PHARMACEUTICAL CARE and DRUG INFORMATION
Pharmaceutical Care (PC)
“The responsible provision of drug therapy for the purpose of achieving definite outcomes which improve a patient’s quality of life” is the definition of PC provided many years ago by Hepler & Strand. PC is a philosophy of pharmacy practice which requires pharmacy to shift its focus of work from products to patients and recognizes a variety of responsibilities for pharmacy in addition to the technical components (i.e. counting, filling, dispensing). PC emphasizes commitment to the most important responsibility of the profession which is individual patients.
Pharmaceutical Care Model
For the past few decades, there has been steady movement away from the pharmacist-patient relationship whereby the Pharmacist decided what patients needed to know and toward the Pharmacist and patient working together in a cooperative, trusting manner to determine 1. What patient needs are and 2. What care should be provided to meet those needs. The goal of PC is to improve the patient’s quality of life which only the patient can determine for him or herself. A trusting pharmacist-patient relationship must be developed if PC can be provided. The Pharmacist works with the patient to determine if drug related needs exist that are preventing the patient from achieving his/her Quality of Life (QOL) goals. The Pharmacist is responsible for meeting the identified needs that are within his/her scope of practice to achieve. Above all, PC relies on an honest, open relationship with the patient.
Defining Drug-Related “Needs”
The PC model describes drug-related needs as Drug-Related Problems (DRPs). Drug-Related Problems are defined as “any physical or psychological sign or symptom which is undesirable to the patient and which is in some way related to drug therapy.” DRPS may be a potential sign or symptom which is likely to develop if changes are not made in the patient’s drug therapy. Identifying a patient’s Drug-Related Problems may seem overwhelming due to the fact that patients, in particular those in hospital, are often on multiple drug therapies.
In addition, there are many ways in which drugs may cause problems including if the person: 1. Is taking a drug for NO medically valid indication, 2. Needs a drug and one has NOT been suggested or prescribed, 3. Is taking the wrong drug or drug product, 4. Is taking too little or too much of the right drug, 5. Needs a drug, has been prescribed or suggested one, but is not actually taking it or is not taking it appropriately, 6. Is experiencing an adverse effect (I.e. side effect) or 7. Is experiencing a drug reaction (e.g. ADR, ADE, idiosyncratic reaction)
Patient, drug and disease information is collected with the patient and HC professional. This allows identification of possible DRPs. The Pharmacist works with the patient to determine the priority of problems (e.g. patient is experiencing dizziness and nausea but clearly states they are more concerned with one or the other). The Pharmacist, patient, and physician must 1. determine and develop a therapeutic plan, the Pharmacist must 2. provide follow-up with the patient and the physician (this is crucial) and 3. documentation (by all HC practitioners involved) of all activities is mandatory. In order to meet the criteria for providing PC all 3 components must be provided in an organized and continuous manner.
Importance of Resources
Pharmacists require sufficient structure, tools and resources to provide optimal Pharmaceutical Care. This involves: 1. Patient Care (e.g. time to meet with other HC professionals and access to patient health record); 2. Administrative Issues (e.g. time for Professional Development and access to resources) and 3. Support Systems (e.g. a mechanism for ADR reporting and communication link with community based Pharmacists).
Clinical Pharmacy and Drug Information (DI) Services
Development of the concept of the Pharmacist as a provider of clinically useful drug information has grown and strengthened in recent years. DI Services can be applied to the therapeutic management of patients complimentary to Clinical Pharmacy. The formation of an organized, centralized Drug Information Service is required due to the need for efficient delivery of health care and increasing patient populations. Dissemination of drug information by Pharmacists to nursing units in their clinical field should be organized in a similar manner.
Despite technology people are still plagued with disease, poverty and insufficient education. Applying 'our' drug information knowledge to provide people with a more efficient system of health care is possible. One way to accomplish this is through the formation of Drug Information Services.
