Introduction to Clinical Pharmacy PDF

# Introduction to Clinical Pharmacy **Definition** - The area of pharmacy concerned with the science and practice of rational medication use. (Patient oriented) **Where to practice clinical pharmacy?** - Clinical Pharmacy includes all the services performed by pharmacists practicing in hospitals...

# Introduction to Clinical Pharmacy **Definition** - The area of pharmacy concerned with the science and practice of rational medication use. (Patient oriented) **Where to practice clinical pharmacy?** - Clinical Pharmacy includes all the services performed by pharmacists practicing in hospitals, community pharmacies, nursing homes, 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. **What are clinical pharmacy Requirements?** | Requirement | | :--------------------------------------------- | | Knowledge of drug therapy | | Knowledge of non-drug therapy | | Knowledge of the disease | | Therapeutic planning skills | | Patient care | | Knowledge of laboratory and diagnostic skills | | Communication skills | | Drug Information Skills | | Physical Patient assessment skills | | Monitoring skills | **Qualifications to be expert clinical pharmacist** 1. Clinical Pharmacy Fellowship 2. Board of Pharmacy Specialties 3. Clinical Pharmacy Diploma 4. PharmD 5. Clinical pharmacy Master, and PhD 6. Clinical pharmacy Bachelor **Clinical pharmacists work area in the hospital** - Inpatient - Outpatient - Drug Information Center **How a Clinical pharmacist can be effective in outpatient?** **Responsibilities** 1. Medication reconciliation 2. Adjust medication doses as necessary 3. Improve patient compliance 4. Report medication errors 5. Educate patients and providers about medications **Drug information center (DIC)** 1. Provision of specific comprehensive drug information upon request from healthcare providers, and consumers from the general public in a timely manner, based on a complete analysis of available evidence. 2. Maintenance of resources to provide the most current and accurate information to inquirers. 3. Publishing a drug information newsletter. 4. Educating pharmacy students, and professionals about resources and medical literature analysis and enhancing the skill of accurately communicating response (both verbally and in-writing). **Inpatient care** **Ward Clinical pharmacist role:** 1. Involved in medical rounds with the other health care professionals 2. Documenting patient information on a specially designed record 3. Creating a pharmaceutical care plan 4. Identify Medication related problems. 5. Answering Medication information queries to physicians & other health professionals. 6. Patient education and counseling. **Examples of clinical pharmacy practice areas** | Service Area | | :---------------------------- | | **(High service departments)** | | ICU/ICCU/HDU | | PICU/Neonatal | | Renal Haemodialysis | | Oncology care units | | **(Moderate service departments)** | | Internal medicine departments | | Cardiac ward units | | Pediatric ward | | Acute psychiatric departments | | General surgery | | Chest diseases department | | Neurology ward | | Endocrinology ward | | **(Low service departments)** | | Maternity / Obs & Gynae | | ENT | | Orthopedics | | Long stay Psychiatric | | Dermatology and plastic surgery | | One day surgery units | **Ward clinical pharmacists work directly with** - Patient Files Management **The pharmaceutical care plan** - Is a written, individualized, comprehensive medication therapy plan based on clearly defined therapeutic goals. - The pharmaceutical care plan, which is available to all pharmacists caring for a patient, is updated with each major change in patient status. - It is important that the physician be informed about the care plan to ensure common goals. - Patients should also be informed about the general content of the care plan as means of gaining their agreement regarding drug therapy. **A) Create patient database** The first step in the care planning process is the creation of a comprehensive patient database, which includes at minimum, the following information: 1. Patient demographics 2. Diagnoses and past medical history 3. Present medications and medication history 4. Medication allergies/intolerances 5. Smoking/alcohol/caffeine/drug use history 6. Abnormal laboratory and physical exam results 7. Renal and liver function **B) Assess drug-related problems** Following the creation of a comprehensive patient database, the pharmacist should evaluate the patient's drug therapy. - Most drug-related problems are the result of: 1. Not receiving an indicated drug 2. Receiving the wrong drug 3. Receiving too little of the drug (Subtherapeutic dose) 4. Receiving too much of the drug (Supratherapeutic dose) 5. Experiencing an adverse drug reaction 6. Experiencing a drug interaction 7. Not receiving the prescribed drug 8. Drug without indication **C) Establish a therapeutic goal** Therapeutic goals should be definite, realistic and, if possible, measurable. Most therapeutic goals relate to: 1. Approach normal physiology (i.e., normalize blood pressure). 2. Slow progression of disease (i.e., slow progression of cancer). 3. Alleviate symptoms (i.e., optimize pain control). 4. Prevent adverse effects. 5. Educate the patient about his or her medication. **D) Specify monitoring parameters** - Finally, monitoring parameters must be specified so that the patient’s progress can be followed. - Monitoring parameters must also include potential adverse effects. - Determine desired end points for each parameter and the frequency of monitoring. **E) Document patient’s progress** - The pharmacist evaluates and documents the patient’s progress in achieving the desired therapeutic goals and avoidance of potential adverse effects. - The pharmaceutical care plan is updated with each major change in patient status. - In summary, the general steps involved in creating a pharmaceutical care plan are: 1. Create comprehensive patient database. 2. Assess for actual and potential drug-related problems. 3. Establish therapeutic goals. 4. Specify monitoring parameters with end points and frequency. 5. Document the patient’s progress towards therapeutic goals. **Drug checklist** 1. Checklists provide a framework of standardization and regulation of interventions in a systematic manner, allowing individuals to assess the presence or absence of the items. 2. Provides structure to important ICU-related interventions in an effort to reduce errors of omission and increase compliance with evidence-based practices to improve outcomes in the ICU patient population. **Drug checklist in the ICU** 1. Drug interactions 2. Medication without indication 3. Right dose 4. Dosage adjustment according to hepatic and renal functions 5. Right preparation and administration 6. Monitoring ADR 7. Monitoring of treatment response 8. Lab values monitoring 9. Indication without medication 10. Stress ulcer prophylaxis 11. DVT prophylaxis 12. Feeding 13. Analgesia and Sedation 14. Head of bed elevation 15. Glycemic control **1-Drug interactions** **Four factors for assessment:** - Risk rating scale (A,B,C,D,X) - Reliability (Excellent, good, fair, poor) - Onset (delayed, rapid) | Reliability Rating | Definition | | :---------------- | :---------------------------------------------------------------------------------------------------------- | | 1- EXCELLENT | (multiple RCTs OR single RCT plus >2 case reports) | | 2- Good | (single RCT plus < 2 case reports) | | 3- Fair | (> 2 case reports; OR < 2 case reports plus other supporting data; OR a theoretical interaction based on known pharmacology) | | 4- Poor | (<2 case reports with no other supporting data) | | Category | Management | | :-------- | :------------------------ | | Category A | No interaction | | Category B | No action needed | | Category C | Monitor therapy | | Category D | Consider therapy modification | | Category X | Avoid combination |