Innovative Pharmacy Practices: Pharmacist Prescribing

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Innovative Pharmacy PracticesPharmacist
Prescribing

• Cynthia Jackevicius, B.Sc.Phm., M.Sc., FCSHP
• Pharmacy Practice Leader, Heart Circulation
  Program
• Associate, Womens Health Program,
• University Health Network
• Assistant Professor, Faculty of Medicine
  Pharmacy, U of Toronto
• Adjunct Scientist, Institute for Clinical
  Evaluative Sciences
• December 2002

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Developing Innovative Practices

• specific activities
• warfarin dosing
• monitoring drug therapy
• total parenteral nutrition
• practice sites
• Heart Function Clinic
• Thrombosis Treatment Program
• Secondary Prevention Clinic
• Emergency Department

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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

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Who Prescribes?

• Physicians
• Nurse practitioners
• Expanded role nurses
• Clinical nurse specialists
• Midwives
• Optometrists
• What about pharmacists?

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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

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CSHP Survey

• Therapeutic interchange-intervals 70.6
• Order clarifications 55.0
• Modify non-Rx medications 39.4
• Pharmacokinetics 29.8
• Routine labs 23.0
• Pain service 20.7

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Types of Prescribing Models

• Independent
• Dependent
• Collaborative

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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

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Dependent Prescribing

• Delegation of authority from an independent
  prescribing professional
• Shared responsibility for patient outcomes
• formal agreement usually containing
• written guidelines or protocols
• description of responsibilities
• description of documentation
• policies for review and revision

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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

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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

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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

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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.

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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

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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

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Potential Benefits

• process outcomes vs outcome outcomes
• structure, process and outcome
• hard vs soft outcomes
• clinical outcomes
• financial outcomes

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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)

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Monitoring Drug Therapy
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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

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Coumadin

• Pharmacist Assisted Warfarin Dosing Program
  (PAWD)
• Delegated Medical Act
• Approved for use in the Cardiac Program
• Pharmacists certification and CQI
• Daily dosing by protocol according to INR

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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.

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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.

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Timing of Anti-Xa levels in Renal Patients
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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

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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.
• (PT and MAC February/April 1997)

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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
• INR
• anti-Xa
• TSH and LFTs
• Serum Creatinine
• aminoglycoside trough levels
• vancomycin trough levels
• Approved by UHN Clinical Decision Support

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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)