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Clinical pharmacy


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compiled for lecture note B.Pharm viii semester(final semester)

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Clinical pharmacy

  1. 1. Clinical Pharmacy Dr Sitaram Khadka,PharmD Clinical Pharmacist Shree Birendra Hospital,Chhauni
  2. 2. Health Care SystemComposed of physician (including other medical and dental staffs), pharmacist ,nurse and other paramedicsPhysician ; diagnosis, prescription, monitoring, medical carePharmacist; prescription*, dispensing, counseling, monitoring, pharmaceutical careNurse ; administering, monitoring, nursing careOther paramedics ; their own workLoad to physician & nurse ; high due to the system of "physicians are all in all inhospital for the treatment of patient, with the help of nurse."Concept of normal public/patient ; same
  3. 3. Perceptions of Pharmacists How do others see us?
  4. 4. ”They just count a few tablets“
  5. 5. ”They just weigh and measure things“
  6. 6. ”A bunch of shop-keepers“
  7. 7. Tell me how and when to use the“”Medicine
  8. 8. ”Counter-prescribing“
  9. 9. Not really health care practitioners – they’re “”businessmen
  10. 10. ?”Do you need a degree to be a pharmacist“
  11. 11. 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
  12. 12. Introduction; Clinical PharmacyClinical pharmacy may be defined as the science and practice of rationale use ofmedications, where the pharmacists are more oriented towards the patient carerationalizing 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) ofscientific principles of pharmacology, toxicology, therapeutics, and clinicalpharmacokinetics, pharmacoeconomics, pharmacogenomics and other alliedsciences for the care of patients”.(Reference: American college of clinical pharmacy)
  13. 13. HistoryUntil the mid 1960’s ; Traditional role.The development of clinical pharmacy started in USA.More clinically oriented curriculum were designed with the award ofPharmD degree.These developments influenced the practice of pharmacy in U.K.,Initially prescription and drug administration records were introduced followedby an increasing pharmacy practice in hospital wards. Master degree programsin clinical pharmacy were introduced for first time in 1976.The progress of clinical pharmacy development remained at low profile in thefirst decade after its birth in U.K. However, Nuffield report in1986 geared up themomentum for progression of clinical pharmacy.Until today, the clinical pharmacy practice in Nepal is in embryonic stage.
  14. 14. How does clinical pharmacy differ from pharmacy?The discipline of pharmacy embraces the knowledge onsynthesis, chemistry and preparation of drugsClinical pharmacy is more oriented to the analysis ofpopulation needs with regards to medicines, ways ofadministration, patterns of use ,drugs effects on thePatients,‘the overall drug therapy management’.The focus of attention moves from the drug to the singlepatient or population receiving drugs.
  15. 15. Clinical Pharmacy Requirements Knowledge of drug therapy Knowledge of Knowledge of nondrug therapy the diseaseTherapeutic Knowledge of planning laboratory skills and diagnostic skills Patient careDrug Information Communication Skills skills Physical Patient assessment monitoring skills skills
  16. 16. Level of Action of Clinical PharmacistsClinical pharmacy activities may influence the correct useof medicines at three different levels:Before the prescriptionDuring the prescriptionandAfter the prescription is written.
  17. 17. 1. Before the prescription• Clinical trials• Formularies• Drug information• Drug-related policies
  18. 18. 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.
  19. 19. 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.
  20. 20. 3. After the prescription– Counselling– Preparation of personalised formulation– Drug use evaluation– Outcome research– Pharmacoeconomic studies
  21. 21. Functions of Clinical Pharmacists1. Taking the medical history of the patient2. Patient Education3. Patient care4. Formulation and management of drug policies5. Drug information6. Teaching & training to medical and paramedical staff
  22. 22. 7.Research and development8.Participation in drug utilization studies9.Patient counseling10.Therapeutic drug monitoring11.Drug interaction surveillance12.Adverse drug reaction reporting13.Safe use of drugs14.Disease management cases15.Pharmacoeconomics
  23. 23. 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
  24. 24. 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
  25. 25. Clinical Pharmacy Practice areas  Investigational Drugs Ambulatory care Critical care  Pharmacoeconomics Drug Information  Nephrology Geriatrics and long –term care  Obstetrics and gynecology Internal medicine and  Pulmonary disease subspecialties Cardiology  Psychiatry Endocrinology Gastroenterology  Rheumatology Infectious disease  Nuclear pharmacy Neurology  Pediatrics Nutrition Support ADR/DUE  Pharmacokinetics Transplant  Surgery
  26. 26. 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
  27. 27. Hospital pharmacist Vs Clinical pharmacist
  28. 28. 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 theirown, work-load to them is low-Patients feel more comfortable  "Every drug is poison, it’s 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.
  29. 29. 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 don’t 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"
  30. 30. Medicines are Dangerous
  31. 31. Pharmaceutical care• “ A practice in which a practitioner takes responsibility for a patient’s 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.
  32. 32. • 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 patient’s drug related needsGoal of Pharmaceutical Care• Goal of pharmaceutical care is to optimize the patient’s health-related quality of life and achieve positive clinical outcomes, within realistic economic expenditures
  33. 33. Essential Components of Pharmaceutical Care1.Pharmacist-patient relationshipCollaborative effort between pharmacist & patient2.Pharmacist’s 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 informationPatient’s demographic data: age, sex, race etc.Pertinent medical information
  34. 34. 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 & signsII. 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
