Bibliographic Notes
Chapter 3 RECURSIVE FINITE-DOMAIN PROGRAMS
3.3 Context-Free Languages
O estágio no LMPQFsP conclui a minha formação enquanto estudante do MICF permitindo-me aplicar o que aprendi durante estes últimos 5 anos, num ambiente profissional e real.
Durante 3 meses, pude experienciar o trabalho dum farmacêutico comunitário. Algo que vai muito para além de todo o conhecimento científico adquirido já que os utentes não estão nos livros e artigos.
Sem dúvida que foi uma experiência enriquecedora, que me permitiu confirmar que a farmácia comunitária é um espaço de excelência no que toca à prestação de cuidados de saúde e
confiabilidade para os portugueses sendo sempre estes o foco da atividade do farmacêutico. Os desafios que me foram lançados durante estes meses, permitiram acrescentar valor ao LPMQFsP bem como contribuir para a minha formação e, independentemente, do que o futuro me reservar, levo a certeza de que este estágio foi mais uma pedra basilar na minha construção enquanto farmacêutico e cidadão.
É com orgulho que me sinto parte duma profissão que se preocupa não só com o utente, mas com a preservação da Saúde Publica, munida de conhecimento e com vontade de afetar positivamente a vida das pessoas que nela confiam diariamente. No entanto, nada destas palavras bonitas seriam aplicáveis se não houvesse uma equipa de trabalho motivada, qualificada e com um espírito de entreajuda que diariamente trabalha para providenciar um serviço de qualidade, diferenciado e digno de quem quer melhorar a vida de pessoas. E essa, encontrei aqui no LMPQFsP.
É o fim de uma época, mas o início de outra e acredito que saiu deste estágio com mais maturidade, responsabilidade e esperançoso para novos desafios que virão.
Gostaria só de finalizar com uma frase que escrevi, após um belo dia na farmácia:
O conhecimento científico e a inteligência emocional característica da bata branca, permitem quebrar barreiras de comunicação e auxiliar os doentes no seu tratamento através dum ouvido atento, que compreende e que urge em ajudar, desmistificando dúvidas, aconselhando e, se necessário, confortando.
Muito Obrigado,
Bibliografia:
[1] História do LMPQF https://www.exercito.pt/ [Consultado a 5/10/2019]. [2] Decreto-Lei n.º 102/2019
[3] Laboratório Militar de Produtos Químicos e Farmacêuticos
https://pt.wikipedia.org/wiki/Laborat%C3%B3rio_Militar_de_Produtos_Qu%C3%ADmicos_e_ Farmac%C3%AAuticos [Consultado a 15/11/2019].
[4] SoftReis,SPharm http://www.sier.pt/services/softreis/ [Consultado a 15/11/19)
[5] Boas Práticas de Farmácia Comunitária https://www.ordemfarmaceuticos.pt/ [Consultado a 15/11/2019]
[6] Decreto-Lei n.º 307/2007
[7] Farmácia Comunitária https://www.ordemfarmaceuticos.pt/pt/areas-profissionais/farmacia- comunitaria/a-farmacia-comunitaria/ [Consultado a 15/11/2019]
[8] Portaria n.º 137-A/2012
[9] Portaria n.º 224/2015 de 27 de julho
[10] Deliberação N.º 173/CD/2011 do INFARMED
[11] Normas relativas à prescrição de medicamentos e produtos de saúde
https://www.infarmed.pt/documents/15786/17838/Normas_Prescri%C3%A7%C3%A3o/bcd0b3 78-3b00-4ee0-9104-28d0db0b7872 [Consultado a 15/11/19]
[12] Jacinto, A. and S. Oliveira-Martins, Substâncias psicoativas: problemática, estudo da legislação atual e da sua adequação face à realidade. Revista Portuguesa De Farmacoterapia, 2015. 7(2): p. 110-116.
