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The Evolution of Pharmacy at Royal Adelaide Hospital

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1 The Evolution of Pharmacy at Royal Adelaide Hospital
SA Medical Heritage Society The Evolution of Pharmacy at Royal Adelaide Hospital In May this year I was honoured to present the William Wright Oration at the Royal Adelaide Hospital’s Foundation Day Service an annual tradition at the hospital since 1979. Millicent & Chris attended the service and felt the presentation would be of interest to your Society. At the time of the Oration I felt it was extremely timely that Pharmacy was the focus for this year. A/Prof Chris Doecke BPharm PhD FSHP 1 1

2 Pharmacy at RAH– Back to the Future
Statewide Clinical Support Services Part of SA Pharmacy since July this year Service Level Agreement between SA Pharmacy and Central Adelaide LHN With the seemingly never ending restructure of public hospital governance, on July 1st this year the Pharmacy Services provided to all public hospitals in SA became a single Statewide Service, as a new SA Health entity called SA Pharmacy. While at this stage there has been no change to the essential services at the RAH coalface, the governance of these services is, or will be when it is eventually defined, under a service level agreement between SA Pharmacy and the Central Adelaide Local Health Network. This is a similar model to SA Pathology created a couple of years ago and SA Imaging created at the same time as SA Pharmacy. In effect, the RAH will no longer have its “own” Pharmacy Service. Pharmacy Services to the RAH will be provided under a contract, albeit a contract with an SA Health entity. In reviewing the history of the hospital this could be seen as back to the future. 2 2

3 Pharmacy at RAH– Back to the Future
First lay appointment to the Adelaide Hospital Dispenser Mr J Weston and then John Slatter in 1840 External providers – fee based on service agreement 1842 – Adelaide Hospital – First Resident Dispenser The very first “lay” post created at the new Adelaide Hospital, around 1840, was in fact that of Dispenser. Mr J Weston and later Mr John Slatter occupied the position. Both pharmacists provided these services on a contract or fee for service basis, albeit from premises outside the hospital. Records show that Mr Weston provided services under a contract for a fee of six pence per dispensing and a 30% surcharge on the cost of the drugs. I’m sure that this won’t be the same financial arrangement for the future service level agreement between SA Pharmacy and the Central Adelaide LHN. The surcharge alone would now generate approximately $15 million per year to the pharmacy provider. The original contract arrangement at the Adelaide hospital only remained in place for two years until the first Resident Dispenser was appointed in June 1842. I will return to the story of the hospital’s Resident Dispenser shortly. 3 3

4 The Evolution of Pharmacy
Manufacture and supply of medicines -> now ALSO Improving medication management for patients directly through the provision of medicines information I have made the presumptuous assumption that many of you today have the perspective of contemporary pharmacy as a profession solely involved in the preparation and/or supply of medicines. I would like to leave you this evening with an understanding of how this fundamental aspect of pharmacy practice has evolved into one where pharmacists now also have an essential role in improving medication management directly through the provision of medicines information to patients, carers, prescribers and other health care providers. This evolution has been most pronounced in public hospital based pharmacy services, however, over the last decade it is also occurring in private community practice settings. Some of you will be aware of the Commonwealth funded Home Medicine Review program, where a GP requests an Accredited Pharmacist to review a patient’s medication in their home for a fee, without the supply of medicine being involved. Again I will return to this a little later, as I now want to briefly address the broader history of pharmacy and its relationship with medicine. 4 4

5 Ebers Papyrus ~ 1550 BC 811 Prescriptions Treatments for Asthma
Depression Dementia Heart ailments Chapter on Contraception The documented preparation of medicines for human use dates back to the Pharaohs of Egypt around 2000 BC. The most famous of such documentation is the so called Ebers Papyrus written around 1550 BC and obtained by the German Egyptologist Georg Ebers in 1873. It is currently held at the University of Leipzig in Germany. The 110 page, 22 yard long scroll describes 811 prescription remedies grouped into their intended purpose, with many of the ingredients still in use today. Most human ailments and conditions were covered with even a Chapter on contraception. 5 5

