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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

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