對臨床藥學(xué)焦點(diǎn)問題的認(rèn)識課件

對臨床藥學(xué)

焦點(diǎn)問題的認(rèn)識邵宏北京大學(xué)藥學(xué)院藥事管理與臨床藥學(xué)系對臨床藥學(xué)

焦點(diǎn)問題的認(rèn)識邵宏ACCP(AmericanCollegeofClinicalPharmacy).,2008ACCP(AmericanCollegeofCli主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？何為臨床藥學(xué)？ClinicalPharmacy何為臨床藥學(xué)？臨床(clinical)的概念【美國傳統(tǒng)詞典】Involvingorbasedondirectobservationofthepatient【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(xué)實(shí)踐(PharmacyPractice)ClinicalPharmacyisacommonlyusedterminpharmacypracticeandinpharmacyliterature核心——合理用藥theactivitiesandservicesoftheclinicalpharmacisttodevelopandpromotetherationalandappropriateuseofmedicinalproductsanddevices使命與患者基本需求——藥學(xué)監(jiān)護(hù)(PharmaceuticalCare)necessaryphilosophyandmissionofpharmacypractice,abasicpatientneed歷史地位：Revolution

orRenaissance?臨床藥學(xué)是醫(yī)療發(fā)展的必然結(jié)果臨床(clinical)的概念1850–1870社區(qū)藥學(xué)一統(tǒng)天下1870–1950醫(yī)藥分家醫(yī)院藥學(xué)開端藥廠、協(xié)會、教育發(fā)展1950–1960醫(yī)院藥學(xué)發(fā)展1960–1990社區(qū)藥學(xué)復(fù)蘇臨床藥學(xué)開端藥師職責(zé)轉(zhuǎn)變1990–臨床藥學(xué)發(fā)展1850–18701870–19501950–1先進(jìn)(美國)發(fā)達(dá)(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(xué)水平先進(jìn)發(fā)達(dá)發(fā)展中初期落后藥師職業(yè)與國家臨床藥學(xué)水平美國藥學(xué)院校教學(xué)重心轉(zhuǎn)移美國藥學(xué)院校教學(xué)重心轉(zhuǎn)移何為臨床藥師？ClinicalPharmacist何為臨床藥師？臨床藥師是為患者提供藥學(xué)服務(wù)的藥學(xué)專家（PharmacySpecialist）美國藥學(xué)人員的分類Pharmacist(Pharmacyspecialist,ClinicalPharmacist)Pharmacytechnician臨床藥師相關(guān)問題——Part

orFull？——FTEPharmacists(FullTimeEquivalent，40hrs/w)——臨床藥師的數(shù)量、學(xué)位和社會地位臨床藥師是為患者提供藥學(xué)服務(wù)的藥學(xué)專家（PharmacyS臨床藥師的數(shù)量國家醫(yī)院床位臨床藥師數(shù)床位/臨床藥師美國ASHP2004年肯塔基大學(xué)醫(yī)學(xué)中心馬薩諸塞大學(xué)醫(yī)學(xué)中心康涅狄格大學(xué)Hartford醫(yī)院4733501006平均9.81112217平均84.31660英國WithybushGeneralHospitalAshfordandStPeter'sHospitalOxfordRadcliffeHospitals2956931100112335133048澳大利亞CanberraHospitalRoyalDarwinHospitalRoyalPerthHospitalPrinceofWalesHospitalFrankstonHospital500363855700336小醫(yī)院2～3大醫(yī)院40～50平均12臺灣臺北新光吳火獅紀(jì)念醫(yī)院長庚紀(jì)念醫(yī)院林口分院臺中林新醫(yī)院高雄基督教信義醫(yī)院1000340040010010280205100122025北醫(yī)三院1187？(20)60臨床藥師的數(shù)量國家醫(yī)院床位臨床藥師數(shù)床位/臨床藥師美國ASH臨床藥師的學(xué)位臨床藥師的學(xué)位MONEYMagazine2006CareerSurveyPharmacists9/50Stress:BFlexibility:CCreativity:BDifficulty:CTenYearGrowth: 24.5%AveragePay: $91,988MONEYMagazine2006CareerSur主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？臨床藥師為誰而工作？如何工作？主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？工作對象：醫(yī)生or患者？工作對象：工作環(huán)境：個(gè)人or群體？工作環(huán)境：PhysiciansAttendingFellowResidentInternMedicalstudentPhysicianassistant&NursepractitionerNursingStaffPharmacistsPharmacySpecialistPreceptor,Advisor&ResidentInstructor&Pharm.D.studentDieticiansHousekeepersEthicsCommitteeHealthCareTeamPhysiciansHealthCareTeam工作性質(zhì)：監(jiān)管or服務(wù)？工作性質(zhì)：工作手段鑒別、解決、預(yù)防潛在的或?qū)嶋H發(fā)生的DRPs工作手段鑒別、解決、預(yù)防TypesofDrug-RelatedProblemsUntreatedindicationsImproperdrugselectionSubtherapeuticdosageFailuretoreceivemedicationOverdosageAdversedrugreactionsDruginteractionsDrugusewithoutindicationTreatmentfailuresTypesofDrug-RelatedProblems工作步驟通過PWDT完成一個(gè)具體的服務(wù)項(xiàng)目工作步驟通過PWDTPWDT

