Clinical Skills for Pharmacists: A Patient-Focused Approach

327 Pages·2011·7.6 MB·English

by  Karen J. Tietze PharmD

CLINICAL
SKILLS
FOR
PHARMACISTS
A Patient-Focused Approach
E
D
I
T
I
O
N

3
Karen J. Tietze, PharmD
Professor of Clinical Pharmacy
University of the Sciences in Philadelphia
Philadelphia, Pennsylvania
3251 Riverport Lane
St. Louis, Missouri 63043
CLINICAL SKILLS FOR PHARMACISTS: A PATIENT-FOCUSED APPROACH 978-0-3230-7738-5
Copyright © 2012, 2004, 1997 by Mosby, Inc., an affiliate of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notice
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein.
In using such information or methods they should be mindful of their own safety and the safety
of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to
check the most current information provided (i) on procedures featured or (ii) by the manu-
facturer of each product to be administered, to verify the recommended dose or formula,
the method and duration of administration, and contraindications. It is the responsibility
of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Tietze, Karen J.
Clinical skills for pharmacists : a patient-focused approach / Karen J. Tietze. -- 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-05485-0 (alk. paper)
1. Pharmacy. 2. Pharmacy--Practice. 3. Communication in pharmacy. I. Title.
[DNLM: 1. Pharmaceutical Services. 2. Pharmacists. 3. Pharmacy--methods. 4. Professional-
Patient Relations. QV 737]
RS91.T54 2011
615’.1--dc22
Acquisitions Editor: Kellie White
Developmental Editor: Kelly Milford
Publishing Services Manager: Catherine Jackson
Project Manager: Sara Alsup
Design Direction: Teresa McBryan
Printed in
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my students
Preface
I
n the preface to the first edition of Clinical Skills for Pharmacy, was updated to reflect the current state
Pharmacists, I described how the book was developed, of pharmacy practice, including medication therapy
the organization, structure, and format of the book, as management, medication reconciliation, and pharmacy-
well as my hopes for the book. I ended the preface by based immunization. Cultural diversity and telecommu-
stating that the book was a work in progress and that all nication were added to Chapter 2, Communication Skills
suggestions for improvement were welcome. Although for the Pharmacist. The immunization history as a com-
I thought the book was unique, and hoped it would ponent of the medication history, examples illustrating
find a useful niche within the profession, I was unsure each component of the medication history, and a medi-
of its acceptance. I have been quite surprised by the cation history checklist were added to Chapter 3, Taking
overwhelmingly positive response the first two editions Medication Histories. Chapter 4, Physical Assessment Skills,
of the book have elicited. Although my students delight was expanded and reorganized to provide more contextu-
in pointing out the occasional typographical error or al context for pharmacists, including checklists for assess-
inconsistency, feedback regarding the style and content ing skills performance. A new biomarker section was
has been consistently positive. The book has found a added to Chapter 5, Review of Laboratory and Diagnostic
niche as a unique compilation of skill-related topics, and Tests. Examples illustrating each component of the struc-
is complementary to clerkship manuals and physical tured patient case were added to Chapter 6, The Patient
assessment, pharmacotherapeutics, and ethics textbooks. Case Presentation. More examples and guidance were
The third edition has been completely updated. The added to Chapter 7, Therapeutics Planning, and Chapter
book is now in color and in a larger format. More than 8, Monitoring Drug Therapies. Chapter 9, Researching and
100 images (figures, photographs, illustrations), most in Providing Drug Information, was completely updated and
color, were added to this edition. A list of chapter acro- example drug information questions, including answer,
nyms was added to the book, for easy reference. Also new source, and comments were added. A discussion of con-
to the third edition are chapter-specific application exer- temporary pharmacy-related ethical issues, including
cises. Located at the end of each chapter, the application conscientious objection, and issues related to confiden-
exercises are best completed in small groups, though they tiality and research were added to Chapter 10, Ethics in
can be completed individually. Pharmacy and Health Care.
