1. Hospital Pharmacy in Canada Report 2005/06 Report Summary Patricia Macgregor Ontario Management Seminar May 6, 2007

2. Hospital Pharmacy in Canada Report Sections Demographics Clinical Pharmacy Services Drug Information and Drug Use Evaluation Drug Distribution Drug Purchasing and Inventory Control Human Resources Medication Safety Technology Education and Research Ethics Benchmarking, staffing and drug costs - Acute Care - Pediatric Mental Health

3. 2005/06 HPCR Report Focus Medication safety, incident reporting, disclosure and medication reconciliation Clinical practice, priority and reality Distribution delivery systems, enhanced role of technicians Escalating drug costs Human resources – impacts of shortages, student training Technology uptake Ethics – special interest section

4. Demographics 142 hospitals responded Nationally – Inclusion criteria – 100 beds, 50 acute – Represents 60,000 beds (115,120 beds in Canada) 74% response rate overall, 90% for teaching hospitals 66% of respondents were multi-site facilities, 59% last survey, (only 39% in Ontario, 60% Quebec, other 90%)

5. New for 2006 Teaching hospital designation changed – Uses CHAHO definition – Note some data may not be comparable to previous surveys Mental Health recognized as distinct group – Specific report to follow

6. Service volume comparisons 2005-06 vs 2003-04 Acute care admissions 5.3% increase since previous survey Acute care patient days 3.4% increase Emergency dept visits 11% higher

7. General Points 92% of hospitals reported pharmacist as leader of dept – CSHP recommendation Facilities with program management, 82% report pharmacist salaries paid by pharmacy but only 79% indicated the pharmacists report to pharmacy 20% reported shared responsibility but only 13% shared the salary cost Several outpatient services receive NO clinical pharmacy services. Provincial differences ALL inpatient clinical services reported received clinical pharmacy services. Provincial differences in focus

8. General points Decrease in pharmacist verification of technician orders, 69% vs 87% in 2003/04 80% of hospitals report some patients do not receive pharmaceutical care, amounting to an average of 34% of all beds. (No change from previous survey) IV admixture service increased to 94% of respondents from 75% in 2003/04 – Areas serviced include OR, 49%, emerg 63%, outpatients 75%, critical care 83%, inpatients 95%

9. Proportion of Time Spent by Pharmacists in Each Category of Service 2005-06 Base: All respondents (142 Drug Distribution 43% Clinical 41% Other Non-patient Care 8% Teaching 6% Research 2% 2003-04 Base: All respondents (144) Drug Distribution 48% Clinical 38% Other Non-patient Care 8% Teaching 5% Research 1%

10. Clinical Data Captured by the Report Clinical pharmacy practice models – prevalence Specific clinical activity priority ranking and actual service level Specific programs -% hospitals with assigned clinical pharmacists by clinical program Seamless care activities, % hospitals providing specific activities Methods and types of practice evaluation Prescribing privileges by profession Pharmacist prescribing authority by activity ASHP/CSHP 2015 goals and baseline from current survey – How well do our priorities line up with evidence for outcomes

11. Outpatient Clinical Pharmacy services provided by more than 50% of respondents Outpatient Program Hematology-oncology 80% Renal dialysis, 63% Emergency 54% Hematology- anticoagulation 52% Regional Prevalence -Ontario, Quebec -Ontario -Ontario) -All provinces similar

12. Different Provinces – different priorities - Clinical Pharmacy Outpatient Pharmacy Clinical Service NOT Provided or significant variation from provincial pattern Transplant – Quebec, (0/17) Mental Health – Atlantic, (0/11) Emergency –Atlantic only 8%, (1/13) Geriatrics – British Columbia only 8 %, (1/13) Palliative Care – Ontario only 12%, (3/26) Rehabilitation – BC, Quebec, Atlantic Diabetes – BC only 13%, (2/16)

