Implementation of clinical pharmacy services in non- academic hospitals: opportunities and links to university programmes Pharm. Elke De Troy 8th june 2006
Content Content 1.Link with university program of Leuven 2.Implementation in a non-academic hospital 3.Pilot-project on an oncology service 4.Future plan 5. Conclusion and opportunities
Content Content 1.Link with university program of Leuven 2.Implementation in a non-academic hospital 3.Pilot-project on an oncology service 4.Future plan 5.Conclusion and opportunities
1. Link university university program program 1. Link Leuven Leuven Background Background • hospital pharmacist at Virga Jesse Hospital since 1995 • 2003:Opportunity: fellowship in clinical pharmacy at university of Leuven Fellowship Fellowship cooperation between • faculty of farmaceutical sciences • university hospital Gasthuisberg • farmaceutical industry
1. Link university university program program 1. Link Leuven Leuven Basic education education to to become become a a hospital hospital pharmacist pharmacist Basic ° extensive extensive knowledge knowledge … … ° -pharmacology pharmacology, , pharmacokinetics pharmacokinetics, , interactions interactions, , antibiotics antibiotics, , - cytotoxics, ,… … cytotoxics ° but but… … ° - theoretical theoretical knowledge knowledge - - insufficiently insufficiently linked linked to to clinical clinical practice practice - ° need need for for additive additive knowledge knowledge … … ° -pathophysiology pathophysiology - … pediatrics … - -specific specific domains domains: intensive care, : intensive care, oncology oncology, , pediatrics => Refresh Refresh basic basic knowledge knowledge and and s self elf- -study study! ! =>
1. Link university university program program 1. Link Leuven Leuven Fellowship Fellowship trainingscourse of 12 of 12 months months trainingscourse => mainly mainly practical practical => ° UZ UZ leuven leuven: : traumatology traumatology and MICU and MICU ° ° teaching teaching hospital hospital in London: 14 in London: 14 days days ° ⇒ posters ⇒ posters ⇒ script ⇒ script
1. Link university university program program 1. Link Leuven Leuven Develop methodology methodology to to evaluate evaluate medication medication therapy therapy Develop ⇒ Start ⇒ Start from from pathology pathology, , clinical clinical status, lab parameters, status, lab parameters, medication medication on on admission admission ⇒ Evaluate ⇒ Evaluate medication medication therapy therapy: : - Medication Medication on on admission admission? ? - - Pathology Pathology: : what what is is indicated indicated? ? - - Correct Correct dose dose and and frequency frequency? ? - - Correct route of Correct route of administration administration? ? - - Interactions Interactions? ? - - TDM TDM? ? - - Guidelines Guidelines for for use use of of antibiotics antibiotics? ? - - Enteral Enteral and and parenteral parenteral feeding? feeding? - - Adverse Adverse effects effects? ? -
Content Content 1.Link with university program of Leuven 2.Implementation in a non-academic hospital 3.Pilot-project on an oncology service 4.Future plan 5.Conclusion and opportunities
2. Implementation Implementation in in non non- - 2. academic hospital hospital academic Implementation in different steps: Implementation in different steps: 1. Preparation in cooperation with medical director 1. Preparation in cooperation with medical director 2. Discuss with management commission Discuss with management commission 2. 3. Discuss with physician, head of service 3. Discuss with physician, head of service
2. Implementation Implementation in in non non- - 2. academic hospital hospital academic 2.1 Preparation in cooperation with medical director 2.1 Preparation in cooperation with medical director → determine determine target: target: → - policy of policy of “ “patient safety patient safety” ” of VJH of VJH - - anticipate in anticipate in “ “medication medication- -budget budget” ” - → determine method determine method : clinical pharmacist : clinical pharmacist ½ ½ time on time on → service and ½ ½ time in pharmacy time in pharmacy service and → choice of service choice of service : : → - polypharmacy, polypathology polypharmacy, polypathology - - patient tour patient tour => oncology ward - => oncology ward - consult together consult together -
