对临床药学焦点问题的认识

对临床药学

焦点问题的认识邵宏史录文北京大学药学院药事管理与临床药学系主要内容对临床药学内涵的理解临床药师为谁而工作？临床药师主要干什么？临床药师都在哪里工作？临床药师的水平如何分出高下？行业协会与药师的认证评估我国临床药学的可持续发展何为临床药学？ACCP和ESCP的定义：ClinicalPharmacyisacommonlyusedterminpharmacypracticeandinpharmacyliterature形式——药学实践(PharmacyPractice)Itdescribestheactivitiesandservicesoftheclinicalpharmacisttodevelopandpromotetherationalandappropriateuseofmedicinalproductsanddevices核心——合理用药药学监护(PharmaceuticalCare)——necessaryphilosophyandmissionofpharmacypractice,abasicpatientneed临床药学对人，药学对物Revolution

orRenaissance?临床药学是医疗发展的结果何为临床药师？美国药学人员的分类Pharmacist(Pharmacyspecialist,ClinicalPharmacist)Pharmacytechnician临床药师——Part

orFull？——FTEPharmacists(FullTimeEquivalent，40hrs/w)——临床药师的数量和学位

药师的社会地位临床药师的工作对象与工作性质工作对象——医师or患者?工作性质——监管or服务?工作手段≠工作性质——鉴别、解决、预防潜在的或实际发生的DRPs工作目的≠工作内容——改善患者生命质量(qualityoflife)临床药师的工作内容药师职业角色的发展——药学实践(Pharmacypractice)药学实践的几种模式美国药师岗位培训——Residency美国药师继续教育规范临床药师的工作范围ACCP和ESCPItincludesalltheservicesperformedbypharmacistspractisinginhospitals,communitypharmacies,nursinghomes,home-basedcareservices,clinicsandanyothersettingwheremedicinesareprescribedandused药学实践的主要方向我国现阶段的情况——主要在三甲医院临床药师的工作层次初级（Fundamental）在对病人提供安全的药学监护中起关键作用18项具体指标中级（Desirable）提供更专业化和专科化的药物治疗学服务13项具体指标高级（Optimal）提供整合的、专业化的和精细的专科服务，旨在通过最高层次的教学、研究和药物治疗实践活动优化药物治疗效果12项具体指标RudisMIandBrandlKM.CritCareMed2000;28(11):3747南加州大学；新墨西哥州大学每个等级都包含了4个方面的活动：clinical,educational,administrative,scholarly行业协会与药师的认证评估APhA–AmericanPharmacistAssociation(1852)NARD–NationalAssociationofRetailDruggists(1898)NABP–NationalAssociationofBoardsofPharmacy(1904)ACPE–AccreditationCouncilforPharmacyEducation(1932)AACP–AmericanAssociationofCollegesofPharmacy(1937)ASHP–AmericanSocietyofHealth-SystemPharmacists(1942)ASCP–AmericanSocietyofConsultantPharmacists(1969)ACCP–AmericanCollegeofClinicalPharmacy(1979)AAPS–AmericanAssociationofPharmaceuticalScientists(1986)NISPC–TheNationalInstituteforStandardsinPharmacistCredentialing(1998)ESCP–EuropeanSocietyofClinicalPharmacyTheBoardofPharmaceuticalSpecialties(B.P.S.)1976NuclearPharmacy(1978)——BCNPNutritionSupportPharmacy(1988)——BCNSPPharmacotherapy(1988)——BCPSPsychiatricPharmacy(1992)——BCPPOncologyPharmacy(1996)——BCOPTheCommissionforCertificationinGeriatricPharmacy(C.G.P.)1997CertifiedDiseaseManager(C.D.M.)ofdiabetes,asthma,dyslipidemia,andanticoagulationtherapy.2006年美国临床药师工作状况MacLarenR,RudisMI,etal.AnnPharmacother2006;40:612-8科罗拉多州大学；南加州大学382个医疗机构活动比例直接临床药学活动62.2％个单位药师轮转查房时间4.4±0.5d/w工作时间分配病人监护药品分配药品管理教育教学43％26.2％12.6％10.9