Clinical Pharmacy

Objective

Define clinical pharmacy, its functions and services.

Define pharmaceutical care and identify the 4 outcomes that improve a patient’s QOL.

Differentiate Pharmacy from Clinical Pharmacy.

List the 3 goals and five core elements of MTM

List the knowledge and skills needed for patient-focused pharmacy practice

Objective

Define Clinical Pharmacist and identify the different theories on levels of action.

Enumerate the 10 functions and/or the activities done by a clinical pharmacist in an Institution.

Identify the members of the Healthcare team and functions.

Enumerate the four guidelines to be a Pharmacotherapy Specialists.

Define Clinical Pharmacokinetics.Define TDM and functions of a pharmacist in

TDM.

Objective

Know the 6 factors influencing the development of Clinical Pharmacy

CLINICAL PHARMACY It is an added dimension of hospital

pharmacy that requires the application of patient-oriented services super imposed upon the pharmaceutical sciences-to the subject of rational therapeutics .

As articulated in the 2002 strategic plan, ACCP's 20- to 30-year vision for the profession is that "pharmacists will be recognized and valued as the preeminent health care professionals responsible for the use of medicines in the prevention and treatment of disease."

Clinical Pharmacy

  -defined as that area

of pharmacy concerned with the science

and practice of rational medication use thru application of specialized knowledge and

functions in patient care and which necessitates specialized education and/or

structured training.

What is the difference?

Clinical Pharmacy

Pharmaceutical care

Pharmaceutical care‘’Pharmaceutical care used to describe the broad-based,

patient-focused responsibilities of pharmacists.

‘’Pharmaceutical care is the direct, responsible

provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life.’’

• Cure of the diseaseCure of the disease• Elimination or reductionElimination or reduction

of symptomsof symptoms• Arrest or slowing of aArrest or slowing of a disease processdisease process• Prevention of disease Prevention of disease

or symptomsor symptoms

Clinical PharmacyClinical 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. 

How does clinical pharmacy differ from pharmacy?

the discipline of pharmacy embraces the knowledge on synthesis, chemistry and preparation of drugs

clinical pharmacy is more oriented to the analysis of population needs with regards to medicines, ways of administration, patterns of use and drugs effects on the patients.

The focus of attention moves from the drug to the single patient or population receiving drugs.

Goal of Clinical PharmacyTo promote the correct and appropriate use of

medicinal products and devices.

These activities aim at: maximizing the clinical effect of medicines, i.e., using

the most effective treatment for each type of patientminimizing the risk of treatment-induced adverse

events, i.e., monitoring the therapy course and the patient's compliance with therapy

minimizing the expenditures for pharmacological treatments, i.e., trying to provide the best treatment alternative for the greatest number of patients.

Medication Therapy Management (MTM)Defined as a distinct service or group of

services that optimize therapeutic outcomes for individual patients.

Medication Therapy Management (MTM)

3 GOALS of MTM include:a. Improved medication understanding

b. Adherence to medication therapy

c. Detection of medication-related problems, including adverse drug reactions

Medication Therapy Management (MTM)The 5 Core elements of MTM

a. Provide a comprehensive or targeted medication therapy review

b. Complete and update the patient’s personal medication record (PMR)

c. Develop a medication-related patient-directed action plan (MAP)

d. Intervene and/or refer when appropriate

e. Document all services and interventions, communicate results encounter, and provide appropriate follow up.

Clinical Pharmacy Requirements

Knowledge of nondrug therapy

Therapeutic planning

skills

Drug Information Skills

Physical assessment

skills

Patient monitoring

skills

Communication skills

Knowledge of laboratory

and diagnostic skills

Knowledge of the disease

Knowledge of drug therapy

Patient care

Essential KNOWLEDGE and SKILLS for a CLINICAL PHARMACIST

PATIENT CARE

Drug therapy

Disease

Non-drug therapy

Lab & Diagnostic Test

Communication

Therapeutic Planning

Drug Information

Patient Monitoring

KNOWLEDGE

SKILLS

Physical Assessment

Clinical Pharmacist

Primary job was to interact with the health care team, interview and assess patients, make patient-specific therapeutic recommendations, monitor patient response to drug therapy, and provide drug information.

