We had a session with Curtis Harder regarding microbiologic lab data. What I took away from the session was:
1) What Vitek and KB mean in Powerchart 2) For blood cultures, two sets (4 bottles) should be sent to the lab for testing. They should also be drawn 10 minutes apart. 3) To look at the “whole picture” when determining therapy for a patient or when monitoring a patient. Do not just focus on labs! Consider temperature, clincal improvement, etc.This week we started our direct patient care rotation. Basically it is an introduction on the process we use to assess patients. We talked about pharmaceutical care, how to communicate with physicians, the different “types” of DRPs, and how to “systematically” interview and assess a patient. We spent two mornings with Sean (Spina) practicing physical assessment on each other. Although, I am not sure if I am comfortable doing that on real patients without someone supervising me. I think the physical assessment part will help though when I am reading charts and will help me understand different information in the progress notes.
I actually went to see a real live patient yesterday and observed an interview. I also hadn’t look at a patient chart since May so I had to get my bearings around that again. It was a bit overwhelming in the sense that there are so many factors to consider and I am scared when I’m the one doing the interviews that I will miss something. But I guess that’s why there is a systematic approach! We managed to raise a couple of DRPs that weren’t resolved and will continue to follow the patient next week.
One thing I will always have to keep in mind is that not all patients will be able to give you answers to all your questions and to be patient when they are answering questions. Our patient was elderly, just had 8 mg of morphine and had delirium so she was having trouble staying awake when we talked to her.
All in all, it was a good introduction and I am slowly learning the “process”. Hopefully, I will be preped for August 17th when I start my first clinical rotation!
4 days of Pharmacokinetics
Posted on: July 23, 2009
We spent the first four days of this weekend reviewing pharmacokinetics for drugs such as vancomycin, aminoglycosides, digoxin and phenytoin. The section on aminoglycosides was the most over-whelming but hopefully when it comes down to calculating parameters such as Ke, T1/2, Vd, dosing interval and new maintenance dose I will be more comfortable with it when I have real levels for a real patient. There was also a quick review of statistics on Wednesday afternoon. It reviewed a lot of stuff I have since forgotten since school and I am actually thinking of changing one of the statistical tests I am using for my research project.
Kudos to Dr. Ensom! She is a really knowledable and thorough lecturer and I wish she had taught me kinetics during pharmacy school.
Drug Distribution Wrap-Up!
Posted on: July 17, 2009
I spent most of this week working on a project for Sherry Lalli. I basically had the task of sorting through the “special delivery forms” that RJH pharmacy uses when a medication is requested to be “ASAP”. I ended up counting almost 1500 slips and the information I managed to extract include following:
- The majority of the requests we get are for antibiotics, anti-hypertensives and medications related to electrolyte imbalances (potassium chloride, potassium phosphate, magnesium).
- 15% of the requests, in my opinion, were not an appropriate use of a porter’s time or pharmacy’s resources. Examples of these drugs include calcium, multivitamins, thiamine, vitamin B12, calcitonin nasal sprays, Risperidal Consta, Bradasol lozenges, levothyroxine, and creams.
- There were a couple of medications which could be considered for addition to AcuDose/ward stock based on the number of requests we got → gabapentin and gliclazide.
Overall, it was cumbersome to count all the slips but I hope the work I did can be used to educate nurses about which medications truly need to be given right away versus which ones can be given later. This is also an opportunity for pharmacy staff to ask if the medication(s) can be placed on the next run.
Medication Use Management Wrap Up
Posted on: July 15, 2009
Today, I attended didactic sessions as the final requirement for the Medication Use Management rotation. Although the material could have been really “dry”, Richard and Lara managed to make the session interactive and more interesting. We talked about different topics such as restrictions, drug shortages and formulary changes and applied real-life examples. A few issues that we discussed were the removal of nystatin powder of the market and formulary change from tinzaparin to dalteparin. We also looked at the CADTH website and looked through the Common Drug Review (CDR) database. A few things I learned about from the session and the rotation that I did not know before were:
- The P & T Committee makes recommendations (to add or not to add a drug to formulary), however HAMAC has the ultimate power to approve it.
- The Antibiotic Review Subcommittee sometimes makes recommendations to the P & T Committee.
- The P & T Committee does not just deal involve the formulary. Other issues they are responsible for are medication safety, adverse drug event monitoring, medication error prevention, etc.
Renal Dosing – Therapeutic Sessions
Posted on: July 8, 2009
We had our second therapeutic session of the year today and the topic was renal dosing. I learned the “Process” of renal dosing (i.e. is there an alternative? how sick is the patient? is the response to the drug needed ASAP?).
