美国临床药师临床实践管见课件

美国美国临床床药师临床床实践管践管见美国临床药师临床实践管见美国临床药师临床实践管见美国临床药师1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。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。2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 SpecialistBoard Certified Oncology SpecialistBoard Cerfitified Ambulatory Care SpecialistBoard Certified Nutrition Support SpecialistBoard Cerfitifed Pediatric SpecialistBoard Certified Infectious Disease Specialist美国临床药师资质本科3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）美国临床药师分类政府机关4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医院临床药师分类职能住院部5推广临床药师的数据五个花钱追多的病症五个返诊率最高的疾病五个门诊病人最集中的科室推广临床药师的数据五个花钱追多的病症62010 Disease TargetsGregoryDill,CentersforMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperations2010DiseaseTargetsGregoryD72010 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:”HypertensionHeart FailureDiabetesDyslipidemiaRespiratory Diseases(Asthma,COPD,Chronic Lung disorders)Bone Disease-Arthritis(Osteoporosis,RA,OA)Mental Health issues(Depression,Schizophrenia,Bipolar Disorder,others)GregoryDill,CentersforMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperations2010MultipleChronicDiseases8 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HennepinCountyMedicalCente9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用药政策临床药师参与医院工作介绍临床用药安全经理-用药安全10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11（危机）挑战In 2007,multiple untoward events occurred to patients discharged to nursing homesComplaints from nursing home patients about confusing discharge ordersAugustana nursing homeBenedictine health care systemTransplant clinicOutpatient dialysis unitExtended care12（危机）挑战In2007,multipleuntowa追根溯源One unit with one team over 12 weeksDocument medical record number,number of medications,time spentErrors were reported in HCMCs event reporting system and tracked by the medication safety committee13追根溯源Oneunitwithoneteamove追根溯源Reviewed 37 patients discharged to SNF17 discharge meds per patientAveraging about 20 minutes per patient,plus additional communication time with the team members,mostly physicians追根溯源Reviewed37patientsdisch14追根溯源Investigation confirms existing problemOf the 37 patients,only 3(8%)were error-freeCommon themes noted:Formulation errors(extended release etc)Inappropriate duplicatesIncorrect doses(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)15追根溯源Investigationconfirmsexi问题在哪里？问题在哪里？MultipleresidentphysicianstakingcareofonepatientPhysiciansdonothaveenoughtimefordischargepaperworkMissingcoordinationatdischargeTheexistingEMRprocessesallowedforerrors.Note:MedRecwascompleted90+%ofthetime问题在哪里？Multipleresidentphysic16相关文献Dischargeerrorsoftenresultedinreadmissionstothehospital1-3Medicationerrorsinterferewiththepatientsconfidenceintheirmedicalservices41.GillespieU,AlassaadA,HenrohnD,etal.Acomprehensivepharmacistinterventiontoreducemorbidityinpatients80yearsorolder:arandomizedcontrolledtrial.ArchInternMed.2009;169(9):894-900.2.KoehlerBE,RichterKM,YoungbloodL,etal.Reductionof30-daypost-dischargehospitalreadmissionoremergencydepartment(ED)visitratesinhigh-riskelderlymedicalpatientsthroughdeliveryofatargetedcarebundle.JHospMed.2009;4(4):211-218.3.SchnipperJL,HamannC,NdumeleCD,etal.Effectofanelectronicmedicationreconciliationapplicationandprocessredesignonpotentialadversedrugevents:acluster-randomizedtrial.ArchInternMed.2009;169(8):771-780.4.BurroughsTE,WatermanAD,GallagherTH,etal.Patientsconcernsaboutmedicalerrorsduringhospitalization.JtCommJQualPatientSaf.2007Jan;33(1):5-14.相关文献Dischargeerrorsoftenres17减少患者再次入院率One out of five patients discharged from a US hospital will be readmitted in 30 days17.4 billion(out of 102.6 billion,17%)of Medicare annual cost Jencks,SF,Williams,MV,Coleman,EA.RehospitalizationsamongPatientsintheMedicareFee-for-ServiceProgram.NEnglJMed2009;360:1418-1428.