[13] Gastos em Saúde https://eco.sapo.pt/2019/07/04/gastos-em-saude-em-2018-tiveram-o- maior-aumento-numa-decada/ [Consultado a 5/10/2019]
[14] Gasto do Estado com Medicamentos https://expresso.pt/sociedade/2019-10-10-Gastos-do- Estado-com-medicamentos-atingiram-em-2018-o-valor-mais-alto-dos-ultimos-sete-anos [Consultado a 7/10/2019]
[15] Decreto de Aprovação da Constituição [16] Decreto-Lei n.º 48-A/2010
[17] Portaria n.º 330/2016 de 20 de dezembro [18] Portaria n.º 1034/2009 de 11 de setembro
[19] Manual de Relacionamento das Farmácias com o Centro de Conferência de Faturas do SNS https://www.ccf.min-
saude.pt/portal/page/portal/estrutura/documentacaoPublica/ACSS/Manual%20de%20Relaciona mento%20de%20Farm%C3%A1cias%20VF%201.13.pdf [Consultado a 15/11/2019]
[20] Decreto-Lei n.º 134/2005 [21] Medicamentos de Venda Livre
https://www.apifarma.pt/tratardemim/Medicamentos%20de%20Venda%20Livre/Paginas/defaul t.aspx [Consultado a 15/11/19]
[22] Automedicação https://www.farmaciasportuguesas.pt/menu-principal/doencas- cronicas/automedicacao-e-bom-senso.html [Consultado a 15/11/19]
[23] Despacho n.º 17 690/2007
[24] Dispositivos Médicos https://www.infarmed.pt/web/infarmed/perguntas-frequentes-area- transversal/dm [Consultado a 15/11/19]
[25] Proposta para a regulação do Parlamento Europeu e do Conselho nos Dispositivos médicos https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A52012PC0542 [Consultado a 15/11/19]
[26] Portaria n.º 594/2004, de 2 de junho
[27] FIP. El Papel del Farmacéutico en el Sistema de Atencíon a la Salud: Atención
Farmacéutica. Informe de la Reunión de la OMS Tokio, Japón, 31 de Agosto al 3 de Septiembre 1993. Buenas Práticas de Farmácia: Normas de Calidad de Servicios Farmacéuticos. Tóquio: FIP, 1993-1994.
[28] Pharmacy Academy https://www.pharmacy-academy.pt/ [Consultado a 15/11/19] [29] Gastos Com Medicamentos https://www.sabado.pt/dinheiro/detalhe/gastos-com- medicamentos-sao-os-mais-altos-desde-2011) [Consultado a 15/11/19]
[30] Portugueses deixaram de comprar medicamentos por falta de dinheiro
(https://www.publico.pt/2018/03/06/sociedade/noticia/em-2017-11-dos-portugueses-deixaram- de-comprar-medicamentos-por-falta-de-dinheiro-1805512) [Consultado a 15/11/19]
[31] Medicamentos Genérico Infarmed https://www.infarmed.pt/web/infarmed/perguntas- frequentes-area-transversal/medicamentos_uso_humano/muh_medicamentos_genericos [Consultado a 15/11/19]
[32] Rana, P. and Roy, V., 2015. Generic medicines: issues and relevance for global health. Fundamental & clinical pharmacology, 29(6), pp.529-542.
[33] Poupança com Medicamentos Genéricos https://www.netfarma.pt/apogen-preve- poupanca-de-416-milhoes-ate-2020-com-medicamentos-genericos-e-biossimilares/) [Consultado a 15/11/19]
[34] Minas, R., 2014. Regulamentação Farmacêutica na garantia da qualidade, eficácia e segurança dos medicamentos genéricos. Ordem dos Farm, p.52.
[35] Decreto-Lei n.º 176/2006
[36] Quem verifica a qualidade, segurança e eficácia dos medicamentos genéricos https://www.zentiva.pt/products/generic-faq [Consultado a 15/11/19]
[37] Idosos tomam mais de sete medicamentos por dia
https://www.publico.pt/2009/04/24/sociedade/noticia/idosos-tomam-mais-de-sete- medicamentos-por-dia-em-media-1376559 [Consultado a 8/11/19]
[38] População Idosa 2011
https://www.pordata.pt/Portugal/Popula%c3%a7%c3%a3o+residente+segundo+os+Censos+tota l+e+por+grandes+grupos+et%c3%a1rios-512-2541 [Consultado a 8/11/19]
[39] Santulli, G. (2013). Epidemiology of cardiovascular disease in the 21st century: updated numbers and updated facts. J Cardiovasc Dis, 1(1), 1-2.