6 Ebers Papyrus ~ BC Remedy to clear out the body and to get rid of the excrement in the body of a person Berries of the Castor Oil Tree Chew and swallow down with Beer in order to clear out all that is in the body This is .an example of a remedy that is still used today by some as a laxative. So the concept of formal prescriptions for treating ailments has been around for at least 4,000 years. 6 6

7 Pharmacy and Medicine Caliph al-Mansur (754 – 774 AD)
Abbasid dynasty of the Islamic Empire Separation of Pharmacy and Medicine Benefits for patients First known Pharmacy Bagdad 770 AD Pharmacy and medicine have had a close, interesting and fluctuating inter-relationship throughout history. Initially the role of diagnosing the ailment, deciding on treatment and providing that treatment was by the one individual. It is generally recognised that the first known separation of pharmacy from medicine came during the Abbasid dynasty of the Islamic Empire under Caliph al-Mansur who reigned from 754 to 775 AD. It was these enlightened Arabs that recognised the benefits of separating the role of the dispenser from that of the physician. The benefits of such separation included mitigating the obvious conflict of interest with the same individual prescribing and then financially gaining from the sale of the prescribed product. In addition, these enlightened individuals also recognised the safety benefits to the patient of having a second review of the orders of the physician. It was at this time that the first known pharmacy was started in Bagdad in 770 AD. 7 7

8 Frederick II von Hohenstaufen - Holy Roman Emperor (1220 – 1250)
Historical scholars generally credit this man, the Holy Roman Emperor, Frederick II von Hohenstaufen, with the formalisation of pharmacy as a profession. 8 8

9 Frederick II von Hohenstaufen
Constitutiones Imperiales AD dogmatic medicine, which made diagnoses; manual medicine, which performed surgical interventions; and pharmaceutical medicine, which collected, mixed and conserved medicines. Frederick II von Hohenstaufen In 1231 Frederick enacted his Constitutiones Imperiales, in which he divided medicine into 3 distinct groups: 1) dogmatic medicine, which made diagnoses; 2) manual medicine, which performed surgical interventions; and 3) pharmaceutical medicine, which collected, mixed and conserved medicines. Frederick was the first to legislate these distinctions and to stipulate the training required for each component. Despite these very early efforts to keep medicine and pharmacy as separate professions for the integrity of both professions and for the safety of patients, the separation waxed and waned with time due to practical necessity and professional self-interest. There is a direct relevance of this brief historical perspective about the relationship between pharmacy and medicine to the original Adelaide Hospital that I will get to shortly. 9 9

10 Frederick II von Hohenstaufen
Constitutiones Imperiales AD Medical Education Required a public examination before the Masters of Salerno for a licence to practise medicine was granted Four year of pre-training in logic Five years of medicine One of these being surgery and anatomy to practise surgery One year of practical training under an experienced physician Frederick II von Hohenstaufen Before that and as an aside, the same laws created by Frederick are generally accepted to be the basis of current medical training requirements. His stipulations sound remarkably familiar. The reason that the relationship between pharmacy and medicine has direct relevance to the original Adelaide Hospital is that the first Resident Dispenser was in fact a medical practitioner – Dr Alexander Charles Kelly. 10 10

11 Dr Alexander Charles Kelly
Scottish Medical Practitioner Struggling medical practice in Port Adelaide First Resident Dispenser Adelaide Hospital June – August 1842 Dr Alexander Charles Kelly was born in 1811 and educated in France and Scotland before training in Medicine at the University of Edinburgh. After practising briefly in Scotland, he became a surgeon aboard the East India Co. ship Kellie Castle on a voyage from England to Bengal in 1833. He later visited Canada before returning to Scotland for a period before emigrating to Adelaide in 1840. He was the 12th name in the Medical Register of SA and set up practice in Port Adelaide. The practice struggled and so he took the position offered by the Colonial Surgeon of Resident Dispenser at the Adelaide Hospital for the small annual salary of £50. Dr Kelly only remained in the post for 10 weeks, although after some time he did eventually return to the hospital as an assistant surgeon. The reason he left was probably relating to his interest in becoming a winemaker. 11

