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A Clinical Pharmacist in the Quebec Health System Denise Kalyvas, Bsc. Pharmacy, CCRP Pharmacy Site Manager McGill University Health Centre (MUHC) Montreal General Hospital December 2005 Montreal General Hospital McGill University Health Centre 1 Objectives • To look at past pharmacist roles and compare to the present • Expanding pharmacy technical assistant roles in order for pharmacists to promote clinical pharmacy services • Pharmacy specialization • Roles of Professional Organizations in the recognition of specialization Education • Two University Faculties of Pharmacy in the province of Quebec • University of Laval, University of Montreal • 4 year Baccalaureate program • Masters program (16 month post-graduate course) (29% in the province of Quebec) • Doctor in Pharmacy Degree (Pharm D) (Ontario, British Columbia, United States- 2 years) (19% in Canada) • Residency Specialty Programs (1 year) • University professors and hospital pharmacy 2 Professional Standards of Practice (Canadian Society of Hospital Pharmacists) • Professional Accountability and Continued Competence Each pharmacist is accountable and responsible to the patient and continually acquires competencies relevant to their patients’ needs. • Provision of Quality Services Each pharmacist provides, facilitates and promotes pharmacy services that meet the needs and expectations of the patient and healthcare providers • Evaluation, Application and Provision of Unique Knowledge Each pharmacist evaluates, applies and provides unique knowledge to achieve safe and effective outcomes to enhance practice. Professional Standards of Practice (Canadian Society of Hospital Pharmacists) • Patient Advocate Based on drug related needs, each pharmacist acts as an advocate for: – Their patient and patient groups – Continuous improvement in pharmacy practice within the institution – Continuous improvement in the overall healthcare system • Educator Each pharmacist promotes safe, effective and efficient use of drugs through the provision of education to patients, pharmacists and other healthcare providers. 3 Pharmaceutical services is composed of five major components • • • • • Drug distribution Education Research Management Clinical pharmacy Pharmacists’ practice and medication error • Centralized pharmacy – number of medication error were 3.15 per occupied bed • Centralized pharmacy but occasional floor visits – 1.93 error per occupied bed • Decentralized pharmacy generally on floor- 1.74 error per occupied bed • Decentralizing pharmacists decreased errors by 45% 4 Medication Errors in Health Institutions Observations Bond & al. Pharmacotherapy 2002;22(2) Priority and services Level of Clinical Services • • • • • • • • • • Drug histories upon admission Pharmacist participation in medical rounds Reporting of adverse drug reactions Drug Information Drug Therapy Monitoring and evaluation Pharmacy and Therapeutic Committee Patient counseling In-service Education Discharge prescription Total parenteral Nutrition Participation 5 Factors allowing the promotion of clinical services • • • • • Information Systems Computer Physician Order Entry (COPE) Pharmacy Technician Involvement Computer order entry Screening of phone calls (direct pharmacist line for medical staff if needed) – Automation and robotization – Direct Verification of Contenant-contenu (DVCC) Clinical pharmacists have a positive impact on: • Making a favorable choice in treatment based on evidence in scientific literature • Help a patient get a better therapeutic response from the treatment chosen for him/her • Help in reducing the cost of treatment for the hospital, the community and the patient • Help in increasing patient compliance to their treatment • Increase the level of satisfaction of the clientele and staff • Increase the scientific knowledge and of practice of other medical staff and of patients 6 Clinical pharmacists have a positive impact on: • • • • • Minimize patient’s hospital stay Minimize the risk of side effects in patients Minimize the risk of medication errors in patients Minimize the risk of morbidity and mortality in patients Decrease nursing’s and physician’s workload by improving the management and organization of patient’s pharmacotherapy • Teach students and pharmacy residents • Ensure seamless care (from hospital to the community) Law 90- Quebec legislation- June 2002 Dream or Reality ?? Objective: Assures the protection of the public Recognizes the multidisciplinary acts among medical professions • 11 professionals affected • Physicians, nurses and auxiliary nurses, pharmacists, respiratory therapists, physiotherapists, radiology technicians, medical technicians, nutritionists, orthophonists, audiologists and ergo therapists 7 Law 90- Quebec legislation- June 2002 • Physicians- treats disease and prescribes medications • Nurses- administer nursing care and medical treatment • Assistant nurses or nurses aide- administer nursing care and medical treatment up to the point that is allowed by their professional organization (Ordre des infirmiers) • Pharmacists – Evaluate and assure proper usage of medications (prepare, store and distribute medications) without a medical prescription. – Allows pharmacist to initiate or adjust drug therapy for a particular patient – COU Contraception Orale d’Urgence (morning after pill) Law 90- Quebec legislation- June 2002 • Reserved act- Associated to a health professional within their field of practice – Specific to one patient (for example nurse triage patient in emergency room) • Collective order for a specific indication/clinical condition - must refer to a protocol • Nurse only for patients under her direct care • Pharmacist-Can be for any patient- not only for a specific patient 8 MRC 0119 10 2003 intranet:200-2.1 MGH PROTOCOLE D’HÉPARINE – HGM HEPARIN PROTOCOL- MGH Heparin Protocol CAUTION: PTT target ranges are hospital- specific and therefore may be different at the RVH Patient’s ACTUAL Weight: __________ kg 1. NO intramuscular injections. 2. Discontinue Low-Molecular-Weight Heparins at least 12 hours before starting heparin infusion. 3. Discontinue NSAIDs before starting heparin (ibuprofen, naproxen, indomethacine, ketorolac) 4. Laboratory Tests: Check CBC & PT/PTT/INR before beginning infusion, 6 hours after beginning infusion and 6 hours after each change in rate & once daily as long as the PTT remains within the target range. 5. Concomitant ASA, clopidogrel or warfarin orders must be written on a regular prescription form. 6. DO NOT GIVE Heparin IV BOLUS either at initiation of heparin or subsequently if patient in the immediate post-op period (24h) or if LMWH received within previous 12 hours: Initial Bolus: YES ________ MD INIT NO INITIAL BOLUS ________ MD INIT Subsequent bolus as per nomogram: YES ________ MD INIT NO SUBSEQUENT BOLUS ________ MD INIT *****SELECT ONLY ONE OF THE FOLLOWING NOMOGRAMS - MD must cross out unused nomogram REGULAR DOSE HEPARIN NOMOGRAM _______ MD INIT Indications: Deep Vein Thrombosis, Pulmonary Embolism Initiation of Heparin Therapy 25,000 Units of Heparin in 250 mL D5W (100 Units/mL) Actual Weight (kg) 40-50 51-60 61-70 71-80 81-90 91-100 101-110 111-120 > 121 Bolus (U) (~80 U/Kg) 3,500 4,500 5,000 6,000 7,000 7,500 8,500 9,000 10,000 Infusion (U/h) (~18 U/Kg/h) 800 1000 1200 1400 1500 1600 1800 1900 2000 Infusion (mL/h) 8 10 12 14 15 16 18 19 20 Maintenance of Heparin Therapy 25,000 Units Heparin in 250 mL D5W (100 Units/mL) Bolus (U) Stop Infusion Change in maintenance Infusion (U/h) Change in maintenance Infusion (ml/h) Bolus as specified No by 400 by 4 above 0 No by 300 by 3 0 No No change No change 0 Hold X 1 hour by 100 by 1 0 Hold X 2 hours by 200 by 2 0 Hold X 2 hours by 300 by 3 HOLD HEPARIN, CALL MD < 60 61-84 85-135 136-150 151-170 171-200 > 200 40-50 51-60 61-70 71-80 Bolus (U) (~60 U/Kg) Max:4,000 U 2,500 3,500 4,000 4,000 >80 4,000 Actual Weight (kg) Infusion (U/h) (~12 U/Kg/h) Max: 1,000 U/h 550 650 800 900 1,000 Infusion(mL/h) 5.5 6.5 8 9 10 PTT target range 65-115 sec. PTT target range : 85-135 sec. PTT (sec) LOW-DOSE HEPARIN NOMOGRAM ______ MD INIT Indications: Myocardial Infarction (with or without thrombolytics), Acute Coronary Syndrome (with or without GP 2b/3a), Atrial Fibrillation if indicated, Post-op anticoagulation Initiation of Heparin Therapy 25,000 Units of Heparin in 250 mL D5W (100 Units/mL) Maintenance of Heparin Therapy 25,000 Units Heparin in 250 mL D5W (100 Units/mL) PTT (sec) < 51 51-64 65-115 116-130 131-150 151-170 > 170 Bolus (U) Stop Infusion Change in maintenance Infusion (U/h) Change in maintenance Infusion (ml/h) Bolus