PhCare 331: Hospital Pharmacy

HOSPITAL It is a complete organization utilizing combinations of intricate, specialized scientific equipment, and functioning
through a corps of trained people educated to the problems of modern medical services.
As stated by the AHA, the primary function of the institution is to provide patient services, diagnostic and therapeutic, for particular or general
medical conditions.

HISTORY OF HOSPITAL
1752 - Pennsylvania Hospital, the first hospital in Colonial America was established
* medicine and pharmacy-was practiced together
* medical apprentice - prepared the drug
1800 -the U.S. had only 2 hospitals – in a 5 M population early 1800s
- the drug therapy consisted of :strong cathartics, emetics, diaphoretics
1830s-1870s -clean air and good food was emphasized in hospital rather than medicine
Mid 1800s - used newer alkaloid: Morphine, Strychnine
- directors seek pharmacists for: extemporaneous manufacturing, purchasing of medical goods
1870s - 1880s -the number of hospitals in cities doubled due to influx of immigrants (Roman Catholics)
-era of hospital expansion (coincided with: reforms in nursing, development of germ theories, rise of scientific
medicine and surgery
1873 - the U.S. had only 178 hospitals with fewer than 50,000 beds – in a 43 M population
- hospitals played a small role in health care; pharmacists played a small role in hospitals
1890s -hospital became the center of medical care due to general adoption of aseptic surgery

INFLUENCES THAT AFFECT HOSPITAL DEVELOPMENT

*Religion * Flexner report * Florence Nightingale Activities * Public interest (private and government participation)

*Religion ---Prior to the Christian era, hospitals were temples dedicated to the god of medicine in which the care of the sick was accompanied
by magical, mystical, and religious ceremonies. Greek temples were forerunners of the modern hospital in the sense that they provided refuge
and treatment for the sick and also provided for the teaching of young medical students. Temples as the Temple of Aesculapius (Greek god of
Medicine) existed in 1134 BC, while the temple at Kos, Greece, was where Hippocrates (born about 460 BC) practiced. The temples of the gods
in early Greek and Roman civilization were used as hospitals where healing was associated with divine powers, while continued illness or death
was associated with a lack of purity.

* Military
Another major factor in the development and expansion of hospitals was the military influence. Much of the stimulus toward medical and
surgical progress over the centuries has come from the urgent need for care of the battlefield wounded. This was true during the Roman
Empire; it was also true in the US before, during, and after the Civil War.

Other Factor:
-Flexner and Activities of Florence Nightingale
The Flexner report on medical education (1910), which caused revolutionary developments in medical evolution per se and in
medical internship training, which helped the development of minimum standard for patient care in hospital surroundings. The activities of
Florence Nightingale during and after the Crimean War, which served as the basis for revolutionizing the quality of nursing care in hospitals
and for the development of schools of nursing. The public interest in hospitals through greater dependence and improved confidence in
hospital Care.

Requirements for Registration by American Hospital Association (AHA) as a hospital:

1. The institution shall maintain at least six inpatient beds, which shall be continuously available for the care of patients who are
n0nrellated and who stay on the average in excess of 24 hour per admission.
2. The institution shall be constructed, equipped, and maintained to ensure the health and safety of patients and to provide uncrowded,
sanitary facilities for the treatment of patients;
3. There shall be an identifiable governing authority legally and morally responsible for the conduct. of the hospital;
4. There shall be a CEO to whom the governing authority delegates the continuous responsibility for the operation of the hospital in
accordance with established policy.
5. There shall be an organized medical staff of fully licensed physicians that may include other licensed individuals permitted by
law and by the hospital to provide independent patient care services in the hospital. The medical staff shall be accountable to
the governing authority for maintaining proper standards of medical care, and it shall be governed by bylaws adopted by said
8taff and approved by the governing authority.
6. Each patient shall be admitted on the authority of a member of the medical staff who has been granted the privilege to admit
patients to inpatient t service5 in accordance with state law and criteria for standards of medical care established by the individual
medical staff.
Each patient’s general medical condition is the responsibility of a qualified physician member of the medical staff.

