Introduction to Clinical Pharmacy

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Introduction to Clinical Pharmacy a key role for
pharmacists.Year 3 Peradeniya University SOP

• Dr Ian Coombes,
• Clinical senior Lecturer - School of Pharmacy
  Medicine, University of Queensland, and Senior
  Pharmacist, Safe Medication Practice
  Unit, Brisbane, Australia
• Mrs Judith Coombes
• Conjoint Lecturer - School of Pharmacy,
  University of Queensland and Senior Education
  Pharmacist, Princess Alexandra Hospital,
  Brisbane, Australia.

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Content

• Introduction to Us and You
• What is clinical pharmacy and why do we need it
• Medicine management and patient journeys
• Adverse drug events the problem
• Product versus patient focused services
• Perception of the profession
• Drivers for change its development elsewhere
• Core practitioner skills, knowledge and
  attitudes,
• Plan for the next 6 weeks

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Background - Queensland
700 km W - E
1900km N - S
1.8Million km2
4 M people in Qld
Brisbane
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Queensland
Brisbane
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Comparisons
Sri Lanka (7 degrees N of equator) Australia (14 degrees S of equator)
66,000km2 7,600,000km2 (120x)
20 million people 20.3 million people ()
8.5 gt65 year 13.3 gt65 yr (1.5 x)
3.7 GDP on healthcare 9.5 GDP on healthcare (2.5x)
160M/ yr/ on free Health 80 BN/ yr/ Health
42 /person/year on health 3,900/person/year on health
2 hospital beds/ 1000 people 3.6 hospital beds/ 1000 people
New 4 year pharmacy degree 4 year pharmacy degree
1000 hospital pharmacists, 14,000 pharmacists, 3000 hospital
Doctor order, pharmacist supply Separation of supply from ordering
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Judith Coombes

• University Queensland
• Pre-registration (apprenticeship year) community
• District hospital (Rockhampton) 700km N
• UK hospitals 2 years, wards and dispensary
• PAH renal specialist pharmacist
• UK MSc (Clin Pharm) DI research pharmacist
• PAH, 700 bed teaching, Drug use evaluation
• Conjoint Lecturer U of Qld PAH education

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Ian Coombes

• University of London wanted be in advertising!
• Pre-registration year - London Hospital
• Junior training London Hospital
• Working holiday in Brisbane, 2 hospitals
• Msc in Clin Pharm, ICU, renal, cardiac jobs - UK
• Manage Clinical Services cardiac PAC PAH
• Safe Medication Practice Unit
• PhD
• State wide pharmacy prescriber education

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Perceptions of Pharmacists

• How do others see us?

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They just count a few tablets
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They just weigh and measure things
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A bunch of shop-keepers
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Tell me how and when to use the Medicine
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Counter-prescribing
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Not really health care practitioners
theyre businessmen
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Do you need a degree to be a pharmacist?
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Drivers for change

• Competence of health care practitioners
• - Diploma to BSc to BPharm Pre-registration
  registration
• - Continuing Professional Development.
• Re-engineering of community medicine supply
• - Provided by competent practitioners
• - Recognition that dispensing is a technical
  function
• Informed general public increased expectation
• Realisation that .

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Medicines are Dangerous
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Pharmaceutical Care
A practice in which a practitioner takes
responsibility for a patients drug related needs
and holds him or herself accountable for meeting
these needs. Linda Strand 1997
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Safe drug therapy
Effective drug therapy
Aims of Pharmaceutical Care
Economic drug therapy
Improve quality of life
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A case

• 44 year old lady with fever and green sputum and
  cough no known previous medical history
  Diagnosed with upper resp. tract infection
• Prescribed
• Co-Amoxiclav 1 tds
• Doxycycline 100mg D
• Prednisolone 40mg D
• Theophylline 200mg bd
• Omeprazole 20mg D
• Metoclopramide 10mg tds
• Salbutamol 2 puff inhale prn

Pharmaceutical problems Common organisms for
URTI? Need for atypical organism ? History of
asthma risk vs benefit? History asthma risk
vs benefit Need for acid suppression? Why is she
nauseous ? Benefit of brochodilation? Does she
know what to take? Will she take it?
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Why did you choose to do this course?

• What do you envisage doing when you become a
  pharmacist?
• 2 minutes talk to your neighbour and then feedback

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Question?

