Abstract
Objectives: For decades, the role of hospital pharmacists has been instrumental in elevating pharmacy practice worldwide. Recently, the Hospital Pharmacy Section of the International Pharmaceutical Federation (FIP), the European Association of Hospital Pharmacists (EAHP), and the American Society of Health-System Pharmacists (ASHP) updated their statements about the future role and responsibilities of the pharmacy executive in hospitals and health systems. A series of surveys were conducted around the globe to better understand the current state of hospital pharmacy practice. The purpose of these surveys was to identify challenges in hospital pharmacy practice and to develop improvement strategies. The objective of this national survey is to evaluate hospital pharmacy practice in Lebanon. Methods: A cross-sectional observational study was performed among pharmacists working in hospital settings in Lebanon, from January through June 2016. Based on a literature review, a questionnaire to elicit Lebanese hospital pharmacists’ practice was developed. Results: The results showed a nonsignificant difference between university teaching and nonuniversity teaching hospitals in the processes of drug procurement, preparation, dispensing, and drug administration. However, statistically significant differences were observed between university teaching and nonuniversity teaching hospitals with respect to having clinical pharmacists (P < .001) and highly qualified personnel (P < .005). Pharmacy services in teaching hospitals seemed to be more advanced cooperating with affiliated medical schools. Furthermore, teaching hospitals were more likely to have pharmacists providing information about the safety of the medications used (P = .029). Although not statistically significant, there was a higher trend toward having a designated champion for medication safety (P = .052). Conclusion: The results of our survey showed that teaching hospitals were more compliant with the International Statements of Hospital Pharmacy Practice compared with nonteaching hospitals. There is room for improvement especially if the application of the accreditation standards for safe hospital pharmacy practice becomes mandatory for all hospitals, which is expected to standardize pharmacy practice and secure both medication and patient safety.
Keywords: teaching hospitals, nonteaching hospitals, pharmacy practice, medications, patient safety, Lebanon
Introduction
Lebanon is a small middle-income country with an estimated 6 million inhabitants located in the Middle East. In 2012, the World Health Organization statistics report confirmed that the number of hospital beds in Lebanon equaled 3.5 per 1000 inhabitants. In 2014, the total health care expenditure accounted for 6.4% of the national gross domestic products.1 The Ministry of Public Health contracted a total of 163 hospitals2 and employed 339 hospital pharmacists (out of 10 000 pharmacists who were registered at the Lebanese Order of Pharmacists and licensed to practice). For decades, the role of hospital pharmacists has been instrumental in elevating pharmacy practice worldwide.3 In 2015, the Hospital Pharmacy Section of the International Pharmaceutical Federation (FIP) released its newest Basel Statements describing the future of hospital pharmacy practice.4 The European Association of Hospital Pharmacists (EAHP) used the Basel Statements when developing its hospital pharmacy practice statements. In 2016, the American Society of Health-System Pharmacists (ASHP) updated its statement about the role and responsibilities of the pharmacy executive, also known as the chief pharmacy officer, in hospitals and health systems. The pharmacy executive’s responsibilities include, but are not limited to, strategic planning, optimizing medication management and advancing pharmacy practice, advancing the application of information technology in the medication management system and improvement, quality outcomes, drug utilization management, supply chain management, financial management, managing the pharmacy workforce, regulatory and accreditation compliance, research and educational missions, institutional representation, and leadership.5
A series of surveys were conducted around the globe to better understand the current state of hospital pharmacy practice, identify key issues facing it, and design improvement strategies. Furthermore, the findings from the aforementioned surveys were partially or entirely adopted in some countries to leverage the political infrastructure to support hospital pharmacy practice. The ASHP and EAHP6 published broad surveys of institutional pharmacy practice. However, the applicability of those statements was limited to hospital pharmacy practice in specific regions of the world. In light of the international guidance and emphasis on the developing role of hospital pharmacists, data on hospital pharmacy practice in Lebanon needed to benchmark against international practices. The objective of this national survey is to evaluate hospital pharmacy practice in Lebanon.
