EKSISTENSI FARMASIS DI WARD:

APA DAN MENGAPA

S. Sjamsiah Sargo

Ketua Program Studi SpFRS

Fakultas Farmasi Unversitas Airlangga
LAYANAN KESEHATAN BERSIFAT :
• Universal & terpadu
• Mempunyai dampak pada (Impact to) dan
harapan dari (expectation) individu dan
masyarakat.
PARADIGMA LAYANAN KESEHATAN :
• Kualitas hidup (Quality of Life)
• Health outcomes

PROFESIONAL BIDANG KESEHATAN :

• Dokter / Dokter Gigi
• Para Medis
• Farmasis
• Ahli di bidang Kesehatan Masyarakat
EKSISTENSI FARMASIS DI WARD:
UNTUK APA, APA FUNGSINYA, MENGAPA
• Melakukan layanan kefarmasian
• Falsafah layanan kefarmasian, ialah :
i) Peka terhadap kondisi sosial
ii) Pendekatan fokus pada pasien (Patient Centered
Approach)
iii) Caring sebagai modus operandi
iv) Specific responsibilities dalam hal:
 Identification
 Resolve
 Prevent
Drug Therapy Problem  Quality Use of Medicines
Sampai dimanakah keberadaan Farmasis Klinik/Farmasis Ward
kini? Indonesia Sehat 2010, Health for All by 2010 (WHO).
• 1970  di AS Farmasi Klinik eksis  >1990 Ph. Care
• 1985  Malaysia Farmasi Klinik eksis di RS
• 1990  Regional Asia (Thai, China, Korea, Singapore, Filipina)
• 1991 (SpFRS UnAir berdiri dg SK Dirjen YanMed
No.0402/YanMed/RSK/91 dan SK Dikti No.73/DIKTI/Kep/1991 NOV 1991)
 a.l.:
• 1994 & 1997 Asia Pacific Congress on Clinical Pharmacy di Jakarta & Bali
• 2003 Strategi Peningkatan Peran Farmasis di Rumah Sakit (HISFARSI
JATIM, Surabaya Maret 15- 2003)
• 2004 Optimalisasi Pelayanan Kefarmasian di Rumah Sakit & Komunitas
(Seminar Nasional Farmasi Rumah Sakit & Komunitas, Makasar, Juni 28-
2004)
• 2007 Seminar Implementasi Pelayanan Farmasi dalam Tatanan Klinik
(Surabaya, JanuariI 16 &17, 2007)  ?
 Kebijakan Pemerintah terkait Fungsi Farmasis
di Rumah Sakit
KARS 2003:
 Kebijakan Farmasi Satu Pintu (SK Dirjen YanMed
No.0428/YanMed/RSKS/SK/89
 Tenaga yang memenuhi kualifikasi untuk tugas kefarmasian sesuai UU
No.23 Th 1992, tentang Kesehatan Ps.63  jumlah kebutuhan tenaga
dan peningkatan pendidikannya
 Perbekalan Farmasi Peraturan MenKes SK No.922/MenKes/Per/X/1993
 Komite/Panitia Farmasi dan Terapi SK Dirjen YanMed No.
HK00.06.2.3.730, Juli 1995 (Tentang Pembentukan & Tata Kerja.(a.l. Uji
Klinik ditetapkan oleh Dir.RS atas usul Komite)
 Pelayanan Farmasi (S.1.P2):
A. Perencanaan, pengadaan, penyimpanan,produksi (di RS)
pengemasan kembali, distribusi & penyerahan pada pasien,
informasi, eduksi staf medik, tenaga kesehatan
B. Pelayanan Farmasi Klinik (lih berikutnya)
KARS 2003
B. Pelayanan Farmasi Klinik a.l.
i. Melakukan Konseling (Counseling)
ii. Monitoring Efek Samping Obat (ADRs monitoring)
iii. Pencampuran Obat Suntik Secara Aseptis (Aseptic
Dispensing)
iv. Menganalisa Efektivitas Biaya (Pharmacoeconomy)
v. Penentuan Kadar Obat Dalam Darah (Clin. Pharcokin/TDM)
vi. Penangan Obat Sitostatika (Cytostatic Handling)
vii. Penyiapan Total Parenteral Nutrisi (TPN)
viii. Pemantauan Penggunaan Obat (Drug Monitoring)
ix. Pengkajian Penggunaan Obat (DUS)
Operasional Fungsi Layanan Farmasi di Rumah Sakit a.l:
1. Managerial, pengadaan dan distribusi perbekalan farmasi
2. Dispensary services:
• hospital inpatients; out patients/ambulatory patients
• ward stock, emergency department
• clinical trial medications/uji klinik obat
3. Production Service (produk dihasilkan oleh RS ybs)
4. Clinical Ward services (farmasis klinik)
5. After hours service  shift (untuk urgent drug supply)

