Transcript Pharmacist Assisted Warfarin Dosing Program

Innovative Pharmacy Practices:
Pharmacist Prescribing
Cynthia Jackevicius, B.Sc.Phm., M.Sc., FCSHP
Pharmacy Practice Leader, Heart & Circulation Program
Associate, Women’s Health Program,
University Health Network
Assistant Professor, Faculty of Medicine & Pharmacy, U of Toronto
Adjunct Scientist, Institute for Clinical Evaluative Sciences
December 2002
Developing Innovative
Practices
 specific
activities
– warfarin dosing
– monitoring drug therapy
– total parenteral nutrition
 practice
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–
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–
sites
Heart Function Clinic
Thrombosis Treatment Program
Secondary Prevention Clinic
Emergency Department
What is prescribing?
 To
designate in writing a remedy for
administration
 Several related and complex steps
– decide to initiate therapy
 selection
 prescription
 monitoring
 modification
– decision to cease therapy
Who Prescribes?
 Physicians
 Nurse
practitioners
 Expanded role nurses
 Clinical nurse specialists
 Midwives
 Optometrists
 What about pharmacists?
Examples of Pharmacist Prescribing
Therapeutic
interchange
 Non-prescription Rx
 Aminoglycoside
dosing
 Vancomycin dosing
 TPN
 Insulin dosing

Renal dosing
program
 HTN clinics
 Lipid clinics
 Refill clinics
 Warfarin dosing
 Cancer-related pain
and antiemetic
management

CSHP Survey
 Therapeutic
interchange-intervals
 Order clarifications
 Modify non-Rx medications
 Pharmacokinetics
 Routine labs
 Pain service
70.6%
55.0%
39.4%
29.8%
23.0%
20.7%
Types of Prescribing Models
 Independent
 Dependent
 Collaborative
Independent Prescribing
Prescribing practitioner is solely responsible
for patient outcomes
 Must possess legally defined levels of
knowledge and skills to diagnose conditions

– e.g., physician licensing process

Most Cdn pharmacy schools do not teach
diagnostic and physical assessment skills
required to practice at this level
– not required skills for pharmacist licensure
Dependent Prescribing
 Delegation
of authority from an
independent prescribing professional
 Shared responsibility for patient
outcomes
 formal agreement usually containing:
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–
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written guidelines or protocols
description of responsibilities
description of documentation
policies for review and revision
Types of Dependent Prescribing
 By
protocol - most common
– specific diseases, drugs, drug categories
 According
to formulary
– delegation of prescribing for a limited list of
medications
– less explicit than by protocol
 By
patient referral
– common in ambulatory practices
Collaborative Prescribing
 Cooperative
practice relationship
between a pharmacist and a physician or
practice group with legal authority to
prescribe
 not same as protocols since do not dictate
the specific pharmacist activities
Collaborative Prescribing
 “Ideal”
model:
– physician diagnoses and makes initial
treatment decisions
– pharmacist selects, initiates, monitors,
modifies, continues and discontinues therapy
as appropriate to achieve desired patient
outcomes
 Both
share in responsibility and risk
CSHP Statement
CSHP advocates the role of pharmacists as
capable prescribers and supports the
pharmacists’ role in a collaborative
prescribing model to improve patient
health outcomes and increase the
successful and efficient delivery of
pharmaceutical care.
Core elements for collaborative prescribing
 Support
from prescriber groups
 Written declaration - contractual
understanding
 Explicit prescribing activities
 Clear definition of scope of practice
 When to contact physician
 Procedures for documentation
 Time limit - review, quality assurance
The Plan…..
 rationale
for the service
 support from other departments
– teamwork is imperative
 supportive
literature, if available
 pilot test the service
 evaluate the benefits
 make necessary revisions
 continue to justify the service
Potential Benefits
 process
“outcomes” vs outcome
“outcomes”
 structure, process and outcome
 “hard” vs “soft” outcomes
 clinical outcomes
 financial outcomes
Prescribing Statements
Canadian Society of Hospital Pharmacists
(CSHP)
 American College of Clinical Pharmacy
(ACCP)
 American Society of Health-System
Pharmacists (ASHP)
 Canadian Pharmacists’ Association (CPhA)
 National Association of Pharmacy Regulatory
Authorities (NAPRA)

Monitoring Drug Therapy
Monitoring Drug Therapy
 Role
of the pharmacist
– monitor drug therapy
– prevent drug related adverse events
– ensure accurate dosing for clinical efficacy
 Sources
of monitoring parameters
– patient
– written chart
– electronic chart
Coumadin
 Pharmacist Assisted
Warfarin Dosing
Program (PAWD)
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Delegated Medical Act
Approved for use in the Cardiac Program
Pharmacists certification and CQI
Daily dosing by protocol according to INR
20
Coumadin
 Issue:
– INRs are not ordered routinely and
information is not available for daily dosing.
– Nurses have been ordering INR test as
requested by the pharmacists but will no
longer be doing this.
 Request
to CDS Committee
– Pharmacists be granted authorization to
order INR test for patients on PAWD
Program.
Heparin- LMWH

Current hospital guidelines suggest to contact
the pharmacists for difficult to dose patients
(i.e. renal and obese patients).
– Requires anti-Xa levels
– Physicians are unfamiliar with ordering anti-Xa
levels

Improper timing can lead to inappropriate
dosing changes.
Timing of Anti-Xa levels in Renal
Patients
Anti Xa Levels in Renal Patients with q12h Dosing
1.8
1.6
Anti Xa Level
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
0
5
10
15
20
Hours between dose and post level
25
30
Amiodarone

Amiodarone can have significant long term
toxicity.
– Hepatic/ thyroid/ pulmonary toxicity
Baseline function tests are required when
initiating patients on amiodarone therapy.
 This practice is not occurring, particularly for
thyroid function

– 5/26 (19%) patients had TSH done
– often delayed up to 7 days after initiating therapy
Aminoglycosides

UHN aminoglycoside guidelines require:
– baseline Serum Creatinine prior to initiation of
therapy and 3 times per week while on active
therapy
– 24 hour trough levels for patients on 7 days or more
of aminoglycosides

Pharmacists have been granted authorization
to order the levels and SrCr but not the access
to do so electronically.

(P&T and MAC February/April 1997)
Vancomycin
Baseline serum creatinine is required for initial
dosing and ongoing monitoring.
 In select patients vancomycin trough levels are
required to monitor for efficacy and /or drug
accumulation.
 Pharmacists are often asked to provide
consultations regarding vancomycin dosing.
This often requires the ordering of SrCr and
vancomycin levels.
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SUMMARY

Request authorization for pharmacists to order
the following tests:
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INR
anti-Xa
TSH and LFT’s
Serum Creatinine
aminoglycoside trough levels
vancomycin trough levels
Approved by UHN Clinical Decision Support
Conclusion
 Pharmacist
prescribing occurs widely in
hospital/institutional practice
 Many opportunities exist for improving
patient care with pharmacist prescribing
 Pharmacy practice is evolving to
encompass prescribing responsibilities
 Useful tools are available to assist
pharmacists with implementation (e.g.,
CSHP)