1、美国临床药师的临床实践管见,第十一届中国临床药师论坛 陆芸,内容提要,美国医院从事药学技术工作的分类,配置的,比例和职责。 美国的住院药师(在临床工作的,相当国内的临床药师)如何参与临床药物治疗工作,保证患者用药安全、合理用药的;制度、资质、工作流程、绩效、酬报等,有无书面的文书,如药历等。 美国的住院药师在用药安全、合理方面做出的成绩,课题,数据等。,美国临床药师资质,本科 药学管理硕士 药学博士 住院药师训练 专业证书 (Board of Pharmacotherapy) Board Certified Pharmacotherapy Specialist Board Certified
2、Oncology Specialist Board Cerfitified Ambulatory Care Specialist Board Certified Nutrition Support Specialist Board Cerfitifed Pediatric Specialist Board Certified Infectious Disease Specialist,美国临床药师分类,政府机关 教学机构 保险公司 医药公司的药物信息部 医院住院部 门诊 (独立门诊和医院门诊) 药店 (独立或连锁),医院临床药师分类职能,住院部 中心药房 普通病房 专科病房 (ICU, 各个专
3、科- 心脏,肾脏,儿科,肿瘤,流行病,心理精神) 门诊部 内科和家庭医生门诊 各个专科,推广临床药师的数据,五个花钱最多的病症糖尿病、心衰、高血压、高血脂、肺气肿五个返诊率最高的疾病心肌梗死、心衰、肾衰、呼吸系统疾病、精神病五个门诊病人最集中的科室心脑血管疾病、肿瘤、糖尿病、关节炎、肥胖,2010 Disease Targets,Gregory Dill, Centers for Medicare & Medicaid Services, Region V Associate Regional Administrator for Financial Management and Fee-for
4、-Service Operations,2010 Multiple Chronic Diseases,“Sponsors cannot require more than 3 chronic diseases as the minimum number of multiple chronic diseases” and “sponsors must target at least four of the seven core chronic conditions:” Hypertension Heart Failure Diabetes Dyslipidemia Respiratory Dis
5、eases (Asthma, COPD, Chronic Lung disorders) Bone Disease-Arthritis (Osteoporosis, RA, OA) Mental Health issues (Depression, Schizophrenia, Bipolar Disorder, others),Gregory Dill, Centers for Medicare & Medicaid Services, Region V Associate Regional Administrator for Financial Management and Fee-for
6、-Service Operations,Hennepin County Medical Center 药师配置,465 张病床 药房管理人员- 全职:主任,住院部经理,临床药学部经理,门诊部经理,特种药房经理,用药安全经理 兼职:药物治疗学经理,住院药师经理,药学博士生经理, 中心药房 临床药师 普通病房 专科病房 门诊药师 普通门诊 专科门诊 住院药学博士 技术员 药学院学生,临床药师参与医院工作介绍,临床用药安全经理-用药安全 医院用药安全决策 (院办,临床药物治疗) 领导各级用药安全委员会 (用药安全,医疗事故,临床药学,护理) 临床药物治疗经理- 合理用药 药物种类 药物使用分析 临床
7、用药政策,临床药师在用药安全上对医疗体系的影响,患者出院药学查房案例分析,(危机)挑战,In 2007, multiple untoward events occurred to patients discharged to nursing homes Complaints from nursing home patients about confusing discharge orders Augustana nursing home Benedictine health care system Transplant clinic Outpatient dialysis unit Exten
8、ded care,追根溯源,One unit with one team over 12 weeks Document medical record number, number of medications, time spent Errors were reported in HCMCs event reporting system and tracked by the medication safety committee,追根溯源,Reviewed 37 patients discharged to SNF 17 discharge meds per patient Averaging
9、 about 20 minutes per patient, plus additional communication time with the team members, mostly physicians,追根溯源,Investigation confirms existing problem Of the 37 patients, only 3 (8%) were error-free Common themes noted: Formulation errors (extended release etc) Inappropriate duplicates Incorrect do
10、ses (e.g. antibiotic at half dose, anticoagulant at double the dose) Missing medications (e.g. missed BP med) Insulin dosing errors (missing ss, duplicate orders, etc),问题在哪里?,Multiple resident physicians taking care of one patient Physicians do not have enough time for discharge paper work Missing c
11、oordination at discharge The existing EMR processes allowed for errors. Note: Med Rec was completed 90+% of the time,相关文献,Discharge errors often resulted in readmissions to the hospital1-3 Medication errors interfere with the patients confidence in their medical services41.Gillespie U, Alassaad A, H
12、enrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894-900. 2.Koehler BE, Richter KM, Youngblood L, et al. Reduction of 30-day post-discharge hospital readmission or emergency departm
13、ent (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211-218. 3.Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cl
14、uster-randomized trial. Arch Intern Med. 2009;169(8):771-780. 4. Burroughs TE, Waterman AD, Gallagher TH, et al. Patients concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf. 2007 Jan;33(1):5-14.,减少患者再次入院率,One out of five patients discharged from a US hospital will be re
15、admitted in 30 days 17.4 billion (out of 102.6 billion, 17%) of Medicare annual cost,Jencks, SF, Williams, MV, Coleman, EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009; 360:1418-1428.,行动方案,Reported to the hospital executive committee Presented a solut
16、ion Collaborated with a multidisciplinary team Medication safety manager,执行方案,Take the advantage of new technology,PDSA Model,Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Josse
17、y-Bass Publishers; 2009: 23-24,Failure Modes and Effects Analysis (FMEA),Identify patient discharging to SNF at rounds Social Worker (SW) obtains bed and immediately pages Clinical Coordinator (CC), MD, and PharmD MD has 4 hours within which to write the discharge orders. If notified after 2:00 p.m.