Approximately one-third of the book content is new. This book remains a work in progress. Comments and
Basic clinical pharmacy skills remain the focus of the suggestions for improvement are always welcome.
book, but the skills have been expanded to facilitate
longitudinal development throughout the pharmacy cur- Karen J. Tietze
riculum. Chapter 1, Introduction: The Practice of Clinical
vii
Acknowledgments
I
t is impossible to individually thank all those who Developmental Editor; Laura MacAdam, Developmental
contributed to the development of this book. I hope Editor; Jennifer Roche, Acquisitions Editor; and Jennifer
that my global thanks reach everyone involved in the Furey, Production Editor. Their guidance and enthusiasm
development and publication of this book. I thank all were invaluable. The editors for the second edition, Kellie
my students who continue to teach me how best to learn White, Editor, and Kim Fons, Senior Developmental
clinical pharmacy skills. I also thank my colleagues at Editor had a “can do” attitude and never-failing enthu-
the Philadelphia College of Pharmacy, University of the siasm for the book that kept me motivated and on track
Sciences whose moral support during the developmental with a very ambitious production timeline. For the third
stages of the book and the writing of the second and edition, I was very privileged to work once again with
third editions of the book was invaluable. Kellie White, Executive Editor. Kellie has an intuitive
Special thanks to the following individuals who pro- understanding of what this book is all about; it was great
vided detailed reviews of one or more chapters when the fun to plan out the changes for the third edition of the
first edition of the book was being developed: Jerry L. book with her. Other members of the editorial team for
Bauman, Pharm.D.; Janice A. Gaska, Pharm.D.; Arthur the third edition included Kelly Milford, Developmental
I. Jacknowitz, Pharm.D.; Paul L. Ranelli, Ph.D.; and Editor, Jennifer Watrous, Senior Developmental Editor,
Timothy H. Self, Pharm.D. Emily Thomson, Editorial Assistant, and Sara Alsup,
I am especially indebted to Dr. Janice Gaska. Our origi- Associate Project Manager. Publishing is truly a team
nal plan was to coauthor the book. We spent countless effort, and I am grateful for everyone’s support and
hours planning the book before she changed careers. The patience.
book reflects both of our philosophies and is much better Finally, thanks to my family for their support and
than I could have created on my own. understanding of what it takes to get this type of project
No book can succeed without the resources and sup- completed.
port of the publisher. I have been incredibly lucky to
work with very talented editors from Elsevier, Inc. My Karen J. Tietze
editorial team for the first edition included Sandra Parker,
viii
C H A P T E R
1 Introduction: The Practice
of Clinical Pharmacy
LEARNING OBJECTIVES
• Define pharmaceutical care and identify the four • State the eligibility requirements for pharmacist board
outcomes that improve a patient’s quality of life. certification and identify the areas for which board
• Define medication therapy management. certification is available.
• List the three goals and five core elements of • Define residency and fellowship and differentiate them
medication therapy management. with regard to length of training and mechanisms for
• List the knowledge and skills needed for patient- credentialing.
focused pharmacy practice. • Identify and differentiate among the various types of
• State the requirements for pharmacy state licensure health care settings and environments.
and relicensure. • Define health maintenance organization, point-of-
• Differentiate between pharmacist board certification, service plans, and preferred provider organizations.
pharmacist-specific disease-specific credentialing, • State the purpose of the medical team and identify the
multidisciplinary disease-specific credentialing, and roles and responsibilities of each team member.
pharmacy certificate programs in terms of eligibility and • Identify and describe unresolved health care system
requirements. issues.
P
 harmacy practice is moving toward a model that  implies the integration of patient- and product-oriented 
integrates patient-focused care (also known as patient- pharmacy practice.
centered care) and drug distribution services. To be success- Patient-focused pharmacists work closely with physi-
ful, pharmacists must understand and speak the language  cians and other health care professionals to provide optimal 
of the health care system and function in a system that  patient  care.  Some  pharmacists  in  traditional  product- 
to the uninitiated is foreign and excessively complex.  centered practice settings use clinical pharmacy skills in a 
The variety of providers, rapidly evolving types of health  limited capacity, such as when they obtain a medication 
care delivery systems, and complexities of relationships  history or triage a patient to self-care with nonprescrip-
among  the  various  heath  care  professionals  working  tion drugs. Some pharmacists have no traditional product- 
within the health care system add to the confusion. This  centered  responsibilities  and  instead  provide  full-time 
chapter describes patient-focused pharmacy practice and  patient-focused care. Regardless of the setting and the degree 
the clinical environment in which patient-focused phar- to which patient-focused skills are used, patient-focused care 
macists function. is an integral part of the practice of pharmacy (Figure 1-1).
