SISTEM PENDUKUNG KEPUTUSAN PELAYANAN FARMASI KLINIS
DRA.L. ENDANG BUDIARTI,M.PHARM., APT (RS BETHESDA)
ANNUAL SCIENTIFIC MEETING (ASM) 2017 FK UGM
KAMIS, 23 MARET 2017
OUTLINE
FarmasI klinik
Masalah farmasi klinik
Pendukung keputusan farmasi klinik
OUTLINE
FarmasI klinik
Masalah farmasi klinik
Pendukung keputusan farmasi klinik
APOTEKER - PASIEN
FARMASI KLINIK
• KLINIK = SEKITAR PASIEN
• FARMASI KLINIK = PELAYANAN FARMASI TERKAIT LANGSUNG DENGAN PASIEN
• PERAN :
• IDENTIFIKASI MASALAH TERKAIT PENGOBATAN (DRUG THERAPEUTIC
PROBLEMS=DTP)
• MENYELESAIKAN MASALAH TERKAIT PENGOBATAN
• MENCEGAH DTP
• TUJUAN :
• EFEKTIFITAS PENGGUNAAN OBAT
• SAFETY
PHARMACEUTICAL CARE - HOSPITAL
• THIRTY-SIX STUDIES MET THE INCLUSION CRITERIA,
• INCLUDING 10 THAT EVALUATED PHARMACIST PARTICIPATION ON MEDICAL ROUNDS,
• 11 MEDICATION RECONCILIATION STUDIES AND 15 ON DRUG-SPECIFIC PHARMACIST SERVICES.
• 5 ADVERSE DRUG EVENTS,
• ADVERSE DRUG REACTIONS OR MEDICATION ERRORS WERE
REDUCED IN 7 OF THE 12 TRIALS THAT INCLUDED THESE OUTCOMES.
• MEDICATION ADHERENCE, KNOWLEDGE AND APPROPRIATENESS IMPROVED IN 7 OF 11 STUDIES,
• WHILE THE DURATIONS OF HOSPITAL STAYS DECREASED IN 9 OF 17 TRIALS.
• NO INTERVENTION LED TO WORSE CLINICAL OUTCOMES AND ONLY ONE STUDY
REPORTED MORE USE OF HEALTHCARE SERVICES BY PATIENTS.
(KABOLI ET AL., 2006).
STUDY RESULT
MED ROUND 10
RECONCILIATION 11
SPECIFIC SERVCES 15 INCREASE
Adverse Drug Event 5 DECREASE
LOS 9(17) DECREASE
ADHERENCE 7(11) INCREASE
CRITICAL ILLNESSES
MONITORINGTENSI, NADI,
RESPIRASI, TEMP, SATURASI
ALAT BANTU NAFAS
(VENTILATOR)
KESADARAN MENURUN
AKSES MAKANAN MELALUI NGT
GANGGUAN PERFUSI
JARINGAN
PERUBAHAN KLINIS MEMERLUKAN PERUBAHAN REJIMENTASI OBAT
OBAT-OBATDENGAN
BERBAGAI RUTE
CLASIFICATION OF DTPCIPOLLE, STRAND, MORLEY HEPLER AND STRAND
NEED FOR ADDITIONAL THERAPY UNTREATED INDICATIONS
UNNECESSARY THERAPY IMPROPER DRUG SELECTION
WRONG DRUG SUBTHERAPEUTIC DOSAGE
DOSE TOO LOW FAILURE TO RECEIVE DRUGS
ADVERSE DRUG REACTION OVERDOSAGE
DOSE TO HIGH ADVERSE REACTIONS
ADHERANCE PROBLEM DRUG INTERACTIONS
DRUG USE WITHOUT INDICATIONS
Cipolle, RJ, Strand, LM, Morley, PC, Pharmaceutical Care Practice :the clinician guide, 2nd ed, NY:Mc Graw Hill, 2004
RUANG LINGKUP
PATIENT CENTERED CARE
“CARE THAT IS RESPECTFUL OF AND
RESPONSIVE TO INDIVIDUAL PATIENT
PREFERENCES, NEEDS, AND VALUES.”
