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Austria 1652011

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Role of the clinical Pharmacist in pediatric oncology setting in Egypt

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Austria 1652011

  1. 1. Sherif kamal 2010
  2. 2. Role of Pharmacists in Pediatric Oncology Sherif Kamal DPS Director
  3. 3. Sherif kamal 2010
  4. 4. Sherif kamal 2010
  5. 5. Clinical Pharmacy - Egypt Sherif kamal 2010
  6. 6. Clinical Pharmacy Story - Egypt <ul><li>Implementation </li></ul><ul><li>Measurement </li></ul><ul><li>Sharing </li></ul>Sherif kamal 2010
  7. 7. NCI/Naser/Pyramids/Zagazig/Tanta Menya Clinical Pharmacy Program Assuit Clinical course
  8. 8. Sherif kamal 2010
  9. 9. Challenge s
  10. 10. Value of the Clinical Pharmacist <ul><li>1 $ for Clinical Pharmacy = 14 $ ROI </li></ul><ul><li>1 $ for Patient Education = 4 $ ROI </li></ul><ul><li>IV saving </li></ul><ul><li>TDM saving </li></ul><ul><li>Hospital Mortality </li></ul>
  11. 11. <ul><li>In Egypt, </li></ul><ul><li>8,000 children </li></ul><ul><li>are diagnosed </li></ul><ul><li>with cancer </li></ul><ul><li>every year </li></ul>Our Challenge
  12. 12. Change
  13. 13. Change <ul><li>NCI </li></ul><ul><li>CCHE </li></ul>
  14. 14. <ul><li>Change </li></ul><ul><ul><li>Design, </li></ul></ul><ul><ul><li>Functionality </li></ul></ul><ul><ul><li>space </li></ul></ul>
  15. 15. Sherif kamal 2010
  16. 16. Vision <ul><li>The vision of the CCHDPS is to enhance patients' quality of life And to obtain positive patient outcomes . </li></ul>
  17. 17. Mission <ul><li>The DPS will provide a state-of-art comprehensive pharmaceutical care that is patient centered; focusing on evidence based innovative techniques and scientific research, to reduce morbidity and mortality of children with cancer. </li></ul>
  18. 19. 57357 Children’s Cancer Hospital Cairo, Egypt 6-10 June, 2010
  19. 21. Sherif kamal 2010
  20. 23. Pharmacy Statistics <ul><li>Items charged = 70,921 </li></ul><ul><li>MAE = 62,137 </li></ul><ul><li>Total no. of orders = 30,100 </li></ul><ul><li>Doses = 91,142 </li></ul><ul><li>Patient transaction = 4216 </li></ul><ul><li>Days of medication service = 5229 </li></ul><ul><li>IV orders = 15,438 </li></ul><ul><li>IV dose = 31491 </li></ul><ul><li>Lab= 552 </li></ul><ul><li>Working hours = >13000 </li></ul><ul><li>Total no. of trainees =210 </li></ul>Sherif kamal 2010
  21. 24. Org Structure
  22. 25. CCHE DPS Components <ul><li>I.V admixture </li></ul><ul><li>Patient Services </li></ul><ul><li>Ambulatory Care (OPD/DC/MSC) </li></ul><ul><li>TPN </li></ul><ul><li>Dispensing </li></ul><ul><li>Drug Information </li></ul><ul><li>Therapeutic Drug Monitoring </li></ul><ul><li>Nuclear Pharmacy (New Service) </li></ul><ul><li>Critical Care Pharmacy (New Service) </li></ul><ul><li>Pain Service (New Service) </li></ul><ul><li>Controlled Substances </li></ul><ul><li>Neuro-Care Pharmacy (New Service) </li></ul><ul><li>Pharmacoeconomic services </li></ul><ul><li>Drug Procurement Office </li></ul><ul><li>Pharmacoinformatics </li></ul><ul><li>Quality Management </li></ul><ul><li>Safe handling of Hazards Material and Waste management </li></ul><ul><li>Clinical Trials </li></ul><ul><li>Newsletter and websites </li></ul>
  23. 26. Drug Procurement Office Tender Document
  24. 27. IV admixture <ul><li>IV prep </li></ul><ul><li>IV Mix </li></ul><ul><li>TPN </li></ul><ul><li>IV check </li></ul>
  25. 28. Dispensing <ul><li>Out Patient </li></ul><ul><li>In Patient </li></ul><ul><li>Day Care </li></ul><ul><li>Patient Education </li></ul>
  26. 29. Assessing Dispensing Errors
  27. 30. Patient Education Sherif kamal 2010
  28. 31. <ul><li>WHENEVER POSSIBLE USE PATIENT EDUCATION MATERIAL </li></ul>Imatinib Labels
  29. 32. <ul><li>PATIENT EDUCATION MATERIAL </li></ul><ul><li>Brochures </li></ul>
  30. 33. <ul><li>Wall Papers </li></ul>PATIENT EDUCATION MATERIAL
  31. 34. Wall Papers in the Waiting Area
  32. 35. <ul><li>Patient Booklets </li></ul>PATIENT EDUCATION MATERIAL
  33. 36. <ul><li>Patient Flyers </li></ul>PATIENT EDUCATION MATERIAL
  34. 40. Sherif kamal 2010
  35. 42. Assessing Quality of Patient Education
