Masters in Clinical Pharmacy Chulalongkorn University, Thailand 2004

Basic Concepts of Ambulatory Care: A Software for Pharmaceutical Care in Outpatient Setting
Paul C. Wong, Pharm.D. E-mail: pharmd2544@yahoo.co.jp

Ambulatory Care
The United States National Ambulatory Medical Care Survey (NAMCS) defines ambulatory care as: health services rendered to individuals under their own cognizance, any time when they are not in a hospital or other health care institution.

Terminology
Ambulatory care Primary Care Family Medicine patient vs client

Pharmaceutical Care
The American Society of Health System Pharmacists (ASHP) defines Pharmaceutical Care as: the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improves a patients quality of life.

Characteristics of AmCare
Symptoms
subjective less severe

Education: preventive medicine, chronic diseases Business (?)

I cannot sleep at night.

A 61 year old lady complains to you that she cannot fall asleep at night. [Scenario 1] Insomnia? Not working anymore and having naps in the afternoon.

I lost my keys again.

A 67 year old man came to get his blood pressure pills again. He said he just went to get another set of keys because he forgot where he placed it. This is the fifth time already in two months. I am really getting old, he sighed. [Scenario 2]

What is disease?
Abnormal signs / symptoms reflect a disease? Normal condition reflects disease-free state?

Pharmacists activities in AmCare

Monitor stable patients Prescribe medications patients have been taking under contract Adjust doses of medications patients have been taking under contract Order laboratory related to drug therapy (e.g. INR/PT)

Pharmacists activities in AmCare (contd)

Perform simple physical assessment to evaluate symptoms or drug efficacy Give recommendation on health care / Over-the-counter products Prescribe certain prescription drugs to clients with documentation Administer vaccines to clients if certified

Who else can prescribe in U.S.A.?

Physician Assistant (PA) Nurse Practitioner (NP) Pharmacists

Collaborative Practice (Drug Therapy Management)

Pharmacists are able to start or modify drug therapy under protocols established jointly with the physician / institution.

Clinics in which U.S. pharmacists often are involved:

General medicine Clinic / Refill Clinic Seizure Clinic Anticoagulation Clinic Kidney Transplant Clinic Bone Marrow Transplant Clinic Diabetic Clinic

Rule of Thumb in AmCare

NOT TO DIAGNOSE but to help to rule out disorders and provide care if pharmacotherapy is appropriate. ALWAYS ENSURE the problem is a DRUG-INDUCED one or not

Pharmacotherapy
NESt (related to health care providers) Necessity Efficacy / Effectiveness Safety

Pharmacotherapy & Some Subjects in Pharmacy School

Clinical Pharmacy N, E Pharmacokinetics, Pharmacology E, St Physical Pharmacy Pharmaceuticals E

Pharmacotherapy
ACE (related to patients) Adherence Cost / Affordability Education

Adherence?
A 50 yo male patient is taking metoprolol for his hypertension. His BP today is 152/98, HR 86. [Scenario 3]
Do you think the dose of metoprolol is appropriate? What are the clues?

How do you evaluate adherence?

Factors related to adherence: Table 1 Non-adherence & Overuse How much drug left?
E.g.Out of eye drop in one week? Out of inhaler in two weeks?

Patient with metoprolol with a heart rate of 86. Use of stimulants (caffeine/supplements)

Case: Education
A 45 year man has bought furosemide for his hypertension. The pharmacist is helping him to understand the side effects of the drugs. He said, It can cause hypokalemia and renal failure. [Scenario 4] Hypokalemia!! Renal failure!!

Information sources & Documentation

Depends on the practice setting: Clinical pharmacists Inpatient dispensing pharmacists Outpatient dispensing pharmacists Community pharmacists

When a client walks in. . . .

Pick up unsolved (old) problems Pick up new problems Evaluate therapy

How to gather information?

3S Sharp observation Specific questions Simple evaluation

Sharp Observation
Can extend from observe (sight) to using your other senses sight hearing: voice is loud, soft smell: characteristic ? Touch: hot, cold, swollen. . . . .

Case: Sharp Observation

A CHF patient comes into your pharmacy to get more digoxin. What will you look for as sharp observation? Figure 1. Eye movements.

Specific Questions
Related to signs/ symptoms (S/S) you observed Information regarding those S/S All information regarding drugs (including herbs, food)

Simple Evaluation
Data can be taken in Pharmacy
Basic vital signs BP, HR, RR, T, Pain score, (Ht, Wt, BMI)

Medical record, if available Keep a record of it (Monitoring Profile), if possible

Pharmacy Documentation
Contact number / address Allergy Active medication list Keep in pharmacy Copy for patient CONTINUITY OF CARE [Figure 2. Example.]

What information to gather for Assessment?

Table 2

Chronology of symptoms Quality of symptoms Associated symptoms Factors affect the symptoms Any medications tried Patients concern

Assessment
What are my choices? Pharmacotherapy? Non-pharmacotherapy? Triage? Business issue??

