Transcript Hospital Pharmacy in Canada Summary Report 2003-04

Measuring Your Department’s Progress in the
Advancement of Pharmacy Practice and
Patient Safety
CSHP Professional Practice Conference - Jan 2006
Patricia Macgregor, Nancy Roberts
Editorial Board members
Outline

Overview of the sections of the 2003/04
Hospital Pharmacy in Canada Report (HPCR)
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Specialty Focus of the 2003/04 Report
HPCR 2003/04 Indicators and trends
Conducting a Self-Operational Review
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Using ave. results for all hospital types
Using specific results by hospital size & type
Aligning Your Organizations Priorities
Testimonials
Hospital Pharmacy in Canada Report
(HPCR)



Measuring hospital pharmacy progress
Data collection every two years
Also known as “Lilly” report

www.lillyhospitalsurvey.ca
HPCR Sections
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Demographics
Clinical Pharmacy Services
Drug Information and Drug Use Evaluation
Drug Distribution
Drug Purchasing and Inventory Control
Human Resources
Medication Safety
HPCR Sections continued
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Technology
Education and Research
Pharmacy Staffing and Drug Costs for
Clinical Programs
- Acute Care Hospitals
- Pediatric Hospitals
Benchmarking
2003/04 HPCR Report Focus
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Medication safety and role of pharmacy leaders
Clinical practice, direct patient care, pharmacist
prescribing
Incident reporting and reduction strategies
Distribution delivery systems
Escalating drug costs - utilization issues
Human resources – impacts of shortages
Technology applications
Demographics
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144 hospitals responded Nationally
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Inclusion criteria – 100 beds total, 50 acute beds
77% response rate overall
59% of respondents were multi-site facilities,
similar to previous survey
(higher in BC, Prairies and Atlantic)
Clinical Data Captured
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Staffing allocations per specialty program
Clinical pharmacy activity by type with
occurrence rate
Specific clinical activity priority and service
level
Methods and types of practice evaluation
Prescribing privileges by profession
Pharmacist prescribing authority by activity
Clinical practice models and seamless care
Clinical Practice Trends

