sistem pendukung keputusan pelayanan farmasi...

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