％7.3％初级临床工作75％的工作日中级与高级工作部分进行我国临床药学的可持续发展处于初级起始阶段普通药师与临床药师并存，需设立适当门槛，普通药师需经过专门培训合格后方可成为临床药师临床药师社会化——由医院临床药师逐渐向社区临床药师发展我国临床药学的可持续发展人才培养是可持续发展的根本数量与质量——由少而精逐渐往多而专发展大专院校人才储备要多层次多方向培养不同院校应根据自己的特点进行某些层次某些方向的培养明确普及教育与精英教育、理学(学位)教育与专业(职业)教育的不同教学目标和教学方式岗位人才培训将转型培训与继续教育分开转型培训以初级岗位培训项目为主继续教育以中级和高级培训项目为主由全能型培养往方向型培养转换我国临床药学的可持续发展相关制度的跟进是可持续发展的保障临床药师岗位制度“编制、配比、分级”从“三无”到“三有”临床药师的“头衔”可以在现有药师职称的基础上附加，无需另设职称认证与评估制度Helpindividualhospitalinpatientsandnonhospitalizedpatientsachievethebestuseofmedications.Applyevidence-basedmethodstotheimprovementofmedicationtherapy.Improvingthesafetyofmedicationuse.Applytechnologyeffectivelytoimprovethesafetyofmedicationuse.Engageinpublichealthinitiativesonbehalfoftheircommunities.Thanks!1860–1870Communitypharmacy,APhA1870–1950Differentiationbetweenmedicine&pharmacy,Drugfactories,NARD,ACPE1920–1933Alcoholmanagement,Hospitalpharmacy1928AACP4-yearB.S.1942ASHP1944R.Wait“ClinicalPharmacy”1948ASHPInternship1950–1960Hospitalpharmacydevelopment1951OTC,Communitypharmacistsrestriction19546-yearentry-levelPharm.D.atCASF1960–1990Clinicalpharmacyinitiation药师职责转变19605-yearBS;Communitypharmacyre-development1962UKMCDIC——Pharmacyspecialist1965DonaldBrodie:Pharmacypractice,patient-centered1966NinthFloorProject,CASF——Pharmacyspecialist/technician;DIC;Unitdose1967UKResidency1970s2-yearpost-B.S.Pharm.D.program;“clinicalpharmacy”1980-1983临床药学概念形成，药学会全国首次临床药学专题讨论会1989中国5年制临床药学专业本科开始1990–2020Clinicalpharmacydevelopment1990;1992Hepler&Strand:Pharmaceuticalcare2000AACP6-yearentry-levelPharm.D.programinUS2001TheSocialSecurityAct(享有医疗合作保险的患者服务).中国6年制临床药学专业研究生培养开始2002医院药事管理暂行规定（第4章第17条）2005-2006第1个临床药学专业研究生毕业；中国临床药师培训基地试点；临床药学专业（职业）学位申请2007-2008两届6年制临床药学专业硕士毕业；临床药师制试点；临床药学专业博士毕业2020ACPEResidencyrequirement:1yrMONEYMagazine2006CareerSurveyPharmacists9/50Stress:BFlexibility:CCreativity:BDifficulty:CTenYearGrowth: 24.5%AveragePay: $91,988临床药师的数量与学位医院床位数FTE药师床位数/药师ASHP2004年调查平均9.88肯塔基大学医学中心4731114.3马萨诸塞大学医学中心3502216康涅狄格大学Hartford医院10061760北医三院1187？60PhysiciansAttendingFellowResidentInternMedicalstudentPhysicianassistant&NursepractitionerNursingStaffPharmacistsPharmacySpecialistPreceptor&ResidentInstructor&Pharm.D.studentDieticiansHousekeepersEthicsCommitteeHealthCareTeamPharmaceuticalCareSelf-CareDrugInformationClinicalDistributive沟通技巧药学实践的模式为促进健康和预防疾病准备教育材料利用分析技术影响药物利用和药物利用策略具有健康筛查和诊断的技巧，药物治疗方案的设计与推介，治疗方案的判别药物治疗方案的设计、推介、监测和评估药物治疗方案的设计、推介、监测和评估利用高级沟通技巧与患者形成合作关系并参与医疗团队的决策工作的重心由解决用药相关问题转移到关注患者生存质量具有药品准备与分发的技巧NimmoCMandHollandRW.AJHP