12 Dr Alexander Charles Kelly - Winemaker
August 1843 – 80 Acres at Morphett Vale Planted first vines Built house – “Trinity” Wrote two books The Vine in Australia (Melbourne, 1861) Wine-Growing in Australia (Adelaide, 1867) Both influential books that did much to establish Australian technical expertise in viniculture In August 1843 purchased 80 Acres in Morphett Vale and planted his first vines in 1845. for his first book, The Vine in Australia (Melbourne, 1861); it introduced wine chemistry and modern science to Australian winegrowers and was so popular that it was reprinted next year. His Wine-Growing in Australia (Adelaide, 1867) followed. Kelly's two influential books did much to establish Australian technical expertise in viniculture. 12

13 Dr Alexander Charles Kelly - Winemaker
Formed the Tintara Vineyard Co with Sir Thomas Elder Alexander Elder Sir Samual Davenport Robert Barr Smith Sir Edward Stirling Started clearing 213 acres heavily wooded area near McLaren Vale Eventually sold to Thomas Hardy in 1877 In November 1862 he and five of Adelaide's businessmen—(Sir) Thomas and Alexander Lang Elder, (Sir) Samuel Davenport, Robert Barr Smith and (Sir) Edward Stirling—formed the Tintara Vineyard Co., with Kelly as manager. Next year he sold Trinity to concentrate on clearing the 213 acres (86.3 ha) of heavily-timbered country near McLaren Vale which the trustees had bought in December 1862, and on planting vines, building cellars and, eventually, making mainly table wine. In September 1877 it was announced that Thomas Hardy had purchased the vineyard, with 27,000 gallons (122,742 litres) of wine. 13

14 Charles James Carleton
Studied medicine at Guy’s Hospital Didn’t complete degree Left England for Adelaide with wife and children in 1839 Resident Dispenser until 1845 Became Medical Practitioner in Kapunda Dr Kelly’s replacement as Resident Dispenser was a Mr Charles James Carleton, who also had studied medicine, this time at Guy’s Hospital in London, albeit without ever completing his degree. Mr Carelton left England in 1839 to come to Adelaide with his wife and two young children. It was a difficult trip with both children dying and being buried at sea. Resident Dispenser until 1845 and then became a Medical Practitioner in Kapunda. Mr Carleton’s wife, Caroline, ultimately earned greater notoriety than her husband. 14

15 CAROLINE CARLETON Caroline was a poet who in 1859 wrote the words to “The Song of Australia” in response to the Gawler Institute's contest for a patriotic poem that could be set to music. 15

16 Dr Robert Travers Lewis
Resident Dispenser and House Surgeon 1845 – 1847 All Resident Dispensers at the Adelaide Hospital until 1847 had a medical background Mr Carleton remained at the hospital for 3 years until 1845 and was replaced by Dr Robert Travers Lewis who worked as both Resident Dispenser and House Surgeon until 1847. So for the first six or so years of its existence, the Adelaide Hospital had itself blurred the separation of medicine and pharmacy. This was of course a time of early colonial settlement with a limited ability to regulate professional practice and in fact often an essential requirement for individuals to provide services outside their area of training. There was no Pharmacy Act in South Australia until 1891 to regulate the credentials of those offering pharmacy services. 16