Decentralizing pharmacists may decrease
medication errors by 45%.*

Centralized pharmacist
-errors/bed 3.15
Centralized with occasional unit visits -errors/bed 1.93
Decentralized pharmacist
-errors/bed 1.74
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
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% clinical time unchanged, at 38%, from
previous surveys
*(Bond et al. Pharmacotherapy 2002 22 (2):134-47)
Clinical Practice Trends
Beds serviced by pharmaceutical care %
30%
Clinical pharmacist FTEs for outpatients
2.73
Clinical pharmacist FTEs for inpatients
8.3
Pharmacist time in direct patient care %
38%
Pharmacist time in drug distribution %
48%
Pharmacist FTEs dedicated to Drug Info
1.3
Pharmacist FTEs dedicated to DUE
0.7
Number of undergraduate student days
228
Pharmacist Time spend in research %
1%
Figure F-2. Proportion of Time Spent
by Pharmacists in Each Category
2003/04
Drug Distribution
48%
Research
1%
Teaching
5%
Other Non-patient Care
8%
Clinical
38%
Base: All respondents (144)
Outpatient Pharmacist FTE Ratios
Average 0.14 FTE pharmacist/10,000 visits
 DVT/anticoagulation
2.02 FTE/10,000 visit
 Infectious disease
2.00 FTE
 Cardiovascular/lipid
1.67 FTE
 Diabetes
1.16 FTE
 Hematology/oncology 1.06 FTE
 Emerg
0.02 FTE
Inpatient Pharmacist FTE Ratios
Average 0.53 FTE pharmacist/10,000 pt days
 Adult intensive care
1.53 FTE/10,000day
 Adult medicine
0.65 FTE
 Adult rehabilitation
0.55 FTE
 Adult surgical
0.51 FTE
 Adult mental health
0.47 FTE
 Geriatrics
0.36 FTE
 Pediatric medical
1.27 FTE
Clinical Activities Documentation
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# interventions per admission – 0.64
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Increase from 0.6 in 2001/02 and 0.53 in 1999/00
Annual interventions per pharm FTE – 645
 Still 20% respondents who do document
do not do it in the patient chart
 Pharmacokinetic documentations on the
increase
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Priority Ranking vs Actual Activity
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Bond et al – 6 clinical services associated
with lower total cost of care
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DUE, drug information, ADE monitoring,
Drug protocol management, medical rounds participation,
admission drug histories
Yet none was reported by more than 70% of
respondents as being among the top 10
priorities
Participants rated clinical services by priority
and by extent offered – striking discrepancy
Clinical Practice Models and
Evaluation
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81% reported clinical practice services NOT
offered to some inpatients
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Equals 33% of inpatient beds
Pharmaceutical care – 70% reported using average 30 beds serviced
Only 17% evaluate clinical practice
Prescribing Privileges
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Pharmacists
Midwives
Nurse practitioners
Other professionals
66%
45%
47%
20%
Pharmacists Prescribing
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Lab tests – 21%
Independent dosage adjustments – 23%
New therapy – 5%
Dependent, dosage adjustment – 46%
Dependent, new therapy -13%
Seamless Care-Discharge
Information Provided
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Medications at discharge
Medications discontinued
Care Plan
Monitoring Values
Diagnosis
95%
68%
56%
59%
46%
Drug Information and DUE
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DUE
–
–
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0.8 FTE pharmacist
0.5FTE support staff
Drug Information
- 1.3 FTE pharmacists
-
0.4 FTE support staff
Drug Distribution and Delivery
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Systems used
Order entry
Order verification
MARs, medication profiles etc
Technician check technician
IV admixture
Oncology
Ambulatory services
Distribution Delivery Systems
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Traditional delivery some beds
Total wardstock
Unit dose, >90% beds
63%
21%
31%
Figure D-2. Proportion of Beds
Serviced by Drug Distribution System
2003/04
Unit Dose
51%
Total Wardstock
3%
Carded Dose
6%
Traditional
32%
Unit Based Automated
8%
Base: All respondents (144)
Order Entry
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Pharmacists
Technicians
Nurses
Physicians
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Pharmacist verify pharmacist OE
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79%
78%
5%
3%
*Significant increase from 01/02 report
-41%
- 27%
Medication Administration
Records (MARs)
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Electronic, on-line documentation
Manual
Computer generated
Allergy status on MAR
Cards, tickets (Ontario 4%)
10%
44%
56%
56%
25%
Figure D-4. Technician Activities
Checked by other Technicians 2003/04
A ctivities
Unit Dose
Tray Filling
82%
Unit Dose
Packaging
82%
Replenishing
Automated Cabinets
77%
Cardiac Arrest
Tray Filling
70%
Traditional Prescriptions
(Ref ills)
66%
IV Admixture Preparation
(Batching)
59%
Interim Dose
Filling
58%
Extemporaneous
Compounding
51%
IV Admixture Preparation
(Patient Specif ic)
41%
Traditional Prescriptions
(New Orders)
32%
TPN Preparation
30%
Medication Order Entry
17%
Chemotherapy
Preparation
13%
0%
10%
20%
30%
40%
50%
60%
70%
% of Respondents
Base: Res pondents reporting that f unction is perf ormed
80%
90%
100%
Figure D-5. Certification Required
2003/04
A ctivities
IV Admixture Preparation
(Patient Specif ic)
86%
IV Admixture Preparation
(Batching)
83%
Chemotherapy
Preparation
82%
Traditional Prescriptions
(New Orders)
81%
TPN Preparation
77%
Interim Dose
Filling
76%
Traditional Prescriptions
(Ref ills)
75%
Unit Dose
Tray Filling
72%
Medication
Order Entry
67%
Unit Dose
Packaging
54%
Extemporaneous
Compounding
41%
Cardiac Arrest
Tray Filling
39%
Replenishing
Automated Cabinets
31%
0%
10%
20%
30%
40%
50%
60%
70%
% of Respondents
Base: Respondents using technician check technician
80%
90%
100%
Drug Purchasing and Inventory
Control
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PMRB reported sales from drugs increased
14.5% in 2003
Since 2001/02 report:
–
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Acute care inpatient drug cost/pt day only
increased 26 cents. (Ave $31.25)
Emerg costs/patient day increased 24%
Ave inventory increased by 10.6%
CIHI - Drugs = 16.2% of total healthcare
costs
Figure E-1. Percentage of Drug
Expenses by Patient Care Area 2003/04
Inpatient Acute Care
55%
Ambulatory
(Retail Pharmacy)
3%
Ambulatory
(Take Home)
3%
Emergency
Room
8%
Inpatient Long-Term Care
6%
Clinic / Medical Day Unit
25%
Base: Respondents w ho provided relevant drug cost inf ormation (82)
Human Resources
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Paid hours per acute patient day, average
unchanged at 0.74
Staffing Ratios
–
–
–
–
–
Pharmacist
Technician
Support staff
Management
Residents
40%
46%
7%
5%
2%
Human Resource Shortages
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63% of respondents reported vacancies as
follows:
–
–
–
–
Pharmacist vacancies
Management
Technicians
Residency vacancies
12.9%
6.9%
0.9%
13.8%
*Concern expressed re reduced student
applications
Impact of Human Resource
shortages on Patient Care
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67% respondents reduced services overall
85% reduced direct patient care
56% reduced implementation of approved
service
52% reduced teaching
38% reduced hours
15% reduced distribution
Medication Incident Reporting and
Reduction Strategies
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100% use med incident reporting tool
67% implemented strategies to increase
reporting
63% disclosure policy
80% have committee to review med safety
DTC, risk, quality, MAC, Pharm/nursing
51% completed self assessment tool
95% of assessment tools used were ISMP
Medication Safety
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Verbal and telephone orders limited
Med orders conditional until
pharmacist review
List of non-acceptable abbreviations
High alert medication list identified
Conc. electrolytes removed from
patient care areas
Conc. narcotics removed from
patient care areas
Standardized heparin concs.
76%
52%
40%
38%
72%
47%
81%
Issues for Patient Safety
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Medication safety is related to the extent of
pharmacist involvement in direct patient care,
yet why is:
–
–
–
–
Time spent in clinical activity unchanged since
1999 (38%)
Clinical services still NOT provided to some
inpatients (33% inpatient beds)
Specific safety initiatives only partially
implemented
? Related to pharmacist shortage
Technology
Pharmacy systems with clinical
decision support
 Automated max. dosage alerts
 Fully interfaced lab results
 CPOE
 Handheld devices
 Wireless network with handheld