Drug Information Specialist
A DI Specialist deals with more than basic factual information that can be gathered from the literature. This role involves the “Ability to communicate to the practitioner the clinically relevant information that can be used to facilitate the practice of rational therapeutics that result in positive patient outcomes.” The complexity of the drug (and medical) literature creates problems for Pharmacists (as well as other HC Professionals). Specialized DI services involve Gathering, Reviewing, Evaluating, Organizing, Summarizing, and Distributing/Disseminating Drug information by various (systematic) methods to HC Providers and consumers. The DI Specialist accumulates, organizes, and expedites access to documents that constitute the published record of clinical drug research. DI Specialists provide on-demand literature searches, bibliographic compilations, computer–processed information retrieval services and discriminate among literature sources to reach specific conclusions about a drug or a patient-specific problem. Expertise in critical analysis of current drug literature helps to minimize material necessary to make intelligent, informed, decision regarding a drug therapy question. DI Specialists must have access to books, journals, computer data bases, retrieval systems and literature files in order to adequately search for in-depth information.
Drug Information Services (DIS)
DI activities are primarily communicative in nature involving the collection, evaluation and dissemination of drug information. It is time consuming for Clinical Pharmacists to conduct in-depth literature searches and impossible to do while monitoring patients who are receiving drugs - this in itself is a full time job. Drug information support should be provided by a centralized DIS in a (large or teaching) hospital environment. Decisions must be made and a process must be in place describing how to best communicate existing information (e.g. employee newsletters, e-mail).
Drug Information Services (DIS) – Identification of a Drug (15 items)
In providing identification of a drug the following (at minimum) must be included:
1. Chemical name, Structures and properties (Identification – physical appearance)
2. Diagnostic or therapeutic indications and Contraindications
3. Mechanisms of action
4. Recommended dose and schedule
5. Administration details
6. ADME (Pharmacokinetics)
7. Adverse (side) effects and Drug Reactions (ADE, ADR, DRP)
8. Costs
9. Advantages
10. Signs and symptoms of overdose
11. Treatment of Toxicities
12. Clinical efficacy
13. Comparative data
14. Clinical data
15. Drug use data
(Advertising material; Drug detailing; Clinical impressions – case history, diagnosis, treatment; Testimonial type reporting; Inventory control; Purchasing information are NOT considered)
5 Purposes of DIS
The main purposes of a Drug Information Service are to: 1. Deal with problems with drug therapy, 2. Develop optimal therapeutic regimens, 3. Keep current on new medical/medication discoveries, 4. Inform other HC professionals of discoveries and 5. Answer any questions that may arise with regard to other aspects of medicine and drug-related therapy.
Major Functions of DIS
The greatest function of a DI Specialist is to obtain and evaluate information from the literature and to make important and/or new information known to HC professionals through a process called dissemination. In a hospital environment, the function of a DIS includes monitor inpatients for potential drug interactions. Many hospital inpatients are prescribed multi-drug therapies. DI Specialists may be able to avert possible interactions and side effects which results in patient safety and also can save time and money for the institution and other HC professionals involved.
Benefits of DIS
DISs promote effective and safe use of drugs in the diagnosis and treatment of disease through careful and informed selection, evaluation and dissemination of drug literature. DISs allow for greater efficiency of professional functions by Pharmacists who specialize in the service. They provide up-to-date information to other HC professionals, arguably "better" patient care, and clinically relevant drug information in response to patient-specific and general requests from health care practitioners, skilled care facilities, and the community at large.
ASHP Guidelines on Provision of Medication Information
The ASHP states that a Pharmacist must be able to: “1. Perceive and evaluate the medication information of patients and families, health care professionals, and other personnel, and
2. Use a systematic approach to address medication information needs by effectively searching, retrieving and evaluating the literature and appropriately communicating and applying the information to the patient care situation.”
(Read the ASHP Guideline document posted on FOL. In particular pay attention to the 12 “Medication Information Activities” and the 9-step “Systematic Method for Responding to Medication Information Needs”)
DI Centres (LonDIS, DIRC)
Most drug information requests occur in the hospital environment where most of the complex medical cases are taking place. Other areas where drug information centre systems may be utilized include: Pharmaceutical companies, Government agencies, Schools, Community pharmacies, and Poison Control Centres (PCCs).
DI Role of the Pharmacist and Pharmacy Technician
The responsibility of answering drug information questions lies solely with the Pharmacist. It is a professional responsibility that CANNOT be delegated to another individual. However, Pharmacy Technicians may be responsible for assisting in auxiliary functions in a DI Service such as typing, filing and cataloging. A Pharmacy Technician working in this role must be familiar with textbooks, handbooks, abstracting services, computer databases, journals, catalogs and filing systems. Duties may involve cataloging books, journals, and specific articles and retrieving pertinent drug information. A skilled DI Pharmacy Technician must be able to maintain accurate statistics on the types and numbers of questions received and references used as well as maintaining up-to-date filing systems for abstracts, newsletters, and correspondence. Others tasks may include: assisting in collating drug usage data, drug utilization studies, adverse reaction reporting and systematically recording and filing telephone and/or Internet requests for drug information.
