Pharmaceutical Care Quiz

Introduction to Pharmaceutical Care Practice

• Integrated Therapeutics I course
• Hanan Muzeyin (B.Pharm., MSc)
• Department of Pharmacology & Clinical Pharmacy, Addis Ababa University
• Contact information provided

Learning Objectives

• Differentiate the role of pharmacists in clinical pharmacy services
• Comprehend the development of clinical pharmacy services and pharmaceutical care in Ethiopia
• Identify the roles and responsibilities of pharmacists in patient care process

Do We Still Need Pharmacists?

• Purchase and handling of medicines: Pharmacists are needed to handle medicines.
• Non-pharmacists: Some tasks are done by non-pharmacists.
• Compounding role: Pharmacists are involved in compounding.
• Pharmaceutical manufacturers: Pharmacists are involved in medicine production.
• Medicine availability: Pharmacists contribute to ensuring medicine availability.
• Pharmacies vs. supermarkets and local markets: Pharmacies offer services not always offered at other locations.
• Doctors' offices, clinic nurses: Pharmacists work with these groups.

Case 1

• Nine-month-old baby died after a 10-fold morphine overdose due to a misplaced decimal point in the prescription.
• A physician ordered morphine .5 mg IV for post-op pain.
• A unit secretary misinterpreted the decimal, prescribing morphine 5 mg IV.
• The experienced nurse administered 5 mg morphine and repeated the dose two hours later.
• The baby stopped breathing four hours after the second dose.
• Date: April 20, 2001
• Location: Washington Post

Case 2

• A 39-year-old female patient being treated for metastatic breast cancer at Dana Farber Cancer Institute, Boston in 1995.
• The patient was prescribed cyclophosphamide at 4 grams per meter squared daily.
• The intended dose was 1 gram per meter squared daily.
• The patient received the total dose each day.
• The massive overdose caused death from cardiotoxicity.

What is Wrong with the 'Old Model'?

• Physicians Prescribe and Pharmacists Dispense model
• Inadequate Accountability
• Healthcare Costs
• Increased costs due to medicine related errors (hospitalizations, physician visits, lab tests, and remedial therapy).
• Adverse Drug Reactions
• Non-compliance
• Resistance to treatment

What is Wrong with the 'Old Model?'

• The old Physicians Prescribe and Pharmacists Dispense model is not fully appropriate to reduce drug therapy problems.
• The model needs to improve safety, effectiveness, and patient adherence to drug therapy.
• The need for a better solution led to the creation of the concept of Clinical Pharmacy and Pharmaceutical Care.

Clinical Pharmacy

• Defined as the area of pharmacy concerned with the science and practice of rational drug use.
• Includes services performed by pharmacists across different settings (hospitals, community pharmacies, home-based care, clinics).
• "Clinical" does not imply only hospital work.

Pharmaceutical Care

• Defined as a practice in 1997.
• A patient-centered approach where the practitioner takes responsibility for drug-related patient needs and accountability for this commitment. (Hepler and Strand, 1990).
• Aims to achieve definite outcomes that improve a patient's quality of life.

Pharmaceutical Care... Aim

• Aiming for cure of the disease.
• Elimination or reduction of symptoms.
• Arresting or slowing a disease process.
• Disease prevention or symptom management.
• Ensuring access to advice and quality drugs.
• Promoting rational drug use and patient empowerment.

Pharmaceutical Care...

• A practitioner applies expert pharmacotherapeutic knowledge to benefit patients.
• Practitioners are responsible for optimizing all of a patient's medication therapy regardless of the source to improve patient outcomes and quality of life, in cooperation with other health care providers.
• The practitioner uses a rational decision-making process to make an assessment of a patient's drug-related needs.

Pharmaceutical Care...

• All patients have drug-related needs.
• Assessing the patient, his/her medical conditions, and all drug therapies is necessary to determine if drug-related needs are met.
• Criteria for drug-related needs: indication, effectiveness, safety, and compliance.

Pharmaceutical Care...

• Medications should be appropriate with clinical indication for each medication.
• Patient's medical conditions that benefit from drug therapy must be identified and considered.
• Medications should be effective in use and dosage.

