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Clinicalpharmacy 130207085235 Phpapp02
Clinicalpharmacy 130207085235 Phpapp02
Dr Sitaram Khadka,PharmD
Clinical Pharmacist
Shree Birendra Hospital,Chhauni
Health Care System
Composed of physician (including other medical and dental staffs), pharmacist ,
nurse and other paramedics
Physician ; diagnosis, prescription, monitoring, medical care
Pharmacist; prescription*, dispensing, counseling, monitoring,
pharmaceutical care
Nurse ; administering, monitoring, nursing care
Other paramedics ; their own work
Load to physician & nurse ; high due to the system of "physicians are all in all in
hospital for the treatment of patient, with the help of nurse."
Concept of normal public/patient ; same
Perceptions of Pharmacists
How do others see us?
They just count a few tablets
They just weigh and measure things
A bunch of shop-keepers
Tell me how and when to use the
Medicine
Counter-prescribing
Not really health care practitioners theyre
businessmen
Do you need a degree to be a pharmacist?
For practising Clinical Pharmacy
Competence of health care practitioners
-BPharm to Mpharm to PharmD*
-PharmD+ Pre-registration + registration
-Residency programs
-Continuing Professional Development
Informed general public increased expectation
Introduction; Clinical Pharmacy
Clinical pharmacy may be defined as the science and practice of rationale use of
medications, where the pharmacists are more oriented towards the patient care
rationalizing medication therapy promoting health , wellness of people.
It is the modern and extended field of pharmacy.
The discipline that embodies the application and development (by pharmacist) of
scientific principles of pharmacology, toxicology, therapeutics, and clinical
pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied
sciences for the care of patients.
(Reference: American college of clinical pharmacy)
History
Until the mid 1960s ; Traditional role.
The development of clinical pharmacy started in USA.
More clinically oriented curriculum were designed with the award of
PharmD degree.
These developments influenced the practice of pharmacy in U.K.,
Initially prescription and drug administration records were introduced followed
by an increasing pharmacy practice in hospital wards. Master degree programs
in clinical pharmacy were introduced for first time in 1976.
The progress of clinical pharmacy development remained at low profile in the
first decade after its birth in U.K. However, Nuffield report in1986 geared up the
momentum for progression of clinical pharmacy.
Until today, the clinical pharmacy practice in Nepal is in embryonic stage.
How does clinical pharmacy differ from pharmacy?
The discipline of pharmacy embraces the knowledge on
synthesis, chemistry and preparation of drugs
Clinical pharmacy is more oriented to the analysis of
population needs with regards to medicines, ways of
administration, patterns of use ,drugs effects on the
Patients,
the overall drug therapy management.
The focus of attention moves from the drug to the single
patient or population receiving drugs.
Clinical Pharmacy Requirements
Knowledge of
nondrug therapy
Therapeutic
planning
skills
Drug Information
Skills
Physical
assessment
skills
Patient
monitoring
skills
Communication
skills
Knowledge of
laboratory
and diagnostic skills
Knowledge of
the disease
Knowledge of
drug therapy
Patient care
Level of Action of Clinical Pharmacists
Clinical pharmacy activities may influence the correct use
of medicines at three different levels:
Before the prescription
During the prescription
and
After the prescription is written.
1. Before the prescription
Clinical trials
Formularies
Drug information
Drug-related policies
2. During the prescription
Counselling activity
Clinical pharmacists can influence the attitudes and priorities of
prescribers in their choice of correct treatments.
The clinical pharmacist monitors, detects and prevents the medication
related problems
The clinical pharmacist pays special attention to the dosage of drugs which
need therapeutic monitoring.
Community pharmacists can also make prescription decisions directly, when over
the counter drugs are counselled.
Medication-related Problems
Untreated indications.
Improper drug selection.
Subtherapeutic dosage.
Medication Failure to receive
Medication Overdosage.
Adverse drug reactions.
Drug interactions.
Medication use without indication.
