Post on 07-Apr-2018
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Masters in Clinical Pharmacy
Chulalongkorn University, Thailand 2004
Basic Concepts of Ambulatory
Care: A Software for
Pharmaceutical Care inOutpatient Setting
Paul C. Wong, Pharm.D.
E-mail: pharmd2544@yahoo.co.jp
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Ambulatory Care
The United States National
Ambulatory Medical Care Survey(NAMCS) defines ambulatory care as:
health services rendered to individuals
under their own cognizance, any time
when they are not in a hospital or other
health care institution.
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Terminology
Ambulatory care
Primary Care Family Medicine
patient vs client
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Pharmaceutical Care
The American Society of Health
System Pharmacists (ASHP) definesPharmaceutical Care as:
the direct, responsible provision of
medication-related care for the purpose
of achieving definite outcomes that
improves a patients quality of life.
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Characteristics of AmCare
Symptoms
subjective less severe
Education: preventive medicine,
chronic diseases Business (?)
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I cannot sleep at night.
A 61 year old lady complains to you thatshe cannot fall asleep at night.
[Scenario 1]
Insomnia?
Not working anymore and having naps
in the afternoon.
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I lost my keys again. A 67 year old man came to get his
blood pressure pills again. He said hejust went to get another set of keys
because he forgot where he placed it.
This is the fifth time already in two
months. I am really getting old, he
sighed. [Scenario 2]
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What is disease?
Abnormal signs / symptoms reflect a
disease? Normal condition reflects disease-free
state?
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Pharmacists activities in
AmCare
Monitor stable patients
Prescribe medications patients havebeen taking under contract
Adjust doses of medications patients
have been taking under contract Order laboratory related to drug
therapy (e.g. INR/PT)
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Pharmacists activities in
AmCare (contd)
Perform simple physical assessment to
evaluate symptoms or drug efficacy Give recommendation on health care /
Over-the-counter products
Prescribe certain prescription drugs toclients with documentation
Administer vaccines to clients if
certified
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Who else can prescribe in
U.S.A.?
Physician Assistant (PA)
Nurse Practitioner (NP) Pharmacists
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Collaborative Practice
(Drug Therapy Management)
Pharmacists are able to start or modify
drug therapy under protocolsestablished jointly with the physician /
institution.
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Clinics in which U.S.
pharmacists often are involved:
General medicine Clinic / Refill Clinic
Seizure Clinic Anticoagulation Clinic
Kidney Transplant Clinic
Bone Marrow Transplant Clinic
Diabetic Clinic
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Rule of Thumb in AmCare
NOT TO DIAGNOSE but to help to
rule out disorders and provide care if
pharmacotherapy is appropriate.
ALWAYS ENSURE the problem is a
DRUG-INDUCED one or not
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Pharmacotherapy
NESt (related to health care providers)
Necessity Efficacy / Effectiveness
Safety
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Pharmacotherapy & Some
Subjects in Pharmacy School
Clinical Pharmacy
N, E Pharmacokinetics, Pharmacology
E, St
Physical Pharmacy
Pharmaceuticals
E
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PharmacotherapyACE (related to patients)
Adherence Cost / Affordability
Education
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Adherence? A 50 yo male patient is taking metoprolol
for his hypertension. His BP today is
152/98, HR 86. [Scenario 3]
Do you think the dose of metoprolol is
appropriate?
What are the clues?
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How do you evaluate adherence?Factors related to adherence: Table 1
Non-adherence & Overuse
How much drug left?
E.g.Out of eye drop in one week?
Out of inhaler in two weeks? Patient with metoprolol with a heart rate
of 86.
Use of stimulants (caffeine/supplements)
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Case: Education A 45 year man has bought furosemide
for his hypertension. The pharmacist is
helping him to understand the side
effects of the drugs. He said, It can
cause hypokalemia and renal failure.
[Scenario 4]
Hypokalemia!!
Renal failure!!
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Information sources &
DocumentationDepends on the practice setting:
Clinical pharmacists
Inpatient dispensing pharmacists
Outpatient dispensing pharmacists
Community pharmacists
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When a client walks in. . . .
Pick up unsolved (old) problems
Pick up new problems Evaluate therapy
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How to gather information?3S
Sharp observation Specific questions
Simple evaluation
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Sharp ObservationCan extend from observe (sight) to using
your other senses
sight
hearing: voice is loud, soft
smell: characteristic ? Touch: hot, cold, swollen. . . . .
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Case: Sharp Observation A CHF patient comes into your
pharmacy to get more digoxin.What
will you look for as sharp
observation?
Figure 1. Eye movements.
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Specific Questions Related to signs/ symptoms (S/S) you
observed
Information regarding those S/S
All information regarding drugs
(including herbs, food)
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Simple Evaluation Data can be taken in Pharmacy
Basic vital signsBP, HR, RR, T, Pain score, (Ht,Wt, BMI)
Medical record, if available
Keep a record of it (MonitoringProfile), if possible
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Pharmacy Documentation Contact number / address
Allergy Active medication list
Keep in pharmacy
Copy for patient
CONTINUITY OF CARE
[Figure 2. Example.]
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What information to gather for
Assessment?Table 2
Chronology of symptoms Quality of symptoms
Associated symptoms
Factors affect the symptoms
Any medications tried
Patients concern
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Assessment What are my choices?
Pharmacotherapy? Non-pharmacotherapy?
Triage?
