對(duì)臨床藥學(xué)

焦點(diǎn)問(wèn)題的認(rèn)識(shí)邵宏史錄文北京大學(xué)藥學(xué)院藥事管理與臨床藥學(xué)系主要內(nèi)容對(duì)臨床藥學(xué)內(nèi)涵的理解臨床藥師為誰(shuí)而工作？臨床藥師主要干什么？臨床藥師都在哪里工作？臨床藥師的水平如何分出高下？行業(yè)協(xié)會(huì)與藥師的認(rèn)證評(píng)估我國(guó)臨床藥學(xué)的可持續(xù)發(fā)展何為臨床藥學(xué)？ACCP和ESCP的定義：ClinicalPharmacyisacommonlyusedterminpharmacypracticeandinpharmacyliterature形式——藥學(xué)實(shí)踐(PharmacyPractice)Itdescribestheactivitiesandservicesoftheclinicalpharmacisttodevelopandpromotetherationalandappropriateuseofmedicinalproductsanddevices核心——合理用藥藥學(xué)監(jiān)護(hù)(PharmaceuticalCare)——necessaryphilosophyandmissionofpharmacypractice,abasicpatientneed臨床藥學(xué)對(duì)人，藥學(xué)對(duì)物Revolution

orRenaissance?臨床藥學(xué)是醫(yī)療發(fā)展的結(jié)果何為臨床藥師？美國(guó)藥學(xué)人員的分類(lèi)Pharmacist(Pharmacyspecialist,ClinicalPharmacist)Pharmacytechnician臨床藥師——Part

