Pharmaceutical Care Introduction PDF

7/2/2024 ‫الصيدلة‬ Pharmaceutical Care Introduction Dr. Loai Saadah, BS, MS, PharmD Assistant P...

7/2/2024 ‫الصيدلة‬ Pharmaceutical Care Introduction Dr. Loai Saadah, BS, MS, PharmD Assistant Professor, Clinical Pharmacy ‫ الدكتور أحمد السيد والدكتور لؤي سعادة‬: ‫مدرس المادة‬ 1 ‫صيدلة سريرية و نداواة‬- : ‫اسم المادة‬ Outline 1. Define Pharmaceutical Care 2. Describe patient-centered practice 3. Gather patient health information 4. Assess health information 5. Identify Drug Therapy Problems 6. Classify Drug Therapy Problems 7. Develop Care Plan 8. Follow-up Evaluate Plan 9. Document Patient Care Encounter 2 1  7/2/2024 Abbreviations 1. TRP: Treatment-related problems 2. DTP: Drug therapy problems 3 Pharmaceutical Care Responsible Provision of Pharmacotherapy to produce definite positive outcomes for patients and society So here, the pharmacist become a care provider with responsibility, can diagnose, and manage medications to produce positive outcomes and he or she is held accountable by law 4 2  7/2/2024 Pharmacy Evolution Compounding drugs Dispensing drugs Patient education Provider of drug information Medication profile review Clinical pharmacy Pharmaceutical care 5 Why More Clinical Pharmacy? 1. Undiagnosed Conditions 2. Medication Related Problems/Errors Medical errors are the third leading cause of death. Most of these are drug-related 3. Fragmented Care, Multiple Medical Practitioners 4. Large number of medications 6 3  7/2/2024 5. Complexity of New Drug Therapies: Example biological 6. Increase in Self Care Movement in Society 7. Huge burden of drug-related burden (morbidity, mortality, costs) 7 Medication Error Definition "any preventable event that may cause or lead to inappropriate medication use or patient harm …..," according to the National Coordinating Council for Medication Error Reporting and Prevention. 8 4  7/2/2024 Major Distinction from TRP A medication error is unintentional: 1 in 10 lead to harm. Only 5-10% of CPI Treatment-related problem (TRP) mostly represent a gap in the knowledge of the healthcare provider. It includes in addition to errors, intentional inappropriate plans. These are 90-95% of CPI 9 Major Role Diagnose or identify drug- related problems both actual or potential Prevent the potential problems Manage the actual problems 10 5  7/2/2024 Definite Positive Outcomes ↓ Mortality rates ↓ Hospital readmission rates ↓ Hospital length of stay ↓ Side drug events ↓ Medication errors ↑ Medication adherence ↓ Cost Others (e.g. better control of BP, HbA1c) 11 Patient Centered Care Drug, Disease and System are major circles in pharmaceutical care but at the core is a patient who has a need Sometimes we do not have disease but the patient is there for preventive care Sometimes we do not have a drug but the patient is there for non-pharmacologic reasons Sometimes we do not have a system but the patient is there for advice 12 6  7/2/2024 User Experience Patient experience an illness not a disease which entail all his knowledge, attitude and behavior related to a disease Patient experience a medication therapy which is all the knowledge, attitudes and behaviors related to using a drug for an illness Drug X may work for Patient 1 who has disease Y but the same drug may fail for another patient who has the same disease 13 Therapeutic Relationship So we have to build a therapeutic relationship with the patient that takes all the different factors defining his experience of the illness and his or her response to our therapy plan including medications If the plan works patients will adhere to it Eventually, we are managing patient medications to ensure patient adherence and resolution or prevention of their illnesses or DTP or TRP 14 7  7/2/2024 Drug Therapy Problems I Unmet Major Class & Drug Therapy Problems Major Class Categories of DTP or TRP INDICATION 1. Unnecessary drug therapy 