CNAHS | College of Pharmacy Exclusive for CIT Pharmacy Students only! 1

#TeknoyPharmacist
 PhCare 331: Hospital Pharmacy
When non-physicians members of the medical staff are granted privilege to admit patients, qualified physician makes provision for
prompt medical evaluation of these patients;
Any graduate of a foreign medical school who is permitted to assume responsibilities for patient care shall possess a valid license to
practice medicine, or 5hall be certified by the Educational Commission for Foreign Medical Graduates or shall have qualified for and
have successfully completed an academic year of supervised clinical training under the direction of a medical school approved by the
Liasson Committee on GAT Medical Education.
7. Registered nurse supervision and other nursing services are continuous.
8. A current and complete medical record shall be maintained by the institution for each patient and shall be available for reference.
9. Pharmacy service shall be maintained in the institution and shall be supervised by a registered pharmacist.
10. The institution shall provide patients with food service that meets the nutritional and therapeutic requirements; special diets
shall al60 be available.

CLASSIFICATION OF HOSPITAL
I. Type of services offered

Hospitals are registered with the AHA as one of four types: general, special, rehabilitation and chronic disease, and psychiatric.
General: The primary function of the institution is to provide patient services, diagnostic and therapeutic, for a variety of medical
conditions.
Special: The primary function of the institution is to provide diagnostics and therapeutic services for patients who have
specified medical conditions, both surgical and non-surgical;
Rehabilitation and Chronic Disease: The primary function of the institution is to provide diagnostic and therapeutic
services to handicapped or disabled individuals requiring restorative and adjustive services;
Psychiatric: The primary function of the institution is to provide diagn0stic and therapeutic services for patients who
have psychiatric-related illnesses.

Department of Health (DOH) classification, please check the separate pdf file…

II. Length of Stay: Short term-less than 30 days stay ; Long term – 30 days or more stay;
III. Ownership (Non-government: Private (individual, partnership , Corporation) and Religious, Government: Armed forces, Veterans, US
Public Health Service, county, City, City-county)

Federal hospitals are owned and operated by various branches of the federal government. The United States Army, Air
Force, and Navy hospitals are usually general medical and surgical hospitals, provided to care for military personnel, although
there are specialized mental institutions within these groups. The Veterans Administration (VA) hospitals provide care for
additional specialized groups of our population and operate general medical and surgical hospitals and also some mental
hospitals. State hospitals are owned by the state and controlled by a
board of control or division of the state government or a similar organization responsible to state government. They are
maintained by state appropriations and consist mainly of psychiatric hospitals. In some instances, state hospitals are general
hospitals affiliated with a university involved in the training of physicians and other professional personnel, often referred to as
teaching hospitals. County (district) hospitals are owned by the county and financed and controlled similarly to state hospitals,
only on a county level. They are usually general hospitals caring for the indigent. City hospitals are owned, financed and
controlled by the city government. They are usually general hospitals caring for the indigent.
In the nongovernmental hospital group, most institutions are general medical and surgical hospitals, varying only in their
control and eligibility for receipt of state funds for charity or indigent patient care. The proprietary or private hospital organized
for profit may be privately or publicly held. These hospitals often represent an investment interest of their owners, and profits
are legally shared among the owners. The nonprofit, nongovernmental hospitals are supported financially by fees from paying
patients or by contributions from the several religious orders or churches. These hospitals are owned and controlled either by the
religious order or diocese, as exemplified by the Catholic churches, by a separate governing board, as in churches of other
denominations, or by a not-for profit corporation in the community.
Community hospitals or private, nonprofit hospitals are owned and operated by members of the community, but with
no relationship to the local government. Fees from patients from the community and surrounding area finance them. The cost of
providing medical care for the indigent is a problem for the community hospital, and this cost is partially met through local, state,
and federal assistance.
Hospitals generally are classified