Pharmaceutical Care...

• Medications must be safe.
• Adverse drug reactions and signs of toxicity should be absent.
• Patients should be compliant with taking medications as intended.

Pharmaceutical Care...

• Pharmaceutical care practitioners are responsible for preventing drug therapy problems, resolving them for patients, and ensuring therapy goals are met by developing care plans for each medical condition.

Pharmaceutical Care...

• Pharmaceutical care complements existing practices to ensure more effective and safe drug therapy.
• It is a new provider in the health care system that is not intended to replace physicians, dispensing pharmacists, or other allied health professionals.

Pharmaceutical care... Why is it needed?

• Increased number of medications and related products and devices.
• Complexity of drug therapy.
• An overwhelming amount of drug information.
• Multiple practitioners writing prescriptions for single patients without coordination or communication.
• Patients have an active role in medication selection.

Pharmaceutical care...

• Further need for pharmaceutical care practitioners to improve self-care through alternative and complementary medicine.
• Increased emphasis on primary and preventative healthcare services and long-term care.
• High levels of morbidity and mortality related to medicine and financial costs.
• Improving patient access to health care while controlling costs.

Pharmaceutical Care... New Roles/New Skills

• Medical terminology
• Clinical use of drugs in disease and patients
• Pathophysiology
• Therapeutics
• Therapeutic problem-solving
• Communication (verbal and written)
• Literature evaluation

Clinical Pharmacy Service in Ethiopia

• Pharmaceutical care practice is a primary responsibility of full-time pharmacists (or clinical pharmacists).
• Pharmacists have a minimum of 5 years of academic preparation focusing on pharmacology, pharmacotherapy, and pharmaceutical care practices.
• Old curricula: Pharmacotherapy, Clinical & Hospital Pharmacy
• New curricula (Curricular revision 2008): Nation-wide

Clinical Pharmacy Service in Ethiopia...

• Pharmacy undergraduate curriculum is more patient-oriented with additional internship (4 years + 1 year).
• Clinical pharmacy courses make up 40% of studies.
• First batch of graduates: 2008/09 - 2012/13
• Postgraduate training in clinical pharmacy
• Advanced patient-focused pharmacy training
• Curricula launched in 2008 and 2015

Clinical Pharmacy Service in Ethiopia: EHRIG 2010

• Clinical pharmacists' duties and hospital pharmacists' duties include providing advice to doctors and nurses on medicine use, economic drug utilization, and safety.
• Offer direct patient care, offer advice and support to hospital managers and clinical managers on medicine policy.

Clinical Pharmacy Service in Ethiopia: FMHACA

• Pharmacists should provide effective medication therapy management including managing patient medication therapy, providing information about medicines and health issues, and participation in patient care regarding pharmacotherapy.

Clinical Pharmacy Service in Ethiopia: PESA (EPSS/SIAPS)

• Provides a standard operating procedures manual for the provision of clinical pharmacy services in Ethiopia, first edition.

Language of Practice

• Pharmaceutical care practitioners work with physicians, nurses, and other care providers to optimize care.
• A common vocabulary is needed for collaborative efforts.
• Effective and precise language reflects competency in practice.
• Pharmaceutical care practitioners use the same practice vocabulary as other health sciences to facilitate understanding and common meanings.

Language of Practice...

• Terms like assessment, care plan, and follow-up evaluation are used by all healthcare practitioners in a similar way.
• Pharmaceutical care practice expands the existing vocabulary related to medicine rather than introducing a new language.

Language of Practice...

• The pharmacist's role is both unique and important.
• No other healthcare professional focuses on all of a patient's medications.
• They manage a portion of drug therapy for a finite time.

Pharmacotherapy Workup

• All patient care practitioners need a structured, rational thought process for making clinical decisions.
• A systematic pharmacotherapy workup aids clinicians in assessing medication needs, identifying drug therapy problems, planning interventions for patients, and establishing follow-up evaluation parameters.

Pharmacotherapy Workup...

• Practitioners employ unique knowledge and clinical skills via systematic thought processes to identify, address, resolve, and prevent drug therapy problems.
• This ensures appropriate drug therapy is indicated, effective and safe, and maintains patient compliance.