Pharmacist'sWorkupofDrugTherapyCollectandinterpretrelevantpatientinformationtodetermineifthepatienthasdrug-relatedproblemsIdentifydrug-relatedproblemsDescribethedesiredtherapeuticgoalsDescribefeasibletherapeuticalternativesSelectandindividualizethemostappropriatetreatmentregimenPWDT

Pharmacist'sWorkupofD工作目的通過藥物治療達(dá)到預(yù)定療效來改善患者生命質(zhì)量工作目的通過藥物治療主要焦點(diǎn)問題如何理解臨床藥學(xué)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？主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？藥師職業(yè)角色的發(fā)展藥學(xué)實(shí)踐PharmacyPractice藥師職業(yè)角色的發(fā)展藥學(xué)實(shí)踐PharmaceuticalCareSelf-CareDrugInformationClinicalDistributive溝通技巧藥學(xué)實(shí)踐的模式為促進(jìn)健康和預(yù)防疾病準(zhǔn)備教育材料利用分析技術(shù)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(shè)計(jì)與推介，治療方案的判別藥物治療方案的設(shè)計(jì)、推介、監(jiān)測和評估藥物治療方案的設(shè)計(jì)、推介、監(jiān)測和評估利用高級溝通技巧與患者形成合作關(guān)系并參與醫(yī)療團(tuán)隊(duì)的決策工作的重心由解決用藥相關(guān)問題轉(zhuǎn)移到關(guān)注患者生存質(zhì)量具有藥品準(zhǔn)備與分發(fā)的技巧NimmoCMandHollandRW.AJHP

