對臨床藥學焦點問題的認識邵宏

1、對臨床藥學焦點問題的認識,邵 宏北京大學藥學院藥事管理與臨床藥學系,ACCP (American College of Clinical Pharmacy). http://www.accp.com, 2008,主要焦點問題,如何理解臨床藥學和藥師的內(nèi)涵？,何為臨床藥學？Clinical Pharmacy,臨床(clinical)的概念【美國傳統(tǒng)詞典】Involving or based on direct observati

2、on of the patient【高級漢語詞典】接觸病人，診治疾病ACCP和ESCP的權(quán)威定義形式 —— 藥學實踐(Pharmacy Practice)Clinical Pharmacy is a commonly used term in pharmacy practice and in pharmacy literature核心 —— 合理用藥the activities and services of the cli

3、nical pharmacist to develop and promote the rational and appropriate use of medicinal products and devices使命與患者基本需求 —— 藥學監(jiān)護(Pharmaceutical Care)necessary philosophy and mission of pharmacy practice, a basic patient nee

4、d歷史地位：Revolution or Renaissance ?臨床藥學是醫(yī)療發(fā)展的必然結(jié)果,先進(美國),發(fā)達(歐澳日),發(fā)展中(中國),初期,落后,藥師職業(yè)與國家臨床藥學水平,醫(yī)院藥師,臨床藥師<50%,醫(yī)院藥師,臨床藥師>50%,醫(yī)院藥師,社區(qū)藥師,藥學專家,藥師,藥師(社會藥師),社會藥師,社會藥師,美國藥學院校教學重心轉(zhuǎn)移,何為臨床藥師？Clinical Pharmacist,臨床藥師是為患者提供藥

5、學服務的藥學專家（Pharmacy Specialist）美國藥學人員的分類Pharmacist (Pharmacy specialist, Clinical Pharmacist)Pharmacy technician臨床藥師相關問題—— Part or Full ？—— FTE Pharmacists (Full Time Equivalent，40 hrs/w)—— 臨床藥師的數(shù)量、學位和社會地位,臨床藥師的數(shù)量,臨

6、床藥師的學位,MONEY Magazine 2006 Career Survey,Pharmacists 9/50Stress: BFlexibility: CCreativity: BDifficulty: CTen Year Growth:24.5%Average Pay:$91,988,,主要焦點問題,如何理解臨床藥學和藥師的內(nèi)涵？臨床藥師為誰而工作？如何工作？,工作對象：醫(yī)生 or 患者？,工作環(huán)境：個

7、人 or 群體？,PhysiciansAttendingFellowResidentInternMedical studentPhysician assistant & Nurse practitionerNursing StaffPharmacistsPharmacy SpecialistPreceptor, Advisor & ResidentInstructor & Pharm.D.

8、studentDieticiansHousekeepersEthics Committee,Health Care Team,工作性質(zhì)：監(jiān)管 or 服務？,工作手段,鑒別、解決、預防潛在的或?qū)嶋H發(fā)生的DRPs,Types of Drug-Related Problems,工作步驟,通過PWDT完成一個具體的服務項目,PWDT Pharmacist's Workup of Drug Therapy,工作目的,通過

9、藥物治療達到預定療效來改善患者生命質(zhì)量,主要焦點問題,如何理解臨床藥學和藥師的內(nèi)涵？臨床藥師為誰而工作？如何工作？臨床藥師主要干什么？,藥師職業(yè)角色的發(fā)展,藥學實踐Pharmacy Practice,Pharmaceutical Care,Self-Care,Drug Information,Clinical,Distributive,,,,,,,,,,,溝通技巧,藥學實踐的模式,為促進健康和預防疾病準備教育材料利用分析技術

10、影響藥物利用和藥物利用策略,具有健康篩查和診斷的技巧，藥物治療方案的設計與推介，治療方案的判別,藥物治療方案的設計、推介、監(jiān)測和評估,藥物治療方案的設計、推介、監(jiān)測和評估利用高級溝通技巧與患者形成合作關系并參與醫(yī)療團隊的決策工作的重心由解決用藥相關問題轉(zhuǎn)移到關注患者生存質(zhì)量,具有藥品準備與分發(fā)的技巧,Nimmo CM and Holland RW. AJHP 1999; 56:1981-7,Total Pharmacy Care