13. Inpatient Clinical Pharmacy Services Provided by More than 50% of respondents Inpatient Program Geriatric/LTC 83% Adult critical care 79% Hem-oncology 78% Medicine 78% Pain/Palliative 70% Cardio/lipid 68% Mental Health 63% Surgery 63% Peds/neonates 56% Renal/dialysis 51% Rehab 50% Regional Prevalence Similar across Provinces BC, Prairies, Ontario Ontario, Quebec Prairies 100% All similar, Quebec bit lower Prairies, Ontario Prairies, Ontario, Atlantic BC, Prairies, Ontario Prairies, Ontario Ontario

14. Clinical Pharmacy Services- Priority vs Level of Service

15. Seamless Care Increase in number of respondents with seamless care policy – now 37%, (from 28%), in all Provinces except BC (20%) Ave 24% of patients receive seamless care Seamless care information provided: Medications at discharge, 96% Medications during stay, 72% Drug monitoring parameters, lab values, 60% Care plan, 55% Diagnosis, 34%, (down from 46% in 2003/04)

16. Prescribing Rights for Pharmacists Notable increase in types of prescribing rights for pharmacists 2005/06 2003/04 Independent Lab tests 41% 32% Dependent, dosage 79% 70% adjustment Dependent, new therapy 42% 19% Independent dosage 30% 35% adjustment Independent dosage adjustment by pharmacists much more prevalent in Quebec, 57% vs 13-33% for other Provinces (Ontario 22%)

17. Current status compared to ASHP 2015

18. Drug Evaluation and Drug Information Dedicated staff for DI/DUE – 37% vs 52% in 2003/04 DUE – increased pharmacist and support resources – 1.1 FTE pharmacist, up from 0.8 FTE 2004 – 0.7 FTE support staff, up from 0.5 FTE 2004 Drug Information – no change in pharmacist resources, increase in support - 1.4 FTE pharmacists, similar to 2004 - 0.7 FTE support staff, up fro 0.4FTE in 2004

19. Beds Serviced by Distribution Systems 2004 2006

20. Automated Dispensing Systems Centralized automated dispensing, 66% of unit dose respondents – 83% canister type – 17% robotic Unit based automation 32% – Emergency dept 80% – Critical Care 54% – Operating rooms 43% – Inpatient 39% – Recovery room 35%

22. Technician Activities Checked by other Technicians Blue 2005/06, Pink 2003/04

23. Certification Required for Technician Function Blue 2005/06, Green 2003/04

24. Chemotherapy Preparation Systems 2005-06

25. Drug Purchasing and Inventory Control Spending on drugs in Canada increased by 11% in 2005, (CIHI annual drug expenditures report) Equals 17.5% total healthcare spending 2005 Drug expenditure growth increasing – 10.9% in 2004, 9.1% in 2003 – New drug therapies, consumer marketing, changes in practice, demographics – Future impacts include pandemics, biotechnology, pharmacogenomics Ave inventory turnover is 10.9%

26. How will the Report Help me to Evaluate my Drug Management? By hospital type and size Total drug cost by care area Drug cost per patient day Drug costs by admission Outpatient drug costs per visit Inventory turnover % drug costs by care area % changes in costs by care area – 2005/06 compared with 2004/05

27. Percentage of Drug Expenses by Patient Care Area

28. Drug Expenditure changes 2005/06 vs 2003/04 Ave annual drug costs up by $1.27 million, 15.9% increase Acute care inpatient drug costs per patient day increased 17.3%, Cost per acute care admission increased 16.2% Average drug cost per non-acute admission increased 20.6% – likely due to length of stay as drug cost per patient day was similar – 100-200 bed hospitals cost per admission increased 98% Ave CDU costs/visit decreased 46%, $30.89 compared with $53.83 in 2003/04 Ave emerg visit continues to increase, $8.33 from $8.01 in 2003/04

29. Human Resources Survey questions changed since previous survey – Use budget hours /patient days instead of paid hours/patient day – Allows comparison of organizational commitment to resources and is unaffected by staff shortages, absences Staff shortages continue Number of eligible retirees is similar to number of current vacancies