2. Implementation Implementation in in non non- - 2. academic hospital hospital academic 2.2 Discuss with management commission 2.2 Discuss with management commission → supported supported the proposal the proposal → → agreement: agreement: → - pilot project pilot project - - evaluation after 3,6 and 12 months evaluation after 3,6 and 12 months - - plan for future plan for future - 2.3 Discuss with oncologist → determine tasks of clinical pharmacist determine tasks of clinical pharmacist →
Content Content 1.Link with university program of Leuven 2.Implementation in a non-academic hospital 3.Pilot-project on an oncology service 4.Future plan 5.Conclusion and opportunities
3. Pilot Pilot project project oncology oncology 3. Start: november 2004 Start: november 2004 → Oncology service: 30 beds, 1700 admissions/yr → → daily work: → - preparation:°new pts: medical file, nursing file, labs…. ° others: daily labs, parameters… - patient tour - look for: interactions, guidelines, literature… - discuss possible interventions with physician Further progress of project Further progress of project → evaluation 3 months: report interventions evaluation 3 months: report interventions → → evaluation 6 months: individual patient + procedures evaluation 6 months: individual patient + procedures → → endevaluation → endevaluation
Report interventions interventions Report Interventions by clin pharm on oncology service in 11 months adverse reactions 4% 1% 3% dose correction 3% 8% 21% interactions medication error 7% route administration info start product stop product 9% 10% antibiotic guidelines electrolytes 10% 13% pain therapy 5% 6% enteral and parenteral feeding others Interventions : every proposal that leads to a change in medication therapy � report in Access-file � aim: observe qualitative and financial implications
Report interventions interventions Report Rate of acceptancy Rate of acceptancy 1200 1068 1000 800 600 400 200 133 0
Procedures: standardised standardised schemes schemes Procedures: Te bewaren in chemoboekje Patiëntnaam Boer wortel THERAPIE: mg/m2 * dosis%mg/m2 dosis% Kamernummer B5 Taxol 175 175 100% Gewicht (kg) 70 Lengte (cm) 172 1,83 BSA gelimiteerd (m2) Carboplatine 1,83 5 BSA (m2) AUC (waarde 5-7) 65 leeftijd (aantal jaar) serumcreat (mg/ dl) 0,82 schema: q 3 wk Automatic Geslacht (M/V) M Cl creat man (ml/min) 88,9 prescribing Cl creat vrouw (ml/min) 0,0 88,9 by physician Startdatum 5-okt-05 Cyclus 4 Dag Bijkomende medicatie Aantal
Procedures: standardised standardised schemes schemes Procedures: Schema voor verpleging Boer wortel Cyclus: 4 Patiënt Dag: 0 Kamernummer B5 Datum Paraf Hoev. Medicatie Tijd Uur Opmerking Dosis % spoeling 4-okt-05 Glucose 5% 1 liter + 20 meq KCL 12 u geen naschrift maken spoeling NaCl 0.9% 1 liter + 20 meq KCL 12 u geen naschrift maken Glucose 5% 1 liter + 20 meq KCL waakinfuus 5-okt-05 + 4 g NaCl 12 u geen naschrift maken phenergan 1 amp I.M. toedienen 1 uur vóór taxol dexamethasone 20 mg IV in toedienen 45 minuten vóór NaCl 0.9% 50 ml taxol toedienen 30 min vóór zantac 1 amp I.V. taxol toedienen 30 min vóór kytril 1 amp in NaCl 0.9% 50 ml 10 min taxol Scheme for toedienen met pomp, 0.22 micron filter en infuusleidingen zonder 320 mg TAXOL in NaCl 0.9% 500 ml 3 u weekmakers 100% administration by SPOELEN met 100 ml waakinfuus 10 min mg CARBOPLATINE in glucose nurses 570 5% 250 ml 30 min spoeling Glucose 5% 1 liter + 20 meq KCL 12 uur geen naschrift maken indien verder spoeling ndz: verdere spoeling navragen naschrift maken Heparine slot 500 E Mee naar huis te geven: Dexamethasone 4 mg 2/d ged. 2 dagen (te starten 12 uur na vorige dexamethasone) Novaban 5 co Litican 12 co zo nodig Bijkomende medicatie Aantal voorgeschreven: 0 0 0 0 0 0 0 0 0 0 0 0 stempel en handtekening arts
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