THE INSTITUTE OF MEDICINE (IOM)
Nothing about me , without me AKSES
CONFIDENTIAL
KOLABORATIF
PATIENT CENTERED CARE
KEWENANGAN
- AKSES
- MENULIS RM
KOLABORATIF
PRAKTIK KLINIK APOTEKER
REVIEW RESEP
REKONSILIASI OBAT
COMPOUNDING : STERILE, HAZARD
PENGATURAN REJIMENTASI OBAT
KONSELING
PEMANTAUAN TERAPI OBAT
MONITORING EFEK SAMPING OBAT
PATIENT CARE PROCESS
Memastikan outcome terapiSESUAI dengan tujuan terapiyang diinginkan.
TUJUAN
1. Bukti klinis/lab dibandingkan tujuanterapi2. Bukti klinis/lab terkait ADR/toksisitas3. Dok : status klinis dan perubahan
farmakoterapi4. Asesmen masalh baru5. Menjadwalkan follow-up selanjutnya
1. MENERIMAVALIDASI RESEP
2. MEMAHAMIINTERPRETASI
RESEP
3. PENGAMBILANPe-LABEL
4. CEK AKHIR
5. DOKUMENTASI
6. PENYERAHAN OBAT
ATURAN MINUMSARAN
SIKLUS DISPENSING
R/
L Endang Budiarti 15
STERILE - COMPOUNDING
Indication Drug product
Dosage regimen
Outcome
Effectiveness
Safety
Clinical
Labs
Sign and symptoms
Abnormal lab value
Goals of therapy
Adverse Drug Therapy
Toxicity
Labs
Clinical
MONITORING – PEMANTAUAN TERAPI OBAT
S :…….
O :…….
A :…….
P :…….
Tujuan : evaluasi efek pengobatan terhadap tujuan terapiberdasarkan parameter obyektif maupun subyektifyang ditetapkan. Efek yang diperhatikan : efektifitas, efek samping, medication errors
AKREDITASI KARS VER 2012
OUTLINE
FarmasI klinik
Masalah farmasi klinik
Pendukung keputusan farmasi klinik
DOKUMENTASI
PRAKTIK Akses data
Kelengkapan data
Media dokumentasi
KINERJADTP
JML KONSELING, ESO, PIO
VISITE
CASE-REPORT
MTM
Core Elements of an MTM Service Model in Pharmacy includes the following five core elements: • Medicationtherapy review (MTR) • Personal medication record (PMR)• Medication-related action plan (MAP)• Intervention and/or referral• Documentation and follow-up
BETTER OUTCOME
©2012, American Society of Health-System Pharmacists, Inc. All rights reserved
INTERAKSI OBAT
OBAT 1 OBAT 2 DAMPAK TINDAKAN
PHENYTOIN MEROPENEM Menurunkan konsentrasi Phenytoin
INSULIN FUROSEMIDE Hiperglicemia karena efek terapi insulin berkurang
Memerlukan tambahandosis
SALBUTAMOL FUROSEMIDE Meningkatkan efek diuretic, menurunkan Kalium Monitoring kadar Kalium
CLOPIDOGREL OMEPRAZOLE Omeprazole menurunkan efek antiplatelet danmenurunkan konsentrasi metabolit aktifclopidogrel shg efektifitas Clopidogrel menurun
Alternatif PPI lain, Rabeprazole, Pantoprzole
ENOXAPARIN CLOPIDOGREL Efek antikoagulan meningkat Kontra indikasi Diklofenak(IV), monitoring tandaperdarahan
