Overview of the History of Hospital Pharmacy in the United States

CHAPTER

Overview of the History of Hospital

Pharmacy in the United States

William A. Zellmer

n n n

LEARNING OBJECTIVES

After completing this chapter, readers

should be able to:

1. Describe how hospital pharmacy devel-

oped in the United States.

2. Analyze the forces that shaped the

hospital pharmacy movement.

3. Use history to discuss challenges to the

future of institutional practice.

4. Discuss how professional organizations

such as ASHP advanced the practice of

institutional pharmacy practice.

5. Define key terms associated with the

history of hospital pharmacy.

n n n

KEY TERMS AND DEFINITIONS

ASHP Hilton Head conference: A

conference of hospital pharmacy

leaders and pharmacy educators

conducted in 1985 in Hilton Head,

South Carolina, which emerged with

the idea that hospital pharmacies

should function as clinical depart-

ments with the mission of fostering

the appropriate use of medicines.

Formulary: A list of drugs approved

for use within the hospital or health

system by the pharmacy and therapeu-

tics (P&T) committee.

Formulary system: A structure whereby

the medical staff of a hospital or

health system, working through the

P&T committee, evaluates, appraises,

and selects from among the drug

products available those that are

considered most useful in patient

care. It is also the framework in which

medication-use policies are established

and implemented.

Full-time equivalent (FTE): A method

for standardizing the number of full-

and part-time employees working in

an institution. A full-time employee

working a 40-hour week is equal to

one full-time equivalent (FTE), and an

employee who works for 20 hours per

week is equal to 0.5 FTE.

Mirror to Hospital Pharmacy: A publica-

tion documenting the state of phar-

macy services in hospitals in the late

1950s.

Pharmacy and therapeutics (P&T)

commiee: A committee of the

medical staff of a hospital or health

system with oversight for medication

management. The committee estab-

lishes a formulary, assesses medication

use, and makes recommendations on

policies and procedures associated

with medication management. It is

made up of representatives of the

medical staff, administration, phar-

macy, nursing, and other parties inter-

ested in the medication-use process; a

pharmacist often serves as secretary of

the committee.

Practice standard: An authoritative

advisory document, issued by an

expert body, which offers advice on

the minimum requirements or optimal

method for addressing an important

issue or problem. It does not typically

have the force of law.

20 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

n n n

INTRODUCTION

Hospitals and other institutional practice settings today offer immense opportunities for

pharmacists who want to practice in an environment that draws on the full range of their

professional education and training. It was not always so.

This chapter tells the story of how hospital pharmacy developed in this country, ana-

lyzes the forces that shaped the hospital pharmacy movement, and draws lessons from the

changes in this area of pharmacy practice.

HOSPITAL PHARMACY’S NASCENCE

a,14

Pharmacists have been associated with hospitals as long as there have been hospitals in

America. When the Pennsylvania Hospital (the first hospital in Colonial America) was

established in 1752, Jonathan Roberts was appointed as its apothecary. At that time, medi-

cine and pharmacy were commonly practiced together in the community, with drug prepa-

ration often the responsibility of a medical apprentice.

However, hospital pharmacy practice in the United States never developed into a sig-

nificant movement until the 1920s. Although there were important milestones before that

era (including the pioneering hospital pharmacy practices of Charles Rice [1841–1901]

[see

Figure 2-1] and Martin Wilbert [1865–1916]

), many factors kept hospital pharmacy at the

fringes of the broader development of pharmacy practice and pharmacy education.

For much of the nation’s history, hospital pharmacists were rare because there were

few hospitals. In 1800, with a population of 5 million, the nation had only two hospitals.

Even by 1873, with a population of 43 million, the United States had only 178 hospitals with

fewer than 50,000 beds.

This might have not been a bad thing, because hospitals were

“places of dreaded impurity and exiled human wreckage,” and physicians seldom had any-

thing to do with them.

Hospitals played a small role in healthcare, and pharmacists played

a very small role in hospitals.

1800s

In the early to mid-1800s, drug therapy consisted of strong cathartics, emetics, and diapho-

retics. Clean air and good food rather than medicines were the treatments emphasized

in hospitals. The medical elite avoided drug use or used newer alkaloidal drugs such as

morphine, strychnine, and quinine. An organized pharmacy service was not seen as neces-

sary in hospitals, except in the largest facilities. The situation changed somewhat during the

Civil War when hospital directors sought out pharmacists for their experience in extempo-

raneous manufacturing and in purchasing medical goods.

In the 1870s and 1880s, responding to the influx of immigrants, the number of hos-

pitals in cities doubled. Most immigrants in this period were Roman Catholic, and they

built Catholic hospitals. This was significant for two reasons—Catholic hospitals charged

patients a small fee (which allowed services to be improved) and they were willing to train,

or obtain training for, nuns in pharmacy (see Figure 2-2).

This era of hospital expansion

American Society of Health-System Pharmacists (ASHP) in conjunction with anniversaries of its 1942

founding published well-documented accounts of the development of hospital pharmacy practice in

the United States. Particularly noteworthy are the “decennial issue” of the Bulletin of the American

Society of Hospital Pharmacists and articles that marked ASHP’s 50th anniversary.

1-3

Readers who have

an interest in more detail are encouraged to seek out those references and others.

This section of the

chapter is based closely on reference 2.

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 21

FIGURE 21. Hospital Pharmacy Department, Bellevue Hospital, New York City, late 1800s.

The bulk medicine area, where medicines were packaged for use on the wards, at Bellevue Hospital, New York

City, in the late 1800s. Standing on the right is Charles Rice, the eminent chief pharmacist at Bellevue, who

headed three revisions of the United States Pharmacopeia.