11、(TPC),工作的主要內(nèi)容,,對醫(yī)務人員和病人及其家屬進行教育，講座與宣傳等,Scholarly Activities,理論課學習,Scholarly Activities,科學研究,工作的主要內(nèi)容,,對醫(yī)務人員和病人及其家屬進行教育，講座與宣傳等,Points of Pharmacy Practice,,查房前－更新藥歷 —— Patient Profile & SOAP,Patient Profile,SOAP,Subjec

12、tive 患者主訴,Objective 體檢信息,Objective 體檢信息,Objective 體檢信息,Objective 體檢信息,Objective 體檢信息,Objective 體檢信息,Assessment 評估,Plan 治療方案,Points of Pharmacy Practice,,查房前－更新藥歷 —— Patient Profile & SOAP,,隨治療團隊常規(guī)查房 并進行病例討論,Round Wor

13、ksheet,Neurosurgery ICU Round,Pulmonary ICU Round,Cardiology Round,Points of Pharmacy Practice,,查房前－更新藥歷 —— Patient Profile & SOAP,,隨治療團隊常規(guī)查房 并進行病例討論,,DRPs分析,Points of Pharmacy Practice,,查房前－更新藥歷 —— Patient Profile &

14、amp; SOAP,,隨治療團隊常規(guī)查房 并進行病例討論,,DRPs分析,,Worksheet；提供藥物信息和教育,上報不良反應報告、用藥差錯報告 —— 實時網(wǎng)絡,Worksheet,Routine Work,Points of Pharmacy Practice,,查房前－更新藥歷 —— Patient Profile & SOAP,,隨治療團隊常規(guī)查房 并進行病例討論,,DRPs分析,,用藥醫(yī)囑與藥學服務 —— Pharma

15、cotherapy Workup,,Worksheet；提供藥物信息和教育,上報不良反應報告、用藥差錯報告 —— 實時網(wǎng)絡,Pharmacotherapy Workup,Assessment,Care Plan,Followup,Pharmacotherapy Workup,Assessment,Care Plan,Followup,Pharmacotherapy Workup,Assessment,Care Plan,Followup

16、,Points of Pharmacy Practice,,查房前－更新藥歷 —— Patient Profile & SOAP,,隨治療團隊常規(guī)查房 并進行病例討論,,DRPs分析,,用藥醫(yī)囑與藥學服務 —— Pharmacotherapy Workup,,Worksheet；提供藥物信息和教育,上報不良反應報告、用藥差錯報告 —— 實時網(wǎng)絡,24小時On-Call制度和中心藥房服務,主要焦點問題,如何理解臨床藥學和藥師的內(nèi)涵

17、？臨床藥師為誰而工作？如何工作？臨床藥師主要干什么？臨床藥師都在哪里工作？,工作范圍,It includes all the services performed by pharmacists practising in hospitals, community pharmacies, nursing homes, home-based care services, clinics and any other setting wh

18、ere medicines are prescribed and used哪里有用藥的病人哪里就有藥學實踐哪里就有臨床藥師,藥學實踐的主要方向,主要焦點問題,如何理解臨床藥學和藥師的內(nèi)涵？臨床藥師為誰而工作？如何工作？臨床藥師主要干什么？臨床藥師都在哪里工作？臨床藥師的水平如何分出高下？,臨床藥師的工作層次,初級（Fundamental）在對病人提供安全的藥學監(jiān)護中起關鍵作用18項具體指標中級（Desirable）

19、提供更專業(yè)化和專科化的藥物治療學服務13項具體指標高級（Optimal）提供整合的、專業(yè)化的和精細的?？品?，旨在通過最高層次的教學、研究和藥物治療實踐活動優(yōu)化藥物治療效果12項具體指標,Rudis MI and Brandl KM. Crit Care Med 2000; 28(11):3747南加州大學；新墨西哥州大學,每個等級都包含了4個方面的活動：clinical, educational, administrati