Level of Action of Clinical Pharmacists

Clinical pharmacy activities may influence the correct use of medicines at three different levels: before, during and after the prescription is written.

1. Before the prescription

Clinical trials Formularies Drug information drug-related policies

2. During the prescription

Counseling activity

Clinical pharmacists can influence the attitudes and priorities of prescribers in their choice of correct treatments.

The clinical pharmacist monitors, detects and preventsMedication related problems

The clinical pharmacist pays special attention to the dosage of drugs which need therapeutic monitoring.

Community pharmacists can also make prescription decisions directly, when over the counter drugs are counselled.

Medication-related Problems Untreated indications. Improper drug selection. Subtherapeutic dosage. Medication Failure to receive Medication Overdosage. Adverse drug reactions. Drug interactions. Medication use without indication.

3. After the prescription

Counseling Preparation of personalised formulation Drug use evaluation Outcome research Pharmacoeconomic studies

Levels of Pharmacy Praction

James Hundley MD

General US Public Health Services

Body of Knowledge, Practice and EthicsDonald Brodie RPh

System of Knowledge, understanding, judgment, procedure, skills, control, ethics.

THE PATIENT & THE PHARMACISTS

ADMISSION

1. Drug Information

2. Medication History * Interview

3. Medication Order Review

4. Patient Monitoring

DISCHARGE

5. Patient Counseling

Functions of Clinical Pharmacists The principle activities of a clinical pharmacist include:

Consulting Analysing therapies, advising health care practitioners on the correctness of drug therapy and providing pharmaceutical care to patients both at hospital and at community level.

Selection of drugs Defining "drug formularies" or "limited lists of drugs" in collaboration with hospital doctors, general practitioners and decision makers.

Drug information Seeking information and critically evaluating scientific literature; organising information services for both the health care practitioners and the patients.

.

Functions of Clinical Pharmacists Medication Review

Review medication chart, Review medication history

Attending Rounds

Drug use studies and research Drug use studies/ pharmacoepidemiology/ outcome research/ pharmacovigilance and vigilance in medicinal devices: collecting data on drug therapies, their costs and patient outcome through structured and scientific methods.

Pharmacokinetics/ therapeutic drug monitoring Studying the kinetics of drugs and optimising the dosage.

Clinical Trials Planning, evaluating and participating in clinical trials

Functions of Clinical Pharmacists

. Pharmacoeconomy Using the results of clinical trials and outcome studies to determine cost- effectiveness evaluations. 

Teaching & Training Pre- and post-graduate teaching and activities to provide training and education programmes for pharmacists and other health care practitioners

Information Source

Medical recordPatientFamilyHealth care team

Medical Record re. Px chart

•Admission Information

•Initial history

• physical examination

•Progress notes

•Consultations

•Nursing notes

•Laboratory data

•Diagnostic Procedures

•Radiology

•Surgery

•Orders

•Medication

administration orders

•Consent forms

Medical Team

Physicians- Resp for dx and therapeutic - planNurses

- Direct patient carePharmacists

-rational drug therapy- Drug information provider- Prepares and dispense drugsParamedical

Clinical Pharmacy Practice Service areas Ambulatory care Critical care Drug Information Geriatrics and long –term care Internal medicine and

subspecialties Cardiology Endocrinology Gastroenterology Infectious disease Neurology

Nephrology Obstetrics and gynecology Pulmonary disease Psychiatry Rheumatology Nuclear pharmacy Nutrition Pediatrics Pharmacokinetics Surgery

Practice Guidelines for Pharmacotherapy Specialists

The pharmacotherapy specialist designs, implements, monitors, evaluates, and modifies patient pharmacotherapy to ensure effective, safe and economical patient care.

