The Role of Hospital Pharmacists and Hospital Pharmacy Teams in Irish Hospitals: Where we’ve got to and where we’re going
Written by Ciara Ni Dhubhlaing, Chief I Pharmacist, St Patrick’s Mental Health Services
Hospital Pharmacy Teams have a varied and wide-ranging skillmix with a focus on safe and appropriate use of medicines at the core of each one of those roles.
There are over 1800 people working as part of Hospital Pharmacy Teams, including approximately 18% of the Pharmaceutical Society of Ireland (PSI) registered pharmacists. The hospital pharmacy team-member’s pathway begins with education and training to obtain recognised qualifications and continues in career-long continuing professional development.
Pharmacy Technicians study for a 2 year part-time Level 6 Certificate and may add on a further year for a Level 7 BSc. Some technicians may have undertaken additional accredited training courses, for example in Accuracy Checking or Medicines Management.
Hospital Pharmacy Technicians are represented by The National Association of Hospital Pharmacy Technicians (NAHPT), a voluntary group founded in 1997 dedicated to providing continuous professional development for Hospital Pharmacy Technicians with a mission to increase awareness, enhance professionalism, increase credibility, and build alliances with other members of the health services sector. Fórsa are currently seeking statutory recognition of the role of pharmacy technician.
Pharmacists studying in Ireland undertake a 5 year integrated full-time MPharm degree including placements and a final pre-registration exam to register with the PSI. Many hospital pharmacists (over 75% in Ireland) go on to complete an additional MSc, for example in Clinical or Hospital Pharmacy, or study for postgraduate diplomas in their specialist areas. Increasing numbers of hospital pharmacists continue on to PhD level contributing to pharmacybased research.
The Hospital Pharmacists Association of Ireland (HPAI) is a vocational professional group within the Fórsa trade union representing this group of highly educated and dedicated healthcare professionals. The mission of the HPAI is to: further the development of hospital pharmacy practices; assist in the provision of continuing pharmaceutical education; represent the views of the hospital pharmacist on issues of relevance to hospital pharmacy; and advance the professional welfare of its members. Under Irish legislation, professional bodies do not have negotiating rights with Government in their own right. By virtue of the negotiating licence, Fórsa is the representative for hospital pharmacists on issues of pay and conditions of employment. Most recently, HPAI negotiating teams working with Fórsa have secured a long overdue HSE Advanced Specialist Pharmacist Payscale, in recognition of hospital pharmacists working at an advanced level in complex and challenging specialist areas.
On Admission to Hospital
From the point of admission, medication procurement; storage; and supply can be time critical. Hospital Pharmacy Dispensary Teams, including Pharmacy Technicians, and Pharmacy Porters, ensure that systems are in place for safe and efficient delivery of medications to the patient. This may include sourcing unlicensed medications, ensuring the cold chain is maintained, extemporaneous preparation of medicines, and quality assuring patients’ own medicines for use on the ward, if appropriate. Management of medication shortages is increasingly a high intensity and time-consuming area for pharmacy staff. Sourcing alternative suppliers and products can increase the clinical workload also in cases where treatments need to be switched and additional monitoring and/or patient counselling may be required.
Underscoring these processes are national and local policies and procedures, including those required by regulatory bodies such as the Health Information and Quality Authority (HIQA), the Mental Health Commission (MHC), and the Pharmaceutical Society of Ireland (PSI).
Pharmacy staff have a significant governance role in supporting compliance with regulations and good practice guideline. This includes designing, undertaking, and supporting audits on e.g. the use of medicines, adherence to prescribing and monitoring guidelines, and compliance with statutory regulations.
Hospital Pharmacy teams also work to ensure that the best value is obtained from the considerable investment made in medicines. These teams are tasked with stewardship of the largest nonpay expense in the Irish health system. Medicines rationalisation and optimum management reduces both direct and indirect costs in healthcare.
During a Hospital Admission
Pharmacy Porters are often the ’face’ of Pharmacy on the wards. Their communication and organisational skills are critical to optimise secure and timely delivery of medications, particularly where storage requirements such as refrigeration are important. They therefore facilitate space and time for clinical interventions by other team members.