• Think of someone in your family or a friend that
  has had something go wrong with their
  medicines?
• Caused an adverse or unwanted effect ?
• Had medicines stopped when should have continued?
• Not worked?
• What happened ?
• Could it have been avoided ?

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Medical/medication errors in the UK

• Adverse events occur in 10 of admissions
• An estimated 850,000 adverse events a year
• Adverse events cost approximately 2 billion/yr
• The NHS pays 400 million clinical negligence
• Medication errors accounts for around a quarter
  of the incidents which threaten patient safety
• The Chief Medical Officer
• An Organisation with a Memory
• Department of Health (2000)

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High Profile Examples

• A patient with leukaemia received Intrathecal
  vincristine instead of intravenously. Died
  beginning of February 2001. 14th such case over
  the last 16 years.
• Patient being operated for a AAA received
  bupivicaine intravenously rather than epidurally.
  Patient died 3 days later.
• A 3 year old girl, who had a convulsion post flu
  vaccine. Attended hospital to get checked out.
  Received nitrous oxide instead of oxygen in
  casualty

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High Profile Cases (Cont.)

• Elderly lady prescribed Methotrexate in 1997 for
  her rheumatoid arthritis. Dose increased to
  17.5mg WEEKLY over a 6 month period.
• Jan 2000 patient undergoes right TKR in hospital.
  MTX given as one tablet a week (only 2.5mg).
• 6th April 2000 patient asks GP to reduce number
  of tablets as in hospital.
• Prescription for MTX 10mg/daily written and
  dispensed.
• 30th April patient dies.

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Deaths from medicines in the UK1999 - 2000 (ICD9
10 data)
A spoonful of sugar - Audit Commission (2001)
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So drugs are safe ..
Photosensitivity from Amiodarone
Severe extravasation of amiodarone infusion
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NSAID or COX-2 induced peptic ulcer
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Goitre Hypothyroidism Secondary to Amiodarone
Bleeding due to anticoagulation
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Erythemal rash from penicillin in patient with
a previous Known allergy/ adverse drug reaction
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Necrotising fascititis secondary to infection
at site of IV injection
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Acute Liver failure from Black Cohosh - herbal
medicine
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Human Error(Mistakes, Slips, Lapses)

• Error is inevitable due to our limitations
• limited memory capacity
• limited mental processing capacity
• negative effects of fatigue other stressors
• We all make errors all the time
• Generalised lack of awareness that errors occur
• Patients suffer adverse events much more often
  than previously realised
• Errors often NOT immediately observed

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• The same error, even a minor one, can have quite
  different consequences in different circumstances.

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I assumed the brown glass ampoule was
frusemide (ICU RN after injecting 10mg
adrenaline)
The System Only as safe as its designed to be!
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The Accident Causation Model(Adopted from Reason
Dean)
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The Medicines Management Cycle

• What happens between a doctor seeing a patient
  and them receiving or taking their medicine ?
• 2 minutes discuss with neighbor

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The Medicines Management Cycle
DOCTORS
Decision to prescribe
Monitor response
Pharmacy
Nurses
From Bates et al 1995
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Sources of Error

• Prescribing error - selecting the wrong or
  inappropriate drug/dose/formulation/duration etc
• Communicating those instructions
• Supply error - timely wrong drug, dose, route
  expired medicines, labelling.
• Administration error - timing wrong route wrong
  rate/technique.
• Lack of user education - actions to take.

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Where do things go wrong with medicines?
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Comparability to Australian National Health
Priority Areas

• In 2000-01, hospital admissions
• Angina 88,500
• Myocardial infarction 37,500
• Asthma 49,000
• Diabetes 46,000
• Adverse Drug Events 140,000

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Reducing the risk of adverse events

• Always
• include a detailed drug history in the
  consultation
• Only
• use drug treatment when there is a clear
  indication
• Stop
• drugs that are no longer necessary
• Check
• dose and response, especially in the young,
  elderly and those with renal, hepatic or cardiac
  disease

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Pharmaceutical Care
A practice in which a practitioner takes
responsibility for a patients drug related needs
and holds him or herself accountable for meeting
these needs. Linda Strand 1997
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Safe drug therapy
Effective drug therapy
Aims of Pharmaceutical Care
Economic drug therapy
Improve quality of life
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Aims of Pharmaceutical Care

• Identify actual and potential drug related
  problems,
• Resolve actual drug related problems,
• Prevent potential drug related problems.