Request for Information
Immediate drug information on request is a large part of the service provided by all drug information centres. The information may be patient-specific or drug-oriented information.
Patient specific - inquiries ranging from dosage instructions to outlining specific therapeutic regimens Drug-oriented - dosage forms and availability, product identification, and product compatibility
All questions received must be properly documented in writing (or online). Most questions will be received by telephone or via the Internet. A proper procedure for answering the telephone needs to be established to ensure that questions get answered swiftly and fully. Requests should be fully documented with the name and location of the inquirer. A Request for Information Form (paper or online version) provides a mechanism for the collection of data. It is used to keep statistics and evaluate and review the activities of the DI Centre. The form must be utilized each time a request for information is received. Therefore there should be a single form containing a single question so that questions can be catalogued accordingly for future reference.
Poisoning: What is a poison?
A poison is any substance that may be Ingested, Inhaled, Exposed to the eye(s), Exposed to the skin AND can cause sickness or death.
4 Forms of Poisoning
The four forms of poisoning include: 1. Solids (e.g. tablets, capsules, batteries, plants, berries), 2. Liquids (e.g. antitussives, alcohol, antifreeze, mouthwash), 3. Sprays (e.g. inhalers, local anesthetic products, insect repellant which may be absorbed through the skin or through inhalation via the nose/mouth) and 4. Gas or Vapors (e.g. carbon monoxide – CO2).
Poisoning Problem in Canada
It is estimated that over 100,000 poisoning exposures occur each year resulting in approximately 500 deaths. Children under the age of 5 account for 40% of all poisonings. Approximately 40,000 (40%) of all poisonings involve medications. The remaining poisonings are a result of exposure to environmental or household toxins.
Drug Poisoning
Of the 40,000 (approx.) drug poisonings which occur every year in Canada, Prescription drugs account for 35% (14,000), Narcotics and Controlled Drugs account for 7% (2,800), and Non-Prescription Drugs account for the largest portion at 58% (23,200).
Death Due to Poisoning
In young children, the leading cause of death due to poisoning is from consuming Iron tablets or capsules (e.g. ferrous sulfate, ferrous fumarate, ferrous gluconate). A couple of tablets can cause toxic effects and as few as 10 tablets can cause death. Children are often attracted by the bright colours of the tablets.
Non-Prescription Drug Poisoning
As a percent of all non-prescription drugs causing poisoning Acetaminophen accounts for the highest at 13%, ASA is second at 8% followed by Antihistamines at 7%, Vitamins at 4%, Cough and Cold preparations at 2%, Camphor at 1%, and Iron at 0.1%. Although Iron represents a small percentage of overall non-prescription drug poisonings, in children it remains the highest cause of death due to poisoning.
Storage of Poisonous Products
It is best practice to keep medications in the original container. In the workplace, regulations and policies and procedures dictate how and where chemicals and medications are stored (e.g. designated area with signage and/or locks). Laws also state that all medications must be dispense in a child resistant vial unless an adult specifies otherwise. Since most poisonings happen in the home, it is important to get the message out to caregivers, parents and grandparents to keep chemicals and medications in a safe area away from children.
CHECKPOINT Question ONE: Sharing prescription Opioid medications has been identified as an increasing problem in Canada and one which all too often ends in fatality. Read the ISMP Safe Medication Newsletter concerning a patient sharing a fentanyl patch with a friend. Risk factors for narcotic overdose include narcotic naivety and consumption of alcohol. In addition, not all narcotics are created equally meaning very low doses of one narcotic may provide a very heavy sedative affect compared to another. Have a look at this Narcotic Conversion Chart and identify how many mg of hydromorphone given orally per day (in 24 hours) would be equivalent to morphine 15 mg IV given q8h. Check your answer here. How did you do? Compare the equivalent doses of other drugs included in the chart. Why do you think it is important for Pharmacy Technicians to be aware of the differences in dosing between narcotics?