30. Staffing Composition of Ave Hospital Pharmacy Department 2005-06

31. Human Resources Average budgeted hours per patient day 0.81 2005/06 – Ontario highest at 0.96, British Columbia lowest at 0.65 – Increases of 14% were reported for Ontario and Quebec – 2003/04 paid hours per acute patient day ave 0.74 Staffing Ratios, unchanged from previous survey Salaries – Ave increase 2.1% annual, compared with 5.6% annual reported in 2003/04 survey – Staff pharmacist top level increase ave 2.8% annual, downward trend from the 6.7% annual in 2003/04 – Technician top level increase 3.8% annual compared with 2.6% in 2003/04

33. Human Resource Shortages 73% of respondents reported vacancies compared with 63% in 2003/04 although total pharmacist vacancies were reduced, (270 vs 331 in 2003/04 ) Position 2003/04 2005/06 Ontario – Pharmacist vacancies 12.9% 13.3% 11% – Management 6.9% 7% 8% – Technicians 0.9% 2 1.3% – Residency vacancies 13.8% 6.25 0 *Residency vacancies concentrated in Alberta and Quebec Staggering 11.8% of ALL pharmacists, 16.2% of management and 8.4% of technicians expected to retire in next 5 years (Ontario 11.1%, 12.5% and 8.4% respectively)

34. Medication Incident Reporting and Reduction - How have we changed in 2 years? Not all respondents using a med incident reporting tool (95% vs 100% 2003/04) A higher percentage have implemented strategies to increase reporting (77% vs 67%. See report for strategies) Significant increase in: – presence of disclosure policy, (80% vs 63% in 2003/04) – Completion of self assessment tool, (71% vs 51% in 2003/04. Ontario 87%)

35. CCHSE- Required Operational Practices (ROPs) Focused on improving safety of patient care Medication related ROPs for: Removal of conc electrolytes Standardization Order entry, verification Medication reconciliation Informing and educating patients/family

36. Compliance to Medication Related ROPs 2005/06 2003/04 Verbal and telephone orders limited 42% 38% Med orders conditional until pharmacist review 44% 52% List of non-acceptable abbreviations 58% 40% High alert med list identified 61% 38% 2 patient identifiers for high risk drugs 40% 31% Allergy status prior to dispensing 68% 72%

37. Management of Concentrated High Risk Drugs on Patient Care Units Removal of High conc. 2005/06 2003/04 Narcotics 65% 47% KCl 85% 72% Standardize/limit conc. available Heparin 75% 81% Insulin 48% 47% Morphine 57% 47% Hydromorphone 53% 41 %

38. Medication History and Reconciliation Emergency dept. med history 45% Admission med history 42% Transfer med reconciliation 35% Counseling pamphlet provided 65 %

39. Technology – Clinical Decision Function Availability and Use Strong uptake of function Allergy alerts Drug interaction alerts Input patient specific variables to assess drug therapy Slow but visible growth Wireless networks Bar coding Low uptake of function Computer generated max dose alerts, especially non-teaching hospitals Dose modification alert for renal dysfunction Dose modification alert for hepatic dysfunction Evidence based guidelines (low availability and uptake)

40. Functions Using Handheld Devices

41. Uses of Bar Coding

42. Education and Research Education Student training remained a high priority, especially for Masters and Pharm D levels where the largest increase in training days was observed Significant proportion of hospitals receiving stipends for undergraduate pharmacist and Pharm D training Increase in university funded positions for student training, (11 vs six in 2003/04) Research Similar response to 2003/04 Original research – reduction in ave number of papers

43. Ethics – Special Interest Section Addresses organizational policies, ethical decision making processes Most hospitals have access to on or off site research ethics board, of which most have pharmacist members Most have a biothetics/ethics advisory group or access to one, only 32% have pharmacist Addresses patient care, education, research and business ethics

44. Conflict of Interest 68% hospitals have a conflict of interest policy 45% report P& T conflict of interest policy 51% requirement for declaration of vendor involvement – Report lists comprehensive list of issues e,g gifts, honoraria, outside employment, data selling Risk Areas Educational sponsorship Formulary decisions Research Clinical decision-making

45. Questions www.lillyhospitalsurvey.ca