The Children’s Hospital & Institute of Child Health, Lahore
CLINICAL PHARMACY SERVICES
AT A PUBLIC SECTOR HOSPITAL
Zaufishan Rahman
The Children Hospital & Institute of Child Health
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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
Department of Pharmaceutical Services
Onco
Pharmacy
Satellite
Pharmacy
Ground
Floor
Satellite
Pharmacy
1st Floor
TPN
Section
Central
Pharmacy
Satellite
Pharmacy
2nd Floor
Satellite
Pharmacy
3rd Floor
Government.
Model
OPD
Pharmacy
A&E
Pharmacy
Drug
Information
Centre
Pharmacy
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
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....thereby, a need to provide patient centered care
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”
PHARMACEUTICAL CARE
PLANS
Key elements
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Drug Individualization
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Monitoring of Drug Interactions
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All pediatric patients need weight based dosing; hence at
increased risk of adverse events
Monitoring of In-Vitro and In-vivo drug interactions
Monitoring and Reporting of potential ADRs
Pharmaceutical Care Planning
Patient Category
Pharmacist’s Role
 To
1. Patients on
polypharmacy
check each drug for indication, effectiveness,
safety, and compliance.
 To suggest reduction of doses or drugs
To advice on how to minimize adverse effects, and
on best timing to take each drug in relation to other
drugs, meal times, daily activities, etc
Pharmaceutical Care Planning
Patient Category
Pharmacist’s Role
2. Patients with actual or
potential DRPs
 To follow a structured process to identify
actual or potential
drug-related problems and
 To develop a plan to eliminate or
minimize these problems and maximize
desired outcomes
Pharmaceutical Care Planning
Patient Category
3. Patients who require
education to improve their
compliance with drug
therapy
Pharmacist’s Role
 To discuss the issues with patients to
gauge the reasons for poor compliance
and
 Devising plans to improve compliance
and concordance
Pharmaceutical Care Planning
Patient Category
4. Patients on medicines which require the
use of Devices as
- Asthma inhalers
- Glucometers
Pharmacist’s Role
 To identify problems with how the
patient use the drug giving
devices and
 To train the patient on the proper
use of devices to maximize
the benefit of the drugs.
Pharmaceutical Care Planning
Patient Category
5. Patients on potentially
harmful drugs which require
education and monitoring
(warfarin, steroids,
chemotherapy)
Pharmacist’s Role
 To educate the patients on the
use of drug with potential
for serious adverse effects
or for drug-drug or drug food
interactions, and also
those drugs which require
monitoring to avoid harmful
effects
Pharmaceutical Care Planning
Patient Category
Pharmacist’s Role
6. Patients referred by their
clinicians
 Clinicians may wish to refer specific patients
to the service when they identify
an issue where the pharmacist might have
appropriate input
Extended Scope of clinical pharmacy services
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Participation in clinical rounds
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Drug information centre services
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Poisoning & Drug Overdose management services
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Total Parental Nutrition (TPN)
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Extemporaneous Preparations
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Clinical training program
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Hospital Clinical Committees
Participation in Rounds
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Working in a multidisciplinary team
Interaction with patient’s other healthcare
providers
Ensuring best clinical outcomes
Preparation and Implementation of
Pharmaceutical Care Plans
Drug information Centre Services
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Provision of unbiased, scientific and up to date
information to health care professionals
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Concept Paper
Protocol
Tools:
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DIC Query Form – A
DIC Query Form – B
DIC Query Referral Form - C
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.
Poisoning & Drug Overdose Management
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24/7 Presence of Pharmacist in Emergency Department
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Availability of antidotes
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Backup support from Drug Information Centre
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Examples:
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Management of Kerosine oil poisoning
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Management of patient who has ingested milk with a lizard
Total Parental Nutrition (TPN)
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First of its kind in any public sector hospital in Punjab
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Caters individual needs of patients
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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
TPN
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During last 1 year i.e. December 2010 to November 2011:
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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
Extemporaneous Preparations
Preparations
Sr. No
5
Used in/ for
1.
Zinc Sulphate Sachets
Zinc deficiency with diarrhea
2.
Zinc Acetate Sachets
Wilsons Disease
3.
Jouli’s Solution
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Hydrosol, Eusol Solution
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Sodium Benzoate Solution
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Dexinal Mouthwash
Oncology Patients
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Morphine Suspension
Oncology Patients
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Shohl’s Solution (Polycitra, Polycitra-K, Bicitra)
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Tablet dilutions of Digoxin, Sildenafil,
Indomethacin, Spiromide
Hypo-phosphatemia Rickets
Wet dressings
(Irrigation Solution)
Urea cycle defect and
hyperammonemia
Renal tubular acidosis
Pediatric Cardiology Unit
Clinical Training Programs (>400 students/ year)
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Clinical Pharmacy Residency Program
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Clinical Pharmacy Projects
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Eligibility: Graduates and Awaiting result students
Eligibility: 5th Professional Students
Clinical Pharmacy Internship Program
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Eligibility: 4th Professional Students
Hospital Clinical Committees
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Pharmacy & Therapeutics Committee
Comprises of all department heads, Assistant and
Associate Professors, Pharmacists and administration.
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Hospital Infection Control Committee:
Pharmacists as key members of team for effective
infection control measures
“… and if anyone saved a life; it would be
as if he saved the life of whole mankind”
CASE SCENARIOS
Clinical Pharmacy Services
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.
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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
Case 2: Bronchial Pneumonia
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Patient Name: Zihan
Age: 7 months
Weight: 5kg
Current Medication:
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Paracetamol, Cefuroxime, Amikacin
Nebulize with Aprint, N/Saline and Clenil
Pharmacist’s Intervention:
Patient’s mother education and counseling on
proper nebulizing technique
Case 3: Pericardial Effusion
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Patient Name: Minahil
Age: 2 months
Weight: 3.2 kg
Current Medication:
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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
Case 4: Pneumonia and Sepsis
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Patient Name: Iman Fatima
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Age: 21 days
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Weight: 2.2 kg
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Medication:
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Inj. Meropenam and Inj. Vancomycin are prescribed to patient after resistance to
Ciprofloxacin, Ceftrioxone, Amikacin and Amoxicillin
Pharmacist’s Intervention:
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Pharmacist ensured that culture sensitivity test is done before prescribing the third line
therapy. Culture was positive for Klebsella and Enterobacter
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Separate administration of Ceftrioxone and Amikacin was recommended to nurse as these
drugs can interact when administered together.
Case 5: Nephrotic Syndrome with Acute Renal Failure
Suspected Meningococemia
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Patient Name: Abdul Malik
Age: 16 months
Weight: 10kg
Medication:
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Inj.Benzyl Penicillin, Inj. Solucortif, Inj. Ceftrioxone 500mg IV 12 hourly, Syp Mucain
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
Case 6: Pseudo- Pancreatic Cyst
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Patient Name: Zainab
Age: 2.6 years
Body weight:
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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
WHAT'S NEXT?
Way Forward
Extension of Clinical Services
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Workshop on Identification of potential ADRs monitoring and reporting
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Doctors, Pharmacists and Nurses
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Workshop on Poisoning and Drug Overdose Management
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Drug Utilization Reviews
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Utilization review of Meropenam – In Process
Others - In design phase
Impact Assessment Studies
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Impact assessment study of TPN in improving quality of life of neonatal patients
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
Every Single Life is Valuable….!
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UNICEF Missing Mothers a video message on maternal mortality.mp4
THINK GLOBAL
….…. ACT LOCAL!
Thankyou!