Berapakah kebutuhan farmasis dengan ratio dari (farmasis:

pasien yang dilayani) dengan tugas di atas? Berikut
gambaran “ideal” di negara maju:
Farmasis : Pasien = 1:10 (di Emergensi unit)
Farmasis : Pasien = 1:20 (ward)
Proporsi Tenaga Farmasis diantara Tenaga Kesehatan lain ?
(Data dari Paper Dir. RSUD Dr Soetomo 2006, N0v.)
RSUD Dr. Soetomo Tipe-A, RS Pendidikan dan Layanan Umum
 1600 Beds, 32 Bagian/Sub Bagian Ilmu Penyakit,
 Pasien yang dilayanani/hari: MRS dan Poli …. ? orang
 Staf Spesialis Dokter 458 orang;
 Perawat 1.138 orang
 Staf Temporer PPDS sekitar 982 orang/tahun ;
 Tenaga Administrasi & Tehnisi 1.828 orang
 Farmasis tenaga tetap 12 orang (?)
Macro Issues dalam layanan RS yaitu : Safety is a
fundamental principle of patient care and a critical component of
quality management” (World Alliance for Patient Safety, Forward
Programme, WHO 2004).
Apa Farmasis Ward/ Farmasis Klinik
 < 1960 di semua belahan dunia Dx  R/  informasi obat
pada Px dilakukan dokter sendiri/bantuan perawat
 1970-1980  Farmasi Klinik/Clinical Pharmacy: Services
provided by hospital pharmacist to promote safe, appropriate
and effective use of drug therapy in hospital/patients areas
and health care system settings.  general practioner
pharmacist
 Farmasi Klinik Spesialis/Specialised Clinical Pharmacist:
Specialised training and qualification to provide high quality
services in particular areas (Organ Transplants, Oncology
etc).
 Unair (1991) : FF dan FK dan RSUD Dr.Soetomo:
 Program Studi SpFRS  atau Magister Farmasi Klinik ???
Masalah nama apa kesuaian program dan gelar ?  Magister
 scientific track ? Spesialist  professional praktisi 
akseptabilitas di RS/FK  spesialis SpFRS analog Dokter Sp
Medis/Klinis.
Catatan: ini menjadi masalah pengakuan gelar profesi dan
gelar scientific track MS) untuk alokasi dana sekolah/kanaikan
pangkat? Bila sekolah SpFRSS ada dana  Bgm dg dokter
untuk sekolah spesialisasi?
 >1993  WHO-FIP: pelayanan farmasi/Pharmaceutical
Care (ASHP/FIP): Ph.Care is the direct, responsible provision
of medication/ pharmacotherapy for the purpose of achieving
definite outcomes that improve patient’s quality of life.
Implication of Ph.Care: application on caring of patient in all
practice setting (clinical & community/homecare etc) 
FARMASI KOMUNITAS-KLINIK (?)
 Paradigm Shift? What & Why?

i. Individual role  health care team in a system

ii. Role Transition of Pharmacists:

