of clots in other locations such as extremities, abdominal vein thrombi, and various other forms of thrombosis.” The presentation was interactive, with Mr Power asking the attendees a number of clinical questions throughout the talk.

“CAT is actually a common complication in cancer,” Mr Power told the meeting. “I think it’s fair to say it is under-appreciated — in cancer, we tend to think of all the other complications, but what we are not very good at is warning patients that they are at risk of having a clot… around 20 per cent of cancer patients will have a VTE at some time during their cancer journey.”

He pointed out that second most-common cause of death in cancer patients after the tumour itself is VTE, and presented studies on the use of DOACs in this patient cohort. He described the various complications and high level of risk for VTE, not only in cancer patients, but across the board. Cancer treatments and hospitalisation, in themselves, provide their own additional risks, he said, adding that every cancer patient is different, with their own clinical nuances.

Mr Power also described the first CAT clinic consultation, which is focused on patient education and reassurance. This means explaining what CAT is and the link between cancer and thrombosis. The patient also hears how CAT will be treated and what expectations the patient can have, and he explained that each of these factors involves a certain degree of anxiety for these patients. “A standard clinic consultation appointment slot is generally not enough to adequately address these issues,” he added. The PELICAN study, said Mr Power, showed that these patients have a high degree of anxiety and a strong desire for information.

On how pharmacists can improve the management of patients with CAT, he told the conference: “Pharmacists are a really great resource for these patients… not least in the area of drug interactions. The potential for interactions with DOACs is huge and we can evaluate whether a treatment is acceptable. Pharmacists can also help with pharmacokinetic considerations, and there is a huge amount of patient [treatment] counselling required, and again, this is something that we can offer to patients.”

He concluded: “I hope everyone would agree that CAT is a quite common but complex condition and cancer patients are at a higher risk of thrombosis and bleeding on anticoagulation versus patients without cancer. However, strategies aimed at preventing VTE in cancer are becoming more commonplace and while treatment of CAT was historically with LMWH [low molecular weight heparin], we are now seeing more DOACs being used. This is great for patients but comes with its own challenges, and that is a great opportunity for pharmacists to become involved.”

Mr Power cautioned that careful patient assessment is required to choose between a DOAC of LMWH, and the patient should be involved in this decision process. “CAT services are paramount to ensuring that these challenges are addressed effectively,” he said. “These services are becoming far more commonplace, and models are now available that can be adopted, and to support AHPs with an interest in CAT management, a training programme has been developed and will be available soon.”

Excellent standard at 2023 poster presentations

The HPAI Annual Conference 2023 hosted a number of poster presentations covering a wide range of topics relevant to hospital pharmacy.

First prize in the Research category, which was kindly sponsored by Pfizer, was won by Ms Eileen Whittle of St Vincent’s University Hospital, who presented on the topic ‘The Role of Medicines Information Services in Ireland in the Education and Development of Early Career Clinical Pharmacists — A Qualitative Interview Study’. The judges, led by Mr Stephen Byrne of UCC and team, commented that the presentation was “a really important piece of work which has national implications for education and training”.

Second prize in the category was awarded to Ms Dzana Hadzic of the Mater Misericordiae University Hospital in Dublin, for her work on the theme ‘Pharmacist-led Medicines Reconciliation: An Observational Study to Evaluate Information Sources as a Quality Indicator of the Service’. The judges remarked that the work was an “important evaluation with key findings regarding the accuracy of information sources”.

A number of posters were highly commended by the judging panel, including a presentation by Ms Moninne Howlett, titled ‘Efficiencies on Implementation of an Automatic Dispensing Cabinet into a Paediatric Emergency Department – An Observational Study’ at Children’s Health Ireland, Crumlin. Also highly commended was the presentation by Ms Christine McAuliffe, titled ‘Polypharmacy in Atrial Fibrillation – Potential for Clinical Pharmacy Input’, and Mrs Barbara Nicolaou-Ghekas, who presented on ‘Exploring Intern Doctors’ Views and Experiences of Prescribing at Hospital Discharge: A Qualitative Interview Study’. 

In the Audit category, first prize was awarded to Ms Sinead O’Mahony of St Vincent’s University Hospital in Dublin, who presented on the theme ‘An Audit of the Management of Drug-Drug Interactions Associated with Paxlovid at a Tertiary Dublin Hospital’. Second prize went to Mr Aaron Daunt of St James’s Hospital in Dublin, who presented on the topic ‘A Retrospective Audit of Timing and Appropriateness of Antimicrobial Prescribing in Presentations of Suspected Meningitis/Encephalitis at an Irish Teaching Hospital’.

