Pedro Nuno Braga Ribeiro i
University Hospital Galway
Pedro Nuno Braga Ribeiro
Pedro Nuno Braga Ribeiro i
Faculdade de Farmácia da Universidade do Porto
Mestrado Integrado em Ciências Farmacêuticas
Relatório de Estágio Profissionalizante
University Hospital Galway
Maio a Agosto de 2019
Pedro Nuno Braga Ribeiro
Orientador: Dr. Peter Kidd
Pedro Nuno Braga Ribeiro ii
Declaração de Integridade
Declaro que o presente relatório é de minha autoria e não foi utilizado previamente noutro curso ou unidade curricular, desta ou de outra instituição. As referências a outros autores (afirmações, ideias, pensamentos) respeitam escrupulosamente as regras da atribuição, e encontram-se devidamente indicadas no texto e nas referências bibliográficas, de acordo com as normas de referenciação. Tenho consciência de que a prática de plágio e auto-plágio constitui um ilícito académico.
Faculdade de Farmácia da Universidade do Porto, 13 de Agosto de 2019
Pedro Nuno Braga Ribeiro iii
Acknowledgements
I would like to thank all the pharmacy staff of the University Hospital Galway. They were always there for me and they always took the time to answer my questions and my doubts. If it was an amazing experience, it was mainly because of them. Not only because of what I learned, but also for including me in all the activities and not leaving me aside. It was one of the friendliest groups of people that I ever came across and I really felt that I was part of the team.
I would also like to thank my brilliant colleagues from Portugal that made this journey with me and made me feel like I was at home.
To the Faculty of Pharmacy of the University of Porto and all the staff for teaching me what I know and for providing me with the opportunity to have this experience.
Last but not least, a special thanks to Mr. Peter Kidd that made this all happen. No matter how busy he was, he always found the time to find new things for me to learn and really made this experience worthwhile.
I wish that all the following graduates can have an experience like this one, it would make them a better pharmacist, but most importantly, a better and more mature person.
Pedro Nuno Braga Ribeiro iv I’ve always wanted to have different experiences abroad, not only to face new
challenges, but also to see and live in different realities. Being my second experience away from Portugal, I was already familiarized with this feeling, but during this internship in Galway, I got to see a completely different role that a hospital pharmacist can have.
I can only be grateful for having this opportunity to experience doing clinical
pharmacy, it really showed me how rewarding it can be to take care of others and to provide valuable information and opinions for the well being of the surrounding community.
During these 12 weeks, I visited several wards of the hospital, risk scored patients, analysed laboratory results, did some patients medication histories and checked prescribed medication. Most importantly, I learned a lot about drugs, their interactions and I had the opportunity to test and increase my knowledge.
Overall, I feel that I am now a better pharmacist, and I have a broader vision about the role and the impact that a pharmacist can have in a patients’ life.
Pedro Nuno Braga Ribeiro v
University Hospital Galway ... 2
The Pharmacy... 2
Clinical pharmacy and ward management ... 3
The Process ... 3 Tools ... 4 H scoring ... 4 Pharmabot®... 5 Wards ... 5 Emergency ... 5 Coronary Emergency ... 6
Renal and Endocrinal ... 6
Neurology and Stroke... 7
Respiratory ... 8
Infectious Diseases ... 8
Intensive Care Units ... 8
Medical Admission Wards ... 9
Oncology and Haematology ... 9
Production and Aseptic Unit (PASU) ... 11
Microbiology Rounds ... 11
Medication Recycling... 12
Meetings ... 13
‘Clerking’ Project ... Error! Bookmark not defined. Safety-Cross Project ... 13
Value Stream Mapping Project ... 14
Conclusion ... 15
References ... 15
Appendix... 17
Appendix 1 – Schedule ... 17
Appendix 2 – Ward Handover Sheet ... 18
Appendix 3 – Medication History Questions ... 18
Appendix 4 – H scoring (drug chart + tabela dos medicamentos) ... 19
Appendix 5 – Emetogenic Potential ... 21
Appendix 6 – Antibiotics Traffic Light table ... 21
Appendix 7 – Clerking Chart ... 22
Appendix 8 – Clerking Results ... 22
Appendix 9 – Value Stream Mapping Table... 23
Pedro Nuno Braga Ribeiro vi A&E – Accidents and Emergency
ACE inhibitors – Angiotensin-converting Enzyme Inhibitors ALL – Acute Lymphocytic Leukemia
AMU – Acute Medical Unit CCU – Coronary Care Unit CKD – Chronic Kidney Disease
COPD – Chronic Obstructive Pulmonary Disease CPE – Carbapenemase Producing Enterobacteriaceae DAPT – Dual Anti-platelet Therapy
eGFR – Estimated Glomerular Filtration Rate ESA – Erythropoietin Stimulating Agent ESU – Emergency Surgical Unit
HDU – High Dependency Unit ICU – Intensive Care Unit
INR – International Normalized Ratio LDL – Low Density Lipoprotein
MRSA - Methicillin-resistant Staphylococcus aureus MTX – Methotrexate
NCCP – National Cancer Control Programme NSAID – Nonsteroidal Anti-inflammatory Drug NUIG – National University of Ireland Galway PASU – Production and Aseptic Unit
SSW – Short Stay Ward
Pedro Nuno Braga Ribeiro 1
CHAPTER I
Introduction
I’ve always had the idea of doing an internship outside of Portugal, to get out of my comfort zone and to get a sense of a different reality. Once I had the opportunity to go to University Hospital Galway, I took it, and it has proven to be one of the best and most rewarding experiences of my life.
Thankfully, what I got to see, and be a part of, was a substantially different reality regarding hospital pharmacy when compared to Portugal. In Ireland, as well as in the UK, the role of the hospital pharmacist is different from the current role developed by the hospital pharmacist in Portugal; this big difference consists in the clinical pharmacy role. Clinical pharmacy, as the name states, is the act of providing patient care that optimizes medication therapy and promotes health, wellness, and disease prevention by the pharmacist [1].
This includes medicine reconciliation, checking medication histories, confirming doses as well as checking for drug interactions, amongst others. Having this kind of impact in the life of a patient made me realize how much a pharmacist can do for the well-being of the community and it also showed me how far behind we are in Portugal, regarding clinical hospital pharmacy. A pharmacist, being an expert in mechanisms and effects of medication, can and should always have an important role during a patient’s stay in the hospital. It should always be a coordinated and well balanced work between doctors, pharmacists and nurses, so that the patient can be provided with the best healthcare service possible.
In fact, the pharmacist can have an important role to play when it comes to correcting and identifying possible omissions, dosage errors or frequency issues of pre-admission medication [2]. Besides that, the continuous follow up of patients’ medications as well as laboratory analysis results is also important, since it can help to detect drug-drug interactions of newly prescribed drugs or even not advised drugs regarding the patient health conditions (ex.: kidney function, liver function) [3].
With that said, the clinical pharmacist activity is not only valuable for the patients’ stay in the hospital, but also for the discharge prescription. If medication errors occur and pass by undetected, a patient might leave the hospital with a non appropriate prescription, thus having a possible negative impact in the patients’ health [4, 5].
During my internship I had the opportunity to do the clinical pharmacy activity, but I also had the chance of being in the dispensary sending medication to wards, recycling medicines, and I got the chance of attending many meetings relatable with various and diverse aspects of the good functioning of hospital services (new prescribing program for chemotherapy patients; improving medical services sessions) thanks to Dr. Peter Kidd.
