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Clinical pharmacy services
- 1. Clinical Pharmacy Services:Ward round participation, Drug therapy review (Drug therapy monitoring including medication order review, chart endorsement, clinical review and pharmacist interventions) Submitted To : Dr. KANCHAN VOHRA Assistant Professor Submitted By : Mohd. Rafi Bhat
- 2. Clinical Pharmacy Services The pharmacy services can be broadly classified as clinical, hospital and community pharmacy services based on the point of service. The clinical pharmacy services are rendered in a clinic for inpatients and OPD patients. The inpatient services comprise of entire patient care and supplies regarding the aspects involving drugs. For example the activities like ward rounds ,safety, drug information services, poison centre, pharmacovigilance services, development and management of hospital formulary, patient counseling and education along with discharge medication.
- 3. Ward round participation Wardrounds are the routine clinical rounds where the healthcare providers visit the patients in the ward to assess the progress of the health condition of the inpatients. The doctor led ward rounds comprises of the unit of medicine or any other specialty where in professor, associate professors, assistant professors, senior residents, postgraduates and interns along with pharmacists and nurses observe the patient's condition and assess to decide further therapeutics for the patients.
- 4. Goals of theward round participation The goal of the ward round is to closely monitor the patient's condition and take immediate intervention to improve the patient condition and avoid death. The doctors are visiting all the patients admitted in their unit in an order beginning from intensive care unit. Here also there is documented case reports to remind the case history of the patients who quickly updates and is able to change the strategies of treatments.
- 5. Objectives of theward round participation The ward team comprises of doctors, nurses and pharmacists who work in a team with a common objective to ensure safe, effective, economic and patient friendly treatment with knowledge inputs of each professional practice.
- 6. Role of pharmacistin ward round participation The pharmacist being an expert in the matters of drug should be available for the ward round team to decide upon the matters of dosage regimens, formulary interpretations, ADR monitoring, Drug-drug interactions, Drug-food interactions and drug and poison information services. The availability of pharmaceutical services definitely enhances accuracy of treatment, patient safety and efficacy.
- 7. Duties of thepharmacists in ward rounds The pharmacist in ward round should take to 2 times one with the doctors and another one with himself alone. In the first ward round he follows the treatment given and checks the formulary for the dose prescribed. Further he may also critically think any possible risk to the patients due to drug administered he will alert the team and prevents the further causality that would have occurred due to non-viability of clinical pharmacy services. In the 2nd round the pharmacist targets the patients prior to discharge and advice the patients regarding discharged medication practice in the rounds. He also motivates to knowledge diet and exercise required for disease management for a patient to be discharged.
- 8. Importance of wardround participation The withdrawal of pharmacists from the ward rounds will be a great loss for the clinical team and the patients. The medication errors, incorrect dosage can bring down the therapeutic outcomes in a negative perspectives. It is well established that the expectations from the patients does not stop at the clinical cure but for a cost effective economic expenses with improved quality of life. The gaps in the knowledge of healthcare practice in disease management can be fulfilled by a qualified pharmacist in a hospital.
- 9. Drug therapy monitoring Drug therapy monitoring, also known as Therapeutic Drug Monitoring (TDM), is a means of monitoring drug levels in the blood. Therapeutic drug monitoring (TDM) refers to the measurement and interpretation of principally blood or plasma drug concentration measurements with the purpose of optimising a patients drug therapy and clinical outcome while minimising the risk of drug- induced toxicity. TDM involves tailoring a dose regimen to an individual patient by maintaining the plasma or blood concentration within a particular range.
- 10. To achieve optimaldrug therapy 3 objectives should be met: • To attain desired pharmacological effect of the drug. • To reach the maximal effect in shortest possible time. • To decrease the risk of toxicity. TDM is useful in drugs: • With a narrow therapeutic index. • Which are highly protein bound. • Which are liable to interact. • In which the metabolite might be toxic.
