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Hospital pharmacy practice: US versus UK

British pharmacist Hannah Weekes worked as a pharmacy intern in the US. In this article, she explains the main differences she has found in the profession between the two countries

Pharmacy in USA

Source: James Vallee Dreamstime.com

The fundamental principle of “do no harm” is shared by the healthcare systems in both the UK and the US and achieving sustainable healthcare outcomes as an appropriate percentage of gross domestic product (GDP) is important.1

Funding healthcare

Perhaps the most obvious difference between healthcare models in the UK and US is the national, publicly funded system paid for by taxation in the UK, versus a predominantly private scheme in the US. The current system in the US means that, in some situations, those who cannot afford healthcare insurance or cannot pay fully for their treatment receive limited care. Various insurance plans often require a “co-pay” or “excess” to supplement each episode of care.

You may have heard about healthcare reform in the US. ‘Obamacare’ or the ‘Affordable Care Act’ is in the process of being implemented. This has the ultimate aim of ensuring everyone has access to healthcare.2

My interpretation of this is as follows:

  • It will be mandatory for those who do not have healthcare insurance and can afford it to acquire it — financial penalties will otherwise ensue.
  • For those who fall below the poverty line and cannot afford insurance, there will be subsidies. Essentially the system will be more scaled and somewhat means tested, according to earnings.
  • Insurance companies will be forced to cover pre-existing conditions and there will be more of a ‘quality’ over ‘quantity’ aim and more ‘healthcare bundles’. This will mean streamlining and negotiating costs in advance, and preventing unnecessary tests from being performed to generate profit. Healthcare insurance marketplaces will be available to allow people to search for the best insurance policy to suit their needs.

Everyone in the US is currently entitled to receive emergency treatment and delivery in pregnancy, regardless of their insurance status, under the Emergency Medical Treatment and Labor Act”. The aftercare can vary considerably depending on insurance, the state the patient resides in and, in the case of perinatal services, the facilities available in the hospital because some are equipped differently and may include management of complicated pregnancies.3 Long-term care and high-cost treatments create the greatest issue.

For general medical care, there is a confusing multitude of different insurance plans available and eligibility varies for each. Pre-existing conditions may not be covered and healthcare entitlement may also vary from state to state. Depending on which state you reside in, there may be more or less state tax invested in Medicaid and Medicare, which provide free coverage for low-income families and the elderly, respectively. For example, in Massachusetts, health coverage is already mandatory. Financial penalties exist and are set to rise for those who are not covered, with the exception of those individuals for whom healthcare insurance is free because their income is below the federal poverty level.

In addition to the way the systems are funded, there are other substantial differences in the ways UK and US hospital pharmacies operate.

24 hour service

Pharmacies in busy, large hospitals in the US can operate 24 hours a day. The day is often divided into three shifts — morning, afternoon and evening, and overnight. Pharmacists generally rotate between shifts, although a minority of jobs are exclusively overnight. This 24-hour operation is necessary given that they aim to verify 100 per cent of prescriptions before administration. In contrast, the UK currently has an “out-of-hours” on-call emergency-only system.

The role of the technician

Much of a technician’s job relates to the various electronic systems (see below). In the US, by law, technicians cannot perform patient counselling or medicines reconciliation, although pharmacy interns may be involved in the former. In hospital, technicians are primarily involved in the preparation of medicines, which can include compounding, delivery to the appropriate floors and checking for expiry dates. Other tasks include audit or project work, and maintaining accurate records of refrigerator temperatures and, if this is out of range, quarantining medicines accordingly. Reports can be produced to look at user activities.

Automated dispensing and distribution

Probably the most notable difference in the US compared with the UK is the use of advanced, automated machines and systems for drug dispensing and distribution. In large hospitals, almost all unit-dose medicines such as tablets, capsules, liquids, and other small items such as creams and enemas may be stocked in a drug carousel within the inpatient pharmacy (see figures 1a and 1b). 

Figure 1a

Figure 1a

Figure 1b

Figure 1b

This machine is operated by a computer system (eg, Talyst) and is linked to the floor dispensing machines (eg, Pyxis). It rotates like a conveyor belt to the required row and compartment. One major role for technicians is to ensure that newly delivered medicines are rapidly received into their designated location and added to the inventory. To avoid human error, and to check for expired drugs, there may be cyclical checks of medicines. Larger items, bulk liquids and excess stock are stored on shelves organised by compartments. Several refrigerators and freezers also have designated compartments to store medicines.

