Transcript Hospital Pharmacy in Canada Summary Report 2003-04

Hospital Pharmacy in Canada Report
2005/06 Report Summary
Patricia Macgregor
Ontario Management Seminar
May 6, 2007
Hospital Pharmacy in Canada Report
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
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Technology
Education and
Research
Ethics
Benchmarking, staffing
and drug costs
- Acute Care
- Pediatric
Mental Health
2005/06 HPCR Report Focus
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Medication safety, incident reporting,
disclosure and medication reconciliation
Clinical practice, priority and reality
Distribution delivery systems, enhanced
role of technicians
Escalating drug costs
Human resources – impacts of shortages,
student training
Technology uptake
Ethics – special interest section
Demographics
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142 hospitals responded Nationally
– Inclusion criteria – 100 beds, 50 acute
– Represents 60,000 beds (115,120 beds in
Canada)
74% response rate overall, 90% for teaching
hospitals
66% of respondents were multi-site facilities, 59%
last survey, (only 39% in Ontario, 60% Quebec,
other 90%)
New for 2006
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Teaching hospital designation changed
– Uses CHAHO definition
– Note some data may not be comparable to
previous surveys
Mental Health recognized as distinct group
– Specific report to follow
Service volume comparisons
2005-06 vs 2003-04
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Acute care admissions 5.3% increase since
previous survey
Acute care patient days 3.4% increase
Emergency dept visits 11% higher
General Points
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92% of hospitals reported pharmacist as leader of
dept
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CSHP recommendation
Facilities with program management, 82% report
pharmacist salaries paid by pharmacy but only
79% indicated the pharmacists report to
pharmacy
20% reported shared responsibility but only 13%
shared the salary cost
Several outpatient services receive NO clinical
pharmacy services. Provincial differences
ALL inpatient clinical services reported received
clinical pharmacy services. Provincial differences
in focus
General points
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Decrease in pharmacist verification of technician
orders, 69% vs 87% in 2003/04
80% of hospitals report some patients do not
receive pharmaceutical care, amounting to an
average of 34% of all beds. (No change from
previous survey)
IV admixture service increased to 94% of
respondents from 75% in 2003/04
– Areas serviced include OR, 49%, emerg 63%,
outpatients 75%, critical care 83%, inpatients
95%
Proportion of Time Spent by
Pharmacists in Each Category of
Service
Drug Distribution
48%
Drug Distribution
43%
Research
1%
Teaching
5%
Research
2%
Teaching
6%
Other Non-patient Care
8%
Clinical
38%
2003-04 Base: All respondents (144)
Clinical
41%
2005-06 Base: All respondents (142
Other Non-patient Care
8%
Clinical Data Captured by the Report
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Clinical pharmacy practice models – prevalence
Specific clinical activity priority ranking and actual
service level
Specific programs -% hospitals with assigned
clinical pharmacists by clinical program
Seamless care activities, % hospitals providing
specific activities
Methods and types of practice evaluation
Prescribing privileges by profession
Pharmacist prescribing authority by activity
ASHP/CSHP 2015 goals and baseline from current
survey
–
How well do our priorities line up with evidence for
outcomes
Outpatient Clinical Pharmacy
services provided by more than 50%
of respondents
Outpatient Program Regional Prevalence
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Hematology-oncology
80%
Renal dialysis, 63%
Emergency 54%
Hematologyanticoagulation 52%
-Ontario, Quebec
-Ontario
-Ontario)
-All provinces similar
Different Provinces –
different priorities - Clinical Pharmacy
Outpatient Pharmacy Clinical Service NOT
Provided or significant variation from provincial
pattern
 Transplant – Quebec, (0/17)
 Mental Health – Atlantic, (0/11)
 Emergency –Atlantic only 8%, (1/13)
 Geriatrics – British Columbia only 8 %, (1/13)
 Palliative Care – Ontario only 12%, (3/26)
 Rehabilitation – BC, Quebec, Atlantic
 Diabetes – BC only 13%, (2/16)
Inpatient Clinical Pharmacy
Services Provided by More than