Pedro Nuno Braga Ribeiro 2 Despite doing all those different activities, I feel that the clinical pharmacy one was the most important because it made me realise of how much of an impact a pharmacist can have in a patients’ life.
University Hospital Galway
University Hospital Galway started as an infirmary, on 2nd March, 1842 [6]. In 1924,
after having major refurbishing and new buildings, Galway Central Hospital (as it was known then) was completed [7].
Nowadays, UHG plays a leadership role in acute service delivery, providing regional services for a wide range of specialities and is also a designated supra regional centre for cancer and cardiac services serving a catchment area in the region of one million people [8].
Being a model 4 hospital, UHG has 24/7 EDs, acute surgery, acute medicine and critical care plus specialist, supra-regional care [9].
UHG is one of two hospitals comprising Galway University Hospitals (together with Merlin Park), and it is affiliated with the National University of Ireland Galway (NUIG), having more than 700 beds.
The Pharmacy
University Hospital Galway pharmacy has the responsibility of providing and managing medications to be sent to the different wards. It is open from Monday to Friday, from 8:30 to 17:00. It has 2 different areas, the dispensary and the pharmacy office, having pharmacists, pharmacy technicians, auxiliary technicians and porters). The dispensary has a controlled drugs area, plus a designated area for correct separation of medication for different wards. There is also a small section of the dispensary destined to medication recycling.
The pharmacy has 3 offices and a break room area. The pharmacist, besides doing some turns in the dispensary, also does clinical pharmacy, managing and accessing patients on the designated wards (defined early in the morning). There is also a small section of the dispensary destined to medication recycling.
When dispensing medication, the pharmacy has ward sheets where the current stock is kept up to date, so that all the ward requests can be correctly accessed, in order to avoid excessive stocks. Usually the ward re-stocking happens once a week, according to the usual stock spending of the different wards. The medication is usually transported by the porters.
The pharmacy doesn’t have any activity related to outpatients service.
Pedro Nuno Braga Ribeiro 3
Clinical pharmacy and ward management
The Process
The pharmacists’ day usually starts at 8:30am, with a little briefing in order to know which ward they were assigned to. The rounds around the wards usually start around 9am, with the first task being the analysis of the ward board, which contains all the patients and they’re distribution within the beds. In order to keep a record and to keep all the work organized, the pharmacist has a paper sheet (see appendix 2) where the names of all patients are written for each day of the week. This makes easier to know who is new to the ward and possibly who hasn’t been seen yet. On that same paper sheet, the pharmacist can H score the patients.
The ward sheet is not only important to know which patients are new to the ward, but also to help the other pharmacist that can possibly be on that ward later on. Thus, it makes a continuous flow of information within the pharmaceutical services of the hospital.
Every patient should be interviewed. There is a series of systematic questions that should be asked, in order to guarantee that no detail regarding the patient is forgotten. Past prescribed medicines, over-the-counter products, injections, transdermal patches, hormonal therapy or herbal medicines should always be checked (see appendix 3). All those questions are stated on the drug chart, to help the reproducibility of the process of the interview, and also to minimize flaws. Things like allergies or past adverse reactions to medication can have a really big impact if forgotten; past medication that is not stated or referred on the past patient’s notes can also play a big role regarding possible interactions with newly prescribed medication. The interview should be value time where pharmacists can intervene and counsel patients, accessing medication compliance, restating why a patient should be compliant and explaining why they are taking a certain medication, thus empowering the patient regarding medication knowledge, improving medication safety, by reducing medication errors, and increasing therapeutic efficacy [10].
After the interview, the pharmacist should confirm the medication history of the patient. It is very common to find mistakes on drug charts, regarding pre admission medication, whether it is dosing, frequency, or the medication itself. Omission errors are frequent as well. There are plenty of resources that can help doing this step of the process, being the patient the most valuable source of information (attach part of the drug chart); when the patient doesn’t seem capable of giving a correct and flawless medication record, the pharmacist can go through all the patient’s notes, general practitioners’’ letters, ask to the career or even call the local pharmacy from where the patient gets his prescribed medication.
If the medication history is not correctly done, it can imply lots of problems not only during the stay of the patient in the hospital, but also on the discharge prescription. If an omission error is not identified and corrected, a patient might not have a much needed medication on the discharge prescription, possibly having a big impact on his health; or, if a
Pedro Nuno Braga Ribeiro 4 medication that has been stopped a few months ago is charted because the medication history was not correctly done, a patient might be taking medication that is not effective or/and not needed.
Having done the medication history, the next important step is to go through the medication chart in order to confirm frequency and medication dosing. Drug-drug interactions can also be present and are very common. It is possible to write on the chart in order to get the medical team to review the medication, or alert them to switch to another different alternative drug, or even to review dosing or frequency. The laboratory parameters are also checked to see if the dosing is compliant with the kidney function, health function and full blood count of the patient.
Tools
There are plenty of tools available to the pharmacist, such as Medinfo® (provides valuable information regarding maximum dosing and dose adjustments for patients with renal impairment or hepatic failure), UpToDate® (drug-drug interactions checker), GAPP app® (antimicrobials dosing, such as gentamicin, according to a patients’ height, weight and kidney function), among others.
H scoring
After drug charts are accessed and all the medication is verified, the pharmacists H score the patient.
The H scoring of a patient is a systematic approach to a ward, based on medication and co morbidities, implemented to organize and to prioritise the time that a pharmacist has. Patients can a have a H score of 1, 2, 3, or 5, with the score meaning how many times per week a patient should be seen (ex.: if a patient is risk scored as a H3, it should be seen at least 3 times per week). Patients with a H score of 3 are usually seen on Mondays, Wednesdays and Fridays, while the H2 scored patients are usually seen on Tuesdays and Thursdays. A patient is only considered as an H5 when he’s on unfractionated heparin, being necessary to review that patient every day (attach heparin chart).
There are many different factors that can contribute to H scoring a patient, such as highly interactive drugs, co-morbidities and laboratory results (see appendix 4).
Despite having many criteria, the H scoring of a patient is subjective to each pharmacist, and it is present not only on the ward sheet but also on the drug chart. Thus, it avoids work overload on wards and helps time management, adding up on the quality of the service provided because the pharmacist has more time to be with high priority patients.
Pedro Nuno Braga Ribeiro 5 After concluding this process, a pharmacist should continuously check the patient (depending on the H score) in order to access newly prescribed medication and to keep up with the most recent laboratory results.
Pharmabot®
The pharmacists in UHG have a tool that allows them to report and save errors found in patients’ drug charts, called Pharmabot®. It works on every pharmacist’s smartphone, and the process consists in taking a picture of the error and then adding a description, stating which department was responsible, which ward was the patient on and also what kind of medication error it was (frequency, dose, interaction…).
This tool allows having a bigger perspective about the total number of errors and doing a report on those numbers. It can also be a very useful learning tool, since it is possible to read and see all the medication errors found, hence providing great information about the most common and serious medication errors.