40%
28%
25%
5%
49%
8%
Figure H-1 Functions for which
handheld devices are used
94%
Clinical database consultation
68%
Mail, agenda and task management
37%
Formulary information
23%
Workload data collection
17%
Drug utilization activities
3%
Clinical data entry and upload
Clinical data dow nload
from pharmacy records
3%
Clinical data dow nload
from health records
1%
11%
Other
0%
10%
20%
30%
40%
50%
60%
% of respondents
Base: Respondents reporting the use of handheld devices (71)
70%
80%
90%
100%
Bar Code Technology
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FDA - USA mandate bar codes at bedside – by
May 2006
22% respondents use bar code technology
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Up from 11% in 2002
Figure H-2 Uses of Bar Coding
re tu rn d o s e s
34%
to in v e n to ry in th e p h a rm a c y
v e rify d ru g s e le c tio n
16%
p rio r to d is p e n s in g fro m th e p h a rm a c y
v e rify s to c k in g o f
16%
a u to m a te d d is p e n s in g c a b in e ts
v e rify s to c k in g o f
13%
u n it d o s e b in s
id e n tify th e p a tie n t
d u rin g m e d ic a tio n a d m in is tra tio n
3%
v e rify d ru g s e le c tio n
p rio r to p a tie n t a d m in is tra tio n
3%
o th e r
47%
0%
10%
20%
30%
40%
50%
% of re s ponde nt s
Ba s e : R e s p o n d e n ts r e p o r tin g u s e o f b a r c o d in g in me d ic a tio n s y s te m ( 3 2 )
Education and Research