Pharmaceutical Care (PC)
“The responsible provision of drug therapy for the purpose of achieving definite outcomes which improve a patient’s quality of life” is the definition of PC provided many years ago by Hepler & Strand. PC is a philosophy of pharmacy practice which requires pharmacy to shift its focus of work from products to patients and recognizes a variety of responsibilities for pharmacy in addition to the technical components (i.e. counting, filling, dispensing). PC emphasizes commitment to the most important responsibility of the profession which is individual patients.
Pharmaceutical Care Model
For the past few decades, there has been steady movement away from the pharmacist-patient relationship whereby the Pharmacist decided what patients needed to know and toward the Pharmacist and patient working together in a cooperative, trusting manner to determine 1. What patient needs are and 2. What care should be provided to meet those needs. The goal of PC is to improve the patient’s quality of life which only the patient can determine for him or herself. A trusting pharmacist-patient relationship must be developed if PC can be provided. The Pharmacist works with the patient to determine if drug related needs exist that are preventing the patient from achieving his/her Quality of Life (QOL) goals. The Pharmacist is responsible for meeting the identified needs that are within his/her scope of practice to achieve. Above all, PC relies on an honest, open relationship with the patient.
Defining Drug-Related “Needs”
The PC model describes drug-related needs as Drug-Related Problems (DRPs). Drug-Related Problems are defined as “any physical or psychological sign or symptom which is undesirable to the patient and which is in some way related to drug therapy.” DRPS may be a potential sign or symptom which is likely to develop if changes are not made in the patient’s drug therapy. Identifying a patient’s Drug-Related Problems may seem overwhelming due to the fact that patients, in particular those in hospital, are often on multiple drug therapies.
In addition, there are many ways in which drugs may cause problems including if the person: 1. Is taking a drug for NO medically valid indication, 2. Needs a drug and one has NOT been suggested or prescribed, 3. Is taking the wrong drug or drug product, 4. Is taking too little or too much of the right drug, 5. Needs a drug, has been prescribed or suggested one, but is not actually taking it or is not taking it appropriately, 6. Is experiencing an adverse effect (I.e. side effect) or 7. Is experiencing a drug reaction (e.g. ADR, ADE, idiosyncratic reaction)
Patient, drug and disease information is collected with the patient and HC professional. This allows identification of possible DRPs. The Pharmacist works with the patient to determine the priority of problems (e.g. patient is experiencing dizziness and nausea but clearly states they are more concerned with one or the other). The Pharmacist, patient, and physician must 1. determine and develop a therapeutic plan, the Pharmacist must 2. provide follow-up with the patient and the physician (this is crucial) and 3. documentation (by all HC practitioners involved) of all activities is mandatory. In order to meet the criteria for providing PC all 3 components must be provided in an organized and continuous manner.
Importance of Resources
Pharmacists require sufficient structure, tools and resources to provide optimal Pharmaceutical Care. This involves: 1. Patient Care (e.g. time to meet with other HC professionals and access to patient health record); 2. Administrative Issues (e.g. time for Professional Development and access to resources) and 3. Support Systems (e.g. a mechanism for ADR reporting and communication link with community based Pharmacists).
Clinical Pharmacy and Drug Information (DI) Services
Development of the concept of the Pharmacist as a provider of clinically useful drug information has grown and strengthened in recent years. DI Services can be applied to the therapeutic management of patients complimentary to Clinical Pharmacy. The formation of an organized, centralized Drug Information Service is required due to the need for efficient delivery of health care and increasing patient populations. Dissemination of drug information by Pharmacists to nursing units in their clinical field should be organized in a similar manner.
Despite technology people are still plagued with disease, poverty and insufficient education. Applying 'our' drug information knowledge to provide people with a more efficient system of health care is possible. One way to accomplish this is through the formation of Drug Information Services.