Source: AJHP.

KEY POINT . . .

Catholic hospitals were important to

the progress of hospital pharmacy

because they charged patients a small

fee (which allowed services to be

improved), and they were willing to

train, or obtain training for, nuns in

pharmacy.

. . . SO WHAT?

It might surprise some students and

young pharmacists of the critical

importance of religious organizations

in the progress of the pharmacy

profession. Look at pictures of hospital

pharmacy leaders in the 20th century,

and it will be common to see nuns

prominent among that group.

coincided with reforms in nursing, development of germ theories, and the rise of scientific

medicine and surgery. The general adoption of aseptic surgery in the 1890s made the hos-

pital the center of medical care. Advances in surgery led to growth of community hospitals,

most of which were small and relied on community pharmacies to supply medicines.

EARLY 1900s

By the early 20th century, hospitals had

developed to the point of having more divi-

sion of labor, more specialization in medical

practice, a greater need for professional phar-

maceutical services for handling complex

therapies, and recognition that it was more

economical to fill inpatient orders in-house.

Hospital pharmacists retained the tradi-

tional role of compounding, which fostered

a sense of camaraderie among them and

an impetus to improve product quality and

standardization. The advent of the hospital

formulary concept persuaded many hospital

leaders about the value of professional phar-

maceutical services. An important reason

for hiring a hospital pharmacist in the 1920s

was Prohibition—alcohol was commonly

prescribed, and a pharmacist was needed

for both inventory control and to manufac-

ture alcohol-containing preparations, which

were expensive to obtain commercially.

22 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

By the 1930s, pharmacy-related issues in hospitals had coalesced to the point that

the American Hospital Association (AHA) created a Committee on Pharmacy to analyze

the problems and make recommendations.

Hospital pharmacy leaders considered the

1937 report of that committee so seminal

that even a decade later they saw value in

republishing it.

The committee’s aim was

to develop minimum standards for hospi-

tal pharmacy departments and to prepare a

manual on pharmacy operations. The com-

mittee characterized pharmacy practices in

hospitals at the time as “chaotic” and com-

mented, “Few departments in hospital per-

formance have been given less attention

by and large than the hospital pharmacy.”

In the committee’s view, “…any hospital

larger than one hundred beds warrants the

employment of a registered pharmacist…. Unregistered or incompetent service should not

be countenanced, not only because of legal complications but to insure absolute safety to

the patient.”

The proliferation of unapproved and proprietary drug products in hospitals

was the target of the committee’s extensive criticism.

FIGURE 22. Sisters of Mercy in the pharmacy department of St. Francis Hospital in New York City during the

mid-1950s.

Catholic nuns were instrumental in developing U.S. hospital pharmacy practice. In the late 1950s, more than half

of the women who were chief pharmacists in hospitals were members of a religious order.

Source: From the Drug Topics Collection, Kremers Reference Files, American Institute of the History of Pharmacy.

KEY POINT . . .

It was not until the 1930s that hospital

leaders explicitly recognized the need

for pharmacy services.

. . . SO WHAT?

Pharmacy may have a long history, but

it was only about 80 years ago that

hospital leaders recognized a need for

pharmacists.

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 23

A 60YEAR PERSPECTIVE

There is much that can be learned by comparing contemporary hospital pharmacy with

practice of 60 years ago. Sixty years is a comprehensible period of time for most people and,

in hospital pharmacy’s case, the past six decades were a period of astonishing advancement.

Good data sources for making such a comparison are available. A major study of hospi-

tal pharmacy was conducted between 1957 and 1960—the Audit of Pharmaceutical Services

in Hospitals—and published in a book, Mirror to Hospital Pharmacy, which remains a ref-

erence of monumental importance.

11,12

Over the years, ASHP (American Society of Health-

System Pharmacists and before 1995 known as the American Society of Hospital Pharma-

cists) has documented the progress of hospital pharmacy through its annual surveys of

pharmacy practice in hospital settings, yielding contemporary data for comparison with

figures from an earlier era. Five major themes emerge from an examination of changes over

this period:

1. Hospitals have recognized universally that pharmacists must be in charge of drug

product acquisition, distribution, and control.

2. Hospital pharmacy departments have assumed a major role in patient safety.

3. Hospital pharmacy departments have assumed a major role in promoting rational

drug therapy.

4. Many hospital pharmacists have become patient care providers.

5. Hospital pharmacy departments have expanded their clinical activities to include

patients in ambulatory care clinics.

To fully appreciate the changes in hospital pharmacy over the past 60 years or so, it

is important to keep in mind what was happening in the United States as a whole. Since

1950, the U.S. population has more than doubled. Expenditures for healthcare services have

grown from about 5% of gross domestic product to more than 17% (which has fostered

an enduring stream of initiatives to curtail healthcare spending). Nonfederal, short-term

general hospitals in 1950 numbered 5,031 and rose to a zenith of 5,979 in 1975; in 2012 the

number stood at 5,010—16% fewer than the peak of 37 years earlier. On a per-capita basis,

the number of inpatient hospital beds has declined 22% since 1950. Between 1965 and 2012,

hospital outpatient visits increased nearly sevenfold.

13-15

DRUG PRODUCT ACQUISITION, DISTRIBUTION, AND CONTROL

Sixty years ago, pharmaceutical services were still of marginal importance to hospitals.

The 1949 hospital rating system of the American College of Surgeons had only three ques-

tions related to pharmacy, and responses to those questions contributed only 10% to the

overall rating. Pharmacy was perceived as a

complementary service department, not as

an essential service.

Fewer than half the hospital beds in

the nation (47%) in the late 1950s were

located in facilities that had the services of

a full-time pharmacist.