Education - Student training remained a high
priority with:
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–
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83% reporting training for under-graduate
pharmacy students
26% reporting training for pharmacy residents
Research
–
Sites conducting research decreased to 35% from
43% in 1999/2000 ( may be related to the 13.8%
residency position vacancy rate)
Hospital Pharmacy in
Canada Annual Report
Analysis of Indicators
Lilly Report User Customizable
Benchmarking Report
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Paid hours per acute patient day
Paid hours per acute patient day by
distribution system
Drug costs per acute patient day
Drug costs per acute admission
Inventory turns
IV production per acute patient day
Interventions per admission
Drug Costs Per Acute Patient Day
Your hospital
Average
Average Teaching
$45
$40
$35
$30
$25
$20
$15
$10
$5
20
01
/0
2
20
03
/0
4
00
99
/2
0
97
/9
8
96
/9
7
95
/9
6
94
/9
5
93
/9
4
$0
Interventions per Admission
Your hospital
Average
Average Teaching
20
01
/02
20
03
/04
00
99
/20
97
/98
96
/97
95
/96
94
/95
93
/94
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Paid Hours (Budget) per Acute Patient Day
by Distribution System
Your hospital
Unit Dose
96/97
97/98
Traditional
UD/CIVA
Traditional/CIVA
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
99/2000
2001/02
2003/04
Additional benchmarking tables
in the Report
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Ave drug costs per day by clinical program
Ave paid hours per admixture – CIVA, oncology, per
investigational drug study
Ave paid hours for inventory/procurement and for
DUE per $1m drug purchases
Ave paid hours per patient day for high acuity
programs e.g bone marrow transplant, neonatal or
pediatric ICU
Changes in drug expense by patient care area
Total drug costs by patient care area
What’s Next?
How does your Organization shape
up in comparison to your peers?
Conducting a
Self-Operational Review
Leadership and Management

Bar Code Technology
HPCR 03/04 (n= 144)
% with some level of Barcoding implemented
Your
201 –
Hospital 500
Beds
21%
Over
500
Beds
Teaching
Status
39%
41%
Leadership and Management

Uses of Bar Code Technology (Numbers too small to
break down by site size)
HPRC 03/04 ( n=32)
Your
Hospital
All
Hospitals
Returning doses to Inventory
34%
Verify drug, stock, dispense
16%
Verify unit dose bin stocking
13%
Verify drug prior to patient admin
3%
Leadership and Management

Computerized Provider Order Entry - CPOE
201 –
500
Beds
Over Teaching
500
Status
Beds
Operational CPOE
1%
13%
11%
Sites (%) with approved
plan to implement CPOE
15%
26%
25%
HPCR
2003/04 (n = 144)
Your
Hospital
Leadership and Management

Clinical Decision Support
HPCR
2003/04 (n = 144)
Your
201Hospital 500
beds
Over
500
Beds
Teaching
Status
Pharmacy systems
with clinical decision
34%
42%
32%
Automated Max
dosage Alerts
31%
26%
38%
Fully Interfaced Lab
results
29%
24%
20%
Trend Table 1 - Human Resource Shortages
Type
Vacancy (%)
Pharmacist
12.9%
Technician
6.9%
Residents
0.9%
Management
13.8%
Human Resources
Technicians
Certification programs for technician checking functions
HPCR
2003/04 ( n = 144)
Respondents (%) with
technician certification
Respondents (%) with fully
implemented recertification program
(36/102)
Your
Hospital
All Hospitals
71%
35%
Trend Table 2- Direct Patient Care/Clinical
Pharmacy Services
201Your
500
Hospital beds
Over
500
beds
Teach
35
Beds serviced by
pharmaceutical care %
Clinical pharmacist FTEs for
outpatients
27
33
1.89
4.83 4.32
Clinical pharmacist FTEs for
inpatients
Pharmacist time in direct
patient care %
5.4
15.8 12.7
38
44
38
Pharmacist time in drug
distribution %
49
41
38
Trend Table 3 - Direct Patient
Care/Clinical Pharmacy Services
Your
Hospital
201- Over
500 500
beds beds
Teach
Pharmacist FTEs dedicated
to DUE
0.7
0.8
0.8
Number of undergraduate
student days
Pharmacist FTEs dedicated
to Drug information
153 474
404
0.9
1.6
1.5
Pharmacist Time spend in
research %
1%
2%
2%
Direct Patient Care/Clinical Pharmacy
Services

