Innovative Pharmacy Innovative Pharmacy Practices: Practices: Pharmacist Prescribing Pharmacist Prescribing Cynthia Jackevicius, B.Sc.Phm., M.Sc., FCSHP Pharmacy Practice Leader, Heart & Circulation Program Associate, Women’s Health Program, University Health Network Assistant Professor, Faculty of Medicine & Pharmacy, U of Toronto Adjunct Scientist, Institute for Clinical Evaluative Sciences December 2002 December 2002
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Therapeutic interchange-intervals 70.6% Order clarifications 55.0% Modify non-Rx medications 39.4% Pharmacokinetics 29.8% Routine labs 23.0% Pain service 20.7%
Types of Prescribing Models
Independent Dependent Collaborative
Independent Prescribing
Prescribing practitioner is solely responsible for patient outcomes
Must possess legally defined levels of knowledge and skills to diagnose conditions– e.g., physician licensing process
Most Cdn pharmacy schools do not teach diagnostic and physical assessment skills required to practice at this level– not required skills for pharmacist licensure
Dependent Prescribing
Delegation of authority from an independent prescribing professional
Shared responsibility for patient outcomes formal agreement usually containing:
– written guidelines or protocols
– description of responsibilities
– description of documentation
– policies for review and revision
Types of Dependent Prescribing
By protocol - most common– specific diseases, drugs, drug categories
According to formulary– delegation of prescribing for a limited list of
medications– less explicit than by protocol
By patient referral– common in ambulatory practices
Collaborative Prescribing
Cooperative practice relationship between a pharmacist and a physician or practice group with legal authority to prescribe
not same as protocols since do not dictate the specific pharmacist activities
Collaborative Prescribing
“Ideal” model:– physician diagnoses and makes initial
modifies, continues and discontinues therapy as appropriate to achieve desired patient outcomes
Both share in responsibility and risk
CSHP Statement
CSHP advocates the role of pharmacists as capable prescribers and supports the pharmacists’ role in a collaborative
prescribing model to improve patient health outcomes and increase the successful and efficient delivery of
pharmaceutical care.
Core elements for collaborative prescribing
Support from prescriber groups Written declaration - contractual
understanding Explicit prescribing activities Clear definition of scope of practice When to contact physician Procedures for documentation Time limit - review, quality assurance
The Plan…..
rationale for the service support from other departments
– teamwork is imperative supportive literature, if available pilot test the service evaluate the benefits make necessary revisions continue to justify the service
Potential Benefits
process “outcomes” vs outcome “outcomes”
structure, process and outcome “hard” vs “soft” outcomes clinical outcomes financial outcomes
Prescribing Statements
Canadian Society of Hospital Pharmacists (CSHP)
American College of Clinical Pharmacy (ACCP)
American Society of Health-System Pharmacists (ASHP)
Canadian Pharmacists’ Association (CPhA) National Association of Pharmacy Regulatory
Authorities (NAPRA)
Monitoring Drug Therapy
Monitoring Drug Therapy
Role of the pharmacist– monitor drug therapy– prevent drug related adverse events– ensure accurate dosing for clinical efficacy
Sources of monitoring parameters– patient– written chart– electronic chart
20
Coumadin Pharmacist Assisted Warfarin Dosing
Program (PAWD)– Delegated Medical Act– Approved for use in the Cardiac Program– Pharmacists certification and CQI– Daily dosing by protocol according to INR
Coumadin Issue:
– INRs are not ordered routinely and information is not available for daily dosing.
– Nurses have been ordering INR test as requested by the pharmacists but will no longer be doing this.
Request to CDS Committee– Pharmacists be granted authorization to order
INR test for patients on PAWD Program.
Heparin- LMWH
Current hospital guidelines suggest to contact the pharmacists for difficult to dose patients (i.e. renal and obese patients).– Requires anti-Xa levels
– Physicians are unfamiliar with ordering anti-Xa levels
Improper timing can lead to inappropriate dosing changes.
Timing of Anti-Xa levels in Renal Patients
Anti Xa Levels in Renal Patients with q12h Dosing
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
0 5 10 15 20 25 30Hours between dose and post level
Ant
i Xa
Leve
l
Amiodarone Amiodarone can have significant long term
toxicity.– Hepatic/ thyroid/ pulmonary toxicity
Baseline function tests are required when initiating patients on amiodarone therapy.
This practice is not occurring, particularly for thyroid function– 5/26 (19%) patients had TSH done
– often delayed up to 7 days after initiating therapy