orFull？——FTEPharmacists(FullTimeEquivalent，40hrs/w)——臨床藥師的數(shù)量和學(xué)位

藥師的社會(huì)地位臨床藥師的工作對(duì)象與工作性質(zhì)工作對(duì)象——醫(yī)師o(wú)r患者?工作性質(zhì)——監(jiān)管or服務(wù)?工作手段≠工作性質(zhì)——鑒別、解決、預(yù)防潛在的或?qū)嶋H發(fā)生的DRPs工作目的≠工作內(nèi)容——改善患者生命質(zhì)量(qualityoflife)臨床藥師的工作內(nèi)容藥師職業(yè)角色的發(fā)展——藥學(xué)實(shí)踐(Pharmacypractice)藥學(xué)實(shí)踐的幾種模式美國(guó)藥師崗位培訓(xùn)——Residency美國(guó)藥師繼續(xù)教育規(guī)范臨床藥師的工作范圍ACCP和ESCPItincludesalltheservicesperformedbypharmacistspractisinginhospitals,communitypharmacies,nursinghomes,home-basedcareservices,clinicsandanyothersettingwheremedicinesareprescribedandused藥學(xué)實(shí)踐的主要方向我國(guó)現(xiàn)階段的情況——主要在三甲醫(yī)院臨床藥師的工作層次初級(jí)（Fundamental）在對(duì)病人提供安全的藥學(xué)監(jiān)護(hù)中起關(guān)鍵作用18項(xiàng)具體指標(biāo)中級(jí)（Desirable）提供更專(zhuān)業(yè)化和專(zhuān)科化的藥物治療學(xué)服務(wù)13項(xiàng)具體指標(biāo)高級(jí)（Optimal）提供整合的、專(zhuān)業(yè)化的和精細(xì)的專(zhuān)科服務(wù)，旨在通過(guò)最高層次的教學(xué)、研究和藥物治療實(shí)踐活動(dòng)優(yōu)化藥物治療效果12項(xiàng)具體指標(biāo)RudisMIandBrandlKM.CritCareMed2000;28(11):3747南加州大學(xué)；新墨西哥州大學(xué)每個(gè)等級(jí)都包含了4個(gè)方面的活動(dòng)：clinical,educational,administrative,scholarly行業(yè)協(xié)會(huì)與藥師的認(rèn)證評(píng)估APhA–AmericanPharmacistAssociation(1852)NARD–NationalAssociationofRetailDruggists(1898)NABP–NationalAssociationofBoardsofPharmacy(1904)ACPE–AccreditationCouncilforPharmacyEducation(1932)AACP–AmericanAssociationofCollegesofPharmacy(1937)ASHP–AmericanSocietyofHealth-SystemPharmacists(1942)ASCP–AmericanSocietyofConsultantPharmacists(1969)ACCP–AmericanCollegeofClinicalPharmacy(1979)AAPS–AmericanAssociationofPharmaceuticalScientists(1986)NISPC–TheNationalInstituteforStandardsinPharmacistCredentialing(1998)ESCP–EuropeanSocietyofClinicalPharmacyTheBoardofPharmaceuticalSpecialties(B.P.S.)1976NuclearPharmacy(1978)——BCNPNutritionSupportPharmacy(1988)——BCNSPPharmacotherapy(1988)——BCPSPsychiatricPharmacy(1992)——BCPPOncologyPharmacy(1996)——BCOPTheCommissionforCertificationinGeriatricPharmacy(C.G.P.)1997CertifiedDiseaseManager(C.D.M.)ofdiabetes,asthma,dyslipidemia,andanticoagulationtherapy.2006年美國(guó)臨床藥師工作狀況MacLarenR,RudisMI,etal.AnnPharmacother2006;40:612-8科羅拉多州大學(xué)；南加州大學(xué)382個(gè)醫(yī)療機(jī)構(gòu)活動(dòng)比例直接臨床藥學(xué)活動(dòng)62.2％個(gè)單位藥師輪轉(zhuǎn)查房時(shí)間4.4±0.5d/w工作時(shí)間分配病人監(jiān)護(hù)藥品分配藥品管理教育教學(xué)43％26.2％12.6％10.9％7.3％初級(jí)臨床工作75％的工作日中級(jí)與高級(jí)工作部分進(jìn)行我國(guó)臨床藥學(xué)的可持續(xù)發(fā)展處于初級(jí)起始階段普通藥師與臨床藥師并存，需設(shè)立適當(dāng)門(mén)檻，普通藥師需經(jīng)過(guò)專(zhuān)門(mén)培訓(xùn)合格后方可成為臨床藥師臨床藥師社會(huì)化——由醫(yī)院臨床藥師逐漸向社區(qū)臨床藥師發(fā)展我國(guó)臨床藥學(xué)的可持續(xù)發(fā)展人才培養(yǎng)是可持續(xù)發(fā)展的根本數(shù)量與質(zhì)量——由少而精逐漸往多而專(zhuān)發(fā)展大專(zhuān)院校人才儲(chǔ)備要多層次多方向培養(yǎng)不同院校應(yīng)根據(jù)自己的特點(diǎn)進(jìn)行某些層次某些方向的培養(yǎng)明確普及教育與精英教育、理學(xué)(學(xué)位)教育與專(zhuān)業(yè)(職業(yè))教育的不同教學(xué)目標(biāo)和教學(xué)方式崗位人才培訓(xùn)將轉(zhuǎn)型培訓(xùn)與繼續(xù)教育分開(kāi)轉(zhuǎn)