Methods
Study Type and Sampling
We conducted a cross-sectional, observational, questionnaire-based survey performed among pharmacists working in hospital settings in Lebanon, from January through June 2016. Based on the most recent Order of Pharmacists in Lebanon (OPL) list for hospital pharmacists, the participants were selected according to a proportionate random sampling of hospital pharmacies across the 5 different Lebanese districts: Beirut, Beqaa, Mount Lebanon, North Lebanon, and South Lebanon.
Data Collection Tool
Based on a literature review,7-9 a questionnaire to elicit Lebanese hospital pharmacists’ practice was developed. This questionnaire included 45 questions categorized in 7 sections relevant to the current scope of pharmacy practice in Lebanon: (1) sociodemographic characteristics of the participants and hospital characteristics, (2) pharmacy staff workforce including qualifications, (3) pharmacy services including responsibilities and jurisdictions, (4) budget planning, (5) quality management, (6) interprofessional relationship of the pharmacist with other hospital department/services/committees, and (7) informatics and technology used in the pharmacy (online Appendix A). The questionnaire was developed in English and then translated into French using a forward-backward translation process for validation. Pilot-testing was conducted before dissemination, to ensure validity and clarity of all the questions.
Data Collection
A team of OPL employees approached pharmacists working in the randomly selected hospitals and distributed multiple surveys per hospital. They explained the study objectives and highlighted the voluntary participation and confidentiality of the collected data. Once oral consent was received with willingness to participate, the self-administered questionnaire was handed to participants and then collected back upon completion. The time required to fill the survey was about 15 minutes.
Statistical Analysis
Descriptive statistics were used to calculate all participants’ responses. Continuous variables were described using mean and standard deviation. Categorical variables were described using frequencies. Analyses were performed using SPSS software, version 23.0 (IBM Corp, Armonk, New York) and a P value less than .05 was deemed statistically significant.
Ethical Considerations
Considering the observational nature of the study, it was considered exempt from the institutional review board review by the Lebanese University Review board, as it was anonymous and respected participant’s confidentiality.
Results
Hospital Characteristics
The characteristics of the hospitals are summarized in Table 1. The majority of nonteaching hospitals were located in Mount Lebanon (48.2%), whereas half of the teaching hospitals were found in Beirut. Around 50% and 68.2% of the nonteaching and teaching hospitals had 100 to 199 beds, respectively. Moreover, 30.6% and 54.5% of the nonteaching and teaching hospitals had 6 to 10 intensive care unit beds, respectively. An oncology unit was reported to exist in more than 43% of the nonteaching hospitals and in 90.9% of teaching hospitals.
Table 1.
Characteristics of Hospitals Where Pharmacists Were Recruited.
| Variables | Nonteaching hospitals |
Teaching hospitals |
|---|---|---|
| (n = 85) | (n = 22) | |
| Districts | ||
| Beirut | 9 (10.6%) | 11 (50%) |
| Mount Lebanon | 41 (48.2%) | 7 (31.8%) |
| North | 3 (3.5%) | — |
| South | 14 (16.5%) | 2 (9.1%) |
| Beqaa | 15 (17.6%) | 2 (9.1%) |
| Nabatieh | 3 (3.5%) | — |
| Types | ||
| Public | 71 (83.5%) | 1 (4.5%) |
| Private | 14 (16.5%) | 21 (95.5%) |
| Number of beds | ||
| 1 to 99 beds | 45 (52.9%) | — |
| 100 to 199 beds | 40 (47.1%) | 15 (68.2%) |
| 200 to 299 beds | — | 6 (27.3%) |
| >300 beds | — | 1 (4.5%) |
| Number of intensive care unit beds | ||
| 1 to 5 beds | 19 (22.4%) | — |
| 6 to 10 beds | 26 (30.6%) | 12 (54.5%) |
| 11 to 20 beds | 47 (25.8%) | 8 (36.4%) |
| >20 beds | — | 2 (9.1%) |
| Specialized units | ||
| Oncology unit | 34 (43.6%) | 20 (90.9%) |
| Transplantation unit | 1 (1.3%) | 6 (27.3%) |
| Burn unit | 1 (1.2%) | 2 (9.1%) |
| Psychiatry unit | 1 (1.3%) | 3 (13.6%) |
| Geriatric unit | 6 (7.7%) | 2 (0.1%) |
Hospital Pharmacy Working Schedule
A significantly higher percentage of teaching hospitals had “on-call” assistants and clinical pharmacists compared with nonteaching hospitals (P < .05; Table 2).
