PHRM 6401 Hospital/Ambulatory

hospital classifications

community/noncommunity

teach/nonteaching

number of beds

multihospital chains

acute

less than 30 days

long-term

more than 30 days

federal government / noncommunity hospital

nonfederal gov (public)

community hospitals

hospitals for specific populations

non profit

investor owned - for profit

teaching hospitals

practice of medicine

training site for physicians

associated with med school

nonteaching hospitals

serve as training site for students in other allied health professions

• pharmacy

• nursing

• clinical lab

multihospital system

mergers

freq national

hospital management

• board of trustees

• hospital administration

• medical staff

board of trustees

mission/goals of hospital

develop policies

hospital administration

implementing policies by board of trustees

managers → CEO assist → CEO

direct patient care

nursing

emergency dpt

urgent care

ambulatory care

surgery

lab/delivery

ancillary services

pharmacy

laboratory

diagnostic imaging

support services

housekeeping

dietary laundry

purchasing

materail management

security

joint commision

accredit hospitals and others

accredit is voluntary

medicare/medicaid

hospitals must be accredited to receive reimbursement

joint commission standards

hospital manages high alert/hazardous medications

safely stores medication

pharmacist reviews appropriate medication orders

national patient safety goals

identify patients correctly

use medicines safely

prevent infection

improve health care equity

director of pharmacy

oversee personnel/budget

develop job description

recruit/interview process

represent interprofessional committees

quality standard of department

larger pharmacies

associate directors, managers and supervisors tto help

staff pharmacist

routine pharmacy operations

order verification, checking medications, product preparation

supervise pharm techs

clinical pharmacists

patient-care

rounding w medical teams

technical/support staff

special training in drug distribution

supervision of pharmacist, perform distribution functions of pharmacy

2 national voluntary technician certification programs that provide formal national recognition

do pharmacy students perform technician tasks?

yes, so they fullfull internship requirements

2 national voluntary technician ceritfication

examination for certification of pharmacy techs

pharmacy tech certification examination

2 disadvantages drug distribution system: floor stock

pharmacist didn’t review for accuracy/drug interaction

pharmacist could not monitor for safety/efficacy

floor stock

bulk supplies

emergency medications

nuses use predetermined dosage forms

• basic IV solutions

  • D5W

  • normal saline

automated dispensing system

dispenses medications after reviews by pharmacy

• examples

  • pxyis tech

  • omicell tech

advantages of unit-dose systems

fewer medication errors

reduced inventory stock

reduced drug delivery time

provide emergency doses in absence of 24 hr pharmcies

disadvantages of unit-dose systems

increase labor costs for preeping/filling doses

delays in meds

centralized services

single location provides all pharmacy services

common in smaller hospitals

decentralized

satallite location

first-dose dispensing and pharmacist order review

supported by central pharmacy

additional staff/products needed

intravenous admixture services

pharmacy personnel prepare sterile dosage forms of medications

requires special training in aseptic technique to reduce infectious complications

must comply with U.S pharmacopeia

U.S pharmacopeia

define how products should be prepared based on risk level (low, med, high)

• risk determined by

  • # of manipulation

  • prepared from sterile/nonsterile ingredients

large volume

parental/electrolyte solutions

small volume

antibiotics

intravenous admixture prep

clean rooms

laminar work bench

nondistributive pharmacy services

drug therapy monitoring

in-service education

medication-utilization evaluation

drug therapy monitoring

promote safe/effective use of medications

conduct admission/discharge medication reconcilation

consider financial/clinical impact of drug orders

conduct admission/discharge medication reconcilation

help resolve discrepancies in home vs inpatient medications

increase risk of adverse events during transitions of care

consider financial/clinical impact of drug orders

less expensive therapeutic alternatives

IV → PO switch

in-service education

• pharmacists are drug resources

• provide in-service education programs related to drug therapy

• publish hospital newsletter to update hospitals

provide in-service education programs related to drug therapy

continuing medication education (CME)

cont for pharmicists/tech

medication utilization evaluation (MUE)

evaluate select drugs comparing specific criteria select for medications

improve drug based results

ex: apixaban (eliquis) prescribing or proton pump inhibitor use for stress ulcer prophylaxis

drugs may be selected fir evaluation if …

• high risk

• high cost

• potentially toxic

medwatch

FDA’s safety information reporting, medication error reports, product complaints

report ADR’s

hospitals are required to identify and report ADRs to hospital quality assessments/performance improvement programs

formulary

list of medications routinely stocked by pharmacy

is formulary continually revised?

yes it is continually revised

what is the purpose of hospital formulary?

