对临床药学焦点问题的认识ACCP (American College of Clinical Pharmacy). , 2008主要焦点问题1.如何理解临床药学和药师的内涵？何为临床药学？何为临床药学？Clinical Pharmacy临床(clinical)的概念u【美国传统词典】Involving or based on direct observation of the patientu【高级汉语词典】接触病人，诊治疾病ACCP和ESCP的权威定义u形式 药学实践(Pharmacy Practice)Clinical Pharmacy is a commonly used term in pharmacy practice and in pharmacy literatureu核心 合理用药the activities and services of the clinical pharmacist to develop and promote the rational and appropriate use of medicinal products and devicesu使命与患者基本需求 药学监护(Pharmaceutical Care)necessary philosophy and mission of pharmacy practice, a basic patient need历史地位：Revolution or Renaissance ?u临床药学是医疗发展的必然结果先进(美国)发达(欧澳日)发展中(中国)初期落后药师职业与国家临床药学水平药师职业与国家临床药学水平美国药学院校教学重心转移何为临床药师？何为临床药师？Clinical Pharmacist临床药师是为患者提供药学服务的药学专家（Pharmacy Specialist）美国药学人员的分类Pharmacist (Pharmacy specialist, Clinical Pharmacist)Pharmacy technician临床药师相关问题 Part or Full ？ FTE Pharmacists (Full Time Equivalent，40 hrs/w) 临床药师的数量、学位和社会地位临床药师的数量国家国家医院医院床位床位临床药师数临床药师数床位床位/临床药师临床药师美国ASHP 2004年肯塔基大学医学中心马萨诸塞大学医学中心康涅狄格大学Hartford医院4733501006平均9.81112217平均84.31660英国Withybush General HospitalAshford and St Peters HospitalOxford Radcliffe Hospitals2956931100112335133048澳大利亚Canberra HospitalRoyal Darwin HospitalRoyal Perth HospitalPrince of Wales HospitalFrankston Hospital500363855700336小医院23大医院4050平均12台湾台北新光吴火狮纪念医院长庚纪念医院林口分院台中林新医院高雄基督教信义医院1000340040010010280205100122025北医三院1187？(20)60临床药师的学位MONEY Magazine 2006 Career SurveyPharmacists 9/50Stress: BFlexibility: CCreativity: BDifficulty: CTen Year Growth:24.5%Average Pay:$91,988主要焦点问题1.如何理解临床药学和药师的内涵？2.临床药师为谁而工作？如何工作？工作对象：工作对象：医生医生 or 患者？患者？工作环境：工作环境：个人个人 or 群体？群体？PhysiciansPhysiciansAttendingAttendingFellowFellowResidentResidentInternInternMedical studentMedical studentPhysician assistant & Nurse practitionerPhysician assistant & Nurse practitionerNursing StaffNursing StaffPharmacistsPharmacistsPharmacy SpecialistPharmacy SpecialistPreceptor, Advisor & ResidentPreceptor, Advisor & ResidentInstructor & Pharm.D. studentInstructor & Pharm.D. studentDieticiansDieticiansHousekeepersHousekeepersEthics CommitteeEthics CommitteeHealth Care Team工作性质：工作性质：监管监管 or 服务？服务？工作手段工作手段鉴别、解决、预防潜在的或实际发生的DRPsTypes of Drug-Related Problems工作步骤工作步骤通过PWDT完成一个具体的服务项目PWDT Pharmacists Workup of Drug Therapy工作目的工作目的通过药物治疗达到预定疗效来改善患者生命质量主要焦点问题1.如何理解临床药学和药师的内涵？2.临床药师为谁而工作？如何工作？3.临床药师主要干什么？药师职业角色的发展药师职业角色的发展药学实践Pharmacy PracticePharmaceutical CareSelf-CareDrug InformationClinicalDistributive沟通技巧药学实践的模式l为促进健康和预防疾病准备教育材料l利用分析技术影响药物利用和药物利用策略l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l药物治疗方案的设计、推介、监测和评估l药物治疗方案的设计、推介、监测和评估l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l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l具有药品准备与分发的技巧Nimmo CM and Holland RW. AJHP 1999; 56:1981-7Total Pharmacy Care (TPC)工作的主要内容工作的主要内容药学药学实践实践Pharmacy Practice课堂学习与课堂学习与科研活动科研活动Scholarly Activities对对对对医医医医务务务务人人人人员员员员和和和和病病病病人人人人及及及及其其其其家家家家属属属属进进进进行行行行教育，讲座与宣传等教育，讲座与宣传等教育，讲座与宣传等教育，讲座与宣传等Scholarly