FROM TO
Making DRUGS Making DRUGS WORK BETTER
(production,dispensing) (quality use of drugs)

iii. Traditional Health Outcomes measured:

 death
 disability
 disease stage
 discomfort
 dissasisfaction
iv. Outcomes pertinent to Pharm Care (as a health
provider in a team work setting)
a) Clinical: therapeutic outcome (recovery, morbidity,
mortality)
b) Humanistic:
Quality of Life (objective & subjective assessment)
Ethic (acts with honesty, integrity in professional manner)
Patient’s (compliance, dignity , confidential and privacy)
Adverse Drug Events (ADEs, prevention, solution)
c) Economic: Cost Analysis (Cost benefit; effectiveness;
minimization; utility).
Health Care System  Need Pharmaceutical Care
a. Drug/medication aspect
(i) drug consumption big portion in total health care cost
(ii) drug therapy  most common form of treatment
(iii) drug therapy usually paid out of Pxs’ pockets, health
insurance/ etc
(iv) drug price  constantly increase
(v) drug expenditure  (easily isolated in the accounting
of cost  pharmaco-economy))
 (government’s drug policy, drug expenditure etc)
b. Caring aspect: QUM (Quality Use of Medicines)
(i) explosion of drug products drug of choice,
safety, efficacy, economy?
(ii) complexity of etiology – pathogenesis,
pathophysiology of diseases  complexity of
drug use  drug induced diseases?
(iii) availability of objective, scientific and valid drug
informations ?
(iv) multiple prescribers  for a single patient  DRP
(1 Px 20-30 items ? )
(v) drug related morbidity, mortality
 THE NATURE OF DISEASE

Inherited Environmental
characteristics factors

Tissue/ Physiological
Gene Protein Cell Individual Family Society
organ system
Mutation Amount Growth Growth Hypoxia Symptoms Relation- Disease
Expression Function Shape Atrophy Hyper- Disabilities ships prevalence
Differentn Repair glycaemia Prognosis Finances Healthcare
Movement Inlam n
Hypertension Life Activities costs
Division Infection Heart failure expectancy Care Social costs
Apoptosis Ischaemia Renal failure burden etc
Metabolism Necrosis Epilepsy
Secretion etc Hemiplegia
Excitability Obesity
etc etc
THERAPEUTIC AIMS
DRUGS ACT HERE DIRECTED HERE
 Recombinan product
Antiherpes
Calcium antagonists
Immunosuppressants
Antihormones
Antidepressants
Cephalosporins
Phenotia Zines
Halothane
-adrenergik blockers
Antimalarials
Local Antihistamines
Salicylates abaesthetics Sulphonamides

1890 1910 1930 1950 1970 1990

Nitrous Amphetamines
oxide Hydantoins
Isoprenaline
Anthelmintics
Neuromuscular biockers
Antimetabolites
Corticosteroids
Diuretics
-adrenergic blockers
Tranquillizers
Semi-synthetic penicillins
H2 blockers
ACE inhibitor
HMG coensyme
reductase
Inhibitor
 1965 1970 Year Introduced Tertatolol
Carvedilol
Esmolol
Bopindolol
Bisoprolol
Celiprolol
Betaxolol
Befunolol
Carteolol
Mepindolol
Penbutolol
Carazolol
Nadolol
Acebutolol
Bunitrolol
Atenolol
Metipranol
Metoprolol
Timolil
Sotalol
Talinolol
Oxprenolol
Pindolol
Bupranolol
Alprenolol
Propanolol 1975 1980 1985 1990

Avalanche-like increase in commercially available -sympatholytics

 Tabel. 1. Antihypertensive drugs : Beta-adrenergic blocking agents

Cost for 30 Special Properties

Days’
Proprietary Treatment Renal vs
Drug Cost per Unit β1 Lipid Comments5
Name (Based on ISA3 MSA4 Hepatic
Average Selectivity2 Solubility
Elimination
Dosage)1
Positive ANA; rare LE
syndrome; also indicated for
Acebutolol Sectral $1.21/400mg $36.30 + + + + H>R
arrhythmias. Doses > 800
mg have β1 and β2 effects
Also indicated for angina
pectoris and post-MI. Doses
Atenolol Tenormin $0.74/50mg $22.20 + 0 0 0 R
> 100 mg have β1 and β2
effects

Betaxolol Kerlone $0.83/10 mg $24.90 + 0 0 + H>R

Bisoprolol
$1.04/2.5/6.25 Low-dose combination
and hydro- Ziac $31.20 + 0 0 0 R=H
mg approved for initial therapy
chlorothiazide

