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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