Wards
During my stay in UHG, I’ve worked in the following areas:
Emergency – Accidents and Emergency (A&E), Emergency Surgical Unit (ESU)
Coronary Emergency - Coronary Care Unit (CCU)
Renal and Endocrinal – St. Teresa’s
Neurology and Stroke – St. Anne’s
Respiratory – St. Anthony’s
Infectious Diseases – Shannon
Intensive Care Units – High Dependency Unit (HDU) and Intensive Care Unit (ICU)
Medical Admission Wards - St. Enda’s, Acute Medical Unit (AMU), Short Stay Ward (SSW)
Oncology and Haematology – Corrib, Claddagh
Emergency
My very first experience as a clinical pharmacist was in the (A&E) department. It is a really busy ward, where the pharmacist has to cover a lot of patients. One never knows what to expect in this sort of ward, medication varies greatly. It was the first time I noticed how important is the hospital pharmacist in this kind of environment, being one of the first contacts that a patient has inside the hospital, it gives a chance of doing correct drug verification.
Related to the emergency area, I also worked in the ESU. This ward, despite being an emergency department, is much calmer than A&E. Still, I got to work on this ward for a long
Pedro Nuno Braga Ribeiro 6 time, which provided me knowledge about diversified medication, as well as different diseases and conditions.
Everyday there were about 10 to 12 new patients. There was a handover sheet of the ward, which states the patient’s history and admission reason, making work much faster because it allowed me to prioritize patients even before I had access to their drug charts. Being an Emergency Surgical Ward, most of the patients were due to surgery (majority were for appendectomy), so I got the chance to get to know more about prophylactic antibiotics and their dosing, as well as prophylactic blood thinners.
It was the first ward where I had the chance of working alone on a ward.
Coronary Emergency
The Coronary Care Unit is a ward destined for patients who need continuous heart monitoring and treatment. Myocardial infarctions, deep vein thrombosis, severe heart failure and angina are the most common conditions, so the medication does not vary much. Antiplatelets (to prevent clots), anticoagulants (blood thinners), ACE inhibitors (lower blood pressure and heart stress), β-blockers (lower blood pressure) and statins (lower LDL) were very common amongst this population.
I got to learn a lot about the risk assessment related to DAPT – dual antiplatelet therapy – since the risk of having a clot in many of these patients would overcome the risk of bleeding. DAPT has to be close monitored and the duration of the therapy is still a matter of discussion, because on one hand a patient benefits with the prevention of a possible myocardial infarction or a stent thrombosis; on the other hand, the risk of a major haemorrhage is greatly increased. So it is a very sensible trade-off that largely varies from patient to patient [11].
Renal and Endocrinal
St. Teresa’s ward is specialized in renal and/or endocrinal malfunctions. With that said, checking laboratory parameters, such as eGFR, creatinine, urea and potassium levels is a must. There is also a need of knowing specific pharmacokinetics, since drugs metabolized and eliminated by the kidneys may cause further damage. A lot of these patients were in dialysis, either peritoneal dialysis or haemodialysis, so it was quite common to find really low eGFR results.
Dialysis patients often are on trigger medications [12], such as Erythropoietin Stimulating Agents (ESA), since Chronic Kidney Disease (CKD) patients can develop anaemia for their lack of production of erythropoietin [13]; 1-alpha vitamin D, since the process of metabolizing vitamin D into the active form is done by the kidneys, thus keeping calcium bone incorporation balance, preventing osteomalacia and osteoporosis [14]; Iron supplementation,
Pedro Nuno Braga Ribeiro 7 to improve red blood cell production (alongside with ESA). Besides these trigger medications, other medications such as blood thinners, blood pressure tablets, diuretics and phosphate binders are very common. Due to kidney impairment, phosphates are not largely excreted, thus increasing phosphate blood levels; to correct this deficit in excretion, phosphate binders are usually given, to decrease intestinal absorption [15].
Working in such a specialized area made me realize that there are many details that a pharmacist must attend when reviewing a patient with kidney impairment, and I got to learn a lot about the management of chronic and acute kidney diseases.
Neurology and Stroke
St. Anne’s ward mostly deals with stroke patients. It provided me with the knowledge about the different types of strokes as well as the medication usually prescribed either to patients who are highly prone to have a stroke or to patients who had one or more strokes. Medication in this ward in mainly used to prevent patients from having a second stroke, since the chances of having a second stroke after the first one are very high [16].The most common ones are anticoagulants, such as warfarin, antiplatelet drugs, such as clopidogrel, and cholesterol lowering medicines, such as atorvastatin. Blood pressure tablets like ACE inhibitors, β-blockers and calcium channel blockers were also very common alongside with diuretics, with the most common one being furosemide.
Having a large amount of patients on warfarin, gave me the chance to learn how important the monitoring of this drug is. International Normalised Ratios (INR) should be continuously checked as well as vitamin K levels. It is a highly interactive drug [17] so all the possible interactions must be addressed and reviewed, but more importantly the patients’ medication history must be correctly done.
Last but not least, if the patient is supposed to continue with warfarin treatment at home after staying in the hospital, there is a need to council about the possible side effects and risk of bleeding related to the drug, importance of stating that he’s on a warfarin regimen, as well as some important information to make sure that the drug is effective (the vitamin K level of the patient’s diet must be monitored, so that warfarin can be effective [18]. This drug is so relevant that the patients’ drug charts even have a dedicated page to the warfarin regimen, in order to draw attention to it, and to make sure that it doesn’t go unnoticed (see appendix 5). Besides that, there is also some really useful information in the drug chart concerning anticoagulants and their use and posology, depending on different conditions and laboratory results (see appendix 6)
Overall, I got to learn a lot about stroke prophylaxis medication and anticoagulants in general, which proved to be useful when I was on other wards (many patients are in anticoagulant prophylaxis while staying in the hospital).
Pedro Nuno Braga Ribeiro 8
Respiratory
Being St. Anthony’s ward a respiratory focused ward, many of the patients have chronic obstructive pulmonary disease (COPD), pneumonia, asthma, or any other condition related to the respiratory tract. The pharmacists’ role here is not only to review the patients’ medication and past history, but also to do some counselling about how to use medical dispositives, such as nebulizers and inhalers, if the patient is not familiar with it, as well as some very useful tips such as to rinse the mouth with water if the inhaler contains steroids, thus avoiding a possible fungal infection.
Steroids are very common in this ward; in fact, it is of major importance to alert about the side effects related to them and also to make sure that (in case of being a long term medication) the patient is getting calcium supplements and vitamin D to avoid osteoporosis.
It was a useful experience not only because of how much I learnt about respiratory conditions, but also because of the patients’ counselling.
Infectious Diseases
While I was on Shannon ward, I had the opportunity to see a lot of different antibiotics and learn about their dose and frequency. Being an infectious diseases ward, the ward only has individual rooms, being two of them negative pressure rooms (usually used for tuberculosis patients).
There, I could learn about the specific regimens for resistant bacteria (CPE+, MRSA), and the adjustments made when patients are allergic to a certain antibiotic (Ex.: allergy to tazobactam). I could also learn about reserve antibiotics, which proved to be useful later on when doing the Microbiology Rounds.
The lab culture results are essential to know if the patient is getting the right treatment; contact with microbiology and infectious diseases teams is of major importance to be sure that the patient has been reviewed recently and is getting the proper antibiotic to fight the infection.
Intensive Care Units
I didn’t get to spend as much time in the Intensive Care Units as I did in all the other wards; still, it is an area very different from all the others, not only because there are fewer patients, but also because the prescription is electronic.