Carteolol Cartrol $1.06/5 mg $31.80 0 + 0 + R>H

α:β blocking activity 1:9; may

$92.40 (25 cause orthostatic symptoms;
Carvediolol Coreg $1.54/25 mg 0 0 0 +++ H
mg bid) approved for congestive
heart failure
Once-daily preparation aiso
Propranolol Inderal $0.18/40 mg $10.80 0 0 ++ +++ H available. Also indicated for
angina pectoris and post-MI
 Tabel 2. Antihypertensive drugs : Calcium channel-blocking agents
Cost for 30 Special Properties
Days’ Cardiac
Proprietary
Drug Treatment Peripheral Automaticity Adverse Effects Comments
Name Contractility
(Average Vasodilation and
Dosage)1 Conduction

Nondihydropyridine agents
$64.20 ++ ↓↓ ↓↓ Edema, headache, Also approved for
Diltiazem Cardizem SR bradycardia, GI angina
(240 mg qd)
disturbances, dizziness,
Cardizem CD $59.64 AV block, congestive
(240 mg qd) heart failure, urinary
frequency
Dilacor XR $38.10
(240 mg qd)

Tiazac SA $44.38
(240 mg qd)

Verapamil Calan SR $46.50 ++ ↓↓↓ ↓↓↓ Same as diltiazem but Also approved for
Isoptin SR* $46.50 more likely to cause angina and
Verelan $44.40 constipation and arrhythmias
Covera-HS (240 mg qd) congestive heart failure
$48.30

Dihydropyridines
Amlodipine Norvasc $72.48 +++ ↓/0 ↓/0 Edema, dizziness, Amiodipine,
(10 mg qd) palpitations, flushing, nicardipine, and
headache, hypotension, nifedipine also
Felodipine Plendil $51.98 +++ ↓/0 ↓/0 tachycardia, GI approved for
(10 mg qd) disturbances, urinary angina
frequency, worsening of
congestive heart failure
(may be less common
with felodipine,
amlodipine).
 Tabel. 3. Oral antidiabetic drugs

Cost for 30 Days’

Treatment Based
Drug Tablet Size Cost per Unit
on Maximum
Dosage1

Generasi S.U. 1.25, 2.5, and 5 $0.53/5 mg $63.60

Glyburide mg
(Diaβeta, Micronase)
(Glynase) 1.5, 3, and 6 mg $1.13/6 mg $101.70
Glipizide (Glucotrol) 5 and 10 mg $0.59/10 mg $70.80

