functional elements of clinical pharmacy practice phcl 471 nouf m aloudah

Functional Elements Of Clinical Pharmacy PracticePHCL 471Nouf M Aloudah

Functional Elements Of Clinical Pharmacy Practice•Clinical pharmacy have evolved and still

evolving in a variety of ambulatory and institutional pharmacy settings

•Many hospitals now providing medication histories, patient drug counseling, patient drug monitoring, and drug information services

•Specialized clinical services such as clinical pharmacokinetics, nutritional support, clinical toxicology

Functional Elements Of Clinical Pharmacy PracticeHistorical development of clinical

pharmacy•Definitions of clinical pharmacy:

▫Clinical pharmacy practice as a practice in which the pharmacist utilizes his professional judgment in the application of pharmaceutical sciences to foster the safe and appropriate use of drugs, in or by patients, while working with members of the health care team

Functional Elements Of Clinical Pharmacy PracticeHistorical development of clinical pharmacy•Definitions of clinical pharmacy:

▫American Association of Colleges of Pharmacy : clinical pharmacy is that area within the pharmacy curriculum which deals with patient care with emphasis on drug therapy. Clinical pharmacy seeks to develop a patient oriented attitude. The acquisition of new knowledge is secondary to the attainment of skills in inter-professional and patient communication


pharmacy•Definitions of clinical pharmacy:

▫Others: the primary mission of clinical pharmacy is the promotion and assurance of rational and safe drug therapy, the other health care practitioners share this goal with clinical pharmacists, though this is not their sole, intensive concern!

Functional Elements Of Clinical Pharmacy PracticeHistorical development of clinical pharmacy• Definitions of clinical pharmacy:

▫Clinical pharmacy is a health science specialty whose responsibility is to assure the safe and appropriate use of drugs in patients through the application of specialized knowledge and function in patient care, and which necessities specialized education and/or structure training. It requires use of judgment in the collection and interpretation of data, patient- specific involvement, and direct inter-professional interactions

Functional Elements Of Clinical Pharmacy PracticeHistorical development of clinical pharmacy•Definitions of clinical pharmacy:

▫In summery clinical pharmacy involves the application of drug knowledge on behalf of the patient, while considering the patient’s disease conditions and his need to understand drug therapy

▫The practice requires a close association between the pharmacy and the patient, physician, and other providing health care services

Functional Elements Of Clinical Pharmacy PracticeHistorical development of clinical pharmacy• Factors influencing the development of clinical

pharmacy:1. Unresponsiveness of health care delivery system to

public needs2. Absence of a single discipline with broad responsibility

for drug use control3. Overeducated and underutilized pharmacists4. Diminished demand for the traditional compounding

skills of pharmacists5. Major unresolved problems with drug use in society6. Inadequate drug knowledge on the art of health

professionals and patients


pharmacy:▫ In the past, the pharmacist has often isolate himself

from the patient and from other health practitioners▫ The health professions are now facing the problem of

how to design a health care system which will provide health maintenance for all people at the most reasonable cost

▫ It is becoming clear that such a system will depend on close cooperation among all health professions

▫ Clinical pharmacy stands to play a major role in the attainment

Functional Elements Of Clinical Pharmacy PracticeHistorical development of clinical pharmacy•Factors influencing the development of

clinical pharmacy:▫ All of the health disciplines have involved to

some degree with drugs, but no particular discipline has exercised a broad responsibility for the total drug use process

▫ This resulted I drug misuse, overuse, abuse and in serious unwanted drug effects


pharmacy:▫ All of the health disciplines have involved to some

degree with drugs, but no particular discipline has exercised a broad responsibility for the total drug use process

▫ This resulted In drug misuse, overuse, abuse and in serious unwanted drug effects

▫ Led to the thinking that there was a need for one discipline to assume broad leadership and responsibility for the safe and appropriate use of drugs in society


pharmacy•Factors influencing the development of

clinical pharmacy:▫ 1960s recognized that most pharmacist

were overeducated!▫ The climate was right for a major change

in pharmacy practice


pharmacy•Factors influencing the development of

clinical pharmacy:▫ Educators and practitioners began to

press for change in pharmacy practice and education

Functional Elements Of Clinical Pharmacy PracticeClinical pharmacy functions and servicesIncludes one or more of those activities as general or

specializedGeneral clinical pharmacy functions and services• Providing drug information to other health professionals• Aimed to• Defining therapeutic goals and endpoints of drug therapy• Selecting the most appropriate therapeutic agent for drug