The judges, Ms Aisling O'Leary, Ms Fionnuala Brady and Ms Carmel Darcy, commented that “the judging panel was delighted with the standard and obvious enthusiasm for audit”. Highly-commended poster presentations in this category included ‘Clinical Audit of Analgesia and Associated Prescribing on Our Lady of Lourdes Orthopaedic Ward’ by Ms Marie Richardson; and ‘An Audit of Pharmacist Discharge Prescription Review on Orthopaedic Rehabilitation Wards’ by Ms Lydia Duggan of South Infirmary Victoria University Hospital, Cork.

In the Service Development category, first prize was awarded to Ms Rebecca Clarke, who presented on the theme ‘A Study to Assess and Enhance Clinical Prioritisation Within the Clinical Pharmacy Service at St James’s Hospital Dublin’. The judges commented that they “hope to see it in a published paper — useful to many hospital environments”.

Second prize went to Ms Emer O Mahony of Tallaght University Hospital, who presented a poster on ‘Design Implementation and Evaluation of a Medication Counselling Service Provided by Pharmacists Using Teach Back at Hospital Discharge’. The judges remarked that the work is “applicable across many sectors and areas – integrate into teaching”.

Highly-commended presentations included ‘Clinical Pharmacist Interventions and Severity Rating Project at Mayo University Hospital’ by Ms Selena Gill of Mayo University Hospital; ‘A Time-Saving Analysis of Benchtop Preparation of Subcutaneous Monoclonal Antibodies’ by Mr Eoin Tabb of University Hospital Waterford; and ‘Evaluation of the Decisions Made by Clinical Pharmacists When Charting Medication Following Medication Reconciliation in a Tertiary Hospital’ by Ms Sinead O’Mahony of St Vincent’s University Hospital.

In the Innovation category, the first prize went to Ms Maria Mulrooney of Cork University Hospital, who presented on the subject of ‘Improving the Clinical Pharmacist Handover Process Using an Adapted ISBAR Communication Tool when Transferring Patients from CUMH to an ICU within Cork University Hospital’. The judges, led by Mr Stephen Byrne of UCC and team, commented that this is “an excellent body of work with national applicability”.

Second prize was awarded to Ms Roisin O’Connor of St James’s Hospital, who presented on the topic ‘Intervention to Improve Vancomycin Sampling Time at St James’s Hospital’. The judges added that this work is an “excellent patient safety initiative”. Highly-commended posters were by Ms Sandra Lauhoff, who presented on ‘Successful Implementation of a Focused Antimicrobial Stewardship Intervention for the Treatment of Cellulitis, Bon Secours Hospital, Cork’; and Ms Marie Ronan, who presented on ‘Antimicrobial Stewardship in the Digital Era, Mayo University Hospital’.

 

Doing the right research in the right way

Attendees at the HPAI Annual Conference 2023 heard a presentation by Mr Patrick Dicker of the Department of Epidemiology and Public Health Medicine at the RCSI, who delivered a talk titled ‘Critical Appraisal and Research Integrity Evaluation of Randomised Controlled Trials’. Mr Dicker provided guidance on how to ethically conduct research to the best quality possible, while highlighting some of the common pitfalls, such as ethics matters and potential plagiarism.

Mr Dicker has spent 15 years as a trial statistician and currently lectures in the RCSI, teaching evidence-based health to medical students, and is research Integrity Editor for a leading medical journal. Mr Dicker discussed some of the common pitfalls that may lead a researcher to retract their paper. For example, “we know that there are a lot of dodgy Covid-19 trials that have been retracted,” he said. “There have been 300 papers looking at Covid that have been retracted. That’s probably quite a small figure, as approximately 30,000 papers have been published in the first six months of the pandemic. Retractions have become a major concern, and that’s why research integrity has become so important. Nobody wants to have a paper retracted, and that can make it difficult to get published again or to obtain research funding.”

Mr Dicker explained that when a retraction is due to an honest error, some studies have shown there is little evidence of differential stigma. He also talked about the blog ‘Retraction Watch’, which reports on retractions of scientific papers, with its parent organisation being the Centre for Scientific Integrity. “Retraction Watch allows flagging of cases where the authors have owned-up to errors and have taken steps to correct them,” Mr Dicker said. “Everybody makes mistakes, and the scientific community can be forgiving when researchers own up to their mistakes.”

