CIVA

Objectives

CHPRB Standard 2010
The resident shall demonstrate a working knowledge of medication use system(s) as well as pharmacy and other care provider roles within the system, in order to manage and improve medication use for individual patients and groups of patients.

Levels of expectations

1.    Clearly, concisely, and completely describe the functioning of the drug distribution system and medication prescribing processes within the health care organization to another health professional.
2.    Assess prescriptions for accuracy, appropriateness, and adherence to health care organizational policies and practices.
3.    Consistently identify and complete medication incident reports.
4.    Explain & educate others about health care organizational practices and policies related to preparation of sterile products (such as cytotoxic agents, parenteral nutrition, injectable medications), and narcotic & controlled drugs. Independent preparation of sterile products is beyond the expected level of the standards, but active participation in preparing sterile products can help the understanding of aseptic technique.
5.    Document prescriptions and prescription changes clearly and completely.

Overall Goal

To introduce the resident to the area of intravenous admixture by increasing their knowledge, skills and abilities in the following areas:
1.    Aseptic Technique
2.    Aseptic compounding policies & clinical concepts.
3.    Technology in sterile product preparation
4.    Chemotherapy
5.    Total Parenteral Nutrition

Aseptic Compounding/CIVA Rotation Learning Objectives

1.    Sterile Products – General Technical and Clinical Knowledge – The resident will acquire basic knowledge of preparation & administration of sterile products by familiarizing themselves with the following:
a.    Definition of  “aseptic compounding”.
b.    The difference between aseptic compounding v. manufacturing.
c.    The benefits of a CIVA model, as compared to de-centralized or ward-based preparation of sterile products.
d.    The differences between types of laminar air flow hoods and what they are best used for.
e.    The characteristics of an ideal “clean room”.
f.    A comparison of 2 different control systems that ensure product quality – “product sterility testing” vs “process validation.”
g.    Intravenous Access – The resident will become familiar with the various procedures and devices used to access the intravenous route of administration of drugs by spending 1 day with the IV Therapy Team.
h.    VIHA Pharmacy Department Policy & Procedures on Aseptic Compounding (Section 4) – The resident will review policies located at:
O:\CIVA\Staff\ARongve\4_Aseptic Compounding Service

For g. and h. above:  Open book written exam will be carried out CIVA rotation to solidify knowledge of concepts. Exam will be provided by preceptor-entitled:
“Sterile Products Learning Questions for Pharmacy Residents & new Pharmacists:  Aseptic Compounding & Cytotoxic policies plus Clinical component”.  Exam will be marked and reviewed with the preceptor.

Aseptic technique knowledge, skills and abilities.
a.    Demonstrates ability to make calculations related to preparation & administration of parenteral products.
Written exam: “VIHA Aseptic Compounding Certification Math Exam” (ACCE) will be carried out during CIVA rotation to solidify compounding math knowledge. Exam will be provided and will be marked and reviewed with the preceptor.

b.    Describe and demonstrate the correct procedure for washing hands, donning gowns and gloves for entry into the aseptic compounding room.

c.    Describe basic concepts/procedures such as critical site, powder displacement, venting vs. milking withdrawal techniques and demonstrates these techniques when preparing sterile products by:
•    Preparing at least 10 minibags using a vial that requires reconstitution.
•    Preparing at least 1 parenteral product that requires the breaking and withdrawal of solution from an ampoule.

3.    Automated equipment – The resident will become familiar with automated equipment used to facilitate aseptic compounding such as repeater pumps, syringe fillers, and the automated TPN compounder.
•    Resident will set up the automated syringe filler with a technician to compound a minimum of ~100 syringes.
•    Resident will prime and calibrate the automated TPN compounder in the presence of a certified technician checker or a trained pharmacist.

TPN Rotation Learning Objectives

1.    TPN Clinical Concepts: The resident will demonstrate their basic knowledge regarding TPN compounding and clinical application by completing an open book quiz testing information found in the pre-readings.

2.    TPN Order Editing for clinical appropriateness:  The resident is able to perform Adult, Pediatric & Neonatal TPN order checking by reviewing the orders for basic clinical appropriateness.

3.    TPN Order Editing for Stability:  The resident will be able to check TPN for physical compatibility and stability for both 3-in-1 emulsions and 2-in-1 solutions utilizing the “Calculation Worksheets”.

4.    TPN Order Entry & Verification: The resident will become familiar with checking as well as entering TPN orders into the clinical computerized TPN program for the three patient populations: adult, pediatric, and neonatal.  With a sterile product technician the resident will:
•    Enter a minimum of 7 adult TPN orders
•    Enter a minimum of 3 neonatal orders
•    Enter a minimum of 1 pediatric TPN (if available. Note: Pediatric TPN will also be covered during their pediatric rotation.)
•    Verify a minimum of 10 TPN orders – at least 3 of them neonatal

Credit for prior learning

Sterile Products Credit for Prior Learning

CIVA – Week one

January 15, 2010:

I just completed my first week in CIVA at VGH. This past week I have shadowed the sterile products pharmacist, attended neonatal TPN rounds, did TPN calculations for neonates and adults, verified TPN orders and shadowed a dietitian for the morning.

A lot of the information was review this week but what I found most useful was learning about neonatal TPN  because it was something I never got to do at RJH. The calculations are a bit more complicated that adult TPN and subsequently it is easier to make mistakes in calculations or when entering the TPN into Abacus. There was an incident when the Na Acetate was entered in Abacus  as “mmol/kg” instead of “mmol/kg” and the baby ended up getting a lot more in the bag than was ordered.

I also reviewed some “TPN theory” with Kim in regards to fat overload syndrome, refeeding syndrome, TPN compatability, etc. Overall, the TPN review helped bring together what I had learned working as a sterile products pharmacist at RJH.

CIVA – Week two

January 24, 2010:

My last week of rotation was spent in the hood at RJH. I got to shadow the technicians the first day.  I ended up making some hydromorphone and bupivicaine epidural bags, vancomycin minibags, clindamycin minibags and cefuroxime minibags as well. It was nice to get the practice in case I ever get called in to mix something when I’m on call. I also requested to be shown how to mix intravitreal vancomycin syringes as I know pharmacists have been called in before in the middle of the night. Since they didn’t have any orders for this, they used expired drug and Dana, one of the technicians talked me through how to mix them. They quite complicated as the solution has to be diluted and filtered but I think I got the hang out of it. Unfortunately, it was a really slow week in terms of chemo orders so I didn’t get a chance to go into the chemo hood.

When I wasn’t mixing I spent the other time working on some learning questions and calculations. One of the questions I had to use the alligation method to solve. I never thought after using that method in first year pharmacy that I would ever have to use it again in real life.  I guess I was wrong!