17 Mr Henry Briggs First Resident Dispenser without a medical background
Long career from Wife Mrs Henry Briggs Nurse at Adelaide Hospital 1849 Appointed Matron in 1855 From 1847 the Adelaide Hospital Resident Dispensers were all individuals with pharmacy as their sole profession, although the next appointment Mr Henry Briggs, was also required by the Hospital to act as an unqualified house surgeon for some years. He did, however, have a long and successful 26 year career at the hospital as Resident Dispenser until 1873. As with Mr Carleton earlier, it was Mr Brigg’s wife who ultimately became more renowned, particularly at the RAH. Mrs Henry Briggs is recorded as starting as a nurse at the hospital in 1849. In 1855 she was formally appointed Matron of the hospital. Mrs Henry Briggs is of course better known to current RAH staff as Joanna Briggs with The Joanna Briggs Institute being named after her. I will leave the very early history of the Pharmacy at the Royal Adelaide Hospital at this point, simply noting the interesting early links between medicine and pharmacy which closely reflected the contemporary relatively unregulated practise of both medicine and pharmacy at that early time in South Australian history. 17

18 - Chief Pharmacists since 1899
RAH Pharmacy Service - Chief Pharmacists since 1899 George Burns Mr William Hammer ~ 40 years Mr George Burns ~ 30 years Mr Lance Jeffs ~ 3 years Mr Ian Lee ~ 20 years Dr Chris Doecke years From 1899 there has been a relatively stable leadership of the Pharmacy Service at the RAH with only 5 Chief Pharmacists or Directors of Pharmacy in that time. Mr William Hammer was Chief Pharmacist for almost 40 years until 1937 then Mr George Burns for around 30 years. Mr Lance Jeffs took over in 1968 for 3 years before Mr Ian Lee held the position for over 20 years until I commenced in 1994. Lance Jeffs 18

19 RAH Pharmacy Services 1899 -> early 1970s
Until the early 1970’s the majority of the role for pharmacy was in the compounding, preparation and dispensing of pharmaceuticals. Dispensing was a key function for the Outpatient Service at the hospital which was a very interesting and busy place. 19

20 This is a cutting from The Mail – November 30th, 1929
It gives a very colorful desciption of a busy outpatient’s department much more akin to our current emergency departments

21 Patients Awiating Treatment In The Outer Room
More than 9,000 persons visited this room for treatment in the past 12 months, nd of these the great majority were women. Authorities say that men never go to hospital unless driven by absolute necessity. Few normally healthy persons would care to vist this room, for one instinctively senses the suffering that goes on within its walls. But there here also is courage and true beauty, the beauty of human spirit rising above the torture of the flesh.

22 The dispensary is specifically mentioned.
Being amazed that 800 pound was spent on medicines that year.

23 The Advertiser - Friday 16th June, 1911
There are a few skeletons in the Dispensary Closet at the RAH. This is report of a Coroner’s Inquest in the Advertiser in 1911.

24 A DISPENSER'S END. VICTIM TO MORPHIA AND COCAINE. The City Coroner (Dr. Ramsay Smith) conducted an enquiry into the circum- stances surrounding the death of Thomas John Fridy, at the Adelaide Police Court on Thursday. Fridy was assistant dispenser at the Adelaide Hospital, Michael Fridy stated that the deceased was his son, aged 32. For some years past he had been in indifferent health and he had been under two operations. Alfred Herbert Bonney, porter at the Adelaide Hospital said he went to the out patients' dispensary about 3.15 p.m. on June 12 and saw the deceased lying on the floor, apparently in a fit. With help he carried the prostrate man to the consulting room and went for the medical superintendent.

25 Dr. de Crespigny, medical superintendent at the hospital, said when he saw the deceased he was struggling violently and in the witness' opinion was suffering from poisoning. He died in from 7 to 10 minutes after he saw him. The witness suspected he had been taking morphia from time to time, and the deceased told him so about four or five months ago. He had also been taking cocaine lately. Dr. Angas Johnson said he made a post-mortem examination of the deceased and found that all the organs of the body were healthy except the liver, which was affected with hydatids. In his opinion death was due to an alkaloidal poisoning.