Pharmacists and pharmacy technicians routinely build positive therapeutic relationships with the patients under their care, as well as family members or those who support patients prescribed medications. The process of building therapeutic relationships is facilitated by pharmacy team members during:
• Medicines reconciliation
• Documentation of adverse reactions and allergies to medications
• Obtaining medication histories to inform future treatment choice
These relationships mean that pharmacists can be in a position to advocate for patients’ wishes around medication treatment, particularly where the patient may struggle to communicate this otherwise e.g. in some mental health conditions or cognitive impairment.
During an admission, pharmacists undertake regular reviews of medication records to check for accuracy, completeness, and adherence to local and national prescribing policies. Clinical pharmacists will also screen for opportunities to optimise medication regimens and for potential risks that may be presented by pharmacological or physiological interactions, for example, therapeutic duplications and medication, formulation, or dose choices. Pharmacists and pharmacy technicians can provide practical information to patients such as inhaler technique and management of medicationrelated adverse effects thereby supporting adherence to medication and reducing overall costs to the health service.
Pharmacists being part of a multi-disciplinary team (MDT) and contributing to the development of individual treatment plans at the point of prescribing improves quality of care and can support appropriate medication-related monitoring, thereby improving patient safety. Comprehensive knowledge of medications, including the impact of different biological processes and disease states on medicines absorption, distribution, metabolism, and excretion, is an essential skill of MDT pharmacists. The ability to communicate this information clearly and tailor medication choices, doses, and treatment durations are also fundamental skills of pharmacists who work on an MDT.
Pharmacy teams members working with our youngest and oldest patients in Paediatrics or Child and Adolescent Mental Health (CAMHS), and in Older Adult or Geriatrics Teams may spend a lot of time liaising with family members to ensure the patient is adequately supported in their medication needs both during and after an admission.
On Discharge from Hospital
Ensuring continuity of supply of medicines after discharge is often the remit of pharmacy team members, particularly in the case of uncommon or higherrisk medications.
When preparing for discharge, hospital pharmacy team members can check the patient’s understanding of their medication regimen, ensure they know how to use newly prescribed devices such as inhalers, and facilitate seamless transition of care to the community. In some cases that may involve liaising with primary care colleagues on medicines follow up to ensure that care is not compromised by organisational boundaries. Communication with Community Pharmacy colleagues, District Nurses, and GPs can be an important step in maintaining treatment pathways and patient safety.
A large part of many hospital pharmacists’ roles is teaching and training of pharmacy team members such as more junior pharmacists or pharmacy technicians and medical and nursing colleagues on pharmaceutical care issues, including new developments in medicines. Formal training and informal exchange of knowledge and information throughout hospital teams ensures continued professional development and optimised quality of care for inpatients. Pharmacists and pharmacy technicians in education roles can supervise and facilitate learning for pharmacist and technician students and provide learning opportunities to students of other professions such as medicine and nursing. This leads to improvements in the knowledge and skills of the multidisciplinary workforce overall and better interprofessional communication.
Expansion of Pharmacist Roles
Many pharmacists lead on highimpact medication safety initiatives within their areas, for example on falls risk reduction or antibiotic stewardship. Some hospital pharmacists may additionally have roles in outpatient clinics, e.g. anticoagulant clinics; and in other countries pharmacist prescribing has facilitated the development of these services where expertise in medicines is highly advantageous. In recognition of the proven benefits of pharmacist prescribing, the Minister for Health established an Expert Taskforce in July 2023, to support the expansion of the role of pharmacists in Ireland. Legislation and guidance are gradually being introduced with ongoing stakeholder consultation.
In addition to their expertise in broad specialisms, for example, Medication Safety, Antimicrobial Stewardship, Medicines Information, and Research; many pharmacists have specialist knowledge in particular therapeutic areas such as, but not limited to: Oncology/Haematology, Maternity Care, Respiratory/Cystic Fibrosis(CF), Cardiology, Transplant Medicine, ITU, and Palliative Care. A small selection of these roles are examined in more detail below and reflected in the existence of HPAI Special Interest Groups (SIGs) for Aseptics, Care of the Older Person, Cardiology, Critical Care, Mental Health, and Renal.