ensure appropriate drug therapy and control of drug cost

formulary system

process of evaluating and selecting medications to be included on formulary

closed system

• physicians prescribe those agents that are on formulary

• exception: patient’s medication condition dictates nonformulary drug is necessary

open system

• physicians encourage to prescribe formulary drugs

• nonformulary medications more readily available

pharmacy and therapeutic committee

oversees formulary system

director of pharmacy

commonly sets meeting agenda

drug information or clinical pharmacists

prepares evidence-based review of each agents requested for addition to formulary

conditional addition

reevaluated after a period of time

added with restriction

agent can only be prescribed by certain individuals

therapeutic substitution/interchange

allows for switching between medications in the same class

pharmacy residency

organized, directed, postgraduate training program

designed to develop skills beyond those required for licensure

can also pursue advanced or specialized level of training

strongly encouraged if pursuing career in hospital pharmacy

ambulatory care

healthcare services that can be delivered on an outpatient basis and do not require hospitalization

2010 patient protection / affordable care act

• emphasis on providing lower cost options to hospitalization

• requires health insurance to cover “10 essentials benefits”

top chronic conditions

• hypertension

• hyperlipidemia

• diabetes

• depression

• arthritis

• obesity

• asthma

• cancer

• COPD

top 3 chronic conditions

hypertension

hyperlipidemia

diabetes

solo medical practices

opportunity to be self-employed

popular type of practice

avoids organizational dependence

office space owned/leased

group affiliation practice

3 or more providers

share income, expenses, facilities, equipment, medical records, support personnel

provide services through formal organization

less individual freedom, less income, weaker pt interactions, greater restrictions

patient-centered medical home

• provides comprehensive primary medical care to patients

• team-based delivery model led by primary care

  • family practice, internal medicine, peds, obgyn

patient-centered goal

better quality

lower cost of care

patient-centered medical home coordination

coordinates care across health system

• special care

• hospital

• home health care

• community services

roles pharmacists in PCMH

medication management

primary care providers may not share info with community pharmacists

prescription dispensing program info is not shared with provider

teaching hospitals

• group practices

  • medical

  • surgical

  • other

medical teaching

family

dermatology

cardiology

surgical teaching

general surgery

orthopedics

plastic surgery

other teachings

pediatrics

obstetric/gynecology

rehab medicine

veterans affairs medical centers

• leaders in the expansion of pharmacist roles in ambulatory care

  • improve blood pressure

  • increase medication compliance

  • manage anticoagulation

ambulatory surgery centers

hospital-based settings or as a free standing ambulatory surgical center

increase pt satisfaction

many insurance require ambulatory surgery unless deemed unsafe

urgent care centers

care of urgent/non-urgent problem 24/7

low cost/convenient access without appts or long delays

• school physicals

• pts with no primary

• minor trauma

who is urgent care preferred by?

insurance carrier prefer urgent over emergency dept

community health centers (CHCs)

comprehensive health care to low income populations to stimulate societal growth and decrease poverty

community health center criteria

• to receive fed grants ..

  • poverty line

  • excessive infant mortality rate

  • shortage of primary care physicians

indian health service (IHS)

american indians provided certain medical and hospital services

• treaties signed by US/native american tribes

IHS management

US dept of health and human services PUBLIC HEALTH SERVICES

majority of IHS pharmacists

members of PHS commissioned corps

IHS expanded pharmacist role

• medical records

• consults

• pharmacists are primary care providers

IHS - medical records

replaced traditional prescription blanks

allow concurrent of drug appropriateness before dispensing

IHS -consults

first to use private consultation rooms

provide pt counseling to every pt receiving prescriptions

IHS - pharmacist primary providers

pharmacists independently initiated and extended drug therapy

expanded to taking histories, physical assessments and prescribing treatments

prison health services

• distribute drugs from national drug formulary

• counseling pt

• drug use reviews

• monitor

• chronic care

• immunizing

• adminsitering meds

HIV/AIDS

select pharmacists are trained to manage care for pts under collaborative practice agreements

family practice clinics

pharmacists lend expertise to physicians who care for pts → intervention have been show to improve care

retail pharmacy

• pharmacists most accessible

• responsible for saving $$ for pts

• improve therapeutics

how does retail pharmacies diversify?

• minute clinics/walk-ins

  • inside retail stores

  • inexpensive healthcare

  • staffed by nurse practitioners

pharmaceutical care

drug therapy for improving pt’s quality of life

collaborative practice agreements (CPAs)

agreement when licensed provider makes diagnosis, supervises pt care/refers pt a pharmacist under protocol that allows pharmacist to pergorm pt care functions

collaborative drug therapy management (CDTM)

pharmacists work with defined protocol of the CPA and are permitted to :

• pt assessments, counseling, referrals

• ordering/interpreting lab tests

• selecting, monitoring drugs

telepharmacy

two way real time interactive communication between pt and healthcare provider

steps for a successful telepharmacy services

• ask open ended questions

• ask permission to chat

• prepare resources