型培訓(xùn)以初級(jí)崗位培訓(xùn)項(xiàng)目為主繼續(xù)教育以中級(jí)和高級(jí)培訓(xùn)項(xiàng)目為主由全能型培養(yǎng)往方向型培養(yǎng)轉(zhuǎn)換我國(guó)臨床藥學(xué)的可持續(xù)發(fā)展相關(guān)制度的跟進(jìn)是可持續(xù)發(fā)展的保障臨床藥師崗位制度“編制、配比、分級(jí)”從“三無(wú)”到“三有”臨床藥師的“頭銜”可以在現(xiàn)有藥師職稱(chēng)的基礎(chǔ)上附加，無(wú)需另設(shè)職稱(chēng)認(rèn)證與評(píng)估制度Helpindividualhospitalinpatientsandnonhospitalizedpatientsachievethebestuseofmedications.Applyevidence-basedmethodstotheimprovementofmedicationtherapy.Improvingthesafetyofmedicationuse.Applytechnologyeffectivelytoimprovethesafetyofmedicationuse.Engageinpublichealthinitiativesonbehalfoftheircommunities.Thanks!1860–1870Communitypharmacy,APhA1870–1950Differentiationbetweenmedicine&pharmacy,Drugfactories,NARD,ACPE1920–1933Alcoholmanagement,Hospitalpharmacy1928AACP4-yearB.S.1942ASHP1944R.Wait“ClinicalPharmacy”1948ASHPInternship1950–1960Hospitalpharmacydevelopment1951OTC,Communitypharmacistsrestriction19546-yearentry-levelPharm.D.atCASF1960–1990Clinicalpharmacyinitiation藥師職責(zé)轉(zhuǎn)變19605-yearBS;Communitypharmacyre-development1962UKMCDIC——Pharmacyspecialist1965DonaldBrodie:Pharmacypractice,patient-centered1966NinthFloorProject,CASF——Pharmacyspecialist/technician;DIC;Unitdose1967UKResidency1970s2-yearpost-B.S.Pharm.D.program;“clinicalpharmacy”1980-1983臨床藥學(xué)概念形成，藥學(xué)會(huì)全國(guó)首次臨床藥學(xué)專(zhuān)題討論會(huì)1989中國(guó)5年制臨床藥學(xué)專(zhuān)業(yè)本科開(kāi)始1990–2020Clinicalpharmacydevelopment1990;1992Hepler&Strand:Pharmaceuticalcare2000AACP6-yearentry-levelPharm.D.programinUS2001TheSocialSecurityAct(享有醫(yī)療合作保險(xiǎn)的患者服務(wù)).中國(guó)6年制臨床藥學(xué)專(zhuān)業(yè)研究生培養(yǎng)開(kāi)始2002醫(yī)院藥事管理暫行規(guī)定（第4章第17條）2005-2006第1個(gè)臨床藥學(xué)專(zhuān)業(yè)研究生畢業(yè)；中國(guó)臨床藥師培訓(xùn)基地試點(diǎn)；臨床藥學(xué)專(zhuān)業(yè)（職業(yè)）學(xué)位申請(qǐng)2007-2008兩屆6年制臨床藥學(xué)專(zhuān)業(yè)碩士畢業(yè)；臨床藥師制試點(diǎn)；臨床藥學(xué)專(zhuān)業(yè)博士畢業(yè)2020ACPEResidencyrequirement:1yrMONEYMagazine2006CareerSurveyPharmacists9/50Stress:BFlexibility:CCreativity:BDifficulty:CTenYearGrowth: 24.5%AveragePay: $91,988臨床藥師的數(shù)量與學(xué)位醫(yī)院床位數(shù)FTE藥師床位數(shù)/藥師ASHP2004年調(diào)查平均9.88肯塔基大學(xué)醫(yī)學(xué)中心4731114.3馬薩諸塞大學(xué)醫(yī)學(xué)中心3502216康涅狄格大學(xué)Hartford醫(yī)院10061760北醫(yī)三院1187？60PhysiciansAttendingFellowResidentInternMedicalstudentPhysicianassistant&NursepractitionerNursingStaffPharmacistsPharmacySpecialistPreceptor&ResidentInstructor&Pharm.D.studentDieticiansHousekeepersEthicsCommitteeHealthCareTeamPharmaceuticalCareSelf-CareDrugInformationClinicalDistributive溝通技巧藥學(xué)實(shí)踐的模式為促進(jìn)健康和預(yù)防疾病準(zhǔn)備教育材料利用分析技術(shù)影響藥物利用和藥物利用策略具有健康篩查和診斷的技巧，藥物治療方案的設(shè)計(jì)與推介，治療方案的判別藥物治療方案的設(shè)計(jì)、推介、監(jiān)測(cè)和評(píng)估藥物治療方案的設(shè)計(jì)、推介、監(jiān)測(cè)和評(píng)估利用高級(jí)溝通技巧與患者形成合作關(guān)系并參與醫(yī)療團(tuán)隊(duì)的決策工作的重心由解決用藥相關(guān)問(wèn)題轉(zhuǎn)移到關(guān)注患者生存質(zhì)量具有藥品準(zhǔn)備與分發(fā)的技巧NimmoCMandHollandRW.AJHP