There are a series of key questions around critical appraisal and research integrity that authors should ask themselves before and during the course of their study, he told the conference. “These include, is there a valid rationale for conducting the trial in the first place?” he said. “Also, are the objectives clearly described? Are REC approval, prospective registration and informed consent described? What is the PICO, and is the chosen outcome appropriate? Does the trial have key features, such as control, randomisation and blinding? What were the primary results, their uncertainty, and are they realistic? Was there adequate safety assessment? These are all key questions.”

The acronym PICO, he explained, stands for the ‘Population’ of the study, for example infants with spinal muscular atrophy; ‘Intervention’ with a therapy or treatment; ‘Comparisons’, for example with placebo; and the ‘Outcome’, such as motor-milestone response or event-free survival. “PICO is useful when you are looking at a large number of clinical trials, for example, as they might be different in terms of comparative treatment or the outcomes used, and for an initial systematic review, you might want to make note of what the PICO is for the study,” he said.

“Most healthcare professionals are committed to life-long learning,” Mr Dicker concluded. “Many of you are involved in research, and research integrity is an essential ingredient for publishing trustworthy research. Everyone relies on published evidence, and critical appraisal is an essential skill to understanding the literature that’s out there.”

From frail older adults to aseptic pharmacy

The HPAI Annual Educational Conference 2023 featured a range of six workshops that covered practical learning opportunities for hospital pharmacists, which ranged from ‘Care of the Elderly’, to ‘Aseptic Pharmacy Practise’, to Medication-Related Hospitalisations’, and more.

One of the workshops, facilitated by Mr Kieran Dalton and Mr Eoin Hurley of UCC, was titled ‘Patient-Centered Pharmacotherapy Optimisation in Frail Older Adults with Limited Life Expectancy’. The workshop was focused on recognising frailty in older adults, rationalising medications using validated tools and clinical judgement, as well as managing the prescribing process and evaluating outcomes.

Participants were challenged to evaluate factors that should be considered when aiming to optimise pharmacology in frail older adults, such as their remaining life expectancy, the goals of the treatment, the medications’ time to benefit, as well as withdrawal complications and administration issues. It included feedback on case studies based on real-life patients, and participants were invited to discuss proposed treatment plans.

Participants gained a better understanding of the patient-centered approach to medication optimisation and managing opportunities for de-prescribing. The attendees were also challenged to use validated screening tools, such as STOPPFrail, to identify medication-related issues and potential de-prescribing opportunities. Complex patient cases were discussed and participants collaborated to develop medications recommendations and monitoring requirements, as well as assessing drug withdrawal effects and overall outcomes.

Another useful practical workshop was facilitated by Ms Olivia Flynn, Chief II Pharmacist in Cancer Services at University Hospital Limerick, and Mr Tadhg Reddan, Chief II Pharmacist in Cancer Clinical Services at St Vincent’s University Hospital in Dublin. They hosted a workshop titled ‘Aseptic Pharmacy Practice’ and provided an overview of the role of a pharmacist in the Aseptic Compounding Unit.

The learning objectives also included raising awareness of health and safety considerations in the aseptic compounding unit, and the steps involved in the supervising of the compounding of systemic anti-cancer treatment, as well as highlighting the quality management systems in place in an aseptic compounding unit.

Perfecting your hiring skills

The HPAI Annual Educational Conference 2023 also featured a workshop designed to provide essential skills to people managers to improve their confidence and competence in the recruitment and interview process. Facilitated by Ms Jo Irwin of i4trainingservices.com, the workshop was titled ‘Interviewing Skills: The Key to Hiring’ and was kindly sponsored by United Drug, which had no input into the content of the workshop.

Through interactive discussion, the group drew on their own experiences of being on both sides of the interview process and they were invited to enhance their own existing skills in this Management Workshop. One of the several objectives of this workshop was to better understand the aspects of a HSE interview process, particularly the need to be objective, fair and consistent with each candidate. Proper preparation was also covered, including reviewing paperwork and planning the right questions.

Other practically useful workshops at the conference included ‘Medication-Related Hospitalisations’, facilitated by Dr Tamasine Grimes of Trinity College Dublin, and Dr Ulrike Gillespie of Uppsala University Hospital in Sweden. Another highly useful workshop, ‘Care of the Elderly’, was facilitated by Ms Niamh McMahon, Chief II Pharmacist at St James’s Hospital in Dublin and Adjunct Professor in Practice of Pharmacy at Trinity College Dublin; and Ms Aine O’Reilly, Senior Pharmacist at South Tipperary ICPOP, and Tipperary Enablement Programme for Older Persons.