20、ve, scholarly,2006年美國臨床藥師工作狀況,MacLaren R, Rudis MI, et al. Ann Pharmacother 2006; 40:612-8科羅拉多州大學；南加州大學 382個醫(yī)療機構(gòu),主要焦點問題,如何理解臨床藥學和藥師的內(nèi)涵？臨床藥師為誰而工作？如何工作？臨床藥師主要干什么？臨床藥師都在哪里工作？臨床藥師的水平如何分出高下？如何保持和提高臨床藥學工作水平？,職業(yè)培訓與繼續(xù)教育C

21、ontinuing Education,普通藥師,臨床藥學專業(yè)畢業(yè)生,美國藥師崗位培訓——Residency,Job(practice)Residency(10%)PhD,PharmD,PharmacistAcademic Teacher & ResearcherPharmacy technician (No License),PGY1 (普通培訓)PGY2 (?？婆嘤?,,Licensed Pharmaci

22、st,Board certification（有效期6年）,,BCPS BCOP BCPP BCNSP BCNP,,,,,,,,,HospitalRetail stores (60%)Drug CompanyGovernment,,,50%,組織結(jié)構(gòu),Advisor,Preceptor,Resident,Instructor,ResidencyExecutiveCommittee,Resident Program Dire

23、ctor,Chief Resident,Beginning, Quarterly, Exit,Monthly or Daily,Daily,Conclusion,測試與評估,Residency Protest for Pharmacokinetics,,,,,轉(zhuǎn)科,,,,,,,,,,,,,,,,,職業(yè)培訓的評估內(nèi)容,I. Provide Patient Care A. Gather information B. Identify

24、 problem C. Resolve problemD. Collaborate with health care professionals E. Implement patient care planF. Maintain medical record G. Display attitudes, values, habits H. Promote public awareness I. Provide inform

25、ation to health professionals J. Provide information to general public,II. Manage the Practice A. Manage Pharmacy Operations B. Manage Medication Distribution/ControlC. Comply with laws,III. Manage Medication Use Sy

26、stems A. Manage medication errors/adverse drug reactions B. Participate in drug use evaluations C. Understand formulary management D. Understand outcomes research/quality assessment,IV. General Ability-Based Professi

27、onal Skills A. Thinking B. Communication C. Decision makingD. Social and contextual awareness E. Social ResponsibilityF. Social InteractionG. Self-learning abilities,主要焦點問題,如何理解臨床藥學和藥師的內(nèi)涵？臨床藥師為誰而工作？如何工作？臨床藥師主要

28、干什么？臨床藥師都在哪里工作？臨床藥師的水平如何分出高下？如何保持和提高臨床藥學工作水平？行業(yè)協(xié)會能為臨床藥學做些什么？,行業(yè)協(xié)會與藥師的認證評估,APhA – American Pharmacist Association (1852)NARD – National Association of Retail Druggists (1898)NABP – National Association of Boards of

29、Pharmacy (1904)ACPE – Accreditation Council for Pharmacy Education (1932)AACP – American Association of Colleges of Pharmacy (1937)ASHP – American Society of Health-System Pharmacists (1942)ASCP – American Society of

30、 Consultant Pharmacists (1969) ACCP – American College of Clinical Pharmacy (1979)AAPS – American Association of Pharmaceutical Scientists (1986)NISPC – The National Institute for Standards in Pharmacist Credentialing

31、 (1998) ESCP – European Society of Clinical Pharmacy,The Board of Pharmaceutical Specialties (B.P.S.) 1976 Nuclear Pharmacy (1978) —— BCNP Nutrition Support Pharmacy (1988) —— BCNSP Pharmacotherapy (1988) —— BCPS

32、Psychiatric Pharmacy (1992) —— BCPP Oncology Pharmacy (1996) —— BCOP,The Commission for Certification in Geriatric Pharmacy (C.G.P.) 1997,Certified Disease Manager (C.D.M.) of diabetes, asthma, dyslipidemia, and antico

33、agulation therapy.,美國藥師繼續(xù)教育規(guī)范,Help individual hospital inpatients and nonhospitalized patients achieve the best use of medications. Apply evidence-based methods to the improvement of medication therapy. Improving the s