Pharmaceutical Care Practice Overview PDF

INTEGRATED THERAPEUTICS I Introduction to Pharmaceutical care Practice Hanan Muzeyin (B.Pharm. Msc,) Department of Pharmacology & Clinical Pharmacy, Addis Ababa University Email: [email protected]; [email protected]  Learning Objectives 2...

INTEGRATED THERAPEUTICS I Introduction to Pharmaceutical care Practice Hanan Muzeyin (B.Pharm. Msc,) Department of Pharmacology & Clinical Pharmacy, Addis Ababa University Email: [email protected]; [email protected]  Learning Objectives 2 At the end of this session, you will be able to: Differentiate the role of pharmacists in clinical pharmacy services Comprehend development of clinical pharmacy services and pharmaceutical care in Ethiopa Identify the roles and responsibilities of pharmacists in patient care process  Do we still need Pharmacists? 3  Purchase and handling of medicines  Non pharmacists  Compounding role  Pharmaceutical manufacturers  Medicine availability  Pharmacies vs. supermarkets and local markets  Doctor’s office, clinic nurses  Case 1 4  A nine-month old baby died after misplaced decimal causes10-fold morphine overdose  Physician ordered Morphine.5 mg IV for post-op pain, unit secretary does not see the decimal and transcribes the order as Morphine 5 mg IV  Experienced nurse administered 5 mg of Morphine and repeats the dose 2 hours later  Four hours later baby stops breathing Washington Post, April 20, 2001  Case 2 5 Dana Farber Cancer Institute, Boston Mass. 1995  A 39 year old female being treated for metastatic breast CA  Cyclophosphamide ordered as: “4 gram per meter square days 1 - 4”  Was meant to be 1 gram / meter squared daily  The patient received the total dose each day  A massive overdose caused death from cardiotoxicity  What is wrong with the “old 6 model?” “Physicians Prescribe and Pharmacists Dispense”  Inadequate Accountability?  Healthcare costs  Medicine related errors are costly in terms of hospitalizations, physician visits, laboratory tests and remedial therapy  Adverse drug reaction…  Non compliance  Resistance  What is wrong with the “old 7 model?”…  The old “Physicians Prescribe and Pharmacists Dispense” model is no longer fully appropriate to (a) reduce drug therapy problems, (b) ensure safety, (c) ensure effectiveness and (d) adherence to drug therapy  What could be the solution? Concept of Clinical Pharmacy and Pharmaceutical Care  Clinical Pharmacy 8  Clinical pharmacy is defined as  The area of pharmacy concerned with the science and practice of rational medication use. Clinical Pharmaceutica VS. Pharmacy l care  Clinical Pharmacy… 9  Clinical Pharmacy includes all the services performed by pharmacists practising in;  Hospitals,  Community pharmacies,  Home-based care services,  Clinics and any other setting where medicines are prescribed and used.  The term “clinical” does not necessarily imply an activity implemented in a hospital setting.  Pharmaceutical care 10  Defined as a practice in 1997  Pharmaceutical care is a patient-centered practice in which the practitioner assumes responsibility for a patient's drug-related needs and is held accountable for this commitment.  Hepler and Strand, 1990 “Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life”.  Pharmaceutical care… 11  Aim Cure of the disease Elimination or reduction of symptoms Arrest or slowing of a disease process Prevention of disease or symptoms  Calls on pharmacists to:  Ensure access  Ensure access to advice  Ensure quality drug products  Ensure rational drug use  Empower patients to manage their own health and treatment  Pharmaceutical care… 12  It is how a practitioner applies expert pharmacotherapeutic knowledge in practice to benefit the patient.  Practitioners …. accept responsibility for optimizing all of a patient's drug therapy, regardless of the source, to achieve better patient outcomes and to improve the quality of each patient's life.  It occurs with the patient's cooperation and in coordination with other health care providers.  Pharmaceutical care… 13  The practitioner uses a rational decision-making process….  to make an assessment of the patient's drug-related needs  to identify drug therapy problems  to develop a care plan  to conduct follow-up evaluations to ensure that all drug therapies are effective and safe  Pharmaceutical care… 14  All patients have drug-related needs.  During a pharmaceutical care encounter, the patient, his medical conditions, and all of the drug therapies are assessed to determine if the patient's drug-related needs are being met.  Drug-related needs: indication, effectiveness, safety, compliance.  Pharmaceutical care… 15  The medication is appropriate  There is a clinical indication for each medication being taken.  All of the patient's medical conditions that can benefit from drug therapy have been identified.  The medication is effective  The most effective drug product is being used.  The dosage of the medication is sufficient to achieve the goals of therapy.  Pharmaceutical care… 16  The medication is safe  There are no adverse drug reactions being experienced.  There are no signs of toxicity.  The patient is compliant  The patient is willing and able to take the medications as intended.  When the above drug-related needs are not met, drug therapy problems may exist.  Pharmaceutical care… 17  The pharmaceutical care practitioners are responsible….  