ACKNOWLEDGEMENT

We wish to express our sincere gratitude to Medical Director, administration, Karachi institute of Heart disease, Karachi, Pakistan for giving us the opportunity to do Junior Internship at this highly esteemed organization. We are grateful to Dr. Sana (Pharmacist) and Mr Ateeq-ur-rehman (procurement officer) for their valuable guidance, encouragement, suggestion and advice rendered to us at every stage. The guidance and support received from all the members who contributed to this study was vital for the completion of this study. We are grateful to all of them for their constant support and guidance either directly or indirectly towards completion of our internship. Khadija Faryal Ummul Baneen

Table of Contents
Introduction to the hospital...3
Departments and facilities....4 Services...4, 5 Diagnostic services.5, 6 Departments at KIHD...7, 8 Introduction to Pharmacy Department...9 Roles for hospital pharmacists....10 Formulary.11 Sales...11 Outpatients11 Inpatient prescriptions11 Main store..12 Stock checking...13 Breakage.13

Case studies

Karachi Institute of Heart Diseases (KIHD) is one of the main tertiary care teaching hospitals of Pakistan. It is located in the center of city, Karachi and has started functioning on June 3,2005. The main function of the institute is to undertake modern treatment of cardiovascular diseases, carryout research, prevention and control of cardiovascular diseases, undertake training of medical students and nurses both undergraduate and postgraduate level and develops itself into a center of excellence for treatment of cardiovascular diseases. KIHD is 370 beds teaching hospital, including 22 beds fully equipped Emergency Room, CCU, Medical Wards, Surgical Wards, Private Wards, Intensive Care Unit, Two Cardiac Catheterization Laboratories, Two Surgical Theaters, ECHO, ETT and Nuclear Imaging Department, Rehabilitation Center, Research Department and Laboratory for routine blood investigations.

Departments and Facilities:

Clinical Cardiology. Interventional Cardiology. Nuclear Cardiology. ESMR. Non-Invasive Cardiology. Epidemiology & Research. Cardiovascular Surgery. CME & Training. Pediatric Cardiology. Workshop & Symposium.

Services:
1) Emergency The emergency of KIHD is 20 bedded and can be extended up to 25 beds. It is a large spacious hall equipped with state of the art equipment. All the beds have ECG & BP monitors (Welch Allyn, USA), central oxygen & suction, computerized ECG machines, Defibrillator (Life Pack-20, Medtronic, USA) with external pace maker are also available.There is a separate area for female patients. The emergency will work round the clock. The medical and paramedical staffs are posted in three shifts. . 2) CCU The coronary care unit of KIHD is a 20 bedded unit. The CCU is also equipped with state of the art equipments. All the beds have ECG & BP monitors (Welch Allyn, USA) with some other parameters and are connected with the 3 central monitors (Welch Allyn, USA) at the nursing station. There are central oxygen and suction lines, ECG Machines (Mortare,USA), Defibrillators (Life Pack-20, Medtronic,USA) with external pace makers and ventilators (Viasys Health Care-Bird,USA) besides other routine patient care facilities. 3) OPD Karachi Institute of Heart Diseases is the first institute of cardiology of Pakistan providing separate OPD facilities for male and female patients. The entire staff of female OPD including doctors, technicians and nursing staff will be female.Both the male and female OPDs have large waiting areas, doctors rooms, consultant's room, ECG rooms, ETT and Echo facilities separately.

4) Wards There are 3 wards each with 20 beds, Male ward I and male ward II and one ward for female patients. The private ward has 20 rooms. Each ward has been provided with ECG machine, Defibrillator with external pacemaker and equipments.

Diagnostic services:
1) ECG The ECG system is of Mortara, USA providing multichannel ECG connected with a centralized computer system and accessories at predefined PC bases stations. 2) Laboratory The Institute has a fully automated and computerize laboratory which is 4 working under the supervision of a Consultant Pathologist and qualified and trained staff. The laboratory is equipped with the following equipments: Chemistry Analyzer automatic - Selectra E (Netherlands). Chemistry Analyzer Semiautomatic - Microlab-300 (Netherlands). Electrolyte Analyzer - Beckman Coulter EL-ISE (USA). Hematology Analyzer - Beckman Coulter ACT-18 Channel (USA). Cougulometer - Sysmex CA-50 (Japan). Urine Analyzer- Urykon 300 (Germany). Microscope -MC-200 A, Micron (Austria). Sterlizer (Hot air/ oven) ED-53, Binder (Germany). 3) X-Ray The x-ray department of the institute works under the supervision of a consultant radiologist. It is equipped with High frequency C-Arm with fluoroscopy. X-Ray Machine 500 mA. Mobile X-Ray with 100 mA. Automatic X-ray film processor. 4) ETT Lab There are four ETT machines, one for male OPD and other for female OPD. These ETT machines are fully computerized; one is Aspel and the other is Schiller ETT Systems. The ETT labs are equipped with all the necessary equipments including defibrillators and emergency resuscitation facilities. The ETT labs will function under the supervision of a