Business issue??
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Therapy The therapy that helps the patient /
client is the best therapy.
DO NO HARM; DO YOUR BEST
Continuing education Experience
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Scenarios seen in AmCare Clients with symptoms come for
advice
Clients come in to buy old medication
Clients come in to buy new medication
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Actions made in AmCare Sell medication to client
No need to use medication Unable to treat/handle the problem
(TRIAGE)
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Case: Action A man who lives close to your
pharmacy came in today. He wants to
get some strong medication for his leg
pain. He bought simvastatin, isosorbide
dinitrate, and atenolol from you for the
last few months. [Scenario 5]
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SUMMARY OF A VISIT Make patient recall
Review the S/S Record what happened
Remind patient what to do
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Patient-Pharmacist Relationship Treat patient as a person
understand family life cycle (Table 3)
Confirm/clarify feeling
Allow patient to express ones feeling
Convey concern for and interest in thepatient
Empathize
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Relationship (contd) Non-biased
Admit mistake Eye contact
Open-ended question
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Physical Assessment Technique Hands on
Pulse checkingBP
BG
Neurological exam
Hands off
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Pediatrics: Classification Pre-term neonate (premature):gestational age of less than 38 weeks
Full-term neonate: gestational age of38-42 weeks
Newborn: first postnatal month of life
Infant (baby): 1-12 month of age Toddler (young child): 1-5 yo
Older child: 6-12 yo
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Pediatrics:W
hat is normal? Height [Table 4]
W
eight Serum creatinine level
Heart rate
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Pediatrics IMPORTANT: give specific
instruction to family
relatively fragile: same symptoms but
could have more disastrous results
good to triage to doctors/hospitalsunless the symptoms are mild
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Pediatrics (contd) talk to client if old enough
client cannot communicate soobservation is of great importance:
consider immunization
recommendation issues on pharmacotherapy (safer
drug, dosage adjustment)
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Pediatrics: Education Disorder and daily life
can affect adolescent stage also e.g. asthma, diarrhea, fever, seizure
AND sport participation
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Case: Pediatric Care A young mother came into your
pharmacy and want some medicine for
the fever of her 3 year old-son.What
do you recommend? [Scenario 6]
Pharmacists not just sell medications,we sell advice too.
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Things needed to find out: How long the fever has been,
How high? Weight change?
Crying? Tears?
Look dry? Skin change etc.
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Adolescents / Young Adults 13-21 yo
physical, social, psychological developments
need privacy, confidentiality Need public health education Disorders/diseases
Generally non-severe
STD (including HBV, HCV, HIV)
Substance abuse (alcohol, club drugs, etc.) Eating disorder (peer pressure related)
Depression/Stress
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Geriatrics Over 65 years old? Young old (65-75)
Middle old (75-85)
Old old (85 or older)
Old people have more diseases?
Usually more diseases because people live
longer and can control diseases nowadays
more medicines, more side effects, more
drug interactions
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General concepts in Geriatric Care
Confirm compliance/adherence
Minimize number of medications
(especially self medications)
Avoid combination use with traditional
(herbal) medicine
Evaluate ability to take medicine
Assess non-drug effects: alcohol, smoking
Documentation
Home visit: storage
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Pharmacotherapy in Geriatrics Start with low doses
Avoid renally excreted medications (?)
Wait for uncommon adverse effects and
drug interaction
Look for unspecific signs / symptoms
caused by medications
BE CAREFUL WITH SOME DRUGS !!
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Drug Safety in PregnantWoman
FDA (USA) Categories
Category A Category B
Category C
Category D
Category X
(Other category systems in Germany & Australia)
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Case: PregnantWoman
A 24 year-old lady came to yourpharmacy to buy phenytoin that she
has been taking for her seizure disorder.
She said her seizure is well controlled.During the conversation, she told you
that she just got married and she wants
to have a baby soon. She wants toknow if she should stop the medication
because she is fine and no attacks
now. [Scenario 7]
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Choices: recommend not getting pregnant and
consider adoption because of her
seizure history
stop phenytoin when she misses her
first period and then counsel her
physician stop taking phenytoin prior to
conceiving and restarting it in the
second trimester
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Choices (contd)
all the older anticonvulsants are
associated with fetal defects, but there
are some newer agents available andmaybe she would be a canadidate for
one of dose. Recommend her to take to
her doctor.
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Choices (contd)
all the older anticonvulsants are
associated with fetal defects, but there
are some newer agents available and
maybe she would be a canadidate for
one of dose. So you look it up and
recommend her to take it instead of
phenytoin
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Antiemetics used during
pregnancy Avoid if possible
Phenothiazines Antihistamines
meclizine, cyclizine, dimenhydrinate,
doxylamine Ondensetron (Category B)
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Nursing mothers
See if mother can avoid using
medications altogether
Use the lowest effective dose
Try to use medications that do not
cross into breast milk
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Nursing mothers (contd)
Take medication just after baby
feeding so it will be at a lower
concentration when time for the next
feeding
Express breast milk prior to taking
medication
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Case: Critical Thinking
You are a pharmacist working in a
pharmacy in Chiang Rai. This
afternoon a young lady, look like in the
early 20s, came into your store and
want some medicine for her back pain
and urinating problem. [Scenario 8]
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Suggestion
Self continuing education
New study format
Better patient education
Expand roles in hospital clinics
Prepare pharmacy students to deal with
patients
Mentor system