Shaukat Khanum Memorial Cancer Hospital Research Centre Clinical

Shaukat Khanum Memorial Cancer Hospital & Research Centre Clinical Pharmacy Orientation

Shaukat Khanum Memorial Cancer Hospital & Research Centre Dr. Maqsood khan Pharm. D, BCPS, BCLS, ACLS, MACCP , MSCCM. Clinical Pharmacy Specialist Infectious diseases and Medical Oncology

Objective q Define clinical pharmacy q Differentiate between traditional pharmacists role and Clinical Pharmacist q Explain the qualification required for clinical pharmacists q List the clinical pharmacists responsibility q Describe the daily work activity of clinical pharmacists.

Clinical Pharmacy: From Theory to Practic q Pharmacists should move from behind the counter and start serving the public by providing q care instead of pills only. q There is no future in the mere act of dispensing. q That activity can q and will be taken over by the internet, machines, and/or hardly trained technicians.

Clinical Pharmacy A health science discipline that embodies the application and development. By pharmacists, of scientific principles of pharmacology, toxicology, therapeutics, clinical pharmacokinetics, pharmacoeconomics, pharmacogenomics, and other life sciences for the care of patients

Clinical Pharmacy q Clinical pharmacy is defined as “a patient centered, outcomes oriented pharmacy practice that requires the pharmacist to work together with the patient and the healthcare team members to: q - promote health q - to prevent disease q -to assess, monitor, initiate and modify medication use.

Shaukat Khanum Memorial Cancer Hospital & Research Centre After Clinical Rounds with MED ONC TEAM

Clinical Pharmacy q. Maximizing the clinical effect of medicines, i. e. , using the most effective treatment for each type of patient q Minimizing the risk of treatment induced adverse events, i. e. , monitoring therapy course for adverse reactions as well as patient's compliance with therapy q Minimizing the expenditures for pharmacological treatments by governments and by the patients, i. e. , trying to provide the best treatment options for the greatest number of patients at the most cost effective.

Clinical Pharmacy Clinical pharmacy is defined as that area of pharmacy concerned with the science and practice of rational medication use.

What is the difference? Clinical Pharmacy Pharmaceutical care

Pharmaceutical care ‘’Pharmaceutical care is the direct, responsible • Cure of the disease • Elimination or reduction provision of medication-related care for the purpose of of symptoms achieving definite outcomes that improve a patient’s • Arrest or slowing of a disease process quality of life. ’’ • Prevention of disease or symptoms

Clinical Pharmacy q Clinical Pharmacy includes all the services performed by pharmacists practising in hospital community pharmacies, nursing homes, homebased care services, clinics and any other setting where medicines are prescribed and used. q The term “clinical” does not necessarily imply an activity implemented in a hospital setting.

How does clinical pharmacy differ from pharmacy? q the discipline of pharmacy embraces the knowledge on synthesis, chemistry and preparation of drugs q 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. q The focus of attention moves from the drug to the single patient or population receiving drugs.

Goal to promote the correct and appropriate use of medicinal products and devices. These activities aim at: q maximising the clinical effect of medicines q minimising the risk of treatment-induced adverse events q minimising the expenditures for pharmacological treatments.

Clinical Pharmacy Requirements Knowledge of drug therapy Knowledge of nondrug therapy Therapeutic planning skills Knowledge of the disease Knowledge of laboratory and diagnostic skills Patient care Drug Information Skills Physical assessment skills Communication skills Patient monitoring skills

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 q. Clinical trials q Formularies q Drug information q drug-related policies

Pharmacist role during prescription q. Pharmacists have direct interaction with physician and medical team regarding drug therapy. q Pharmacists make medical rounds with physicians. q Pharmacist make recommendations on drug therapy. q Pharmacists are in patient care areas q Pharmacists participate on hospital committees

2. During the prescription q Counselling activity q Clinical pharmacists can influence the attitudes and priorities of prescribers in their choice of correct treatments. q The clinical pharmacist monitors, detects and prevents Medication related problems q The clinical pharmacist pays special attention to the dosage of drugs which need therapeutic monitoring. q Community pharmacists can also make prescription decisions directly, when over the counter drugs are counselled.

Hospital Pharmacy: Clinical Committees q Pharmacy and Therapeutics Committee q Drug Use Evaluation q Adverse Drug Reactions q Medication Error q Infection Control and Antibiotics committee

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

3. After the prescription q. Counselling q. Preparation of personalised formulation q. Drug use evaluation q. Outcome research q. Pharmacoeconomic studies

On Round with Med Onc team

Pharmaceutical Care Plan.

Reduction of the rate of preventable adverse drug events caused by ordering errors q A study published in JAMA in 1999 found that the pharmacist's participation in medical rounds in the intensive care unit reduced the occurrence of preventable adverse drug events caused by ordering errors by 66%. q The study was conducted at the Massachusetts General Hospital in Boston in collaboration with the Harvard School of Public Health. q Leaps LL, Cullen DJ, Clapp M. Dempsey et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282(3): 2(37‑ 270.

