cc licensed ( BY ) flickr photo by Stefan Andrej Shambora: http://flickr.com/photos/st_a_sh/493343628/

Many colleagues have asked for examples of where they can adapt in their practice.  While expanded scope of practice is in different stages in each province, most provinces already have, or will soon have, changes in pharmacy legistlation to allow for pharmacists to adapt prescriptions.  Before we get into practice examples, let’s define adapting a prescription as the following*:

• Renewing a current prescription without having a refill authorized by a prescriber.
• Changing a dose, formulation or regimen of a prescription
• Substituting another drug that is expected to have a similar therapeutic effect.

*(this most closely matches the legislation in Alberta)

Most pharmacists have no trouble renewing existing therapy.  Usually, the perception being that there is little risk in renewing for the short term a medication the patient is already on.  Where pharmacists hesitate is when they are faced with therapy that they feel is either inappropriate or less than ideal for their patient and making the decision to change therapy.

Caring for patients is complex business.  It requires patient assessment, drawing up of a care plan, making clinical decisions, ensuring any necessary follow up is done and collaboration with other health professionals.  As the level of care and decision making rises, so does risk.  Pharmacists often ask me about how to protect themselves against risk when making decisions.  While there is no fail safe, and there will be at some point a decision you will second guess or perhaps realize was in error, it is important to know that all clinicians make errors.  The primary concern of course is patient safety, and keeping our clinical decisions within bounds of our own personal knowledge and skills is essential.

So where to start?  If you are a pharmacist who hasn’t moved beyond extending prescriptions and is feeling uncomfortable with moving forward in clinical decision making, what do you do?  It is undoubtedly the way of the future, so how do you move forward?

One way pharmacists have moved forward in adapting and even further into independent prescribing is to take on a specialty.  There are many out there, for example: Certified Diabetes Educator, Certified Respiratory Educator, Certificate in Travel Medicine, etc.  These certifications often give pharmacists the confidence to make clinical prescribing decisions.

However, not everyone wants to obtain certification or write an exam.  For those who are in community or hospital practice, the confidence and ability to move forward can be gained, and the way to start is to just jump in.  It can seem overwhelming to look at your entire practice and scope of knowledge and pick out where you need to brush up or improve your skills.  What I often tell pharmacists is to start with ONE area.  Choose a therapeutic area that you are interested in or used to be interested in and start with that.

If you happen to have an interest in cardiovascular meds then choose learning in that area and focus on it.  Become familiar with the CCS guidelines for atrial fibrillation, dyslipidemia, heart failure, etc.  Or start with the newest hypertension guidelines.  Then, the most important step is to start applying your knowledge to your patients.   If it’s hypertension you have chosen then make a point of talking with every patient on an antihypertensive to see if they know what their goal blood pressure is.  Ask if they home monitor and teach them what their goal should be.  Ask patients to bring in a history of their home blood pressure monitoring numbers so you can assess whether their therapy is working for them. Once you start engaging patients and are confidant in your knowledge of the current guidelines, it will flow naturally to be assessing whether their antihypertensive therapy is appropriate and keeping them at target.  From there you will find yourself making clinical recommendations for changes in therapy.  So many patients fall through the cracks in pretty much every therapeutic area that there will be no lack of opportunity to make drug therapy decisions.

If you don’t know what your passion is, I usually suggest you start with something like pediatric dosing of antibiotics.  This is an easy foray into adapting doses with fairly clear guidelines for therapy.  Start with every pediatric otitis case you see and check if the drug being prescribed is actually indicated for otitis and whether it is indeed being prescribed at the correct dose.  Make ‘Bugs’n Drugs’ your best friend and double check in a second or even third resource when you start out.  It won’t be long before you won’t have to look up when to use high dose amoxil and what the dose actually is.  In a busy practice you will find yourself seeing many prescriptions that require adapting and it will soon become second nature for you to adapt them.  The first few times you may struggle on the wording of your notification to the prescriber, but soon it becomes second nature.

“Dr._______  I adapted the dose of amoxiciliin to 90mg/kg/day x 5 days for this patient with otitis media; she had antibiotic exposure two months ago and attends daycare (as per Bugs & Drugs 2012).  I have advised the mother on possible adverse reactions and will follow up with her in 5 days to see if symptoms have resolved.   Patient weight= 15kg”

Amoxicillin 450mg tid x 5 days

Joe Pharmacist BscPharm

December 13, 2013

Of course, taking responsibility for the clinical decision and prescribing means you have assessed the patient adequately.  This doesn’t take as long as you might think and becomes quicker and seamlessly part of your work flow the more you do it.  After assessing and adapting the prescription, the part where most pharmacists groan is in documentation.  Yes, you have to notify the prescriber (example above) and document your decision in the patient record.  Again, the more you do it the easier it becomes and the less time it takes.   Pharmacists document in all sorts of ways: DAP, SOAP, narrative, etc.  Something as simple as:  “Patient seen today with chief complaint of otitis media.  Has had one course of cefixime two months ago, attends daycare.   Rx was written at 30mg/kg/day x 10 days.  I adapted dose to 90mg/kg/day x 5 days as per Bugs and Drugs.  Follow up scheduled for 5 days for efficacy and ADRs.”

Of course you must ensure you follow all the regulations and Standards of Practice for your particular province.  Make yourself familiar with them and figure out how to meet requirements in an efficient manner that puts the least amount of stress on your work flow.

Moving out of our comfort zones is scary…that’s why they’re comfort zones, because we’re nice and comfortable where we are.  But guaranteed, once you start expanding your practice, professional satisfaction grows incrementally along with great patient care.