European hospital pharmacy was also well represented in the line-up of workshops. ‘EAHP Academy Seminar Feedback: Qualitative Research Methods’ was facilitated by Dr Suzanne McCarthy, Senior Lecturer in the School of Pharmacy at UCC and Interim Director of the MSc in Clinical Pharmacy; Dr Virginia Silvari, Chief II Pharmacist at Cork University Hospital and Adjunct Lecturer at UCC and Trinity College Dublin; and Ms Sinead Doyle, Senior Clinical Pharmacist in Portiuncula University Hospital and Clinical Lecturer at Trinity College Dublin.

In 2019, the EAHP held a two-day seminar on ‘Qualitative Research Methods’ designed to address a number of questions around qualitative research, including what, why and how do patients think about their medicines. This workshop was designed to help participants better understand qualitative research and why it should be used; formulate qualitative research questions and prepare topic guidelines; and to apply methods used in qualitative interviews, including focus groups. 

98% of hospital pharmacists have struggled with medication shortages in past six months

Attendees at the HPAI Annual Educational Conference 2023 participated in an important poll that asked a series of questions on whether they have had difficulties with shortages of key medications, as well as a range of other questions around the issue. The poll results highlighted how pressing the problem of medicine shortages has become, and the efforts of hospital pharmacists to maintain patient safety. A total of 58 attendees responded to the poll questions.

On the question ‘Have you experienced medication shortages in your hospital in the last six months?’, the responses were stark, with 98% of respondents answering ‘Yes’. This was followed by the question, ‘Were many of these medications for critical medicines or medicines for which there was no alternative available?’ Almost 30 of the respondents said this was the case 10-to-20% of the time, with a little over 25 answering that this happened to them 20-to-40 per cent of the time. More than 20 people answered that there was no alternative available 5-to-10% of the time, while 10 answered that this was the case in 40-to-60 per cent of cases. Five people said there were no alternatives 60-to-80% of the time, with less than 10 respondents saying this was the case less than 5% of the time.

The participants were also asked, ‘How much notice of shortages do you have on average?’ Some 58% of pharmacists said they received no notice at all, with 29% responding ‘1 week’, and 7% answering ‘2 weeks’. Only 2% of respondents said they received notice of three weeks, four weeks or more than four weeks, respectively.

On the question ‘How much of your time is taken up by managing medication shortages in the average week?’, 47% said they spend between one and three hours, while 21 per cent answered three-to-five hours. This was followed by one hour (17%), five-to-10 hours (14%), with 2% saying they spent more than 10 hours per week dealing with shortages.

However, when the question was tweaked to illustrate the impact on a departmental level, the results were striking — 52% of pharmacists said their department spent more than 10 hours per week dealing with shortages, with 29% responding ‘five-to-10 hours’, and 16% answering ‘three-to-five hours’. Only 3% said their department spent one-to-three hours each week dealing with shortages.

On the question ‘Do you know of patients who have received less than optimal treatment or missed out on treatment due to medication shortages?’, 76% answered ‘No’, with 24% responding ‘Yes’.

The attendees were also asked, ‘Who is best placed to strategically manage shortages of critical meds?’ Twenty pharmacists said the AHDMP is best placed, while just under 20 said the HPRA is best placed to handle these situations. Less than 10 said it is the Department of Health, and the remaining responses (less than five each) comprised ‘National clinical programme leads’, ‘marketing authorisation holder’, ‘Local’, ‘Depends on circumstances’, ‘Need separate group’, and ‘Combination of above’.

The final question asked the respondents, ‘Has the HPRA Medicines Shortages Framework improved communication around medicines shortages on the ground?’ Forty-seven pharmacists answered ‘No’, with 36% answering ‘Yes’, and the remaining 17% saying they had ‘No opinion’.

A timeline of discussions with the HSE regarding the development of a  fit for purpose career structure recognising the value and expertise that Hospital pharmacists bring to  modern healthcare has been published under the CAREER STRUCTURE tab.

The length of the negotiations coupled with failed implementation despite clear safety, quality and financial benefits is of great regret to members of the profession who have worked tirelessly and diligently to improve services, expand roles and bring expertise in the use of medicines from the pharmacy to the side of the patient.

The resource on the website speaks to the lengths that the profession has gone to in order to drive change that benefits patients, local hospitals, the health care system and the government. 

 

Dear EAHP Member Presidents and Delegates,

We thank you for your continued support of the EAHP Congress, which we highly appreciate. In this extremely challenging time of the COVID-19 outbreak and, as of yesterday, March 11, pandemic, EAHP has been closely monitoring the problem and has been in constant communication with the Swedish authorities regarding the COVID-19 situation. After much consideration, we are extremely sad to announce the postponement of EAHP’s 25^thAnniversary Congress, which was scheduled to take place in Gothenburg, Sweden from 25-27 March 2020. 

