临床药师参与肾内科联合门诊服务工作的实践

Practice of Multidisciplinary Outpatient Service in the Department of Nephrology Participated by the Clinical Pharmacist

目的探讨临床药师参与肾内科联合门诊服务工作的模式和作用。方法由肾内科医师、临床药师、营养师和护士4方组成治疗团队,为慢性肾脏病(chronic kidney disease,CKD)患者提供全方位的治疗管理。统计2018年1月至2019年7月在肾内科联合门诊就诊的CKD患者基本信息、疾病诊断、依从性评估和药物重整(medication reconciliation,MR)信息等,采用欧洲药学监护网络基金会(PCNE)分类V9.0版对患者存在的药物相关问题(drug related problems,DRPs)进行评估及干预并进行统计分析。结果本研究最终共纳入62例患者88例次就诊资料。其中CKD 2期3例(4.84%)、CKD 3期43例(69.35%)、CKD 4期11例(17.74%)、CKD 5期5例(8.06%)。合并高血压最多,共41例(66.13%)、合并高尿酸血症30例(48.39%)、合并高脂血症14例(22.58%)、合并糖尿病10例(16.13%)、合并贫血9例(14.52%)。每位患者平均服用药物(6.11±2.44)种(1~13种),服药≥5种的患者有47例(75.81%)。药师共发现DRP 93个,危害性分级中C级共29个(31.18%),D级27个(29.03%),A级25个(26.88%),E级11个(11.83%),B级1个(1.08%)。经干预后DRPs全部被解决,86.67%的复诊患者经干预后依从性能达到8分。结论临床药师参与联合门诊可以提高CKD患者的依从性,减少DRPs,保障患者用药安全。

OBJECTIVE To investigate the mode of multidisciplinary outpatient service in the department of nephrology participated by the clinical pharmacist. METHODS The treatment team consist of clinical pharmacist, clinician, nurse and nutritionist in the department of nephrology provides comprehensive treatment for patients with chronic kidney disease(CKD). Clinical pharmacist filled the CKD patients records who visited the outpatient department of nephrology from January 2018 to July 2019 including basic information, disease diagnosis, drug compliance evaluation and medication reconciliation. The PCNE classification(Version 9.00) was used to assess and intervene in the CKD patients drug related problems(DRPs) and statistical analysis of results. RESULTS According to the exclusion criteria, 88 cases and 62 patients were included in this study. 3 patients(4.84%) had stage 2 CKD, 43 patients(69.35%) had stage 3 CKD, 11 patients(17.74%) had stage 4 CKD, 5 patients(8.06%) had stage 5 CKD. 41 patients(66.13%) had hypertension, 30 patients(48.39%) had hyperuricemia, 14 patients(22.58%) had hyperlipidemia, 10 patients(16.13%) had diabetes mellitus, 9 patients(14.52%) had anemia. The average number of drugs used per patient was(6.11±2.44) species(1-13 species) and 47 patients(75.81%) took more than five species drugs. Ninty-three medication-related problems were found, distribution of harmed levels as follows: 29 problems(31.18%) were level C, 27 problems(29.03%) were level D, 25 problems(26.88%) were level A, 11 problems(11.83%) were level E, only one problem(1.08%) was level B. All of them were fully implemented by intervention, compliance score of 86.67% of subsequent visit patients were attached 8. CONCLUSION Through the intervention of clinical pharmacist to the patients with CKD, the compliance of patients can be improved, and DRPs can be reduced to ensure the efficacy and safety of drugs.