Scope of Practice and the Rural Hospital Pharmacy Technician

Rural hospital pharmacies are tasked with providing the best patient care despite dealing with challenges such as minimal staffing levels while maintaining standards of supervision and achieving full scope of practice for pharmacy technicians. In spite of the challenges at remote sites and the struggle to achieve full scope of practice, pharmacy services in rural areas have made great strides.

Located just off the busy highway linking Fort McMurray to Edmonton, Boyle is a community of less than 1000 people. At nearly a two-hour drive from Edmonton, the hospital has 20 beds and a 24-hour emergency department. Janice Hanson is the pharmacy technician at the hospital in Boyle.  She graduated as a pharmacy technician in 2003, and after working a short while at the Grey Nuns Hospital in Edmonton, Janice returned home to Athabasca, working in the retail setting there as well as performing relief work at the Athabasca hospital.  Now working part time as the sole on-site pharmacy member in Boyle, her days are much different than the time she spent working at the Grey Nuns.

There are no duty rotations, no packaging, and no other pharmacy staff members in Boyle. Pharmacist duties are provided by a hospital pharmacist based in Athabasca.  Prior to having a pharmacy technician in Boyle, a pharmacist from Athabasca would spend one day per week at the site.  When the pharmacist noted that she spent much of her time dealing with technical duties, it was decided to hire a pharmacy technician and provide remote pharmacist coverage.  With Janice working five days per week, the pharmacist now only makes monthly visits when possible to attend nursing meetings.  The two pharmacy professionals communicate several times during Janice’s shifts.  Janice pulls the medication orders and resolves any questions she can, highlighting issues for the pharmacist.  The orders are scanned and securely emailed to the pharmacist who reviews and verifies them.  After the orders are entered, the acute care medications are filled by a central production facility in another location and shipped for receipt that afternoon at the nursing station in Boyle. This is one of three models often used in sites where full staffing does not include a pharmacist.

Model 1

1. Nursing station scans medication orders to pharmacy (either remotely or to a pharmacy member onsite)
2. Pharmacy technician or assistant enters medication orders.
3. Remote pharmacist verifies the order, generating label at site
4. Onsite staff picks medications to fulfill orders
5. Offsite staff views selection via camera and a Lync or Skype conversation with staff onsite to provide the final check.

Model 2

1. Nursing station scans medication orders to pharmacy (either remotely or to a pharmacy member onsite)
2. Pharmacy technician or assistant enters orders
3. Drug is selected, reviewed, and checked by staff at offsite pharmacy and sent by courier directly to nursing station

Model 3

1. Nursing station scans medication orders to remote pharmacy
2. Offsite pharmacy enters orders, which are picked up via Pyxis machine (an automated medication dispensing system that supports decentralized medication management, accurately dispensing medication, while supporting pharmacy workflows)[i] or other automated medication dispensing machine at the patient’s location
3. Onsite nursing staff selects medication from Pyxis machine

Interim orders are also completed in three main ways: by an onsite team member who supplies (a final check is required), by an automated medication dispensing machine such as Pyxis, or with a physical night cupboard (a locked storage area designated to store a limited selection of pharmaceutical products) if pharmacy staff is not available.

With many tasks focused on medication order processing and dispensing, some may think working at rural facilities means less opportunity for pharmacy technicians to work to their full scope of practice. So, what do rural technicians do to work within their scope?

The Scope of Practice for pharmacy technicians in Alberta provides an opportunity for rural pharmacy technicians to really shine[ii].  If working in a rural setting, a pharmacy technician needs to focus on implementation of the following to achieve full scope of practice:  completion of best possible medication history (BPMH), device training, sterile product compounding and second checks.  Not all sites will have opportunities in all of these areas.  Although trained in completing Best Possible Medication Histories (BPMH), Janice’s other duties currently leave her with little time to assist nursing staff in this aspect.  She also provides device training and virtual second checks for staff at other facilities.

Providing Final Checks – With the aid of real-time cameras and Skype calls, a pharmacy technician can provide final checks for interim doses, ward stock, cart fills, and any other medication-related check. And this can happen for a site hundreds of kilometers away.

BPMH—Best Possible Medication History. The National Association of Pharmacy Regulatory Authorities (NAPRA) indicates this as a Model Standard of Practice.[iii] In theory it works well. In northern Alberta, there are limiting factors:

• Staffing levels:
  • The pharmacy technician is busy entering medication orders, filling ward stock, doing final checks or batch fills. There are competing priorities with limited staff, and often the pharmacist (if one is onsite) is already on the floor doing clinical tasks.
  • No funding for a dedicated position.
• Hours of work: no pharmacy members are available after regular business hours.
  • In at least one site, there is a part time position for a clinical pharmacy technician who streamlines the discharge or transfer process, and also completes BPMHs. In spite of very good reception at the facility for completion of this task, funding and budget constraints prevent expanding this role within the facility or elsewhere.

Device Training – It is well within scope of practice for pharmacy technicians to teach patients how to use devices such as inhalers.[iv] Although there are regional respiratory technicians, acute care patients may not be able to see them prior to discharge. In the Northeast zone of the province, at least one site utilizes a pharmacy technician to provide teaching for naloxone kits.

Sterile compounding—Sterile product manufacturing occurs in only 10 hospital sites north of Edmonton. There is opportunity for pharmacy technicians currently sterile compounding to lead the work to comply with NAPRA standards[v].

There is some frustration: pharmacy inventory at Boyle is held in a nursing medication room.  The twice-weekly check Janice does involves physical review of each item as inventory is not managed on a computer system.  And although there is support from her pharmacist, it is easy to feel isolated.  The solution for this has been weekly huddles with management and the pharmacist.  Monthly regional meetings are held via Skype and provide further peer encouragement.  These monthly meetings have also fostered relationships with other pharmacy technicians across the region, providing Janice with more ability to have contact with other pharmacy professionals.

Most technicians and assistants based in a rural setting consider technology to be used about 80% of the time to enable them to do their jobs. When asked how technology has impacted her job, Janice replied “Because I’m remote I wouldn’t be able to operate without the technology. I talk to the pharmacist pretty much daily through Lync…all the orders are emailed between us. I wouldn’t be able to do it without the technology just because I’m the only pharmacy personnel here.”

[i] BD Pyxis MedStation™ system. Retrieved July 20, 2018 from https://www.bd.com/en-us/offerings/capabilities/medication-and-supply-management/medication-and-supply-management-technologies/pyxis-medication-technologies/pyxis-medstation-system

[iii] NAPRA Model Standards of Practice for Canadian Pharmacy Technicians (November 2011) 1.11 p7.  Retrieved January 16, 2018 from http://napra.ca/sites/default/files/2017-08/Model_Standards_of_Prac_for_Cdn_PharmTechs_Nov11.pdf

[iv] Alberta College of Pharmacy: Scope of Practice for Alberta Pharmacy Technicians Std 9.4.  Retrieved January 16, 2018 from https://pharmacists.ab.ca/sites/default/files/PharmTech-Scope-Poster.pdf

[v] NAPRA Model Standards for Compounding of Non-hazardous Sterile Preparations (November 2016).  Retrieved January 30, 2018 from http://napra.ca/sites/default/files/2017-09/Mdl_Stnds_Pharmacy_Compounding_NonHazardous_Sterile_Preparations_Nov2016_Revised_b.pdf

Linda Eckel is a medication quality and safety pharmacy technician with AHS. She previously worked in the NorthEast zone. Linda one day aspires to be published in Tech Talk, becoming amazingly famous and outrageously wealthy. Until then she is committed to sharing as much information as her peers will allow.