• Aseptic Services Pharmacy Teams With thanks to: Olivia Flynn, Chief II Pharmacist, University Hospital Limerick; Fiona Begley, Chief II Pharmacist, St. Vincent’s University Hospital Dublin; Eamonn Henry, Chief II Pharmacist Oncology, Haematology & Aseptic Services, Letterkenny University Hospital; and Aisleen Haughey, Senior Pharmacist, Letterkenny General Hospital.
Aseptic Services Pharmacy is a specialised area of Hospital Pharmacy concerned with the safe preparation of sterile medicines for injection, predominantly for the treatment of cancer i.e. Systemic Anti-Cancer Therapy (SACT). 26 Hospital Pharmacy Teams in Ireland currently deliver SACT.
Medicines are prepared in an aseptic compounding unit (ACU) which is a clean room facility supplied with sterile HEPAfiltered air. An ACU contains pharmaceutical isolators to protect staff from exposure to hazardous drugs and to protect sterile drugs from contamination by staff and the environment. Each ACU has its own programme of quality assurance (QA) in place to ensure drugs that are reconstituted are of the quality required and are safe and effective. QA can consist of environmental (agar settle plates) and physical (pressures/ temperature) monitoring. The benefit of QA is to allow the ACU the possibility of extending the shelf-life of the reconstituted drug to allow for the advance preparation of certain drugs.
Once validated to work in an ACU, following intensive 3-6month training programmes, pharmacy staff may undertake some of the following roles in aseptic services:
Pharmacists
• Supervising the aseptic compounding of SACT including pre and in-process checking and final product release
• Overseeing and maintaining facilities to prepare sterile medicines
• Interpretation of QA results
• Overall responsibility for the Quality Management Plan for the ACU
• Education and training of new staff-members
• Writing up and approving standard operating procedures
Pharmacy Technicians
• Performing aseptic compounding duties
• Performing daily QA functions
• Writing up standard operating procedures
• Ordering and stock management
Having an on-site ACU in a hospital means that hospital will have greater flexibility in relation to the supply of SACT, allowing for accommodation of urgent treatments and dose changes in a timely manner and reducing the need to outsource. It also increases the potential for participation in Clinical Trials through preparation of drugs that are not commercially available but offer innovative treatments for patients.
Of particular concern to members of the Aseptics Services Special Interest Group (ASSIG) is the lack of regulation of Hospital Pharmacy ACUs. The H-PICs document published in 2013 was endorsed by the HPAI as standards that ACUs should aspire to, however this document needs updating and, ideally, a governance framework to support pharmacists and pharmacy technicians working in aseptic services.
• Paediatric Pharmacy Teams With thanks to: Diarmaid Semple, Senior Pharmacist PICU, CHI Crumlin; Emma O’Grady, Senior Pharmacist Cystic Fibrosis, CHI Temple Street; and Sara O’Connell, Parental Nutrition Pharmaceutical Technician, CHI Crumlin.
In paediatrics, pharmacists are essential sources of information particularly due to the higher off label and unlicensed use of medicine. The Paediatric Pharmacy Department, unlike most Irish Adult hospitals, supplies
patients with discharge medicines to ensure continuity of supply whilst Community Pharmacies order in unlicensed medicines. A parent remarked that it was fitting the last person they had seen after their child’s heart surgery was the pharmacist as they had also been one of the first people they met having to obtain specialist medication directly from hospital.
Paediatrics itself as a speciality is further sub-divided into other specialities such as Paediatric Intensive Care (PICU), Cardiology, Nephrology, Metabolic, Renal, CF, and Parental Nutrition.
For example, the Paediatric Parental Nutrition Pharmacy Team involves a Chief II and Senior Pharmacist with a Senior Pharmacy Technician working together to ensure that there is good communication between the prescribers and dieticians in determining both a child’s nutritional and electrolyte needs. Linking with suppliers, maintaining stock levels, and quality control are key roles for the pharmacy technician on the team.
