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    Pharmacy Reading PDF

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    fea aiy 1 0 Pharmacy Doyle M. Cummings, PharmD, FCP, FCCP er 4 Learning Objectives Key Terms ‘Atte reading this chapter, students should be able to: + Community pharmacy ‘+ Explain the role of @ pharmacist and a pharmacy technician ‘+ Hospital pharmacy * Identity different work settings and responsibiltis for pharmacists/technicians *» Longeim care phaimacy + Describe the education and licensing process ‘+ Explain the relationship between pharmacists and other members of the healthcare team + Discuss opportunities and challenges for working in the fie & “A Day in the Life” Hello, my name is Crystal and | ar a hospital phar macst I work in large hospital next to th intensive care unit ‘with eal il patients who have heart disease and | am off to morning rounds with the patont care tesm, and then back to ‘the pharmacy satelite Our pharmacy s decentralized win small sharmacies called “satelite pharmacies” located next to patient lowing me more opportunity to have a direct i pact on ptiont cae. tell you all about the pation inthis area ‘ofthe hospital and how we work to optimize their medications Ii going to ba busy day. Join me lator on for details Wilcome back. only ave a few minutes to catch you up on ‘my day, Rounds with the patient care team in our eaciovasculer unit here atthe hospital wont really wl this moming. Our in ‘erprofassional team of health professionals spent tims taking + Pharmaceutical industry Ciinical pharmacy practitioner about how each of the patonts on our unit is doing, concen. traing our alseussion on what we ean do fo help those who ate the sickest get wel Wa taked about a patient who had a heart stack and ie’ come to the hospital uti a day lator This patent ie a 63-yeacold man With dabetes and high bleed pres- sure; he has farmed allo his fe an ves along way from the hospital. He thought his chest pain and sweating was “just ‘some sort of chest col” and he needed to finish his plowing anyway. By delaying coming in, he now has extensive damage tohis heart musela and he seems to have symptoms sugges: tive of congestive heart fllure—a condition in which his heart is now not pumping enough blood to meet the demands of his body. Our doctors have ordered sore addtional tesis 10 ty ‘and measure exactly now wal his hearts pumping. Now | arm (continues) 101 Section Ik Peimary-Cave Professions ‘working with the doctors and nurses to get him sterted on some new mecications that wil reat both his underlying coro: nary artery disease that likely led to his heart atack as wall as his congestive heart fare symptoms. These new medications sll be in addition to the medicines he is aloady toking for aotes and high blood pressure. speak with the patient and {emily members late to find out exactly what madieations he \wa faking at home and haw he was taking them. Ihave 3: ready revievid his mecical char thankfully these are all com: pputerized now) and have roted that he doesn't have any alleygies to mecications; however, Ns Kidney function may be \worsoning anc that might require us te reduce the dosage ot cortain medications for hi. | already discussed treatment op: tions withthe patient's doctor and we agreed on three new ‘medicines to start this patient on. | also talked to tha doctor about the patient's diabetes conttoMhe's not controling his blood glucase very well and we will nes to think about how to teasition him back to outpatient care so that this and his ‘other medical aroblems get proper attention. The doctor just ‘wrote the oiders for thase medications, so | better soe how ry pharmacy technician is doing and got to our werk. Wel catch up at the end ofthe day Wow, what day I's nally over. | have been at work since 7.09 a.m. i's boon along day but thas normal for my ob at tho hospital, hare there ae lots of vary sick patiants, Aer | last met with you, l completed the medication profile for the patient we discussed and weorkod with my pharmscy teen: cian to get him the new medications that he needed. | also talked to the doctor about his dlabetes medications. His glu .0s@ was not under good control and his worsening Kidney function suggested that his previous ciavetes medication rneaded tobe changed or have tha dosage reduced. | was able te chat withthe doctor betore he let to go this oes and ne ‘agreed that we should switch medications. ‘Additionally, we filed orders for medications for the other ations in the unt, one of whom we wore abo to wosn off of Introduction to Pharmacy Description Pharmacy isa carefl an scenitcally trained profession that Ini to ensure the safe and effective manaiacture, dispensing, and use of medications. Pharmacists remain the only profes sionals wo ae trained inthe safe compounding of medica tions. This shill i stil frequently required for certain medications, certain dosages that are not manufactured (€, ‘reduced dosages fr chien), certsin ovtes of rg admin- ition (ag compontstng of pial creams and ointments for dermatological se) andthe mitingof medications inthe correct dosages into bags or bottles of sterile ids that are administered intravenously (through a catheter directly into 102 intravenous metications in favor of oral medication so thst she can start getting ready to go home. Ihave checkod al of the prescription ofders tiled by my technician and veied that she is providing the right maclcation and dosage, We also had @ pationt edited late this sternoon, who was tansfarred from another sinall community hospital for notter evaluation and treatment here. | veiled her curtent medications with the pharmacy staffat the other hospital so that we could