These are the only wards with electronic prescription, which really eases the process of reviewing and prescribing medication. In these wards (HDU and ICU), the nurses are assigned to fewer patients, in order to make sure that every need is attended, since the patients are considered high risk.
Pedro Nuno Braga Ribeiro 9 The electronic prescription really makes it easier to see the complete drug regimen of each patient, hence possibly reducing the amount of errors related to wrongly prescribed medication (duplicates, interactions). It also makes everything clearer; it diminishes the probability of occurring wrong administrations (either dose or frequency) by the nurses [19].
Still, there are some flaws; I didn’t spend much time there and I could see one of the senior pharmacists correcting some of the drug regimens. Errors related to drug duplication or frequency were quite common, which was later explained to being related to doctors ‘not knowing how to work with the e-prescription system’.
There is definitely room to grow in this area, and some of the Meetings that I could attend were about implementing this system in other areas of the hospital.
Medical Admission Wards
I spent quite a few time in these Medical Admission wards. The variety of people and different conditions that I got to be in touch with was huge.
Enda’s mainly receives patients that were admitted in the A&E; it is normal for a patient to stay there while there are no beds available in more specialized wards, so I could get a sense of a lot of different medication. In this ward, the crucial work is doing or verifying the patients’ medical history, to see if everything is correct regarding pre-admission medication. It was the first time that I directly spoke with patients and felt comfortable doing it. I learnt that I could spend a lot of time going through the patients’ notes and their general practitioner letters and, in most of the cases, the patient would still be a better source of information. I learned how to create empathy with these patients and how to address their problems correctly; it was probably the most overwhelming feeling of this whole experience in Ireland.
The AMU and the SSW work together as a whole. The admission phase is done at the AMU and then, the patients who need to stay in the hospital for more than one day generally go to SSW till there are beds available in the long, specialized, staying wards.
The main thing about these two units was the addition of a pharmacist in the process of doing patients’ medication histories (see Error! Reference source not found. project).
Oncology and Haematology
Corrib ward is responsible for managing the treatment of more severe cases of cancer patients. There are a few patients that are waiting on chemotherapy or immunotherapy, pending on their condition, having been admitted to the ward in order to resolve an infection or any other condition (i.e. platelet count), before starting treatment.
. The pharmacist responsible for this ward usually starts by reviewing all the chemotherapy schemes due for that particular day; they should be revised and confirmed until around 11:30am, in order to be sent to PASU, where the chemotherapy is prepared; after that,
Pedro Nuno Braga Ribeiro 10 and since many of these patients are on regular medicines, the pharmacist does a round on the ward just like in all the other wards.
Most of these patients often have medicines for reducing side effects related to cancer treatment. On patients doing chemotherapy, a specific anti-emetic regimen is adopted depending on the emetogenic potential of each regimen (see appendix 7). Antibacterials and antifungals are also very common, as well as antivirals (for prophylaxis of post-chemotherapy infections due to immunosuppression) [20].
Being this ward related to cancer, there are a lot of small details that should be taken into account, particularly when a patient is due to start a new cycle or if he/she just started one.
I could learn a lot about specific precautions related to some regimens including the methotrexate (MTX) regimen. Being able to surpass the blood-brain barrier, MTX can be extremely toxic due to its low excretion rates; to help with that, folinic acid must be administered the day after MTX administration, to decrease toxic effects such as myelosuppression; being eliminated by the kidneys, with that reflecting a potential increase in potassium elimination, so potassium hydrochloride is often given to these patients. It is also a highly interactive drug, so possible interactions must be checked (proton pump inhibitors, NSAIDs…). Other than that, and being considered as a “moderate emetogenic” by the NCCP (National Cancer Control Programme), it’s often administered with Palonosetron and Dexamethasone.
Another important thing that I could learn is that cancer patients shouldn’t take paracetamol, especially if they take it regularly, because it can mask a neutropenic sepsis (neutrophil counts can really decrease due to immunosuppression related to these treatments), since getting a high temperature is one of the most obvious signs.
I feel that this ward was one of the wards where I got to be in touch with medication that was not very familiar to me, allowing me to learn a lot about a very important area regarding UHG.
After being at Corrib, I got the opportunity to spend some time in the Claddagh ward. The pharmacist routines are pretty much the same as in Corrib, despite the chemotherapy regimens being different.
The full blood counts are of major importance as well, and most of the patients that I’ve seen were admitted to the ward because of ALL (Acute Lymphocytic Leukemia) so I got to learn a bit about the most specific regimens used to treat this disease, either new patients or relapsing patients. The emetogenic potential is evaluated just as it is on Corrib ward.
I also got the chance to do the verification of the treatments, so I got very familiar with which drugs were of a fixed dose and which ones were body surface dependent. The method for calculating body surface area was the Du Bois method.
Pedro Nuno Braga Ribeiro 11 Overall, I think that doing these two wards really contributed a lot to my knowledge because I had to do some research work in order to be able to keep up with the clinical pharmacist rounds.
Production and Aseptic Unit (PASU)
After being in the two major wards of the Hospital concerning inpatients’ cancer service and seeing the validation of chemotherapy by the clinical pharmacist in the ward, I got to spend a day working and learning in PASU. There, every chemotherapy regimen is subject of dual verification (by two pharmacists) and then is taken to the preparation rooms. The Production and Aseptic Unit is located above the outpatients ward of the Hospital (where most of the preparations go to) and it is responsible for the preparation and dispensation of all chemotherapy and immunotherapy medicines for the inpatients as well as for the outpatients service.
In order to keep up with all the preparations for the day, PASU staff often prepares the less expensive medication scheduled for the day, before the final confirmation by the doctor. Doses might be changed or treatments can be postponed (due to weight loss, full blood counts, infectious diseases …), but it is the only way of making it possible to prepare every treatment for the day. For more expensive medications, the preparation keeps on hold till the final confirmation by the doctor, and then is prepared straight away. After the preparation, the pharmacists double check every thing again, to make sure that the medication is ready to go.
Having seen the first part of the process when I was with the clinical pharmacist in the wards, I found very useful the time that I spent in PASU not only because I could learn about the latter part regarding the preparation of chemotherapy and immunosuppression medication, but also because I got a sense of how important it is to have such a complex checkpoint system, being cancer medication a high risk medication. I also found very interesting the amount of detail regarding the disinfection process of everything that goes into the clean rooms.
Microbiology Rounds
As in many other countries, Ireland has a contingency program regarding antibiotic prescription. Antimicrobial resistance has been growing due to the incorrect usage of antimicrobials, leading to less effective treatments. Usually, narrow-spectrum antibiotics are preferred over broad-spectrum, due to the fact of targeting more effectively and accurately the infection, thus developing less resistance to the antibiotic, as well as possible side effects [21].
Pedro Nuno Braga Ribeiro 12 To try to regulate the use of antibiotics within the Hospital, a pharmacist frequently does ‘microbiology rounds’, where new patients in antibiotic therapy are seen and evaluated in collaboration with the infectious diseases team. This activity tries to promote the correct and rational use of antibiotics, leading to an increase in therapy efficacy as well as a possible decrease regarding resistance development. In order to help the pharmacist, there is a ‘red light’ antibiotics table (see appendix 8), which helps to evaluate if the antibiotic is of restricted use or if it can be used without approval by the microbiology or infectious diseases department.