- 11. ROLE OF PHARMACIST Areliable and responsive TDM service depends on team work between nurses, doctors, pharmacist, scientist and technical staff. The clinical pharmacist should provide advice to medical staff on the appropriate use and timing of TDM and assist with the interpretation of results. In addition the pharmacist maybe involved in : • Initial selection of drug regimen.this may involve decisions about drug choice, dose, dosing interval, route of administration and dosage form of the drug, taking into account factors such as sex, age, body weight, race, metabolism status, renal function, plasma albumin concentration, use of other drugs and laboratory results.
- 12. Adjustment ofthe dosage regimen based on TDM results and the patients clinical response. Assessment of possible causes for unexpected results, such as non- compliance, bioavailability problems, medication errors, drug interactions or pharmacogenetic variability. Dose adjustment for patients on haemodialysis or peritoneal dialysis. Provision of poisons information.
- 13. MEDICATION CHART REVIEW •It is a fundamental responsibility of a pharmacist to ensure the appropriateness of medication orders. ƒ • It serves as starting point for other clinical pharmacy activities ( medication counselling, TDM, DI, and ADR). ƒ • Organising information according to medical problems ( example disease) helps breakdown a complex situation into its individual parts.
- 14. GOALS: 1. To optimisethe patients drug therapy. 2. To prevent or minimise drug related problems/medication errors. PROCEDURE: The patients medical record should be reviewed in conjugation with the medication administration record. Recent consultations, treatment plans and daily progress should be taken into account when determining the appropriateness of current medication orders and planning each patient’s care. All current and recent medication orders should be reviewed.
- 15. COMPONENTS OF MEDICATIONORDER REVIEW 1. Checking that medication order is written in accordance with legal and local requirements. 2. Ensuring that the medication order is comprehensible and unambiguous, that appropriate terminology is used and that drug name are not abbreviated. Annotate the chart to provide clarification as required. 3. Detecting orders for medication to which the patient may be hypersensitive/intolerant. 4. Ensuring that medication order is appropriate with respect to: a) The patient’s previous medication order. b) Patient’s specific considerations e.g disease state, pregnancy. c) Drug dose and dosage schedule, especially with respect to age, renal function, liver function. d) Route, dosage form and method of administration.
- 16. 5. Checking completedrug profile for medication duplication, interactions or incompatibilities. 6. Ensuring that administration times are appropriate e.g. with respect to food , other drugs and procedures. 7. Checking the medication administration record to ensure that all ordered have been administered. 8. Ensuring that the drug administration order clearly indicates the time at which drug administration is to commence. 9. special considerations should be given especially in short course therapy as in antibiotics and analgesics. 10. Ensuring that the order is cancelled in all sections of medication administration record when the drug therapy is intended to cease. 11. If appropriate follow up of any non-formulary drug orders, recommending a formulary equivalent if required.
- 17. 12. Ensuring appropriatetherapy monitoring is implemented. 13. Ensuring that all necessary medication is ordered. E.g. premedication, prophylaxis. 14. Reviewing medication for cost effectiveness. 15. Identification of drug related problems. • Untreated indication. • Inappropriate drug selection. • Adverse drug reaction. • Failure to receive drug. • Drug interactions. • Drug use without indication. • Overdosage.
- 18. Medication chart Endorsement Another important goal of treatment chart review is to minimise the risk of medication errors that might occur at the level of prescribing and / or drug administration. A medication error is any preventable error that may lead to inappropriate medication use or patient harm. To prevent potential morbidity and mortality associated with these errors, pharmacists should systematically review the medication chart and write annotations on the chart where the medication orders are unclear.
- 19. CLINICAL REVIEW Clinical reviewis one of the integral components of medication review and should preferably be performed on a daily basis. It is the review of the patients’ progress for the purpose of assessing the therapeutic outcome. The therapeutic goal for the specific disease should be clearly identified before the review. GOALS: The primary aims of the clinical review are to: • Assess the response to drug treatment. • Evaluate the safety of the treatment regimen. • Assess the progress of the disease and the need for any change in therapy. • Assess the need for monitoring, if any. • Assess the convenience of therapy(to improve compliance).