2. Needs additional drug therapy EFFECTIVENESS 3. Ineffective drug 4. Dosage too low SAFETY 5. Adverse drug reaction 6. Dosage too high ADHERENCE 7. Nonadherence or noncompliance 15 Drug Therapy Problems II 16 8  7/2/2024 Example 1 The 29-year-old patient is having continued breakthrough seizures due to subtherapeutic phenytoin concentrations. Actual EFFECTIVENESS 3. Ineffective drug 4. Dosage too low Solution: Pump up the dose of phenytoin 17 Example 2 29-year-old patient is noncompliant with phenytoin therapy, as she forgets to take her medication, and she is experiencing continued seizure activity. Actual ADHERENCE 7. Nonadherence or noncompliance Solution: provide patient with a daily medication reminder device or a medication diary to help keep track of her medicine use. 18 9  7/2/2024 Example 3 This 61-year-old male business executive is experiencing gastrointestinal bleeding caused by aspirin 81 mg therapy. Actual SAFETY 5. Adverse drug reaction 6. Dosage too high Determine clinical indication for his aspirin & substitute another with clopidogrel would resolve this drug therapy problem or add PPI or H2RA 19 Example 4 43-year-old female patient, who is being treated for pneumonia with gentamicin therapy, has poor renal function. Potential SAFETY 5. Adverse drug reaction 6. Dosage too high Prevent by adjusting her dose & interval to provide desired peak & trough gentamicin serum concentrations & determine her individual PK parameters for gentamicin. 20 10  7/2/2024 Example 5 43-year-old female patient with pneumonia has acute renal failure secondary to gentamicin therapy. Actual SAFETY 5. Adverse drug reaction 6. Dosage too high This drug therapy problem can be resolved by discontinuing the gentamicin therapy treating the pneumonia with a different antibiotic that is not harmful to the kidneys. 21 Example 6 43-yr-old with MDR pneumonia & risk of seizures has chronic renal failure treated with meropenem 2 g IV TID Potential SAFETY 5. Adverse drug reaction 6. Dosage too high This drug therapy problem can be resolved by deescalating the dose of meropenem to the right dose for renal function 22 11  7/2/2024 Prioritization DTP which can lead to death or require immediate solution higher priority Also DTP that may result in significant harm has higher priority Acute problems has higher priority than chronic problems Problems that has clear solutions have higher priority than problems whose solutions are uncertain 23 List of Problems – No Problem Sometimes in the list of problems you have a problem which is stable or require no interventions this can be of lower priority and can still be documented as stable and no need for intervention 24 12  7/2/2024 Gather Information First Introduce Self Most patients present with a chief complaint State the purpose of the encounter Collect general parameters & pt demographics Elicit history including, HPI, PMH, FH, SH, Medications, Allergies, and ROS May perform some physical examination Collect or request labs, imaging, investigations Assess, list the problems and their solutions 25 Develop Care Plan State the treatment goals Determine what non-pharmacologic interventions you want to make Develop the pharmacologic intervention plan Implement the plan and counsel the patient Set the monitoring parameters and follow up plan Document the encounter 26 13  7/2/2024 Documenting the encounter For future reference use structured case approach and complete electronic records For education use mini-case documentation Use SOAP-F/up format for documentation, this format usually document one problem at a time Bill or reimburse for the pharmaceutical care encounter 27 Patient Encounter Example Hi I am your pharmacist Loai and you, how can I help you? Hi I am Mohammed and what do you have for a CC: "cough and shortness of breath I had for the past five days“ HPI: The patient reports a productive cough with yellow-green sputum, fever (up to 102°F), chills, and increasing shortness of breath. He also complains of fatigue and generalized weakness. The symptoms started five days ago and have progressively worsened. 