1999;56:1981-7TotalPharmacyCare(TPC)美國(guó)藥師崗位培訓(xùn)——ResidencyJob (practice)ResidencyPh.D.Pharm.D.PharmacistTeacher&ResearcherPharmacytechnician

（藥技師，無(wú)執(zhí)業(yè)藥師資格）PGY1(普通培訓(xùn))PGY2(專(zhuān)科培訓(xùn))LicensedPharmacistBoardcertificationBCPS

BCOP

BCPP

BCNSP

BCNP測(cè)試與評(píng)估ResidencyProtestforPharmacokinetics轉(zhuǎn)科Resident主要工作內(nèi)容藥學(xué)服務(wù)(PharmacyService)查房前－更新藥歷——PatientProfile&SOAP隨治療團(tuán)隊(duì)常規(guī)查房——RoundWorksheet上報(bào)不良反應(yīng)報(bào)告、用藥差錯(cuò)報(bào)告——實(shí)時(shí)網(wǎng)絡(luò)填寫(xiě)相關(guān)病例單——PharmacistWorksheet提供藥物信息和教育向指導(dǎo)藥師(Advisor)匯報(bào)病例用藥醫(yī)囑與藥學(xué)服務(wù)——PharmacotherapyWorkup24小時(shí)On-Call制度和中心藥房服務(wù)教學(xué)活動(dòng)(EducationalActivities)課堂學(xué)習(xí)與科研活動(dòng)(ScholarlyActivities)PatientProfileSOAPRoundWorksheetPharmacistWorksheetPharmacotherapyWorkup(1)PharmacotherapyWorkup(2)PharmacotherapyWorkup(3)PharmacotherapyWorkup?notesFOLLOW-UPEVALUATIONMedicalCondition(Indication):______________________________________OutcomeParameterPretreatmentBaseline(Date)FirstFollow-up(Date)SecondFollow-up(Date)EffectivenessSign/symptomSign/symptomLabvalueLabvalueSafetySign/symptomSign/symptomLabvalueLabvalueOtherResident部分課程MedicalLibraryandResourcesMedicationHistoriesAnemiaProtocol,IntensiveInsulin,SedationPediatricOverviewPharmacokineticServicesIVCompounding/SterileTechniquesNutritionSupportServicesPharmacistCareDiabetesClassPharmacistCareCardiovascularClassAnticoagulationclinicPharmacyAdministrationSTLC

(ScholarshipofTeaching&LearningCertificateProgram)PharmacyGrandRounds

（每周1次）STLC

(ScholarshipofTeaching&LearningCertificateProgram)主要內(nèi)容ProgramOverviewAssessmentPrinciplesInstructionalTechniquesCurrentTrendsinPharmacyEducationSyllabus,Objectives,ExamQuestionsLargeGroupInstructionalApproachesAssemblingaTeachingPortfolioExperientialEducationGenerationalApproachestoTeachingUsingTechnologyinClassroomFacultyAppointmentsCivilityintheClassroomPeerAssessmentofTeachingDebate-RoleofResidenciesPharmacyGrandRoundsCriticallyIllPatientsColonizedwithMultidrugResistantOrganismsandImpactonLengthofStayDopositivesurveillanceculturespredictclinicalculturesintheICU?TheEffectsofBasiliximabInductiononSerumCreatinineandTimetoCalcineurinInhibitorInitiationinLiverTransplantRecipientsAntibioticExposureinCriticallyIllPatientsColonizedwithMultidrugResistantOrganismsImpactofMedicationTherapyManagementServicesinaChainPharmacySettingonthePharmacyBusinessandDispensingModelEvaluationofContinuationofStressUlcerProphylaxi