[40] Doenças Cardiovasculares https://www.who.int/news-room/fact- sheets/detail/cardiovascular-diseases-(cvds) [Consultado a 15/11/19]
[41] Doenças Cardiovasculares matam Portugueses https://observador.pt/2017/09/29/doencas- cardiovasculares-matam-35-mil-portugueses-por-ano/ [Consultado a 15/11/19]
[42] Doenças Cardiovasculares https://www.jaba-recordati.pt/areas-terapeuticas/doencas- cardiovasculares [Consultado a 15/11/19]
[43] Prevenção de Doenças Cardiovasculares https://controlaradiabetes.pt/eventos/preveno-das- doenas-cardiovasculares--o-que-estamos-a-fazer-bem-e-o-que-precisamos-de-fazer-mais [Consultado a 15/11/19]
[44] Avaliação do Risco Cardiovascular SCORE https://www.dgs.pt/directrizes-da-dgs/normas- e-circulares-normativas/norma-n-0052013-de-19032013-jpg.aspx [Consultado a 15/11/19] [45] Portugal entre os 11 países mais sedentários https://www.tsf.pt/sociedade/portugal-entre- os-11-paises-mais-sedentarios-do-mundo-10484297.html [Consultado a 5/11/19]
[46] Atividade Física em Adultos https://www.heart.org/en/healthy-living/fitness/fitness- basics/aha-recs-for-physical-activity-in-adults [Consultado a 15/11/19]
[47] Seth, A., 2014. Exercise prescription: what does it mean for primary care?. [48] Levy, G. and Nelson, E., 1961. Pharmaceutical formulation and therapeutic efficacy. JAMA, 177(10), pp.689-691.
[49] Velo, G.P. and Minuz, P., 2009. Medication errors: prescribing faults and prescription errors. British journal of clinical pharmacology, 67(6), pp.624-628.
Anexos
Anexo 1: Equipa de Trabalho Do LMPQFsP
Anexo 3: Panfleto Informativo Sobre os Medicamentos Genéricos
Anexo 5: Póster Publicitário do Rastreio Cardiovascular
Anexo 7: Dados Obtidos no Rastreio Cardiovascular
Anexo 9: Cartaz de Promoção do Boletim Farmacoterapêutico
University Hospital Galway
Rui Miguel de Araújo Oliveira
Faculdade de Farmácia da Universidade do Porto
Mestrado Integrado em Ciências Farmacêuticas
Relatório de Estágio Profissionalizante
University Hospital of Galway
Maio a Agosto de 2019
Rui Miguel de Araújo Oliveira
Orientador: Mr. Peter Kidd
Declaração de Integridade
Declaro que o presente relatório é de minha autoria e não foi utilizado previamente noutro curso
ou unidade curricular, desta ou de outra instituição. As referências a outros autores (afirmações,
ideias, pensamentos) respeitam escrupulosamente as regras da atribuição, e encontram-se
devidamente indicadas no texto e nas referências bibliográficas, de acordo com as normas de
referenciação. Tenho consciência de que a prática de plágio e auto-plágio constitui um ilícito
académico.
Faculdade de Farmácia da Universidade do Porto, 20 de Agosto de 2019
Rui Miguel de Araújo Oliveira
Acknowledgments:
I don’t believe words are a good enough currency to reimburse everyone that made this possible but the truth is that a young man like me couldn’t have done any of this alone and if I can’t give anything else, I would like the following people to accept my words of appreciation and thank for giving me this chance.
To all the pharmacy staff in the Galway University Hospital, for welcoming and allowing me to feel like home in a country that’s not mine. Thanks for the laughs, the patience and the good times (and cakes and sweets) we had! You guys are truly wonderful people.
To Peter Kidd, a hardworking leader with a gigantic heart.
More than being the person that made this possible, you were the one that kept us excited and curious about pharmacy and a whole lot of other things that we didn’t have a clue how important they were. Thanks for the patience, the unrestfulness, for keeping our minds racing with new ideas and problems and for being part of my growth as a pharmacist.
To the University of Porto, for giving me this opportunity and supporting me while I was abroad. To my friends, for the advices, laughs, conversations and for making me smile no matter how far the distance was.
To my parents, for encouraging me to go on adventures even if it makes their hearts tremble a little bit. Thanks for the video calls, the messages and for the unconditional love and support.
Lastly, a big thanks to my sister! For making me laugh all the time, for the support in everything I was unsure about and for speaking a language that only us two can understand. I love you.
Summary
I have a strong belief that being able to interact with different people and embrace new cultures and points of views are the keys to become a better professional and to better understand how we can make the world progress in the right way.
Living and working abroad was something that started to grow on me the past years and I was lucky enough to be part of an Erasmus Exchange Program in Ireland that let me live the life of a hospital pharmacist for 3 months and see the inner works of a health care system that’s in many ways different from my country.
Galway surpassed my expectations in a numerous of ways and for twelve weeks I managed to work with a pharmacy team, dealing with problems that appear daily in hospitals and learning how to be a better healthcare provider.