Table 2.
Hospital Pharmacists’ Working Schedule.
| Variables | Nonteaching hospitals (n = 85) |
Teaching hospitals (n = 22) |
Total (N = 107) |
P value |
|---|---|---|---|---|
| 24-h service | ||||
| No | 68 (80%) | 16 (72.7%) | 84 | .318 |
| Yes | 17 (20%) | 6 (27.3%) | 23 | |
| Night shift | ||||
| No | 82 (96.5%) | 20 (90.9%) | 102 | .272 |
| Yes | 3 (3.5%) | 2 (9.1%) | 5 | |
| “On-call” services | ||||
| “On-call” chief pharmacist | 64 (75.3%) | 20 (90.9%) | 84 | .107 |
| “On-call” assistant pharmacist | 33 (38.8%) | 14 (63.6%) | 47 | .036 |
| “On-call” clinical pharmacist | 11 (12.9%) | 14 (63.6%) | 25 | <.001 |
| “On-call” pharmacy technician | 12 (14.1%) | 7 (31.8%) | 19 | .060 |
Pharmacists’ Degrees and Hospitals’ Affiliations
A significantly higher percentage of teaching hospitals had a chief pharmacist with MBA degree (33.3% vs 4.7%), oncology pharmacists with MPH degree (19% vs 1.2%), assistant pharmacists with PharmD degree (42.9% vs 14.1%), and clinical pharmacists with PharmD degree (33.3% vs 3.5%), MPH degree (9.5% vs 0%), or MBA degree (23.8% vs 1.2%). In addition, a significantly higher percentage of teaching hospitals had an affiliation with a school of pharmacy (86.4% vs 32.5%), a school of medicine (86.4% vs 43.4%), or a school of nursing (86.4% vs 57.8%) compared with nonteaching hospitals (Table 3).
Table 3.
Pharmacists Education and Training and Hospital Affiliations.
| Variables | Nonteaching hospitals (n = 85) |
Teaching hospitals (n = 22) |
Total (N = 107) |
P value |
|---|---|---|---|---|
| Pharmacist education and training | ||||
| Chief pharmacists | ||||
| PharmD degree | 32 (37.6%) | 12 (57.1%) | 44 (41.5%) | .139 |
| Master Public Health | 7 (8.2%) | 4 (19%) | 11 (10.4%) | .222 |
| Master business administration | 4 (4.7%) | 7 (33.3%) | 11 (10.4%) | .001 |
| Post-graduate certificate or diploma | 5 (5.9%) | 2 (9.5%) | 7 (6.6%) | .632 |
| Oncology pharmacists | ||||
| PharmD degree | 4 (4.7%) | 0 (0%) | 4 (3.8%) | .582 |
| Master public health | 1 (1.2%) | 4 (19%) | 5 (4.7%) | .005 |
| Assistant pharmacists | ||||
| PharmD degree | 12 (14.1%) | 9 (42.9%) | 21 (19.8%) | .006 |
| Master business administration | 1 (1.2%) | 1 (4.8%) | 2 (1.9%) | .358 |
| Post-graduate certificate or diploma | 0 (0%) | 1 (4.8%) | 1 (0.9%) | .198 |
| Research pharmacists | ||||
| PharmD degree | 1 (1.2%) | 0 (0%) | 1 (0.9%) | 1 |
| Master business administration | 1 (1.2%) | 1 (4.8%) | 2 (1.9%) | 0.358 |
| Clinical pharmacists | ||||
| PharmD degree | 3 (3.5%) | 7 (33.3%) | 10 (9.4%) | <.001 |
| Master public health | 0 (0%) | 2 (9.5%) | 2 (1.9%) | .038 |
| Master business administration | 1 (1.2%) | 5 (23.8%) | 6 (5.7%) | .001 |
| Post-graduate certificate or diploma | 2 (2.4%) | 0 (0%) | 2 (1.9%) | 1 |
| School affiliations | ||||
| School of pharmacy | 27 (32.5%) | 19 (86.4%) | 46 (43.8%) | <.001 |
| School of medicine | 46 (43.4%) | 19 (86.4%) | 55 (52.4%) | <.001 |
| School of nursing | 48 (57.8%) | 19 (86.4%) | 67 (63.8%) | .010 |
Pharmacy Services
A significantly higher percentage of teaching hospitals reported to have pharmacists responsible for providing drug information for medication use (93.8% vs 63.9%), monitoring formulary compliance (100% vs 70.5%), and supervising the patient counseling service (72.2% vs 47.6%). Finally, a significantly higher percentage of teaching hospitals had both pharmacy undergraduate and PharmD students’ training programs as compared with nonteaching hospitals (Table 4).
