1、美国临床药师临床实美国临床药师临床实践管见践管见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。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 Specialis
2、tBoard Cerfitified Ambulatory Care SpecialistBoard Certified Nutrition Support SpecialistBoard Cerfitifed Pediatric SpecialistBoard Certified Infectious Disease Specialist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
3、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2010 Disease TargetsGregory Dill,Centers for Medicare&Medicaid Services,Region V Associate Regional Administrator for Financial Management and Fee-for-Service Operations2010 Multiple Chronic Diseases“Sponsors cannot require more than 3 chronic diseases as the
4、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,Schi
5、zophrenia,Bipolar Disorder,others)Gregory Dill,Centers for Medicare&Medicaid Services,Region V Associate Regional Administrator for Financial Management and Fee-for-Service Operations 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
6、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（危机）挑战In 2007,multiple untoward events occurred to patients discharged to nursing homesComplaints from nursing home patients ab
7、out confusing discharge ordersAugustana nursing homeBenedictine health care systemTransplant clinicOutpatient dialysis unitExtended care12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 tr
8、acked by the medication safety committee13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Investigation confirms existing problemOf the 37 patients,only 3(8%)we
9、re 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问题在哪里？问题在哪里？Multiple resident ph
10、ysicians taking care of one patientPhysicians do not have enough time for discharge paper workMissing coordination at dischargeThe existing EMR processes allowed for errors.Note:Med Rec was completed 90+%of the time相关文献Discharge errors often resulted in readmissions to the hospital1-3Medication erro
11、rs interfere with the patients confidence in their medical services41.Gillespie U,Alassaad A,Henrohn D,et al.A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older:a randomized controlled trial.Arch Intern Med.2009;169(9):894-900.2.Koehler BE,Richter KM,Youngblood
12、L,et al.Reduction of 30-day post-discharge hospital readmission or emergency department(ED)visit rates in high-risk elderly medical patients through delivery of a targeted care bundle.J Hosp Med.2009;4(4):211-218.3.Schnipper JL,Hamann C,Ndumele CD,et al.Effect of an electronic medication reconciliat
13、ion application and process redesign on potential adverse drug events:a cluster-randomized trial.Arch Intern Med.2009;169(8):771-780.4.Burroughs TE,Waterman AD,Gallagher TH,et al.Patients concerns about medical errors during hospitalization.Jt Comm J Qual Patient Saf.2007 Jan;33(1):5-14.减少患者再次入院率One
14、 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.Rehospitalizations among Patients in the Medicare Fee-for-Service Program.N Engl J Med 2009;360:1418-1428.行动方案Reported to th
15、e hospital executive committee Presented a solutionCollaborated with a multidisciplinary teamMedication safety manager执行方案Take the advantage of new technologyPDSA ModelLangley GL,Nolan KM,Nolan TW,Norman CL,Provost LP.The Improvement Guide:A Practical Approach to Enhancing Organizational Performance
16、(2nd edition).San Francisco:Jossey-Bass Publishers;2009:23-24Failure 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 noti
17、fied 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 PharmD22FMEA 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 revie
18、wed 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 23方案实施方案实施Individual 1-1 communication by PharmD to ordering resident and RN coordinator.Communication sent to all attending physicians,noting
19、that they are accountable to review residents discharge orders and will be notified if errors are found by pharmacists.多边合作再检查PharmD reports errors(near miss)using event reporting processNotified PM&I of this risk Notified Patient Care V.P.sReport to Executive Leadership Team临床药学的大规模推广和应用MD Discharg
20、eOrdersPharmD and CC ReviewSNFWith EPIC update,Error rate without review-70%of dischargesError rate after review-0%27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 ReadmissionSeverit y o f IllnessControlCaseControlCaseMinor14.29%(18/126)0%(0/1)7.94%(10/126)0%(0/1)Moderate19.03%(114/599)13.64%
21、(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,SD et al
22、.Severity of Illness within DRGs:Impact on prospective payment.Am J Public Health.1985;75,1195-9患者再入院率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经济分析HCMC has approximately 185
23、0 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药事管理Cost to increase staffing$112,
24、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 Patient32The Joint Commission National Patient Safety Goals 国家认证“the NPSG on reconciling medication information(originally NPSG.0
25、8.01.01,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”.小结Need for a change-Identify the problemMeans for a change-Executive committee (budget and support)-Action plan and
26、modification(PDSA)Team for a change-multidisciplinary team (MD,RN,RPh Social Service and clinical clerks)34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广而告之ISMP-CanadaNCPDPNAPHIH
27、INQFCMSAJHPLu 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).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