50% of respondents
Inpatient Program
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Geriatric/LTC
Adult critical care
Hem-oncology
Medicine
Pain/Palliative
Cardio/lipid
Mental Health
Surgery
Peds/neonates
Renal/dialysis
Rehab
83%
79%
78%
78%
70%
68%
63%
63%
56%
51%
50%
Regional Prevalence
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Similar across Provinces
BC, Prairies, Ontario
Ontario, Quebec
Prairies 100%
All similar, Quebec bit lower
Prairies, Ontario
Prairies, Ontario, Atlantic
BC, Prairies, Ontario
Prairies, Ontario
Ontario
Ontario
Clinical Pharmacy ServicesPriority vs Level of Service
Seamless Care
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Increase in number of respondents with seamless
care policy – now 37%, (from 28%), in all
Provinces except BC (20%)
Ave 24% of patients receive seamless care
Seamless care information provided:
 Medications at discharge, 96%
 Medications during stay, 72%
 Drug monitoring parameters, lab values, 60%
 Care plan, 55%
 Diagnosis, 34%, (down from 46% in 2003/04)
Prescribing Rights for Pharmacists
Notable increase in types of prescribing rights for
pharmacists
2005/06 2003/04
 Independent Lab tests
41%
32%
 Dependent, dosage
79%
70%
adjustment
 Dependent, new therapy 42%
19%
 Independent dosage
30%
35%
adjustment
Independent dosage adjustment by pharmacists much
more prevalent in Quebec, 57% vs 13-33% for other
Provinces (Ontario 22%)
Current status compared to ASHP 2015
Drug Evaluation and Drug Information
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Dedicated staff for DI/DUE – 37% vs 52% in
2003/04
DUE – increased pharmacist and support
resources
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1.1 FTE pharmacist, up from 0.8 FTE 2004
0.7 FTE support staff, up from 0.5 FTE 2004
Drug Information – no change in pharmacist
resources, increase in support
- 1.4 FTE pharmacists, similar to 2004
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0.7 FTE support staff, up fro 0.4FTE in 2004
Beds Serviced by Distribution
Systems
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2004
Unit Dose
51%
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Total Wardstock
3%
Carded Dose
6%
Traditional
32%
Unit Based Automated
8%
Base: All respondents (144)
2006
Automated Dispensing Systems
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Centralized automated dispensing, 66% of
unit dose respondents
– 83% canister type
– 17% robotic
Unit based automation
32%
– Emergency dept
80%
– Critical Care
54%
– Operating rooms
43%
– Inpatient
39%
– Recovery room
35%
Technician Activities Checked by
other Technicians Blue 2005/06, Pink 2003/04
Activities
Unit Dose
Tray Filling
Unit Dose
Packaging
Replenishing
Automated Cabinets
Cardiac Arrest
Tray Filling
Traditional Prescriptions
(Refills)
IV Admixture Preparation
(Batching)
Interim Dose
Filling
Extemporaneous
Compounding
IV Admixture Preparation
(Patient Specific)
Traditional Prescriptions
(New Orders)
82%
82%
77%
70%
66%
59%
58%
51%
41%
32%
TPN Preparation
Medication Order Entry
Chemotherapy
Preparation
30%
17%
13%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
% of Respondents
Base: Respondents reporting that function is performed
Certification Required for Technician
Function
Blue 2005/06, Green 2003/04
Activities
IV Admixture Preparation
(Patient Specific)
86%
IV Admixture Preparation
(Batching)
Chemotherapy
Preparation
83%
82%
Traditional Prescriptions
(New Orders)
81%
TPN Preparation
Interim Dose
Filling
Traditional Prescriptions
(Refills)
Unit Dose
Tray Filling
Medication
Order Entry
Unit Dose
Packaging
Extemporaneous
Compounding
Cardiac Arrest
Tray Filling
Replenishing
Automated Cabinets
77%
76%
75%
72%
67%
54%
41%
39%
31%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
% of Respondents
Base: Respondents using technician check technician
Chemotherapy Preparation
Systems 2005-06
Drug Purchasing and Inventory
Control
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Spending on drugs in Canada increased by 11%
in 2005, (CIHI annual drug expenditures report)
Equals 17.5% total healthcare spending 2005
Drug expenditure growth increasing – 10.9% in
2004, 9.1% in 2003
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New drug therapies, consumer marketing, changes in
practice, demographics
Future impacts include pandemics, biotechnology,
pharmacogenomics
Ave inventory turnover is 10.9%
How will the Report Help me to
Evaluate my Drug Management?