therapy• Prescribing the most appropriate drug regimen• Monitoring the effect of drug therapy based upon indices

of effect and• Selecting methods for drug administration

Functional Elements Of Clinical Pharmacy PracticeGeneral clinical pharmacy functions and

services▫Significant improvement ▫Drug information and poison centers


services▫Obtaining patient medication histories and

using patient medication profiles to assure proper drug utilization Minimum it should contain ……… Additional drug specific monitoring

information may be obtained on patient files


services▫Monitoring drug therapy▫Effectiveness, ineffectiveness, ADR, toxicity

ect▫Food and drug administration adverse

reaction reporting programs▫Medication profile, laboratory data, physical

examination data, nurses’ and physicians’ notes and even the results of ECG, X ray are used monitor drug therapy response


services▫Providing patient education and medication

counseling


services▫Providing disease screening, monitoring,

and maintenance care for patients with chronic diseases


services▫Participation in the management of

emergency medical care


services▫Serving as a health information and

education source for the public


services▫Participation in drug use review and

patient care audits


services▫Providing in-service education for

physician, nurses, and other health professionals

Functional Elements Of Clinical Pharmacy PracticeSpecialized functions and services:

▫Nutritional support services▫Formal (written) drug therapy

consultations▫Clinical pharmacokinetics services▫clinical toxicology services▫Clinical drug investigations

Functional Elements Of Clinical Pharmacy Practice•Franck’s legacy-

40 years of clinical pharmacy•clinical pharmacy 30 years later !•clinical pharmacy and medication safety•scope of international clinical pharmacy

How To Get Involved in Medical RoundsPHCL 471Nouf AloudahClinical Pharmacy LecturerKing Saud University

How To Get Involved in Medical Rounds•Rationale For The Pharmacist’s

Participation In RoundsA. IMPROVED PATIENT CARE

1. Promotion Of Rationale Drug Therapy1. Evaluate appropriateness of the selected

drug2. Calculating the dosage consistent with the

renal and hepatic function of the patient3. Determining an acceptable dosage interval

that will ensure therapeutic benefit and compliance

4. Preventing drug related adverse effects


Participation In Rounds2. Provision Of Drug Information


Participation In RoundsB. EDUCATION OF THE PATIENT AND

THE HEALTH CARE TEAM1. Educating and interacting with the

patient2. Educating the pharmacist3. Educating other health professionals4. Educating patients and hospital staff

about pharmacy services

How To Get Involved in Medical Rounds•Types Of Rounds

▫Medical teaching service rounds▫Private physician rounds▫Special unit rounds▫Interdisciplinary rounds▫Pharmacy rounds

How To Get Involved in Medical Rounds•Factors In The Pharmacist’s Selection Of

a Rounding Team▫Time available▫Ability to work with the physician▫Continuity of patient care▫Personal interests▫Acceptance by the rounding team

How To Get Involved in Medical Rounds•Pharmacist’s Preparation For Rounds

A. Self preparation Become familiar with appropriate references Keep abreast of current research Determine appropriate patient monitoring

criteria Understand and maintain the rounding

schedule

How To Get Involved in Medical Rounds• Pharmacist’s Preparation For Rounds

B. Specific Planning Develop a monitoring profile and/or patient log

sheet Determine the best method for communicating with

the rounding team Reassess specific drug therapy periodically Prepare lectures on related drug topics Work out a system where you can be contacted

readily Make certain that other pharmacists and supportive

personnel understand what you are doing

How To Get Involved in Medical Rounds•Pharmacist’s Preparation For Rounds

C. Preparation of specific monitoring aids and a daily rounding checklist

Monitoring Drug TherapyPHCL 471Nouf M AloudahClinical Pharmacy LecturerCollege of pharmacyKing Saud University

Monitoring Drug Therapy

•most important clinical function of the pharmacist


•is a process which encompass all those functions necessary to ensure appropriate, safe, efficacious and economical drug therapy to the patient

•functions


•Rationale•literature identified some significant

problems with regards to the drug therapy of patients due to increasing no of available drugs

•problem includes…

Monitoring Drug Therapy• Use Of Medical Records• you should be familiar with patients medical

records• types of patient records

▫ the source oriented record▫ the problem oriented record

data base section problem list plan progress notes discharge summery


•Setting Priorities•do not have staff to be able to monitor

each and every patient receiving drug therapy

•at risk of developing adverse effects from drug therapy should be identified▫patient selection by disease state▫patient selection by drug therapy