28 14  7/2/2024 Patient Encounter Example Cont. PMH: HTN, Type 2 DM, DLP Medications: Metformin 500 mg twice daily Lisinopril 20 mg once daily Atorvastatin 20 mg once daily Allergies: NKDA Family History: Non Contributory Social History: Former smoker, quit 10 years ago, Occasional alcohol use, Lives with spouse, no recent travel history 29 Physical Exam General: Appears fatigued and ill Vital Signs: Temp. 101.8°F, HR 110 bpm, BP 130/80 mmHg, RR 22 breaths/min, Oxygen Saturation 92% on room air HEENT: Mild nasal congestion, no throat erythema Lungs: Dullness to percussion and decreased breath sounds over the right lower lobe, with crackles heard on auscultation Cardiovascular: Regular rhythm, no murmurs Abdomen: Soft, non-tender Extremities: No edema 30 15  7/2/2024 Initial Assessment The patient's symptoms and physical findings are suggestive of a lower respiratory tract infection, likely pneumonia. This is the highest priority now! Second priority is patient blood pressure and kidney function may need to optimize antihypertensive therapy Third priority patient may benefit from high intensity statin Forth priority he seems to be stable for DM if within targets then can continue the same treatment 31 Laboratory Tests and Imaging Complete Blood Count (CBC): Elevated white blood cell count with neutrophilia Basic Metabolic Panel (BMP): Normal, except mildly elevated glucose C-Reactive Protein (CRP): Elevated Blood Cultures: Obtained prior to antibiotic administration Sputum Culture: Obtained for Gram stain and culture Chest X-Ray: Infiltrate in the right lower lobe consistent with pneumonia 32 16  7/2/2024 Normal Chest X Ray 33 RLL infiltrate consistent with Pneumonia 34 17  7/2/2024 Assessment Diagnosis: Community-Acquired Pneumonia (CAP) Actual INDICATION 1. Unnecessary drug therapy 2. Needs additional drug therapy Drug Therapy Problem Identified: The patient has not been started on antibiotics despite a clinical presentation consistent with CAP, which is a delay in initiating appropriate therapy 35 Intervention or Plan Initiate Antibiotic Therapy: Start empirical antibiotic therapy based on CAP guidelines. Levofloxacin 750 mg IV OD, IV initiation due to current severity and hospitalization) Alternatively, Ceftriaxone 1 g IV once daily plus Azithromycin 500 mg IV once daily for broader coverage if needed. Additional Supportive Measures: Administer IV fluids to maintain hydration. Provide supplemental oxygen to maintain SpO2 > 94%. 36 18  7/2/2024 SOAP Follow UP Note I Patient Information: Name: John Doe Age: 65 Gender: Male Date of Visit: [Insert Date] Follow-Up Day: 0 37 SOAP Follow UP Note II Subjective: Productive cough and SOB, Fever, Fatigue Objective: Vital Signs: Temp. 101.8°F, HR 110 bpm, BP 130/80 mmHg, RR 22 breaths/min, Oxygen Saturation 92% on room air Lung Exam: Dullness to percussion and decreased breath sounds over the right lower lobe, with crackles heard on auscultation 38 19  7/2/2024 SOAP Follow UP Note III Objective (Cont.): CBC: Elevated WBC with neutrophilia Basic Metabolic Panel (BMP): Normal, except mildly elevated glucose C-Reactive Protein (CRP): Elevated Chest X-Ray: Infiltrate in the right lower lobe consistent with pneumonia 39 SOAP Follow UP Note IV Assessment: Most likely Blood Cultures: Negative Most likely Sputum Culture: Streptococcus pneumoniae (sensitive to initial antibiotics) Diagnosis: Community-Acquired Pneumonia (CAP) (CURB-65 scoring on Next Slide) Plan: Levofloxacin 750 mg IV OD to complete 7 – 10 days of abx IV hydration & Oxygen to keep above 94% 40 20  7/2/2024 CURB-65 Scoring Confusion: No so 0, if yes +1 BUN >19 mg/dL (>7 mmol/L urea): No 0, Yes +1 Respiratory Rate ≥30: No 0, Yes +1 Systolic BP