By hospital type and size
 Total drug cost by care area
 Drug cost per patient day
 Drug costs by admission
 Outpatient drug costs per visit
 Inventory turnover
 % drug costs by care area
 % changes in costs by care area – 2005/06
compared with 2004/05
Percentage of Drug Expenses by
Patient Care Area
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 who provided relevant drug cost information (82)
Drug Expenditure changes
2005/06 vs 2003/04
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Ave annual drug costs up by $1.27 million, 15.9%
increase
Acute care inpatient drug costs per patient day
increased 17.3%,
Cost per acute care admission increased 16.2%
Average drug cost per non-acute admission
increased 20.6%
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likely due to length of stay as drug cost per patient day
was similar
100-200 bed hospitals cost per admission increased 98%
Ave CDU costs/visit decreased 46%, $30.89
compared with $53.83 in 2003/04
Ave emerg visit continues to increase, $8.33 from
$8.01 in 2003/04
Human Resources
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Survey questions changed since previous survey
– Use budget hours /patient days instead of paid
hours/patient day
– Allows comparison of organizational
commitment to resources and is unaffected by
staff shortages, absences
Staff shortages continue
Number of eligible retirees is similar to number of
current vacancies
Staffing Composition of Ave Hospital
Pharmacy Department 2005-06
Human Resources
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Average budgeted hours per patient day 0.81
2005/06
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Ontario highest at 0.96, British Columbia lowest at 0.65
Increases of 14% were reported for Ontario and Quebec
2003/04 paid hours per acute patient day ave 0.74
Staffing Ratios, unchanged from previous survey
Salaries
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Ave increase 2.1% annual, compared with 5.6% annual
reported in 2003/04 survey
Staff pharmacist top level increase ave 2.8% annual,
downward trend from the 6.7% annual in 2003/04
Technician top level increase 3.8% annual compared
with 2.6% in 2003/04
Human Resource Shortages
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73% of respondents reported vacancies compared
with 63% in 2003/04 although total pharmacist
vacancies were reduced, (270 vs 331 in 2003/04)
Position
– Pharmacist vacancies
– Management
– Technicians
– Residency vacancies
2003/04
12.9%
6.9%
0.9%
13.8%
2005/06
13.3%
7%
2
6.25
Ontario
11%
8%
1.3%
0
*Residency vacancies concentrated in Alberta and Quebec
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Staggering 11.8% of ALL pharmacists, 16.2% of
management and 8.4% of technicians expected to
retire in next 5 years (Ontario 11.1%, 12.5% and
8.4% respectively)
Medication Incident Reporting and
Reduction - How have we changed in 2
years?
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Not all respondents using a med incident
reporting tool (95% vs 100% 2003/04)
A higher percentage have implemented
strategies to increase reporting (77% vs 67%.
See report for strategies)
Significant increase in:
– presence of disclosure policy, (80% vs 63% in
2003/04)
– Completion of self assessment tool, (71% vs
51% in 2003/04. Ontario 87%)
CCHSE- Required Operational
Practices (ROPs)
Focused on improving safety of patient care
Medication related ROPs for:
 Removal of conc electrolytes
 Standardization
 Order entry, verification
 Medication reconciliation
 Informing and educating patients/family
Compliance to Medication
Related ROPs
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2005/06 2003/04
Verbal and telephone orders limited 42%
38%
Med orders conditional until
pharmacist review
44%
52%
List of non-acceptable abbreviations 58%
40%
High alert med list identified
61%
38%
2 patient identifiers for high risk drugs 40%
31%
Allergy status prior to dispensing
68%
72%
Management of Concentrated High
Risk Drugs on Patient Care Units
Removal of High conc.
 Narcotics
 KCl
2005/06 2003/04
65%
47%
85%
72%
Standardize/limit conc. available
 Heparin
75%
 Insulin
48%
 Morphine
57%
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Hydromorphone
53%
81%
47%
47%
41%
Medication History and Reconciliation
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Emergency dept. med history
Admission med history
Transfer med reconciliation
Counseling pamphlet provided
45%
42%
35%
65 %
Technology – Clinical Decision
Function Availability and Use
Strong uptake of
function
 Allergy alerts
 Drug interaction alerts
 Input patient specific
variables to assess drug
therapy
Slow but visible growth
 Wireless networks
 Bar coding
Low uptake of function
 Computer generated max
dose alerts, especially
non-teaching hospitals
 Dose modification alert
for renal dysfunction
 Dose modification alert
for hepatic dysfunction
 Evidence based
guidelines (low
availability and uptake)
Functions Using Handheld Devices
Uses of Bar Coding
Education and Research
Education
 Student training remained a high priority, especially for
Masters and Pharm D levels where the largest increase in
training days was observed
 Significant proportion of hospitals receiving stipends for
undergraduate pharmacist and Pharm D training
 Increase in university funded positions for student training,
(11 vs six in 2003/04)
Research
 Similar response to 2003/04
 Original research – reduction in ave number of papers
Ethics – Special Interest Section
Addresses organizational policies, ethical decision
making processes
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Most hospitals have access to on or off site
research ethics board, of which most have
pharmacist members
Most have a biothetics/ethics advisory group or
access to one, only 32% have pharmacist
Addresses patient care, education, research and
business ethics
Conflict of Interest
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68% hospitals have a conflict of interest policy
45% report P& T conflict of interest policy
51% requirement for declaration of vendor
involvement
–
Report lists comprehensive list of issues e,g gifts,
honoraria, outside employment, data selling
Risk Areas
 Educational sponsorship
 Formulary decisions
 Research
 Clinical decision-making
Questions
www.lillyhospitalsurvey.ca