immedi ato get her startec on the ight medications. She had been having abnormal heart hythms that went undetected and un fortunately she ended up having a significant stoke. Because of her stroke, she cannot talk very well and | have had to get some af the information | needed from her husband and laughter, Also because of her stroke, she is having trouble ‘swallowing both food and her oral meceations. Ihave venta this with the speech pathologist and nutritionist who have been consulted to help with her care. Consequently the doctor had to place a nasogastric tube down through her nose and into her stomach and we are giving her liquid fod thraugh that tubo. We are also crushing most of her eral medications and the nurses are giving those medications down tho tube alco. ne of her medications could not ne crushed, so we have to {ive that maication in an injctableformultion through an in- ttavonous eathotor. Figuring out the bost way to dolver tho Fight medications at tha right time to patients lke these can bea challenge. Hopefully her swallowing will improve late this {ook and we ean begin glving the patont her usu} oral mec: ications. Our team willneed to monitor her carefully as she re covers to help ensure that she doesn't have a second stroke, whic i a serious risk, The patient seems scarad and I have talked 10 the nurses on our unit about giving her a lise extra attention and reassurance. Our goal isto get her abnormal heart hms under control and stabize her so that she can be transferred torahabiitaion to improve her abilities after het stroke, So, there you have t—sanather typical day inthe feof ‘a hospital based clinical pharmacis. the patient's bloodstream) usually in hospital or emergency’ lepartment settings. Because providing too litle of a medi- ine will often not treat the illness correctly and providing too ‘much medicine may leed to unintended adverse effects (often called “side effects"), it isthe pharmacists role to help ensure that the patient gets the right medicine, in the correct dosage, atthe right time. As you might imagine this isa tremendou responsibilty, yet one that can be very exciting and fulfilling "Today's pharmacist is very well trained to accept and fulfill, these advanced responsibilities. The intensive training in pharmacy school involves advanced math and science skills, combined with a thorough knowledge of diseases and med- ‘cations, as wells strong interpersonal skills to communicate effectively with both the patient and the health-care team. Pharmacist Role Femember thatthe primary role ofthe pharmacists to work ‘with other members of the hesltmcare team anc witn the patent to ensure that the patient gets the ight mecicine in the cottect dosage, atthe right time, and thatthe patient un- derstand how to use it properiy. This means thet the por mecist frequently works with doctors, nurses, physician assistants, dentists, and pationts in decsions about medica- tion selection, dasage, requency and timing of administra- tion, and prevention or minimization of potential side effects from medications. This interaction is especialy important in the hospital and estca cara exviranment because petents are often very sick, are on multiple medications at the same time, and may not be abe ta take madications by mouth be- c2use of tubes or other problems; also, their disease state ‘may change very rapidly, Here the pharmacists and other team members ate in (raquent communication about the unique needs of inavidual pations History Medicines have been a part of treating disease for millennia, ‘The use of medications to treat illness has been recorded by ancient Egyptians, Greeks, Romans, and Chines, longbefore thebirh of Chris. These treatments frequently involved the ssc of various plants and botanicals, which were prepared in diferent ways and either taken internally oF applied topealy to a wound. Lite was known about active ingredients (the key ingredient most responsible for producing a desired effet) how they worked, or what the proper desoge and du ration of treatment should be for various patients Plants had to be located and harvested and were eventually cultivated sn local gardens to ensure an adequate supply. However, = portant problems arose in extracting the active ingredients from plants and compounding or making them into medi «ines that patients consumed or used. These problems in- cluded a lack of consistency i compounding from person to person and place to place, resulting in dosages that might be too high or too low andl often not the same from one day to the next, Another common problem was that many of the solvents used in extracting or delivering active ingredients were often themselves highly toxic. Challenges stich as these fused the development of the profession of pharmacy. Regulation of Pharmaceuticals “The US. Food and Drog Aaministation (FDA) isa federal ageney thats legisatively mandated to oversee that tion are both safe and effective before being made availble tothe poblic. With the exception ofccasional prescriptions Chapter 10: Pharmacy here the pharmacist may compound ingredients into a final dosage form for consumption or use by the patient, most medications are manufactured by the modern pharmaceut: cal industry. This enormous international industry now in cludes for-profit companies, both large and small, that comply with all of these regulations in the United States and, around the world. The FDA tests medications for sale by pre scription only, as well as some that are sold aver the counter (ce, without a prescription required) both in pharmacies and in a variety of other retail locations. Pharmacists today are also supported by pharmacy tech hicians who assist in