Drug Information Specialist
A DI Specialist deals with more than basic factual information that can be gathered from the literature. This role involves the “Ability to communicate to the practitioner the clinically relevant information that can be used to facilitate the practice of rational therapeutics that result in positive patient outcomes.” The complexity of the drug (and medical) literature creates problems for Pharmacists (as well as other HC Professionals). Specialized DI services involve Gathering, Reviewing, Evaluating, Organizing, Summarizing, and Distributing/Disseminating Drug information by various (systematic) methods to HC Providers and consumers. The DI Specialist accumulates, organizes, and expedites access to documents that constitute the published record of clinical drug research. DI Specialists provide on-demand literature searches, bibliographic compilations, computer–processed information retrieval services and discriminate among literature sources to reach specific conclusions about a drug or a patient-specific problem. Expertise in critical analysis of current drug literature helps to minimize material necessary to make intelligent, informed, decision regarding a drug therapy question. DI Specialists must have access to books, journals, computer data bases, retrieval systems and literature files in order to adequately search for in-depth information.
Drug Information Services (DIS)
DI activities are primarily communicative in nature involving the collection, evaluation and dissemination of drug information. It is time consuming for Clinical Pharmacists to conduct in-depth literature searches and impossible to do while monitoring patients who are receiving drugs - this in itself is a full time job. Drug information support should be provided by a centralized DIS in a (large or teaching) hospital environment. Decisions must be made and a process must be in place describing how to best communicate existing information (e.g. employee newsletters, e-mail).
Drug Information Services (DIS) – Identification of a Drug (15 items)
In providing identification of a drug the following (at minimum) must be included:
1. Chemical name, Structures and properties (Identification – physical appearance)
2. Diagnostic or therapeutic indications and Contraindications
3. Mechanisms of action
4. Recommended dose and schedule
5. Administration details
6. ADME (Pharmacokinetics)
7. Adverse (side) effects and Drug Reactions (ADE, ADR, DRP)
8. Costs
9. Advantages
10. Signs and symptoms of overdose
11. Treatment of Toxicities
12. Clinical efficacy
13. Comparative data
14. Clinical data
15. Drug use data
(Advertising material; Drug detailing; Clinical impressions – case history, diagnosis, treatment; Testimonial type reporting; Inventory control; Purchasing information are NOT considered)
5 Purposes of DIS
The main purposes of a Drug Information Service are to: 1. Deal with problems with drug therapy, 2. Develop optimal therapeutic regimens, 3. Keep current on new medical/medication discoveries, 4. Inform other HC professionals of discoveries and 5. Answer any questions that may arise with regard to other aspects of medicine and drug-related therapy.
Major Functions of DIS
The greatest function of a DI Specialist is to obtain and evaluate information from the literature and to make important and/or new information known to HC professionals through a process called dissemination. In a hospital environment, the function of a DIS includes monitor inpatients for potential drug interactions. Many hospital inpatients are prescribed multi-drug therapies. DI Specialists may be able to avert possible interactions and side effects which results in patient safety and also can save time and money for the institution and other HC professionals involved.
Benefits of DIS
DISs promote effective and safe use of drugs in the diagnosis and treatment of disease through careful and informed selection, evaluation and dissemination of drug literature. DISs allow for greater efficiency of professional functions by Pharmacists who specialize in the service. They provide up-to-date information to other HC professionals, arguably "better" patient care, and clinically relevant drug information in response to patient-specific and general requests from health care practitioners, skilled care facilities, and the community at large.
ASHP Guidelines on Provision of Medication Information
The ASHP states that a Pharmacist must be able to: “1. Perceive and evaluate the medication information of patients and families, health care professionals, and other personnel, and
2. Use a systematic approach to address medication information needs by effectively searching, retrieving and evaluating the literature and appropriately communicating and applying the information to the patient care situation.”
(Read the ASHP Guideline document posted on FOL. In particular pay attention to the 12 “Medication Information Activities” and the 9-step “Systematic Method for Responding to Medication Information Needs”)
DI Centres (LonDIS, DIRC)
Most drug information requests occur in the hospital environment where most of the complex medical cases are taking place. Other areas where drug information centre systems may be utilized include: Pharmaceutical companies, Government agencies, Schools, Community pharmacies, and Poison Control Centres (PCCs).
DI Role of the Pharmacist and Pharmacy Technician
The responsibility of answering drug information questions lies solely with the Pharmacist. It is a professional responsibility that CANNOT be delegated to another individual. However, Pharmacy Technicians may be responsible for assisting in auxiliary functions in a DI Service such as typing, filing and cataloging. A Pharmacy Technician working in this role must be familiar with textbooks, handbooks, abstracting services, computer databases, journals, catalogs and filing systems. Duties may involve cataloging books, journals, and specific articles and retrieving pertinent drug information. A skilled DI Pharmacy Technician must be able to maintain accurate statistics on the types and numbers of questions received and references used as well as maintaining up-to-date filing systems for abstracts, newsletters, and correspondence. Others tasks may include: assisting in collating drug usage data, drug utilization studies, adverse reaction reporting and systematically recording and filing telephone and/or Internet requests for drug information.