减少患者再次入院率Oneoutoffivepatie18行动方案Reported to the hospital executive committee Presented a solutionCollaborated with a multidisciplinary teamMedication safety manager行动方案Reportedtothehospitale19执行方案Take the advantage of new technology执行方案Taketheadvantageofnew20PDSA ModelLangleyGL,NolanKM,NolanTW,NormanCL,ProvostLP.TheImprovementGuide:APracticalApproachtoEnhancingOrganizationalPerformance(2ndedition).SanFrancisco:Jossey-BassPublishers;2009:23-24PDSAModelLangleyGL,NolanKM21Failure Modes and Effects Analysis(FMEA)Identify patient discharging to SNF at roundsSocial Worker(SW)obtains bed and immediately pages Clinical Coordinator(CC),MD,and PharmDMD has 4 hours within which to write the discharge orders.If notified after 2:00 p.m.,MD must have orders except I/P discharge in before 8:00 a.m.the next day.CC scans orders hourly and pages PharmD22FailureModesandEffectsAnaFMEA 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 Rec screenCC reviews other orders.If issue,pages MD to reconcile.CC checks for I/P discharge;notifies bedside nurse and PSC when orders completed 23FMEAProcessPharmDandCChav方案实施方案实施Individual1-1communicationbyPharmDtoorderingresidentandRNcoordinator.Communicationsenttoallattendingphysicians,notingthattheyareaccountabletoreviewresidentsdischargeordersandwillbenotifiediferrorsarefoundbypharmacists.方案实施Individual1-1communicati24多边合作多边合作25再检查PharmDreportserrors(nearmiss)usingeventreportingprocessNotifiedPM&IofthisriskNotifiedPatientCareV.P.sReporttoExecutiveLeadershipTeam再检查PharmDreportserrors(near26临床药学的大规模推广和应用MDDischargeOrdersPharmDandCCReviewSNFWithEPICupdate,Errorratewithoutreview-70%ofdischargesErrorrateafterreview-0%27临床药学的大规模推广和应用MDDischargePharm病情危重与再入院率的关系病情危重与再入院率的关系All Cause ReadmissionRelated ReadmissionSeverity of IllnessControlCaseControlCaseMinor14.29%(18/126)0%(0/1)7.94%(10/126)0%(0/1)Moderate19.03%(114/599)13.64%(3/22)7.85%(47/599)4.55%(1/22)Major26.54%(280/1055)31.37%(16/51)10.62%(112/1055)5.88%(3/51)Minor+Moderate+Major23.15%(412/1780)25.68%(19/74)9.49%(169/1780)5.40%(4/74)Extreme33.23%(104/313)38.46%(5/13)9.90%(31/313)23.08%(3/13)Overall24.65%(516/2093)31.03%(27/87)9.56%(200/1893)8.05%(7/87)Horn,SDetal.SeverityofIllnesswithinDRGs:Impactonprospectivepayment.AmJPublicHealth.1985;75,1195-9病情危重与再入院率的关系AllCauseReadmis28患者再入院率患者再入院率29临床药学对医疗质量的影响Physicians request it to be applied to all our patientsImproved patient satisfactionImproved customer serviceReduced readmission rate by 47%(5.7%vs 10.2%)30临床药学对医疗质量的影响Physiciansrequest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 hours clinical pharmacy time annually.Pharmacists to help with medication reconciliation in the emergency roomMedication safety manager31经济分析HCMChasapproximately185药事管理Cost to increase staffing$112,000Reduction in expenses$587,000(Reduced Readmissions by 47%)The US payment system is in transition from a fee for service to pay for performance.Improved Quality for the Patient32药事管理CosttoincreasestaffingThe 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 place a spotlight on critical risk points in the medication reconciliation process.NPSG.03.06.01 is effective July 1,2011”.TheJointCommissionNational33小结Need for a change-Identify the problemMeans for a change-Executive committee (budget and support)-Action plan and modification(PDSA)Team for a change-multidisciplinary team (MD,RN,RPh Social Service and clinical clerks)34小结Needforachange-Identify临床药学小结Clinical Pharmacists involvement in a team based modelReal time feedbackEmpowering frontline staff to suggest and enact solutionsStandardizing work and processes临床药学小结ClinicalPharmacistsinv35广而告之ISMP-CanadaNCPDPNAPHIHINQFCMSAJHPLu 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).广而告之ISMP-CanadaLuY.Clifford36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美国临床药师对临床药学影响数据37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，以点带面为中国临床药学进言天时地利人和38谢谢观赏谢谢观赏谢谢观赏39