美国临床药师的临床实践管见

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，保证患者用药平安、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平安、合理方面做出的成果，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（BoardofPharmacotherapy)BoardCertifiedPharmacotherapySpecialistBoardCertifiedOncologySpecialistBoardCerfitifiedAmbulatoryCareSpecialistBoardCertifiedNutritionSupportSpecialistBoardCerfitifedPediatricSpecialistBoardCertifiedInfectiousDiseaseSpecialist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一般病房专科病房（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2010DiseaseTargets

GregoryDill,CentersforMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperations2010MultipleChronicDiseases“Sponsorscannotrequiremorethan3chronicdiseases

astheminimumnumberofmultiplechronicdiseases”and“sponsorsmusttargetatleastfourofthesevencorechronicconditions:”HypertensionHeartFailureDiabetesDyslipidemiaRespiratoryDiseases(Asthma,COPD,ChronicLungdisorders)BoneDisease-Arthritis(Osteoporosis,RA,OA)MentalHealthissues(Depression,Schizophrenia,BipolarDisorder,others)GregoryDill,CentersforMedicare&MedicaidServices,RegionVAssociateRegionalAdministratorforFinancialManagementandFee-for-ServiceOperationsHennepinCountyMedicalCenter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，用药平安经理兼职：药物治疗学经理，住院药师经理，药学博士生经理，中心药房临床药师一般病房专科病房门诊药师一般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平安经理-用药平安医院用药平安决策（院办，临床药物治疗）领导各级用药平安委员会（用药平安，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运用分析临床用药政策临床药师在用药平安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In2007,multipleuntowardeventsoccurredtopatientsdischargedtonursinghomesComplaintsfromnursinghomepatientsaboutconfusingdischargeordersAugustananursinghomeBenedictinehealthcaresystemTransplantclinicOutpatientdialysisunitExtendedcare

追根溯源Oneunitwithoneteamover12weeksDocumentmedicalrecordnumber,numberofmedications,timespentErrorswerereportedinHCMC’seventreportingsystemandtrackedbythemedicationsafetycommittee

追根溯源Reviewed37patientsdischargedtoSNF17dischargemedsperpatientAveragingabout20minutesperpatient,plusadditionalcommunicationtimewiththeteammembers,mostlyphysicians追根溯源InvestigationconfirmsexistingproblemOfthe37patients,only3(8%)wereerror-freeCommonthemesnoted:Formulationerrors(extendedreleaseetc)InappropriateduplicatesIncorrectdoses(e.g.antibioticathalfdose,anticoagulantatdoublethedose)Missingmedications(e.g.missedBPmed)Insulindosingerrors(missingss,duplicateorders,etc)

问题在哪里？MultipleresidentphysicianstakingcareofonepatientPhysiciansdonothaveenoughtimefordischargepaperworkMissingcoordinationatdischargeTheexistingEMRprocessesallowedforerrors.Note:MedRecwascompleted90+%ofthetime相关文献Dischargeerrorsoftenresultedinreadmissionstothehospital1-3Medicationerrorsinterferewiththepatient’sconfidenceintheirmedicalservices41.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.Patients'concernsaboutmedicalerrorsduringhospitalization.JtCommJQualPatientSaf.2007Jan;33(1):5-14.削减患者再次入院率OneoutoffivepatientsdischargedfromaUShospitalwillbereadmittedin30days17.4billion(outof102.6billion,17%)ofMedicareannualcostJencks,SF,Williams,MV,Coleman,EA.RehospitalizationsamongPatientsintheMedicareFee-for-ServiceProgram.NEnglJMed2009;360:1418-1428.行动方案ReportedtothehospitalexecutivecommitteePresentedasolutionCollaboratedwithamultidisciplinaryteamMedicationsafetymanager执行方案TaketheadvantageofnewtechnologyPDSAModelLangleyGL,NolanKM,NolanTW,NormanCL,ProvostLP.TheImprovementGuide:APracticalApproachtoEnhancingOrganizationalPerformance

(2ndedition).SanFrancisco:Jossey-BassPublishers;2009:23-24FailureModesandEffectsAnalysis(FMEA)IdentifypatientdischargingtoSNFatroundsSocialWorker(SW)obtainsbedandimmediatelypagesClinicalCoordinator(CC),MD,andPharmDMDhas4hourswithinwhichtowritethedischargeorders.Ifnotifiedafter2:00p.m.,MDmusthaveordersexceptI/Pdischargeinbefore8:00a.m.thenextday.CCscansordershourlyandpagesPharmD

FMEAProcessPharmDandCChave2hourswithinwhichtocompletereview:PharmDreviewsmedicationorders.Ifissue,pagesMDtoreconcile.IfOK,sonotes:MarksasreviewedinMedRecscreenCCreviewsotherorders.Ifissue,pagesMDtoreconcile.CCchecksforI/Pdischarge;notifiesbedsidenurseandPSCwhenorderscompleted

方案实施Individual1-1communicationbyPharmDtoorderingresidentandRNcoordinator.Communicationsenttoallattendingphysicians,notingthattheyareaccountabletoreviewresidents’dischargeordersandwillbenotifiediferrorsarefoundbypharmacists.多边合作再检查PharmDreportserrors(nearmiss)usingeventreportingprocessNotifiedPM&IofthisriskNotifiedPatientCareV.P.’sReporttoExecutiveLeadershipTeam临床药学的大规模推广和应用

MDDischargeOrdersPharmDandCCReviewSNFWithEPICupdate,Errorratewithoutreview-70%ofdischargesErrorrateafterreview-0%病情危重与再入院率的关系

AllCauseReadmissionRelatedReadmissionSeverityofIllnessControlCaseControlCaseMinor14.29%(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患者再入院率临床药学对医疗质量的影响PhysiciansrequestittobeappliedtoallourpatientsImprovedpatientsatisfactionImprovedcustomerserviceReducedreadmissionrateby47%(5.7%vs10.2%)

经济分析HCMChasapproximately1850SNFdischargesperyear;witheachpatient,medicationreconciliationtakesonaverage24minutesinmind,thisequivalentto700hoursclinicalpharmacytimeannually.PharmaciststohelpwithmedicationreconciliationintheemergencyroomMedicationsafetymanager

药事管理Costtoincreasestaffing $112,000Reductioninexpenses $587,000(ReducedReadmissionsby47%)TheUSpaymentsystemisintransitionfromafeeforservicetopayforperformance.ImprovedQualityforthePatient

TheJointCommissionNationalPatientSafetyGoals国家认证“…theNPSGonreconcilingmedicationinformation(originallyNPSG.08.01.01,butnowNPSG.03.06.01)wasstreamlinedandfocusedtoplaceaspotlightoncriticalriskpointsinthemedicationreconciliationprocess.NPSG.03.06.01iseffectiveJuly1,2011”.://jointcom