A few other interesting tidbits I also took away:
1) “Gault” from the Cockcroft Gault equation was an Alberta physician who died three years ago.
2) Carvedilol is the only beta blocker proven to have cardiac benefits in renal patients.
3) Using the modified CG equation without the weight is probably the best way to adjust doses.
4) Waist circumference is a signficant risk factor for chronic kidney disease (along with diabetes, CVD).
MUM!
Posted on: July 8, 2009
I have just finished three days of my Medication Use Management (MUM) Rotation. Instead of making me read many documents, my preceptors (Lara Campbell and Richard Cormier) have assigned me a project. I am helping them re-organize them replace some of the therapeutic substitutions that will be removed at VIHA with more user-friend charts. These charts will be used not as therapeutic substitution but as a “guide” so pharmacists can use their professional judgment to dispense equivalent products. So far, I have made charts for calcium salts, iron salts and hemorrhoidal products. I will try to post a chart if I am allowed to!
Next week, we will have didactic sessions on topics such as formulary, P & T committees, and databases such as CDR( Common Drug Review).
The life of a DI pharmacist
Posted on: July 2, 2009
Where do I even begin! DPIC is definitely not what I expected it to be. The first day was spent doing orientation, getting introduced to a few tertiary references and role playing scenarios which helped us get a feel of the types of questions to ask. Then all of a sudden we were answering the phones!
I am getting a refresher/more practice in lit searching as it’s been a while since I’ve looked into questions in this much detail. I did discover OVID interface scope terms which is something we did not do at Dal (shocker). My biggest challenge is figuring out what to do when there is no evidence or information at all relating to the question. This seemed to come up a lot for example I got a question about a possible drug interaction between sibutramine and amitriptyline. Some sources listed it as a “theoretical interaction” because they both inhibit the reuptake of serotonin. However, after searching all possible resources I could think of, I didn’t even find a case report on it.
On the last day of our rotation, we had a medication safety session with Barbara Cadario. We talked about different resources such as MedEffect and ISMP. I also was introduced to the WHO Causality Assessment algorithm for determining causality with ADRs and drugs. It is a good resource and I will definitely use it when I come across a patient in my practice who experiences an ADR.
Overall, I was frustrated about the types of questions we were getting (ones with no answers or little information) but I did learn about multiple resources and was introduced to new references that I have never seen before. I am sure I will take some skills I have learned during this rotation and use them in my practice.
DPIC Rotation
Posted on: June 28, 2009
Goals
The goal in the one-week drug information rotation is to develop an understanding of how a pharmacist can serve as an effective provider of drug information. An effective provider combines information retrieval skills with clinical knowledge, and applies them towards the care of individual patients.
Drug Information Rotation Objectives (please go to end of post to see personal learning objectives)
Upon completion of the one-week drug information rotation, the pharmacy resident should have improved their skills in three general areas:
Information retrieval:
- Identify the question.
- Describe the types, functions, and limitations of commonly available drug information resources and demonstrate effective use of these resources.
- Demonstrate efficient search strategies.
Knowledge translation: Analyze, summarize or distill the information into a solid piece of knowledge, and communicate it effectively
- Critically analyze and evaluate information.
- Interpret and combine information from multiple sources.
- Distinguish what is known from what needs to be known.
- Formulate an accurate written and verbal response.
Application: Apply the knowledge to an individual patient
- Take the knowledge distilled from the best information available and combine it with personal clinical experience, specific patient history and concerns of the patient, local knowledge and society’s values in order to provide the best recommendation and outcome.
Personal objectives: DPICobjectives
VGH and Aberdeen
Posted on: June 26, 2009
I spent part of my morning at VGH getting an overview of their dispensary. My main purpose was to compare and constrast a unit dose system (RJH) vs a traditional dose system (VGH). VGH batches every 7 days (or every 3 or 4 days for some wards). I noticed two major issues with this. 1) There is a lot of medication wastage occurs as orders often get discontinued before 7 days are used up and if they aren’t unit dose packed the medications are disposed of. 2) The chance of a picking error increases also with traditional dose systems.
I spent the other part of my day at Aberdeen Hospital which is a LTC/rehab facility. There are so many differences compared to acute care sites. The majority of the medications are blister packed and the set up is quite different as the pharmacists do all the order entry and the technicians do the filling. Meds are sent up in blister packs with 35 tablets/capsules per pack. MARs print once a month only (versus q24h at RJH). The pharmacists also do some clinical work at different LTC sites and do medication reviews with patients and their family members.
Overall, it was interesting to see how different sites are run as I have only worked at RJH.
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