Fewer than 4 out

of 10 hospitals (39%) had the services of a

pharmacist. Hospital size was an important

determinant of the availability of a phar-

macist. All larger short-term institutions—

those with 300 beds or more—employed a

KEY POINT . . .

In the late 1950s, fewer than 4 out of

10 hospitals had the services of a full-

time pharmacist.

. . . SO WHAT?

Many of today’s pharmacists were

born in hospitals without a pharmacist

providing oversight for their care.

24 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

full-time pharmacist. Pharmacist employment declined sharply with decreasing hospital

size—for hospitals of 200–299 beds, 96% employed pharmacists; 100–199 beds, 72%; 50–99

beds, 18%; and under 50 beds, 3.5%.

Today, the vast majority of U.S. hospitals have the services of one or more pharmacists.

Important exceptions are small rural hospitals that sometimes still rely on the services of

local community pharmacists. About 8% of the nation’s hospitals have fewer than 25 beds;

it is not known how many of them employ a pharmacist.

In 1957, the total number of hospital pharmacists was 4,850 full-time and about 1,000

part-time.

Today, there are about 60,000 full-time equivalent (FTE) pharmacists providing

inpatient services in nonfederal short-term hospitals.

(Hospitals employ approximately an

equal number of pharmacy technicians.) About one-fourth of all actively practicing phar-

macists in the United States work in hospitals.

Today’s hospitals employ approximately

17 FTE pharmacists per 100 occupied beds.

The comparable figure for 1957 was approxi-

mately 0.4 FTE pharmacists per 100 occupied

beds. In other words, pharmacist staffing

in hospitals is about 40 times more inten-

sive today than it was 60 years ago. During

the same interval, the intensity of hospital

staffing as a whole increased approximately

fivefold.

14,18

Reflective of more intensified

pharmacist staffing, about 40% of hospitals

offer 24-hour inpatient pharmacy services.

In the middle of the 20th century,

nurses and community pharmacists—not

hospital pharmacists—were responsible for

hospital drug product acquisition, distribu-

tion, and control in many hospitals. The

Mirror to Hospital Pharmacy estimated that 4,000 nurses were engaged in pharmacy work.

Two types of services—bulk compounding and sterile solution manufacturing—were a

major element of the hospital pharmacists’ professional identity in the 1950s (Figure 2-3).

Hospital pharmacy leaders of the time cited the following factors in explaining the heavy

involvement in manufacturing:

The unsuitability of many commercially available dosage forms for hospital use

The close relationship between physicians and pharmacists in hospitals

The opportunity to serve a need of physicians and patients

The opportunity to offer a professional service and build interprofessional relations

In sharp contrast to 60 years ago, hospital pharmacists now prefer to purchase com-

mercial products whenever they are available, in the interests of appropriate deployment

of the workforce and of using products of standard commercial quality. Changes in the laws

and regulations that govern drug product manufacturing and distribution, the development

of a well-regulated generic pharmaceutical industry, and a shift in the perceived mission of

pharmacy practice were among the factors that led to the relegation of manufacturing to

hospital pharmacy’s past.

In summary, from mid-20th century to today, hospital pharmacy in the United States

moved from an optional service to an essential service. It used to be that the administrator,

the physicians, and the nurses in many institutions, especially smaller facilities, believed

KEY POINT . . .

Today, approximately one-fourth of all

actively practicing pharmacists in the

United States work in hospitals.

. . . SO WHAT?

The public image of the pharmacist

is one working in an independent or

chain pharmacy in the community.

The public is generally unaware of the

large number of pharmacists providing

innovative services in hospitals and

other institutional seings.

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 25

that they could function adequately with

a drug room controlled by nurses. Today

it is beyond question by anyone in the

hospital field that medications need to

be controlled by a pharmacy department

managed and staffed by qualified phar-

macists supported by qualified pharmacy

technicians. Moreover, as pharmacists

have become firmly established in hospi-

tals, they have been recognized for their

expertise beyond drug acquisition, dis-

tribution, and control functions, which

has led to greatly intensified pharmacy

staffing. The growing opportunities in

hospitals have attracted more practitio-

ners to the field, which has made hospital

practice a major sector of the profession.

PATIENT SAFETY

A clarion call to professionalism in hospital pharmacy arose in the 1960s following studies

on the incidence of medication errors in hospitals.

Hospital pharmacists have made

immense progress in this arena. Initially, that progress was gauged in terms of minimizing

errors in dispensing and administration of medications, and it has evolved to also focus

on improving prescribing and ensuring that the intended results from medication use are

achieved.

KEY POINT . . .

From the mid-20th century to today,

hospital pharmacy in the United States

has moved from an optional service to an

essential service.

. . . SO WHAT?

Over the years, pharmacists have

identiﬁed opportunities in healthcare

institutions and carved out roles in

managing the medication-use process.

This has taken leadership, hard work,

building strong professional relationships,

and caring for the patient.

FIGURE 23. Sterile Solution Laboratory, Cardinal Glennon Memorial Hospital for Children, St. Louis, Missouri,

circa 1950s. Production of distilled water and the manufacture of large-volume sterile solutions were major phar-

macy activities in medium and large hospitals in the 1950s and 1960s.

Source: ASHP Archives.

26 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

In 1957, drug products were distributed to hospital inpatients using floor stock or indi-

vidual-patient prescription systems.