The term pharmaceutical care is used to describe the 
broad-based, patient-focused responsibilities of pharma-
PATIENT-FOCUSED PHARMACY PRACTICE cists (see Figure 1-1). Hepler and Strand define pharma-
ceutical care as the “responsible provision of drug therapy 
The term clinical pharmacy historically described patient- for  the  purpose  of  achieving  definite  outcomes  that 
oriented rather than product-oriented pharmacy practice.  improve a patient’s quality of life.”1 The four outcomes 
The term clinical pharmacist was used to describe a phar- identified include the following:
macist whose primary job was to interact with the health   1.  Cure of disease
care team, interview and assess patients, make patient-  2.  Elimination or reduction of symptoms
specific therapeutic recommendations, monitor patient   3.  Arrest or slowing of a disease process
response to drug therapy, and provide drug information.   4.  Prevention of disease or symptoms
Clinical pharmacists, working primarily in acute care set- Pharmaceutical care requires an expert knowledge of 
tings, were viewed as “drug experts”; other pharmacists  therapeutics; a good understanding of disease processes; 
could occasionally use “clinical” skills, but they remained  knowledge  of  drug  products;  strong  communication 
focused on product management. The pharmacy profes- skills; drug monitoring, drug information, and therapeu-
sion has evolved to the point that many pharmacists find  tic planning skills; and the ability to assess and interpret 
the term clinical pharmacy redundant; the term pharmacist  physical assessment findings (Figure 1-2).
1
2 Clinical Skills for Pharmacists: A Patient-Focused Approach
Box 1-1 Medication Therapy Management (MTM)
Core Elements
• Provide a comprehensive or targeted medication
therapy review
• Complete and update the patient’s personal
medication record (PMR)
• Develop a medication-related patient-directed action
plan (MAP)
• Intervene and/or refer when appropriate
• Document all services and interventions, communicate
results of the MTM encounter, and provide appropriate
follow-up
Adapted from Bluml BM: Definition of medication therapy management: devel-
opment of profession wide consensus. J Am Pharm Assoc 45:566-572, 2005.
Figure 1-1 Patient-Focused Care in the Community 
Box 1-2 Pharmacist Practice Areas
 Pharmacy. Patient-focused care is an integral part of the practice
of pharmacy in all patient care settings. (Hopper T: Mosby’s phar-
Ambulatory care
macy technician: Principles and practice, ed 2, St Louis, Saunders,
Critical care
2007.)
Drug information
Geriatrics and long-term care
Internal medicine and subspecialties
Cardiology
Endocrinology
Gastroenterology
Infectious disease
Neurology
Nephrology
Obstetrics and gynecology
Pulmonary disease
Psychiatry
Rheumatology
Nuclear pharmacy
Nutrition
Pediatrics
Pharmacokinetics
Surgery
SITES AND TYPES OF PRACTICE
Figure 1-2 Patient Care. Patient care requires integration of
Patient-focused pharmacy practice is performed every-
knowledge and skills.
where patients interact with the health care system, includ-
ing community pharmacies, outpatient clinics, teaching 
and community hospitals, long-term care facilities, and 
Medication therapy management (MTM) services pro- home health care. Pharmacists, like other health care pro-
vide pharmacists with new opportunities for direct patient  fessionals, specialize in practice areas such as pediatrics, 
care. The Medicare Prescription Drug, Improvement, and  critical care, nutrition, and cardiology (Box 1-2). Some 
Modernization Act of 2003 (also known as the Medicare practice areas (e.g., infectious disease, nutrition) parallel 
Modernization Act) established Medicare Part D.2 Medicare  and are similar to traditional medical specialty and sub-
Part D provides for prescription drug benefits for Medi- specialty areas. Other specialty practice areas (e.g., drug 
care beneficiaries, including pharmacist- provided MTM  information, pharmacokinetics) are unique to pharmacy.
services. MTM is defined as “a distinct service or group 
of services that optimize therapeutic outcomes for indi- REQUIREMENTS AND VOLUNTARY
vidual patients. Medication Therapy Services are indepen- CREDENTIALING AND CERTIFICATE
dent of, but can occur in conjunction with, the provision  PROGRAMS
of a medication product.”3 The goals of MTM services 
Requirements
include improved medication understanding, adherence 
and detection of medication-related problems, includ- Licensure. To be eligible for licensure, pharmacists must 
ing adverse drug reactions.4 MTM services include a wide  be graduates of a college of pharmacy accredited by the 
range of responsibilities and activities (Box 1-1). American Council on Pharmaceutical Education (ACPE)
Chapter 1 Introduction: The Practice of Clinical Pharmacy 3
or from a pharmacy school approved by the state board 
of pharmacy. Pharmacists who graduated from foreign 
pharmacy schools are eligible for licensure if they have 
earned  the  Foreign  Pharmacy  Graduate  Examination 
Committee (FPGEC) certification or follow other state-
specific requirements. All states except California require 
successful completion of the North American Pharmacist 
Licensure  Examination  (NAPLEX).  (California  admin-
isters its own licensing examination.) All states require 
that licensure candidates complete a specified number 
of internship hours, typically around 1500 hours, prior 
to seeking licensure. Some states allow the internship 
hours to be earned prior to graduation from pharmacy 
school; some states require that some or all of the hours 
be earned after graduation. Many states also require suc-
cessful completion of the Multi-State Pharmacy Juris-
prudence Examination (MPJE). Some states still require 
successful completion of a laboratory (“wet lab”) exami-
nation. Licensure for authorization to administer inject-
able medications (e.g., immunizations) is a separate but 
parallel licensing process.