trained Registraration and experienced technician. 5) Echocardiography There are three Echo machines, one for male OPD and one for female OPD and one for paediatric OPD. These are the latest version of Toshiba Nemio 35, Xorio. The Echo lab has facilities for trans esophageal echo and stress echo also. This will function under the supervision of qualified and experienced staff. All the reports will be reviewed by a consultant before the issuance of final reports. 6) Ambulatory ECG & BP Lab The ambulatory BP monitoring and ambulatory ECG (Holter) monitoring lab of the institute is fully equipped with latest equipment in the field. The system is fully computerized and both the systems are of Schillar. 7) Cath Lab The cath lab is equipped with two latest versions of Toshiba Angiography machine (Infinix -CSi) with all accessories, including physiological monitoring system (Pruka MacLa-2000 GE, USA) and electronic injector. There is a recovery room of 3 beds attached with the Cath lab equipped with invasive monitoring system, ventilator and defibrillator.

Departments at KIHD:
1) Clinical cardiology:
Unit-1 Located in 2nd Floor in Phase-II. Faculty Members: - Prof: Abdus Samad (MD, FACC), Head of The Department (HOD). - Associate Prof: Dr. Dad M. Jan Baloch. - Asst. Prof. Shoaib Yaqoob. - Sr. R. Dr. Inam Danish. - Sr. R. Dr. Arshad Bilal Usmani. Unit-2 Located in 1st Floor in Phase-I. Faculty Members: - Prof. Mohammad Ishaq (FRCP; FACC), Head of The Department (HOD). - Associate Prof: Dr. Zahid Rasheed. - Asst. Prof. Abdul Rehman. - Sr. R Tariq Farman. - Sr. R Ghazala Irfan.

2) Interventional cardiology:
Faculty Members: - Prof. Muhammad Ishaq. - Associate Prof. Dad Jan Baloch. - Dr. Shoaib Yaqoob. - Dr. Abdul Rehman. - Dr. Inam Danish. - Dr. Tariq Farman. - Dr. Ghazala Irfan.

3) Department of cardiovascular surgery:

Faculty Members: - Associate Prof and HOD: Junaid Alam Ansari (FRCS, CardiacSurgeon). - Asst. Prof. Syed Asad Ullah Hussaini (FRCS). - Sr. R. Sohail Siddiquie (FCPS). Non-Invasive Cardiology (Echo, ETT, Holter and B.P. Monitoring Labs): - Dr. Zahid Rasheed, Head of Department (HOD). - Dr. Izhar Rajput, Incharge.

4) Nuclear Cardiology:
Faculty Members : - Dr. Maseeh-uz-Zaman (HOD). - Dr. Nousheen Fatima.

5) Epidemiology and Research:

KIHD is one of the major tertiary care cardiac specified hospital which established a department of "Research & CME" in April 2008. The department is being supervised by an Assistant Professor, Dr. Javed Ismail, who in addition to his MBBS also has his MSc in epidemiology from Aga Khan University. Promotion of research activities are the top most priority of the "R & CME Department".

6) Department of Anaesthesthesiology:
Chief OT Technician: M. Sajid Khan (Civil Hospital).

Introduction to Pharmacy department:

Pharmacy (from the Greek word 'pharmakon' = drug) is the health profession that links the health sciences with the chemical sciences, and it is charged with ensuring the safe and effective use of medication. The scope of pharmacy practice includes more traditional roles such as compounding and dispensing medications, and it also includes more modern services related to patient care, including clinical services, reviewing medications for safety and efficacy, and providing drug information. Pharmacists, therefore, are the experts on drug therapy and are the primary health professionals who optimize medication use to provide patients with positive health outcomes. The term is also applied to an establishment used for such purposes. The first pharmacy in Europe (still working) was opened in 1241 in Trier, Germany.

The pharmacy is one of the most extensively used therapeutic facilities of the hospital; it is one of the few areas of hospital where large amounts of money are spent of purchases on a recurring basis. It is also one of the highest revenue generating centers. A fairly high percentage of the total expenditure of the hospital goes for pharmacy services. It caters to out patients, inpatients, other areas like OT, Clinical laboratory.

Functions:
The features of the hospital pharmacy are as follows Procuring pharmaceutical items (a) Requisition (b) Purchase (c) Receiving (d) Checking (e) Storing.