We are sure that like EAHP, sponsors and participants will be disappointed as this was planned to be a celebratory event.

EAHP will now seek to reschedule the event for a later date, precise timing and venue still to be determined based on the COVID-19 pandemic development and on venue availability.

EAHP’s primary concern is the safety of both participants, sponsors, committees and all of those who had planned to attend the Congress along with the investment that all have made to be present.

There has been so much uncertainty regarding the COVID-19 outbreak and the situation has been changing daily regarding the travel restrictions imposed by national authorities, hospitals and sponsor companies. A lot of our colleagues have been already cancelling their participations due to restrictions applicable in their home countries.

The final decision was made today based on the announcement made yesterday by the Swedish Government to ban gatherings of over 500 people and quickly growing risk for all possible participants. Conferences and congresses are explicitly mentioned as some examples of banned gatherings and those who violate the ban may be fined or imprisoned. This is a unique decision and no Swedish government has ever made use of this opportunity before.

The Covid-19 pandemic is a force majeure situation, which is outside of our control and certainly could not have been foreseen when preparing the congress over the last 2 years. This extreme situation and the Swedish government’s decision leaves EAHP with no other choice than to suspend the organization of the congress until new circumstances allow EAHP to organize the congress.

We are very thankful for the support that has already been shown to us by sponsors and participants alike given that EAHP’s annual Congress is the highlight of the year for many. 

Committed to providing professional education

EAHP, like all of you, will feel the impact of this decision and we want you to know that we’re fully committed to providing the educational content you have all come to know and value. The success of the Congress is the key element in providing other educational programs, grants and projects which many of you may be aware of.

 
We will keep you posted as soon as we have more information and we thank everyone in advance for your understanding and wish you, your families, colleagues, patients and companies the best during this critical time.

Kind regards on behalf of the Board and EAHP Team.

____________________________

Jennie De Greef 

Chief Operating Officer

European Association of Hospital Pharmacists (EAHP)

Boulevard Brand Whitlock 87 Box 11 (4^th floor)

1200 Brussels

Tel:  +3226692510 

e-mail: jennie.degreef@eahp.eu

www.eahp.eu

EU Transparency Register ID Number: 82950919755-02

High performing organisations see the benefit in training their workforce. This is true in many sectors. It makes sense for members of staff to be up to date and skilled in their areas of expertise. This is especially relevant for professionals who need to use their specialist knowledge to expand and build on their skills to stay up to date and build their expertise.

There is a reward for this investment - better, higher quality services delivered by people who are actively engaged in their own careers and development. 

In healthcare the reasons for investment are strong - if you look back 10 years the technology and medicines that we have to chose from have changed considerably. Our relationship with patients, prescribers and the health service as a whole has become more complex.  

The HSE recognises that key staff require education and provides study allowances to medical staff detailed below. 

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https://www.hse.ie/eng/staff/leadership-education-development/met/ed/fin/

Educational Supports

Financial Supports

There are currently three schemes in operation which provide financial support to NCHDs and consultants funded by the NDTP.  The schemes are:

Training Support Scheme (TSS)

Additional Training Support Funding has been made available to NCHDs from July 2019 onwards. This scheme is in addition to existing financial supports such as the Clinical Course and Exam Refund Scheme and the Higher Specialist Training Fund. Funding is allocated based on Grade and the table below indicates the amount available under the TSS for each registration training year, July – July. Funding is available pro-rata for doctors employed on shorter contract durations.

Grade	Amount per Registration Year
Intern	€750
SHOs and Registrars	€1250
SPRs/GP Registrars/Psychiatry SRs on a training scheme	€2000

A list of approved clinical courses, conferences and examinations that can be claimed for under the TSS are listed here

Further information on how to submit claims for refunds under this Scheme will be communicated to NCHDs over the coming weeks. An Information Sheet / User Guide will also be made available on this page. In the meantime, please see link to flyer which contains additional details regarding the Training Supports Funding Scheme

1. Clinical Course & Examination Refund Scheme for NCHDs

This scheme is open to all NCHDs.  There is an approved list of clinical courses & examinations qualifying for this refund scheme contained in the guidance document. A maximum contribution of €450 is payable to NCHDs for each course or exam on this list. An application form must be completed to apply for this refund.

2. Specialist Training Fund for Higher Specialist Trainees

This scheme is open to higher specialist trainees and 3rd/4th year GP trainees only.  The funding available to each trainee is €500 per year of training and the fund rolls over if not claimed in a particular year. 