Some of the sickest patients in hospitals are in intensive care, where pharmacists’ drug information and pharmacokinetic knowledge is in high demand by Intensivists. Paediatric Intensive care is no different and pharmacists in the PICU provide specialist knowledge in the treatment and use of drugs in patients from hours old to 16years and from 600g to 120kg.
Paediatric Cystic Fibrosis (CF) Pharmacists are at the forefront of optimising personalised medication regimens, providing expert pharmaceutical care tailored to children, and ensuring the safe and cost-effective use of some of our highest cost therapies. Specialist knowledge and expertise in the area of CF offers significant advantages by ensuring personalised, high quality care and fostering a collaborative, informed approach to managing CF. For patients and their families, this means having a dedicated professional who can address their unique medication needs, answer questions, and provide continuous support and education. This role helps to reduce medication related issues, improve adherence to treatment regimens, and offer peace of mind knowing they have a trusted expert as part of their healthcare team. Overall, a specialist CF pharmacist plays a crucial role in improving the wellbeing and health outcomes of patients with CF, while also providing invaluable support to their families.
As a specialist, the pharmacist is ideally positioned to provide education to members of the CF multidisciplinary team (MDT), and contribute to the literature through research and publication, improving the care of CF patients at a local, national, and international level.
• Pharmacy Informatics Teams With thanks to: Moninne Howlett, Chief Pharmacy Information Officer, Children’s Health Ireland.
Pharmacy informaticists are amongst some of the newer specialist roles for in hospital pharmacy. This is a rapidly growing area in response to the long-awaited digitisation and increasing complexity of medication management in Irish hospitals. Specialist Informatics Pharmacists are critical to support the procurement, implementation, and optimisation of health information technology systems. These include both local and national level systems such as pharmacy information systems, electronic health records (EHRs), automated dispensing systems, and smart-infusion pumps; ideally these systems are integrated to allow data to flow freely between them. Achieving this ‘closed loop’ medication management brings significant increases in safety and efficiency but significantly changes how medications are distributed, prescribed, and administered. The day-to-day management of these systems, including staff training, database management, system configuration, and data analysis requires a highly specialised workforce, including specifically trained pharmacists and pharmacy technicians.
• Mental Health Pharmacy
Teams With thanks to: Ciara Ni Dhubhlaing, Chief I Pharmacist, St Patrick’s Mental Health Services and Ita Fitzgerald, Senior Pharmacist St Patrick’s Mental Health Services.
Similarly to paediatrics, there are many sub-specialties within Mental Heath (MH) including Dementia, Child and Adolescent Mental Health (CAMHS), Psychiatric Intensive Care, Eating Disorders, and Substance Misuse. Mental Health Pharmacists will usually have some knowledge of all of these conditions and more.
Physical co-morbidities are common in many MH conditions therefore the pharmacist’s generalist knowledge e.g. regarding COPD or blood pressure management is a valuable addition to the holistic care of the patient. Pharmacists are particularly attuned to patient safety around the evidence-based use and monitoring of medications and MH Pharmacy Teams manage some critical and high-risk medications such as Clozapine, Lithium, and Sodium Valproate to ensure safe and effective use.
Additional complexities within MH include legal considerations around capacity or detention under the Mental Health Act (MHA) that may need to be factored into treatment decisions.
This includes cases of acute illness that can negatively impact a person’s decision-making capacity or where a patient is detained under the Mental Health Act. For example medicines administration via injectable formulation may be supported by MHA legislation and clinically appropriate where it is in the best interests of the person.
MH professionals work within bio-psycho-social models where the medicines; psychological therapies; and social support, including family support, are all important in recovery. Specialist MH Pharmacists must therefore have a good knowledge of their MDT colleague’s roles in addition to their own, and treatment pathways are highly individualised and collaborative according to the patient’s needs, experiences, and preferences. It is a privilege for pharmacy teams to be able to walk the path to recovery with our patients.
The first World Hospital Pharmacy Day was held on the 27th of March 2024 to recognise the importance of, and to celebrate the work done by hospital pharmacies. Like the event, it is clear that we are only getting started on what can be achieved by Hospital Pharmacy Teams to optimise medicines use and to deliver excellence in patient care.
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