preparing medications and prescrip tions for distribution to the patient. Pharmacy technicians are discussed later in ths chapter. Locations and Content of Practice for Pharmacists and Pharmacy Technicians ‘The scopes of practice for pharmacists relate directly to the ‘education and licensure of the individual, the laws/require: iments ofthe state, and the location of practice. Some af these roles have already been alluded to following isa ist of some of the important practice roles of pharmacists in vasious lo cations, many of which continue to evolve in the changing Ialth-care environment.!? L. Community pharmacy: When people think of their pharmacist, they usually think ofthe person who works sta local pharmacy or drugstore. Here the pharmacist rot only dispenses the right medication, he or she also answers questions about dosages and potential side effects, assists in the selection of over-the-counter medications, encourages the patient's adherence to the prescribed medication regimen, and helps patients ‘monitor their disease. This is also a common location where pharmacy technicians work. These individuals support the work of the pharmacist by greeting patients, identifying and filling/refilling preseription medications into vials or bottles, checking with insurance companies about prescription coverage, ‘ensuring adequate inventories of medications and supplies, and finalizing the sale of the medications to the patient and/or family member. Hospital pharmacy: Like those in community settings, pharmacists help select the proper medications for a given patient based on an understanding of the patient's needs and past medication history. Hospital based pharmacists assist with calculating dosages 103 Section Primary-Care Professions FIGURE 10-1 patents scussing his medications with the local shar maxis. The pharmacy may be sivately own or a chain tore pera inyaious location across the Unitad States (especially in situations where the patient's body ‘cannot properly metabolize or excrete the medication), prepare medications, and dispense medications for administration to the patient (although the actual administration is often done by the patient's nurses). Pharmacists also help to monitor how the medications are working to ensure optimal outcomes and to minimize adverse or side effects ofthe medications, as ‘well as drug interactions (a situation in which one medication may have a change in its effects when combined with another medication). Pharmacy ‘technicians help to support the role of the pharmacist by obtaining medication orders from the medical record system, preparing medications for delivery to the patient care unit and for ease of administration (often in single-use doses or prepared/mixed in intravenous fluids), ensuring adequate inventories of medications and suppliss, and checking with nursing staf for any additional patient necds. 3. Long-term care pharmacy: As the population ages, more individuals are spending their final years in a system of congregate care locations for the elderly that range from assisted-living sites and rest homes 108 FIGURE 10-2 In hospital pharmacy, the pharmacist may have to insert ‘medications int inteverous(Vfuds for patent use as directed bythe sysisan, to full skilled-care nursing homes with around-the- clock care, Many of these elderly patients have ‘medical conditions and neeals that prevent them from living alone in their own home. In these settings, pharmacists have multiple roles. In one role, they may work to dispense medications for these patients in a manner similar to that described for community and hospital pharmacy practice, Alternatively, as many states require regular review of the patient's ‘medication regimen by a consulting pharmacist, they ‘may work as consultants—that is, pharmacists who ‘travel to one or more nursing homes, review medical records, discuss care with providers andor nurses, and make formal recommendations to the provider regarding medication selection, dosing, monitoring, and patient follow-up. Much ofthe early consulting in ‘nursing home settings was done by pharmacists who FIGURE 103 This photo porays stele creations ofmsicaons being processed ina hospital ghamacy. The pharmacist has to order, proces, and prepare the macations fr sate use. dovmandchei Tk i i : i were employed by or owners of community pharmacies. This work has evolved in many locations into the development of large consulting pharmacy operations that contract with many local nursing homes to provide these services. 4. Pharmaceutical industry: Much of the actual ‘manufacturing of medications into specific dosage forms (Le. tablets, capsules, liquids, creams) is now ‘managed by companies who then sell these products to local pharmacies for dispensing to patients Pharmacists have important roles in this setting based on their ‘unique knowledge of pharmaceutical compounding. kn this environment, pharmacists work with medicinal chemists, chemical engineers, packaging specialists, and a variety of other individuals to ensure that the active ingredients of the medication are combined With the proper inactive ingredients or vehicles for administration to the patient, as well as the proper sterility of some final products. In this way they ensure proper dissolution of the tablet or capsule in the stomach of intestine of the patient, appropriate sorption into the bloodstream in the concentrations necessary to have a desired therapeutic effect for the patient, and consistency from batch to batch of the ‘medication. They work with chemical engineers to take these procedures, which may work in limited quantities in the laboratory, and scale them up to produce large quantities of product that can be mass produced in advanced machinery. Clinical pharmacy pract mer: ‘The complexity of drug therapy and the growth in number of new ‘medications have led to remarkable evolution in the FIGURE 10-8 A porson with a pharmacy deqoo can wok i a phar ‘ceutical company to make and produce medications for dlvr a vendors suet as hospitals and healthcare faites. 