Activities主要内容主要内容Medical Library and ResourcesMedication HistoriesAnemia Protocol, Intensive Insulin, SedationPediatric OverviewPharmacokinetic ServicesIV Compounding /Sterile TechniquesNutrition Support ServicesPharmacistCare Diabetes ClassPharmacistCare Cardiovascular ClassAnticoagulation clinicPharmacy AdministrationSTLC (Scholarship of Teaching & Learning Certificate Program)理论课学习理论课学习Scholarly ActivitiesuCritically Ill Patients Colonized with Multidrug Resistant Organisms and Impact on Length of StayuDo positive surveillance cultures predict clinical cultures in the ICU?uThe Effects of Basiliximab Induction on Serum Creatinine and Time to Calcineurin Inhibitor Initiation in Liver Transplant RecipientsuAntibiotic Exposure in Critically Ill Patients Colonized with Multidrug Resistant OrganismsuImpact of Medication Therapy Management Services in a Chain Pharmacy Setting on the Pharmacy Business and Dispensing ModeluEvaluation of Continuation of Stress Ulcer Prophylaxis at Hospital DischargeuEvaluating Bleeding Events in Patients Receiving Activated Protein CuEvaluation of a Clinical Scoring Scale (4Ts) for the Diagnosis of Heparin-Induced ThrombocytopeniauA Clinical Pharmacists Guide to USP uJoint Commission Core Measures and Standards: The Pharmacists RoleuHemetologic Emergencies - Spinal Cord CompressionuWarfarin CYP2C9 and VKORC1 Genetic TestinguRenal Cell Cancer- Targeted Therapy BreakthroughuThe Use of rFVIIa in Patients With Diffuse Alveolar Hemorrhage Following Bone Marrow TransplantuA case study.thinking outside the box!uMycobacterium a rapidly growing problem, or is it?uExjade in the treatment of beta thalassemia major科学研究科学研究工作的主要内容工作的主要内容药学药学实践实践Pharmacy Practice课堂学习与课堂学习与科研活动科研活动Scholarly Activities对对对对医医医医务务务务人人人人员员员员和和和和病病病病人人人人及及及及其其其其家家家家属属属属进进进进行行行行教育，讲座与宣传等教育，讲座与宣传等教育，讲座与宣传等教育，讲座与宣传等Points of Pharmacy Practice查房前更新药查房前更新药历历 Patient Profile & SOAPPatient ProfileSOAPSubjective 患者主诉Objective 体检信息Objective 体检信息Objective 体检信息Objective 体检信息Objective 体检信息Objective 体检信息Assessment 评估Plan 治疗方案Points of Pharmacy Practice查房前更新药查房前更新药历历 Patient Profile & SOAP随治疗团队常规随治疗团队常规查房查房 并进行病例并进行病例讨论讨论Round WorksheetNeurosurgery ICU RoundPulmonary ICU RoundCardiology RoundPoints of Pharmacy Practice查房前更新药查房前更新药历历 Patient Profile & SOAP随治疗团队常规随治疗团队常规查房查房 并进行病例并进行病例讨论讨论DRPs分析分析Points of Pharmacy Practice查房前更新药查房前更新药历历 Patient Profile & SOAP随治疗团队常规随治疗团队常规查房查房 并进行病例并进行病例讨论讨论DRPs分析分析Worksheet；提供；提供药物信息和教育药物信息和教育WorksheetRoutine WorkPoints of Pharmacy Practice查房前更新药查房前更新药历历 Patient Profile & SOAP随治疗团队常规随治疗团队常规查房查房 并进行病例并进行病例讨论讨论DRPs分析分析用药医嘱与药学服务用药医嘱与药学服务 Pharmacotherapy WorkupWorksheet；提供；提供药物信息和教育药物信息和教育Pharmacotherapy Workup Pharmacotherapy Workup Pharmacotherapy Workup Points of Pharmacy Practice查房前更新药查房前更新药历历 Patient Profile & SOAP随治疗团队常规随治疗团队常规查房查房 并进行病例并进行病例讨论讨论DRPs分析分析用药医嘱与药学服务用药医嘱与药学服务 Pharmacotherapy WorkupWorksheet；提供；提供药物信息和教育药物信息和教育主要焦点问题1.