3. After the prescription
Counselling
Preparation of personalised formulation
Drug use evaluation
Outcome research
Pharmacoeconomic studies
Functions of Clinical Pharmacists
1. Taking the medical history of the patient
2. Patient Education
3. Patient care
4. Formulation and management of drug policies
5. Drug information
6. Teaching & training to medical and paramedical staff
7.Research and development
8.Participation in drug utilization studies
9.Patient counseling
10.Therapeutic drug monitoring
11.Drug interaction surveillance
12.Adverse drug reaction reporting
13.Safe use of drugs
14.Disease management cases
15.Pharmacoeconomics
Objective
Define clinical pharmacy
Differentiate between traditional pharmacists role and
Clinical Pharmacist
Explain the qualification required for clinical pharmacists
List the clinical pharmacists responsibility
Describe the daily work activity of clinical pharmacists
Define what is Therapeutic Drug Monitoring
Discuss the different types of Therapeutic Drug
Monitoring
Clinical pharmacy specialists
Usually requires residency in a specialty area, in addition to a
pharmacy practice residency
Job functions depend on the specialty and the institution
Usually has teaching and/or research responsibilities
Represent pharmacy for medication use meeting/committee
in specialty areas
Clinical Pharmacy Practice areas
Ambulatory care
Critical care
Drug Information
Geriatrics and long term
care
Internal medicine and
subspecialties
Cardiology
Endocrinology
Gastroenterology
Infectious disease
Neurology
Nutrition Support
ADR/DUE
Transplant
Investigational Drugs
Pharmacoeconomics
Nephrology
Obstetrics and gynecology
Pulmonary disease
Psychiatry
Rheumatology
Nuclear pharmacy
Pediatrics
Pharmacokinetics
Surgery
Various ambulatory services
Anticoagulation Management
Cholesterol Management
Renal Management (CKD)
Oncology Services
Home Health Pharmacy Services
Impact Pharmacy Services (Drug Conversion Program)
Neonatal ICU
Hypertension Management
Integrated Coronary Vascular Disease (CVD)
HIV/ID
New Member Program (assist new MD in prescribing NF
to formulary drugs)
Heart Failure Management
Asthma Management
Hospital pharmacist Vs
Clinical pharmacist
The service including clinical pharmacy/clinical pharmacist
-Patients get right care from all the facets (all the drug related problems can
easily be eliminated)
-Physicians n other health care professionals get more focused in their
own, work-load to them is low
-Patients feel more comfortable
"Every drug is poison, its the dose that differentiate poison or drug the
substance is."
"To kill ill by pill, not by bill"
The last person to be involved in health care team with the patient;
Pharmacist, so the system has to rely upon him/her.
The service without clinical pharmacy/clinical
pharmacist
-Due to high load to physicians and other health care professionals,
the quality of patient care will be low
-Most of the drug related problems cannot be easily eliminated
-Patients may not feel comfortable
"In developing countries like Nepal; Physicians are incompetent, Nurses are careless,
Pharmacists dont know anything(??), System is corrupted, Public is foolish, Patient load is
high."...Prof Furqan Hashmi
"Medicine is for those who need them, not for those who want them."
"If your medicine is not working it may not be your medicine, it may be you"
Medicines are Dangerous
Pharmaceutical care
A practice in which a practitioner takes responsibility for a
patients drug related needs and holds him or herself accountable
for meeting these needs........ Linda Strand 1997
It describes specific services & activities through which an
individual pharmacist cooperates with patients and other health
care professionals in designing, implementing & monitoring a
therapeutic plan that will produce specific outcomes for the
patient.
Wherein the pharmacist is engaged in;
Drug monitoring,
Disease monitoring,
Drug therapy & disease management/collaborative practice
Pharmaceutical care is that component of pharmacy practice which entails the
direct interaction of pharmacist with the patient for the purpose of caring for
that patients drug related needs
Goal of Pharmaceutical Care
Goal of pharmaceutical care is to optimize the patients health-related quality
of life and achieve positive clinical outcomes, within realistic economic
expenditures
Essential Components of Pharmaceutical Care
1.Pharmacist-patient relationship
Collaborative effort between pharmacist & patient
2.Pharmacists workup of drug therapy (PWDT)
Provision of pharmaceutical care is centered around this,
although the methods used for this purpose may vary.