•The Process Of Monitoring Drug Therapy

A. problem orientation off patient data



B. determination of the appropriateness of specific therapy



C. development of specific therapeutic goals



D. development of specific monitoring parameters



E. identification of problems



F. development of alternatives or solutions to problems



G. communication of findings and recommendations


•Developing A Plan Of Self Study

Teaching And Counseling Patients About DrugsPHCL 471Nouf M AloudahClinical Pharmacy LecturerCollege of PharmacyKing Saud University

Introduction•Practiced several years and years•Innovative ways•Limited by financial constrains and the

willingness of pharmacists to participate in this activities

•Understanding the need is basic for designing quality programs

Teaching And Counseling Patients About Drugs

•Who should teach and counsel?▫Not drug information you want to change

behavior▫Noncompliance occur in 30-50%▫Oral or written intervention by the

pharmacist improved compliance


•Who should teach and counsel?▫Physician?

First to see pt They remember 20-40 of what been told to

them Multiple demands on them


•Who should teach and counsel?▫Nurse?

Happened in many institutions Identify it to prevent duplication Approached positively they will welcome Provide educational material Administer drug daily, it is a good chance!


•Who should teach and counsel?▫Pharmacist?

Last to see the pt Needs to develop skills Ethical responsibility Obtain data to support the program


•Who should be taught and counseled?▫Time and manpower determine who one

can teach and what type of educational programs pt referred by physicians Pt with specific disease status Pt receiving specific drug classes Elderly populations Pediatric populations Pt being discharged


• How to teach and counsel?▫Pt education not information▫Not only to teach but to negotiate a regimen▫Assessment phase

Open ended questions Reflective questions Closed ended questions Suggestive questions

▫Planning and implementation phase Verbal communication Nonverbal communication listening

▫Evaluation phase


•What to teach about drugs?▫Major points, helpful to identify which

information specific to retain▫Drug should be researched toughly prior to

session▫Planned presentation to ensure covering

important points


•What to teach about drugs?1. Description and strengths2. Use and schedule3. Mechanism of action4. Effect on life style5. Storage6. Potential adverse effects7. Potential drug or delivery interactions


•Where to teach and counsel?▫Private setting without interruptions▫Better recall if counseled in private areas▫At least 15 min per session


•Where to teach and counsel?▫Inpatient setting

During hospital stay, at the time of discharge▫Outpatient setting


•Teaching aids?▫Printed materials▫Audiovisual materials▫Compliance aids▫Educational display


Providing drug information to health professionalsPHCL 472Nouf M AloudahClinical Pharmacy lecturerKing Saud University

Providing drug information to health professionals•Who needs to know what?•Specific categories of drug information

questions and how these questions differs among various types of health professionals

Providing drug information to health professionals•Drug information categories•If you know question type you will

understand the need, aids in selecting references

Providing drug information to health professionalsMost questions falls into one of the following

categories• Adverse drug reactionsCommon side effects to ADR to be reported to FDA• Ex

▫Which sedative, …………. Or ……… causes the least amount of hangover?

▫ If the pt allergic to ………. Can we safely administer ………?

▫Has leukemia ever been associated with the use of …?

Providing drug information to health professionalsMost questions falls into one of the

following categories•availabilityProduct- oriented questions about old and

new drugs•Ex

▫Has …. Been released yet?▫Who makes …?▫What strength doses …. Come in?


following categories•Drug interactionDrug-drug, drug- food, drug- laboratory

interactions•Ex

▫Can … be used safely with …?▫Dose food affect the absorption of …?▫Will administering … cause a change in the

serum level of …?


following categories•Foreign drugs•Ex

▫An article about … recently appeared in a British journal. What is it?

▫A patient recently returned from europ with a Rx of … what its equivalent?


following categories• identification•Ex

▫What is this tablet?▫What are the ingredients in …?▫Is an … OTC product?


following categories•Pharmaceutical calculations•Ex

▫How many mEq of calcium are in 500 mg of …?

▫How fast should a … drip be run to deliver 5 mcg /min?


following categories•Toxicity and poisoningOverdose or toxic exposures are in this

category•Ex

▫what symptoms can be expected in a pt who has taken a bottle of ….?

▫Should a child who has ingested … receive ipecac?