Table of Contents
1. INTRODUCTION 1
2. PORTUGAL AND IRELAND 2
2.1NUMBERS 2
2.2PHARMACY EDUCATION IN IRELAND 2
3. THE HOSPITAL 2
3.1THE PHARMACY 3
3.2DISPENSARY 3
3.3PASU 3
4. CLINICAL PRACTICE 4
4.1MEDICATION HISTORY/RECONCILIATION 5
4.2DRUG CHART 7
4.3RISK MANAGEMENT SHEET 8
4.4H SCORE 9
4.5TOOLS 9
5. WARDS 9
5.1EMERGENCY WARDS 10
5.1.1ACCIDENTS AND EMERGENCY (A&E) 10
5.1.2EMERGENCY SURGICAL UNIT (ESU) 10
5.2SURGERY 10
5.2.1ST.NICHOLAS’ 10
5.3INFECTION DISEASES 12
5.3.1SHANON’S 12
5.4NEUROLOGY AND STROKE 13
5.4.1ST ANNE’S 13
5.5INTENSIVE CARE UNITS 14
5.5.2ICU AND HSU 14
5.6EYES,EARS,NOSE AND THROAT 15
5.6.1ST MICHAELS’ 15 5.7CANCER WARDS 15 5.7.1CLADDAGH 16 5.7.3CORRIB 17 6. PROJECTS: 17 6.1LUNCH SESSIONS 18 6.2CLERKING 18
6.3VALUE STREAM MAPPING 19
6.4RECYCLING 19
6.5MEROPENEM ROUNDS 19
7. CONCLUSION 20
8. REFERENCES 21
List Of Abbreviations
A&E - Accidents and Emergency ACE – Angiotensin-Converting Enzyme AMU - Acute Medical Unit
aPPT - Activated Partial Thromboplastin Time CCU - Coronary Care Unit
CPE - Carbapenemase Producing Enterobacterae DAPT - Double Antiplatelet Therapy
DOAC - Direct Oral AntiCoagulant DOB - Date of Birth
HSE - Health Service Executive HSU - High Dependence Unit ICU - Intensive Care Unit ID - Infectious Diseases
INR - International Normalized Ratio LMWH - Low Molecular Weight Heparin MedRec - Medicines Reconciliation MI - Myocardial Infarction
MPUH - Merlin Park University Hospital
MRSA - Methicillin-resistant Staphylococcus aureus MUH - Mayo University Hospital
NSAID - Nonsteroidal anti-inflammatory drug NUIG - National University of Ireland Galway OTC - Over the Counter
PASU - Production and Aseptic area PRN - Pro Re Nata
PUH - Portiuncula University Hospital RMS - Risk Management Sheet
RUH - Roscommon University Hospital Roscommon SSW - Short Stay Ward
TB - Tuberculosis TDS - Ter Die Sumendum TIA - Transient Ischemic Attacks UH - Unfractioned Heparin
UHG - University Hospital of Galway UK - United Kingdom
PART 1
1. Introduction
When I was in my teenager years, there was this saying from Robert Baden-Powell that has stuck with me since then:
“Try and leave this world a little better than you found it…”
And for that I knew that I had to become the best version of myself I could be, learn more with everyone and everywhere so bby the time I had half of my course done it was already instilled in my mind that the possibility of working abroad was not as insane as I thought it could be.
There was always this urge to learn new interesting stuff and being able to do that in a country that was ahead of mine in my field of studies was so thrilling that when the opportunity came, it took me under 5 seconds to decide.
That’s how I ended up taking a three-month internship in the University Hospital of Galway (UHG), in Ireland. Nowadays, the health sector faces difficulties that weren’t a concern a few decades back. We live in an age where new problems like antibiotic resistance1 and unexpected complications of an astonishing growth in life expectancy2 among others issues have surfaced and stimulated a will for a continuous improving in healthcare systems worldwide.
From policies to health programs3, Ireland is working towards a better healthcare system that contributes to the wellbeing of their people and where pharmacists have a major role.
Pharmacists are known to assume the role of the experts on medicines, a definition that is vulgarly used but carries a
need for lot of knowledge and responsibility.
The patient side, the economic viewpoint and care for public health are among the responsibilities the pharmacist needs to take into account in her/his daily work and that can be often underappreciated.
During my time in Galway, I managed to practice my first steps in clinical pharmacy which can be seen as the “health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes
health, wellness, and disease prevention”4.
I evolved as a pharmacist during this process by integrating a hospital pharmacy team that was always keen to teach and answer queries with a humble spirit as well as developing projects to improve future patient care and learning a little bit of everything with everyone I came across with.
I visited different wards (my rota can be found in Appendix 1) with different specialities and their own peculiarities; I was able to risk score and talk to patients, analysing lab results and learn a lot about a pharmacist duty and role. This broadening experience gave me tools to become a better pharmacist and the difficulties imposed by the language (and accent), culture and customs forced me to overcome daily life problems allowing me to grow as an individual.
