Free Essay

Pharmacist

In: Science

Submitted By mradwan
Words 4037
Pages 17
COVER ARTICLE
PRACTICAL THERAPEUTICS

Acute Management of Atrial Fibrillation:
Part I. Rate and Rhythm Control
DANA E. KING, M.D., LORI M. DICKERSON, PHARM.D., and JONATHAN L. SACK, M.D.
Medical University of South Carolina, Charleston, South Carolina
Atrial fibrillation is the arrhythmia most commonly encountered in family practice.
Serious complications can include congestive heart failure, myocardial infarction, and thromboembolism. Initial treatment is directed at controlling the ventricular rate, most often with a calcium channel blocker, a beta blocker, or digoxin. Medical or electrical cardioversion to restore sinus rhythm is the next step in patients who remain in atrial fibrillation. Heparin should be administered to hospitalized patients undergoing medical or electrical cardioversion. Anticoagulation with warfarin should be used for three weeks before elective cardioversion and continued for four weeks after cardioversion.
The recommendations provided in this two-part article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality. (Am Fam Physician 2002;66:249-56. Copyright© 2002 American Academy of Family Physicians.)

I

Members of various family practice departments develop articles for “Practical Therapeutics.” This article is one in a series coordinated by the Department of
Family Medicine at the
Medical University of
South Carolina. Guest editor of the series is
William J. Hueston, M.D.
This is part I of a twopart article on atrial fibrillation. Part II, “Prevention of Thromboembolic Complications,” appears in this issue on pages 261-4.

n recent years, management strategies for atrial fibrillation have expanded significantly, and new drugs for ventricular rate control and rhythm conversion have been introduced.1-3 Family physicians have the challenge of keeping current with recommendations on heart rate control, antiarrhythmic drug therapy, cardioversion, and antithrombotic therapy.
Atrial fibrillation is the most common sustained arrhythmia encountered in the primary care setting. Approximately 4 percent of persons in the general U.S. population have permanent or intermittent atrial fibrillation, and the prevalence of the arrhythmia increases to 9 percent in persons older than 60 years.2 Atrial fibrillation can result in serious complications, including congestive heart failure, myocardial infarction, and thromboembolism.
Recognition and acute management of atrial fibrillation in the physician’s office or emergency department are important in preventing adverse consequences.
Diagnosis
The diagnosis of atrial fibrillation should be considered in elderly patients who present with complaints of short-

JULY 15, 2002 / VOLUME 66, NUMBER 2

www.aafp.org/afp

ness of breath, dizziness, or palpitations.
The arrhythmia should also be suspected in patients with acute fatigue or exacerbation of congestive heart failure.3 In some patients, atrial fibrillation may be identified on the basis of an irregularly irregular pulse or an electrocardiogram
(ECG) obtained for the evaluation of another condition.
Cardiac conditions commonly associated with the development of atrial fibrillation include rheumatic mitral valve disease, coronary artery disease, congestive heart failure, and hypertension. Noncardiac conditions that can predispose patients to develop atrial fibrillation include hyperthyroidism, hypoxia, alcohol intoxication, and surgery.4
The ECG is the mainstay for diagnosis of atrial fibrillation (Figure 1). An irregularly irregular rhythm, inconsistent R-R interval, and absence of P waves are usually noted on the cardiac monitor or
ECG. Atrial fibrillation waves (f waves), which are small, irregular waves seen as a rapid-cycle baseline fluctuation, indicate rapid atrial activity (usually between 150 and 300 beats per minute) and are the hallmark of the arrhythmia.
When the fibrillation waves reach 300
AMERICAN FAMILY PHYSICIAN

249

{

{

FIGURE 1. Atrial fibrillation. The tracing demonstrates the absence of P waves (long arrow), as well as the presence of the fine f waves of atrial fibrillation (short arrows). Note the irregularity of the ventricular response, as seen from the variable R-R interval (brackets).

beats per minute, they may be difficult to see
(fine versus coarse fibrillation).5 These waves may be even harder to detect on a cardiac monitor in a busy emergency department because of interference from other electrical equipment. The f waves may be easier to identify on a printed rhythm strip. In addition, when the ventricular response to atrial fibrillation is very rapid (more than 200 beats per minute), variability of the R-R interval can frequently be seen more easily using calipers on a paper tracing.
Atrial flutter is included in the spectrum of supraventricular arrhythmia. This rhythm disturbance is usually distinguishable by its more prominent saw-tooth wave configuration and slower atrial rates (Figure 2). Atrial fibrillation should also be distinguished from atrial tachycardia with variable atrioventricular block, which usually presents with an atrial

rate of approximately 150 beats per minute. In this condition, the atrial rate is regular (unlike the irregular disorganized f waves of atrial fibrillation), but conduction to the ventricles is not regular. The resultant irregularly irregular rhythm may be difficult to differentiate from atrial fibrillation.3
Initial Management
Recent advances in treatment and the introduction of new drugs have not changed initial management goals in patients with atrial fibrillation. These goals are hemodynamic stabilization, ventricular rate control, and prevention of embolic complications.4,6-8 When atrial fibrillation does not terminate spontaneously, the ventricular rate should be treated to slow ventricular response and, if appropriate, efforts should be made to terminate atrial fibrillation and restore sinus rhythm4,7,9 (Figure 3).8

FIGURE 2. Atrial flutter. Note the saw-tooth wave configuration, or flutter waves (arrows).

