Hospital Pharmacist
Vol 9 No 4 p105-106
April 2002

(PDF* 65K)

Living life on the edge — working in an Israeli hospital

By Diane Langleben, BPharm, MRPharmS

A quick glance around the pharmacy department of Shaare Zedek Hospital in Jerusalem suggests much that is familiar to a visiting British hospital pharmacist. Situated as so many departments are, in the bowels of the hospital, it has been designed for its pharmaceutical purpose, with good work flow. The storekeeper has his office near the back entrance to facilitate receipt of incoming goods, with the IV store area in the immediate vicinity. Walking through the department, the visitor sees areas for storage, preparation (both sterile and non-sterile) and dispensing. There is a well equipped seminar room whose bookshelves hold reference books and journals from around the world, including Martindale, The Pharmaceutical Journal and Hospital Pharmacist. The drugs on the shelves are the same as those found anywhere in the developed world.

However, a closer inspection reveals the differences between the Israeli hospital pharmacy and its British counterpart. On the day of my visit, there was a sombre atmosphere in the department. Two days previously, the husband of one of the assistant pharmacists had been killed in a drive-by shooting and his funeral was to take place later that day.

"We are living life on the edge here," explains director of pharmacy, Alan Greenberg. "The situation in the Middle East means that there are many pressures, not only on life in general, but also in the work-place. There are only 20 general hospitals in Israel. In times of war, Shaare Zedek Hospital, like many others, becomes a military hospital since we have no separate military ones. The civilian patients have to be transferred elsewhere."

Because of the political situation, Israel is on permanent alert and there are many signs of this in the department itself. By way of illustration, Mr Greenberg points out the large trolleys to be used in emergencies. As well as a major incident trolley, there are also those packed with drugs to be used, if needed, during a gas or chemical attack.

Mr Greenberg goes on to talk about the profession of hospital pharmacy in the country. "As in the UK, the health care system is under enormous financial pressure. The system is run by doctors — all the top positions are held by doctors and the Minister for Health is usually a doctor. In addition, nurses also have a large power base because there are so many of them. In contrast, there are relatively few pharmacists and so we are only a small voice. In this hospital, pharmacists are now providing a clinical service but drug decisions are very much under the control of doctors. As anywhere, some individual relationships with the doctors are good, and some are bad."

Training

Training takes place at the two schools of pharmacy in Israel. The department of the Hebrew University in Jerusalem has an intake of 60 students per year, and another 40 students per year study at the new school of pharmacy at Beersheva University. The pharmacy course takes four years of study, including a six-month preregistration period. Pharmacists who are registered abroad and who wish to practise pharmacy in Israel, must take a course and pass an exam which they can sit in Hebrew, English or Russian.

"Recently, I had a pharmacist who was registered in Jordan and had to do work experience here before she could be considered for registration," says Mr Greenberg.

Registration of pharmacists is with the Ministry of Health. There are 5,000 registered pharmacists of whom 3,000 are working. Of these, 200 work in the hospital service.

The hospital

In general, hospitals in Israel are either owned by the state or funded privately (usually by a charity). Shaare Zedek (Gates of Righteousness) Hospital is one of the latter and has 400 beds to serve both Jewish and Arab patients. The birth rate at the hospital is the second highest in the country, standing at about 8,000 to 9,000 per year.

Shaare Zedek's pharmacy department is staffed by six pharmacists (including Mr Greenberg), of whom three work part-time, (5.4 full-time equivalent, FTE). By British standards, the number of pharmacists at the hospital seems paltry. However, the phar-macy does not dispense medicines for outpatients or for inpatients on discharge.

In addition there are five FTE technicians, who are known in Israel as assistant pharmacists. As Mr Greenberg explains, "There is a real battle in hospital pharmacy around the issue of technicians. They are perceived as a threat to the jobs of pharmacists who do so much of the technical work. However, at Shaare Zedek, we use technicians to provide our top-up services, CIVAS and total parenteral nutrition (TPN) preparation. This frees up pharmacists' time for clinical work. Many of the assistant pharmacists come from abroad, mainly from the former Soviet Union where there is training for technicians and who are known as pharmacists."

Surprisingly, there are 15 volunteers in the department, including a spry lady of 94 years. In return for undertaking such tasks as pre-packing, they receive lunch, meet their friends and feel that they are still useful to society.

Mr Greenberg introduced a ward pharmacy system in 1986, having brought the idea from Westminster Hospital, London. "All my pharmacists have clinical responsibilities on the wards. They have their own wards which they visit daily and each one develops his or her own specialty. Mine is cardiothoracic surgery," says Mr Greenberg. "Only half the wards are covered, with each pharmacist visiting about 50 beds. They look at the choice of drugs, doses, any interactions and problems associated with nasogastric feeding. I would like more technicians so that I can reduce the technical work still carried out by pharmacists and use the pharmacists to provide a clinical service to the whole hospital."