Nowadays, the major concern in Ireland is about Carbapenemase Producing Enterobacteriaceae (CPE), so there is a strict plan to deal with patients infected with it, in order to keep contagious risk to a minimum [22].
I found this activity very important because the bugs’ resistance development, the so called superbugs, is a growing problem that can potentially affect millions of people worldwide, and by doing this we are trying to delay as much as possible this process, thus having a big impact in the health management of generations to come [23].
Medication Recycling
One of the most important areas that I came across during my internship was the medication recycling area in the dispensary. This area is really important for the finance health of the hospital, since it allows the hospital a lot of savings regarding medicines. The non-stock medication of the wards is usually returned to the pharmacy in designated bins, and is then separated and written into the system again. The system then shows how much money you’re saving with each recycled drug, and it compiles a final report when you log out of your pharmaceutic profile.
This allows reduced medication waste and it also reduces the overall money spending of the hospital pharmacy.
The biggest impact I had related to this activity was when I saw the final report of one of my multiple runs in this service, and I saw savings of over 2000 euros in just a couple of minutes.
This process should be continuously improved, not only because of financial impact, but also due to environmental impact [24].
Pedro Nuno Braga Ribeiro 13
Chapter II
Meetings
While I was in the University Hospital Galway, I also had the opportunity to attend many meetings, all related to improvement of health services within the Hospital. Some of them were related to implementing a electronic and simplified way for prescribing chemiotherapeutic schemes, that would bring many improvements regarding time spent per prescription as well as for ward management, due to the fact of helping the management and scheduling of time that each patient would spend in the word, minimizing wasted time between patients.
The other meetings were about improvements in value time for the patients in the Acute Medical Unit ward, so that the patient wouldn’t have to spend a long time waiting for the providing of health care services within the ward. I ended up developing a project related to this theme (see projects, value stream mapping).
Overall, I feel that these meetings were really important not only to learn about business and people management, as well as systematic improvements related to healthcare services, but these meetings also opened a broad spectrum of different activities and areas of interest that I can pursuit during my following years.
Safety-Cross Project
The safety cross project was related to a ‘clerking’ project, once it was related to the continuous following of the AMU ward admission process.
The ‘Clerking’ project was a project that was finished prior to my arrival at the UHG. It consisted in a study that proved the value of a pharmacist in the admission of new patients to the hospital. Their method consisted in introducing a pharmacist directly on the admission process of patients, instead of reviewing patients admitted by doctors.
The safety-cross, when related to Medication Admission Mistakes and to the ‘clerking’ project, provided valuable information regarding the continuation and the continuous improvement of the admission, reconciliation and patients’ history done by the pharmacist.
In this particular case, I’ve counted all the omissions or incorrect medications regarding pre-admission of patients on AMU, distinguishing between patients admitted by the pharmacist (Clerk Stream) and by doctors (AMU stream). This allowed me to analyse the trend of pharmacist based admissions (see appendix 9) as well as to count all the mistakes (omissions and incorrect prescriptions) of admitted patients in the AMU ward (see appendix 10).
Being this a pilot project, and due to lack of results, I couldn’t take any trustworthy conclusions. What I did was perfecting the process of analysing the number of medical admission anomalies committed by either the pharmacist or a doctor and I left a step-by-step
Pedro Nuno Braga Ribeiro 14 guide so that new interns can continue the project. So this is definitely a project to continue by the next interns, to prove the introduction of a pharmacist on medical admissions.
Value Stream Mapping Project
On one of the meetings that I attended was about value stream mapping [25]and I was invited to participate and help doing a value stream map of AMU.
Value stream mapping is a way of looking to a process and to see which of the time spent is valuable and which is waste; in this case, the value time would be the time that a patient spends with a health care provider, and the waste time would be the amount of time that a patient spends waiting on the ward.
To do so, a time table was given to each and every ambulatory patient and every time they received any type of health care service (time spent with nurses, doctors, exams..), the provider of that service would write the time the patient got to them and the time that they’ve finished with the patient, plus a description of the performed action (see appendix 11).
After I had all the results, I was able to reproduce all the timetables in a graph in order to have a general perspective of the value time vs waste time (see appendix 12).
.Despite being just a pilot project and a first approach to a very complex theme and system, this small project led to reflexion and to further development of value stream mapping within the ward staff.
Pedro Nuno Braga Ribeiro 15
Conclusion
During the time that I spent in Ireland, I got to see a different reality regarding hospital pharmacy, but most importantly I got to learn about a completely different culture. I feel that I am now a more mature person, with a much broader vision about the pharmacist activity.
I finally saw how big of an impact a pharmacist can have in the community, not only regarding health but also regarding counselling and empathy with the patients. It was really a great time, everyone treated me as part of the team, always taking the time to teach me new stuff and more importantly to notify me when there was a rarer, more exciting new case.
I would do it all over again as many times as I could, and I can’t even remotely express my gratitude to all the pharmacy staff of UHG. I will remember this experience for years to come, and I sincerely hope that more students can have an opportunity like I did.
References
1. UCDENVER: The Future of Pharmacy is Here -
http://www.ucdenver.edu/academics/colleges/pharmacy/currentstudents/OnCampusPharmDS tudents/StudentOrganizationsNew/OutsideOrganizations/Documents/ACCP_Information_slide s.pdf, 17/07/2019
2. Galvin, M., Jago-Byrne, M. C., Fitzsimons, M., & Grimes, T. (2013). Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland. International journal of clinical pharmacy, 35(1), 14-21
3. Kaboli, P. J., Hoth, A. B., McClimon, B. J., & Schnipper, J. L. (2006). Clinical pharmacists and inpatient medical care: a systematic review. Archives of internal medicine, 166(9), 955-964. 4. Farley, T. M., Shelsky, C., Powell, S., Farris, K. B., & Carter, B. L. (2014). Effect of clinical
pharmacist intervention on medication discrepancies following hospital discharge. International journal of clinical pharmacy, 36(2), 430-437.
5. Coleman, E. A., Smith, J. D., Raha, D., & Min, S. J. (2005). Posthospital medication discrepancies: prevalence and contributing factors. Archives of internal medicine, 165(16), 1842-1847.
6. Saolta: History of Galway University Hospitals - https://www.saolta.ie/about/guh-history, 17/07/2019.
7. Galway Advertiser: The Central Hospital - https://www.advertiser.ie/galway/article/68809/the-central-hospital, 17/07/2019
8. Saolta: University Hospital Galway - https://saolta.ie/hospital/university-hospital-galway, 17/07/2019
9. Irish Health: Major Shake-up of Hospital System -
http://www.irishhealth.com/article.html?id=22101, 17/07/2019
10. Galvin, M., Jago-Byrne, M. C., Fitzsimons, M., & Grimes, T. (2013). Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland. International journal of clinical pharmacy, 35(1), 14-21.
11. Bittl, J. A., Baber, U., Bradley, S. M., & Wijeysundera, D. N. (2016). Duration of dual
antiplatelet therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 68(10), 1116-1139.
12. NHS: Common Medication for People Receiving Haemodialysis -
Pedro Nuno Braga Ribeiro 16
13. Locatelli, F., & Del Vecchio, L. (2011). Erythropoiesis-stimulating agents in renal medicine. The oncologist, 16(suppl 3), 19-24.