as specified No by 400 by 4 above 0 No by 300 by 3 0 No No change No change 0 Hold X 1 hour by 100 by 1 0 Hold X 2 hours by 200 by 2 0 Hold X 2 hours by 300 by 3 HOLD HEPARIN, CALL MD NOTIFY MD WHEN: • Significant bleeding. Hold Heparin ! • Platelet count < 100 000 • Patient requires more than one (1) bolus per 24h during the maintenance therapy. • Heparin infusion is stopped for an undetermined amount of time. Centre universitaire de santé McGill McGill University Health Centre Draw APTT immediately. Hôpital général de Montréal Montreal General Hospital Prescription Médicale/ Medical Prescription Protocole pour le traitement ambulatoire de la thrombose veineuse profonde Protocol for the Ambulatory Treatment of Deep Vein Thrombosis. Formule/Form #3 DVT Protocol Allergies/Allergies: ___________________________________ Diagnostic: _____________________________________ Ordonnance pour l’Urgence, jour #1 / Orders for the Emergency Department, Day #1 = (date): ________________ 1. RIN (INR), apt, FSC (CBC), BUN/Créat. (tous les patients/all patients) 2. ou/or Entre/Between 8:00-18:00 Tinzaparin 175 unités X ______ poids réel/actual Wt (Kg) = ______ unités S.C. X 1 Entre/Between 18:00-24:00 Tinzaparin 87.5 unités X _____ poids réel/Actual Wt (Kg) = ______ unités S.C. X 1 3. Warfarin ___________ mg PO ce soir/tonight Dose initiale 7.5mg pour patients < 70 ans Dose initiale 5 mg pour patients de 70 ans ou plus ou < 50 kg ou souffrant de malnutrition ou prenant un médicament ayant une interaction avec le Warfarin (consulter le pharmacien) Initial dose of 7.5 mg for patients < 70 years of age Initial dose of 5 mg for patients 70 years of age or more or < 50 kg or malnourished or taking medication with known interactions with Warfarin (Consult the Pharmacist) 4. Cesser toute perfusion d’héparine après la dose de Tinzaparine / Stop Heparin IV infusion after Tinzaparin dose given **JOURS/DAYS #2-3-4-5-6 (SVP écrire dates/Please write dates): ___________________________________________ Ordonnance pour la pharmacie communautaire/Orders for the Community Pharmacy: _________________________ 1. Tinzaparin 175 unités/Kg : _________ unités S.C. QAM X 5 jours (20 000 unités/ml) Mitte : 5 jours/days 2. Warfarin 5 mg tablets tel que prescrit/As directed Mitte : 30 NR 3. Autres Rx/Other meds : REP#1 SVP cesser/Please discontinue : 4. Ordonnance pour le CLSC/Orders for CLSC: ____________________________________________________________ 1. SVP voir le patient avant 10:00 / Please arrange to see the patient before 10:00 Évaluer les signes et symptômes d’hémorragie et/ou d’embolie pulmonaire pour 6 jours (voir formule #5) Assess patient for signs of hemorrhage and/or pulmonary embolism daily for 6 days (see Form #5) 2. Tests sanguins : RIN tous les jours jusqu’à l’obtention des résultats entre 2 et 3 pour 2 jours consécutifs FSC jours #3 et #6 Répéter FSC et RIN jour #11 ou #12 Blood Tests : INR daily until results between 2 and 3 attained for 2 consecutive days CBC on days #3 and #6 Repeat INR and CBC on days #11 or #12 Autres/Others: __________________________________________________________________________________ 3. Tinzaparin S.C. injection QAM X 5 jours/days ou jusqu’à RIN entre 2-3 X 2 jours/or until INR between 2-3 for 2 days SI LE LABORATOIRE N’EST PAS CELUI DE L’HGM OU DE L’HRV, SVP ENVOYER LES RÉSULTATS DES TESTS À LA PHARMACIE DE L’HÔPITAL GÉNÉRAL DE MONTRÉAL CHAQUE JOUR AVANT 14:00 fax : 934-8582 ou Tél. : 934-1934 poste 42767 OU À LA CLINIQUE DE MÉDECINE INTERNE DE L’HÔPITAL ROYAL VICTORIA fax : 843-1582 Tél. : 934-1934 poste 34939 M.D. Signature : ____________________________________ Lic. : _____________________ Date : _________________ 9 Hôpital général de Montréal The Montreal General Hospital Prescription médicale/Medical Prescription Formule/form #4 NOMOGRAMME POUR LE DOSAGE DE WARFARIN / WARFARIN DOSING NOMOGRAM Allergies : _______________________________________________ Patient poids/weight : _______ Kg DVT Protocol . 2. 