PSD 3 Exam I

Ambulatory care pharmacy practice

The provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community.

History of ambulatory care pharmacy - 1960s

Increased recognition of the benefits of optimizing medication use and efforts shifted toward reducing medication-related morbidity and mortality.

History of ambulatory care pharmacy - 1970s

Task force created to develop national standards for pharmacists' clinical practice.

History of ambulatory care pharmacy - 1980s

Multi-institutional pharmacy system was divided into inpatient and ambulatory care practices; ambulatory care practice increased within the Dept. of Veterans Affairs.

History of ambulatory care pharmacy - 1990s

CMS published a report stating that 'clinical pharmacy services add value to care for both institutional and ambulatory patients'; Asheville Project in North Carolina.

History of ambulatory care pharmacy - 2000s

Certification created by BPS for ambulatory care pharmacy (exam debut in 2011).

Opportunities for ambulatory care practice

- Improvement of clinical and economic outcomes
- optimizing safe medication use
- optimizing diabetes, asthma, cardiovascular disease, and renal disease care
- optimizing preventative care
- implementing precision therapeutics
- expanding medication therapy management
- mitigating health care disparities.

Role of an Ambulatory Care Pharmacist

- Direct Patient Care
- Collaboration with other Healthcare Team Members
- Patient and Provider Education
- Quality Improvement

Diabetes quality measure goal

Goal to have >70% of patients with an A1c <9.0%.

Primary Care Ambulatory Care Pharmacist Daily Routine

1. Patients in Clinic to see Provider
2. Patient Visits with Pharmacist
3. PPCP
4. Document
5. Drug Info Resources
6 Education

Pharmacist Telemedicine Visit-Diabetes

Call patient to review home blood glucose readings, lifestyle, medications, and adherence; obtain blood glucose readings and document in excel; confirm adherence to medications and any recent medication changes; review diet and exercise, provide education on improvements; make any appropriate medication changes, educate patient on changes and monitoring; set follow-up visit; document visit using SOAP note and forward to provider.

Pharmacist In Person Visit-HTN

Review all medications with patient to determine current regimen and adherence; review home blood pressure readings if available; review lifestyle factors contributing to hypertension; check patient blood pressure in office using correct technique; make any appropriate medication changes, educate patient on changes and monitoring; provide any lifestyle education; set follow-up visit; document visit using SOAP note and forward to provider.

Object drug

The drug that is affected by the interaction.

Precipitant drug

The drug that causes the interaction.

Pharmacokinetic interactions

Occur when the absorption, distribution, metabolism, or excretion (ADME) of a drug is affected.

Absorption interactions

Those that affect the RATE of drug absorption are usually NOT clinically significant unless an immediate effect is needed; those that affect the EXTENT of drug absorption (bioavailability) MAY be more significant.

Metabolism interactions

These tend to be the most clinically significant; enzyme inducing drugs increase the production and activity of the enzyme that metabolizes the drug, while enzyme inhibiting drugs cause the drug to be cumulated in the body.

Distribution interactions

In general, not clinically significant because the object drug is bonded to the plasma tends to knock out and be free which means it could get eliminated.

Pharmacodynamic interaction

Pharmacologic / Additive effects such as additive CNS depression, additive hypotensive effects, additive anticholinergic effects, changes in various components of the coagulation system, changes in potassium levels, drugs that prolong the QT interval.

Risk factors impacting drug interaction significance

Narrow therapeutic index, duration of therapy, mechanism of action, dose related.

Management strategies for drug interactions

Temporarily discontinue one of the drugs if possible, dose change, change the time of drug administration, choose an alternative therapy if appropriate, monitor the patient, reevaluate risk when drug therapy is changed or stopped, avoid use of contraindicated drugs.

Drug Info Resources

Sources for drug interaction and safety information.

Facts & Comparisons

Online database for drug monographs and interactions.

Lexicomp Online

Comprehensive drug information and interaction screener.

Micromedex

Database providing drug monographs and interactions.

AHFS

American Hospital Formulary Service, drug monograph listings.

Martindale

Complete drug reference with monograph listings.

Drug Information Handbook

Lexicomp's handbook for drug information.

ADR Resources

Resources identifying adverse drug reactions and safety.

Clin-Alert

Resource for alerts on drug reactions and safety.

Reactions Weekly

Weekly publication on drug reactions and safety issues.

Natural Medicines

Resource for herbal and dietary supplement information.

Hansten & Horn

Resource detailing top drug interactions.

PPCP

Pharmacists' Patient Care Process framework.

Collect

Gather patient information for medication history.

Assess

Evaluate collected information for therapy effectiveness.

what is the assessment statement?

[PROBLEM, severity, status] secondary to [CAUSE/ETIOLOGY] as evidenced by [RELATED S & O EVIDENCE]

Plan

Create patient-centered care plans collaboratively.

Implement

Execute care plans with healthcare professionals.

Follow-up

Monitor and evaluate care plan effectiveness.

Sterile Technique

Method to maintain a microorganism-free environment.

Infection Control

Precautions to prevent infection during vaccinations.

Hand Washing

Essential hygiene before patient interactions.

Gloving

Recommended to prevent contamination during procedures.

Syringe Sterility

Syringes must remain sterile until use.

Screening

Assess patients for vaccine contraindications.

Vaccine Safety Communication

Discuss benefits and risks of vaccines openly.

Needle Selection

Choose needle based on vaccine route and viscosity.

Syringe Filling

Proper technique for filling syringes with vaccine.

Patient Positioning

Ensure patient is seated and relaxed during vaccination.

Needle Gauge for IM

Use 22 to 25-gauge needles for intramuscular injections.