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Drug therapy assessment
Six types of problems which may result in
treatment failure

1. Inappropriate selection of medication
2. Inappropriate formulation of medication
3. Inappropriate administration of drug therapy
4. Inappropriate medication-taking behaviour
5. Inappropriate monitoring of drug therapy
6. Inappropriate response to drug therapy

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Pharmaceutical care planning

• Process of work
• collect relevant patient information
• assess information
• identify problems
• state desired outcomes
• prioritise problems
• develop an action plan for each problem
• was desired outcome achieved?

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Pharmaceutical Care Activities (1)

• Patient Consultation - discuss expectations and
  concerns,
• Pharmacists assessment - identify current or
  potential drug therapy problems,
• Creation of a care plan - establish goals of
  therapy, action to be taken and outcomes to be
  monitored.
• Communication of that plan eg Dr, nurse other
  pharmacist, patient, carer

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Pharmaceutical Care Activities (2)

• Patient education and/or referral
• provide individualised, current information about
  drug therapy and how to use Demonstrate special
  techniques refer to doctor or other HCP.
• Patient monitoring and follow-up
• are the goals being met.

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• Refocusing the profession because -
• Problems caused by drug use in society,
• 2. Business orientated approaches place the
  product before the patient,
• Pharmaceutical care is -
• a patient-centred approach (not drug-centred),
• a process of managing drug-related problems,
• Where pharmacists take responsibility for
  provision of drug therapy.

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Clinical Pharmacy Role in Reducing Risks
Admission medication history
Formulary
Prescribing protocols
Allergy check
Prospective review
Administration instructions
Clinical pharmacy
Drug distribution system
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Outcomes of Pharmaceutical Care(1)

• The patient receives effective drug therapy -
  based on the evidence of current medical
  literature (Evidence based Medicine).
• The patient receives safe therapy - based on a
  knowledge of their individual clinical
  circumstances.

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Outcomes of Pharmaceutical Care(2)

• The patient receives the most economic therapy -
  not compromising efficacy or toxicity
• The patient receives drug therapy desired to
  improve their quality of life.

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Patient Assessment Questions

• Does the patient need this drug ?
• Is this drug the most effective and safe ?
• Is this dosage the most effective and safe ?
• If side effects are unavoidable does the patient
  need additional drug therapy for these side
  effects?
• Will drug administration impair safety or
  efficacy ?
• Are there any drug interactions ?
• Will the patient comply with prescribed regimen ?

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To be a drug expert society needs practitioners
who ..
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Key knowledge, skills and attributes

• Knowledge base
• Chemistry,
• Pharmaceutics,
• Pharmacology,
• Therapeutics,
• Law, Ethics, Professional conduct.
• Skills base
• Problem solvers,
• Make decisions,
• Good communication Effective consultation
  process,
• Gather information,
• Calculate doses,
• Offer advice thats timely and accurate (Pts,
  Drs and Nurses),
• Dispense medicines,
• Monitor and follow up

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Key knowledge, skills and attributes

• Attributes
• Takes responsibility for actions
• Punctual
• Caring nature
• Professional behaviour
• Open minded
• Positive attitude
• Treats patients equally
• Treats information confidentially

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Key Responsibilities

• Act in the interest of patients and seek to
  provide the best possible health care for the
  community.
• Treat all with courtesy, respect and
  confidentiality.
• Respect patients rights to participate in
  decisions about their care
• Provide information which can be understood.
• Must ensure that their knowledge, skills and
  performance are of high quality, up to date,
  evidence based and relevant.
• Behave with integrity
• adhere to accepted standards of personal and
  professional conduct

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Summary

• Drugs are beneficial but can also cause harm.
• Society needs a gatekeeper who manages the use of
  drugs.
• Pharmacists must adopt a patient focused approach
  to identifying and resolving drug related issues.
• The consultation process and effective
  communication lies at the heart of achieving this.

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Plan for next 6 weeks

• Topics
• Abbreviations,
• Evidence based medicine
• Medication history taking, confirmation,
  reconciliation
• Effective communication with other clinical staff
• Therapeutic c-vasc, respiratory, renal,
  neurology (pain) , gastro
• Teaching and learning methods
• Didactic, set some tasks, feedback go through in
  tutorials

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The End
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• Any Questions?