The Specialist Training Fund for Higher Specialist Trainees (2017) guidance document contains a detailed explanation of the Scheme should be completed and submitted to the your Postgraduate Medical Training Body to claim your refund.

3. Consultant CME

This Scheme is open to Consultants employed in the public service. It allows Consultants claim a maximum of €3,000 pa towards courses and conference, reference materials and professional fees. Further information is available in the memo claiming travel costs the guidance document and the application form should be completed in full and returned to the relevant employer for processing.

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Within Hospital Pharmacy there is no formal agreement over the need for or provision of individual training budgets. As you can see it is quite feasible that hospital; pharmacists could be working as part of a multidisciplinary team where their up to date specialist knowledge is relied upon in order to get the best patient outcomes, however unlike their medical practitioner colleagues they are not in an equal position of having the support in terms of time or funding .

Hospital Pharmacists are motivated and keen to both keep up to date and upskill. The health system that we work in relies up on this but does not automatically provide support for it. 

It is not uncommon for Hospital Pharmacists throughout their careers to self or part fund education that does not directly financially benefit themselves, but increases their effectiveness and their value as an asset to the health service. 

As we are now looked upon as specialists in the area of medicines use should we expect parity on funding for education? Should our employers recognise that Hospital Pharmacists are an asset that require support and development to get their maximum potential?

Head over to the forum to discuss...

 

The HPAI President Fionnuala Kennedy has been interviewed as part of their "In conversation with..." series.

Take a look on the link here for an interesting piece covering a wide range of topics including FMD, Brexit , the roles of hospital pharmacists and opportunities that exist . 

Pharmacist Staffing Ratios – An Opinion

Irish Hospital pharmacists operate under a job description from the 1970s.  The 2011 McLoughlin Report (Hospital Pharmacy Review) identified specialisation as an area for implementation for the Irish Hospital System.

In 2016 HIQA began its first real foray into Irish Hospital Pharmacy with its medication monitoring inspections.  HIQA are now entering a second phase of Medication Monitoring Inspections.  In 2019, with specialisation still unimplemented,  this article will review is it also time to look at staffing levels for Irish Hospital Pharmacy Services to help support implementation of  recommendations from past and future HIQA reviews?

Typically hospital managers have looked at the effectiveness of hospital pharmacy services on basis of budget; drug spend.   With the increasing acuity of hospitalised patients receiving complex medication regimens, the national focus on medication safety and the increasing number of drug safety warnings from the FDA, EMEA and HPRA, the focus on hospital pharmacy effectiveness needs to move away from drug spend only.  The Society of Critical Care Medicine has recognised the pharmacist as an essential member of the intensive care team.3  The American Academy of Paediatrics policy statement on prevention of medication errors in inpatients specifies the need for adequate pharmacy staffing ,and the Joint Commission has stated that effective staffing is a critical component in the provision of safe, high quality care.3  Meanwhile in Ireland, there is no body that regulates pharmacy or that has made staffing recommendations.  Instead recommendations are made for services without recognition of the ability of a department to provide such services.

There are limited studies available in Ireland, but some suggest that clinical pharmacist services also positively contribute towards the overall hospital budget.^,

Are patient ratios really that important?

Evidence exists to show that pharmacists with excessive patient load adopt a belt and braces approach to medication reviews.  Pharmacists in these circumstances focus on; recommended drug dosages by enquiry rather than being medication experts who provide a comprehensive assessment of medication therapy, recommending IV to PO switches, limited antimicrobial stewardship advice, limited interaction advice, and general troubleshooting.   Other health professionals use patient ratios and caps to deal with strain on increasing demand.  Doctors for example use patient ratios to ensure that each ECG or ECHO is reported correctly and adequately, rather than compromising the quality of such reports and patient care through excess load.  Limiting activities to troubleshooting by other professionals is not accepted, and neither should it be when it comes to pharmaceutical care.7  Other authors have stated that ‘For pharmacists to be utilized to their maximum scope, we need to align our work with all of the patient’s medication-related goals, not just some of them’.7

These quality measures all support a need to examine and implement pharmacy staffing levels.

What would adequate pharmacy staffing look like?

There is a conundrum in what skills mix is required.  SHPA’s key Standard of Practice stipulates 30 as the maximum number of patients per hospital pharmacist.  Other authors offer the opinion that mortality and morbidity increases with every patient over 1:100.7  A sensible approach would be to stratify depending on acuity and clinical area such as that adopted by O’Leary et al.