Authors of the Mirror to Hospital Pharmacy high-

lighted a critical limitation of medication systems of that era:

From the viewpoint of patient safety, one of the major advances in dispensing pro-

cedures would be the interpretation by the pharmacist of the physician’s original …

order for the patient. In many hospitals, the pharmacist never sees the physician’s

original order. In cases where the physician does write an original prescription, he

does so only for a limited number of drugs, the other drugs being stock items on the

nursing units. In many cases the pharmacist receives only an order transcribed by a

nurse or even more commonly by a lay person such as a ward clerk. As a result, errors

made by the prescribing physician and errors made in transcribing his orders often

go undetected, while the patient receives the wrong drug, the wrong dosage form, or

wrong amount of the drug, or is given the drug by injection when oral administra-

tion was intended, and vice versa.

11(p115)

Studies documented important benefits to unit dose drug distribution, includ-

ing greater nursing efficiency, better use of the pharmacist’s talents, cost savings, and

improved patient safety.

20,21

The key elements of unit dose drug distribution, as the system

has evolved from the original studies, are as follows:

1. The pharmacist receives the physician’s original order or a direct copy of the order.

2. A pharmacist reviews the medication order before the first dose is dispensed.

3. Medications are contained in single-unit packaging that is labeled appropriately.

4. Medications are dispensed in as ready-to-administer form as possible.

5. Not more than a 24-hour supply of doses is delivered or available at the patient

care area at any time.

6. A patient medication profile is concurrently maintained for each patient.

These fundamental precepts for safe drug distribution are met widely in U.S. hospitals

today.

Early unit dose drug distribution systems were very labor intensive, which stimulated

an expansion in the use of pharmacy technicians (see Figure 2-4).

Working from pharma-

cist-reviewed handwritten physician orders, pharmacy staff added patients’ medications

(in unit dose packages) to mobile cabinets, which were then transported to patient care

areas. Guided by a record of physicians’ orders, nurses administered the medications and

manually created a medication-administration record. Modern unit dose systems are highly

automated, including the use of computerized physician order entry (with clinical decision

support in most hospitals), application of machine-readable labeling of unit dose packages

in dispensing and administration, robotic picking of doses for unit dose carts, or automated

dispensing cabinets that are accessed by nurses. U.S. hospitals have exerted immense effort

in applying computer technology to improve the safety of the medication-use process,

stimulated in part by federal incentives.

The development of pharmacy-based intravenous (IV) admixture services, beginning

in the 1960s, made a tremendous contribution to patient safety. Previously, nurses largely

carried out this task in patient care areas.

Because of the advocacy of groups such as the National Academy of Medicine and vari-

ous federal health agencies, improving patient safety is a major national priority.

Because

that general interest in patient safety embraces medication-use safety, hospital pharma-

cists have cheered and felt “it’s about time!” Breakthrough advances in medication-use

safety will depend on further reengineering of the entire medication-use process, a shift

toward a true team culture in providing care, and continued implementation of informa-

tion technology.

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 27

PROMOTING RATIONAL DRUG USE

Edward Spease (dean of the School of Pharmacy at Western Reserve University) and Robert

Porter (chief pharmacist at the University’s hospitals) first promulgated the concept of a

pharmacy and therapeutics (P&T) committee in U.S. hospitals as a formal mechanism

for the pharmacy department and the medical staff to communicate on drug-use issues

in 1936.

11(p139)

Subsequently, the AHA and ASHP jointly developed guidance on the P&T

committee and on the operation of a hospital formulary system. The formulary system

is a method whereby the medical staff of a hospital, working through the P&T committee,

evaluates and selects from among the drug products available those that are considered

most useful in patient care. The formulary system is also the framework in which a hospi-

tal’s medication-use policies are established and implemented.

A major imperative for the advocates of the formulary system in the mid-1900s was

to manage the proliferation of drug products. In just one year, 1951, the number of market

entries consisted of 330 new drug products, including 35 new drug entities, 74 duplications

of drug entities, and 221 combination products.

In 1957, slightly more than half of all hos-

pitals operated under the formulary system.

Today, essentially all hospitals do so.

In 1957,

58% of hospitals had an active P&T committee, and a similar percentage of hospitals had a

formulary or approved drug list. However, about one-fourth of the P&T committees were

inactive.

Today, nearly all hospitals in the United States have an active P&T committee

that meets an average of seven times a year.

In the late 1950s, the functions of P&T committees focused on very basic activities such

as delegating to the chief pharmacist responsibility for preparing product specifications

and selecting sources of supply (66% of committees) and approving drugs by nonpropri-

etary name (50%).

In most hospitals today, under the guidance of the P&T committee,

pharmacists are involved in selecting a patient’s medication and its dosing following a phy-

sician’s diagnosis, developing drug therapy guidelines, engaging in therapeutic interchange,

and conducting medication-use evaluations.

FIGURE 2-4. A sense of the labor- and paper-intensiveness of early unit dose drug distribution systems is con-

veyed in this image from the pharmacy department at Providence Hospital, Seale, Washington, circa mid-1960s.

Source: ASHP Archives, Herbert Flack Photograph Collection.

28 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

In summary, concepts first advanced

in the 1930s regarding a formal linkage

between the hospital pharmacy department

and the medical staff with respect to drug-

use policy have taken hold firmly. Hospital

pharmacists are heavily engaged in helping

the medical staff establish drug-use policies,

in implementing those policies, in monitor-

ing compliance with those policies, and in

taking corrective action as needed. Addi-

tionally, there is a trend toward authorizing

hospital pharmacists to select the medica-

tion regimen for a patient after a physician

has made the diagnosis. The invention of

the P&T committee and the formulary sys-

tem has facilitated continuous advancement

in the involvement of pharmacists in pro-

moting rational drug use in hospitals.