  36. 43. Assessment of patient adherence <ul><li>Objective: </li></ul><ul><ul><li>This study is an attempt to examine patient compliance. </li></ul></ul><ul><li>Specific objective: </li></ul><ul><ul><li>to investigate the extent to which a patient's behavior taking medications. </li></ul></ul><ul><ul><li>To investigate adherence to physician's orders. </li></ul></ul>
  37. 44. Assessment of patient adherence
  38. 45. Round 10:1
  39. 46. Sherif kamal 2010
  40. 47. Case <ul><li>Name : AS </li></ul><ul><li>Presented on 17/12/2007- ICU 7 pm </li></ul><ul><li>TLC 390 000 </li></ul><ul><li>LDH 15438 </li></ul>Management on 17/12 Hydration Urine PH = 6 S.cr 4.1 Decision to give Rasburicase 0.2 mg /kg G-6PD tested Sherif kamal 2010
  41. 48. Case L4 <ul><li>Name : NI </li></ul><ul><li>Presented on 7/2/2008- ICU 16:00 pm </li></ul><ul><li>TLC 23 500 </li></ul><ul><li>LDH 2283 IU/l </li></ul>Sherif kamal 2010
  42. 49. Sherif kamal 2010
  43. 50. Effectiveness of Ondansetron
  44. 51. First ICU Clinical Pharmacy <ul><li>37% higher mortality and 14.8% longer ICU stays </li></ul><ul><li>184 extra deaths, 59,429 extra hospital days, $215,397,354 extra total Medicare charges, and $26,363,674 extra drug charges,&quot; </li></ul>MacLaren R and Bond CA. Effects of pharmacist participation in intensive care units on clinical and economic outcomes of critically ill patients with thromboembolic or infarction-related events. Pharmacotherapy. 2009; 29:761-8.
  45. 52. Sherif kamal 2010
  46. 53. Stewardship program
  47. 56. Discussion and recommendations
  48. 57. Discussion and recommendations
  49. 58. Discussion and recommendations
  50. 59. Restricted drug List
  51. 60. Sherif kamal 2010
  52. 61. Sherif kamal 2010
  53. 62. Sherif kamal 2010
  54. 63. Sherif kamal 2010
  55. 64. Dexamethasone Use inBT Sherif kamal 2010
  56. 65. My Experience with Brain T in a baby Girl Sherif kamal 2010
  57. 66. Role of Pharmacists in Protocol Management
  58. 67. PK lab
  59. 68. Sherif kamal 2010
  60. 69. Sherif kamal 2010
  61. 70. Sherif kamal 2010
  62. 71. Sherif kamal 2011
  63. 72. RELATION BETWEEN VALPROIC ACID ADMINSTRATION AND THE INCIDENCE OF THROMBOCYTOPENIA <ul><li>Introduction : Valproic acid is used in our setting as antiepileptic drug either alone or in combination with other antiepileptic drugs.Thromhocytopenia in association with valproic acid therapy has been reported in patients of various ages with incidences ranging from 1 to 32%. Regarding the pathophysiology of the Thromhocytopenia associated with valproic acid therapy, there is evidence to suggest that valproic acid can evoke an immune response with the production of antibodies directed against platelets. Sandler described circulating and bound platelet antibodies of the IgM type . Especially in pediatric oncology setting where thromhocytopenia is common it is very essential to study this association. </li></ul><ul><li>Materials & Methods : To evaluate this association in a pediatric population, we retrospectively studied 55 children treated with valproic acid(VPA) at our institution in April 2010.The patient medical files were reviewed The Incidence of thrombocytopenia were recorded based onthat Thrombocytopenia was defined as a platelet count ~200 x 103/mm3.The valproic acid levels of these patients were also recorderded in this period of time . </li></ul><ul><li>Results: We retrospectively studied  children treated with valproic acid(VPA) at our in April 2010. The Incidence of thrombocytopenia in Valproic acid population was 17% which is within the range of the benchmark .Only 50 % of the cases having thrombocytopenia showed normal therapeutic level values .25 % of the patients having thrombocytopenia showed higher level of valproic acid and 25% showed subtherapeutic levels and required increase in dose . </li></ul><ul><li>Discussion, Conclusion: The Incidence of thrombocytopenia in Valproic acid population is less than 17% which is within the range of the benchmark .The correlation between the incidence of thrombocytopenia and the drug level need to be further studied and this is next on our agenda.But we recommend that  platelet counts should be closely monitored in patients recieving valproic acid especially in patients were we are going to increase the dose due to subtherapeutic levels. </li></ul>