Targeted Inpatient Clinical Practice Sites
HPCR 03/04
(n = 100)
Gen Medicine
Other acute
Adult Surgical
Adult ICU
Haem-Onc
Your
201- 500
Hospital Beds
1.9 FTE
1.5
1.2
0.6
0.5
Over 500
Beds
Teaching
Status
5.8 FTE
4.0
3.1
2.5
1.8
5.0 FTE
3.9
2.8
2.0
1.5
Direct Patient Care/Clinical Pharmacy
Services

Targeted Inpatient Clinical Practice Sites
HPCR 03/04
(n = 100)
Adult Mental Health
Geriatrics
Obs/Gyn
Pediatric medical
Pediatric ICU
Pediatric haem-onc
Your
201- 500
Hospital Beds
0.5 FTE
0.5
0.5
1.1
1.5
1.7
Over 500
Beds
Teaching
Status
1.0 FTE
0.8
0.4
0.5
0.8
0.8
0.8 FTE
0.6
0.6
1.3
1.2
1.3
Direct Patient Care/Clinical Pharmacy
Services

Targeted Outpatient Clinical Activities
HPCR 03/04
(n=102)
Haem-onc
Renal/Dialysis
Infect-Dis
ER
DVT/Anticoag
Cardiovas/lipid
Diabetes
Your
Hospital
Bed Size
201 - 500
Bed size
Over 500
Teaching
Status
0.82 FTE
0.71
0.67
0.54
0.51
0.13
0.22
1.79 FTE
1.14
1.33
1.10
1.16
0.52
0.59
1.57 FTE
0.82
1.12
1.02
1.20
0.66
0.52
Direct Patient Care/Clinical Pharmacy
Services
Seamless Care – Discharge information provided
HPRS 03/04
Your
201-500 Over Teaching
Hospital
Beds
500
Status
(n=41)
Beds

Medication list at
Discharge
100%
93%
100%
Meds discontinued
54
73
86
Care Plan
69
47
55
Monitoring Values
54
67
68
Diagnosis
38
53
55
Drug Use Management

Drug Information
Hand-held devices supplied to physicians and
other professionals for clinical activities
HPCR
2003/04 ( n = 144)
Respondents (%)
supplying hand-held
devices for clinical
activities
Your
201-500 Over
Hospital Beds
500
Beds
51%
63%
Teaching
Status
61%
Trend Table 4 - Handheld Device Use
HPCR 2003/04
Your
Hospital
201500
Beds
Over
500
Beds
Teaching
Status
Clinical data Base Consult
94%
96%
100%
Mail, Calendar, tasks
60
75
71
Formulary info
34
38
32
Workload
17
25
24
DUE
17
17
24
Clinical Data Entry
3% - only 5 sites total
Drug Distribution

Medication Administration Records (MARs)
HPCR
2003/04 (n = 144)
Your
Hospital
Bed Size Over 500
201 - 500 Beds
Teaching
Status
Electronic, on-line
12%
13%
14%
Hard copy, computer
generated MARs
54%
61%
50%
Manual
40%
45%
36%
Cards, Tickets
Yes (≥90%)
9%
13%
9%
Allergy on Mar
56%
63%
57%
Drug Distribution

Parenteral Drugs
HPCR
2003/04 (n = 65)
Average No. of admixtures per
acute patient day
Your
Bed Over Teaching
Hospital Size 500 Status
201 - beds
500
1.00
1.07
1.37
Drug Distribution