Request for Information
Immediate drug information on request is a large part of the service provided by all drug information centres. The information may be patient-specific or drug-oriented information.
Patient specific - inquiries ranging from dosage instructions to outlining specific therapeutic regimens Drug-oriented - dosage forms and availability, product identification, and product compatibility
All questions received must be properly documented in writing (or online). Most questions will be received by telephone or via the Internet. A proper procedure for answering the telephone needs to be established to ensure that questions get answered swiftly and fully. Requests should be fully documented with the name and location of the inquirer. A Request for Information Form (paper or online version) provides a mechanism for the collection of data. It is used to keep statistics and evaluate and review the activities of the DI Centre. The form must be utilized each time a request for information is received. Therefore there should be a single form containing a single question so that questions can be catalogued accordingly for future reference.
Poisoning: What is a poison?
A poison is any substance that may be Ingested, Inhaled, Exposed to the eye(s), Exposed to the skin AND can cause sickness or death.
4 Forms of Poisoning
The four forms of poisoning include: 1. Solids (e.g. tablets, capsules, batteries, plants, berries), 2. Liquids (e.g. antitussives, alcohol, antifreeze, mouthwash), 3. Sprays (e.g. inhalers, local anesthetic products, insect repellant which may be absorbed through the skin or through inhalation via the nose/mouth) and 4. Gas or Vapors (e.g. carbon monoxide – CO2).
Poisoning Problem in Canada
It is estimated that over 100,000 poisoning exposures occur each year resulting in approximately 500 deaths. Children under the age of 5 account for 40% of all poisonings. Approximately 40,000 (40%) of all poisonings involve medications. The remaining poisonings are a result of exposure to environmental or household toxins.
Drug Poisoning
Of the 40,000 (approx.) drug poisonings which occur every year in Canada, Prescription drugs account for 35% (14,000), Narcotics and Controlled Drugs account for 7% (2,800), and Non-Prescription Drugs account for the largest portion at 58% (23,200).
Death Due to Poisoning
In young children, the leading cause of death due to poisoning is from consuming Iron tablets or capsules (e.g. ferrous sulfate, ferrous fumarate, ferrous gluconate). A couple of tablets can cause toxic effects and as few as 10 tablets can cause death. Children are often attracted by the bright colours of the tablets.
Non-Prescription Drug Poisoning
As a percent of all non-prescription drugs causing poisoning Acetaminophen accounts for the highest at 13%, ASA is second at 8% followed by Antihistamines at 7%, Vitamins at 4%, Cough and Cold preparations at 2%, Camphor at 1%, and Iron at 0.1%. Although Iron represents a small percentage of overall non-prescription drug poisonings, in children it remains the highest cause of death due to poisoning.
Storage of Poisonous Products
It is best practice to keep medications in the original container. In the workplace, regulations and policies and procedures dictate how and where chemicals and medications are stored (e.g. designated area with signage and/or locks). Laws also state that all medications must be dispense in a child resistant vial unless an adult specifies otherwise. Since most poisonings happen in the home, it is important to get the message out to caregivers, parents and grandparents to keep chemicals and medications in a safe area away from children.
CHECKPOINT Question ONE: Sharing prescription Opioid medications has been identified as an increasing problem in Canada and one which all too often ends in fatality. Read the ISMP Safe Medication Newsletter concerning a patient sharing a fentanyl patch with a friend. Risk factors for narcotic overdose include narcotic naivety and consumption of alcohol. In addition, not all narcotics are created equally meaning very low doses of one narcotic may provide a very heavy sedative affect compared to another. Have a look at this Narcotic Conversion Chart and identify how many mg of hydromorphone given orally per day (in 24 hours) would be equivalent to morphine 15 mg IV given q8h. Check your answer here. How did you do? Compare the equivalent doses of other drugs included in the chart. Why do you think it is important for Pharmacy Technicians to be aware of the differences in dosing between narcotics?