250

AMERICAN FAMILY PHYSICIAN

www.aafp.org/afp

VOLUME 66, NUMBER 2 / JULY 15, 2002

Atrial Fibrillation

Initial Management of Atrial Fibrillation
Patient with diagnosis of atrial fibrillation

Hemodynamically stable (no angina, no hypotension, etc.)?

No

Yes
Control ventricular rate (goal = 48 hours or unknown duration:
Later elective cardioversion (electrical cardioversion with or without medical cardioversion) after
3 weeks of warfarin (Coumadin)
Early TEE–guided cardioversion (electrical cardioversion with or without medical cardioversion)

Atrial fibrillation persists?

No

Yes
Consider long-term anticoagulation. Assess cause of atrial fibrillation; hospital discharge, follow-up

FIGURE 3. Initial approach to the patient with acute atrial fibrillation. (IV = intravenous; J = joule;
TEE = transesophageal echocardiography)
Information from Falk RH. Atrial fibrillation. N Engl J Med 2001;344:1067-78.

JULY 15, 2002 / VOLUME 66, NUMBER 2

www.aafp.org/afp

AMERICAN FAMILY PHYSICIAN

251

In patients with atrial fibrillation, the initial management goals are hemodynamic stabilization, ventricular rate control, and prevention of embolic complications.

VENTRICULAR RATE CONTROL

Ventricular rate control to achieve a rate of less than 100 beats per minute is generally the first step in managing atrial fibrillation. Beta blockers, calcium channel blockers, and digoxin (Lanoxin) are the drugs most commonly used for rate control3,4,7 (Table 1).3
These agents do not have proven efficacy in converting atrial fibrillation to sinus rhythm and should not be used for that purpose.4,7,10,11
Beta blockers and calcium channel blockers are the drugs of choice because they provide rapid rate control.4,7,12 These drugs are effective in reducing the heart rate at rest and during exercise in patients with atrial fibrillation.4,7,12 Factors that should guide drug selection include the patient’s medical condition, the presence of concomitant heart failure, the characteristics of the medication, and the physician’s experience with specific drugs.

The Authors
DANA E. KING, M.D., is associate professor in the Department of Family Medicine at the Medical University of South Carolina, Charleston. Dr. King graduated from the University of Kentucky College of Medicine, Lexington, and completed a family practice residency at the University of Maryland Hospital, Baltimore. He also completed an academic faculty development fellowship at the University of North Carolina at Chapel Hill
School of Medicine.
LORI M. DICKERSON, PHARM.D., is a board-certified pharmacotherapy specialist and associate professor in the Department of Family Medicine at the Medical University of
South Carolina. Dr. Dickerson completed a clinical pharmacy residency in family medicine at the Medical University of South Carolina.
JONATHAN L. SACK, M.D., is assistant professor and medical director of University Family Medicine, the community site for the Department of Family Medicine at the Medical
University of South Carolina. He received his medical degree from the University of the
Witwatersrand, Johannesburg, South Africa, where he also completed his internship and residency training. In addition, Dr. Sack completed an academic faculty development fellowship at the University of North Carolina at Chapel Hill School of Medicine.
Address correspondence to Dana E. King, M.D., Family Medicine Research Section,
Medical University of South Carolina, 295 Calhoun St., P.O. Box 250192, Charleston,
SC 29425 (e-mail: kingde@musc.edu). Reprints are not available from the authors.

252

AMERICAN FAMILY PHYSICIAN

www.aafp.org/afp

Compared with beta blockers and calcium channel blockers, digoxin is less effective for ventricular rate control, particularly during exercise. Digoxin is most often used as adjunctive therapy because of its slower onset of action (usually 60 minutes or more) and its weak potency as an atrioventricular node– blocking agent.3,13 It can be used when rate control during exercise is of less concern.4,7,12
Digoxin is a positive inotropic agent, which makes it especially useful in patients with systolic heart failure.7
The calcium channel blockers diltiazem
(Cardizem) and verapamil (Calan, Isoptin) are effective for initial ventricular rate control in patients with atrial fibrillation. These agents are given intravenously in bolus doses until the ventricular rate becomes slower.7 Dihydropyridine calcium channel blockers (e.g., nifedipine [Procardia], amlodipine [Norvasc], felodipine [Plendil], isradipine [DynaCirc], nisoldipine [Sular]), are not effective for ventricular rate control.
Physicians can use the “rule of 15” in administering diltiazem to patients weighing
70 kg (154 lb): first, give 15 mg intravenously over two minutes, repeat the dose in 15 minutes if necessary, and then start an intravenous infusion of 15 mg per hour; titrate the dose to control the ventricular rate (5 to 15 mg per hour). Verapamil, in a dose of 5 to 10 mg administered intravenously over two minutes and repeated in 30 minutes if needed, can also be used for initial rate control. Although all calcium channel blockers can cause hypotension, verapamil should be used with particular caution because of the possibility of prolonged hypotension as a result of the drug’s relatively long duration of action.
Beta blockers such as propranolol (Inderal) and esmolol (Brevibloc) may be preferable to calcium channel blockers in patients with myocardial infarction or angina, but they should not be used in patients with asthma. As initial treatment, 1 mg of propranolol is given intravenously over two minutes; this dose can be repeated every five minutes up to a maxiVOLUME 66, NUMBER 2 / JULY 15, 2002