  35. 35. III.Identify PRIME Pharmacotherapy Problems This includes pharmacists 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
  36. 36. 3.Documentation of pharmaceutical careFormulate a FARM note or SOAP note to describe or document theinterventions needed or provided by pharmacistFARM Progress NoteDescription & documentation of interventions intended or provided bypharmacistF = Findings, pt-specific information—gives basis for recognition of pharmacotherapy problems or indication for pharmacist intervention.A = Assessment, The pharmacist’s 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
  37. 37. Short term goals: elimination of symptoms , Lowering of BP ,Management of acute asthma without requiring hospitalizationLong term goals:Prevent recurrence of disease,Control B.P.,Prevent progression of diabetesR = Resolution, including prevention Observing & reassessing Counseling or educating the patients & care givers Informing the prescriber Making recommendation to prescriber Withholding medication or advising against useM = Monitoring to assess the efficacy, safety & outcome of the intervention This should includeThe parameters to be followed (e.g. pain, depressed mood, serum levels)The intent of monitoring e.g. efficacy, toxicity, adverse eventsHow the parameters will be monitored e.g. interview patients, serum druglevel, physical examination
  38. 38. Frequency of monitoring—weekly 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
  39. 39. Clinical skills & pharmacist’s role in Pharmaceutical CarePatient assessmentPhysical assessmentBarriers to adherencePsychosocial issuesEducation & counselingInterview skillsCommunication skills (e.g. empathy, listening, speaking orwriting at patients level of understanding)Ability to motivate & inspireDevelop & implement patient education plan based on an initialeducation assessmentIdentification & resolution of compliance barriers
  40. 40. Patient Specific Pharmacist Care PlanRecognition, prevention & management of drug interactionsPharmacology & therapeuticsInterpretation of lab testsKnowledge of community resources, professional referralsCommunication & support with community medical providersDrug Treatment ProtocolDevelop & maintain (update) protocolsFollow protocols as pharmacist-clinicianMonitor,aggregate adherence to the treatment protocols e.g. drugutilization evaluation, especially for managed care or healthsystem facility
  41. 41. Dosage adjustmentIdentify patients at high risk for exaggerated orsubtherapeutic responseApply pharmacokinetic principles to determine patientspecific dosingPrescriptive authorityIn designated practice site and positions
  42. 42. Effective drug Will the patient take Safe drug therapy ?the therapy therapy Aims of What does the Pharmaceutical patient view as an Care improved quality of ?life Improve Economic drugquality of life therapy
  43. 43. 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 Pharmaceutical problems  Prednisolone 40mg D ?Common organisms for URTI  Theophylline 200mg bd ?History of asthma – risk vs benefit  Omeprazole 20mg D  Metoclopramide 10mg tds ?Need for acid suppression  Salbutamol 2 puff inhale prn ?Why is she nauseous ?Benefit of brochodilation ?Does she know what to take ?Will she take it
  44. 44. 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 ?
  45. 45. High Profile ExamplesA patient with leukaemia received Intrathecal vincristine •instead of intravenously. Died beginning of February.2001. 14th such case over the last 16 yearsPatient being operated for a AAA received bupivicaine •intravenously rather than epidurally. Patient died 3 days.laterA 3 year old girl, who had a convulsion post flu vaccine. •Attended hospital to get “checked out”. Received nitrousoxide instead of oxygen in casualty
  46. 46. Elderly lady was prescribed Methotrexate in 1997 for herrheumatoid arthritis. Dose increased to 17.5mg.WEEKLY over a 6 month periodJan 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 •
  47. 47. Deaths from medicines in the UK(1999 - 2000 (ICD9 & 10 data (A spoonful of sugar - Audit Commission (2001
  48. 48. ………………..So drugs are safePhotosensitivity from Severe extravasation ofAmiodarone amiodarone infusion
  49. 49. NSAID induced peptic ulcer
  50. 50. Goitre – Hypothyroidism Bleeding due toSecondary to anticoagulationAmiodarone
  51. 51. Erythemal rash from penicillin – in patient with a previousKnown allergy/ adverse drug reaction
  52. 52. Necrotising fascititis – secondary to infection at site of IV injection
  53. 53. Acute Liver failure from Black Cohosh - herbal medicine
  54. 54. 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.
  55. 55. The System: !Only as safe as it’s designed to be“I assumed the brown glass ampoule was frusemide”
  56. 56. The Accident Causation Model (Adopted from Reason & Dean) Error Active Latent Failures producingConditions Slips&lapses- conditions Mistakes- Accident Defences
  57. 57. Sources of ErrorPrescribing error - selecting the wrong or inappropriate •drug/dose/formulation/duration etcCommunicating those instructions •Supply error - timely; wrong drug, dose, route; expired •.medicines, labellingAdministration error - timing; wrong route; wrong •.rate/technique.Lack of user education - actions to take •
  58. 58. Drug therapy assessmentSix types of problems which may result in treatmentfailure : Inappropriate selection of medication.1 Inappropriate formulation of medication.2 Inappropriate administration of drug therapy.3 Inappropriate medication-taking behaviour.4 1. Inappropriate monitoring of drug therapy.5 Inappropriate response to drug therapy.6
  59. 59. Clinical Pharmacy Role in Reducing Risks Admission medication history Formulary Prescribing protocols Allergy check Prospective review Administration instructions Clinical pharmacy Drug distribution systemOpportunityFor Error
  60. 60. !What if we are not there Admission medication history Formulary Prescribing protocols Allergy check Prospective review Administration instructions Clinical pharmacy Drug distribution systemOpportunityFor Error
  61. 61. 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 •
  62. 62. To be a drug expert,society needs practitioners who ……..…
  63. 63. Today’s pharmacists
  64. 64. Ideal Pharmacist Candidate?• Competent• Motivated/Enthusiastic• Teamwork spirit• Good communication skills• Responsible• Problem solver• Dedicated
  65. 65. The End
  66. 66. Any Questions?