1999;56:1981-7TotalPharmacyCare(TPC)PharmaceuticalCareSelf-CareDr工作的主要內(nèi)容藥學(xué)實(shí)踐PharmacyPractice課堂學(xué)習(xí)與科研活動ScholarlyActivities對醫(yī)務(wù)人員和病人及其家屬進(jìn)行教育，講座與宣傳等工作的主要內(nèi)容藥學(xué)實(shí)踐課堂學(xué)習(xí)與對醫(yī)務(wù)人員和病人及其家屬進(jìn)行ScholarlyActivities主要內(nèi)容MedicalLibraryandResourcesMedicationHistoriesAnemiaProtocol,IntensiveInsulin,SedationPediatricOverviewPharmacokineticServicesIVCompounding/SterileTechniquesNutritionSupportServicesPharmacistCareDiabetesClassPharmacistCareCardiovascularClassAnticoagulationclinicPharmacyAdministrationSTLC(ScholarshipofTeaching&LearningCertificateProgram)理論課學(xué)習(xí)ScholarlyActivities主要內(nèi)容MedicaScholarlyActivitiesCriticallyIllPatientsColonizedwithMultidrugResistantOrganismsandImpactonLengthofStayDopositivesurveillanceculturespredictclinicalculturesintheICU?TheEffectsofBasiliximabInductiononSerumCreatinineandTimetoCalcineurinInhibitorInitiationinLiverTransplantRecipientsAntibioticExposureinCriticallyIllPatientsColonizedwithMultidrugResistantOrganismsImpactofMedicationTherapyManagementServicesinaChainPharmacySettingonthePharmacyBusinessandDispensingModelEvaluationofContinuationofStressUlcerProphylaxisatHospitalDischargeEvaluatingBleedingEventsinPatientsReceivingActivatedProteinCEvaluationofaClinicalScoringScale(4T's)fortheDiagnosisofHeparin-InducedThrombocytopeniaAClinicalPharmacist’sGuidetoUSP<788>JointCommissionCoreMeasuresandStandards:ThePharmacistsRoleHemetologicEmergencies-SpinalCordCompressionWarfarinCYP2C9andVKORC1GeneticTestingRenalCellCancer-TargetedTherapyBreakthroughTheUseofrFVIIainPatientsWithDiffuseAlveolarHemorrhageFollowingBoneMarrowTransplantAcasestudy….thinkingoutsidethebox!Mycobacteriumarapidlygrowingproblem,orisit?Exjadeinthetreatmentofbetathalassemiamajor科學(xué)研究ScholarlyActivitiesCritically工作的主要內(nèi)容藥學(xué)實(shí)踐PharmacyPractice課堂學(xué)習(xí)與科研活動ScholarlyActivities對醫(yī)務(wù)人員和病人及其家屬進(jìn)行教育，講座與宣傳等工作的主要內(nèi)容藥學(xué)實(shí)踐課堂學(xué)習(xí)與對醫(yī)務(wù)人員和病人及其家屬進(jìn)行PointsofPharmacyPractice查房前－更新藥歷——PatientProfile&SOAPPointsofPharmacyPractice查房前PatientProfilePatientProfileSOAPSubjective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SOAPSubjective患者主訴Objective體PointsofPharmacyPractice查房前－更新藥歷——PatientProfile&SOAP隨治療團(tuán)隊(duì)常規(guī)查房并進(jìn)行病例討論P(yáng)ointsofPharmacyPractice查房前RoundWorksheetRoundWorksheetNeurosurgery

ICURoundNeurosurgeryICURoundPulmonaryICURoundPulmonaryICURoundCardiologyRoundCardiologyRoundPointsofPharmacyPractice查房前－更新藥歷——PatientProfile&SOAP隨治療團(tuán)隊(duì)常規(guī)查房并進(jìn)行病例討論DRPs分析PointsofPharmacyPractice查房前PointsofPharmacyPractice查房前－更新藥歷——PatientProfile&SOAP隨治療團(tuán)隊(duì)常規(guī)查房并進(jìn)行病例討論DRPs分析Worksheet；提供藥物信息和教育PointsofPharmacyPractice查房前WorksheetRoutineWorkWorksheetRoutineWorkPointsofPharmacyPractice查房前－更新藥歷——PatientProfile&SOAP隨治療團(tuán)隊(duì)常規(guī)查房并進(jìn)行病例討論DRPs分析用藥醫(yī)囑與藥學(xué)服務(wù)——PharmacotherapyWorkupWorksheet；提供藥物信息和教育PointsofPharmacyPractice查房前PharmacotherapyWorkupPharmacotherapyWorkupPharmacotherapyWorkupPharmacotherapyWorkupPharmacotherapyWorkupPharmacotherapyWorkupPointsofPharmacyPractice查房前－更新藥歷——PatientProfile&SOAP隨治療團(tuán)隊(duì)常規(guī)查房并進(jìn)行病例討論DRPs分析用藥醫(yī)囑與藥學(xué)服務(wù)——PharmacotherapyWorkupWorksheet；提供藥物信息和教育PointsofPharmacyPractice查房前主要焦點(diǎn)問題如何理解臨床藥學(xué)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？主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？工作范圍Itincludesalltheservicesperformedbypharmacistspractisinginhospitals,communitypharmacies,nursinghomes,home-basedcareservices,clinicsandanyothersettingwheremedicinesareprescribedandused哪里有用藥的病人哪里就有藥學(xué)實(shí)踐哪里就有臨床藥師工作范圍Itincludesalltheservic藥學(xué)實(shí)踐的主要方向社區(qū)藥學(xué)實(shí)踐(CommunityPharmacyPractice)零售藥店實(shí)踐(RetailPharmacyPractice)長期監(jiān)護(hù)實(shí)踐(Long–termCarePractice)醫(yī)院藥學(xué)實(shí)踐