26 Dr. de Crespigny examined the dispensary and found all the bottles of the preparations of morphia were empty, also a 6 oz. bottle of sulphate of atropine solution. In ordinary circumstances they would not be empty as they were used daily. Things were much confused on the shelves and on the floor of the dispensary, and the contents of the bottles of drugs had been spilt. The Coroner found that deceased came to his death from poisoning, self administered, while in an unsound state of mind.

27 Production Services The Department’s production activity was often on a near commercial scale. For example sterile large volume intravenous fluids to meet the hospital’s requirements were mainly prepared in the Department. This expertise in compounding and formulation did result in significant therapeutic advances and innovations. I provide one example of international significance that also highlights the successful collaboration of pharmacy and medicine at the RAH. 27

28 Eye Drop Sterilisation & Preservation
Before 1960 it was believed eye drops needed to be clean but not sterilised. All eye drops were multi-dose, however, preservatives were not used. Up until this time it was universally considered unnecessary for eye drops to be sterile. It was usual practise for eye drops to be prepared as bottles of clean but unsterile solution, often with a cork stopper! Even though all eye drops were intended for multiple administrations, preservatives were also considered unnecessary, and by some harmful to the eye. 28

29 Mr David Crompton - RAH Eye Surgeon
Believed contaminated eye drops were the cause of post operative eye infections Was supported by the RAH Pharmacy by preparing sterile eye drops for his research It was the now renowned RAH Eye Surgeon, then a registrar, Mr David Crompton, who was stimulated by a case of post-surgical blinding keratitis in 1957 to question the role of microbiological contamination of eye drops as the source of the infection. The RAH pharmacy supported his work by preparing sterile drops. 29

30 Mr PL (Lance) Jeffs Deputy Chief Pharmacist at the RAH at the time
Developed chlorhexidine as a preservative for eye drops Published internationally in 1959 Mr Lance Jeffs, the Deputy Chief Pharmacist at the RAH in the late 1950s had a significant collaboration with Mr Compton. Lance Jeffs worked to support Mr Crompton by not only preparing sterile drops but also by developing formulations using chlorhexidine as a preservative. This internationally ground breaking work was published by Mr Jeffs in 1959. 30

31 The Sterile Eye Drop Official Initial Responses
"the sterilisation of eye drops is unnecessary“ "not in practise possible" Mr DO Crompton Eye Surgeon Despite the dramatic reduction of eye infections shown by Mr Crompton by using sterile eye drops, he had great difficulty in convincing the broader medical and regulatory community of the benefits of sterile eye drops. He lobbied the Ophthalmic Society of Australia and The Federal Pharmaceutical Benefits Advisory Committee but was told that "the sterilisation of eye drops is unnecessary" and "not in practise possible". 31

32 The Sterile Eye Drop Dr Kevin Anderson, Head of Bacteriology, IMVS
Eventually in the early 1960s Australia the first country in the world to mandate that eye drops must be sterile Not daunted he worked with Dr Kevin Anderson, Head of Bacteriology at the Institute of Medical and Veterinary Science, publishing many papers in journals such as The Lancet. The result ultimately was that in the early 1960s Australia became the first country in world to mandate that eye drops must be sterile. This, along with preservatives for multi-dose eye drops, eventually became the international standard of care, originating through collaboration between medicine and pharmacy at the RAH. 32

33 Late 1960s onwards Explosion in the number an range of pharmaceutical products available Great need for independent medicines information RAH Drug Information Centre One of the first in Australia It was also around this time in the mid 1960’s that the range of available pharmaceuticals increased dramatically. This caused an explosion of information about medications, their effects and adverse effects. Pharmacists rapidly became relied upon to provide independent information to prescribers and patients. The Royal Adelaide Hospital was at the forefront of these developments with the establishment of one of the first Drug Information Centres in Australia providing information to hospital staff as well as GPs and the general public. 33