Pharmacotherapy Workup...

• Determining the cause of, or cure for, a drug therapy problem helps find problems other practitioners might miss.
• The approach helps address gaps within healthcare systems to reduce drug-related morbidity and mortality.

Patient Care Process

• The patient care process describes the interaction between the patient and practitioner.
• The process serves as a guide, practice standard, comprehensive description of practitioners' work, and allows for rational decision-making.

Patient Care Process...

• A systematic approach for pharmaceutical care provision uses four core processes: (1) assessing drug therapy needs, (2) developing a patient care plan, (3) implementing the care plan, and (4) evaluating and reviewing the care plan.

Patient Care Process...

• Assessment quality depends on the established therapeutic relationship; care plan success depends on how well the assessment is performed; and patient outcomes depend directly on decisions made during plan development.

Patient Care Process...

• Establishing a therapeutic relationship is critical for an effective assessment.
• Assess the patient wants/needs and develop a care plan.
• Continuously evaluate if and how the care plan works.

Assessment

• A systematic review of a patient's drug-related needs.
• The purpose of the assessment is to understand the patient well enough to make rational drug therapy decisions.
• Assess if patient's drug therapy is appropriate, effective, safe and, if they are compliant.

Assessment

• Data needed includes patient demographics, medication experiences, medical history, nutritional status (review of systems), current/past medications, social drug use, immunizations, and allergies.

Assessment

• The two primary activities are eliciting information from the patient and making clinical decisions.
• Start with establishing a therapeutic relationship, which helps in discussing the patient's experiences with medication.

Assessment... Medication Experience

• Includes patient's personal approach to medication, their beliefs, perceptions, understandings, attitudes, and behaviors.
• Patient experience with medications frequently directly affects decisions around medication use, dosage, and method of administration.

Assessment...

• The assessment process involves effective communication with patients and relatives, coordination with healthcare team members, and reviewing patient medication and clinical records.
• All drug-related needs must be assessed in the same systematic order, starting with determining whether the indication is appropriate for the drug.
• Evaluate the effectiveness and safety of the drug regimen.

Case Study

• A 10-year-old girl with symptoms of a flu-like illness, nausea, vomiting, and stomach issues.
• Presented with symptoms after several weeks, and excessive fluid intake.
• Extensive lab testing done, revealing metabolic acidosis and related symptoms.
• Diagnosis of diabetic ketoacidosis due to undiagnosed Type 1 diabetes.

Case Study... Lab Results

• Results of lab work showing high blood glucose, bicarbonate, ketones, serum sodium, potassium, chlorine, urine glucose, urine ketones.

Case Study... Questions

• How is this patient assessed?
• What relevant data must be collected?

Answers to Case Study Question 1: Approach

• Establish a therapeutic relationship with the patient (or caregiver).
• Greet the patient, introduce yourself, and ensure the patient is comfortable.
• Determine patient's comfort level.
• Gather patient information and take notes in standardized formats.
• Review patient's medical records.

Answers to Case Study Question 2: Data Collection

• Patient sociodemographic data (age, gender, weight, family history, social history).
• Clinical data including symptoms (prolonged flu, fever, nocturia, polydipsia, weight loss, nausea, and vomiting).
• Lab findings (RBS, urine and serum ketones, pH, bicarbonate).
• Patient's medication experience (past and current medication history).

Components of a FARM/SOAP Note

• A framework for documenting a pharmacist's workup of medication therapy (PWDT), with sections for Findings (F), Desired Outcomes, Desired Endpoints, Drug-related Problems (DRPs), Therapeutic Selection, Monitoring (M) parameters, and follow-up.

Drug Therapy Problems (DTPs)

• An undesirable event or experience involving drug therapy that interferes with a patient's desired outcome or drug therapy is not effective.

Drug Therapy Problems (DTPs) - Potential and Actual

• Potential DTPs: Likely to occur.
• Actual DTPs: Already occurred.

Identifying the Cause of Each DTP

• The pharmacist must determine the cause for each DTP.

Categories and Common Causes of DTPs

• Lack of valid medical indication
• Multiple medications used for a condition needing only one.
• Drug therapy is unsuitable for the condition.
• Drug therapy is used for a preventable adverse reaction with another medication.