HOSPITAL PHARMACISTS AS PATIENT CARE PROVIDERS

U.S. hospital pharmacists have evolved markedly in their self-concept over the past 60

years. Thirty years ago, the traditional pharmacist mission still predominated, a mission

that was captured in the words, right drug, right patient, right time, connoting a drug-

product-handling function. Right drug in this context meant whatever the physician

ordered. Today’s philosophy about the mission of pharmacists focuses on whether patients

are achieving the optimal outcomes from the use of medicines. An expression sometimes

used to summarize this philosophy is, “The pharmacist is responsible for helping a patient

make the best use of medicines.”

The Joint Commission of Pharmacy Practitioners (JCPP),

an alliance of all national pharmacist organizations, has expressed its consensus vision

as follows: “Patients achieve optimal health and medication outcomes with pharmacists

as essential and accountable providers within patient-centered, team-based healthcare.”

However expressed, the words reflect a profound paradigm shift with respect to the primary

purpose of pharmacy practice.

The active consensus-building efforts by hospital pharmacy leaders stimulated the

transformation of the hospital pharmacy department from a product orientation to a clini-

cal orientation. One important example of such efforts was the ASHP Hilton Head confer-

ence.

32,33

The Hilton Head meeting was a consensus-seeking invitational conference conducted

in 1985 in Hilton Head, South Carolina, officially designated as an invitational conference

on Directions for Clinical Practice in Pharmacy. The purpose of the meeting was to assess

the progress of hospital pharmacy departments in implementing clinical pharmacy. What

emerged from the event was the idea that clinical pharmacy should not be thought of as

something separate from pharmacy practice as a whole. Rather, hospital pharmacies should

function as clinical departments with a mission of fostering the appropriate use of medi-

cines. This was a very important idea because most hospital pharmacists thought in terms

of adding discrete clinical services (e.g., pharmacokinetic monitoring) rather than concep-

tualizing the totality of the department’s work as a clinical enterprise.

KEY POINT . . .

The invention of the P&T commiee

and the hospital formulary system has

facilitated the deep involvement of

pharmacists in promoting rational drug

use in hospitals.

. . . SO WHAT?

The pharmacist’s role on the P&T

commiee has allowed pharmacists

to build their professional standing

in institutions. If they had never

accepted leadership in establishing and

maintaining these commiees, their

inﬂuence might have been diminished.

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 29

Working through its affiliated state societies, ASHP supported repetitions of the Hil-

ton Head conference on a regional basis. ASHP leaders spoke at meetings around the coun-

try about the ideas of Hilton Head, and the American Journal of Hospital Pharmacy pub-

lished numerous papers on the subject.

As a result, many individual pharmacy departments began to hold retreats of their

staffs to reassess the fundamental mission of their work. It was common for departments

to adopt mission statements that, for the first time, framed their work not in terms of drug

distribution but in terms of achieving optimal patient outcomes from the use of medicines.

They were supported by a growing body of scientific evidence, published in both the medi-

cal and pharmacy literature, about the positive outcomes achieved through pharmacist

involvement in direct patient care.

34-37

In more recent times, ASHP conducted

important consensus-seeking events related

to the pharmacy practice model in hospi-

tals and in ambulatory care clinics.

38,39

Both

conferences issued bold recommendations

on how to better align the capacity of phar-

macists with the challenge of improving

the responsible use of medicines. This chal-

lenge faces all sectors of pharmacy practice,

and important work is being done on that

broader front, as evidenced by JCPP’s prom-

ulgation of a standard patient care process

for pharmacists, which can be applied in

all practice settings.

Expanded pharma-

cist engagement in patient care is a natural

side benefit of healthcare leaders’ efforts to

improve team-based patient care.

Some examples of hospital pharma-

cists’ growing role as patient care providers

include pharmacists routinely monitoring

medication serum levels (95% of hospi-

tals),

pharmacists managing anticoagulation therapy (84% of hospitals),

pharmacists

performing patient care functions in the emergency department (22% of hospitals),

and

pharmacists routinely assigned to monitor a majority of patients at least 8 hours per day, 5

days per week (53% of hospitals).

In summary, U.S. hospital pharmacists today are engaged in extensive clinical activity

(often as full-fledged members of patient care teams), which is a major change from prac-

tice of 60 years ago. In many hospitals today, patients can be confident that their medica-

tion therapy is receiving close oversight by pharmacists.

HOSPITAL PHARMACISTS AND AMBULATORY CARE

Stimulated by various healthcare marketplace changes (including payment reform), most

hospitals have become components of health systems that encompass primary care and

specialty physician services as well as other facets of healthcare such as home care, long-

term care, outpatient surgery, chemotherapy infusion, and urgent care. The trend in health

KEY POINT . . .

Aer the Hilton Head conference,

hospital pharmacy departments began

to frame their work not in terms of

drug distribution but in terms of

achieving optimal patient outcomes

from the use of medicines.

. . . SO WHAT?

The Hilton Head conference changed

the practice model in institutions away

from the process of drug distribution

to a system of care that aempts to

achieve optimal health outcomes.

Many of the profession’s initiatives in

hospital practice have their origin in

this conference.

30 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

insurance coverage is to reward good patient outcomes and penalize poor outcomes,

focusing on an entire episode of care, before, during, and after hospitalization. This gives

hospitals a strong incentive to ensure that patients experience successful recovery after

discharge from inpatient care. Because post-discharge healing and recovery often depend

on how well medication therapy is handled, many hospitals are engaging pharmacists in

medication adherence and monitoring programs for discharged patients.

A strong movement has emerged to place all facets of the pharmacy enterprise in a

health system under consolidated leadership.