Components are:
I.Data collection;
Collect, synthesize & interpret relevant information
Patients demographic data: age, sex, race etc.
Pertinent medical information
Medical history (current & past)
Family history
Dietary history
Medication history (prescription, OTC, allergies)
Physical findings (weight, height, B.P)
Lab results (serum drug levels, potassium levels, serum creatinine levels relevant
to drug therapy)
Patient complaints, symptoms & signs
II. Develop or identify the CORE pharmacotherapy plan
C = condition or patient need
O = outcome desired for that condition
R = regimen selected to achieve that outcome
E = evaluation parameters to assess outcome achievement
III.Identify PRIME Pharmacotherapy Problems
This includes pharmacist's intervention
The goal is to identify actual or potential problems that could
compromise the desired patient outcome
P = pharmaceutical based problems
R = risks to patient
I = interactions
M = mismatch between medication & condition or patient needs
E = efficacy
3.Documentation of pharmaceutical care
Formulate a FARM note or SOAP note to describe or document the
interventions needed or provided by pharmacist
FARM Progress Note
Description & documentation of interventions intended or provided by
pharmacist
F = Findings,
pt-specific informationgives basis for recognition of pharmacotherapy
problems or indication for pharmacist intervention.
A = Assessment,
The pharmacists evaluation of the findings, including a statement of:
Any additional information needed to best assess the problem to make
recommendation
The severity, priority or urgency of the problem
The short term & long term goals of the intervention proposed
Short term goals: elimination of symptoms , Lowering of BP ,Management of acute
asthma without requiring hospitalization
Long term goals:Prevent recurrence of disease,Control B.P.,Prevent progression of
diabetes
R = Resolution, including prevention
Observing & reassessing
Counseling or educating the patients & care givers
Informing the prescriber
Making recommendation to prescriber
Withholding medication or advising against use
M = Monitoring to assess the efficacy, safety & outcome of the intervention
This should include
The parameters to be followed (e.g. pain, depressed mood, serum levels)
The intent of monitoring e.g. efficacy, toxicity, adverse events
How the parameters will be monitored e.g. interview patients, serum drug
level, physical examination
Frequency of monitoringweekly or monthly
Duration of monitoring e.g. until resolved, while on antibiotics,then monthly for
one year
Anticipated or desired finding e.g. no pain, healing of lesion
Decision point to alter therapy when or if outcome is not achieved e.g. pain still
present after 3 days, mild hypoglycemia more than 2 times a week.
SOAP Note ;
This is used primarily by physicians,
S=subjective findings
O=objective findings
A=assessment
P=plan
Clinical skills & pharmacists role in
Pharmaceutical Care
Patient assessment
Physical assessment
Barriers to adherence
Psychosocial issues
Education & counseling
Interview skills
Communication skills (e.g. empathy, listening, speaking or
writing at patient's level of understanding)
Ability to motivate & inspire
Develop & implement patient education plan based on an initial
education assessment
Identification & resolution of compliance barriers
Patient Specific Pharmacist Care Plan
Recognition, prevention & management of drug interactions
Pharmacology & therapeutics
Interpretation of lab tests
Knowledge of community resources, professional referrals
Communication & support with community medical providers
Drug Treatment Protocol
Develop & maintain (update) protocols
Follow protocols as pharmacist-clinician
Monitor,aggregate adherence to the treatment protocols e.g. drug
utilization evaluation, especially for managed care or health
system facility
Dosage adjustment
Identify patients at high risk for exaggerated or
subtherapeutic response
Apply pharmacokinetic principles to determine patient
specific dosing
Prescriptive authority
In designated practice site and positions
Aims of
Pharmaceutical
Care
Effective drug
therapy
Safe drug
therapy
Economic drug
therapy
Improve
quality of life
Will the patient take
the therapy?
What does the
patient view as an
improved quality of
life?
A case
44 year old lady with fever and green sputum and cough no known
previous medical history Diagnosed with URTI, Prescribed:
Co-Amoxiclav 1 tds
Doxycycline 100mg D
Prednisolone 40mg D
Theophylline 200mg bd
Omeprazole 20mg D
Metoclopramide 10mg tds
Salbutamol 2 puff inhale prn
Pharmaceutical problems
Common organisms for URTI?