Dispensing items
(a) Preparing (b) Packaging (c) Labeling (d) Dispensing.

Roles for hospital pharmacists:

Some roles of pharmacists in hospitals are > Clinical pharmacy: Working in wards and other clinical areas, such as the emergency department and outpatient clinics to provide patient care alongside doctors and nurses. > Medicines information: Searching and evaluating published medical and pharmaceutical literature to provide answers to enquiries from patients, doctors, nurses and other pharmacists. > Dispensing and patient counseling: Hospital patients often require complex and specialized medicine regimens that you don't often see outside a hospital. These patients rely heavily on the hospital pharmacist for information to ensure they know how to use their medicines. > Clinical trials: Some hospitals are involved in large numbers of clinical trials, and pharmacists are responsible for coordinating and monitoring these trials. > Hospital in the Home: Some patients are treated as hospital inpatients in their homes, many are treated daily with intravenous medicines that are prepared and monitored by the hospital pharmacist. > Drug Use Evaluation: An important part of hospital pharmacy services is the ongoing monitoring of prescribing patterns and development of prescribing guidelines to improve the quality use of medicines.

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Formulary:
There is a Pharmacy Advisory Committee comprising of the director, medical director, and then manager of pharmacy etc.This committee has prepared a list of approved drugs that can be prescribed by their hospital doctors. This list of hospital approved drugs is circulated among all the departments. This list is reviewed on a regular basis at a frequency of at least 3 months.

Sales:
The pharmacy caters to Outpatient, Inpatients, patients undergoing surgery and walk-in patients also.

Outpatients:
Doctors give the prescriptions to the patient which he/she brings it to the pharmacy. The Pharmacist receives the prescription. He/she then places all the medicines and items required one by one at the space below the dispensing counter. She then gives the prescription to the computer operator for entering the particulars taken, amount taken and issue a bill for the same. In the mean while the pharmacist packs the medicines well and puts it in a hand cover. After the bill is generated the computer operator hands it over to the pharmacist. Once the pharmacist receives the bill she gives it along with the packed medicines to the cashier. As the pass box through the cashiers counter is not too big, large amount of medicines cannot be given to the customer through the box. At such times the pharmacist gives only the bill to the cashier. After payment is done by the customer the pharmacist hands over the medicines. The cashier receives the cash from the customer puts a seal saying cash received and gives a copy to the customer and keeps the copy with himself.

Inpatient prescriptions:
The doctor prescribes the medicines required. The prescription is brought by the patients attendees to the pharmacy. The drugs are dispensed in the same way as for outpatients and its the same principle cash and carry.

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Main store:

There are plastic trays in the cabinets. In cabinets tablets, capsules, are stored in the trays and below the trays syrups, tonic bottles are kept. All the medicines, tablets and capsules are arranged in the alphabetical order.
1) In the cabinets ointment, lotions, drops, ampoules, fluids, respiratory solutions crepe Bandages, injections are also stored. 2) In each tray in the cabinets there are compartments where different companys drugs are stored. 3) Each tray is labeled with the drugs in it. 4) In the cabinets there is a separate storage area for only syringes. 5) Fast moving ampoules, syringes, IV fluids, IV set and lozenges like strepsils and few tables like digene are placed in trays. This provides for easy and fast access to frequently asked medicines. 6) There are closed cabinets below each shelf. The drugs are not replaced or placed in the cabinets until the medicine is over or almost over in the tray. Only when it is very less in number new drugs are placed in the tray. Until then the drugs are stocked in the closed cabinet below. This ensures the first in first out principle of drug delivery that is it ensures the drugs which were bought earlier are sold before the new stock being sold. 7) There is also a closed attic area for providing more storage area for drugs. 8) There is a separate store area for specific OT requirements. Here the items required for OT like, gloves, masks, orthopedic surgical requirements are stored. This area is called surgical stores. 9) There are two cupboards where costly items for surgical need are stored like tracheotomy tubes mesh etc is kept.

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10) In the same area there is a separate rack where expired drugs are kept until the particular distributor takes it back. This separate rack ensures that it does not get mixed with other drugs.

Stock checking:
Stock checking is done every half yearly. That is once in 6 months. The management decides upon a date for the stock checking and informs the chief pharmacist. The stock checking is done by all the pharmacy staff except 2 of them who will handle the sales during that period. Stock checking is completed within 24 hrs. A list of all the drugs in the pharmacy is taken from the software. A print out is taken the particular drug is checked and entry is made against the drug name the quantity present. The list at the end of the stock check is submitted to the management. As and when sales of medicines occur during the stock checking so much of the quantity is deducted from the list.

Breakage:
Breakage if occurs in the pharmacy, the broken number of pieces are informed to the supplier for replacement.

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