The Silent War in Inpatient Pharmacy

Introduction

Much of the public's perception of a pharmacist's role is shaped by their interactions in the ward and at outpatient or community pharmacies.

• However, a significant number of dedicated pharmacists work diligently in inpatient settings, ensuring accurate medication dispensing to hospitalized patients.
• Daily tasks often involve managing medication stock (through floor stock supply and filling medication trolleys) and providing patient counselling, especially in wards without dedicated clinical pharmacists.

Transition From Outpatient Pharmacy

Having transitioned from outpatient to inpatient pharmacy, I personally prefer the latter due to reduced patient-related stress, such as dealing with aggressive patients and dispensing at crowded, noisy counters.

• Unlike outpatient settings with strict waiting time policies and crowded waiting areas, inpatient pharmacy work seems more flexible, but remains demanding.
• When staff are absent or in meetings, we still need to complete tasks timely before the lunch break, so that nurses can serve the next dose as scheduled.

Another significant difference is the complexity of inpatient medication orders.

• Outpatient prescriptions are typically shorter, while inpatient orders can span multiple pages.
• This requires careful attention to detail and significant mental efforts, as pharmacists must identify new or discontinued medications, potential drug interactions and polypharmacy while fulfilling medication orders.
• Long-term patients may have extensive medication charts, adding to the complexity.
• This challenge is less prominent in hospitals with electronic prescription systems.

Oral And IV Doses Are Not Always The Same

While some medications are common to both inpatient and outpatient settings, many intravenous drugs, such as adrenaline, ceftriaxone, cefoperazone, meropenem, and propofol, are primarily used in acute care.

• Also, patient conditions may necessitate higher-than-usual dosages, requiring pharmacists to stay updated on drug information and dosing guidelines.

It is not uncommon to encounter new physicians, particularly recent graduates, who may prescribe oral medications at intravenous dosages and vice versa. For instance,

• Tablet Metronidazole 500 mg TDS
• Metronidazole tablets are only available in 200 mg strength.
• Tablet Cefuroxime 500 mg TDS
• Maximum oral dose of cefuroxime is 500 mg twice daily.
• IV Bromhexine 8 mg TDS
• Maximum recommended IV dose is 12 mg/day (i.e. 4 mg TDS).

Calculations of Vials Required

Another area where experience is crucial is calculating the required volume for infusion medications like noradrenaline, adrenaline, dexmedetomidine, and dobutamine.

• For example, what is the infusion rate in milliliters per hour for dexmedetomidine in a 70 kg patient at a dose of 0.7 mcg/kg/hour?
• Additionally, what are the concentrations of single-strength and double-strength noradrenaline infusions?

Renal Dose Adjustment

Inpatient settings often require more frequent renal dose adjustments compared to chronic outpatient care, especially for critically ill patients with acute kidney injury.

• Uncommon once daily dosing for drugs like amikacin, acyclovir, or cefuroxime, may indicate impaired renal function.

Summary

By working in various pharmacy settings (e.g. inpatient, outpatient, ward), pharmacists can develop a well-rounded skill set that benefits patients and healthcare providers.

• While clinical pharmacists are often associated with advanced clinical knowledge, inpatient pharmacists possess a unique skill set honed through daily challenges.
• Remember, all pharmacists play a crucial role in delivering pharmaceutical services.