Table 4.
Pharmacy Services Provided by Hospital Pharmacists.
| Variable | Nonteaching hospitals (n = 85) |
Teaching hospitals (n = 22) |
Total (N = 107) |
P value |
|---|---|---|---|---|
| Procurement | ||||
| Procurement, selection, and purchasing medications | 68 (81%) | 20 (90.1%) | 88 (83%) | .221 |
| Procurement, selection, and purchasing medical supplies | 49 (58.3%) | 8 (36.4%) | 57 (53.8%) | .055 |
| Procurement, selection, and purchasing diagnostic tests | 14(16.7%) | 3(13.6%) | 17(16%) | .511 |
| Procurement, selection, and purchasing medical gases | 9 (10.7%) | 3 (13.6%) | 12 (11.3%) | .473 |
| Procurement, selection, and purchasing radiopharmaceutical products | 28 (33%) | 5 (22.7%) | 33 (31.3%) | .246 |
| Preparation and delivery | ||||
| Medication dispensing | 76 (90.5%) | 21 (95.5%) | 97 (91.5%) | .404 |
| Compounding hazardous products | 51 (60.7%) | 14 (63.6%) | 65 (61.3%) | .503 |
| Compounding admixtures | 40 (47.6%) | 10 (45.5%) | 50 (47.2%) | .524 |
| Compounding total parenteral nutrition | 34 (40.5%) | 11 (50%) | 46 (42.5%) | .473 |
| Dispensing medical supplies | 36 (42.9%) | 6 (27.3%) | 42 (39.6%) | .138 |
| Administration | ||||
| Pharmacists provides adequate information for safe medication use | 39 (63.9%) | 15 (93.8%) | 54 (70.4%) | .29 |
| Designated quality champion for medication safety | 51 (67.1%) | 19 (90.5%) | 70 (72.2%) | .052 |
| Strategies and policies are implemented to prevent medication errors | 47 (61%) | 14 (63.6%) | 61 (61.6%) | 1 |
| Consultation on medication management | 77 (91.7%) | 21 (95.5%) | 98 (92.5%) | .475 |
| Influences on prescribing | ||||
| Leadership role in formulary management and update | 66 (88%) | 22 (91.7%) | 88 (88.9%) | 1 |
| Pharmacy monitoring formulary compliance | 43 (70.5%) | 19 (100%) | 62 (77.5%) | .005 |
| Pharmacist is a member of the pharmacy and therapeutics committee | 42 (72.4%) | 16 (27.6%) | 58 (100%) | .144 |
| Antibiotic stewardship | 73 (86.9%) | 19 (86.4%) | 92 (86.8%) | .593 |
| Pharmacokinetic consult | 60 (71.4%) | 17 (77.3%) | 77 (72.6%) | .399 |
| Pharmacotherapy consult | 63 (75%) | 19 (86.4%) | 82 (77.4%) | .201 |
| Monitoring of medication practice | ||||
| Documentation in medical records | 68 (81.9%) | 14 (82.4%) | 82 (82%) | .636 |
| Patient counseling | 40 (47.6%) | 16 (72.2%) | 56 (52.8%) | .030 |
| Patient care rounds | 31 (36.9%) | 8(36.4%) | 39 (36.8%) | .585 |
| Medication reconciliation upon admission, transfer of care, and discharge | 25 (36.8%) | 12 (52.2%) | 37 (40.7%) | .225 |
| Human resources and training | ||||
| Pharmacy undergraduate training | 30 (35.7%) | 18 (85.7%) | 48 (45.7%) | <.001 |
| PharmD student training | 17 (20.9%) | 13 (61.9%) | 30 (28.6%) | <.001 |
Discussion
In this study, we found that teaching hospitals had significantly more personnel with additional qualifications, particularly in the fields of clinical pharmacy and pharmacy management (chief pharmacists mainly) than nonteaching hospitals. Furthermore, pharmacy services in teaching hospitals seemed to be more progressive and affiliated with health care schools. However, due to the limited number of hospital beds in nonteaching hospitals, the number of pharmacists may be justified especially in the absence of Pharmacy laws that set the minimum number of pharmacist to patient ratio.