(Glucotrol XL) 5 and 10 mg $0.66/10 mg $59.40

Glimeperide (Amaryl) 1, 2, and 4 mg $0.72/4 mg $21.60
PP੪RA 200, 300, and $2.98/300 mg $49.80
Troglitazone (Rezulin) 400 mg
 Klinisi + Ward Klinisi + Farmasis PMFT :
Farmasis + Mikrobiol + Patol. dll PDT, Formularium RS,
perawat - pasien Guidelines
DUS - Infection pattern A.ntimicrobial category :
Infectious Disease - Antimicrobials used 1. A.-unrestricted use
- Micr. Resisten. patte 2. B- imited Release
3. C- reserved
Internal & cardiov. Drugs use for: 1. first liners, 2nd liners
medicines - underlying disease 2. absolute contra indic./
Liver, kidney, endocrine - co-morbids relative contra indic
/DM, - complications 3. caution/precaution
Heart diseases 4. DRP, clinically signific
Dept.Paediatrics,
Neurology, etc
Monitoring of ADR s Diorectly or nondirectly Reported observable dt:
ADR - Acute ? observeable skin: eruption,edema,
- Chronic? Drug-induced diseases SLE, photosensitive, vas
- identification of drug a.o: Disorder of skin; culitis,allergic/pseudo
 type of ADRs renal; heart; liver; allergic
pulmonary; neurologic etc hemathologic: anemia,
(list of the drugs and the thrombocytop, agranoloc
related ADRs presented liver:cholestasis, nekros
separately from this pulmonary:edema,apnea
table) broncho spasm, etc
renal: acute tubular
necrosis, glom.nephr,
nephritic syndr.
neuroleptic:
epileptogenic, seizures,
delirium etc
ADRs guideline
Handling - EN/TPN Formulation/composistion: Guidelines (selected) of
of special - I.V admixture - content  therap. Use - iv drug administration
preparations - cystostatics - aseptic handling guidelines
- blood products, - calculation ion-gap, etc - drug compatibility
- crystalloid, trace - stability, incompatibity information
elemnts - interaction with drugs - enteral feeding and drug
adm. Guidelines, etc
UDD Drugs dispensing; Therap outcomes - Patients recover
information, Patient’s objections/claim - mortality, motbiodity
counselling, education Patient’s compliance - length of hospitalization
to patients. Drug use/adminitration
Drug dosage according correctly
to indication, pathol Drug storage (stability etc)
condition etc
Drug duplications,
potentiation, antagostic,
reverse etc
Pharmacoeco- Alternative drugs /brand QoL (Quality of Life, Drug Cost policy
nomy name/generation, subjective and objective Drug expenditure
dosage form, route ??? evaluation; -cost benefit ( Hospital/gouvernment
etc -cost minimization expense, health
-cost effective ness insurance) etc
Part of Multi center study Drug safety and efficacy,
on pre or/ad post and economy for
Clinical Trial Research marketed drugs (Clin Indonesian population.
Bagian phase III/IV)
Apa Tuntutan Kompetensi Farmasis Ward?  meets the
requirements for Professional Clinical Pharmacist (Bench
Mark AS/FAPA etc)
a. SpFRS Unair: Keilmuan Medis Klinis - Farmasi, clerkship
di 7 Bagian 2 th : Interne & Onkologi, Bedah, Ob-Gyn,
Pediatri, Neurologi, Jantung dan penelitian Tesis klinikal
b. memahami makna terminologi medis klinis Dx penyakit
c. mengenali tanda-utama klinikal penyakit dan makna data
laboratorik biokimiawi/patolog klinik terkait penyakit Px
d. memahami etiologi, patofisiologi, proses penyakit, co-
morbid, dan komplikasi yang timbul
e. memahami tujuan kegunaan obat, merekomdasikan
pilihan obat, aturan dosis, terkait penyakit pasien
f. mengenali response terapi dan efek samping obat terjadi
g. memberikan solusi dan konsultasi pencegahan dan
penyelesaian masalah obat secara bertanggung jawab
profesional dan bekerja dalam team klinis-medis lainnya)
SISTEM LAYANAN KESEHATAN
MELIBATKAN KETERPADUAN / PARTNERSHIP
• Kebijakan Obat National
• Tegaknya Aturan & UU Negara
• Informasi Objective, bertanggung jawab,
• Jaminan kualitas / kontrol sistem dan data operasional
layanan
 Quality Assurance
 Quality Control
 Quality Assessment
• Services & Intervention
•*Pelatihan dan pendidikan berkelanjutan
• (Stakesholders : Government, Publics, Drug Industries, Health
Institution & Educations, Health Providers, Health Insurance)
 Terapan Pelayanan Kefarmasian:

 Perubahan paradigma layanan kesehatan, karena

tuntutan perkembangan ilmu teknologi dan outcome
terapi
 Multidisiplin keilmuan kesehatan diperlukan dalam kerja
tim terpadu
 Sumber daya manusia berkualitas memadukan
moral/ahlak, kompetensi, tanggung jawab dan layak
dipercaya (trustworthiness, accountability)
 Pendekatan holistik fokus pada pasien , kerja sama intra
profesional dan interprofesional penerapan etika,
humanistik.
 Tegaknya disiplin, peraturan, perundangan dan etika
profesi, terkait kesehatan & kualitas hidup setiap
individu (Health for all by the year 2010?)
 Enforcement positif Departemen dan Institusi terkait
 Motto Farmasis ( source unknown):
“ I am a pharmacist,
I am a specialist in medication ………….. This
is my calling …….this is my pride …..,
this is the way I walk through ……… to dedicate
my profession to life and humanity”
Mari kita wujudkan bersama Pelayanan
Kefarmasian Nasional membangun bangsa
Indonesia Sehat dan Berkualitas.
May God be with Us. Amen.
TERIMA KASIH