Needle Length for IM

Length varies by patient age and size.

Subcutaneous Injection Technique

Inject at a 45-degree angle into fatty tissue.

Needle Gauge for SubQ

Use 23 to 25-gauge needles for subcutaneous injections.

Disposal Procedures

Dispose of needles in puncture-proof containers.

Accidental Needle Sticks

Immediate washing and reporting of needle stick injuries.

Describe the Pharmacists' Patient Care Process

Collect
Assess
Plan
Implement
Follow-up

What is the needle size for a subcutaneous injection for all ages?

5/8 inch

What is the needle size for IM injections in neonates?

5/8 inch

What is the needle size for IM injections in children aged 1-12 months?

1 inch

What is the needle size for IM injections in children aged 1-10 years --> thigh?

1-1.25 inch

What is the needle size for IM injections in children aged 1-10 years --> deltoid muscle?

5/8-1 inch

What is the needle size for IM injections in adolescents aged 11-18 years?

5/8-1 inch

What is the needle size for IM injections in adults under 152 lbs?

1 inch

What is the needle size for IM injections in men weighing 152-260 lbs?

1-1.5 inch

What is the needle size for IM injections in women weighing 152-200 lbs?

1-1.5 inch

What is the needle size for IM injections in men over 260 lbs?

1.5 inch

What is the needle size for IM injections in women over 200 lbs?

1.5 inch

Review of disposal procedures for contaminated needles

- Position sharps container within reach where risk of needlesticks is minimized
- Pharmacist should not cross their body to deposit the syringe in the sharps container after the injection.
- NEVER recap a contaminated needle

Proper procedures for accidental needle sticks

1. Wash needle-stick injuries with soap and water immediately.
2. Report the exposure right away and seek medical treatment.
3. Discuss the risks of acquiring HBV, HCV, and HIV, and consider the need for post-exposure treatment.
4. Follow-up testing is available for all workers concerned about possible infection.
5. Follow the workplace or organization's policies and procedures for needle-stick injuries.

what are drugs that are enzyme inducers?

• carbamazepine
• phenobarbital
• phenytoin
• rifampin
• St. John's Wort

what drugs are enzyme inhibitors?

• amiodarone
• clarithromycin
• diltiazem
• fluconazole
• itraconazole

List the background information that might be needed to answer a drug interaction question

- Patient specific information (age/weight/height…)

- Patient’s other medical problems

- Indication for the drugs

- Expected duration of therapy

- Dosage / Route / Frequency

- When were the drugs were started? (or when will they be?)

- Other medications

Discuss risk factors that might impact the clinical significance of a drug interaction

1. Not all interactions are clinically signifigant
2. Does the drug that have a narrow therapeutic index
3. Duration of therapy
4. Mechanism of the interaction
5. Is it dose related
6. What is expected to occur in the patient
7. Timing: When does interaction start/go away
8. Level of evidence

Provide the ASHP's definition of adverse drug reaction (ADR)

An unexpected, unintended, undesired, or excessive response to a medication

Medication misadventures

- Any iatrogenic hazard or incident associated with medications
- Always unexpected or undesirable to patient and health professional

ADE

Any injury caused by a medication

ADR

An unexpected, unintended, undesired, or excessive response to a medication

Medication error:

Any preventable event that has the potential to lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer

Describe the various ways adverse drug reactions are classified

Classification by SEVERITY, MECHANISM, PROBABILITY

Discuss factors that contribute to the assessment of causality

Timing: Did the effect appear soon after starting a drug/increasing dose?

Dechallenge: Did the effect go away after stopping drug/decreasing dose?

Rechallenge: Did the effect appear again if the drug was given after a period of the drug being out of the system?

Describe the purpose and usefulness of ADR causality algorithms

Promote a consistent systematic evaluation process

Common algorithms:

Naranjo (1981) 10 questions / score

Jones (1982) series of Y/N questions

Liverpool (CAT) series of questions

Discuss appropriate background information needed to answer ADR drug information questions

1.Complete description of reaction

2.Information about drug (dose, duration, route, preparation)

3.Patient information (pharmacokinetic alterations, age, genetic background, allergy history, other medications, indication for drug)

how to manage chronic disease management

Coordinated healthcare interventions and communications aimed at reducing healthcare costs, enhancing quality of life, preventing or minimizing disease effects

Discuss the role of the pharmacist in chronic disease management

• Assist in the identification of individuals
• Assist with medication adherence
• Conduct disease state monitoring
• Provide direct patient care
• Provide patient education
• Evaluate outcomes of programs

Define population health

Interdisciplinary, customizable approach that allows health departments or facilities to connect practice to policy and allow local change

Health outcomes of a group of individuals including the distribution of such outcomes within the group

Define collaborative practice agreements

A formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions.

What is a collaborative practice agreement

• Pharmacist and physician enter into a legal agreement • Agreement allows pharmacist to manage agreed upon conditions • Agreements are specific in what the pharmacist can do • Pharmacist becomes an extension of the provider and collaborator in patient care

Describe collaborative practice agreement legislation in the United States

- Pharmacists don't have to be in a consult agreement to bill for certain services anymore
- Pharmacists have their own provider ID that they use to bill Medicaid's

Describe collaborative practice agreement legislation in Ohio

Pharmacists can now enter into a consult agreement with Physician assistants, Clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners if authorized by a supervising or collaborating physician

Identify strategies to implement collaborative practice agreements into practice

1. Create and expand infrastructure
2. Use simple, understandable, and empowering language
3. Allow providers to define details of each agreement
4. Examine and redesign professional scope of practice
5. Properly align incentives
6. Use technology to improve patient care
7. Maintain strong, trusting, and mutually beneficial relationships