to prevent drug therapy problems from occurring,  to resolve drug therapy problems with and for the patient,  to assure that the goals of therapy are achieved; throughdeveloping a care plan for each medical condition  Pharmaceutical care… 18  Pharmaceutical care is designed to complement existing patient care practices to make drug therapy more effective and safe.  The pharmaceutical care practitioner …is not intended to replace the physician, the dispensing pharmacist, or any other health care practitioner. Rather, it is a new patient care provider within the health care system.  The responsibilities associated with drug therapy have become so numerous and complex that the  Pharmaceutical care… 19  Why we need Pharmaceutical care practitioner?  d number of medications and related products & devices  d complexity of drug therapy  Overwhelming amount of drug information  Multiple practitioners writing prescriptions for a single patient, without coordination and communication  Patients play a more active role in the selection  Pharmaceutical care… 20  Why we need Pharmaceutical care practitioner? …  d in self-care through alternative & complementary medicine  Increased emphasis on primary and preventive health services, and long term care  High level of drug-related morbidity and mortality which results in significant human and financial costs  Concerns about improving patients' access to  Pharmaceutical care… 21  New Roles Required New Skills  Medical terminology  Clinical use of drugs in disease and patients  Pathophysiology  Therapeutics  Therapeutic problem-solving  Communication: verbal and written  Literature evaluation 22 Clinical Pharmacy Service in Ethiopia  Clinical Pharmacy Service in 23 Ethiopia  As a responsibility, pharmaceutical care practice is a primary role of the Pharmacist (or Clinical Pharmacist) as full-time career.  The pharmacist is equipped with a minimum of 5 years of academic preparation;  focuses on …. Pharmacology, Pharmacotherapy, and Pharmaceutical care practices  Ethiopia;  Old curricula: Pharmacotherapy, Clinical & Hospital Pharmacy  New curricula [Curricular revision 2008: nation wide]  Clinical Pharmacy Service in 24 Ethiopia…  The new curricula,  Pharmacy UG curriculum: more patient oriented training (4 years + 1year internship) Clinical pharmacy courses …. > 40% The 1st batch: 2008/09 – 2012/13  PG training in Clinical Pharmacy: Advanced patient-focused pharmacy training launched in 2009 Curricula: 2008, 2015  Clinical Pharmacy Service in Ethiopia: 25 EHRIG 2010 Duties of clinical pharmacists and hospital pharmacists, EHRIG 2010:  Provide advice to doctors, nurses and other health care workers on the clinical use of Medicines, Economic drug utilization and Safety,  Offer direct patient care services  Offer advice and support to hospital managers & clinical managers on  Medicines policy,  Clinical Pharmacy Service in 26 Ethiopia: FMHACA Pharmacists should provide effective medication therapy management including;  managing patient medication therapy,  providing information about medicines and health-related issues to client, and  participating in patient care regarding pharmacotherapy  Clinical Pharmacy Service in Ethiopia: 27 PFSA (EPSS)/SIAPS  Language of Practice 28  The pharmaceutical care practitioners work with physicians, nurses, and other patient care providers to optimize care.  This collaborative effort requires a common vocabulary.  The ability to use precise language appropriately in practice will directly reflect upon your level of competency and confidence.  Pharmaceutical care practitioners use the same practice vocabulary as the other health sciences  Language of Practice… 29  E.g., Terms such as assessment, care plan, and follow-up evaluation are used by all health care practitioners in the same way.  Pharmaceutical care is a unique practice [focuses on the patient's drug-related needs];  Pharmaceutical care practice does not introduce a new language into health care; rather it expands the vocabulary that currently exists.  Language of Practice… 30  The practitioner’s primary and unique responsibility in the health care team is to manage all of the patient's pharmacotherapy (drug therapy). These include:  all of the patient's prescription medications, OTC products, nutritional supplements, herbal remedies, or other traditional medicines, and any other products the patient may take for therapeutic purposes.  all products being used to treat medical conditions, to prevent illnesses, and to improve  Language of Practice… 31  Pharmacist’s role is both unique and important;  no other health care practitioner focuses attention on all of a patient's medications; and  they manage a portion of drug therapy for a finite amount of time. 32 Pharmacotherapy Workup  Pharmacotherapy Workup 33  All patient care practitioners need a structured, rational thought process for making clinical decisions.  The pharmacotherapy workup  guides the decisions as the clinician assesses the patient’s drug-related needs and identifies drug therapy problems;  organizes the interventions that need to be made on behalf of the patient;  establishes appropriate parameters to evaluate at  Pharmacotherapy Workup… 34  The practitioners apply a unique knowledge and clinical skills using a systematic thought process.  