3. Discontinuer toutes les ordonnances de Warfarin précédentes/Discontinue all previous Warfarin orders. Avant de débuter le Warfarin vérifier/Before starting Warfarin check : RIN (INR), aPTT, FSC (CBC), BUN/Créat. Stop all ASA, NSAIDs or I.M. injections. (Sauf si le médecin spécifie le contraire/Unless specifically ordered otherwise by Physician) WARFARIN 4. Indication pour/for Warfarin : ____________________________________________ 5. Le pharmacien ajustera la dose de Warfarin selon le nomogramme ci-bas jusqu’à l’obtention d’un RIN thérapeutique entre 2 et 3 / The Pharmacist will adjust and order daily Warfarin dose according to nomogram to obtain a therapeutic INR of 2-3. Certains ajustements ne pourront être faits à l’aide du nomogramme. Dans ce cas, le dosage sera individualisé selon le patient / Some patient requirements may not correspond to the nomogram. Patient specific dosing may be necessary. Jour/Day 1 Jour/Day 2 Pour les patients <70 ans For patients <70 years of age Warfarin 7.5 mg Pour les patients de 70 ans et plus OU mal nourrit OU de moins de 50 Kg OU prenant des médicaments ayant une interaction avec la Warfarine For patients 70 years of age or more OR malnourished OR weighing under 50 Kg OR taking medication with known interactions with Warfarin Warfarin 5 mg INR < 1.3 1.3 – 1.5 1.6 – 2.0 > 2.0 WARFARIN DOSE (mg) 7.5 5 2.5 0 Jour/Day 3 < 1.3 1.3 – 1.5 1.6 – 1.9 2.0 – 2.5 > 2.5 10 7.5 5 2.5 0 Jour/Day 4 < 1.3 1.3 – 1.5 1.6 – 1.9 2.0 – 2.5 2.6 – 3.0 > 3.0 12.5 10 7.5 5 2.5 0 Jour/Day 5+ < 1.5 1.6 – 1.8 1.9 – 2.1 2.2 – 2.7 2.8 – 3.0 > 3.0 12.5 10 7.5 5 2.5 0 Au moindre signe de saignement avec un RNI > 6 ou bien d’hémorragie indépendamment du RNI, appeler le médecin STAT!! At any sign of bleeding with an INR > 6 or of hemorrhage with any INR, call Physician STAT!! M.D. signature: _____________________________________ Lic #: _________________ Date: _______________________ MD Nom/Name (en toutes letters/Please print) : _____________________________________________________________ Law 90- Quebec legislation- June 2002 • Pre printed orders • Intensive care according to specific protocol (insulin, post cardiac surgery) • Oncology- approved protocol by disease state • (Approved by pharmacy and therapeutics committee and CPDP) 10 PROTOCOL: Doxorubicin/Cyclophosphamide x 4 cycles Followed by Paclitaxel x 4 cycles in Adjuvant Treatment of Breast Cancer q3week cycle CODE: BRADJACT(T) – Paclitaxel portion MGH RVH Cycle # ___/4 Pre-printed oncology order MNH Allergies (with reaction): Height(cm): Treatment Date (YY/MM/DD): MD Weight(kg): BSA (Body Surface Area) m RN & time (00:00) Medical Orders 2 PH Parameters - To be given IF within the last 24 hours 9 ANC (absolute neutrophil count) ≥ 1.5 x 10 /L or 9 Platelets ≥ 100 x 10 /L or Other(s): Hydration NS for Primary I.V. Line to KVO via non-PVC or polyethylene-lined filtered tubing set. Pre-Treatment 30 minutes prior to Paclitaxel- Give Dexamethasone 20 mg IV in 50 ml NS over 15 minutes 30-60 minutes prior to Paclitaxel- Give Diphenydramine 50 mg IV + Famotidine 20 mg IV via Y-site over 30 minutes Treatment – Prescribed in order of administration Monitor patient’s vital signs first 15 minutes of infusion 2 2 Paclitaxel 175 mg/m or _________X BSA (m ) = ________ mg IV in 500 ml NS (non PVC bag) over 3 hours. • Use non-PVC equipment and in-line filter • If dose of paclitaxel < 150 mg dilute in 250 ml NS Excel. Treatment of Paclitaxel Hypersensitivity Reaction For Moderate and Severe symptoms- Stop Paclitaxel Infusion, call MD and give: Diphenhydramine 25-50 mg IV (circle desired dose) Methylprednisolone 125 mg IV x 1 or Hydrocortisone 100 mg IV x 1 Post-Treatment - Outpatient prescription reviewed by Nurse & Pharmacist Prochloperazine 10 mg PO/PR q4h PRN For arthralgias: Acetaminophen/Codeine 30 mg (Empracet) 1-2 tablets q4-6h PRN – sig: 30 tablets If not relieved with above: Prednisone 10 mg PO BID x 5 days- to begin 24h after paclitaxel infusion – sig: 10 doses Other (s): Initial Signature Rx prescribed by (MD): Licence No. Date(YY/MM/DD): Time (00:00) Rx screened/validated by (PH): Rx prepared by (PH): Rx administered by (RN) initial & signature Rx administered by (RN) initial & signature Pharmacy Specialization • National association of Pharmacy Regulatory Authorities (NAPRA) in 2002 • Supported the recognition of specialties in pharmacy • Three provinces – British Columbia, Alberta and Quebec working groups have been set up by professional organizations to consider the advisability to recognize specialties in pharmacy • Recognition of specialization will promote optimum use of pharmacists’ services 11 Where do we go from here??? Ice Storm - 1998 12