A Prescription for Success

“When people think of hospital pharmacy, they usually think of dispensing medication,” says Lefebvre. “Actually, overseeing drug dispensing – called pharmacy services – is only part of what we do. The other big piece of the puzzle is called clinical pharmacy, which refers to our role as caregivers, working with doctors, nurses and other specialists to integrate a drug regimen into the overall strategy for treating and discharging a patient. At the MUHC, we also conduct important pharmacological research and train new pharmacists from across the province. It’s this side of things that makes it so exciting to work at the MUHC, where pharmacists have the opportunity to participate in the kind of high-level care that takes place at a university hospital centre.”

Lefebvre has first-hand experience with what this enhanced clinical function means. Since she graduated from pharmacy school at the Université de Montréal in 1983, she has witnessed a sea change in her profession. “When I was hired at the General in 1985, the notion that pharmacists could play a role beyond the writing of prescriptions was still relatively new,” she says. “I was hired with a specific mandate to introduce the clinical pharmacy program, which was incredibly exciting.” This was also the era when interdisciplinary care teams were coming into fashion, so it made sense that pharmacists should join these teams and add their expertise to the collaborative dynamic. Lefebvre was integral in helping the McGill hospital system move to the forefront of this new paradigm of pharmaceutical care, and she was also front and centre for the next major step in the department’s evolution: the merger of the separate pharmacies of the five MUHC hospitals into one.

“Our merger took place in 2000, three years after the MUHC was created,” Lefebvre recalls. “This was of course a complicated process, since each hospital had its own policies, procedures and institutional cultures. Nevertheless, I think we did it as smoothly as it could be done.” According to Lefebvre, there was already considerable collaboration and even site-to-site mobility among the pharmacists of the McGill hospitals, so the staff was familiar with each other and with the various clinical environments in which they worked. They also benefited from a common background, as almost all pharmacists in Quebec are trained at either the Université de Montréal or the Université de Laval (McGill has no school of pharmacy). Finally, Lefebvre and her colleagues approached the merger with a clear vision and a strong shared purpose: to begin and end all decisions with the needs of the patient. “We sat down before the merger and redid our vision and mission statements to reflect our singular focus on improving patient care. We also drafted a three-year plan for how we wanted to achieve that vision.”

Aided by this well-defined purpose and structure, the MUHC now has one of the most advanced and admired pharmacy programs in the province. Its pharmacists, all of whom have completed a master’s degree, work in teams focused on a specialized clinical area such as neonatology, oncology, HIV, geriatrics, transplant, intensive care or emergency medicine. “With such a rapid pace of advancement in every area of medicine and with the development of thousands of new drugs every year, it’s critical that pharmacists be specialized enough that they can be totally familiar with the latest innovations and standards in their field,” Lefebvre explains.

There is one pharmacist for every 25 to 30 beds at the MUHC, except in the ICU, where the ratio is considerably higher. From the moment a patient is admitted, a pharmacist is intimately involved in his or her care. Pharmacists compile a comprehensive medication history, taking into account such factors as complementary medicines, herbal treatments and nutritional supplements, information many patients might have forgotten to impart to their physician. Then, along with doctors, nurses and other professionals, they participate in the creation of a treatment plan, making sure that the drug component is appropriate. Throughout a patient’s stay, his or her pharmacist will monitor prescriptions and the results of blood and other tests to be sure there are no adverse reactions. Finally, when the patient is ready to be discharged, the pharmacist will reconcile new prescriptions with what the patient is taking at home and will make sure that the patient is informed about and comfortable with any new drugs.

Because of the MUHC’s strong reputation in a wide range of pharmaceutical disciplines, it is an attractive place for pharmacists from across Quebec to do their postgraduate training. The MUHC is accredited to train fourth-year undergraduate, master’s and doctoral students in more pharmacy specialties than any other university health centre in the province, despite not having its own associated school of pharmacy. “It’s a sign of the quality of our program that we train students in so many highly specialized areas, and also that so many students apply to the MUHC each year,” says Lefebvre. “Students are also attracted to our unique pediatrics-to-geriatrics mandate, which gives them the chance to train in children’s and adult specialties at the same institution.” Undergraduate students are exposed to all of the MUHC’s 19 clinical pharmacy rotations, while master’s students hone their expertise by specializing in one area.