Identification, statement of cause, prioritization, resolution, and prevention of drug therapy problems  These represent the unique contribution of the pharmaceutical care practitioner.  Pharmacotherapy workup helps,  to determine if a patient's drug therapy is appropriately indicated, effective, and safe and if the patient is being compliant.  Pharmacotherapy Workup… 35`  The practitioner's clinical approach should be… determining whether the drug therapy is the cause of or cure for the problem.  Such approach allows the pharmacist;  to find problems that other practitioners are not looking for,  to solve problems in ways that other practitioners would not consider,  to address a gap in the health care system that has allowed drug-related morbidity and mortality  Patient care process 36  The patient care process describes the interaction between the patient and the practitioner.  The patient care process is …  a guide for the practitioner  a standard for the practice  a comprehensive and consistent description of the practitioner’s work  a method that allows the practitioner to make rational decisions  Patient care process… 37  A systematic approach for PC provision involves four processes:  Assess the patient’s drug therapy needs and identify actual (already occurred) and potential (likely to occur) DTPs  Develop a care plan to prevent and/or resolve the DTPs  Implement the care plan  Evaluate and review the care plan  Patient care process… 38  Quality of assessment depends on …..the quality of the relationship you have established,  The success of the care plan …. a direct result of how well performed the assessment,  The outcomes the patient achieves are the direct result of the decisions made when the care plan developed.  The Patient Care Process 39  Assessment 40  A systematic review of the patient’s drug- related needs.  The purpose of the assessment: 1. to understand the patient well enough to make rational drug therapy decisions with and for him 2. to determine if the patient's drug therapy is appropriate, effective, and safe, and to determine if the patient is compliant with his medications  Assessment… 41  The information required includes;  Patient data (demographic information, medication experience),  Disease data (current medical conditions, medical history, nutritional status, review of systems),  Drug data (current medications, past medication use, social drug use, immunizations, allergies).  Assessment… 42  The two major activities during assessment:  Eliciting information from the patient,  Making clinical decisions about the patient's medications and meeting his drug-related needs.  Start by establishing a therapeutic relationship with the patient.  discuss the patient's medication experience  Assessment… 43  Medication experience  It is the patient's personal approach to taking medication.  It is the patient's beliefs, perceptions, understandings, attitudes, and behaviors about drug therapy.  The patient’s medication experience will most directly influence the patient's decisions about medication,  whether to take or not, how much to take, and  Assessment… 44  The assessment process involves:  effective communication with patients, care givers or relatives  Communicate with other members of the health care team and  Reviewing patient medication and clinical records  Always assess the patient's drug-related needs in the same systematic order.  First determine if the indication is appropriate for the Drug  Evaluate the effectiveness of the drug regimen  Determine the level of safety of the drug regimen.  Case Study 45 RA, a 10-year-old girl who lived with her mother and two younger sisters, was brought into pediatric ward by her mother. She weighed 22 kg and had always been a healthy, active child. The whole family had had colds and fevers over the last few weeks, but RA was still suffering from flu-like symptoms as well as having some nausea, vomiting and a recurrent stomach ache. Her mother was concerned because her symptoms were not improving and she appeared to have lost weight over the last few weeks. On questioning, it became apparent that RA had been drinking large quantities of water and juice  Case Study… 46  Laboratory investigations at admission were:  RBS 396 g/dL (N 70-180)  Bicarbonate 11 mmol/L (N 22—29)  Blood pH 6.7 (N 7.35-7.45)  Ketones 5.5 mmol/L (N=0)  Sodium 150 (N 135-145)  Potassium 4.5 (N 3.5-5)  Chlorine 110 (N 95-105)  Urine glucose +2  Her urine tested +ve for ketones (normally O)  Case Study… 47  A diagnosis of diabetic ketoacidosis was made presenting secondary to newly diagnosed type 1 diabetes. You are clinical pharmacist working in pediatric ward, while you are preparing for major round you identified this patient is newly admitted patient. 1. How do you approach for assessing this patient? 2. What pertinent patient data are you going to collect?  Answer to case Study 48 1. How do you approach for assessing this patient?  First, establishing therapeutic alliance with the patient and/or the career (mother) is required for effective provision of PC:  greet the patient, introduce yourself, ensure the patient is comfortable for assessment,  assess and elicit the patient information to identify drug related needs and take notes (use standard Formats)  Review the patient’s medical record  Answer to case Study… 49 2. What pertinent patient data are you going to collect?  