14. Carmeliet, G., Dermauw, V., & Bouillon, R. (2015). Vitamin D signaling in calcium and bone homeostasis: a delicate balance. Best Practice & Research Clinical Endocrinology & Metabolism, 29(4), 621-631.
15. Chan, S., Au, K., Francis, R. S., Mudge, D. W., Johnson, D. W., & Pillans, P. I. (2017). Phosphate binders in patients with chronic kidney disease. Australian prescriber, 40(1), 10. 16. Burn, J., Dennis, M., Bamford, J., Sandercock, P., Wade, D., & Warlow, C. (1994). Long-term
risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project. Stroke, 25(2), 333-337.
17. Ament, P. W., Bertolino, J. G., & Liszewski, J. L. (2000). Clinically significant drug interactions. American family physician, 61(6), 1745-1754.
18. HealthLinkBC: Warfarin and Vitamin K - https://www.healthlinkbc.ca/health-topics/abo1632, 18/07/2019.
19. Ammenwerth, E., Schnell-Inderst, P., Machan, C., & Siebert, U. (2008). The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. Journal of the American Medical Informatics Association, 15(5), 585-600.
20. Alibek, K., Bekmurzayeva, A., Mussabekova, A., & Sultankulov, B. (2012). Using antimicrobial adjuvant therapy in cancer treatment: a review. Infectious agents and cancer, 7(1), 33. 21. Gerber, J. S., Ross, R. K., Bryan, M., Localio, A. R., Szymczak, J. E., Wasserman, R., ... &
Zaoutis, T. E. (2017). Association of broad-vs narrow-spectrum antibiotics with treatment failure, adverse events, and quality of life in children with acute respiratory tract infections. Jama, 318(23), 2325-2336.
22. HSE: CPE General Information Background -
https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/hcai/resources/cpe/fact-sheet-2-cpe-general-information-and-background.pdf, 22/07/2019.
23. Aslam, B., Wang, W., Arshad, M. I., Khurshid, M., Muzammil, S., Rasool, M. H., ... & Salamat, M. K. F. (2018). Antibiotic resistance: a rundown of a global crisis. Infection and drug
resistance, 11, 1645.
24. Boxall, A. B. (2004). The environmental side effects of medication. EMBO reports, 5(12), 1110-1116.
25. Rother, M., & Shook, J. (2003). Learning to see: value stream mapping to add value and eliminate muda. Lean Enterprise Institute.
Pedro Nuno Braga Ribeiro 17
Appendix
Appendix 1 – Schedule
Weeks Monday Tuesday Wednesday Thursday Friday
Week 1 A&E Anne’s Anthony’s A&E Anthony’s Anne’s A&E QI meeting Anne’s A&E Anne’s ICU Anne’s HDU ICU Week 2 Neonates unit ESU Anne’s ESU Anne’s Microbiology Round ESU
Anne’s Psichiatry Anne’s Anne’s ESU
Week 3 Anne’s ESU Anne’s ESU ICU HDU ICU HDU ICU HDU Week 4 ESU Theresa’s Microbiology Round ESU Theresa’s ESU Theresa’s Medication Recycling ESU Theresa’s
Week 5 Theresa’s Enda’s Theresa’s Enda’s
ESU Theresa’s QI meeting
ESU
Theresa’s Theresa’s ESU
Week 6 Theresa’s ESU AMU SSW AMU SSW AMU SSW AMU SSW Week 7 AMU SSW AMU SSW Shannon QI meeting
Week 8 Shannon Enda’s
Value Stream Mapping Shannon Shannon Enda’s Shannon Enda’s Shannon Enda’s Week 9 Corrib CCU Corrib CCU Corrib CCU QI meeting Week 10 Corrib CCU Corrib CCU PASU SSW Anthony’s SSW Anthony’s SSW Anthony’s
Week 11 Anthony’s SSW Anthony’s’ SSW
Claddagh ESU QI meeting Claddagh ESU Claddagh ESU Week 12 Claddagh ESU Claddagh ESU Claddagh Safety Cross A&E AMU A&E AMU Week 13 Claddagh ESU Claddagh ESU QI meeting A&E AMU A&E AMU
Pedro Nuno Braga Ribeiro 18
Appendix 2 – Ward Handover Sheet
Pedro Nuno Braga Ribeiro 19
Appendix 4 – H scoringCriteria
Pedro Nuno Braga Ribeiro 20
Pedro Nuno Braga Ribeiro 21
Appendix 6 – Anti-Emetogenic Regimens
Pedro Nuno Braga Ribeiro 22
Appendix 8 – Pharmacist Admissions Trend
Appendix 9 – Clerking Results
0 1 2 3 4 5 6 7 8 AMU Clerk 0 1 2 3 4 5 6 C le rk AM U AM U AM U C le rk AM U AM U AM U AM U AM U AM U AM U AM U AM U C le rk AM U AM U AM U C le rk C le rk AM U AM U AM U AM U AM U 12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970717273747576777879808182838485868788899091929394959697
Sum of Day 1 MAA Score Sum of Drug Missing Sum of Rx error
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Pedro Nuno Braga Ribeiro i
Farmácia Peninsular
Pedro Nuno Braga Ribeiro
Pedro Nuno Braga Ribeiro i
Faculdade de Farmácia da Universidade do Porto
Mestrado Integrado em Ciências Farmacêuticas
Relatório de Estágio Profissionalizante
Farmácia Peninsular
Agosto a Novembro de 2019
Pedro Nuno Braga Ribeiro
Orientador: Dra. Ana Loureiro
Pedro Nuno Braga Ribeiro ii
Declaração de Integridade
Declaro que o presente relatório é de minha autoria e não foi utilizado previamente noutro curso ou unidade curricular, desta ou de outra instituição. As referências a outros autores (afirmações, ideias, pensamentos) respeitam escrupulosamente as regras da atribuição, e encontram-se devidamente indicadas no texto e nas referências bibliográficas, de acordo com as normas de referenciação. Tenho consciência de que a prática de plágio e auto-plágio constitui um ilícito académico.
Faculdade de Farmácia da Universidade do Porto, 20 de Novembro de 2019
Pedro Nuno Braga Ribeiro iii
Agradecimentos
Gostaria de começar por agradecer a todos os funcionários que fazem parte dessa grande família que é a Farmácia Peninsular.
À Dra. Ana Loureiro, pela compreensão em todos os momentos e pelas várias oportunidades de aprendizagem que me facultou durante todo o estágio; à Dra. Rosário, por tudo aquilo que me ensinou e pelo que me demonstrou no domínio da compreensão do utente; à Dra. Luísa, não só por tudo aquilo que me ensinou mas também pela paciência que demonstrou ter para me explicar tudo vezes sem conta; ao Ivo e ao João pelos bons momentos passados e por todos os conselhos que me foram dando ao longo do estágio; à Tiffany e à Sofia, por toda a confiança que me transmitiram e por terem contribuído para que me sentisse realmente em casa; por ultimo, e como não poderia deixar e ser, à D. Maria, por todas as gargalhadas dadas durante estes três meses e por todas as boas conversas que formos tendo. Não poderia ter encontrado um local melhor para aprender e para amadurecer.