Providing drug information to health professionalsNeeds of health professionals•Each one may ask any of the question

mentioned but each has a different need•Physicians:Questions related to prescribing or monitoring

drug therapy•Nurses:Drug administration, adverse drug reaction•Pharmacists:Numerous questions need access to resources

Providing drug information to health professionalsDrug information sources•Basic drug information reference libraryReferences which contain information on

ten categories •Extent depends on funding

▫“Must have”▫“Should have”▫“Nice to have”

Providing drug information to health professionals•“Must have reference”: tertiary

references (textbooks) five basic types:1. Product oriented2. Drug oriented3. Disease oriented4. Specific topic5. specialty

Providing drug information to health professionals•Product- Oriented ReferencesBest source for availability and identification

questions•Ex

▫Facts and comparison: product monographs, comparative information on similar products, cost index

▫Handbook of nonprescription drugs: contain monographs on various classes of nonprescription drugs, compare contents of products in similar classes

Providing drug information to health professionals•Drug- Oriented ReferencesStronger emphasis on the particular drug

or drug class than on the product•Ex

▫Martindale, the extra pharmacopeia published every five years, contain extensive referenced monographs on drugs and drug classes with international coverage excellent source for adverse reactions, therapeutic and pharmacology

Providing drug information to health professionals•Disease- Oriented ReferencesChapters on disease states, very useful for

questions in the therapeutics and pharmacology category from disease perspective

•Ex▫Applied therapeutics published every 3-4

years

Providing drug information to health professionals•Specific topic referencesCompatibilities of IV drugs, DI, and

poisoning •Ex

▫Handbook of injectable drugs▫Handbook of poisoning▫Applied pharmacokinetics

Providing drug information to health professionals•Specialty referencesUnder “should be” references

Providing drug information to health professionals• a “must have” list would be incomplete

without primary references or journals•Ex

▫American journal of hospital pharmacy

Providing drug information to health professionals• Should have “ referencesAfter selection of your “must have” reference the others

can be considered “should have”• Specialty references could be considered “should have”

▫ Cancer chemotherapy▫ Pediatrics▫ infectious disease

• At least one journal which discuss drugs and drug therapy

• Ex▫ The medical letter▫ pharmacotherapy

Providing drug information to health professionals•“nice to have” referencesSecondary source of drug information•Ex

▫Clin -alert▫IOWA drug information services

• Pharmaceutical manufactures

Providing drug information to health professionalsAnswering questions•Knowing the real question

▫What the requester actually wants to know, classify the requester (physician, nurse, pharmacist) and obtain the necessary background information

▫What is the dose of …?possibilities are endless

▫Patient information: age, weight…, disease condition…, whole medical history ! extent of the question asked

Providing drug information to health professionalsAnswering questions•Systemic search

▫Which category?▫which reference? update?▫Not found in tertiary references go to

secondary references

Providing drug information to health professionalsAnswering questions•Communicate an answer

▫Timing ex administration maximum 6 hours▫Brief , concise, accurate▫Verbally ▫Sometimes written, should be well

organized, grammatically correct, timely manner

Providing drug information to health professionalsAnswering questions•Follow up

▫When possible with certain types of questions especially directed to pt care

▫Ex adverse reaction

Providing drug information to health professionalsAnswering questions•As more questions are asked the more

confidence will grow•The key to increase the clinical role is

exposure

Providing drug information to health professionalsDrug information support to hospital

committeeParticipation increase exposure and aids in

recognition of our role• The P & T committee• It is a policy recommending body, several

functions can be supported by DI• Evaluating drug for inclusion in the hospital

formulary• What to includes?• Decision is more difficult, keep it simple


committee•Decision is more difficult, keep it simple•Educational function of the committee


committee•DUR

▫Frequently asked questions may pinpoint areas for which drug use review studies are needed

•Others▫Human research committee, infection

control committee, nutrition committee

Providing drug information to health professionalsVehicles for providing drug information• Pharmacy newsletter• Provide information and help in pharmacist

recognition as drug information source• Selecting topics:

▫drug information▫P & T committee actions▫DUR programs▫Journal articles

• Writing for a particular audience• Publication and disterbution• Verbal presentation

Providing drug information to health professionalsVehicles for providing drug information•Verbal presentation

▫Formal or informal lectures, in service presentations, ground rounds,

▫Starts by the pharmacists▫Topics▫Particular audience▫Teaching techniques and strategies: length,

formality, objectives, instructional aids, handouts, summery

Providing drug information to health professionalsIn summery•Drug information is a component of all

clinical pharmacy services•Providing DI can be rewarding by

▫Fully utilized our knowledge▫We become more active members of the

team▫It can open doors to other clinical functions▫Achieving rational therapeutics leading to

improved pt care

•Best wishes!