Despite the availability of national hospital accreditation standards that apply for all kinds of hospitals, there is no existing data published on the compliance with these standards or the current scope of hospital pharmacy in Lebanon. Furthermore, there are no local guidelines in Lebanon issued by the Republic of Lebanon Ministry of Public Health or by the OPL10 for hospital pharmacy practice. According to expert opinion, hospital pharmacy practice in Lebanon is primarily centered on the operational management of medication acquisition and distribution.11 Guidance on the minimum requirements for hospital pharmacy is only provided by international bodies including the ASHP and FIP Basel statements.12 The overarching goals of hospital pharmacy by both the ASHP and the FIP advocate for optimizing patient outcomes via pharmacy services through the appropriate use of medications. Although the application of these guidelines in Lebanon is not mandatory, they seem to be applied better in teaching hospitals than in nonteaching ones.
Moreover, transcending geographical locations and the defined scope of hospital pharmacy within individual countries, common goals include engaging pharmacists in preventing medication errors in prescribing, dispensing, and in administration to improve patient safety.13 As evidenced in the results of the survey, teaching hospitals were more likely to have pharmacists providing information on safe medication use, and although not statistically significant, there was a higher trend toward having a designated champion for medication safety. On the contrary, data showed nonsignificant differences between teaching and nonteaching hospitals in the processes of drug procurement, preparation, and delivery, in addition to drug administration.
Recently, important roles for hospital pharmacy include, but are not limited to, pharmaceutical waste minimization, information technology, and informatics.4 The FIP Basel statements provide both minimum and aspirational requirements to account for the difference among many countries; however, they do not provide prioritization for tackling these statements.14 We recommend these statements to be adapted to the Lebanese setting and applied in Lebanese hospitals to optimize patient outcomes.
Moreover, the majority of teaching hospitals were affiliated with schools of pharmacy. Such affiliations have been identified as a factor positively associated with the advancement of pharmacy practice models.11,13,15 In our study, a considerably higher number of teaching hospitals were affiliated with Schools of Pharmacy, Nursing, and/or Medicine. We expect these multidisciplinary affiliations to improve practice of several health care professions in Lebanon, pharmacy in particular.
As reflected by the survey, the current scope of practice of hospital pharmacists in Lebanon in comparison with the elements of service suggested by ASHP12 includes drug procurement and inventory of medication and sterile supplies, medication use policy development, optimizing medication therapy, influences on prescribing, monitoring of medication use, and evaluating the medication use system. Furthermore, the current scope of practice also includes pharmaceutical waste management, which was recently added by the FIP to the Basel Statements.4 In fact, the complexity in pharmacy practice in health care settings has been documented in the literature since the early millennium. This complexity has been attributed to the numerous and increasing drugs on the market, demand for pharmacy service expansion, increased expectations for quality, technology and automation, frequent drug shortages as well as challenges in maintaining cost-effectiveness for health care systems.16 Furthermore, in 2008, the ASHP and ASHP Research and Education Foundation introduced the Pharmacy Practice Model Initiative (PPMI) as a call toward change in the way pharmacists practice in health systems. This call targeted pharmacy practice leaders with the goal of developing and disseminating a futuristic practice model that supports pharmacists as direct patient care providers in diverse health care settings.17 Given the diversity in cadres for hospital pharmacist practice, it is important for pharmacists working in health care settings to have received adequate education and training within the scope of the pharmacy services provided.18 In this study, more pharmacists with advanced degrees or training were found in teaching hospitals. Therefore, we recommend that nonteaching hospitals increase the variety of recruited pharmacists’ specialties to accommodate for the pharmacist contemporary role.