IV. Bed capacity - Small Hospital has maximum of 50 beds;

FUNCTIONS OF HOSPITAL
*Patient Care
*Education (Medical and allied health professional, patient)
*Research
*Public Health

CNAHS | College of Pharmacy Exclusive for CIT Pharmacy Students only! 2

#TeknoyPharmacist
 PhCare 331: Hospital Pharmacy
DIFFERENT DEPARTMENTS OF HOSPITAL
Ambulatory care, Clinical Laboratories, Dietary and Nutrition Services, Emergency Room, Medical Library, Medical Records, Medical Social
Service, Nuclear medicine, Nursing service, Pharmacy service, Physical medicine, Respiratory medicine, Accounting, Admitting, Business office,
Housekeeping, and etc.

Note: Please check any reference for the description of each department;

ORGANIZATION OF HOSPITAL
*Compose of CEO, department heads, and other staff

The CEO reports all essential facts concerning the operation of the hospital to the Board and receives from the Board all directives it
issues. For CEOs to carry out the overall responsibilities assigned by the governing board, they need assistance. Depending on the size of the
hospital, there may be one or more administrators reporting to the CEO. The administrator responsible for that service also appoints a leader
for each department. The department leaders have the responsibility of operating the departments effectively and properly, within the overall
policies and philosophies established by the hospital's governing board.

Hospital Staff
*Open staff, Closed staff, Medical Staff (Honorary, consulting medical staff, active or attending medical staff, associate medical staff, courtesy
medical staff, resident medical staff)
There are two main types of hospital staffs: open and closed.
An open staff is one in which certain physicians other than those on the attending or active medical staff are allowed to use the
facilities, providing they comply with all rules and regulations of the institution. These physicians are termed members of the courtesy medical
staff; the hospital is termed an open staff hospital. A closed staff is one in which all professional services, private and charity, are provided and
controlled by the attending or active medical staff. A hospital with this type of staff is termed a closed-staff hospital. The closed staff, although
it has minor drawbacks, is the more desirable for the average hospital and especially for the teaching hospital because it allows careful
selection of a group of specialists with excellent reputations.
The medical staff may consist of any of the following groups: an honorary staff, a consulting staff, an active staff, an associate
staff, a courtesy staff, and a resident staff.
The honorary medical staff is composed of physicians who have been active in the hospital but who are retired and those whom it is
desired to honor because of outstanding contributions. The consulting medical staff consists of specialists who are recognized as such by right
of passing specialty boards or belonging to the national organization of their specialty and who serve as consultants to other members of the
medical staff when called upon. The active or attending medical staff is the group primarily concerned with regular patient care. It is the group
most actively involved in the hospital. In internal staff government, the medical staff is the authoritative body. The associate medical staff is
composed of junior or less-experienced members of the staff. Appointment to this group is the first step toward active or attending staff
membership. The courtesy medical staff consists of those physicians who desire the privilege of attending private patients, but who do not
desire active staff membership. The resident medical staff is composed of residents, who are fulltime employees of the hospital. These persons
provide specific services in the care of the patient, for which they receive education and experience.

HOSPITAL PHARMACY
----A field of pharmacy practice within the framework of the hospital’s organizational structure that accommodate the needs of admitted
patients (in-patients) and out patients of the hospital (ambulatory).
-----The primary function of the institution(hospital) is to provide patient services, diagnostic, and therapeutic, for a particular or general medical
conditions. AHA
-----A division or department of the hospital wherein the procurement, storage, compounding, manufacturing, packaging, controlling, assaying,
dispensing, distribution, and monitoring of medications through drug-therapy management for hospitalized and ambulatory patients are
performed by legally qualified, professionally competent pharmacists. REMINGTON