44,45

In particular, pharmacy practice leaders

who have such system-wide responsibility have moved assertively to establish pharmacists

on the patient care teams of primary care and specialty clinics.

ASHP data indicate that

about one-third of hospitals have pharmacists practicing in ambulatory care or primary

care clinics.

There is substantial evidence of patient benefit when pharmacists collaborate closely

with primary care and chronic care providers, for example in optimizing the care of patients

with diabetes, asthma, or cardiovascular disease.

Contemporary observers predict that

hospital pharmacists will become increasingly active in rigorously coordinating post-acute

care services

and that individual hospital pharmacists will have patient care responsibili-

ties for both inpatients and outpatients.

Specialized pharmacy residency training

and

specialty certification

are expanding the number of pharmacists who are qualified to con-

tribute to the care of ambulatory patients.

In summary, after a half century of concentrating on the medication-related needs of

inpatients, hospital pharmacists are increasingly expanding their focus to the care of ambu-

latory patients; it is likely that the historic lines separating acute care pharmacy practice

from ambulatory care pharmacy practice will become blurred.

RECAP OF MAJOR THEMES

Thus, we have a picture of the thrust of major changes in hospital pharmacy over the past

60 years. The five major themes have been, first, the universal recognition by hospitals

that pharmacists must be in charge of drug product acquisition, distribution, and control;

second, hospital pharmacy departments have assumed a major role in patient safety; third,

pharmacy departments have assumed a major role in promoting rational drug therapy;

fourth, hospital pharmacists have become patient care providers; and, finally, pharmacy

departments have expanded their focus to include patients in ambulatory care clinics.

Taken together, these changes signify that pharmacy practice in U.S. hospitals over the

past 60 years has become more intensive in its professional staffing, more directly focused

on patient care, and more directly influential on the quality and outcome of patient care.

Hospital pharmacy has been transformed from a marginal, optional activity into a vital

profession contributing immensely to the health and well-being of patients and to the

stability of the institutions that employ them.

EXPLAINING THE TRANSFORMATION

A combination of indirect and direct factors helps explain this transformation in hospital

pharmacy. Indirect factors are those forces external to hospital pharmacy that fostered

development of the field. These external factors include the following:

Shift of national resources into healthcare, especially hospital care (stimulated

immensely by implementation of Medicare in 1965 and expansion of other health

insurance coverage)

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 31

Expanded research on human health, which led to greater understanding of dis-

ease and development of targeted drug therapies

Greater complexity and cost of drug therapy accompanied by sophisticated phar-

maceutical product marketing

Expanded information technology and automation

A national commitment to improving healthcare quality and moderation of health-

care expenditures

More important for this chapter’s discussion are the internal factors within hospital

pharmacy that precipitated the field’s advancement. In this category, five points merit dis-

cussion:

1. Visionary leadership

2. Professional associations

3. Pharmacy education

4. Postgraduate residency education and training

5. Practice standards

VISIONARY LEADERSHIP

One cannot read the early literature of hospital pharmacy in the United States without

being impressed by the clear articulation of an exciting, uplifting vision by that era’s prac-

tice leaders. These views were being expressed at a time when pharmacy was a marginal

profession in the United States; when most pharmacists were engaged primarily in retail,

mercantile activities; when hospital pharmacy had little visibility and respect; and when

hospital pharmacy was a refuge for

pharmacists who preferred minimal

interactions with the public. Out of

this environment emerged a number

of hospital pharmacists, many of

them at university teaching hospi-

tals, who expressed an inspiring

vision about the development of

hospital pharmacy and the role of

hospital pharmacy in elevating the

status of pharmacy as a whole.

These were leaders such as

Arthur Purdum, Edward Spease,

Harvey A. K. Whitney, and Donald

E. Francke (to mention only a few)

who were familiar with the his-

tory of pharmacy and had a sense

of pharmacy’s unfulfilled potential.

Many of them had seen Western

European pharmacy firsthand and

decried the significant gap in profes-

sional status and scope of practice

between that area of the world and

the United States.

KEY POINT . . .

One cannot read the early literature of hospital

pharmacy in the United States without being

impressed by the clear articulation of an

exciting, upliing vision by that era’s practice

leaders.

. . . SO WHAT?

Hospital pharmacy has not always been the

way it is now. It was built by pharmacists who

led change in practice. In order for institutional

pharmacy practice to thrive in the future,

pharmacy students and newly graduated

pharmacists will need to accept leadership

positions vacated by pharmacy leaders

who retire or leave the profession for other

opportunities. They will need to provide a new

vision for the profession for the 21st century.

32 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

A sense of these leaders’ deep feelings is found in the following comment by Edward

Spease, a retired pharmacy dean speaking in 1952 about his initial exploration of hospital

pharmacy 40 years earlier:

I expected to see true professional pharmacy in hospitals and was much disap-

pointed that it did not exist there. The more I observed and heard about the growing

tendency towards commercialism in drugstores, the more I felt that if professional

pharmacy was to exist, let alone grow to an ideal state, it would have to be in the

hospital where the health professions were trained…. Good pharmacy is as impor-

tant in hospitals away from teaching centers as it is in the teaching and research

hospital. It can be developed to a high degree of perfection there, too, if the pharma-

cist can get the picture in his mind.

The words, if the pharmacist can get the picture in his mind, reflect the goal of creating

a new model for pharmacy practice in hospitals that transcended the marginal profession-

alism that prevailed in most community pharmacies. Spease and other hospital pharmacy

leaders of the day were change agents who had a missionary zeal and were blessed with the

ability to infect others with their passion.

It is noteworthy that the Mirror to Hospital Pharmacy framed the entire audit of the

field in the context of professional advancement. Remarkably, more than 50 years after its

publication, the Mirror’s discussion of the essential characteristics of a profession

11(pp35-40)

still has the capacity to inspire pharmacy students and practitioners.