Atrial Fibrillation

mum of 5 mg. Maintenance dosing of propranolol is 1 to 3 mg given intravenously every four hours. Esmolol has an extremely short half-life and may be given as a continuous intravenous infusion to maintain rate control
(Table 1).3
Despite depressive effects on contractility
(unless the ejection fraction is below 0.20), calcium channel blockers and beta blockers can be used for initial ventricular rate control in patients with heart failure. Oxygen delivery to the heart is usually much improved once the ventricular rate is controlled (less than 100 beats per minute). A slower ventricular response rate also allows more filling time for the heart and, thus, improved cardiac output.14 However, the benefits of long-term treatment with calcium channel blockers or beta blockers should be carefully weighed against the negative inotropic effects. Drugs for rate control can generally be stopped once sinus rhythm is restored.3

Limited data suggest that combination regimens provide better rate control than any agent alone.15
RESTORATION OF SINUS RHYTHM

Medical (Pharmacologic) Cardioversion.
After patients with atrial fibrillation have been stabilized and the ventricular rate has been controlled, conversion to sinus rhythm is the next consideration. The decision to restore sinus rhythm should be individualized.
The many reasons for not attempting pharmacologic cardioversion include duration of atrial fibrillation for more than 48 hours, recurrence of atrial fibrillation despite multiple treatment attempts, poor tolerance of antiarrhythmic agents, advanced patient age and concomitant structural disease, large size of left atrium (greater than 6 cm), and the presence of sick sinus syndrome.2 However, continued atrial fibrillation is associated with

TABLE 1

Drugs Commonly Used to Control Ventricular Rate in Patients with Atrial Fibrillation
Drug
Calcium channel blockers
Diltiazem (Cardizem)
Verapamil (Calan,
Isoptin)
Beta blockers
Esmolol (Brevibloc)

Propranolol (Inderal)

Digoxin (Lanoxin)

Initial dosing

Maintenance dosing

Comments

15 to 20 mg IV over 2 minutes; may repeat in 15 minutes

5 to 15 mg per hour by continuous IV infusion

Convenient; easy to titrate to heart rate goal

5 to 10 mg IV over 2 minutes; may repeat in 30 minutes

Not standardized

More myocardial depression and hypotension than with diltiazem

Bolus of 500 mcg per kg IV over 1 minute; may repeat in
5 minutes

50 to 300 mcg per kg per minute by continuous
IV infusion

Very short-acting; easy to titrate to heart rate goal

1 mg IV over 2 minutes; may repeat every 5 minutes to maximum of 5 mg

1 to 3 mg IV every 4 hours

Short duration of action; hence, need for repeat dosing

0.25 to 0.5 mg IV; then 0.25 mg
IV every 4 to 6 hours to maximum of 1 mg

0.125 to 0.25 mg per day
IV or orally

Adjunctive therapy; less effective for rate control than beta blockers or calcium channel blockers

IV = intravenous.
Adapted with permission from Li H, Easley A, Barrington W, Windle J. Evaluation and management of atrial fibrillation in the emergency department. Emerg Med Clin North Am 1998;16:389-403.

JULY 15, 2002 / VOLUME 66, NUMBER 2

www.aafp.org/afp

AMERICAN FAMILY PHYSICIAN

253

long-term complications that can best be avoided by prompt return to sustained normal sinus rhythm and correction of underlying ischemic or structural abnormality. Early successful cardioversion may also reduce the incidence of recurrent atrial fibrillation.3
Medical cardioversion may be appropriate in certain situations, especially when adequate facilities and support for electrical cardioversion are not available or when patients have never been in atrial fibrillation before. Pharmacologic agents are effective in converting atrial fibrillation to sinus rhythm in about
40 percent of treated patients.2,3
Physicians should use medical cardioversion only after careful consideration of the possibility of proarrhythmic complications, particularly in patients with structural heart disease or congestive heart failure.7 Because cardioversion can lead to systemic emboli, heparin should be given before medical cardioversion is attempted7 (see part II for more information on this subject). Anticoagulation with warfarin (Coumadin) should be continued for four weeks after cardioversion.
After anticoagulation is initiated, quinidine sulfate (Quinidex), flecainide (Tambocor), or propafenone (Rythmol) may be used to attempt pharmacologic conversion. The following intravenously administered drugs may also be used: dofetilide (Tikosyn), ibutilide (Corvert), procainamide, or amiodarone (Cordarone).8,16
A recent review4 and a meta-analysis17 concluded that flecainide, ibutilide, and dofetilide were the most efficacious agents for medical conversion of atrial fibrillation, but that propafenone and quinidine were also effective. In the presence of Wolff-ParkinsonWhite syndrome, procainamide is the drug of choice for converting atrial fibrillation.7 Less evidence supports the use of disopyramide
(Norpace) and amiodarone, and evidence supports a negative effect for sotalol (Betapace).4,17 However, some investigators consider amiodarone to be the most effective agent for converting to sinus rhythm in patients who do not respond to other agents.7
254