DEVELOPMENT OF HOSPITAL PHARMACY

1920s - hospital pharmacy practice started to develop into a significant movement

- hiring of pharmacist due to: prescription-containing alcohol, inventory control, manufacture of alcohol-containing
preparations
1930s -the American Hospital Association (AHA) created a Committee of Pharmacy to analyze pharmacy-related issues in hospitals.
Aim of the committee of pharmacy : 1.) to develop minimum standards for hospital pharmacy department, 2.) to
prepare a manual of pharmacy operation
1957-1960 – a major study of changes in hospital pharmacy was conducted
4 major themes that emerge from examination of changes during this period:
1. hospitals have recognized that pharmacists must be in charge of drug product acquisition, distribution, and control
2. Hospital pharmacy department have assumed a major role in patient safety
3. Hospital pharmacy have assumed a major role in promoting rational drug therapy
4. Hospital pharmacy department have come to see their mission as developing optimal patient outcomes from medication use

Early 20th century - more division of labor, more specialization in medical practice, greater need for professional pharmaceutical
services for handling complex therapies, hospital pharmacists retained the traditional role of compounding

Note: JONATHAN ROBERTS is the first pharmacist in Pennsylvania Hospital (Philadelphia)

CNAHS | College of Pharmacy Exclusive for CIT Pharmacy Students only! 3

#TeknoyPharmacist
 PhCare 331: Hospital Pharmacy
FACTROS AFFECTING THE PRACTICE OF PHARMACY IN HOSPITAL
✓ Internal Factor: Organizational structure
✓ External factors: Licensing agencies, Office of Inspector General-compliance standards, Social and governmental welfare agencies-
medically indigent, Accreditation agencies – exert their influence on the practice of pharmacy

*Major accrediting bodies:

➢ Private or Non-government: Joint Commission on Accreditation of Healthcare Organizations (JCAHO), American Osteopathic
Association (AOA), Centers for Medicare and Medicaid Services (CMS), United States Pharmacopeia (USP), National Fire Protection
Association (NFPA)
➢ Federal and State Government Entities: Food and Drug Administration (FDA), Drug Enforcement Administration (DEA), Occupational
Safety and Health Administration (OSHA), National Institute for Occupational Safety and Health (NIOSH) Centers for Disease Control
and Prevention (CDC), Office for Civil Rights, Agencies with Shared Responsibilities, State Boards of Pharmacy
➢ Pharmacy Professional Organization: American College of Clinical Pharmacy (ACCP), American Pharmacists Association (APhA),
American Society of Consultant Pharmacists (ASCP), American Society of Health-System Pharmacists (ASHP)

FUNCTIONS OF HOSPITAL PHARMACY

*To provide and evaluate service in support of medical care
*To implement policies, and standards of the department
*To provide and implement a departmental plan of administrative authority that clearly describes the responsibilities and duties of each
category of personnel
*To participate in the coordination of the functions of the department with the functions of all other departments
*To implement policies and procedures to maintain an adequate and competent staff.
*To develop and maintain an effective system of clinical and/or administrative records and reports
*To estimate needs for facilities, supplies, and equipment and to implement a system for evaluation control, and maintenance
*To participate in and adhere to the financial plan of operation for the hospital
*To participate in studies or research projects for the improvement of patient care, administrative and maintenance
*To participate in and /or facilitate all educational programs
*To participate in and adhere to the safety program of the hospital.
Hospital pharmacy staff primarily can be grouped into three categories: pharmacists, technicians, and clerical.