Additional Supporting Evidence Clinical Pharmacy Services associated with decreased mortality rates 1. Pharmacist-provided drug use evaluation (4491 reduced deaths p=0. 016) 2. Pharmacist-provided in-service education (10, 660 reduced deaths, p=0. 037) 3. Pharmacist-provided ADR management (14, 518 reduced deaths, p=0. 012) 4. Pharmacist-provided drug protocol management (18, 401 reduced deaths, p=0. 017) 5. Ref# Pharmacotherapy 2007; 27(4): 481– 493

Clinical Pharmacy from theory to Practice LLearn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning. " Albert Einstein

Activities 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. .

Activities 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. .

Activities of Clinical Pharmacists Medication 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

Clinical Pharmacy from theory to Practice When it becomes more difficult to suffer than to change. . . you will change. " Albert Einstein

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

Information Source q. Medical record q. Patient q. Family q. Health care team

Medical Record • 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

Clinical Pharmacy Practice areas q q q q q Ambulatory care Critical care Drug Information Geriatrics and long –term care Internal medicine and subspecialties Cardiology Endocrinology Gastroenterology Infectious disease Neurology q q q q q Nephrology Obstetrics and gynecology Pulmonary disease Psychiatry Rheumatology Nuclear pharmacy Nutrition Pediatrics Pharmacokinetics Surgery

Practice Guidelines for Pharmacotherapy Specialists q 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 q 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 q The pharmacotherapy specialist participates in the generation of new knowledge relevant to the practice of pharmacotherapy, clinical pharmacy and medicine q The pharmacotherapy specialist educate health care professionals and students, patients, and the public regarding rational drug therapy q 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

Responsibilities q Designing patient-specific drug dosage regimens q Recommending or scheduling measurements of drug concentrations in biological fluids q Monitoring and adjusting dosage regimens q Evaluating unusual patient responses to drug therapy for possible pharmacokinetic and pharmacologic explanations.

Responsibilities q 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 q. 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.

Responsibilities q Developing quality assurance programs for documenting improved patient outcomes and economic benefits q Promoting collaborative relationships with other individuals and departments involved in drug therapy

Responsibilities Pharmacists with specialized education, training, or experience may have the opportunity to assume the following additional responsibilities: 1. Designing and conducting research 2. Developing and applying computer programs and point-of-care information systems to enhance the accuracy and sophistication of pharmacokinetic modeling and 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.

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 mointoring

Change your view Knowledge into action

SKMCH & RC WHAT DOES LOCAL DATA SAY ABOUT VALUE OF PHARMACIST? q SKM 150 BEDS HOSPITAL INCLUDING 10 ICU BEDS 6 19 HOSPITAL PHARMACISTS, WITH FULL TIME DEDICATED CLINICAL PHARMACISTS PATIENTS TO PHARMACIST RATIO AT ANY ATC IS 15 -20/1 q SPECIALIZED CLINICAL PHARMACY SERVICES TO MEDONC q IM. I. D TEAM: IN THE NEAR FUTURE HIRING MORE PHARMACISTS. q STARTED RESIDENCY PROGRAM FOR CLINICAL PHARMACY.

Pharmaceutical Services q. Aseptic Services q. Unit dose dispensing System q. General Dispensing Services q. Clinical Pharmacy Services q. Drug Information Services q. Training and Education Services q. Inventory Control Management Services

Clinical Interventions Number SKM - Clinical Pharmacy Interventions Trend (Jan to Nov, 2011) 700 600 577 500 493 416 389 328 300 471 344 334 Series 1 330 265 200 100 0 Jan, 11 Feb Mar Apr May Jun Months Jul Aug Sep Oct Nov

SKM Pharmacy Interventions Acceptance / Rejection Rate (Jan - Nov, 11) 5% Rejection Acceptance 95%

Al ra lerg in y di ca D o sa tio D n os g ag e C e ty alc. D ru pe g D e D o ub rro is ea r le D s En e ru I g try D nte ra ru g In In ctio ap n t In pr era ap c o pr pria tion op te r d i In a os te ap In pr du e ap o r pr pria atio op n t ria e R o te S ute Th ch e er ap PK du le eu P tic rob l W dup em ro l ng icat In ion M dic a is ce tio n lla ne ou s on t C 1400 1200 0 1198 1000 976 800 600 492 200 86 01 4 0 3 1 15 9 1 3 30 507 400 320 222 132 28 99 3 5 25 0 51 6 0 31 0

Shaukat Khanum Memorial Cancer Hospital & Research Centre

Conclusion Clinical Pharmacy is Really Rewarding & Interesting , but Its Highly Challenging. If you want to be a Clinical Pharmacist than go beyond the limits of Excellency in Science and Knowledge