One of the vital functions of a hospital pharmacy department is to provide services to in-patients. All hospital invariably offers in-patient services, though they may or may not offer services to out-patients. An in-patient is “admitted” to the hospital and stays in the hospital till he recovers or is discharged by the doctor. The patient's stay in the hospital can extend from overnight to an indeterminate time, as in the case of coma patients.
Objectives
The objectives of the drug distribution system for in-patients are:
1. To provide drugs for all in-patients of the hospital on a 24 hours per day basis.
2. To inspect and control the distribution of drugs in
all treatment areas.
Location Layout and Planning
The unit should be located at such a place in the
hospital that is readily accessible to all departments and free from
disturbances. The various sections of the in-patient pharmacy should be
continuous. The unit should be well equipped. The physical plan of this department
should be well planned by considering the future growth of the hospital and avoiding
further modifications. The facilities and equipment’s used to store the drugs
should be designed in such a way that it facilitates the routine inspection of
the drugs before their administration and these are readily available to the
physician and pharmacist.
In-patient pharmacy is a multi-function department –
storage, dispensing, manufacturing, IV fluids, parenterals, etc. These
functions form a continuous whole and bear a direct vertical relationship. In
recent years, there is a tendency to operate satellite pharmacies either at the
level of wards or based on doors. This is a case of decentralized service. Each
of these pharmacies is operated by a professional pharmacist.
Personnel for In-patient Services
There is no standard rule for the requirement of
personnel. Manpower requirements are a function of the type of services
provided by the pharmacy and the capacity of the hospital. Generally, manpower is correlated to the
number of beds. The following table is illustrative:
Table.1: Pharmacists
Requirement in Hospital Pharmacy
|
Capacity
in Bed |
No.
of Pharmacists Required |
|
Up
to 50 beds |
3 |
|
Up
to 100 beds |
5 |
|
Up
to 200 beds |
8 |
|
Up
to 300 beds |
10 |
|
10
Up to 500 beds |
15 |
In terms of job specification, they must have professional qualifications and a proven track record. The chief executive pharmacist is a thought-bred professional, with some managerial training. In addition, if there is a manufacturing facility attached to the pharmacy, technical persons in related areas like; tableting, liquid orals, parenterals, ointments, etc. are also part of staffing. They should get back up to operative and maintenance personnel.
The Side Head with Types of Drug Distribution System
Within the general hospital practice four systems are
used to distribute drugs from the pharmacy to the wards:
Individual Prescription Order (for each patient) System
Small and private hospitals adopt this system since it
can be operated with less manpower, economic consideration, and under the
direct supervision of a pharmacist. Here, the drugs are dispensed and labeled
for each patient. The prescription sheets are usually sent to the pharmacy.
Pre-packaged doses are generally very useful. The nurses are advised by the
pharmacist about proper storage labeling and accounting of the drugs. If on administration,
there are untoward reactions, there is a system of contacting the physician as well
as the pharmacist, so that immediate corrective action can be taken.
Advantages:
• Reduces manpower requirement.
• All prescriptions are directly reviewed by the
pharmacist.
• Opportunity for close interaction between the
pharmacist, nurse, and physician.
• It provides close control of stock.
• Medication errors can be spotted.
• Facilitates charging of private patients.
Disadvantages:
• Possibility of delay in obtaining medication.
• Increases in the cost of drugs to patients.
• In cannot be practiced in big hospitals.
Complete Floor or Ward Stock System
Under this system, the nursing station carries both
“charge” and “non-charge” patient medication. According to this system, the
drugs are stored at the nursing station and are administered by a nurse
according to the chart order of the physician. Only the commonly used drugs in
considerable quantities are stocked on the floor stock or in the ward (ward stock).
Rarely used or costly drugs are not included in the floor stock but are dispensed
when the order is received for the individual patients. Mainly this system is
used in hospitals where the charges are not made to patients.