À Faculdade de Farmácia da Universidade do Porto e a todos os que fazem parte dessa grande instituição, por me terem disponibilizado condições sem igual para o meu desenvolvimento enquanto futuro farmacêutico e enquanto pessoa.
Por fim, a todos aqueles que me acompanharam ao longo desta jornada, desde amigos a família, que sempre estiveram presentes nos bons e nos maus momentos e que sempre me ajudaram a ultrapassar toda e qualquer dificuldade.
Pedro Nuno Braga Ribeiro iv Estes cinco anos de Mestrado Integrado em Ciências Farmacêuticas proporcionaram-me conheciproporcionaram-mentos e faculdades que decerto proporcionaram-me vão auxiliar ao longo de toda a vida. Este ciclo de estudos culmina no estágio profissionalizante que é a etapa que realmente nos prepara para os anos vindouros naquilo que diz respeito à vida profissional enquanto farmacêutico.
Foi-me dada a oportunidade de estagiar na Farmácia Peninsular em Matosinhos Neste relatório de estágio proponho relatar a minha experiência de estágio em farmácia comunitária que se desenrolou de agosto a novembro de 2019.
Numa primeira parte deste documento, para além de relatar o espaço físico e o funcionamento geral da farmácia Peninsular, proponho também descrever a minha experiência de estágio nas diversas áreas da farmácia.
Na segunda parte, pretendo explanar os projetos realizados durante o tempo de estágio, bem como os motivos que me moveram a realizar tais projetos.
Num primeiro projeto, com o objetivo de sensibilizar a população, decidi elaborar três diferentes prospetos, relacionados com colesterol, pressão arterial e Diabetes Mellitus, com a definição de alguns termos bem como com alguns conselhos no que toca a medidas não farmacológicas.
Num segundo projeto, decidi realizar um rastreio relacionado com a hipertensão arterial, por forma também de alertar todos os utentes para essa condição tão presente na realidade dos portugueses, e que muitas consequências pode acarretar.
Pedro Nuno Braga Ribeiro v Recursos Humanos ...1 Espaço Físico da Farmácia ...1 Sistema Informático ...3 Gestão da Farmácia ...3 Gestão de Stocks ...3 Encomendas ...4 Receção de Encomendas ...5 Armazenamento de Produtos ...6 Prazos de Validade ...7 Devoluções ...7 Reservas ...8 Dispensa de Produtos Farmacêuticos ...8 Dispensa de Medicamentos Sujeitos a Receita Médica (MSRM)...8 Validação da Prescrição Médica ...9 Dispensa de Medicamentos Manipulados ... 10 Dispensa de Estupefacientes e Psicotrópicos ... 11 Regimes de Comparticipação ... 11 Conferência de Receituário ... 12 Dispensa de Medicamentos Não Sujeitos a Receita Médica (MNSRM) ... 13 Produtos Cosméticos e de Higiene Corporal e Produtos de Puericultura ... 13 Medicamentos de Uso Veterinário ... 14 Suplementos Alimentares ... 14 Dispositivos Médicos ... 15 Serviços Adicionais ... 15 Determinação de Parâmetros Físicos e Bioquímicos ... 15 Medição da Pressão Arterial ... 15 Medição de Colesterol Total e Triglicerídeos... 15 Medição da Glicemia Capilar ... 16 Aconselhamento Nutricional... 16 Podologia ... 16 Administração de Vacinas e de Medicamentos Injetáveis ... 16 VALORMED® ... 17
Pedro Nuno Braga Ribeiro vi Projeto 1 - Sensibilização Acerca do Colesterol, Diabetes e Pressão Arterial ... 18
Introdução ... 18 Colesterol Total ... 18 Diabetes Mellitus ... 19 Hipertensão Arterial ... 19 Conclusão ... 20 Projeto 2 – Rastreio Cardiovascular ... 20 Introdução ... 20 Hipertensão Arterial ... 21 Risco Cardiovascular ... 22 Arritmias Cardíacas ... 23 Resultados ... 24 Conclusão ... 25 Conclusão Reflexiva ... 26 References ... 27
Abreviaturas
FP – Farmácia PeninsularCNP – Código Nacional de Produto PVP – Preço de Venda a Público PVF – Preço de Venda à Farmácia
DCI – Denominação Comum Internacional
MSRM – Medicamentos Sujeitos a Receita Médica MNSRM – Medicamentos Não Sujeitos a Receita Médica RM – Receita Médica
SNS – Serviço Nacional de Saúde HTA – Hipertensão Arterial PA – Pressão Arterial DM – Diabetes Mellitus
Pedro Nuno Braga Ribeiro 1
Parte I
A Farmácia
A Farmácia Peninsular (FP) situa-se no concelho de Matosinhos, na Avenida da República, uma das áreas mais desenvolvidas da cidade e que é atualmente uma das suas principais zonas comerciais. Estando situada relativamente perto da praia e perto também de várias estações do metro do Porto, a farmácia não se cinge apenas a habitantes da freguesia, tendo também, diariamente, diversos utentes de outras partes do concelho.
A FP está aberta de segunda a sábado, das 9:00h às 20:00h, estando apenas encerrada aos domingos e aos feriados. Esta farmácia, e derivado a estar integrada no concelho de Matosinhos, a FP está também aberta durante a noite de 29 em 29 dias (Farmácia de Serviço), por forma a poder suprir possíveis necessidades da população.
O horário que me foi atribuído foi variando ao longo das 12 semanas de estágio, sendo que, por vezes e quando necessário, me disponibilizei para estagiar aos sábados.
Recursos Humanos
A FP é constituída por uma equipa vasta, multidisciplinar e consideravelmente jovem. Cada elemento tem funções específicas atribuídas, por forma a que exista uma maior organização e um melhor funcionamento de todas as atividades relacionadas com a farmácia.
A Diretoria Técnica é da responsabilidade da Dra. Ana Loureiro, sendo que o quadro farmacêutico fica completo com a Dra. Luísa Brás e com a Dra. Rosário Pereira. Para além dos três farmacêuticos, a equipa é também constituída por quatro técnicos de farmácia, sendo eles Tiffany Cardoso, João Carmo, Ivo Moreira e Rafaela Rodrigues. A equipa fica completa com a técnica auxiliar de farmácia, Sofia Costa, não esquecendo também a auxiliar de limpeza, Maria Silva.
Espaço Físico da Farmácia
No exterior da FP está presente a cruz verde identificativa do espaço de farmácia, bem como, afixado na porta, o horário de funcionamento, a Diretoria Técnica e as farmácias de serviço no concelho de Matosinhos.
No interior, A FP tem um espaço físico aprazível, dado que é um espaço amplo e com uma montra de loja considerável, permitindo assim muita iluminação natural do espaço, facilitando também a visualização dos produtos disponíveis. Para além da zona estratégica onde está situada, o seu espaço físico também contribui muito para a grande afluência de utentes que regista; aliado à montra e da elevada luminosidade natural, o interior da FP tem tons suaves e claros, fazendo com que seja um espaço realmente acolhedor.
Pedro Nuno Braga Ribeiro 2 • Gabinete de Podologia e Nutrição: a FP disponibiliza aos seus utentes um serviço de podologia, com consultas semanais, serviço esse de muita utilidade nomeadamente para prestação de consultas relacionadas com o pé diabético; este espaço é também dedicado às consultas de nutrição, que se realizam de duas em duas semanas;
• Gabinete de suporte ao utente: espaço destinado aos utentes, nomeadamente para a prestação de serviços tais como a medição de parâmetros bioquímicos (tensão arterial, colesterol e glicemia). A administração de injetáveis (intramusculares) é também realizada neste gabinete.