1. Specialized areas of pharmacy pract Chapter 10: Pharmacy ‘practice of pharmacy tothe extent that some pharmacists today no longer dispense medications but work solely in clini, hospital, or other patient care environments ‘where they provide medication therapy consulting and ‘management {0 providers and patients to optimize health-care outcomes. By working with providers such as doctors and nurse practitioners or physician assistants, these pharmacists recommend and monitor specific drug therapies to maximize disease improvement while minimizing side effoets and drug interactions. Some practitioners also help patients lear how to use complex. ‘medications such as medication inhalers Forasthma and. insulin injections for diabeties, and many counsel patients about their medications and encourage adherence in chronic disease states. Many states have ‘now established “collaborative practice agreements” oF agreed-on relationships between clinical pharmacy practitioners and physicians that allow the pharmacist in selected disease states such as diabetes or hypertension, to initiate medications, adjust dosages, order laboratory fr other monitoring tests, and, under the oversight of, ‘the physician, manage the patient’s medication regimen. ‘This relationshi therapy management. Medical and pharmacy boards in many states have recognized the value of this collaboration and established these agreements, but the insurance industry has been slower in recognizing pharmacists as independent practitioners that can bill insurance carriers for non~product-telated services, However, this situation is changing and many health-care systems, managed-care agencies, and state Medicaid programs are employing pharmacists in these roles because overall health-care costs are often reduced, is often referred to as medication usually by optimizing medication choices thatare made available and by reducing emergency department and hospital visits yharmacists and pharmacy technicians may find employment in 4 variety of other specialized areas. One of these is radiopharmacy, in which specific quantities and dosages of radioactive pharmaceuticals that are uused in diagnosing and treating certain diseases are compounded and dispensed, Another area is working with governmental or military agencies. State and federal government agencies such as the National Institutes of Health, the FDA, the Veterans Administration, and various branches of the U.S. Armed Forces hire pharmacists for a variety of traditional and innovative roles. Another example is working in drug information and poison control 105 Section I: Primary-Care Professions ‘centers. Large health systems frequently have a drug Information center, run by pharmacists, that serves asa “help desk” or information resource about medications {for health professionals throughout the health system. Similarly, there is a nationwide network of poison control centers that may employ pharmacists. These ‘pharmacists answer questions about toxic ngestions or ‘exposures and their acute management—usually in ‘emergency situations—from patients local citizens, and health-care practitioners Sel Doyle M. Cummings, PharmD, FCP, FCCP Dr. Cummings has been in academic rmadicine and pharmacy for many years land has helped totrain countless young pharmacists, as well as physicians and other heath profes: sionels ter finishing his intial pharmacy schoo! training, he decided that he wanted to practice in an interprofes- sional environment with physicians, nurses, and othr health professionals, He moved to Chicago and completed 2 hospital pharmacy residency training program at a large Unversity hospital eyetem there, wher@ he had the exeting Coppertunity of exploring different roles and making patiant rounds with physicians, After this he matriculated into the {ahon) post BS PhsrmD propram—a 2-year program in Philadelphia whore he received intensive training in patho: physiology and clnial therapeutics. After completion he went on fo complete a post-Pharmd training program in ‘ambulatory care clinical pharmacy where he helped take ‘ate of pationts in ccs and outpatient environments, This asa total of 9 years of education and taining, and it pro: Vided him with unique and advanced skils to contribute in fa changing haalth-care sysiom. Since then, his career has advanced, allowing him to bocome a loading professor in 2 University health-care systam that trains pharmacy stu dents and a wide variety of other health professionals, ‘Much of his werk nw focuses on patients with high blood pressure and diabetes, two important and comman preb- lems in our nation today. He has always enjoyed pharmacy bocause it allows the pharmacist to bring a unique know edge and skillbase—an in-depth understanding of medics tions and how they work—to the compelling needs of pationts, both those acutely il in the hospital and those with chronic linessos such as hypertension and dlabotos in the outpatient setting. Ifyou do well n school, love sc {ence and math, and havea passion for helping others, phar ‘macy just might be right for you. 106 Required Education Pharmacists ‘The entry-level degree for admittance into the profession of pharmacy as a pharmacist is the doctor of pharmacy (PharmD) degree. Because ofa shortage of pharmacists in the fate 1990s:and early 2000s, there has been rapid growth in the number of pharmacy