Barriers

Obviously, one barrier presently to effective staffing mix, is the unrecognised position of hospital pharmacy specialists in Ireland.  The lack of a national approach to hospital pharmacy regulation is another such barrier.

It is this authors opinion that to fully realise the benefits of clinical pharmacist servicers the below actions need to be implemented:

• Implementation of the Hospital Pharmacy Review (Mc Laughlin Report)
• Expand the role of the Chief Pharmacist in the Department of Health to a Directorate of Pharmaceutical Care and Pharmacy Services. 
• Appointment of a Director of Pharmaceutical Care and Pharmacy Services at Department level with the office and resources akin to that of the Chief Pharmaceutical Officer in the UK, and on par with the Chief Medical Officer in Ireland.
• A pharmacy Act part 2 to deal with regulation of hospital pharmacy services, and provision of clinical services, that clearly designates the Pharmaceutical Society of Ireland as the regulator ad standard setting agency.
• The creation of recommended pharmacist per patient staffing ratios for Ireland, specific to specialist.
• A department (DoH) lead approach to implement these staffing ratios
• In the absence of a regulator with interest, a Directorate of Pharmaceutical Care and Pharmacy Services, and a professional body, the HPAI has been operating in a vacuum to influence and implement better pharmacy services for Irish Hospital patients.

Disclaimer

• The HPAI encourage discussion and views on the provision of hospital pharmacy services.  The above is neither a view of the Exec or intended to act as a peer reviewed piece of research.  All opinions expressed are those of the author and facilitation of those opinions on www.hpai.ie are not intended as the official position of the HPAI Executive Committee.

References

Report on the review of hospital pharmacy, Chair: Dr Ambrose McLoughlin, November 2011. [online] Available at: https://hpai.wildapricot.org/resources/Documents/Report%20on%20the%20Review%20of%20Hospital%20Pharmacy%202011%20with%202102%20JD%20included.pdf%20

HIQA. Medication safety monitoring programme in public acute hospitals – An overview of findings. Dublin: HIQA, 2018. Available at https://www.hiqa.ie/sites/default/files/2018-01/Medication-Safety-Overview-Report.pdf

Shane R, Gouveia W. The dilemma of establishing effective pharmacy staffing levels. American Journal of Health-System Pharmacy. 2009;66(23):2103-2103.

Stucky ER. Prevention of Medication Errors in the Pediatric Inpatient Setting. PEDIATRICS. 2003;112(2):431-436.

Kinahan C, Heery H. WIDE Review. Poster Presented at: HPAI Conference; 2019 April 5-7th; Dublin

IAPG.  Impact of Antimicrobial Pharmacists has been shown: a €3 return for every €1 spent on salary. 2010 Dublin

Wang E, Co M, Man D, Mabasa V. Should There Be a Cap on the Number of Patients Under the Care of a Clinical Pharmacist?. The Canadian Journal of Hospital Pharmacy. 2012;65(4).

Haggan M. Pharmacist to patient ratios matter: SHPA | AJP [Internet]. AJP. 2019 [cited 17 April 2019]. Available from: https://ajp.com.au/news/pharmacist-to-patient-ratios-matter-shpa/

O’Leary et al. Can J Hosp Pharm. 2012 Jul-Aug; 65(4): 319–321

Medicines currently benefit from free movement across Europe. For Ireland, many of the medicines on the market are dual English packs for Ireland, UK and Malta. Brexit has the potential to disrupt the provision of medicines to not only UK patients, but Irish patients too. Why is this?

The medicine supply chain is a complex International trading arrangement. Active ingredients are usually manufactured in cheaper manufacturing bases in Asia, before then being sent to a pharmaceutical company for processing into the tablet, capsule, or liquid that can be taken by a patient. These products may have time critical deadlines – short expiry dates for example adrenaline mini-jets, adrenaline auto-injectors, or may require refrigeration such as insulin biological products, and anticancer agents. Delays at ports and or airports between Ireland and the UK could result in the medicines delivered to the patient having a shortened expiry for use, pushing up the supply required per patient per year. Disruption will place substantial pressure on hospital pharmacy teams who are already continuously responding to supply issues in the present supply chain. Hospital pharmacies are scanning for potential disruptions, taking action by sourcing alternatives and working with prescribers to ensure patients continue to receive a safe supply of medicine.

The EAHP has described medicines shortages that are currently experienced in the pre Brexit era as serious, and a threat to patient care in hospitals, requiring urgent action (EAHP Practice and Policy Medicines Shortages available here). The EAHP has identified medicines shortages as a diversion of significant amounts of the time and attention of a hospital pharmacist, diverting from other tasks. Irish hospital pharmacists daily face an empty shelf when looking for potentially life altering medicines. During the ‘Storm Emma’ disruption many hospital pharmacies in Ireland had to resort to the Irish Army for deliveries of much needed medicines. Imagine a situation where these medicines are not stuck in Ireland at a warehouse, but at an international border.