Patient sociodemographic data (age, gender, weight, FH, SH)  Clinical (prolonged flu and fever symptoms, nocturia, polydipsia, weight loss, nausea and vomiting…)  Laboratory finding (RBS, Urine and serum ketones, PH, bicarbonate)  Patient's medication experience (past and current medication history)  Components of a FARM/SOAP Note 50  Drug Therapy Problems 51  Identifying drug therapy problems  Definition: “An undesirable event, a patient experience that involves, or is suspected to involve drug therapy, and that actually or potentially, interferes with a desired patient outcome”. [Cipolle et al., 1998]  Potential vs. Actual  Identifying the cause for each DTP  Categories and Common Causes of 52 DTPs  Categories and Common Causes of 53 DTPs…  Categories and Common Causes of 54 DTPs…  Categories and Common Causes of 55 DTPs…  Identify DTPs in the following 56 cases Case Study 1:  KT, a 65 years old female known congestive heart failure patients taking furosemide 20mg po daily, lisinopril 5 mg daily and digoxin 0.5 mg daily. The patient developed bradycardia and second-degree heart block. Case Study 2:  MR, a 30 years old newly diagnosed hypertensive woman presented with a prescription of lisinopril 5 mg daily. Up on assessing her, you have understood that she is  Identify DTPs in the following 57 cases… Case Study#03:  AB, a 24 years old woman taking combined oral contraceptives, was diagnosed with TB and started anti TB medications (RHZE). Case Study#04:  A patient complains frequent asthma attack, almost in a daily basis, & requests a new albuterol inhaler every two weeks at a nearby community pharmacy. Pharmacist assesses the patient’s inhalation technique & seems appropriate.  Answers 58 Case Study#01:  Unsafe drug therapy (dose too high for digoxin, drug interaction b/n digoxin and furosemide).  The heart block and bradycardia might be due to high dose of digoxin in which its toxicity might also be enhanced following hypokalemic state due to furosemide. Case Study#02:  Unsafe drug therapy (ACE inhibitors are contraindicated during pregnancy – ADR).  Answers… 59 Case Study#03:  Ineffective drug therapy (dose too low): RIF is liver enzyme inducer thus resulting in increased metabolism of COC thus unwanted pregnancy risk is high. Case Study#04:  Needing additional drug therapy but not receiving: the patient needs inhaled corticosteroid for effective control of his asthma.  Developing care plan 60  Purpose: to organize all of the work agreed upon by the practitioner and the patient to achieve the goals of therapy.  Care plans are organized by medical condition, and a separate care plan is constructed for each condition or illness.  Constructing a care plan involves three steps.  Developing care plan… 61  Establish goals of therapy for each medical condition  goals consist of a parameter, a value, & a timeframe  Negotiate and agree upon endpoints and timeframe for pharmacotherapies with the patient  Select appropriate individualized interventions  to resolve DTPs, achieve the goals of therapy, prevent new DTPs from developing  Developing care plan… 62  Establish goals of therapy for each medical condition  goals consist of a parameter, a value, & a timeframe  Negotiate and agree upon endpoints and timeframe for pharmacotherapies with the patient  Select appropriate individualized interventions  to resolve DTPs, achieve the goals of therapy, prevent new DTPs from developing  Follow up evaluation 63  Elicit clinical and/or lab evidence of actual patient outcomes and compare them to the goals of therapy to determine the effectiveness of drug therapy.  Elicit clinical and/or lab evidence of adverse effects to determine safety of drug therapy.  Determine patient compliance  Follow up evaluation… 64  Document clinical status & any changes in pharmacotherapy  Make a judgment as to the clinical status of the patient's condition being managed with drug therapy  Assess patient for any new DTPs Schedule the next follow-up evaluation  The Provide continuous evaluation care step is where clinical experience and new knowledge are gained.  Follow up evaluation… 65  Follow-up evaluation is to determine the outcomes in relation to the desired goals of therapy.  Each medication can be reviewed for appropriateness, effectiveness, safety and patient adherence  Parameters used for evaluation (clinical signs and symptoms and/or laboratory values, evidence of ADRs and/or toxicity)  Within the follow-up process, the effectiveness of the care plan should be monitored and  Outcomes Status Terminologies 66  Documentation 67  Documentation refers to creating a pharmaceutical care patient chart that records the information used, decisions made, and outcomes achieved at each patient encounter.  Any care, advice, services, or information provided to the patient that is not recorded remains “invisible” within the health care system and therefore has little value.  “No documentation means you did not do it!”  Thus, the record keeping is essential so that care  Reasons to Document 68  To ensure that patients receive high quality care  To evaluate performance  To justify professional role  To effectively manage large and growing practices  evaluate the quality and quantify of care provided  evaluate the economic impact of the services  Source of data for research and education  Summary 69  What did you learn from this lecture? thank you !