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.
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.
- 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.
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