AMERICAN FAMILY PHYSICIAN

www.aafp.org/afp

Quinidine, disopyramide, propafenone, and sotalol have been found to be effective in maintaining sinus rhythm. One study comparing amiodarone and disopyramide found moderate evidence of efficacy for amiodarone in the maintenance of sinus rhythm.17
Overall, antiarrhythmic drug selection should be individualized based on the patient’s renal and hepatic function, concomitant illnesses, use of interacting medications, and underlying cardiovascular function. Because of intravenous-formulation availability and effectiveness, one drug may be used for conversion and another for maintenance therapy. Amiodarone is the recommended agent in patients with a low ejection fraction (below 0.35) or structural heart disease. Patients should be monitored closely because quinidine, propafenone, and amiodarone may increase the
International Normalized Ratio when they are used with warfarin. These same drugs and verapamil raise digoxin levels, which may necessitate a decrease in the digoxin dosage.7
The question of whether rate control or rhythm control should take precedence is currently being investigated in a randomized trial
(Atrial Fibrillation Follow-up Investigation of
Rhythm Management).18 A recent small study19 examined rate control (using diltiazem) versus rhythm control (using amiodarone) plus anticoagulation. Overall, rate control was as good as rhythm control in reducing or eliminating symptoms and in reducing hospitalization rates, but the comparative effect on stroke risk was not studied.
Electrical Cardioversion. When patients with atrial fibrillation are hemodynamically unstable
(e.g., angina, hypotension) and not responding to resuscitative measures, emergency electrical cardioversion is indicated. In stable patients, elective cardioversion is performed after three weeks of warfarin therapy.7,8 To prevent thrombus formation, warfarin is continued for four weeks after cardioversion. Although the success rate for electrical cardioversion is high (90 percent), proper equipment and expertise are necessary for safe performance.3
VOLUME 66, NUMBER 2 / JULY 15, 2002

Atrial Fibrillation

If there is time and patients are conscious, sedation should be achieved before cardioversion is attempted. Synchronized external direct-current cardioversion is performed with the pads placed anteriorly and posteriorly (over the sternum and between the scapulae) at
100 joules (J). If no response occurs, the current is applied again at 200 J; if there is still no response, the current is increased to 300 J, and then to a maximum of 360 J. If patients cannot be moved, the pads can be applied over the right sternal border and left lateral chest wall.3
Patients with atrial fibrillation at a ventricular rate of less than 150 beats per minute who are hemodynamically stable can be initially treated with drugs for ventricular rate control and intravenously administered heparin for anticoagulation (see part II for more information). Medical cardioversion or elective electrical cardioversion can then be considered as appropriate. Patients are usually monitored in the hospital while cardioversion is being attempted. However, one study20 documented positive results for emergency-department performance of cardioversion followed by direct discharge of hemodynamically stable patients without congestive heart failure.
An alternative approach for achieving earlier return to sinus rhythm is early electrical cardioversion and the use of transesophageal echocardiography according to American
Heart Association guidelines.7 Transesophageal echocardiography is used to detect thrombi in the right atrium. If no thrombi are present, electrical cardioversion can be performed immediately; if thrombi are detected, cardioversion can be delayed until patients have undergone three weeks of oral anticoagulation using warfarin.21 One recent comparative study22 found no differences in thromboembolic complications between conventional treatment and early cardioversion following transesophageal echocardiography.
Because of the risk of complications such as heart failure and embolic stroke, restoration of sinus rhythm is thought to be preferable to allowing atrial fibrillation to continue. HowJULY 15, 2002 / VOLUME 66, NUMBER 2

Although the success rate for electrical cardioversion is high
(90 percent), proper equipment and expertise are necessary for safe performance.

ever, restoration of sinus rhythm is not always possible. In elderly patients with longstanding atrial fibrillation, repeated attempts at cardioversion may be counterproductive. The chances of reverting to and maintaining sinus rhythm are lower with longer duration of atrial fibrillation and decrease to particularly low levels when atrial fibrillation has been present for more than one year. When cardioversion is inappropriate or unsuccessful, medication should be used for ventricular rate control, and anticoagulation therapy should be considered.
General recommendations for the initial management of atrial fibrillation are summarized in Table 2.2,3,7,8,22
The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

TABLE 2

General Recommendations for Initial Management of Atrial Fibrillation
Acute control of the ventricular rate is best achieved with an intravenously administered calcium channel blocker (e.g., diltiazem [Cardizem]) or beta blocker (e.g., esmolol [Brevibloc]).
Immediate electrical cardioversion should be considered in hemodynamically unstable patients with atrial fibrillation.
Medical (pharmacologic) or electrical cardioversion following anticoagulation should be considered in hemodynamically stable patients with atrial fibrillation.
Elective electrical cardioversion should be used in patients with persistent or recurrent atrial fibrillation. The success rate for electrical cardioversion is 90%.
Medical cardioversion is a convenient and reasonable alternative in some patients, but it does not always terminate atrial fibrillation. The success rate for medical cardioversion is about 40%.
Early cardioversion after transesophageal echocardiography with intravenous anticoagulation is an increasingly used alternative strategy.
Information from references 2, 3, 7, 8, and 22.