PROFESSIONAL ASSOCIATIONS

ASHP, the national organization of hospital pharmacists, has had a profound effect on the

advancement of the field. The visionary hospital pharmacists of the early 1900s focused

much of their energies on the creation of an organizational structure for hospital pharmacy.

One landmark event was the creation of the Hospital Pharmacy Association of Southern

California in 1925. On a national level, organizational efforts were funneled through the

American Pharmaceutical Association (APhA), the oldest national pharmacist organization

in the country. For years, hospital pharmacists participated in various committee activities

of APhA focused on their particular interest. Then, in 1936, a formal APhA subsection on

hospital pharmacy was created. This modest achievement evolved to the creation of ASHP

in 1942 as an independent organization affiliated with APhA.

There are two essential things that ASHP has done for the advancement of hospital

pharmacy. One is to serve as a vehicle for the nurturing, expression, and actualization of

the professional ideals and aspirations of hospital pharmacists. This was done through the

pages of the Bulletin of the American Society of Hospital Pharmacists (which later became

the American Journal of Hospital Pharmacy). In its early years, ASHP conducted a series of

educational institutes that were very influential in enhancing knowledge and skills and in

building esprit de corps among hospital pharmacists.

Also noteworthy, especially as the

organization has grown in size and diversity, is ASHP’s efforts to develop consensus about

the direction of pharmacy practice.

32,33,38,39,54

The second essential act of ASHP has been its creations of resources to assist practitio-

ners in fostering the development of hospital pharmacy practice. One example is the AHFS

Drug Information reference book and database that are widely used independent sources

of drug information in U.S. hospitals. ASHP publications and other activities such as the

Midyear Clinical Meeting have produced a source of funds beyond membership dues that

are used to develop a broad array of services to help members advance pharmacy practice.

The original objectives of ASHP were as follows:

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 33

Establish minimum standards of pharmaceutical service in hospitals

Ensure an adequate supply of qualified hospital pharmacists by providing stan-

dardized hospital pharmacy training for 4-year pharmacy graduates

Arrange for interchange of information among hospital pharmacists

Aid the medical profession in the economic and rational use of medicines

The core strengths of ASHP today are as follows:

Practice standards and professional policy

Advocacy (government affairs and public communications)

Network of autonomous affiliated state societies

Practitioner education

Residency and technician training accreditation

Drug information resources

Publications and web-based resources

Practitioner networking

One of the reasons for ASHP’s success has been its clarity about objectives and its

concentrated focus on a limited number of goals. It is a testament to the wisdom of ASHP’s

early leaders that the goals expressed in 1942 still serve to guide the organization, although

different words are used today to express the same ideas, and some other points have been

added. The organization continues as a powerful force in the ongoing efforts to align phar-

macists with the needs that patients, health professionals, and administrators in hospitals

have related to the appropriate use of medicines.

PHARMACY EDUCATION

There are three important points about the role of pharmacy education in transforming

hospital pharmacy. First, as pharmacy education as a whole has been upgraded over the

years, hospital pharmacy has benefited by gaining practitioners who are better educated

and better prepared to meet the demands in hospital practice. Second, hospital pharmacy

leaders have put considerable pressure on pharmacy educators to upgrade the pharmacy

curriculum, to make it more consistent with the needs in hospital practice. This is signifi-

cant because practice pressure to meet the demands in hospitals served to elevate education

for all pharmacists. Also, beginning in the 1970s, corresponding with increased emphasis

on clinical pharmacy in the curriculum, hospital pharmacies played a much larger role in

pharmacy education as clerkship (experiential) rotation sites for pharmacy students. Third,

in the early days of clinical education, faculty members from schools of pharmacy began

establishing practice sites in hospitals, which often had a large impact on the nature of the

hospital’s pharmacy service.

Table 2-1 shows how the minimum requirements for pharmacy education have evolved

over the years. It took a long time for pharmacy in the United States to settle on the

PharmD as the sole degree for pharmacy practice. Many bitter fights—between educators,

between practitioners, among educators and practitioners, and among educators and the

retail employers of pharmacists—occurred over this issue. After the matter was settled,

everyone has moved on with the intention of making the best application of the pharma-

cist’s excellent education.

Over the past 30 years, pharmacy education in the United States has been transformed

completely from teaching primarily about the science of drug products to teaching primar-

ily about the science of drug therapy. Transformation of hospital pharmacy practice from

a product orientation to a patient orientation was greatly stimulated by this change in

education.

34 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

POSTGRADUATE RESIDENCY EDUCATION AND TRAINING

Stemming from their concerns about the inadequacy of pharmacy education for hospital

practice, early ASHP leaders advocated internships in hospitals and worked for years to

establish standards for such training. This led to the concept of residency training in

hospital pharmacy and a related ASHP accreditation program.

53,56,57

Early hospital pharmacy leaders noted the following imperatives for hospital pharmacy

residency training

11(pp157-167)

Hospitals were expanding, thereby creating a growing unmet need for pharmacists

who had been educated and trained in hospital pharmacy

Pharmaceutical education was out of touch with the needs in hospital pharmacy

The internship training required by state boards for licensure was not adequate

preparation for a career in hospital pharmacy practice

Hospital pharmacists required specialized training in manufacturing, sterile solu-

tions, and pharmacy department administration

Organized effort was needed to achieve improvements in hospital pharmacy

internships or residencies

Tens of thousands of pharmacists in hospital pharmacy practice today have completed

accredited residency training. These individuals have been trained as practice leaders and

change agents. Early in their careers, they came to understand the complexity of hospital

pharmacy, including inpatient operations, outpatient services, drug product technology

and quality, and medication-use policy. Residency training is the height of mentorship in

professionalism in American pharmacy. Residency training guides young pharmacists in

developing a personal vision (along with the requisite knowledge, abilities, and attitudes)

for dedicating their careers to helping the profession achieve its full potential.