Since these drugs are used in large quantities, they
are pre-packed in standard containers. Nursing staff from each floor or ward
sends their written demands of drugs according to the list provided to each
floor and ward, daily to the hospital pharmacy or through a messenger and
collects the medicines from the pharmacist.
Advantages:
• These are readily available for administration.
• Minimum return of drugs.
• Reduced in-patient prescription orders.
• Reduction in the number of pharmacy personnel
required.
Disadvantages:
• Increase in chances of medication errors due to lack
of review by pharmacists.
• Greater opportunity for misuse of drugs resulting in
financial loss.
• Increase in drug inventory.
• Increased chances of drug deterioration due to lack
of proper storage facilities.
• Increased work load on nurses due to medication
activities.
|
Ward No. 3
A |
|
Ibuprofen-Paracetamol
Tablet Formula Ibuprofen
- 400 mg Paracetamol
– 325 mg |
Fig.1: Labelling of Floor Stock Drug
The drugs in the nursing station are known as Floor
Stock Drugs. They are classified into two parts:
1. Charge floor stock drugs.
2. Non-charge floor stock drugs.
Dispensing of Charge Floor Stock Drugs:
• Charge floor stock drugs are those for which the patient is charged for every single dose administered to him. Selections of these drugs in various wards are decoded by “The pharmacy and Therapeutics Committee”.
• Once the floor stock list is prepared, it becomes the responsibility of the hospital pharmacist to make the drugs available.
• Charge floor stock drugs are stored at various nursing
stations.
• The patients are charged mostly because of the high
cost of such drugs. Such drugs include injections or other unit dosage
forms.
• An envelope is used to dispense such drugs at
nursing stations.
• Under this system, pre-labeled envelopes are filled
with a pre-determined quantity of specific drugs and are placed at the disposal
of the nursing unit.
• When the drug is administered, the patient’s name
and room number are entered on the envelope and sent to the pharmacy for
records.
|
Ward Patient |
|
Phenobarbitone
Tablets Each
tablet contains Phenobarbitone
- 50 mg GARDENAL |
|
XYZ Hospital Pharmacy, Mumbai |
Fig.2: Label for a Charge Floor Stock Medication
Dispensing of Non-Charge Floor Stock Drugs:
Non-charge floor stock drugs are the medicaments that
are placed at the nursing station for the use of all patients on the floor. For
these drugs, there shall be no direct charge from the patient's account.
• Non-charge floor stock drugs consist of a
pre-determined list of medications available in every nursing unit of the
hospital. The non-charge floor stock drugs are selected based on the cost of
drugs, quantity required frequency of use, etc.
• ‘Drug basket method’ is adopted where nurses check
the medicines in all rooms and the refrigerator and prepare a master list for
the pharmacy.
• Nurses fill out a requisition form for the delivery
of drugs to their floor.
• When there is an empty container, the nurse places
it in the drug basket.
• Once the procedure is completed the drug basket containing
the empty containers and requisition for floor stock supplies are then sent to
the pharmacy.
• Immediately in the morning, the pharmacy staff
commences to fill each container and dispense the requested drugs.
• Once the basket is completed, it is delivered to the
floor via messenger services.
• Alternatively, a Mobile Dispensary Unit can be
utilized: It is a specially constructed stainless-steel truck measuring 60
inches high, 48 inches wide, and 25 inches deep. It is mounted on bottom tires,
four of which are swivel type.
|
Ward |
|
Ferrous Sulphate
Tablets (Fersolate) Each
tablet contains Ferrous
Sulphate – 0.3 gm |
|
XYZ Hospital
Pharmacy, Mumbai |
Fig.3: Label for Non-Charge Floor Stock
Medication
Combination of Individual Drug Orders and Floor Stock System
This system is used in those hospitals where patients
pay for their hospitalization and the hospitals use the individual prescription
order system as their primary means of dispensing but have several drugs in the
floor stock.