In addition to getting an in-depth education in both pharmacy services and clinical pharmacy care, students training at the MUHC have the chance to participate in significant research projects. “Evaluative research is an extremely important part of what we do,” Lefebvre explains, noting that last year alone the MUHC’s pharmacists published an impressive five textbook chapters and 19 peer-reviewed journal articles. “We’re always testing and assessing our in-hospital procedures, patient compliance, new treatment regimens like the at-home administration of antibiotics, and other aspects of our practice to make sure we’re doing things in the best and safest possible manner.”

As a result of these research projects, pharmacists are able to refine their procedures to make sure that patients are getting the most from their drug regimes, and that the potential for prescribing and dispensing errors is minimized. “Everything we do at the MUHC is evidence-based,” Lefebvre says. “We’re constantly asking ourselves why we’re doing things the way we do, and looking at what the research tells us about how to do things better.” One example of how the department goes about making improvements is the creation of so-called “satellite pharmacies” in key areas of the hospital to supplement the central pharmacy on each site. “Studies have shown that, by setting up satellite pharmacies in care areas that have very specific drug dispensing needs, we can noticeably improve the safety of our procedures. Medication errors are fortunately fairly rare, but with satellite pharmacies we make them even rarer,” Lefebvre says. The MUHC now operates ten satellite pharmacies in areas like oncology, intensive care, the neonatal ICU and the coronary care unit, each of which is set up to optimally respond to the specific medication demands of their specialty.

Another way that MUHC pharmacists have improved their procedures is through the integration of new technologies. Beyond the army of pharmacists and technicians measuring out doses of medication by hand, visitors to the central pharmacies can see a number of science-fiction-worthy machines spitting out individually packaged and labelled prescriptions. According to Lefebvre, automation is the wave of the future. “Two things are critical in drug dispensing: making sure the drugs are prepared as prescribed and that they’re administered correctly. At both ends of the chain, we need to make things as foolproof as possible.” At the prescribing end, this means relying on the Pharmacy Information System (PIS), a software package that was introduced in 2000 and is part of the MUHC’s overall patient management software called the Clinical Information System. The PIS allows doctors to enter prescriptions directly into a patient’s electronic file, where they can be easily checked by a pharmacist and relayed to the pharmacy for preparation.

"The redevelopment of the Glen and Mountain gives us the opportunity to build pharmacies that have the most up-to-date automated systems, and where the co-ordination between our central and satellite pharmacies works seamlessly."

At the other end, the goal is to make it as easy as possible for ward nurses to give each patient their medication exactly as prescribed. Research has shown that this occurs most successfully when medication is packaged in individual doses, each of which is labelled with the patient’s hospital number, name, the date and other key information. This is where the fancy equipment comes in. The MUHC’s newest central pharmacy at the Montreal General Hospital site contains machines that, at the touch of a button, automatically measure, package and label an entire day’s worth of medication for a patient. “We’ve got a way to go, but our aim is to create a system wherein the PIS will relay prescriptions to our fully automated pharmacy, and technicians will oversee the automated production of individually packaged doses. These will be produced on a 24-hour cycle and delivered to the wards so that nurses will have every patient’s daily regimen ready to go with no guesswork.”

Achieving this goal is part of what makes Lefebvre so enthusiastic about the MUHC’s redevelopment, which represents the culmination of everything she has been working for since the consolidation of the Pharmacy Department seven years ago. “Our vision for the future of pharmacy at the MUHC is completely in line with the ideals behind the redevelopment project,” she says. “Like the MUHC as a whole, we’ve become stronger by working together as a single administrative department. Our breadth as a teaching centre and our ability to conduct important research has grown considerably in the last few years. It will only increase when our pediatric and adult centres are consolidated on two sites. Finally, the redevelopment of the Glen and the Mountain gives us the opportunity to build pharmacies that have the most up-to-date automated systems, and where the co-ordination between our central and satellite pharmacies works seamlessly.”

After more than two decades dedicated to bringing first the Montreal General and then the MUHC Pharmacy Department into a leading position in the field, Lefebvre is gratified to see so many of her efforts coming to fruition. Ironically, each of her successes comes not with a shout but with a whisper. For the MUHC’s invisible caregivers, the sign of a job well done is when you don’t even know they are there.