www.aafp.org/afp

AMERICAN FAMILY PHYSICIAN

255

Atrial Fibrillation

REFERENCES
1. Ellenbogen KA, Wood MA, Stambler BS. Intravenous therapy for atrial fibrillation: more choices, more questions, more trials. Am Heart J 1999;
137:992-5.
2. Podrid PJ. Atrial fibrillation in the elderly. Cardiol
Clin 1999;17:173-88,ix-x.
3. Li H, Easley A, Barrington W, Windle J. Evaluation and management of atrial fibrillation in the emergency department. Emerg Med Clin North Am
1998;16:389-403.
4. Management of new onset atrial fibrillation. Evid
Rep Technol Assess (Summ) 2000;(12):1-7.
5. Wagner GS, Marriott HJ. Marriott’s Practical electrocardiography. 10th ed. Philadelphia: Lippincott
Williams & Wilkins, 2001:302-11.
6. Pritchett EL. Management of atrial fibrillation. N
Engl J Med 1992;326:1264-71.
7. Prystowsky EN, Benson DW Jr, Fuster V, Hart RG, Kay
GN, Myerburg RJ, et al. Management of patients with atrial fibrillation. A statement for healthcare professionals. From the Subcommittee on Electrocardiography and Electrophysiology, American Heart
Association. Circulation 1996;93:1262-77.
8. Falk RH. Atrial fibrillation. N Engl J Med 2001;
344:1067-78.
9. Ergene U, Ergene O, Fowler J, Kinay O, Cete Y,
Oktay C, et al. Must antidysrhythmic agents be given to all patients with new-onset atrial fibrillation? Am J Emerg Med 1999;17:659-62.
10. Noc M, Stajer D, Horvat M. Intravenous amiodarone versus verapamil for acute conversion of paroxysmal atrial fibrillation to sinus rhythm. Am J
Cardiol 1990;65:679-80.
11. Schreck DM, Rivera AR, Tricarico VJ. Emergency management of atrial fibrillation and flutter: intravenous diltiazem versus intravenous digoxin. Ann
Emerg Med 1997;29:135-40.
12. Segal JB, McNamara RL, Miller MR, Kim N, Good-

256

AMERICAN FAMILY PHYSICIAN

www.aafp.org/afp

13.

14.
15.

16.

17.

18.

19.

20.

21.

22.

man SN, Powe NR, et al. The evidence regarding the drugs used for ventricular rate control. J Fam
Pract 2000;49:47-59.
Falk RH, Leavitt JI. Digoxin for atrial fibrillation: a drug whose time has gone? Ann Intern Med 1991;
114:573-5.
Rich MW. Heart failure. Cardiol Clin 1999;17:12335.
Farshi R, Kistner D, Sarma JS, Longmate JA, Singh
BN. Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens.
J Am Coll Cardiol 1999;33:304-10.
Masoudi FA, Goldschlager N. The medical management of atrial fibrillation. Cardiol Clin 1997;
15:689-719.
Miller MR, McNamara RL, Segal JB, Kim N, Robinson
KA, Goodman SN, et al. Efficacy of agents for pharmacologic conversion of atrial fibrillation and subsequent maintenance of sinus rhythm: a meta-analysis of clinical trials. J Fam Pract 2000;49:1033-46.
Wyse DG. The AFFIRM trial: main trial and substudies—what can we expect? J Interv Card Electrophysiol 2000;4(suppl 1):171-6.
Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet 2000;356:1789-94.
Michael JA, Stiell IG, Agarwal S, Mandavia DP. Cardioversion of paroxysmal atrial fibrillation in the emergency department. Ann Emerg Med 1999;33:
379-87.
Camm AJ. Atrial fibrillation: is there a role for lowmolecular-weight heparin? Clin Cardiol 2001;24(3 suppl):I15-9. Klein AL, Grimm RA, Murray RD, Apperson-Hansen
C, Asinger RW, Black IW, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med
2001;344:1411-20.

VOLUME 66, NUMBER 2 / JULY 15, 2002

A

Similar Documents

Free Essay

Pharmacist Refusal

...Hiring a pharmacist for a rural 100-bed hospital does not leave a CEO many options for alternative dispensing of medications. There are usually only a few pharmacist in the hospital and in the town itself. The pharmacist is mandated by standards that manage their practice. The physician writes an order that is specific and in good standing for a patient. The pharmacist checks the order and other medications the patient is on at the time of the new prescription. The pharmacist must make sure that there is no interaction between any of the medication. A pharmacist is obligated to contact the physician if there is any other medication in the system that is not a good interaction with the new medication. A pharmacist must now offer all patients a consultation regarding their new or old medications. When hiring any employee, it is not legal to ask them their religious beliefs therefore, one cannot know if prescribing a certain type of medication would be against those beliefs. As a CEO, she would have to come up with an alternative plan for dispensing these medications. The CEO would need to meet with the affected parties. In a small hospital, this would be any other pharmacists, director of nursing and possible other pharmacists in the community. This would need to be a confidential meeting. The pharmacist that is refusing to give certain medications due to religious reasons does not need to......

Words: 631 - Pages: 3

Premium Essay

Portfolio of a Pharmacist

...personnel to promote health, to provide, assess, and coordinate safe, acute, and time-sensitive medication distribution in order to improve therapeutic outcomes of medication use. In regards to management and use of resources in the healthcare system, I think I am progressing quite well, but believe that there is room for improvement towards becoming a pharmacist. Prior to lectures, such as pharmacotherapeutics, I had very little knowledge in regards to utilization of resources to improve therapeutic outcomes. Now I am knowledgeable on utilization of resources such as where and how to search for important information about a drug. This course has greatly improved my search skills in order to effectively assist patients in improving therapeutic outcomes of medication use. For instance, in regards to my search skills, I can now use the knowledge I acquired from this course and counsel my patients in regards to any questions that they may have about a drug. In this manner, I would be managing and using resources not only to provide education but also to promote health. In general, this will greatly impact my future as a pharmacist. It will allow me to grow accustomed to managing and using trusted resources to help improve therapeutic outcomes. Curricular Endpoint C: Public Health Promote health improvement, wellness, and disease prevention in cooperation with patients, communities, at-risk populations, and other members of an interprofessional team of health care......