Brexit has the potential to cause serious disruption to the medicines supply chain, and the British Government have identified this with calls for a minimum of 6 weeks of medicines to be stockpiled in the UK. (https://www.gov.uk/government/news/dhsc-publishes-brexit-guidance-for-pharmaceutical-industry-and-suppliers-of-medical-devices)

The HPAI as the  representative body for Irish hospital Pharmacists has written to the Minister for Health to ensure that the Government of Ireland has an awareness of this issue.

Members can view the letter and initial response on the forum.

The HPAI is awaiting a formal response, and plan from the Government of Ireland on this issue that will cause significant disruption to Irish Hospital patients, and has the potential to divert already under pressure pharmacy resources from front line clinical duties. Whilst no one wants a no deal Brexit, even a good deal may result in significant disruption to the provision of these complex goods, and the HPAI advocates that the Government with stakeholders prepare a report and work on mitigating this disruption to Irish patients.

Barcelona, Spain

Venue: The CCIB - Centre de Convencions Internacional de Barcelona

http://www.eahp.eu/congresses

The 24th Congress of the EAHP will focus on the need for tailored medication and

approach to treatment for different patient groups and individuals. We are building a

scientific programme in which the aim is to rediscover the need for tailored medication and approach to treatment for different patient groups and individuals.

The scientific program of the Congress is also tailored to the needs of individual hospital pharmacists and their interest groups as the Congress offers the possibility to choose

between many parallel sessions, keynote presentations, workshops and symposia, and plenty of networking opportunities.

The programme will serve as the source of knowledge and inspiration that is needed for our future role and engagement in personalised medication.

This is your opportunity to join experts from around the world in Barcelona to share

experience and ideas and to learn from each other and to discuss all aspects of personalised

medication under one roof.

Join us for the 24th Congress of the EAHP and enjoy an all-round Barcelona experience!

The adoption of pharmacy dispensary automation is low in Ireland. The benefits in terms of safety, stock management, accountability, security, speed and efficiency  are now well understood and have been implemented elsewhere. This tweet celebrates the replacement of automation at a well known London hospital. They have enjoyed the benefits of this central piece of infrastructure for 14 years and are now replacing with updated and upgraded hardware. 

We are in a beneficial position where hospital pharmacy in Ireland has largely missed out on the developmental and refinement pitfalls due to the low uptake and could now purchase mature offerings from vendors, if resources were made available. 

The ever increasing adoption of pharmacy dispensing automation is allowing the redeployment of hospital pharmacy teams away from traditional dispensary based activities and in to near patient clinical activities. By providing these ward based services pharmacy teams are generating both increases in the quality of patient care and ensuring the maximum return on the financial investment in costly medicines.   

After all if patients are treated optimally with their medicines and get the support to ensure they are taking them correctly they stand to get the best outcomes from treatment.  

This increasing use of specialist pharmacists in ward environments, using their in depth knowledge of pharmacotherapy is supported by the HPAI in their negotiations to enable specialist pharmacists to be recognised and supported by the largest employer of hospital pharmacists in the state. 

With a robust structure for expanding services and investment in developing hospital pharmacy around the country both patients and the taxpayer alike stand to benefit. 

If you are a hospital pharmacist member of the HPAI we are negotiating on your behalf to ensure that practice is supported and developed.  

 

The Fórsa bulletin “Pharmacist grading to be aired at WRC” was published earlier in the week here 

Firstly, thank you for maintaining your support of the HPAI, which has enabled us to get to this critical point in negotiations with the HSE.

It is more important than ever to be a member of the HPAI as it adds weight to the negotiations. Fórsa, guided by the HPAI, are the only body authorised to negotiate on terms and conditions with the major employer of Hospital Pharmacists in the State.

 If Hospital pharmacists have been waiting for the “right moment” to join, the announcement of progress on this long standing issue is a key opportunity to maximise our strength in numbers to get an agreement across the line.  Please consider asking colleagues to sign up to show their support for the development of the profession of hospital pharmacist, the recognition of specialisation, and the need for structures to drive practice development in pharmacy in the hospital sector.

This will ensure that Hospital Pharmacists can sustainably build on their existing work improving patient care, safety and providing maximum value from the use of medicines. 

We will keep members updated of any developments via the membership forum.