CNAHS | College of Pharmacy Exclusive for CIT Pharmacy Students only! 4

#TeknoyPharmacist
 PhCare 331: Hospital Pharmacy

Pharmacy and Therapeutics Committee (PTC)

Pharmacy and Therapeutics Committee (PTC)
------ is a committee of the medical staff chaired by a physician, the director of the pharmacy is the secretary. It is an advisory group
of the medical staff and serves as the organizational line of communication or liaison between the medical staff and the pharmacy
department. It is also a policy-recommending body to the medical staff and to the administration of the hospital on all matters
related to the use of drugs.
Members of the PTC:
representative from: medical staff specialties, pharmacy, nursing service, administration, laboratory and other
pertinent departments
 Purpose:
✓advisory : recommends the adoption or assists in the formulation of broad
professional policies regarding evaluation, selection, procurement,
distribution, use, safe, practices, and other matters pertinent to drugs in
hospitals.
Educational: recommends or assists in the formulation of programs designed
to meet the needs of the professional staff (doctors, nurses, and the
pharmacist) for complete current knowledge on matters related to drugs and
drug practices.

 Functions of the P & T Committee:

a. establishes and maintains the formulary system (Formulary System
Maintenance)
FORMULARY SYSTEM-The formulary system and formularies have existed in the US since the days of the American.
Revolution and in European hospitals for centuries prior to this. The need for hospital formularies continues to increase
due to:
• The increase in number and complexity of medication available increased utilization due to direct-to-consumer
and physician
marketing strategies of the pharmaceutical industry;

CNAHS | College of Pharmacy Exclusive for CIT Pharmacy Students only! 5

#TeknoyPharmacist
 PhCare 331: Hospital Pharmacy
• The obligation of health care providers to exercise good stewardship in the appropriate use of medications;
b. selects medications for formulary inclusion (Medication Selection and
Review)
c. evaluates medication use and related outcomes (Medication Use Evaluation
(MUE))
Other names of MUE: Drug Usage Review (DUR)
Drug Usage Evaluation (DUE)
d. prevents and monitors adverse drug reactions and medication errors
(Medication Safety Evaluation)
 medication safety is evaluated through:
ADR and medication error reports (basis for deletion,
addition, retention)
Committee’s Role in the ADR Program
an Adverse Drug Reaction Report Form should be prepared by
the PTC
>ADR Report Form – available on every nursing station
* Adverse Drug Reaction (ADR) is a response to a drug that is noxious and unintended, and that occurs at doses
normally used in humans for the prophylaxis, diagnosis, or therapy of diseases, or for the modification of physiologic
function. (WHO definition) ( Remington, 21st edition, page 1221)
Type of ADR: Type A, B, C, D, E
e. evaluates or develops and promotes use of drug therapy guidelines
(Drug Therapy Guidelines)
 is often the result of medication use review or medication safety
evaluation
f. develops policies and procedures for handling medications (Policy and
Procedure Development) which includes procurement, prescribing , distribution, administration
❖ The PTC serves as a potent force in helping the pharmacist establish adequate specifications for the purchase of quality
pharmaceutical ( Remington’s Practice, 21st ed. p. 2260)
g. educates health professionals to the optimal use of medications (Education)
 assist in developing programs to educate health care professionals or
patients regarding medications
 PTC communicates its decisions to health-system staff and physicians
through newsletter, website, email and meetings
Pharmacist’s role as a member of the PTC:
 establish PTC meeting agenda
 conduct drug use evaluation
 analyze and disseminate clinical and health economic information regarding
a medication for review by the committee
participates in formulating policies and procedures for handling
investigational medications in the hospital
record PTC actions
 communicate PTC decisions to health care professionals
 follow up with research when necessary
❖ The committee is responsible to the medical staff as a whole and its recommendations are subject to approval by the
organized medical staff as well as the routine administrative approval process.

References:
Brown, T. (2010). Introduction to Hospital and Health-System Pharmacy Practice. Bethesda: American Society of Health-System
Pharmacists
Gennaro, A. et.al. (2000). Remington’s Pharmaceutical Sciences, 20th ed., 2000, Pennsylvania: Mack Publishing Company.

CNAHS | College of Pharmacy Exclusive for CIT Pharmacy Students only! 6

#TeknoyPharmacist