Words: 1115 - Pages: 5

Free Essay

Safety & Quality - Sop for Pharmacists

...professionals including pharmacists. Patient safety is defined as ‘the prevention of harm to patients, including through errors of commission and omission’. The role of pharmacists has been clinically proven to improve many outcomes regarding patient health, including greater patient safety, improved disease and drug therapy management, effective healthcare spending, improved adherence and improved quality of life (Canadian Pharmacists Association, 2008). The focus on patient care stemmed from a 1999 US report by the institute of Medicine titled, ‘To Err is Human: Building a safer Health System’. This report detailed the costs of medical errors to the US economy and how medical errors numbered higher than deaths due to AIDS, motor vehicle accidents, and breast cancer, combined. The report went on to descried how errors can be reduced (Institute of Medicine,1999). For centuries, pharmacists have been the guardians/safeguards against "poisons" those substances which could cause harm to the public. Now more than ever pharmacists are charged with the responsibility to ensure that when a patient receives a medicine, it will not cause harm. As highlighted in a report produced in November 2009 "Pharmacy Intervention in the Medication-use Process - the role of pharmacists in improving patient safety", the involvement of pharmacists in patient safety can be as early at the prescribing phase and up to the administration of the medicines. In many cases, pharmacists are supported......

Words: 1018 - Pages: 5

Free Essay

Professional Work Ethics of Pharmacists

...PROFESSIONAL WORK ETHIC OF PHARMACISTS IN GOVERNMENT TERTIARY HOSPITALS IN BAGUIO AND BENGUET ______________ A Thesis Proposal Presented to the Faculty of the Graduate School Baguio Central University Baguio City ______________ In Partial Fulfillment of the Requirements for the Degree Master in Public Administration _____________ Sharon M. Cuyugan January 2015 APPROVAL SHEET This thesis proposal entitled, “PROFESSIONAL WORK ETHIC OF PHARMACISTS IN GOVERNMENT TERTIARY HOSPITALS IN BAGUIO AND BENGUET”, prepared and submitted by SHARON M. CUYUGAN, in partial fulfillment of the requirements for the degree, MASTER IN PUBLIC ADMINISTRATION (MPA), has been reviewed and examined and is hereby endorsed for acceptance and approval for proposal defense. LOUELLA M. BROWN, Ed.D. Professor 300-A PROPOSAL EXAMINATION COMMITTEE JOSE R. BALCANAO, Ph.D. Chairman LOUELLA M. BROWN, Ed.D. ESTRELLA V. BISQUERRA, Ph.D. Member Member ACKNOWLEDGMENT The researcher wishes to thank the following for their assistance in the completion of this dissertation proposal: The Good Lord, for giving the researcher sufficient encouragement so she may pursue this challenging endeavor; Her family, for all the support, understanding and unconditional love; Members of the proposal committee, Dr. Jose R. Balcanao, Dr. Estrella V. Bisquerra, and Dr. Louella M. Brown, for their critiques and helpful suggestions;...

Words: 4946 - Pages: 20

Free Essay

Comparison of Pharmacist Transcript and Dead Parrot Sketch

...Comparison of Pharmacist Transcript and Dead Parrot Sketch Both Texts A and B focus on a ‘service encounter’, where a customer enters a shop, expecting an issue or complaint to be resolved. Whilst Text A follows many of the conventions of a service encounter, such as a question/answer structure, the parody purpose of Text B, coupled with the fact it is speech that is crafted to entertain the audience, both employs and mocks convention. The common conventions of a service encounter are shown in a variety of ways in Text A. It opens with the pharmacist uttering the phatic ‘good morning’, who then follows this with the interrogative ‘can I help you’, which is to be expected in his role as advisor. Text B equally employs an opening greeting, ‘Hello’, but this unusually is from the customer instead of the shopkeeper, and the stage directions indicate that the shopkeeper wants to do anything but help, as he ‘tries to hide below [the] cash register’. This parody of generic conventions at the beginning of the scene sets the comedic tone for Text B, and emphasises that this scene is an artificial construct, created to amuse the audience and to mock social conventions. This is typical of Monty Python sketches, which often seek to ridicule convention and authority. Both texts deal in different ways with the relationships between the participants. In Text A, the pharmacist shows a professional and helpful attitude by asking a range of pragmatic questions, such as ‘have you got a......

Words: 933 - Pages: 4

Free Essay

Pharmacist

...What is workplace violence? Workplace violence is violence or the threat of violence against workers. It can occur at or outside the workplace and can range from threats and verbal abuse to physical assaults and homicide, one of the leading causes of job-related deaths. However it manifests itself, workplace violence is a growing concern for employers and employees nationwide. Who is vulnerable? Some 2 million American workers are victims of workplace violence each year. Workplace violence can strike anywhere, and no one is immune. Some workers, however, are at increased risk. Among them are workers who exchange money with the public; deliver passengers, goods, or services; or work alone or in small groups, during late night or early morning hours, in high-crime areas, or in community settings and homes where they have extensive contact with the public. This group includes health-care and social service workers such as visiting nurses, psychiatric evaluators, and probation officers; community workers such as gas and water utility employees, phone and cable TV installers, and letter carriers; retail workers; and taxi drivers. what to do if they witness or are subjected to workplace violence, and how to protect themselves. s Secure the workplace. Where appropriate to the business, install video surveillance, extra lighting, and alarm systems and minimize access by outsiders through identification badges, electronic keys,......

Words: 1037 - Pages: 5

Premium Essay

You Are the Ceo of a 100-Bed Community Hospital in Rural Alabama. the Newly Hired Pharmacist Refuses to Dispense Emergency Contraception Based Upon Religious/Moral Grounds.