Categories and Common Causes of DTPs...

• Need for additional drug therapy due to a new or developing medical condition.
• Need for additional drug therapy to achieve synergistic or additive effects.
• Ineffective drug therapy due to the drug not being the most effective option.
• Medical condition is refractory to therapy.
• Drug product dosage form is inappropriate.
• Drug product fails to produce an effective response in patient.

Categories and Common Causes of DTPs...

• Dosage too low to have an effect on the patient.
• Dosage interval is too infrequent.
• Drug interaction reduces the amount of active drug.
• Duration of therapy is too short.

Categories and Common Causes of DTPs...

• Unfavorable reaction from drug therapy that is not dose-related.
• A safer drug therapy option may be needed due to risk factors.
• Dosage regimen should be changed or administrated properly.
• Adverse reaction to the medication, drug being contraindicated.

Categories and Common Causes of DTPs... - Dosage Too High

• The dose of a medication is too high.
• Dosing frequency is too high or interval frequency is too short.
• Duration of drug therapy is too long.
• Drug interaction creates a toxic reaction to the drug product or to overdose.

Categories and Common Causes of DTPs... - Patient Compliance Issues

• The patient does not understand the instructions for drug therapy.
• The patient chooses not to take the medication.
• The patient forgets to take the medication.
• The drug is expensive for the patient.
• The patient cannot swallow or self-administer the medication.
• The drug product is not available for the patient.

Case Study 1, 2, & 3

• Case Study 1 (KT): Possible DTPs: Drug therapy (digoxin dose too high), drug interaction b/n digoxin and furosemide, possible heart block and bradycardia due to high-dose digoxin and hypokalemia due to furosemide.
• Case Study 2 (MR): Possible DTPs: Unsafe drug therapy (ACE inhibitors) contraindicated during pregnancy.
• Case Study 3 (AB): Possible DTPs: Ineffective drug therapy due to RIF's liver enzyme induction, leading to increased COC metabolism and increased pregnancy risk.

Developing Care Plan - Purpose

• Organizing work to achieve therapy goals as agreed with the patient.
• Organizing care plans by medical condition; individual plans for each condition or illness.

Developing Care Plan... Steps

• Establish therapy goals for each medical condition (with a parameter, value, and time frame for the goal).
• Negotiate endpoints and timeframe for treatments with the patient.
• Select appropriate, individualized interventions to resolve problems, achieve goals, and prevent further problems.

Follow-up Evaluation

• Eliciting clinical/lab evidence of patient outcomes and comparing those results with the established therapy goals for effectiveness evaluation.
• Eliciting clinical/lab evidence of adverse effects to determine therapy safety.
• Establishing patient compliance for proper therapy execution.

Follow-up Evaluation...

• Documenting clinical status changes and drug therapy adjustments.
• Assessing patients for any new drug therapy problems (DTPs).
• Scheduling future follow-up evaluations to allow ongoing clinical experience and knowledge gain.

Follow-up Evaluation...

• Evaluate therapy outcomes in relation to desired goals.
• Each medication's effectiveness, safety, and appropriate use should be reviewed.
• Parameters used for evaluation include clinical signs and symptoms, lab values, and adverse drug reactions.

Outcomes Status Terminologies

• Summary of patient outcomes from therapy (Resolved, Stable, Improved, Partial Improvement, Unimproved, Worsened, Failure, and Expired).

Documentation

• Creating comprehensive patient records outlining pharmaceutical care, including information used, decisions made, and outcomes for each patient encounter.
• Recording all care, advice, and services provided to the patient for evaluation by others and continued improvement.

Reasons to Document

• Ensure patient receives high-quality care.
• Evaluate performance and justify the professional role taken.
• Effectively manage expanding healthcare practices.
• Evaluate quality and quantify care provided alongside its economic impact.
• Be a data source for research and education.

Summary

• What was learned throughout the lecture.

Test your knowledge on the core responsibilities of pharmaceutical care practitioners, the differences between clinical pharmacy and pharmaceutical care, and the patient care process. This quiz covers key concepts essential for understanding the role of pharmaceutical care in healthcare delivery.