OUTLINE
FarmasI klinik
Masalah farmasi klinik
Pendukung keputusan farmasi klinik
HAK AKSES
• KEWENANGAN KLINIK : READ ONLY,
MENULIS/MERUBAH
• KOLABORATIF : INTEGRATED NOTE
SESUAI KEWENANGAN KLINIK
AKSES LAB, IMAJING
DIAGNOSIS
PROFESINAL NOTE
MENULIS INTEGRATED NOTE
APOTEKER NOTE
DOKUMENTASI
REVIEW RESEP
INDIKASI
DOSIS
INTERAKSI
EFEK SAMPING
OBAT/HERBAL/SUPLEMEN RUTIN
REKONSILIASI OBAT
TELUSUR RIWAYAT OBAT, SUPLEMEN, HERBAL
RIWAYAT KEPATUHAN
RIWAYAT ESO
KOMUNIKASI DGN DOKTER
PENETAPAN OBAT LANJUT/STOP/PERUBAHAN REJIMEN
DTP PENETAPAN DTP
PERENCANAAN PENYELESAIAN
PELAKSANAAN
MONITORING
MONITORING EFEK SAMPING OBAT
MESO IDENTITAS PASIEN
IDENTITAS OBAT
RIWAYAT KEJADIAN
ANALISIS NARANJO
QUESTION
YES
NO
DO NOT KNOW
9.1.1 Are there previous conclusive reports on this reaction?
+1 0 0
9.1.2 Did the adverse event appear after the suspected drug was administered?
+2 -1 0
9.1.3 Did the adverse reaction improve when the drug was discontinued or specific antagonist was administered?
+1 0 0
09.1.4 Did the adverse reaction reappear when the drug was readministered?
+2 -1 0
9.1.5 Are there alternative causes (other than the drug) that could on their own have caused the reaction?
-1 +2 0
9.1.6 Did the reaction reappear when a placebo was given?
-1 +1 0
9.1.7 Was the drug detected in the blood (or other fluids) in concentration known to be toxic?
+1 0 0
9.1.8 Was the reaction more severe when the dose was increase, or less severe when the dose was decreased?
+1 0 0
9.1.9 Did the patient have a similar reaction to the same or similar drugs in any previous exposure?
+1 0 0
9.1.10 Was the adverse event confirmed by any objective evidence?
+1 0 0
TOTAL SCORE SCORE : Adverse event possible : 1-4; probable= 5-8; definite = 9 or more Maximum possible score = 13
PELAYANANINFORMASI
OBAT
ReferensiTERPERCAYA
KEPUTUSAN KLINIK
• PENETAPAN OBAT : NAMA, KEKUATAN, JUMLAH, LEGALITAS
• PENETAPAN OBAT LANJUT/STOP/PERUBAHAN REJIMEN
• PENETAPAN :
• INDIKASI,
• PILIHAN OBAT,
• DOSIS,
• INTERAKSI,
• EFEK SAMPING,
• KONTRA INDIKASI
• PENETAPAN TINDAKAN APOTEKER
• EFEKTIF, AMAN, MONITORING
INDIKATOR KINERJA
# pharmaceutical care interventions / standardised denominator
# of patients counselled / standardised denominator,
# formal written feed-back
responses from patients
# adverse drug event reports /
year.
90% COUNCELING PX WITH MEDICAL DEVICES
80% - WARFARIN
80% ELECTROLYTE (CONCENTRATED)
100% COUNCELLING-ARV
DATA - TABEL
DATA PASIEN USIA, SEX, TB, BB, DIAGNOSIS, MEDIA AKSES
DATA OBAT NAMA BRAND, ZAT AKTIF, KEKUATAN, BENTUK SEDIAAN, VOL, RUTE, NO BATCH, NO MANUFAC, ED, PELARUT, STABILITAS
ALERT INTERAKSI, OVER DOSIS, RIWAYAT ESO, HIGH ALERT, CONTROLLED DRUG, FORMULARIUM, FORNAS
RUMUS IBW, ClCr, BEE, KELARUTAN
DTP TGT REFERENSI YG DITETAPKAN
TINDAKAN APOTEKER
PERUBAHAN BENTUK SEDIAAN
PERUBAHAN DOSIS
STOP OBAT
MONITORING
APOTEKER LEGALITAS, KEWENANGAN, HAK AKSES
TERIMA KASIH