school programs. In addition to broad. bbased general education requirements (eg, English, foreign language, history/humanities), admission to a pharmacy school in the United States usually requires several things” + Completion of at leat 2 yeats of undergraduate college Ithough the ‘majority of students in many programs already have an education at an accredited institution, undergraduate college degree at the time of admission/ matriculation. + Completion of specific prerequisites, usually including advanced mathematics courses such as calculus and statistics, as well asadvanced science courses in chemistry, ‘organic chemistry, biology, microbiology, anatomy! physiology, and physics, all with grades of C or higher (Bor bigheris preferred) + A composite grade point average (GPA) usualy above 3.0. In most competitive programs, a GPA above 35s prefered cor required. Successful completion of the Pharmacy College Admissions Test (PCA) with scores that are competitive based on the guidelines set by each college's admissions. program. Many programs focus on the average PCAT. composite percentile rank score, Students can take this standardized test multiple times to try to improve their score, The testis offered ata wide variety of testing centers around the United States FIGURE 10-5 Pharmay ston ra required to compltoirtomshis be fore receiving thei degra, The student is working in acarmmuity based rmigcant health cline the ua community. Heis advising the mathe on| proper modication dosages forthe bay, Suecessfial completion of an in-person interview with admissions committee members from the College of Pharmacy. Application is made through « national consolidated ‘Web-enabled admissions process (PharmCAS) and requires submission of letters of recommendation, Supplemental ap plication materials are also often required by each pharmacy school applied to, The admissions committees carefully re~ view application forms, often along with a personal state ‘ment about carcer goals, as well as any relevant work experience and extracurricular activities. Once accepted, the traditional program of sedy in most schools of pharmacy is 4 years in length, the same as medical and dental schools Demographically, many pharmacy schools have a greater percentage of females in entering classes than males. Once successfully matriculated into pharmacy school, coursework or topics include the following: biochemistry, medicinal chemistry, physiology/pathophysiology, pharmacology, pharmaceutics, pharmaceutical calculations, pharmacokinet ies, pharmacotherapy, pharmacy law and ethics, pharmaceu~ tical care delivery, drug literature analysis, and multiple clinical or applied rotations in pharmacy and medical set~ tings similar to those described previously. Most schools re= quire maintenance at or above a certain GPA standard and passage of all coursework to graduate Graduates must successfully pass a comprehensive max tional licensure examination to be licensed forthe practice of pharmacy in a particularstate, Most students ake this exam ination right after graduation from pharmacy school and therelore passage rates are high. Once successfully licensed in a particular state, there ae often reciprocity procedures (eg application form, personal interview, state law examination, {es) available that allow Ficensees to also become licensed in Tho folowing list includes some of tha skils and characteristics required for workingin the field of ‘pharmacy: ‘Able to handle stress ‘Advanced math and science skis cellent computing? databaso-soatchingskils Excellent team member (on interprotessional team Cinical skis to assess patient symptoms/ tinaings Critical appraisal ofthe medica literature Manual dexterity for ‘compoundingfenaring Multtasker Dota odanted Ethical Responsible Chapter 10: Pharmacy “another slate, thercby increasing job potential. Additionally, the vast majority of states require the completion of a mini: ‘mum number of continuing education hours of training each ‘year to maintain an active practice license in that state, Pharmacy Technicians For pharmacy technicians, there is wide variability in re {quirements across states, Most states do not require phar: macy technicians to have completed a pharmacy technician training program to wark as « pharmacy technician; how. ‘ever, many students still choose to go through the training rather than simply having on-the-job experience, There is no required uniform national accreditation process for phar -macy technician training programs, Some programs are in dependently accredited by the American Society of Hospital Pharmacists or other pharmacy organizations; some ate lo cated in institutions that are themselves accredited even though the individual training program is not accredited; and some programs have no accreditation at all, Programs are available involving face-to-face classroom and laboratory ‘trainings othersare available largely online. A voluntary cer tification process is now available for pharmacy technicians that involves completion ofa certification examination and long-term maintenance of certification through regular con ‘inuing education. Although voluntary, this certification process can help one stand out from other applicants by demonstrating competency and commitment to the ja. Salary ‘The salary for pharmacists is very good and varies according to the specific area of practice and locaton, According tothe Bureau of Labor Statistics, the median salary fora pharmacist, was $113,390 per year in 2011 with the top 10% of pharma cists making approximately $144,000 a year. This median salary puts phacmacst third among health-care workers in

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