Innovative Pharmacy Practices:Innovative Pharmacy Practices:Pharmacist PrescribingPharmacist 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 2002December 2002

Developing Innovative Practices

specific activities– warfarin dosing– monitoring drug therapy– total parenteral nutrition

practice sites– Heart Function Clinic– Thrombosis Treatment Program– Secondary Prevention Clinic– Emergency Department

What is prescribing?

To designate in writing a remedy for administration

Several related and complex steps– decide to initiate therapy

selection prescription monitoring modification

– decision to cease therapy

Who Prescribes?

Physicians Nurse practitioners Expanded role nurses Clinical nurse specialists Midwives Optometrists What about pharmacists?

Examples of Pharmacist Prescribing

Therapeutic interchange

Non-prescription Rx Aminoglycoside

dosing Vancomycin dosing TPN Insulin dosing

Renal dosing program

HTN clinics Lipid clinics Refill clinics Warfarin dosing Cancer-related pain

and antiemetic management

CSHP Survey

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

treatment decisions– pharmacist selects, initiates, monitors,

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

Aminoglycosides UHN aminoglycoside guidelines require:

– baseline Serum Creatinine prior to initiation of therapy and 3 times per week while on active therapy

– 24 hour trough levels for patients on 7 days or more of aminoglycosides

Pharmacists have been granted authorization to order the levels and SrCr but not the access to do so electronically.

(P&T and MAC February/April 1997)

Vancomycin

Baseline serum creatinine is required for initial dosing and ongoing monitoring.

In select patients vancomycin trough levels are required to monitor for efficacy and /or drug accumulation.

Pharmacists are often asked to provide consultations regarding vancomycin dosing. This often requires the ordering of SrCr and vancomycin levels.

SUMMARY

Request authorization for pharmacists to order the following tests:– INR

– anti-Xa

– TSH and LFT’s

– Serum Creatinine

– aminoglycoside trough levels

– vancomycin trough levels

Approved by UHN Clinical Decision Support

Conclusion

Pharmacist prescribing occurs widely in hospital/institutional practice

Many opportunities exist for improving patient care with pharmacist prescribing

Pharmacy practice is evolving to encompass prescribing responsibilities

Useful tools are available to assist pharmacists with implementation (e.g., CSHP)