 

Panel 1: automated machines to store medicines

Most inpatient floors have automated machines to store medicines (see figure 2a). Technicians can refill these machines using a barcode scanning system. The machine may consist of:  

Figure 2a

“Cube” pockets of varying size in a drawer, with a hinged lid operated by a catch (see figure 2b).

Figure 2b

“Matrix” drawers may be available in the main Pyxis to store largermedicines (see figure 2c). These are less restricted (once a matrix drawer is opened a user has access to all the pockets).

Figure 2c

A “wedge” shape drawer for controlled substances. The wedge compartments have restricted access and for many functions require a second person to be a witness for activity (see figure 2d).

Figure 2d

A “tower” or “cabinet” with larger compartments (see figure 2e)

A locked refrigerator (see figure 2e)

Figure 2e

Only specific users may access Pyxis, by last name and fingerprint identification (see figure 2f)

Figure 2f
  

Nurses bring up patient profiles and select the required drug. If it is available, the relevant compartment then opens. Some hospitals use systems (eg, Omnicell) that contain one day of medicines per specific patient and are restocked every 24 hours. First-dose medicines, creams, eye drops and enemas may be stored outside these systems in bulk bins, since the risk associated with their use is lower and they are not always available as unit doses.

When a specific medicine is loaded to the Pyxis console in the pharmacy for a specific floor, a minimum and maximum level (PAR level) will be set, based on the dose and frequency of usage. The Pyxis machine on a floor interfaces with a patient’s medication profile list. Certain frequently used medicines will always remain as stock in the Pyxis. When stocks of a medicine run low, the floor Pyxis machine will automatically communicate to the Talyst computer system and carousel in the pharmacy, prompting further dispensing. In addition, at defined points during the day, a “sweep” of PAR levels will be calculated across the hospital and provide an output in the dispensary to highlight any refills necessary.

The increased automation can improve efficiency, provide additional medicines safety and be used to account for medicines for billing purposes.

“Tall man lettering” and name-alert stickers

One way of minimising drug errors is to capitalise parts of similar drug names to differentiate them, which is known as “tall man lettering”. This is something that could easily be adopted in the UK — examples include “EPINEPHrine” and “ePHEDrine”, and “cycloSPORINE” and “cycloSERINE”.7

Additionally, for two patients with similar names in close proximity, alerting stickers are placed prominently to avoid confusion. Some hospitals in the UK have a similar system.

Compounding medicines

Most large hospital pharmacies in the US have their own “clean rooms” for technicians to prepare medicines under aseptic conditions. Medicines prepared in this way include: reconstituted intravenous antimicrobials, “mini bags” for standard-dose intravenous antibiotics (essentially a vial attached to a dextrose or saline bag via a connector that can be snapped when ready to use to facilitate mixing), ophthalmic preparations and epidurals. Hence preparing such medicines is predominantly the responsibility of the pharmacy team, whereas it is more commonly the nursing team’s responsibility in UK practice. Additionally, there may be a “clean room” for preparing chemotherapeutic agents.

Larger formulary of medicines

UK formularies are influenced by the National Institute for Health and Care Excellence and limited by local prescribing committees, which generally results in more restrictions, particularly in hospitals. There is no equivalent of NICE in the US and the increased catalogue may partly account for increased healthcare costs there. If a medicine is licensed by the US Food and Drug Administration (FDA) it can be prescribed — although this may be limited by insurance companies’ individual policies and individual coverage. In both countries, prior authorisation may be required for high-cost drugs. For people in the US with low or no insurance, sponsorship or “compassionate use” from the drug manufacturer may sometimes be granted if treatment is otherwise unavailable.

General “paperless” system

Technology advances and the idea of a unified electronic healthcare record are in the pipeline in both countries – although as a whole automation is more advanced in the US.  The healthcare record system “Epic” is already operating in some US hospitals — this is in its infancy in the UK. Electronic medical records within individual hospitals are already widespread in the US, and include electronic drug charts.