PRACTICE STANDARDS

Numerous legal and quasi-legal requirements affect hospital pharmacy practice. On the

legal end of the spectrum are various federal laws governing drug products and state prac-

tice acts governing how the pharmacist behaves and how pharmacies are operated. At the

opposite end of the spectrum are voluntary practice standards promulgated by organiza-

tions such as ASHP.

TABLE 21.

Evolution of Minimum Requirements for Pharmacist Education in the

United States

Year Minimum Requirement (Length of Curriculum and Degree Awarded)

1907 2 years (Graduate in Pharmacy)

1925 3 years (Graduate in Pharmacy or Pharmaceutical Chemist)

1932 4 years (BS or BS in Pharmacy)

1960 5 years (BS or BS in Pharmacy)

2004 6 years (PharmD)

Transition period; some schools offered only the BS or the PharmD degree; many schools offered both degrees,

with the PharmD considered an advanced degree.

CHAPTER 2 OVERVIEW OF THE HISTORY OF HOSPITAL PHARMACY IN THE UNITED STATES 35

A practice standard is an authoritative advisory document, issued by an expert body,

offering advice on the minimum requirements or optimal method for addressing an impor-

tant issue or problem. A practice standard does not generally have the force of law. Meth-

ods used to foster compliance with practice standards include education and peer pressure.

ASHP’s practice standards have been very important in elevating the scope and quality of

hospital pharmacy practice in the United States.

The origins of hospital pharmacy practice standards go back to 1936 when the Ameri-

can College of Surgeons adopted the Minimum Standard for Pharmacies in Hospitals. This

document was semi-dormant for a number of years, but it served as a rallying point for

hospital pharmacists

and revision and promulgation of the Standard became a priority

for ASHP.

The revision pursued by ASHP in the 1940s specified the following minimum

requirements:

An organized pharmacy department under the direction of a professionally com-

petent, legally qualified pharmacist

Pharmacist authority to develop administrative policies for the department

Development of professional policies for the department with the approval of the

P&T committee

Ample number of qualified personnel in the department

Adequate facilities

Expanded scope of pharmacist’s responsibilities:

• Maintain a drug information service

• Nurse and physician teaching

• File periodic progress reports with administrator

P&T committee must establish a formulary

From this modest beginning, ASHP in 2016 had more than 100 practice standards

(including some endorsed documents developed by others) that covered a wide range of

philosophical and practical aspects of hospital pharmacy practice and several important

areas of therapeutics.

ASHP actively updates existing standards and develops new docu-

ments to guide emerging issues in practice.

ASHP practice standards have been used effectively over the years as a lever for advanc-

ing the scope and quality of hospital pharmacy services. The standards have been used in

the following ways:

Requirements for pharmacy practice sites that conduct accredited residency pro-

grams

Guidance to practice leaders who aspire to provide state-of-the-art pharmacy ser-

vices

Guidance to hospital accreditation organizations such as The Joint Commission in

establishing requirements for the medication-use process

Tools for pharmacy directors who are seeking administrative approval for practice

changes

Guidance to regulatory bodies and courts of law

Guidance to curriculum committees of schools of pharmacy

36 INTRODUCTION TO ACUTE AND AMBULATORY CARE PHARMACY PRACTICE

SUMMARY OF INTERNAL FACTORS

In summary, five internal factors have played a major role in transforming U.S. hospital

pharmacy over the past 60 years: (1) visionary leadership, (2) a strong professional society,

(3) reforms in pharmacy education, (4) residency training, and (5) practice standards.

The common element among these forces has been dissatisfaction with the status quo

and a burning desire to bring hospital pharmacy in better alignment with the needs of

patients and the needs of physicians, nurses, other health professionals, and administra-

tors in hospitals related to the responsible use of medicines. These success factors are far

more than historical curiosities; contemporary leaders of the field continue to be faithful

to them, as reflected in the organizational activities and current literature of hospital and

health-system pharmacy.

n n n

SUMMARY

From the author’s perspective, colored to be sure by participation in the hospital pharmacy

movement for many years, four tentative lessons may be drawn from the history of U.S.

hospital pharmacy:

1. Fundamental change of complex endeavors requires leadership and time. Hospital

pharmacists are sometimes frustrated by the slow pace of change. Wider study

of history might help practitioners dispel that discouragement while learning to

formulate more effective strategies for advancement.

2. It is important to engage as many practitioners as possible in assessing hospital

pharmacy’s problems and identifying solutions, so that a large number of individu-

als identify with the final plan and are committed to pursuing it.

3. It is critical to recognize and capitalize on changes in the environment that may

make conditions more favorable to the advancement of hospital pharmacy. This

requires curiosity about the world at large and the ability to spot and analyze rel-

evant trends.

4. It is important to regularly and honestly assess progress and embark on a new

approach if the existing plan for constructive change is not working or has run its

course. This requires open-mindedness and a good sense of timing.

Today’s challenges in hospital pharmacy are no more daunting than those that faced

hospital pharmacy’s leaders and innovators in the past. Fortunately, hospital pharmacy is

imbued with a culture of taking stock, assessing the environment, setting goals, making

and executing plans, measuring results, and refining plans. If hospital pharmacy sticks to

this time-tested formula, it will continue to be a beacon for the profession as a whole.