34 RAH Drug Committee Established in 1969
Multidisciplinary committee primarily supported by pharmacy Advice to the hospital on drug usage, prescribing trends and new drugs Also linked to the issue of the increasing cost of medicines In 1969 the hospital Board established a Drug Committee with medical, nursing, pharmacy and administration representatives to provide advice on drug usage, prescribing trends and new drugs. It was primarily supported by the pharmacy department. It was at this time that the increasing cost of pharmaceuticals also became significant for hospitals. 34

35 Drug Formulary & Therapeutic Handbook
Regular printed editions Now on-line This eventually lead to the development of an RAH Drug Formulary and Therapeutic Handbook. This publication continued as regular editions in printed form until replaced by an on-line version in the last few years. The RAH was again an early adopter of the concept of guiding drug use in a large hospital by limited the range of similar agents available and at the same time establishing guidelines for the use of drugs on the Formulary. 35

36 Clinical Pharmacy Services
Requirement for Pharmacists to support medication use at the bedside Support for prescribers Support with medicine administration Support for patients and their carers This growth in the number and complexity of medicines for therapeutic use in the early 1970s also saw a demand for pharmacists to leave the four walls of the pharmacy department to support prescribers, nursing staff and patients at the bedside. This was initially known as Ward Pharmacy and then Clinical Pharmacy. A greater understanding of the Medication Management Cycle and its negative impact on patient outcome if not appropriately followed has seen of lot of work undertaken to identify ways of ensure patients are appropriately supported. 36

37 The Medication Management Cycle
This schematic of the Medication Management Cycle with the patient at the centre, identifies many steps in the cycle that are either best undertaken by a pharmacist including review of the order, issue of the medicine, provision of medicine administration and distribution and storage, or steps that are helped greatly by the support and advice of pharmacists such as prescribing, medicine administration and monitoring of response. The ultimate aim is to ensure the quality use of the medicine for each consumer. 37 37

38 Pharmaceutical Reforms 2009
Commonwealth – State Agreement Aims to improve the continuity of medication management Currently 30 of the 50 RAH pharmacists work fulltime in clinical areas In 2009 the Commonwealth and SA agreed and implemented Pharmaceutical Reforms. These were designed to improve the continuity of medication management for patients transitioning from community to hospital and then back again after discharge. Again pharmacists were seen as critical to these reforms and as a result the numbers of Clinical Pharmacists at all SA Publics Hospitals significantly increased to support this continuity of medication management for patients. At the RAH today 60% of our pharmacists are working full time in ward areas as clinical pharmacists. Certainly a significant and relatively rapid evolution of the pharmacists role from that of production and distribution only. 38

39 Pharmacy Teaching and Research
Formal link between UniSA and RAH Joint appointment Director of Pharmacy Services A/Professor of Pharmacy Practice Second in Australia in 1994 I will finish with a brief discussion of one further major change that occurred for the RAH Pharmacy Department in 1994. Driven largely by Prof Lloyd Sansom from the School of Pharmacy at the University of South Australia, a formal link for the fostering of pharmacy teaching and research was forged between the RAH and UniSA. In 1994, with the retirement of Mr Ian Lee as Director of Pharmacy Services, a Joint University-Hospital position was created. The combined Director of Pharmacy and Associate Professor of Pharmacy Practice role was only the second of its type at that time in Australia. Its success in fostering practice based teaching and research has now seen it replicated in most of Australia’s larger teaching hospitals. In many ways this formal University –Hospital link has rounded out the evolution of pharmacy at the RAH over more than 150 years. Pharmacy over this time has move from a place where dispensing and manufacture by pharmacists was undertaken from an apprenticeship training to a profession where a rigorous academic qualification is required to undertake and support the patient focussed clinical pharmacy activities in addition to the traditional dispensing and manufacturing roles. 39

40 Royal Adelaide Hospital 40

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