  64. 73. Pharmacy Automation
  65. 74. 57357 - Vital Signs Work Load * August 2010 Monthly Cumulative Figures Metric Name Total Daily Average Appointments 15,222 491 Registrations 11,970 386 Charts Open 209,879 6,770 Orders 239,088 7,713 Inbound Interfaces 17,323 642 Outbound Interface 45,722 1,475
  66. 75. 24 Hour Snap Shot in 57357 * Data Captured Thursday September 16 th 2010 Metric Value Logins 3,421 Nurse Assessments / Forms Completed 2,001 PAL Opened 828 All Orders Written 10,177 Total Medication Orders 4,033 Total Medications Administered 4,379 Lab Orders 4,868 Total Charts Opened 7,460 Physicians – PowerNotes Documented 263 Physicians – PowerNotes Signed 301 Alerts Fired 411
  67. 76. Sherif kamal 2010
  68. 77. 4169
  69. 80. Newsletter
  70. 81. Vincristine <ul><li>Lookalike /Soundalike </li></ul><ul><li>TALLman :vinCRIstine====vinBLAstine </li></ul><ul><li>Peripheral neuropathy </li></ul><ul><li>Bilrubin </li></ul><ul><li>Cell cycle specific </li></ul><ul><li>Extravasation </li></ul>Sherif kamal 2010 Role Of Pharmacists as patient Safety Officers
  71. 82. LASA Sherif kamal 2011
  72. 83. Sherif kamal 2011
  73. 84. Sherif kamal 2010
  74. 85. Triple ITH <ul><li>3 drugs together? </li></ul><ul><li>Package (Filter ,Alcohol swabs,dressing) </li></ul><ul><li>When to give /HDMTX? </li></ul><ul><li>Error </li></ul>Sherif kamal 2010
  75. 86. What To Do? <ul><li>Color Coding </li></ul><ul><li>VCR as IV bag </li></ul>Sherif kamal 2010
  76. 89. Sherif kamal 2010
  77. 90. Sherif kamal 2010
  78. 91. Sherif kamal 2010
  79. 92. HFMEA <ul><li>Cheng C. H. et al. (2010). Applying HFMEA to Prevent Chemotherapy Errors. Journal of Medical Systems. Available at http://www.springerlink.com/content/j47u588376g58p87/fulltext.pdf </li></ul><ul><li>Failure mode and effect analysis (FMEA) is a systematic and prospective risk evaluation method initially adopted in the industrial field. </li></ul><ul><li>It has been widely used by engineers to improve the reliability, quality, and safety of their products and to reduce potential risks. The most important function of FMEA is to identify potential failure modes for each subsystem or component. </li></ul>Sherif kamal 2010
  80. 93. IHI Sherif kamal 2010
  81. 94. Sherif kamal 2010
  82. 95. Mucositis <ul><li>I - Accurate number of patients having OM </li></ul><ul><li>Which include: category II & IV (NO/YES & YES/YES) </li></ul><ul><li>a) % of mucositis occurrence : 51% </li></ul><ul><li>b) Relation to gender: male (60%) & females (40%) </li></ul><ul><li>c) Relation to age : </li></ul><ul><li> • From 0.6 to 6 years : 50% </li></ul><ul><li> • From 7 to 12 years : 24% </li></ul><ul><li> • From 13 to 19 years : 26% </li></ul>
  83. 96. Analysis of data <ul><li>e) Relation to prophylaxis : </li></ul><ul><ul><ul><ul><li> • 48% of these patients use prophylaxis. </li></ul></ul></ul></ul><ul><ul><ul><ul><li> • 52% of these patients don’t use it. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>f) Type of prophylaxis : </li></ul></ul></ul></ul>Type Percentage % Hexitol 41% Nystatin 76% Miconazole 63% mouthcare 43%
  84. 97. Analysis of data <ul><ul><ul><ul><li>d) Cancer type : </li></ul></ul></ul></ul><ul><ul><ul><ul><li> • ALL : 37% </li></ul></ul></ul></ul><ul><ul><ul><ul><li> • AML : 27% </li></ul></ul></ul></ul><ul><ul><ul><ul><li> • NHL : 18% </li></ul></ul></ul></ul><ul><ul><ul><ul><li> • OS : 1% </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> • RMS : 11% </li></ul></ul></ul></ul></ul><ul><li> • Others : 3% (ES,RM & WT) </li></ul>
  85. 98. Analysis of data <ul><li>g) Grade of mucositis: </li></ul>grade Percentage % G1 10% G2 24% G3 10% G4 10% HL 16% WP 9% PI 9% PI & Can 1% Ulcers on mouth 8%
  86. 99. Analysis of data <ul><li> h) Dose of chemotherapy: </li></ul><ul><li> • The doses of chemotherapy are just before occurrence of OM : </li></ul>doses Percentage % MTX 14% 6-MP 9% VCR 14% CYTRA 16% DOXO 18% DEXA 2% ETOPO 7% CYCLO 7% HC 3% PREDN .06% ASPARA 4% IFOSF .1% BETA .06% CARBO .06% DAUNO .06%