(HospitalPharmacyPractice)急救監(jiān)護(hù)實(shí)踐

(AmbulatoryCarePractice)專科人群實(shí)踐

(SpecialtyPopulationPractice)藥學(xué)實(shí)踐的主要方向社區(qū)藥學(xué)實(shí)踐零售藥店實(shí)踐長期監(jiān)護(hù)實(shí)踐醫(yī)院藥主要焦點(diǎn)問題如何理解臨床藥學(xué)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？主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？臨床藥師的工作層次初級（Fundamental）在對病人提供安全的藥學(xué)監(jiān)護(hù)中起關(guān)鍵作用18項(xiàng)具體指標(biāo)中級（Desirable）提供更專業(yè)化和?？苹乃幬镏委煂W(xué)服務(wù)13項(xiàng)具體指標(biāo)高級（Optimal）提供整合的、專業(yè)化的和精細(xì)的?？品?wù)，旨在通過最高層次的教學(xué)、研究和藥物治療實(shí)踐活動優(yōu)化藥物治療效果12項(xiàng)具體指標(biāo)RudisMIandBrandlKM.CritCareMed2000;28(11):3747南加州大學(xué)；新墨西哥州大學(xué)每個(gè)等級都包含了4個(gè)方面的活動：clinical,educational,administrative,scholarly臨床藥師的工作層次初級（Fundamental）Rudis2006年美國臨床藥師工作狀況MacLarenR,RudisMI,etal.AnnPharmacother2006;40:612-8科羅拉多州大學(xué)；南加州大學(xué)382個(gè)醫(yī)療機(jī)構(gòu)活動比例直接臨床藥學(xué)活動62.2％個(gè)單位藥師輪轉(zhuǎn)查房時(shí)間4.4±0.5d/w工作時(shí)間分配病人監(jiān)護(hù)藥品分配藥品管理教育教學(xué)43％26.2％12.6％10.9％7.3％初級臨床工作75％的工作日中級與高級工作部分進(jìn)行2006年美國臨床藥師工作狀況MacLarenR,Rud主要焦點(diǎn)問題如何理解臨床藥學(xué)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(xué)工作水平？主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？職業(yè)培訓(xùn)與繼續(xù)教育ContinuingEducation轉(zhuǎn)崗培訓(xùn)畢業(yè)后培訓(xùn)在崗培訓(xùn)合格臨床藥師普通藥師臨床藥學(xué)專業(yè)畢業(yè)生職業(yè)培訓(xùn)與繼續(xù)教育轉(zhuǎn)崗培訓(xùn)畢業(yè)后培訓(xùn)在崗培訓(xùn)合格臨床藥師普通美國藥師崗位培訓(xùn)——ResidencyJob(practice)Residency(10%)PhDPharmDPharmacistAcademicTeacher&ResearcherPharmacytechnician(NoLicense)PGY1(普通培訓(xùn))PGY2(專科培訓(xùn))LicensedPharmacistBoardcertification（有效期6年）BCPS

BCOP

BCPP

BCNSP

BCNPHospitalRetailstores(60%)DrugCompanyGovernment50%美國藥師崗位培訓(xùn)——ResidencyJobPharmDPh對臨床藥學(xué)焦點(diǎn)問題的認(rèn)識課件組織結(jié)構(gòu)AdvisorPreceptorResidentInstructorResidencyExecutiveCommitteeResidentProgramDirectorChiefResidentBeginning,Quarterly,ExitMonthlyorDailyDailyConclusion組織結(jié)構(gòu)AdvisorPreceptorResidentIn測試與評估ResidencyProtestforPharmacokinetics測試與評估ResidencyProtestforPha轉(zhuǎn)科轉(zhuǎn)科職業(yè)培訓(xùn)的評估內(nèi)容職業(yè)培訓(xùn)的評估內(nèi)容主要焦點(diǎn)問題如何理解臨床藥學(xué)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(xué)工作水平？行業(yè)協(xié)會能為臨床藥學(xué)做些什么？主要焦點(diǎn)問題如何理解臨床藥學(xué)和藥師的內(nèi)涵？行業(yè)協(xié)會與藥師的認(rèn)證評估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.行業(yè)協(xié)會與藥師的認(rèn)證評估APhA–AmericanPh美國藥師繼續(xù)教育規(guī)范美國藥師繼續(xù)教育規(guī)范Helpindividualhospitalinpatientsan