This report describes what I’ve done in this period of time as well as other information I found relevant for my growth as a pharmacist.
2. Portugal and Ireland
2.1 Numbers
As for 2018, Ireland had a population of 4,848,2425 people comparing to the 10,253,7436 of Portugal making Ireland a country with less than half the population my country has. That stirred up my curiosity about the number of pharmacists that were working in Ireland in comparison to Portugal. I found out that as for 2016, there were 5,636 registered pharmacists7 (10% in hospital7) and 1,8857 registered pharmacies in Ireland comparing with the 14,423 registered pharmacists8 (8% in hospital9) in Portugal and 2,923 pharmacies10 meaning that there’s 1 pharmacist per 860 people in Ireland comparing to 1 per 711 in Portugal.
2.2 Pharmacy Education in Ireland
In terms of education, the Master in Pharmacy in Ireland is a 5 year course11 that has subjects relevant to the profession.
Apart from the laboratory classes and lectures the future pharmacist must work in community pharmacy, hospital, industry or regulatory organizations during the course.
There will be a one-day placement in first year, two weeks in second year, two months at the end of third, four months in fourth year and eight months in the final year.
The final eight months must be carried out in a patient-facing setting and when completed the student will have practice exams that evaluates the student ability to handle hypothetical patient-pharmacist interactions ensuring that they are ready to assist patients in every working environment they then choose.
3. The Hospital
On the 2nd of March 1842, in Newcastle Road, a county infirmary for the poor opened for reception. Only later, it became The University Hospital Galway (Ospidéil na hOllscoile Gaillimh)12. Today, the UHG is composed of 4 buildings divided in a total of 33 wards with more than 693 beds and other commodities like bars, canteen, chapel and classrooms.
The hospital belongs to the Saolta University Health Care Group composed of 7 University Hospitals making Saolta group the main group of Health Service Executive (HSE) hospitals in Western Ireland.
UHG is a Model 4 hospital providing 24/7 acute surgery, acute medicine, tertiary care, and critical care recognised as one of the major academic teaching hospitals in all specialities being closely connected to the National University of Ireland Galway (NUIG).
In 2017, the hospital had 276,217 outpatients and 39,148 inpatients with over 3,400 people working making it the busiest hospital in the Saolta group13.
3.1 The pharmacy
The pharmacy department in Galway University Hospitals is responsible for the provision, organization and control of medications of the whole hospital.
It’s open 5 days a week, always trying to provide a safe, efficient and cost-effective service. Every morning the pharmacists check the white board with the assigned wards or activities for the day as well as who’s on holidays and who’s the troubleshooter for the day. There’s always one person assigned as the troubleshooter whose job is to help with any unforeseen event or situation that can happen throughout the day and help other ward pharmacists doing their wards.
The department is divided in 2 areas: the main dispensary and office (located on the ground floor of the Hospital) and the Production and Aseptic Area (PASU) and the staff is composed of pharmacists (with clinical, managing and administrative functions), pharmacy technicians, auxiliary technicians and porters.
3.2 Dispensary
The dispensary is located in the ground floor of UHG and it is core for medicines’ distribution to the whole hospital being only responsible for providing medicines to the wards and not to any outpatients’ services.
It’s divided in areas for a better organisation allowing to cover for all the services the dispensary can give. There is an “extemporaneous preparations and controlled drugs” area where medicines that aren’t cancer-related can be prepared and controlled drugs (e.g. methadone and morphine) can be safely stored.
A refrigerated area to store medicines that need to be at lower temperatures, an area to receive new orders, a work/flow area where technicians move freely to deliver and accept stock, an office/purchasing area and a shoot tube that receives containers with new orders.
There’s also a dispensing area with bags labelled for each ward that the pharmacy technicians pack with the wards’ needs. There’s also a small window for sporadic medicines requests.
Around twelve people work daily to keep the dispensary working: 1 pharmacist, 1 healthcare assistant, and 9 pharmacy technicians being 1 of the technicians the one in charge of ordering new stock.
Each ward possesses a “green book” where it’s written down the order for the day and then it’s delivered to the dispensary.
Over 1,200 orders are put up daily in those books and the technicians make sure to have everything ready before the 11:00 a.m. nurses drug route.
After that, every request comes as a “supplementary order” and will be evaluated on its priority hence high priority supplementary requests can be firstly delivered even if they came later.
There’s also a “query book” where medicine-related queries are written down by the staff on the ward and would then be answered by the pharmacist assigned to that ward.