The current survey also showed a considerable influence of hospital pharmacists on physician prescribing practices, as reflected by pharmacists being members of the Pharmacy and Therapeutics (P&T) committee, responsible for formulary compliance, management, and updates. Furthermore, reflected within the scope of services was also the involvement in antimicrobial stewardship, pharmacotherapy, and pharmacokinetic consults. According to the Basel statements, the presence of a formulary, P&T committee, involvement in policy development, and the involvement of pharmacists on patient care rounds and receipt of pharmacotherapy consults all reflect pharmacy services’ influence on prescribing.4
However, despite the fact that increasing the number of pharmacists in direct patient care improves patient outcomes,19 the availability of clinical pharmacy services in hospitals across Lebanon is still limited. Pharmacists participating in patient care rounds were reported to be less than 50% of hospitals, even though clinical pharmacists were available. This is comparable with some international reports, where 91% of hospitals reported having clinical pharmacy services, but only 28% of the hospitals reported that their pharmacists regularly attended patient care rounds.20 Our results are also comparable with data from Saudi Arabia, where only 26% of 46 governmental and private hospitals reported that hospital pharmacists attended patient care rounds.21
Based on the survey results, some reported services were indicative of partial clinical pharmacy practice such as the pharmacotherapy consults and medication counseling. In addition, as shown in the results, hospital pharmacists in Lebanon are involved in quality management and interprofessional committees such as antimicrobial stewardship. The role of the hospital pharmacist in quality improvement programs and the evaluation of the effectiveness of the medication use system is supported by both the FIP and the ASHP. Engaging in quality improvement activities and organizational committees pertaining to the medication use, selection, prescription, procurement, storage, preparation, dispensing, distribution, administration, and monitoring, in collaboration with other health care professionals is recommended to ensure safe medication use processes.12,22 Further research initiatives regarding hospital pharmacy, utilizing the FIP Basel statements, and other international standards are needed to benchmark to published international studies.
Conclusion
In conclusion, the study showed high compatibility of hospital pharmacy practice in Lebanon with international hospital pharmacy practice statements. Both teaching and nonteaching hospitals had similar practices at the level of drug procurement, preparation, and administration; however, teaching hospitals had significantly better influences on medication prescription and monitoring and had a more established clinical pharmacy practice in terms of number and qualifications of clinical pharmacists and approach in securing patient safety. The Ministry of Public Health in Lebanon, in collaboration with the OPL, should set standardized requirements for hospital pharmacy practice including the minimum qualifications for educational training and years of experience, role of the hospital pharmacist in the medication use process, and number of pharmacists needed in each setting to secure medication safety and improve patients’ outcomes. The law in addition to hospital accreditation will standardize and optimize hospital pharmacy services across the country.
Supplemental Material
Supplemental material, Hospital_pharmacy_survey._11.26.18 for Current Trends in Hospital Pharmacy Practice in Lebanon by Nibal Chamoun, Ulfat Usta, Lamis R. Karaoui, Pascale Salameh, Souheil Hallit, Patricia Shuhaiber, Anna-Maria Henaine, Youssef Akiki, Rony M. Zeenny and Katia Iskandar in Hospital Pharmacy
Acknowledgments
The authors would like to thank the members of the Hospital Pharmacy Scientific Committee at the Order of Pharmacists of Lebanon.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material: Supplemental material for this article is available online.
ORCID iDs: Lamis R. Karaoui 
https://orcid.org/0000-0002-7857-7374
Youssef Akiki
https://orcid.org/0000-0003-2062-4737
Katia Iskandar
https://orcid.org/0000-0001-5544-6681
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Supplementary Materials
Supplemental material, Hospital_pharmacy_survey._11.26.18 for Current Trends in Hospital Pharmacy Practice in Lebanon by Nibal Chamoun, Ulfat Usta, Lamis R. Karaoui, Pascale Salameh, Souheil Hallit, Patricia Shuhaiber, Anna-Maria Henaine, Youssef Akiki, Rony M. Zeenny and Katia Iskandar in Hospital Pharmacy