...[pic] Title: Total and State Medicaid Spending Growth FY 2000 - FY 2012 Description: With the expiration of federal stimulus funding in 2011, state spending on Medicaid is projected to rise 28.7% in 2012, while overall Medicaid spending will increase 2.2%. Source: Historic Medicaid Growth Rates, KCMU Analysis of CMS Form 64 Data; FY 2008, 2009 and 2010, KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, 2011. Topics: Medicaid / CHIP Included in these Slideshows: KFF.org Data Spotlight Slide Date: October 28, 2011   Introduce the issue. Describe the problems in the U.S. healthcare system and how we might use another nation's healthcare system for reform. Evaluate how a new system would improve access to care, quality of care, and the efficient utilization of resources. Define the problem. a. High insurance premiums and out of reach for many American who remain uninsured. b. Drug companies are widely perceived as greedy and insensitive. c. Differences in prescription patterns related to insurance coverage. d. Medicaid patients are more likely to be prescribed generic drugs than patients who have commercial health insurance. e. Unethical behavior by the insurers that shows many institutions have violate fundamental values. f. Negative relationship between the insurers and physicians, personal-satisfaction ratings for health insurance plans, public concern about HMOs in particular and the health......

Words: 4716 - Pages: 19

Premium Essay

Girl

...A career in Medicine A pharmacist is a healthcare professional who is a expert on pharmaceutical drugs and how they act to fight disease and improve the heath of the patient. Pharmacists are responsible for the implementation of drug therapy with the intention of improving the quality of a patient’s life. Some examples of such improvements include curing diseases, reducing or eliminating a patient’s symptoms, slowing the process of a disease, and preventing disease. A pharmacist works with patients and other healthcare professionals in order to design, implement, and monitor a drug therapy plan specifically designed for that patient. Not only do pharmacists advise doctors and patients on prescription drugs, but they also provide information on the best medications that can be purchased “over the counter”. The most common goal of pharmacists is to move beyond their traditional role of simply dispensing medication and deal with patients more directly and on a more personal level. They strive to be a source of advice on medications for both heath-care professionals and patients. They also are dedicated to providing individualized services to patients. Such services include consultations and providing more understandable information about the side effects of the medications that the patient is receiving. More than 1,000 years ago, religious and magic practitioners controlled the medical aspects of people’s lives. They believed that many aspects of disease were beyond......

Words: 1809 - Pages: 8

Premium Essay

Describe a Carrer

...abilities. A pharmacist role is critical to the quality of healthcare and delivering the best care. The pharmacist’s role is critical by delivering quality care. In the article “Occupational Outlook Handbook, By Bureau of Labor Statistics (2013) Pharmacists dispense prescription medications to patients and offer advice on their safe use. Career Description The career of pharmacists concentrated in the correct interpretation and proper correction of administering the prescriptions along with dispensing the product describe by the FDA. Pharmacist are the approval and last check before the product is dispense out of the pharmacy and given to the patient for the patients’ personal use. Most pharmacist are either in a hospital setting or drugstore and are responsible for the drugs they dispense to the patients but pharmacist also practices as wellness providers, promote health, clinicians, and industrial pharmacist in pharmaceutical companies. Pharmacist also provide consultants, teachers along with owning pharmacies and other pharmacy chains. Pharmacist duties focus on the wellbeing of the patients in either public or private their duty continues for patients Services Provided Pharmacists are healthcare providers with numerous services, and product for their patients. Pharmacists dispense medications, educate, research, manufacture, advise, and consult on how properly to use each drug for each patient’s needs. There are many services that......

Words: 825 - Pages: 4

Premium Essay

Apa Research

...Running head: WHAT ARE THE REQUIRMENTS TO BECOME A PHARMACIST? 1 What are the Requirements to Become A Pharmacist? Review of the Pharmaceutical Life Insert Name Lone Star College Cy-Fair Author Note This paper was prepared for English 1301 taught by Professor Jamil Summer. WHAT ARE THE REQUIREMENTS TO BECOME A PHARMACIST? 2 ABSTRACT A pharmacist is a healthcare professional who is a expert on pharmaceutical drugs and how they act to fight disease and improve the heath of the patient. Pharmacists are responsible for the implementation of drug therapy with the intention of improving the quality of a patient’s life. Some examples of such improvements include curing diseases, reducing or eliminating a patient’s symptoms, slowing the process of a disease, and preventing disease. A pharmacist works with patients and other healthcare professionals in order to design, implement, and monitor a drug therapy plan specifically designed for that patient. Not only do pharmacists advise doctors and patients on prescription drugs, but they also provide information on the best medications that can be purchased “over the counter”. The most common goal of pharmacists is to move beyond their traditional role of simply dispensing medication and deal with patients more directly and on a more personal level. They strive to be a source of advice on medications for both heath-care professionals and patients. They also are dedicated to providing individualized......

Words: 1521 - Pages: 7

Free Essay

Week 4 Assignment

...Health Care Careers Diagram and Summary HCS/531 Health Care Careers Diagram and Summary Pharmacists play an important role in providing and supporting pharmaceutical care.   Providing pharmaceutical care includes, but is not limited to, establishing patient relationships, obtaining medication history information, preventing, identifying and resolving medication related problems (MRP), dispensing medications, and educating and counseling patients and healthcare providers (japha, 2010). This paper highlights the pharmacist role in various services, the workforce roles within those services, and the impact pharmacists play in health care organizations. Role of a Pharmacist Pharmacists interpret prescriptions and dispense medications prescribed by a credentialed provider. In cases where patients receive multiple medications, an in-depth understanding of drug interactions is required. Pharmacists monitor the pharmacologic effects of medications for certain disease states including, but not limited to, diabetes, asthma, hypertension, seizures, hyperlipidemia, anticoagulation, and infectious diseases. The rapid, dramatic advances in medication therapy created a niche for pharmacy practitioners that specialize in specific treatment and care (rheumatology, 2013). Medication Therapy Management Pharmacists have a broad knowledge base to assess and respond to a patient's medication therapy needs, thereby contributing to the inter-professional management of......