  87. 100. Asparaginase prep Sherif kamal 2010
  88. 101. Cyclophosphamide Sherif kamal 2010
  89. 102. Sherif kamal 2010
  90. 104. Tannic Acid as effective Hemostatic agent in pediatric adenocarinoma :A case Study <ul><li>Introduction:  Standard treatment of profuse bleeding was done using patches of oxidized regenerated cellulose .There are no reports on managing failure of oxidized regenerated cellulose patches .Using tannic acid solution was recommended by the Chief Surgeon in the hospital ,the pharmacy looked up the extemporaneous formulation of tannic acid and followed up the patient . </li></ul><ul><li>Materials & Methods:   This was a real time case study  in the children cancer hospital Egypt Tannic acid was prepared as a 40% solution in water and was applied to the surgical site three times daily as compresses for 3 month as the patient was on palliative treatment. The number of transfusion before and after using the Tannic acid preparation were studied. The efficacy of the haemostatic activity was measured by the number of blood transfusion and stopping the bleeding. </li></ul><ul><li>Results:   </li></ul><ul><li>After the last operation the patient suffered from severe bleeding from the surgical site. </li></ul><ul><li>Patches of oxidized regenerated cellulose was given to control bleeding with no success, where 3 blood transfusions were needed. After using the Tannic acid 40 % the need for transfusion decreased to one transfusion in the first week followed by three weeks without transfusion. </li></ul><ul><li>Discussion, Conclusion: As mentioned by the mother the severe bleeding prevented the efficacy of the Patches of oxidized regenerated cellulose by detaching the patch from the site of bleeding  also she noted that the size of surgical site was preventing fitting the patch. The tannic acid 40% preparation in water and was applied to the surgical site three times daily as compresses for 3 month was ver effective in stoping bleeding and improving the quality of life of our patient . The Role of the pharamcists was very clear in following up the case detecting the need for another intervention , searching for evidence for the new intervention ,implementing the intervention then following up and reporting the case.  </li></ul>
  91. 105. Monitoring of Toxicity Sherif kamal 2010
  92. 106. Amphotericin B vs. Liposomal Ampho B
  93. 108. Tele-Pharmacy <ul><li>Using hybrid solutions for maximizing the return on investment from telemedicine in pharmacy education </li></ul><ul><li>5^th Annual Pediatric Tele-health Colloquium at the 2010 American Telemedicine Association </li></ul>Sherif kamal 2010
  94. 110. Sherif kamal 2010
  95. 115. Training <ul><li>15 Orientation Trainee per week </li></ul><ul><li>Sudan </li></ul><ul><li>Salam Hospital </li></ul><ul><li>MOH Oncology Centers </li></ul><ul><li>Clinical Pharmacy Students (100 hr) </li></ul><ul><li>SCOPS </li></ul><ul><li>Helwan </li></ul>Sherif kamal 2010
  96. 116. Training Program <ul><li>This program will discuss aspects of Clinical Pharmacy and pharmaceutical care with particular emphasis on the application in the hospital. </li></ul><ul><li>The duration of the program will be 2 Weeks (100 hrs) from Sunday – Thursday, 8 hours each day, where there will be lectures (1 hr min x5 lectures= 5 hrs), on the job training (OJT) (8 hr X 10 days= 80hrs) and 15 hrs final project . </li></ul><ul><li>During the OJT the trainee will be rotated to work in the different areas of the Department of pharmaceutical services in hospital 57357. </li></ul><ul><li>The participant will undergo pre and post-lecture Exams and will be evaluated at the different work sites, each trainee will be assigned to make a project with a final exam written. </li></ul><ul><li>The project assignment will be the development of Pharmaceutical Care Plans for the patients and Study proposal. </li></ul>Sherif kamal 2010
  97. 122. Cairo 100 hr Perceptorship and Academic Platform
  98. 125. Helwan University
  99. 128. Sherif kamal 2010
  100. 129. MISK
  101. 131. DPS 2020 Sherif kamal 2010
  102. 138. Sherif kamal 2010
  103. 139. Sherif kamal 2010

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