A Position Statement of the American College of Clinical Pharmacy

Practice Guidelines for Pharmacotherapy Specialists

The pharmacotherapy specialist retrieves , analyzes, evaluates, and interprets the scientific literature as a means of providing patient- and population-specific drug information to health professionals and patients

A Position Statement of the American College of Clinical Pharmacy

Practice Guidelines for Pharmacotherapy Specialists

The pharmacotherapy specialist participates in the generation of new knowledge relevant to the practice of pharmacotherapy, clinical pharmacy and medicine

The pharmacotherapy specialist educate health care professionals and students, patients, and the public regarding rational drug therapy

The pharmacotherapy specialist continually develops his/her knowledge and skills in applicable practice areas and demonstrates a commitment to continued professional growth by engaging in a lifelong process.

A Position Statement of the American College of Clinical Pharmacy

Rational Drug Therapy

Basically follows the Rule of Rights, RIGHT PATIENT, RIGHT DRUG, RIGHT DOSAGE AND ADMINISTRATION AND RIGHT FREQUENCY.

Factors that will provide rational drug therapy:

1. Having strong distribution system

2. Putting the knowledge in action thru pxs

3. Clinical experience

4. Role models

Rational use of drug

S afe

A ffordable

N eeded

E ffective

Q uality 

Rule of right:

Right drugRight patientRight doseRight timeRight durationRight route of administrationRight informationRight price

GOAL

Outcome

Therapeutic Effects

Adverse Effects

Clinical pharmacokinetics

Clinical pharmacokinetics is the process of applying pharmacokinetic principles to determine the dosage regimens of specific drug products for specific patients

to maximize pharmacotherapeutic effects and minimize toxic effects.

TDM stands for therapeutic drug monitoring

Clinical pharmacokinetics

Application of these principles requires

an understanding of the absorption, distribution, metabolism, and excretion characteristics of specific drug products in specific diseases and patient populations

Drugs that can be monitored

when the range between minimal effectiveness and toxicity is narrow

the results of the drug assay provide significant information for clinical decision-making.

Why request TDM?

Noncompliance Inappropriate dosage Poor bioavailability Drug interaction Kidney and liver disese Altered protien binding Fever Cytokines Genetically determined fast or slow metabolizers

ResponsibilitiesDesigning patient-specific drug dosage

regimens

Recommending or scheduling measurements of drug concentrations in biological fluids

Monitoring and adjusting dosage regimens

Evaluating unusual patient responses to drug therapy for possible pharmacokinetic and pharmacologic explanations.

Responsibilities

Communicating patient-specific drug therapy information to physicians, nurses, and other clinical practitioners and to patients orally and in writing, and including documentation of this in the patient’s health record.

Responsibilities

Educating pharmacists, physicians, nurses, and other clinical practitioners about pharmacokinetic principles and appropriate indications for clinical pharmacokinetic monitoring, including the cost-effective use of drug concentration measurements.

ResponsibilitiesDeveloping quality assurance programs for

documenting improved patient outcomes and economic benefits

Promoting collaborative relationships with other individuals and departments involved in drug therapy

Responsibilities

Pharmacists with specialized education, training, orexperience may have the opportunity to assume the

following additional responsibilities:

1. Designing and conducting research

2. Developing and applying computer programs andpoint-of-care information systems to enhance theaccuracy and sophistication of pharmacokinetic modelingand applications to pharmaceutical care.

Responsibilities

3. Serving as an expert consultant to pharmacists with a general background in clinical pharmacokinetic monitoring.

Responsibilities

3. Serving as an expert consultant to pharmacists with a general background in clinical pharmacokinetic monitoring.

Development of Clinical Pharmacy

Started in 1960s in USA1974- Pilot Program at Makati Medical center

Factors that influence the growth of CP

1. Unresponsiveness of health care delivery system to public needs

2. Absence of a single discipline with broad responsibility for drug use control

3. Overeducated and underutilized pharmacists

4. Diminished demand for the traditional compounding skills of RPh

5. major unresolved problems with drug use in society

6. Inadequate drug knowledge on the part of health professional and patients.

Development of Clinical Pharmacy