1999;56:1981-7TotalPharmacyCare(TPC)美国药师岗位培训——ResidencyJob (practice)ResidencyPh.D.Pharm.D.PharmacistTeacher&ResearcherPharmacytechnician

（药技师，无执业药师资格）PGY1(普通培训)PGY2(专科培训)LicensedPharmacistBoardcertificationBCPS

BCOP

BCPP

BCNSP

BCNP测试与评估ResidencyProtestforPharmacokinetics转科Resident主要工作内容药学服务(PharmacyService)查房前－更新药历——PatientProfile&SOAP随治疗团队常规查房——RoundWorksheet上报不良反应报告、用药差错报告——实时网络填写相关病例单——PharmacistWorksheet提供药物信息和教育向指导药师(Advisor)汇报病例用药医嘱与药学服务——PharmacotherapyWorkup24小时On-Call制度和中心药房服务教学活动(EducationalActivities)课堂学习与科研活动(ScholarlyActivities)PatientProfileSOAPRoundWorksheetPharmacistWorksheetPharmacotherapyWorkup(1)PharmacotherapyWorkup(2)PharmacotherapyWorkup(3)PharmacotherapyWorkup©notesFOLLOW-UPEVALUATIONMedicalCondition(Indication):______________________________________OutcomeParameterPretreatmentBaseline(Date)FirstFollow-up(Date)SecondFollow-up(Date)EffectivenessSign/symptomSign/symptomLabvalueLabvalueSafetySign/symptomSign/symptomLabvalueLabvalueOtherResident部分课程MedicalLibraryandResourcesMedicationHistoriesAnemiaProtocol,IntensiveInsulin,SedationPediatricOverviewPharmacokineticServicesIVCompounding/SterileTechniquesNutritionSupportServicesPharmacistCareDiabetesClassPharmacistCareCardiovascularClassAnticoagulationclinicPharmacyAdministrationSTLC

(ScholarshipofTeaching&LearningCertificateProgram)PharmacyGrandRounds

（每周1次）STLC

(ScholarshipofTeaching&LearningCertificateProgram)主要内容ProgramOverviewAssessmentPrinciplesInstructionalTechniquesCurrentTrendsinPharmacyEducationSyllabus,Objectives,ExamQuestionsLargeGroupInstructionalApproachesAssemblingaTeachingPortfolioExperientialEducationGenerationalApproachestoTeachingUsingTechnologyinClassroomFacultyAppointmentsCivilityintheClassroomPeerAssessmentofTeachingDebate-RoleofResidenciesPharmacyGrandRoundsCriticallyIllPatientsColonizedwithMultidrugResistantOrganismsandImpactonLengthofStayDopositivesurveillanceculturespredictclinicalculturesintheICU?TheEffectsofBasiliximabInductiononSerumCreatinineandTimetoCalcineurinInhibitorInitiationinLiverTransplantRecipientsAntibioticExposureinCriticallyIllPatientsColonizedwithMultidrugResistantOrganismsImpactofMedicationTherapyManagementServicesinaChainPharmacySettingonthePharmacyBusinessandDispensingModelEvaluationofContinuationofStressUlcerProphylaxi