History of asthma risk vs benefit?
Need for acid suppression?
Why is she nauseous ?
Benefit of brochodilation?
Does she know what to take?
Will she take it?
Question?
Think of someone in your family or a friend
that has had something go wrong with their
medicines?
Caused an adverse or unwanted effect ?
Had medicines stopped when should have
continued?
Not worked?
What happened ?
Could it have been avoided ?
High Profile Examples
A patient with leukaemia received Intrathecal vincristine
instead of intravenously. Died beginning of February
2001. 14th such case over the last 16 years.
Patient being operated for a AAA received bupivicaine
intravenously rather than epidurally. Patient died 3 days
later.
A 3 year old girl, who had a convulsion post flu vaccine.
Attended hospital to get checked out. Received nitrous
oxide instead of oxygen in casualty
Elderly lady was prescribed Methotrexate in 1997 for her
rheumatoid arthritis. Dose increased to 17.5mg
WEEKLY over a 6 month period.
Jan 2000 patient undergoes right TKR in hospital. MTX
given as one tablet a week (only 2.5mg).
Prescription for MTX 10mg/daily written and dispensed.
30th April patient dies.
Deaths from medicines in the UK
1999 - 2000 (ICD9 & 10 data)
A spoonful of sugar - Audit Commission (2001)
So drugs are safe ..
Photosensitivity from
Amiodarone
Severe extravasation of
amiodarone infusion
NSAID induced peptic ulcer
Goitre Hypothyroidism
Secondary to
Amiodarone
Bleeding due to
anticoagulation
Erythemal rash from penicillin in patient with a previous
Known allergy/ adverse drug reaction
Necrotising fascititis secondary to infection at site of IV injection
Acute Liver failure from Black Cohosh - herbal medicine
Human Error
(Mistakes, Slips, Lapses)
Error is inevitable due to our limitations:
- limited memory capacity
- limited mental processing capacity
- negative effects of fatigue other stressors
We all make errors all the time
Generalised lack of awareness that causes errors
Patients suffer adverse events much more often than previously
realised
Errors often NOT immediately observed
The same error, even a minor one, can have quite different
consequences in different circumstances.
I assumed the brown glass
ampoule was frusemide
The System:
Only as safe as its designed to be!
The Accident Causation Model
(Adopted from Reason & Dean)
Active
Failures
- Slips&lapses
- Mistakes
Error
producing
conditions
Accident
Defences
Latent
Conditions
Sources of Error
selecting the wrong or inappropriate - Prescribing error
drug/dose/formulation/duration etc
Communicating those instructions
timely; wrong drug, dose, route; expired - Supply error
medicines, labelling.
timing; wrong route; wrong - Administration error
rate/technique.
. actions to take - Lack of user education
Drug therapy assessment
Six types of problems which may result in treatment
failure :
1.Inappropriate selection of medication
2.Inappropriate formulation of medication
3.Inappropriate administration of drug therapy
.1 4.Inappropriate medication-taking behaviour
5.Inappropriate monitoring of drug therapy
6.Inappropriate response to drug therapy
Formulary
Prescribing protocols
Prospective review
Clinical pharmacy
Admission medication history
Allergy check
Drug distribution system
Opportunity
For Error
Administration instructions
Clinical Pharmacy Role in Reducing Risks
Formulary
Prescribing protocols
Prospective review
Clinical pharmacy
Admission medication history
Allergy check
Drug distribution
system
Opportunity
For Error
Administration instructions
What if we are not there!
Patient Assessment Questions
Does the patient need this drug ?
Is this drug the most effective and safe ?
Is this dosage the most effective and safe ?
If side effects are unavoidable does the patient need
additional drug therapy for these side effects?
Will drug administration impair safety or efficacy ?
Are there any drug interactions ?
Will the patient comply with prescribed regimen ?
To be a drug expert,society needs
practitioners who ..
Todays pharmacists
Ideal Pharmacist Candidate?
Competent
Motivated/Enthusiastic
Teamwork spirit
Good communication skills
Responsible
Problem solver
Dedicated
The End
Any Questions?