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The St. Jude Pharmacy: More than medicine

More than medicine

They dispense more than a half-million doses of medications each year, but that’s just the beginning for the dedicated professionals in the St. Jude Pharmacy.

The next time you grab your daily vitamin, special medication or prescription, stop and think about the team of people who diligently work behind the scenes to make sure that what you take is safe and of the highest quality.

At St. Jude Children’s Research Hospital, the list of a child’s daily medications can seem a mile long. A dedicated team of pharmacists and technicians collaborate to ensure that not only are the correct doses given, but that the drugs safely interact with each other with the lowest number of side effects.

“Almost all of the drugs we have at St. Jude are high risk, so the steps we take in the Pharmacy before they ever reach the patient are crucial,” says Chief Pharmaceutical Officer William Greene, PharmD. “Our goal is to achieve the desired therapeutic outcome with the least risk possible for our patients. This can be challenging, because we are often using investigational drugs or drugs that have a very limited track record in children.”

True teamwork

In a year’s time, the Pharmacy at St. Jude is responsible for approximately 500,000 doses of medication dispensed to children in the Medicine Room, clinics and procedures areas—and an additional 80,000 prescriptions for ambulatory outpatients.

“When people think of a pharmacy, that’s what they think of—the dispensing of medication. But we do much more at St. Jude,” Greene says.

“A lot of what we do is dispense medication information. Moreover, we must focus on detail. We refine our day-to-day activities to attempt to do it right 100 percent of the time for all of our patients and to do everything we can to maximize the quality of services, the safety and the outcomes of medication therapy that’s offered.”

About 100 employees work in Pharmaceutical Services.

“The areas of responsibility we cover include purchasing, storage and inventory; collaboration in prescribing and administration; preparation and dispensing; monitoring and modification; quality management; translational and clinical research. All of this leads to improving therapeutic outcomes,” Greene explains.

Those 100 people work in a checks-and-balances structure that encompasses areas from basic pharmacy operation and clinical services to medication outcomes and safety, and pharmacy information services.

“We recently conducted a review of the steps or decisions that a pharmacist at St. Jude must make in handling a single chemotherapy order,” Greene says. “We identified 12 major decision points and 42 subpoints for a total of 54 different checks—all for one order. And we have staff who interface at every point.”

For the patients

When new patients and their families come to St. Jude, they meet with one of the hospital’s outpatient pharmacists. An integral part of the patient care team, the pharmacist wants to be sure each patient and family understands how the pharmacy works, how to take medication safely and anything else related to their daily medication needs.

“We want to ensure that the patient feels comfortable asking questions about their drug dosages, medication interactions, side effects and even how nutrition plays a role,” says Clinical Pharmacist Cyrine Haidar, PharmD. “And, when they go home, they need to understand what to take, how to take it and how often. We are here to assist them along the way.”

Pharmacists also offer tools for patients such as medication cards, which are offered in the hospital’s pharmacy locations. Each card contains a brief description of a specific drug, special instructions and a list of some of its possible side effects.

“It’s important that our patients, and especially their parents, learn as much as they can about their medications,” says Clinical Pharmacist Shane Cross, PharmD. “Knowing more will help them take their medicines exactly as they are prescribed and be aware of common side effects to watch for. By using the medication cards, we are arming them with information.”

A pharmacist is assigned to each patient care area and is incorporated into all patient care teams. The pharmacist reviews results of plasma drug-level and pharmacogenetic tests and works with the patient’s care team to make sure the right changes in drug dosages are made, if needed.

Optimizing outcomes

Pharmaceutical Services employees also work hand-in-hand with other clinical and research staff to assure optimal medication outcomes.

“Work completed in the Pharmaceutical Sciences labs, for example, is being translated into how we can better design our drug therapy in the clinical setting to achieve the outcome and minimize the risks,” Greene says.

For example, there are more than 15 drugs in the Total XVI protocol. The Total XVI protocol is the most comprehensive treatment plan developed to date for acute lymphoblastic leukemia, detailing the management of foreseeable complications of the disease or its therapy. Pharmacodynamic and pharmacogenetic principles are applied to optimize therapy. That is where the Pharmacy comes into play.

“Science from the research lab interfaces with the Clinical Pharmacokinetics Laboratory and with the practice of pharmacy. The pharmacists serve as the primary interface between the laboratory and patient care,” Greene says. “It’s one step to describe it in a lab; it’s another step to make it happen routinely and properly interpret the information and adjust the dosing.”

Work in the lab that affects how and when certain patients are exposed to specific drugs could affect prescribing, monitoring and follow-up.

“The integration of science and practice at St. Jude allows us to quickly take what is learned in the lab and apply it in the clinical setting. That makes St. Jude different from most other hospitals and community pharmacies,” Greene says.

“Some of the research done is based on the idea that you can monitor drug concentrations in patient samples, estimate how patients differ from each other using pharmacokinetic tools and, based on characteristics of a patient and the lab results you gather, you can adjust the dose to achieve a certain outcome,” he says. “As the patient’s status changes, we might have to reassess the drug concentrations.”

The clinical pharmacist’s role is to engage directly with the patient care team about what is being done with the drugs and medications.

“The lab results are communicated to the clinical pharmacists and the clinical pharmacists either make a recommendation to the doctor or modify the dosage if necessary,” Greene explains.

During the last few years, the United States has experienced an increasing number of drug shortages, which affect many of the medications that are important for St. Jude patients. The hospital is countering this issue by carefully monitoring the situation and proactively investigating at the first sign of a potential problem. Because of the team’s diligence, shortages that have been severe at other hospitals have had little or no impact on St. Jude patients.

“We are careful to communicate the latest information about drug shortages to all St. Jude clinicians,” says Medication Outcomes and Safety Officer James Hoffman, PharmD. “There is a lot we have to think through from a safety standpoint, since alternative drugs are being used in some cases.”

“Due to our proactive efforts to manage drug shortages, significant clinical delays in therapy have not occurred at this time for St. Jude patients,” Hoffman adds.

Beyond clinic and lab

Pharmacy staff members are integrated into multiple areas far beyond the hospital’s walls. They interface with state and national professional pharmacy groups, hold faculty positions outside of St. Jude and provide teaching and training for pharmacy students and clinical residents.

St. Jude pharmacy professionals also monitor state and federal regulatory requirements, provide support for the implementation of clinical protocols and serve on many institutional committees. In addition, Pharmaceutical Services employees provide decision support for the electronic medical record, program devices such as automatic medication dispensing machines, track and provide supplies to all areas of the hospital and provide administrative support.

Through the diligent work of Pharmacy staff, along with support from the hospital’s legal and administrative teams, St. Jude also saved more than $1.5 million in drug costs during the past year.

In 2009, the Pharmacy experienced a renovation that expanded the main area to more than twice the space it previously had, enhancing the Pharmacy’s ability to dispense drugs safely and to educate patients. This year, it is expanding to provide “specialty” pharmacy services, providing home infusion and certain high-cost agents directly to outpatients. This expansion will result in savings for the hospital and more comprehensive care for its patients.

“As a department, we really look at the whole picture,” Greene says. “Staff members are on call, work weekends and are engaged at all times. We are focused on being collaborative on all levels and want the best for our patients.”

Reprinted from Promise Winter 2011

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