Advantages:
1. All the drug procurement is one system so the
pharmacy assistant and patient’s time can be saved.
2. As per respective medical specialties and ward
units like cardiology, neurology, nephrology, urology, etc first line, and
follow-up drugs can be dispensed and refilled through proper selection of
inventory control methods.
3. Combination leads to better patient medication
adherence, counseling, and interventions.
Disadvantages:
1. Extra space and cabinets may be required.
2. Staff pharmacy (assistant, pharmacy technician) and
wages including extra framework and infrastructure is required hence, the budget
requirement is another typical task.
3. Special care division may be affected.
4. Storage space may be required more.
Unit Dose Dispensing System
In unit dose dispensing, the multiples of single-dose
administration of medication are prepared by the pharmacist who is ready for
administration to particular patients by a prescribed route and the prescribed
time rather than supplying containers of drugs to nursing units where the nurse
is required to prepare the drug for administration. A single unit package contains
one complete pharmaceutical dosage form, e.g. one tablet, one capsule, or 10 ml
oral liquids, etc. Liquids are pre-measured, powders are accurately weighed and
diluted, and parenterals preparations are suitably diluted and accurately
measured into sterile syringes ready for administration.
Advantages:
• Patients receive improved services round the clock and
are charged for only those doses which are administered to them.
• All doses of medications required at the nursing
station are prepared by the pharmacy thus allowing nurses more time for direct
patient care.
• Medication errors are decreased because of direct
checks by the pharmacist.
• Excessive duplication of orders and paper work at
the nursing station and pharmacy is eliminated.
• Contamination due to handling is eliminated.
• It eliminates the wastage of drugs and
pilferage.
• More efficient utilization of professional and
non-professional personnel is promoted.
• More space is available in nursing units by
eliminating bulky floor stock.
• Extends pharmacy coverage and control throughout the
hospital from the time the physician writes the order to the time patient
receives the unit dose.
• Communication of medication orders and delivery
systems are improved.
Disadvantages:
• It requires more space since packaging material
increases the bulk of the dosage forms.
• It requires an increased number of skilled and lay
people in the pharmacy.
• The cost of medication is increased to the patient
due to increased handling charges.
Fig.4: Unit Dose Drug Fulfillment Process
The unit dose dispensing concept may be introduced
into the hospital in either of two ways:
1. Centralized unit-dose drug distribution system
(CUDD).
2. Decentralized unit-dose drug distribution system (DUDD).
Centralized Unit-Dose Drug Distribution System (CUDD):
• All in-patient drugs are dispensed in unit doses and
all the drugs are stored in the central area of the pharmacy and dispensed at
the time the dose is due to be given to the patient.
• To operate the system as an effective delivery
system various medication carts are used to carry unit doses to the patients
and also to send a copy of the physician’s original medication order to the
pharmacy for direct interpretation and filling.
Decentralized Unit-Dose Drug Distribution System (DUDD):
• This operates through small satellite pharmacies
located on each floor of the hospital.
• The main pharmacy is for procurement, storage,
manufacturing, and packaging. It serves all the satellite pharmacies.
• This type of system is used in a hospital with
several buildings.
The following procedure is adopted in a hospital when a
decentralized unit dose system is adopted:
• Patient profile card containing full date, disease, and
diagnosis, is prepared.
• Prescriptions are sent directly to the pharmacists
which are then entered into the patient profile card.
• Pharmacist checks medication orders for allergies,
drug interactions, drug laboratory tests, etc.
• Dosage schedule is made and coordinated with nursing
personnel.
• Patient profile card and prescription order is
filled by pharmacy technicians.
• Pharmacist then checks cards before their
release.
• The nurses administer the drugs and make the entry
in their records.
• Upon return to the pharmacy the cart is
rechecked. This process requires the
availability of a pharmacist for consultation by doctors and nursing staff.
Fig.5: Comparison of Key Features of Drug Distribution
Systems