Relicensure. Most licensing boards require that pharma-
cists earn continuing education units (CEUs) for relicen-
sure. The CEUs are earned by successful participation in  Figure 1-3 Pharmacist Credentials. Pharmacists are eligible for
a variety of voluntary credentials. (Jupiter Images)
ACPE-accredited  continuing  education  programs  (e.g., 
live programs and continuing education articles in pro-
fessional journals). Some states require that pharmacists 
earn some of the CEUs by participating in specific types  Table 1-1 Board of Pharmacy Specialties (BPS)
of continuing education programs (e.g., live programs).  Recognized Pharmacy Specialties
Some states require specific content (e.g., human immu-
Initial
nodeficiency virus [HIV] or immunization continuing 
Specialty Acronym Recognition
education).
Nuclear Pharmacy BCNP 1978
Voluntary Credentialing and Certificate Programs
Pharmacotherapy BCPS 1988
Postlicensure  credentialing. Postlicensure  credential- Nutrition Support Pharmacy BCNSP 1988
ing is voluntary and is available at the specialist or dis-
Psychiatric Pharmacy BCPP 1992
ease level. Postlicensure credentials indicate that the 
Oncology Pharmacy BCOP 1996
pharmacist has additional expertise above and beyond 
what is required for licensure (Figure 1-3). The Council  BCNP, Board Certified Nuclear Pharmacist; BCNSP, Board Certified
on Credentialing in Pharmacy (CCP) defines certifica- Nutrition Support Pharmacist; BCOP, Board Certified Oncology Pharmacist;
tion as “a voluntary process through which a nongov- BCPP, Board Certified Psychiatric Pharmacist; BCPS, Board Certified
ernmental agency or an association grants recognition  Pharmacotherapy Specialist.
to an individual who has met certain predetermined 
qualifications specified by that organization. This formal 
recognition is granted to designate to the public that this  the BPS6 (Table 1-1). Requirements vary by board. For 
individual has attained the requisite level of knowledge,  example, BPS board certification requires an entry-level 
skill, and/or experience in a well-defined, often special- pharmacy degree (bachelor of science in pharmacy or doc-
ized, area of the total discipline.”5 The term certification  tor of pharmacy), an active pharmacy license, additional 
should not be confused with the term certificate, which  experience and/or training (residency or fellowship) in 
is the document given to a person upon completion of  the specialty area, and passage of a specialty-specific writ-
a program. ten examination. Recertification is required every 7 years. 
Specialist  credentialing. Board  certification  (official  The BPS also recognizes additional expertise within a sub-
recognition of specific knowledge and skills) is achieved  specialty area by the designation “Added Qualifications 
in addition to state and federal professional licensure.  (AQ)” (e.g., Board Certified with Added Qualifications). 
Some employers require board certification for specific  Added Qualifications in infectious diseases pharmaco-
jobs, whereas other employers reward pharmacists who  therapy and cardiology pharmacotherapy are currently 
become board certified with additional career advance- available within the pharmacotherapy specialty practice 
ment opportunities and salary differentials. The Board  area. The Added Qualifications designation is earned by 
of Pharmacy Specialties (BPS), created in 1976 by the  demonstrating the additional expertise through a portfo-
American Pharmacists Association (APhA), is responsible  lio process (Box 1-3).
for setting standards for certification and recertification  Multidisciplinary  disease-specific  credentialing: A 
and for administering the certification and recertification  variety of health care professionals, including pharma-
proc esses. Five specialty practice areas are recognized by  cists, are eligible for certification in select disease-specific
4 Clinical Skills for Pharmacists: A Patient-Focused Approach
multidisciplinary  certification  programs  (Table  1-2).  program. Certificate programs are voluntary and do not 
Requirements are different for each program. For exam- require any additional training or experience beyond 
ple, the 2010 requirements for application for the Certi- that required for pharmacy licensure. ACPE certificate 
fied Diabetic Educator (CDE) program include a minimum  programs provide at least 15 hours of programming that 
of 2 years of professional practice, completion of a mini- must include practice experiences to demonstrate the 
mum of 1000 hours of diabetes self-management edu- given professional competency. Participants are evalu-
cation (DSME), completion of a minimum of 15 hours  ated by a summative evaluation process. Completion of 
of relevant continuing education activities within the 2  a certificate program provides evidence of achievement 
years prior to application, and status as either a licensed  of professional competencies beyond those required for 
clinical psychologist, registered nurse, occupational ther- pharmacy licensure.