18、, MD must have orders except I/P discharge in before 8:00 a.m. the next day. CC scans orders hourly and pages PharmD,FMEA Process,PharmD and CC have 2 hours within which to complete review: PharmD reviews medication orders. If issue, pages MD to reconcile. If OK, so notes: Marks as reviewed in Med R
19、ec screen CC reviews other orders. If issue, pages MD to reconcile. CC checks for I/P discharge; notifies bedside nurse and PSC when orders completed,方案实施,Individual 1-1 communication by PharmD to ordering resident and RN coordinator. Communication sent to all attending physicians, noting that they
20、are accountable to review residents discharge orders and will be notified if errors are found by pharmacists.,多边合作,再检查,PharmD reports errors (near miss) using event reporting process Notified PM&I of this risk Notified Patient Care V.P.s Report to Executive Leadership Team,临床药学的大规模推广和应用,MD Discharge
21、 Orders,PharmD and CC Review,SNF,With EPIC update, Error rate without review- 70% of discharges,Error rate after review- 0%,病情危重与再入院率的关系,Horn, SD et al. Severity of Illness within DRGs:Impact on prospective payment. Am J Public Health. 1985; 75, 1195-9,患者再入院率,临床药学对医疗质量的影响,Physicians request it to be
22、 applied to all our patients Improved patient satisfaction Improved customer service Reduced readmission rate by 47% (5.7% vs 10.2%),经济分析,HCMC has approximately 1850 SNF discharges per year; with each patient, medication reconciliation takes on average 24 minutes in mind, this equivalent to 700 hour
23、s clinical pharmacy time annually. Pharmacists to help with medication reconciliation in the emergency room Medication safety manager,药事管理,Cost to increase staffing $ 112,000 Reduction in expenses $ 587,000 (Reduced Readmissions by 47%) The US payment system is in transition from a fee for service t
24、o pay for performance. Improved Quality for the Patient,Institute for Safe Medication Practices 2010 Cheers Award,The Joint Commission National Patient Safety Goals 国家认证,“ the NPSG on reconciling medication information (originally NPSG.08.01.01, but now NPSG.03.06.01) was streamlined and focused to
25、place a spotlight on critical risk points in the medication reconciliation process. NPSG.03.06.01 is effective July 1, 2011”.,http:/www.jointcommission.org/assets/1/18/National_Patient_Safety_Goals_6_3_111.PDF,小结,Need for a change - Identify the problem Means for a change- Executive committee (budge
26、t and support)- Action plan and modification (PDSA) Team for a change- multidisciplinary team (MD, RN, RPh Social Service and clinical clerks),临床药学小结,Clinical Pharmacists involvement in a team based model Real time feedback Empowering frontline staff to suggest and enact solutions Standardizing work
27、 and processes,广而告之,ISMP- Canada NCPDP NAPH IHI NQF CMS AJHP,Lu Y. Clifford P, Bjorneby A, Thompson B, Van Norman S, Won K, Larsen K, Quality Improvement Case Study: Discharge Order Reconciliation for Skilled Nursing Facility Discharges in a Safety Net Teaching Hospital. Am J Health-Syst Pharm, (in press).,美国临床药师对临床药学影响,数据 政策 其他行业支持 医生 护士 医助 高级护师,为中国临床药学进言,天时地利人和 国家政策引领,专家进言 星星之火可以燎原 重点突出,以点带面,