Ambulatory care

- Definition
- Examples of ambulatory care and
role of pharmacist
1. Residential care
2. HPN (Home Parenteral Nutrition) and
Home Dialysis
- Pharmacists fee in ambulatory care?
 What is ambulatory care?
Health services provided on an outpatient basis to
those who visit a hospital or another health care
facility and depart after treatment on the same day.
(Mosby's Medical Dictionary, 8th edition.2009,
Elsevier)
Pelayanan kesehatan kepada pasien rawat
jalan.
Siapa saja?
 Residential care
Three types of residential, depend on
the clientele:
independent residents
elderly residents
people with specific medical
requirements
 Medicine administration in homes
Patient have complete control of all their medicine,
both prescribed and OTC (esp. independent)

Pharmacists role
1. Preparing the medicines
2. Documentation and recording
3. Storage and control of medicines
4. Assistance in maintaining compliance
5. Ordering and delivery of medicines
6. Disposal of unwanted medicines
7. Regular visits
 Can be prepared for 1-month supply.
Stages:
1. Check the identity of the patient.
2. Check the residents medication record,
noting any changes made by the doctor.
3. Identify the medicine and check that the
label has the residents name and
corresponds with the medication record.
4. Administer the medicine.
5. Endorse the medication record
immediately
6. Record if there any reason why a dose is not
taken
 At least three type of records should be used:
1. A medicines record, which is used as a central
record of ordering and receiving medicines
effective stock control.
2. The medication profile for each patient (PMR);
will include information such as allergy and
current and past medicines.
3. The administration record, should be in the
same sheet with medication profile.
 Independent patient responsible for
the storage of their medicines,
however in a resident like nursing
homes there must be a place
(medicine cupboard) that can be used
to store the medicines centrally.
 Pharmacist must understand the
reason for non-compliance and
helped to solve the problems.
Understanding about the medicines,
most of times is a keyword for
improving patients compliance.
 Agreement on minimum stock level
must be made, to allow adequate time
for prescription preparation,
collection, dispensing and delivery.
 Medicines that are no longer used
because treatment has been
discontinued or completed should be
destroyed, and the overall
responsibilty is lies with the
pharmacist with the help of the carer.
 The pharmacist should check the
medication records in a regular basis,
expiry date checks, and add a more
clinical role by reviewing the
medications profile of the patients; help
to identify problems arising with
combination of medicines, dosage form
or selection of drug.
 Frequently given to patients especially
post-op patients, who potentially suffer
from nutritional defficiencies.
Short-term IV of 5% D5NSSufficient for
post-op patients (provide 500 cal/day
without any proteins, vitamins or
minerals), but longer-term patients need
total parenteral nutrition (TPN). Its
supplied to patients at home Home
parenteral nutrition (HPN)
 Indications for TPN:
- GIT disease Crohns disease and
malabsorption syndrome
- Major trauma including severe burns,
intensive care patients, and acute renal failure
- Major abdominal surgery
- Malignancy of the small bowel
- High dose chemotherapy, radiotherapy,
and bone marrow transplantation.
 TPN formulation
Made in hospital Strict aseptic conditions, or
readily available from pharmaceutical
companies.
Component:
- Water
- Protein
- Energy source carbohydrate and possibly fat
- Electrolytes
- Trace elements
- Vitamins and minerals.
 HPN
- Becoming popular for long-term TPN
patients does not require hospitalisation.
- Given to patients via central vein or peripheral
vein.
- Suitable candidates for HPN initially
provided with TPN until their medical
condition is stabilized undergo training for
administration TPN at home.
- Require regular check-up to hospital
 Potential problems for HPN
patients:
a) Mechanical problems
b) Metabolic problems
c) Catheter-related problems
d) Psychological and social problems
 Pharmacists role in
TPN/HPN

Give training on aseptic technique for

handling and setting up TPN bags
Formulation requirements
Potential complications or stability
problem
Give information on storage conditions
required.
 An artificial method used to substitute the
act and function of kidney (ultrafiltration)
in patients with impaired renal condition.
Not completely replace renal function, but
can be used as a way of removing toxic
metabolites, correcting acid-base balance
and avoiding fluid overload.
Main types:
- Haemodalysis (HD)
- Peritoneal dialysis (PD)
 Haemodialysis (HD)
- In HD blood is removed from the patients
body and filtered by passing it over an
artificial semipermeabel membrane known
as a dialyser before being return to the
patients body again.
- Much more efficient in treating renal failure
than peritoneal dialysis and can correct the
fluid overload and electrolyte imbalance
more rapidly, however it is a much more
complicated procedure for home patients.
 Haemodialysis
 Peritoneal Dialysis (PD)
- In PD the dialysis fluid is passed directly into
the patients body (peritoneum-lined
abdominal cavity) and no blood removal
occurs.
- Peritoneal membrane acts as a
semipermeabel membrane allowing exchange
between the blood and the dialysis solution.
- Continuous ambulatory peritoneal dialysis
(CAPD) is the most widely used for home
dialysis.
 Advantages:
- Less disruption to the bodys
electrolyte balance
- Blood loss is avoided
- Simple process, easy to teach
patients
- Useful technique for children
- Blood sugar level can be controlled by
adding insulin to dialysis fluids, if
required.
 Disadvantages:
- Not as efficient as haemodialysis
- Obesity can be a problem for some
patients
- Contraindicated in patients who have
recently undergo abdominal surgery
- Potential develop of peritonitis.
 Peritoneal dialysis
 Pharmacists role in dialysis

- Give training on aseptic technique and

catheter care
- Clinical assesment of patients
- Provision of drug information
(bioavailability of renally excreted drugs)
- Ordering and supplying dialysis fluid and
ancillaries to home dialysis patients.
 Pharmacists fee in ambulatory care?

Pharmacist-directed patient care services

patient education, patient counselling, product
use demontration, therapy monitoring,
utilization review, disease management and
wellness management Traditionally have not
been paid for by private-pay patients or included
as benefits in healtcare plans.
Still debatable
 Winfield AJ, Richards RME, eds. Pharmaceutical
Practice. 3rd ed. Churchill Livingstone:2004.
Bradberry JC, Srnka Q. Pharmacist compensation
for ambulatory patient care services. Am J Man
Care.1998; 4(12):1727-38.