• Gabinete privado da direção técnica: gabinete onde geralmente são recebidos os delegados comerciais e onde, por vezes, se realizam formações destinadas aos profissionais da FP;
• Back office: espaço onde atua a responsável pelas encomendas e
aprovisionamento da farmácia, possuindo para isso 2 balcões para a confirmação das encomendas entregues. Para além disso, são também lá arquivados e realizados os exercícios de contabilidade da farmácia, bem como o registo do livro de ponto e onde são geridas as marcações das consultas de nutrição e de podologia. No fundo, é o espaço responsável pelo registo e pelo apoio aos profissionais que se encontram na área de atendimento, nomeadamente na previsão de entrega de encomendas que possam ser requisitadas por utentes da FP. É também neste espaço que se encontra o frigorífico destinado ao armazenamento dos medicamentos de frio;
• Área de atendimento: é sem dúvida a maior área de funcionamento da FP; é constituída por 6 balcões de atendimento, sendo que um dos balcões se encontra distante do resto dos balcões, por forma a prestar um serviço mais personalizado a quem procura produtos de dermocosmética e de higiene corporal para uma qualquer condição específica; os restantes 5 balcões encontram-se em fila, no final da área de atendimento, e atrás dos mesmos é onde se encontram os medicamentos não sujeitos a receita médica (MNSRM), que são geridos e que vão sendo preteridos de acordo com a sua sazonalidade. Para além das 3 paredes recobertas com prateleiras destinadas a produtos de dermocosmética, higiene corporal e puericultura, a área de atendimento da FP conta ainda com 3 gôndolas centrais, onde são geralmente expostos produtos com promoção ou produtos que necessitam de escoamento de stock. Também estes são geridos de acordo com a sua sazonalidade;
• Dispensário: área situada entre o back office e a área de atendimento, onde estão armazenados todos os Medicamentos Sujeitos a Receita Médica (MSRM), bem como os respetivos excedentes (quer de MSRM ou de MNSRM);
• Laboratório: área anexada ao armazém. Muito embora este espaço tenha as condições para a preparação de manipulados, este é geralmente utilizado apenas para a reconstituição de suspensões orais, mais concretamente de antibióticos;
Pedro Nuno Braga Ribeiro 3 • Instalações sanitárias: espaço partilhado por funcionários e utentes, com chuveiro para alguma eventualidade;
• Escritório: local onde está armazenada grande parte da documentação da farmácia, relacionados com a gestão financeira e não só, bem como documentação antiga que já não faça sentido manter no back office.
• Sala de convívio: local destinado aos funcionários para lazer ou até mesmo para as refeições;
• Armazém: local onde são armazenados cartazes ou publicidade alusivas a campanhas promocionais passadas bem como materiais excedentes destinados ao bom funcionamento e organização da farmácia. É também neste espaço que se encontram os cacifos dos funcionários.
Sistema Informático
Tal como acontece em diversas farmácias, o sistema informático utilizado pela FP é o SIFARMA®. Para além de ser um sistema intuitivo e que permite a consulta de informação relativamente aos medicamentos a dispensar de forma rápida, é também um sistema que permite a gestão de prazos de validade bem como de stocks presentes na farmácia, facilitando o atendimento ao balcão.
No que diz respeito às encomendas de stock inexistente na farmácia, são utilizados os gadgets das distribuidoras farmacêuticas, devido à sua facilidade de utilização e por disponibilizarem o dia e hora concreta em que os artigos serão distribuídos, facilitando a informação ao utente relativamente à chegada da sua encomenda.
Para além destes sistemas, a FP possui também um cartão de fidelização associado aos dados dos clientes que assim o desejem, e funciona por acumulação de saldo a cada compra que o utente faz, independentemente do artigo que adquirir. Este saldo pode mais tarde ser descontado em futuras compras, mas apenas em produtos sujeitos a 23% de IVA. Permite também consultar a lista de medicação habitualmente adquirida pelo utente, facilitando e agilizando assim a dispensa de medicamentos no que diz respeito à distinção de laboratórios de medicamentos genéricos.
Gestão da Farmácia
Gestão de Stocks
A gestão de stocks é peça fulcral da boa saúde financeira de uma farmácia. Cada vez mais é necessário racionalizar as encomendas em função das vendas e requisições dos utentes mais habituais. Uma má gestão de stocks pode compreender certos produtos que por
Pedro Nuno Braga Ribeiro 4 não terem escoamento e serem habitualmente encomendados se encontrem claramente em excesso e por vezes fora do prazo de validade; por outro lado, se a gestão de stocks não tiver em conta a imensa variedade de produtos existente e a possível necessidade de outrem em adquirir um artigo específico, a farmácia pode também acabar por não prestar um serviço de qualidade, aliado intimamente à variedade, aos seus utentes. É por isso essencial que se encontre um equilíbrio entre vendas e compras de forma a que se encontre a estabilidade financeira e, se possível, o crescimento da farmácia.
O SIFARMA® é essencial para a correta gestão de stocks, uma vez que possui ferramentas que permitem consultar as vendas em determinado período do ano, facilitando assim a definição das encomendas de stock em função das vendas realizadas.
Sendo que a FP é uma farmácia pertencente a um grupo de farmácias, certos produtos eram adquiridos de uma plataforma própria do grupo, apresentando por isso custos mais baixos relativamente aos praticados pelos habituais distribuidores farmacêuticos, logicamente beneficiando a saúde financeira da farmácia.
É uma área de extremo interesse para a gestão de uma farmácia e acredito que deve ser explorada ao máximo nos tempos que correm, sendo essencial ter profissionais responsáveis e com muito conhecimento, por forma a que o negócio possa prosperar.
Encomendas
As encomendas são maioritariamente feitas através de quatro distribuidores grossistas, sendo eles OCP Portugal, Cooprofar, Magium Pharma e Alliance Healthcare.
Por norma, a aquisição de MSRM ou medicamentos em que o preço de venda ao público (PVP) é feita através da OCP Portugal, sendo que os produtos de venda livre são requisitados à Cooprofar. Só no caso de estes dois distribuidores não terem stock disponível dos produtos requisitados, ou no caso de se encontrarem com boas campanhas promocionais, é que a FP realiza encomendas à Magium Pharma e Alliance Healthcare.
A OCP Portugal disponibiliza a plataforma para a encomenda de medicação adquirida pelo grupo de farmácias ao qual a FP pertence, disponibilizando por isso, na maioria das vezes, preços mais favoráveis relativamente a outros distribuidores.
Durante o meu estágio, tive a oportunidade de realizar encomendas de quatro tipos distintos: encomendas diárias, encomendas instantâneas, encomendas de esgotados e encomendas diretas aos laboratórios.
As encomendas diárias são realizadas duas vezes por dia (às 13:00h e às 20:00h) e dizem respeito sobretudo a medicação com grande escoamento de stock. Consiste por isso numa lista já pré criada no SIFARMA®, que tem em conta os stocks mínimos e máximos pré-definidos para cada produto e que é posteriormente comparada com o stock ainda existente em farmácia;