Words: 727 - Pages: 3

Premium Essay

Career in Pharmacy

...aspects of life. Choosing a career is important for people to know which direction they are going in life. To become a pharmacist one must earn a Doctor of Pharmacy degree known as a Pharm.D. The pharmacy program is usually four years long and must be accredited by the Accreditation Council for Pharmacy Education ( ACPE). Pharmacists play a vital role in the heal care system through the medicine and information they provide. Some of the reasons for becoming a pharmacist are helping people get well, being an important member of the health care team, and enjoying a wide variety of career opportunities. Pharmacists play a key role in helping people feel better and get well as quickly as possible. Pharmacists usually work in clean, well-lit and well-ventilated areas. Many pharmacists spend most of their workday on their feet. When working with sterile or potentially dangerous pharmaceutical products, pharmacists wear gloves and masks and work with other special protective equipment. Pharmacists dispense medications prescribed by physicians and other health practitioners and monitor patient health. They advise physicians and other health practitioners on the selection, dosages interactions and side effects of medications. Pharmacists must understand the use, clinical effects and composition of drugs including their chemical, biological and physical properties. Pharmacists are the medication experts. They protect the public by ensuring drug purity and strength. They can be......

Words: 880 - Pages: 4

Free Essay

Refusal Clauses

...Carina Smith Rosemont College Week 6 paper Abstract The broad structure of this case is whether a pharmacist has the right to refuse a prescription if the pharmacist is morally opposed to a possible outcome of the use of that prescription or whether a patient has the right to have that prescription filled without the pharmacist opinion of whether the use of that medication is either ethical or moral. In America we have access to all types of things that others don’t have access to; For instance, Twitter, Facebook, weed delivery services, supermarkets bigger than the Comcast building. But yet, when a women get prescribe legitimate medication from her doctor for either HIV, miscarriage or birth control, she is being denied by her pharmacist. Pharmacist are now refusing to dispense emergency contraception based on their own religious or moral beliefs overriding women's decisions about their bodies, lives and also denying referrals from physicians. In this case it shows no right or wrong with the decision the pharmacist choose to take. A pharmacy can refuse to fill your prescription because of refusal clauses. These laws allow people and corporations to put their beliefs before your needs. Some refusal clauses even let people and companies deny you information on where else you can get the services they refuse to provide (prochoiceamerica.com). As the customer I will feel angered and stressed, because you would think that you’ll be able to get a prescription......

Words: 725 - Pages: 3

Free Essay

Professional Regulation and Criminal Liability

...Professional Regulation and Criminal Liability July 16, 2015 HCS/430 Professional Regulation and Criminal Liability: Pharmacists A profession is “an occupation based on the mastery of a complex body of knowledge and skills. It is a vocation in which the practice of an art is used in the services of others” (Schmitz & Martin, 2008, p. 1). Belonging to a certain profession requires one to agree to demonstrate integrity, selflessness, competency as well as morality. This becomes the foundation on which the medical profession gets autonomy of practice from the society and a chance to experience self-regulation. Pharmacy is one of the medical professions whose practitioners help people to utilize medications to the best. It is notable that since professionals own specialized knowledge which the client does not have, the possibility of the professional exploiting the client exists. It is however important to note that such exploitation leads to very severe consequences since it has violated the guiding regulations for pharmacists. While executing the duties of a pharmacist, it is possible to make mistakes that have serious consequences. There are a number of ways in which professional misconduct among pharmacists can be handled. The Board of Pharmacy may take action against the pharmacists where a hearing is made before any disciplinary action is taken. The violation of regulations may also be presented before a civil court or before a criminal court. In case of a......

Words: 1740 - Pages: 7

Free Essay

Ethical and Legal Issues in Pharamcy

...generating such related professional challenges as drug interactions, drug product selection, and therapeutic drug interchanges, suggesting new professional roles and relationships for pharmacists (Buerki & Vottero,2002). Physicians and patients depend on and expect pharmacists to fill their prescriptions for treatment as prescribed. Pharmacists are specialists in the field of chemistry and medicinal compounds and have a duty and responsibility to the patient and physician to render information honestly and without bias, about drug interactions or side effects for the medications received (ACCP, 2009). According to Pozgar, G., medication errors are foremost in the cause of medical injuries via adverse reactions (2010). In keeping with the imperative duty of care and responsibility, most modern pharmacies keep electronic medication profiles to monitor medication drug interactions. A more recent role placed on pharmacists is insurance companies reimbursing pharmacists for administering vaccines to patients in the pharmacy. The American Medical Association has expressed that it has reservations about the pharmacists’ duties of care overstepping into the physician’s realm of practice and engaging in, “the practice of medicine”. When this occurs, it has the potential to violate the pharmacists’ code of ethics, legally limiting their rights to deliver the levels of care in dispensing of medicine for which they are more qualified than their counterparts are, and even......

Words: 1701 - Pages: 7