如何理解临床药学和药师的内涵？2.临床药师为谁而工作？如何工作？3.临床药师主要干什么？4.临床药师都在哪里工作？工作范围工作范围It includes all the services performed by pharmacists practising in hospitals, community pharmacies, nursing homes, home-based care services, clinics and any other setting where medicines are prescribed and used哪里有用药的病人哪里就有药学实践哪里就有临床药师药学实践的主要方向药学实践的主要方向主要焦点问题1.如何理解临床药学和药师的内涵？2.临床药师为谁而工作？如何工作？3.临床药师主要干什么？4.临床药师都在哪里工作？5.临床药师的水平如何分出高下？临床药师的工作层次初级（Fundamental）l在对病人提供安全的药学监护中起关键作用l18项具体指标中级（Desirable）l提供更专业化和专科化的药物治疗学服务l13项具体指标高级（Optimal）l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l12项具体指标Rudis MI and Brandl KM. Crit Care Med 2000; 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, scholarly2006年美国临床药师工作状况MacLaren R, Rudis MI, et al. Ann Pharmacother 2006; 40:612-8科罗拉多州大学；南加州大学 382个医疗机构活动活动比例比例直接临床药学活动62.2个单位药师轮转查房时间4.40.5 d/w工作时间分配l病人监护l药品分配l药品管理l教育l教学4326.212.610.97.3初级临床工作75的工作日中级与高级工作部分进行主要焦点问题1.如何理解临床药学和药师的内涵？2.临床药师为谁而工作？如何工作？3.临床药师主要干什么？4.临床药师都在哪里工作？5.临床药师的水平如何分出高下？6.如何保持和提高临床药学工作水平？职业培训与继续教育职业培训与继续教育Continuing Education普通药师普通药师临床药学专业毕业生临床药学专业毕业生美国药师岗位培训ResidencyJob(practice)Residency(10%)PhDPharmDPharmacistAcademic Teacher & ResearcherPharmacy technician (No License)PGY1 (普通培训)PGY2 (专科培训)Licensed PharmacistBoard certification（有效期6年）BCPS BCOP BCPP BCNSP BCNPHospitalRetail stores (60%)Drug CompanyGovernment50%组织结构AdvisorPreceptorResidentInstructorResidencyExecutiveCommitteeResidentProgramDirectorChiefResidentBeginning, Quarterly, ExitMonthly or DailyDailyConclusion测试与评估Residency Protest for Pharmacokinetics转科职业培训的评估内容职业培训的评估内容主要焦点问题1.如何理解临床药学和药师的内涵？2.临床药师为谁而工作？如何工作？3.临床药师主要干什么？4.临床药师都在哪里工作？5.临床药师的水平如何分出高下？6.如何保持和提高临床药学工作水平？7.行业协会能为临床药学做些什么？行业协会与药师的认证评估1.APhA American Pharmacist Association (1852)2.NARD National Association of Retail Druggists (1898)3.NABP National Association of Boards of Pharmacy (1904)4.ACPE Accreditation Council for Pharmacy Education (1932)5.AACP American Association of Colleges of Pharmacy (1937)6.ASHP American Society of Health-System Pharmacists (1942)7.ASCP American Society of Consultant Pharmacists (1969) 8.ACCP American College of Clinical Pharmacy (1979)9.AAPS American Association of Pharmaceutical Scientists (1986)10.NISPC The National Institute for Standards in Pharmacist Credentialing (1998) 11.ESCP European Society of Clinical PharmacyThe Board of Pharmaceutical Specialties (B.P.S.) 1976 Nuclear Pharmacy (1978) BCNP Nutrition Support Pharmacy (1988) BCNSP Pharmacotherapy (1988) BCPS Psychiatric Pharmacy (1992) BCPP Oncology Pharmacy (1996) BCOP The Commission for Certification in Geriatric Pharmacy (C.G.P.) 1997Certified Disease Manager (C.D.M.) of diabetes, asthma, dyslipidemia, and anticoagulation therapy.美国药师继续教育规范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 safety of medication use. Apply technology effectively to improve the safety of medication use. Engage in public health initiatives on behalf of their communities. Thank you !Any Questions ?