Order Entry
HPCR 03/04 (n = 144)
Your
201Hospital 500
Beds
Over
500
Beds
Teaching
Status
Pharmacists only
76%
82%
77%
Technicians
76%
87%
82%
Nurses
1%
8%
5%
Physicians
3%
4%
6%
Trend Table 5 – Medication Safety and
Quality Improvement
HPCR 03/04
(n=144)
Your
201 –
Hospital 500
Beds
Over
500
Beds
Teaching
Status
% completing medication
safety Self-Assessment
49%
61%
61%
Strategies to increase error
reporting
75%
71%
71%
Disclosure policy
65%
71%
75%
Committee review med safety
78%
87%
91%
Use ISMP assessment tool
97%
87%
91%
Drug Costs
HPCR
2003/04 ( n = 144)
Your
Hospital
201- 500
Beds
Over
500
Beds
Teaching
Status
Average Total
($1,000,000s)
5.3
17.3
14.7
% increase in Costs
13.3
10.7
11.6
Aligning Your
Organizations
Priorities
Supporting your Priorities



Canadian Society of Hospital Pharmacists
(CSHP) Standards, Statements and
Guidelines - www.cshp.ca
Canadian Council on Health Services
Accreditation (CCHSA) – New Patient Safety
Standards effective 2006 – www.cchsa.ca
Institute for Safe Medication Practices
(ISMP) – Canada - www.ismp-canada.org
Supporting your Priorities Cont’d…





Canadian Patient Safety Institute www.patientsafetyinstitute.ca
Safer Healthcare Now Initiatives www.saferhealthcarenow.ca
American Society of Health System Pharmacists –
www.ashp.org
Institute for Healthcare Improvement (IHI) www.ihi.org
Institute of Medicine (IOM) - www.iom.edu
Supporting your Priorities Cont’d…
Last but not least……
 Hospital Pharmacy in Canada Report –
www.lillyhospitalsurvey.ca – extensive
inventory of references at the end of each
section of the document.
Hospital Pharmacy in
Canada Annual Report
Analysis of Indicators
Paid Hours (Budget) per Acute Patient Day
by Distribution System
Your hospital
Unit Dose
96/97
97/98
Traditional
UD/CIVA
Traditional/CIVA
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
99/2000
2001/02
2003/04
Drug Costs Per Acute Patient Day
Your hospital
Average
Average Teaching
$45
$40
$35
$30
$25
$20
$15
$10
$5
20
03
/0
4
20
01
/0
2
00
99
/2
0
97
/9
8
96
/9
7
95
/9
6
94
/9
5
93
/9
4
$0
Drug Costs per Acute Admission
Your hospital
Average
Average Teaching
$350
$300
$250
$200
$150
$100
$50
20
01
/0
2
20
03
/0
4
00
99
/2
0
97
/9
8
96
/9
7
95
/9
6
94
/9
5
93
/9
4
$-
Inventory Turns
Your hospital
Average
Average Teaching
20
01
/0
2
20
03
/0
4
00
99
/2
0
97
/9
8
96
/9
7
95
/9
6
94
/9
5
93
/9
4
14
12
10
8
6
4
2
0
I.V. Production Per Acute Patient Day
Your hospital
Average
Average Teaching
2.00
1.75
1.50
1.25
1.00
0.75
0.50
0.25
20
01
/0
2
20
03
/0
4
00
99
/2
0
97
/9
8
96
/9
7
95
/9
6
94
/9
5
93
/9
4
0.00
Interventions per Admission
Your hospital
Average
Average Teaching
20
01
/0
2
20
03
/0
4
00
99
/2
0
97
/9
8
96
/9
7
95
/9
6
94
/9
5
93
/9
4
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Paid Hours (Budget) Per Acute Patient Day
Your hospital
Average
Average Teaching
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
93/94
94/95
95/96
96/97
97/98
99/2000 2001/02 2003/04
Using the Data - Testimonials
“…it takes 17 years for a new piece of
science/evidence to be propagated through
the system.” (IOM Report)
Contact Information


Patricia Macgregor - [email protected]
Nancy Roberts – [email protected]
THANK-YOU - MERCI