Research

At present, there is no pharmaceutical practice research in Israel. Mr Greenberg would welcome some, eg, to find out how many people are re-admitted to hospital because of their drug treatment.

"When we discovered that there were 100,000 errors each year (the vast majority being due to drug administration), it shook the hospital," says Mr Greenberg. "This represents 5 per cent of our dispensing and probably 1,000 of the errors are clinically relevant." Although the figure seems high, Mr Greenberg recognises that, in fact, it compared favourably with the error rate in the UK, which has been variously estimated at between 3 and 6 per cent.

Part of the team

Pharmacy can be seen as a key player in the hospital team by its participation each year in the hospital "grand round" where each clinical department gives a lecture to all professionals working there.

"We have taken part for the past six years and are considered equal to the other clinical departments," says Mr Greenberg. Topics covered include: compliance, drug review, monitoring of antibiotic drug levels, medication errors and their analysis for risk management.

The pharmacy department

A tour of the department revealed the familiar and the unfamiliar.

Non-sterile production Little non-sterile production is carried out at Shaare Zedek Hospital, and consists of only those items which cannot be bought in. The unit manufactures 20–30 items including silver nitrate solution, iodine solution and soap enemas. One interesting area of work relates to the treatment of metabolic problems. Within Arab society it is not unusual to find intrafamily marriages. The children of such marriages often have recessive gene problems which can give rise to metabolic diseases. The unit produces sodium phenyl- acetate to treat hyperammonaemia which is a feature of inborn errors of the urea cycle.

Sterile production The sterile production unit manufactures 1,500 IV additives per month. The work is carried out by a technician (0.7 FTE) and I am surprised to hear that her work is not checked. However, as Mr Greenberg explains, she has been thoroughly trained and the work consists of adding the contents of complete vials to infusion bags. "The methods used are based on those in the US and it is our experience that pharmacists make major mistakes in this type of work, not technicians," he says.

Shaare Zedek Hospital has one of the largest neonatal intensive care units in Israel, with room for more than 20 babies. Sometimes, the pharmacy prepares TPN for 10 babies at any one time.

The unit also makes up about 800 units of cytotoxic drugs per month. There is a well-organised system in place that ensures the cytotoxic drugs are prepared a day earlier than the patient's appointment so that they are immediately available when the patient arrives for treatment.

Clinical trials Shaare Zedek Hospital has a dedicated clinical trials room and takes part in most clinical trials being undertaken in Israel. The department writes its own protocols and Mr Greenberg sits on the hospital's Helsinki Committee which comprises doctors, mainly, with a few lay people, and representatives of nurses and pharmacists. The committee applies the principles of the Helsinki Declaration which is a recommendation to guide doctors in biomedical research involving human subjects and which is embodied in Israeli legislation covering the approval of clinical trials.

The dispensary The dispensary opens its doors between 10.30am and 4pm. This allows the staff, who begin their working day at 8am, to complete their clinical ward visits and such tasks as ward top-ups, cytotoxic production and filling of cardiac arrest boxes.

As explained earlier, only half of the wards are visited by a pharmacist. For the other wards, ward aids (usually young women doing National Service) bring the patients' drug charts down to the pharmacy.

The ups and downs

Mr Greenberg, born and educated in England, tells Hospital Pharmacist why he had chosen hospital pharmacy in Israel as his career path.

"I was attracted to hospital pharmacy because there is a sense of control. I don't think that you have that control in community pharmacy. You are buffeted by doctors and patients, and there is always the fear of leap-frogging."

Mr Greenberg concludes our conversation by describing some of the frustrations and much of what he says will have echoes for pharmacists working in the UK.

"The down side of pharmacy in Israel is the lack of unity, with three organisations representing different pharmaceutical interests.

"First, there is the Pharmaceutical Society of Israel which is the professional body and of which I am a member of the council. It should be issuing licences for pharmacists to practise, and not the Ministry of Health. The Society represents all branches of the profession and its aims are to improve pharmacy services, to deal with professional issues and to initiate necessary legislature to achieve these goals. It publishes a newsletter several times a year, and arranges regional meetings, international conferences and a continuing education programme.

"Second, there is Histadrut which represents the interests of pharmacy proprietors.

"Third, there is the union, Igud, which is roughly equivalent to the Guild of Healthcare Pharmacists. It looks after the interests of pharmacy employees, both pharmacists and assistant pharmacists, and negotiates their salaries. The core of people running Igud are non-pharmacists and they hold a lot of power. In a recent pay review, the salaries of pharmacists came out badly when compared with those of the assistants. This is a political issue which needs to be addressed."

At Shaare Zedek Hospital, Jews and Arabs work together and are treated as patients together, with respect and understanding. What is true in a hospital should be true in the wider society.

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