Therapy
The therapy that helps the patient / client is the best therapy. DO NO HARM; DO YOUR BEST Continuing education Experience

Scenarios seen in AmCare

Clients with symptoms come for advice Clients come in to buy old medication Clients come in to buy new medication

Actions made in AmCare

Sell medication to client No need to use medication Unable to treat/handle the problem (TRIAGE)

Case: Action
A man who lives close to your pharmacy came in today. He wants to get some strong medication for his leg pain. He bought simvastatin, isosorbide dinitrate, and atenolol from you for the last few months. [Scenario 5]

SUMMARY OF A VISIT
Make patient recall Review the S/S Record what happened Remind patient what to do

Patient-Pharmacist Relationship
Treat patient as a person
understand family life cycle (Table 3)

Confirm/clarify feeling Allow patient to express ones feeling Convey concern for and interest in the patient Empathize

Relationship (contd)
Non-biased Admit mistake Eye contact Open-ended question

Physical Assessment Technique

Hands on Pulse checking BP BG Neurological exam Hands off

Pediatrics: Classification
Pre-term neonate (premature): gestational age of less than 38 weeks Full-term neonate: gestational age of 38-42 weeks Newborn: first postnatal month of life Infant (baby): 1-12 month of age Toddler (young child): 1-5 yo Older child: 6-12 yo

Pediatrics: What is normal?

Height [Table 4] Weight Serum creatinine level Heart rate

Pediatrics
IMPORTANT: give specific instruction to family relatively fragile: same symptoms but could have more disastrous results good to triage to doctors/hospitals unless the symptoms are mild

Pediatrics (contd)
talk to client if old enough client cannot communicate so observation is of great importance: consider immunization recommendation issues on pharmacotherapy (safer drug, dosage adjustment)

Pediatrics: Education
Disorder and daily life can affect adolescent stage also e.g. asthma, diarrhea, fever, seizure AND sport participation

Case: Pediatric Care

A young mother came into your pharmacy and want some medicine for the fever of her 3 year old-son. What do you recommend? [Scenario 6] Pharmacists not just sell medications, we sell advice too.

Things needed to find out:

How long the fever has been, How high? Weight change? Crying? Tears? Look dry? Skin change etc.

Adolescents / Young Adults

13-21 yo physical, social, psychological developments need privacy, confidentiality Need public health education
Disorders/diseases Generally non-severe STD (including HBV, HCV, HIV) Substance abuse (alcohol, club drugs, etc.) Eating disorder (peer pressure related) Depression/Stress

Geriatrics
Over 65 years old?
Young old (65-75) Middle old (75-85) Old old (85 or older)

Old people have more diseases? Usually more diseases because people live longer and can control diseases nowadays more medicines, more side effects, more drug interactions

General concepts in Geriatric Care

Confirm compliance/adherence Minimize number of medications (especially self medications) Avoid combination use with traditional (herbal) medicine Evaluate ability to take medicine Assess non-drug effects: alcohol, smoking Documentation Home visit: storage

Pharmacotherapy in Geriatrics
Start with low doses Avoid renally excreted medications (?) Wait for uncommon adverse effects and drug interaction Look for unspecific signs / symptoms caused by medications BE CAREFUL WITH SOME DRUGS !!

Drug Safety in Pregnant Woman

FDA (USA) Categories Category A Category B Category C Category D Category X
(Other category systems in Germany & Australia)

Case: Pregnant Woman

A 24 year-old lady came to your pharmacy to buy phenytoin that she has been taking for her seizure disorder. She said her seizure is well controlled. During the conversation, she told you that she just got married and she wants to have a baby soon. She wants to know if she should stop the medication because she is fine and no attacks now. [Scenario 7]

Choices:
recommend not getting pregnant and consider adoption because of her seizure history stop phenytoin when she misses her first period and then counsel her physician stop taking phenytoin prior to conceiving and restarting it in the second trimester

Choices (contd)
all the older anticonvulsants are associated with fetal defects, but there are some newer agents available and maybe she would be a canadidate for one of dose. Recommend her to take to her doctor.

Choices (contd)
all the older anticonvulsants are associated with fetal defects, but there are some newer agents available and maybe she would be a canadidate for one of dose. So you look it up and recommend her to take it instead of phenytoin

Antiemetics used during pregnancy

Avoid if possible Phenothiazines Antihistamines
meclizine, cyclizine, dimenhydrinate, doxylamine

Ondensetron (Category B)

Nursing mothers
See if mother can avoid using medications altogether Use the lowest effective dose Try to use medications that do not cross into breast milk

Nursing mothers (contd)

Take medication just after baby feeding so it will be at a lower concentration when time for the next feeding Express breast milk prior to taking medication

Case: Critical Thinking

You are a pharmacist working in a pharmacy in Chiang Rai. This afternoon a young lady, look like in the early 20s, came into your store and want some medicine for her back pain and urinating problem. [Scenario 8]

Suggestion
Self continuing education New study format Better patient education Expand roles in hospital clinics Prepare pharmacy students to deal with patients Mentor system