Pre-packed “code” carts

Resuscitation kits are pre-packaged by pharmacy and differ in content according to location. Different kits are available for specific locations such as anaesthesia, cardiothoracics, operating rooms and the emergency department, and may vary in their content.

Discharge process with respect to medicines

The discharge process is substantially different in the US. Medicines reconciliation is conducted by pharmacists who liaise with a primary care physician or retail pharmacist or both to ensure an accurate reflection of medicines on admission and at discharge. However, patients are not routinely encouraged to bring their current medicines to hospital and nor is the hospital obliged to ensure the patient is discharged with an adequate supply. If the patient does not have a regular provider then they will be encouraged to attend the outpatient pharmacy (during standard, day-time business hours) within the hospital. This system substantially speeds discharge, but can potentially result in missed doses.

National healthcare survey

The “hospital consumer assessment of health plans” survey is a national healthcare audit to find out what a patient thinks of their experience at the hospital. Patients receive a telephone interview after they have been discharged and are asked various questions. Results can be used to examine clinical care, critical compliance and can aid operational improvement of healthcare outcomes and experiences.8

Costs, mortality and morbidity

It may come as no surprise then that there is a large cost associated with US healthcare. A study conducted by the World Health Organisation in 2012 suggested that the US spends 17.9 per cent of its GDP, or $8,362 per person per annum and it is not all private — Government spending is at $4,437 per person. By comparison the UK figures are 9.6 per cent, $3480 and $2919, respectively.9

Panel 2: terminology

There are a number of different terms pertaining to pharmacy operations in the US:4

  • Institutional pharmacy includes hospitals, hospices, long-term care facilities (e.g.  nursing homes) and prisons.
  • Centralised and decentralised pharmacy models. The former refers to when pharmacy-related activities are all performed in one location, whereas the latter consists of a central or inpatient pharmacy, multiplesatellite pharmacies and an outpatient pharmacy, with pharmacists basedin each.
  • Inventory is a detailed tracking system of incomingand outgoing stock. “Periodic/pre-set automatic replenishment/reordering” (PAR) levels are closely tied with inventory and ensure maintenance of adequate stock levels in the dispensary and onthe hospital floors.5
  • Floors:  Wards are more commonly referred to as floors.
  • Order:  “Order” is often used instead of the word “prescription”.
  • Controlled substances:  Controlled Drugs are more commonly referred to as “controlled substances”, with opioids specifically referred to as “narcotics”.
  • Diversion:  Diversion describes the fraudulent disappearance of controlled substances or medicines that can potentially be abused.
  • Different Latin abbreviations may be used. Common examples include;
    • qd ”denoting “once daily” in the US, not to be confused with “qds ” denoting“four times daily” in the UK or with “qid ” denoting “four times daily” in the US.
    • “od” denoting “to the right eye” in the US not to be confused with “od” denoting “once daily” in the UK
    • Per diem: Per diem ’ is the common term used for casual work (ie, ‘bank’ or ‘locum’ work in the UK)
  • Carousel:  Carousel is a dispensing machine with rows of barcoded compartments for storing medicines in the pharmacy department.
  • Vault:  This is the term to describe a computerised safe or room for storage of controlled substances (see figure 3). This includes narcotics and non-opioids that can be abused, for example fentanyl and pregabalin. Some non-controlled medicines are stored in the vault due to their expense or potential for theft, for example sildenafil.
  • “Unit-dose barcoding”: Most individual tablets, capsules and some liquids are packaged with an individual bar code. In addition to determining costs of medicines for billing purposes, this provides additional tracking and safety checking and contributes towards maintaining an accurate inventory of medicines. Amanual check of the expiry date is still required. If medicines arrive from a manufacturer in a bulk pack, it can be a technician’s responsibility to pre-pack the drug into individual doses, using variouscomputerised equipment. Barcodes enable stringency around safety, ensuring the correct patient receives the correct drug and dose.
  • Computerised physician order entry (CPOE):  This means electronic prescribing and is intended to reduce possible errors due to poor handwriting or transcription of orders. CPOE systems can often be integrated with e-prescribing systems to alert prescribers to allergies or drug interactions. This system mandates that every prescription order is verified before it is administered to a patient. 6

 

 

 

 

Citation: Tomorrow's Pharmacist URI: 11138998

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