apist, optometrist, pharmacist, physical therapist, physi- Postlicensure residency and fellowship training pro-
cian (MD or DO), or podiatrist, or as a registered dietitian,  grams. Pharmacy  graduates  obtain  additional  experi-
physician assistant, exercise physiologist, or other health  ence, knowledge, and skills by completing a variety of 
care professional with a minimum of a master’s degree.7 residency and fellowship postgraduate training certifi-
Certificate  programs. In  2000,  the  ACPE  assumed  cate programs. Most residency and fellowship programs 
responsibility  for  voluntary  pharmacy  certificate  pro- require candidates to have either entry-level or postbac-
grams based on specific professional competencies (Phar- calaureate doctor of pharmacy degrees. The American 
macy-Based  Immunization  Delivery,  Pharmaceutical  Society of Health-System Pharmacists (ASHP) publishes 
Care for Patients with Diabetes, Pharmacy-Based Lipid  a directory of ASHP-accredited residency programs. The 
Management,  OTC  Advisor:  Advancing  Patient  Self- American College of Clinical Pharmacy (ACCP) publishes 
Care, and Delivering Medication Therapy Management  a directory of residency and fellowship programs offered 
Services in the Community). Pharmacists who success- by members of the ACCP. The APhA provides a searchable 
fully complete a postgraduate certificate program receive  on-line community pharmacy residency locator directory.
a certificate documenting successful completion of the  A residency is defined as an “organized, directed, post-
graduate training program in a defined area of pharmacy 
practice”8 (Table 1-3). Residencies provide pharmacists 
Box 1-3 Portfolio Requirements for Added with 1 to 2 years of supervised experience in practice 
Qualifications in Cardiology and management activities. Postgraduate year 1 (PGY-
1)  residency  programs  train  generalists;  postgraduate 
Letter requesting portfolio review
year 2 (PGY-2) residency programs train pharmacists in 
Detailed summary of each of the following elements:
a specialty patient care area. Residents generally gain 
Specific and current professional responsibilities
experience by providing a variety of inpatient and out-
Bibliography of professional publications
patient  pharmacy  services  under  the  supervision  of 
Past (within last 7 years) and present research and other
one or more preceptors. Most residencies are based in  
scholarly activities
hospitals;  however,  increased  interest  in  community 
Past (within last 7 years) and current activities in
pharmacy and ambulatory care residencies has resulted 
didactic or clerkship, residency, or fellowship
in the creation of an increasing number of community 
education of health care professionals in
pharmacy and ambulatory care residency programs. The 
cardiovascular pharmacotherapy
ASHP accredits residency programs, but there are many 
Current memberships in professional organization
nonaccredited residency programs.
related to cardiology
A  fellowship  is  a  highly  individualized  program 
Special or unique training or professional development
designed to prepare the pharmacist to become an inde-
programs
pendent researcher.8 Fellows spend approximately 80% 
Professional awards, honors, or special achievements
of their time in research-related activities. Currently no 
related to cardiovascular pharmacotherapy
mechanism for accreditation of fellowship programs is 
Current curriculum vitae
available. However, the ACCP Fellowship Review Com-
From Board of Pharmacy Specialties: Current Specialties. Available at: http:// mittee conducts a voluntary peer review of fellowship 
www.bpsweb.org/specialties/specialties.cfm. Accessed October 12, 2009. programs.  As  of  2009,  17  fellowship  programs  were 
Table 1-2 Examples of Multidisciplinary Credentials
Specialty Credentialing Organization Title Acronym
Anticoagulation National Certification Board for Anticoagulation Certified Anticoagulation Care CACP
Providers Provider
Asthma National Asthma Educator Certification Board Certified Asthma Educator AE-C
Diabetes National Certification Board for Diabetic Educators Certified Diabetic Educator CDE
Lipidology Accreditation Council for Lipidology Clinical Lipid Specialist CLS
Pain American Academy of Pain Management Credentialed Pain Practitioner CPP
Toxicology American Board of Applied Toxicology Diplomate of the American Board of DABAT
Applied Toxicology