This rotation and the presentation has shown me a small glimpse into the complexities and discussions happening behind the scenes.
Many patients with latex allergies are admitted to hospitals; however, there is controversy regarding what is considered “best practice” for sterile compounding in these patients. Though rare, some vials have a latex-containing septum which can potentially result in anaphylaxis if coring occurs. While there is a Fraser Health Policy from 2007 which addresses some of the concerns, the Quality Team was approached by frontline staff who wanted more clarity. My presentation focused on the processes of different organizations who have latex procedures in addition to a review of the evidence to help with policy revision.
Doing this presentation helped me to identify many aspects that I will incorporate into future presentations.
- Careful planning in the beginning sagesmay help me to understand the context of my presentation and where I would like to focus. For instance, what is the goal of my presentation, who is the target audience and what is the bridge between the background, evidence and my goal. By having a direction or focus, I’m better able to utilize my time and adjust the content appropriately.
- An overview of the presentation contents may help the audience to orient themselves and understand the flow
- Where possible, the use of pictures helps attendees to better understand the information that is being told verbally.
- And…a tip from the audience: depending on the lecture, possibly ask attendees to hold questions until later to help with flow.
Each time the residents come together, I’m impressed with the different knowledge we’ve acquired. These two sessions focused on CHF and electrolytes – areas which are seen commonly in clinical practice.
Management of electrolyte abnormalities is very common in patients admitted to the hospital. This session helped to remind me about key considerations. The first is that there are many drugs which can cause electrolyte abnormalities; therefore, it’s important to assess the causes rather than immediately adding a medication for treatment. Another concept to consider is the degree of abnormality – i.e. is there immediate danger. My last take home message from the electrolyte session was more general to practice. If I put the additional effort into understanding the underlying physiology, rather than straight memorization, I will be better able to utilize this information in practice.
Similar to electrolytes, one of my important takeaways is the importance of early treatment. IV loop diuretics (<60min) have been associated with lower in-hospital mortality. During this session, I also didn’t know that ARBs didn’t have strong evidence for decreasing mortality in patients with HFrEF. In the past, I’ve seen patients on an ARB and I hadn’t thought that the patient may not have had a trial of an ACEI. My future practice will include ensuring that an ACEI has been trial if it’s not properly documented in the chart. The session on HFpEF also helped to improve my knowledge of the disease state. The discussion helped me consolidate the importance of not only management of fluid retention, but also the patient’s comorbid conditions like blood pressure.
Summary: In patients with atrial fibrillation and recent medically managed NSTEMI, how does warfarin compare to apixaban?
This presentation took much longer than expected; however, it was a great first experience and showed me the importance of careful planning. During a part of my presentation, I didn’t answer a question as I misinterpreted the wording. Therefore, next presentation, I will aim to listen and reiterate the question before answering.
- There are many regimens to treat any disease state…not only the ones listed in the guidelines.
- Knowing the antibiogram of a site can help to characterize a person’s risk of contracting the organism. This information can be helpful in considering whether a patient may be covered with a narrower agent.
- For HAP, consider: higher doses, boarder coverage, local resistance patterns, and calling the microbiology lab for assistance in antibiotic coverage.
Digoxin and Phenytoin Takeaways:
- Digoxin can be monitored simply by heart rate for efficacy and safety. A level may be warranted if there are signs of toxicity
- When considering Digibind, call DPIC for assistance . Be prepared to give the level and patient’s dose of digoxin.
- Calculate the maintenance dose of PHT (mg/kg) to help determine the amount of dose adjustment. If it’s 5-7mg/kg, the dose more likely in the zero order portion and there is saturation of enzymes therefore, smaller dose adjustments need to be made. If in the linear portion (~3mg/kg), we can be more aggressive with the dose titration.
It feels like I was just oriented to the program and BAM! Clinical orientation and medicine rotation are complete. Hello first project week.
My research project is a descriptive analysis of pharmacy CE providers with respect to conflict of interest. For instance, what methods do our CE providers use to mitigate the conflict of interest? Do they have policies, what’s the adherence to them? Do sponsored CEs have different content? When I first thought about these questions, the project seemed simple; however, my catchphrase this year should be “ignorance is bliss”.
I went into my first meeting a few weeks ago feeling confident, but the further and further I dove into the research, the more times I’m spin around. With new insight and further knowledge comes a greater epiphany that there is so much more to understand!
How do I think this project will go overall? 2 steps forward and 1 step back. It won’t be simple and I’m sure to make mistakes along the way; however, each will present with learning opportunities. Whether I will have such a positive attitude in a couple months time, only time will tell.
Plan for this week:
- Develop a methodology for identifying CE providers
- Develop a spreadsheet for characterizing CE providers
- Background section of protocol written with multiple edits
MA and RCTs
- Applying evidence to a patient is based on many factors
- Quality of study
- Quality of studies included (MA)
- Outcomes of interest (hard outcomes?)
- Composite make sense?
Explaining Evidence to Patients
- Chat with the team
- Set the stage (who, why, when)
- Intention of conversation and request for collaborative decision-making
- Patient experience
- Explanation of disease and meds (why, how, what)
- Evidence quality
- Patient values and summary of discussion points
- Check for understanding
- Chart it
Applying Evidence to Patient Care – The importance of a SMART PICO
- S – Specific:
- Location, Clinical Setting, Patients
- M – Measurable outcome
- Failure vs. success
- A – Achievable
- R – Relevant
- surrogate or hard outcome?
- T – Time
- when should the outcome occur?
- Role: confidential, coaching, communication facilitator
- Common resident discussions with the ombudsperson
- interpersonal conflict regarding power dynamics, environment issues
- Residency survival:
- communication: residency doesn’t need to be stressful – be aware and prepare, but also, be proactive. Reach out
- Communication – almost 50% of our time is spent listening to others therefore, it’s important to be active in the process
- the emotional reaction may not be the message that was meant to be conveyed – objectivity when listening to feedback
- Understanding my own goals – prioritization and being realistic
BC-Wide Case Presentations
- Find the right DTP (not a DIR)
- Change therapy
- Before literature searching…double check that case is appropriate for BC Wide
Birds are to flying, Bees are to honey and PK is to Mary Ensom – the PK wizard. Luckily, she passed her knowledge on and we were able to have great mentors for our session.
My take-home points of interpreting a level:
- DUE! (do we need to intervene now?)
- draw (drawn on time)
- duration (infusion over correct time?)
- drug (were the previous doses given on time?)
- Ideally we want the concentration to be effective right before the next dose
- Renal function:
- Urine output (SCr lags behind)
- BUN, SCr
- Urine output (SCr lags behind by a couple days)
- Anuric –> concentration stable
- It’s okay to check multiple levels if the patient’s renal function is fluctuating
- Don’t forget about the decreasing concentration if the level is drawn 30 minutes before the next dose
- To avoid a panicking health care team, one can consider a note for interpretation of levels
- Check the baseline Egfr
- Pre-3rd/Pre-4th = maintenance dose
- Calculate a quick check
- Prosthetics are sticky stuff…
- Load: 25mg/kg
- Load ’em up by ABW (get above that MIC)
- Maintenance: 15mg/kg
- can either increase or decrease the concentration
- Is it indicated? (MRSA negative or negative screen)
- Other nephrotoxic drugs: furosemide, AMG, Ampho B
Session 1: Critical Appraisal
Prior to this session, I hadn’t given much thought to what components made a reliable guideline. In my head it was a given that guidelines were a good source of information – it was written by people that knew more than I did about critical appraisal and it summarized the contents in an easy to read format; however, this session showed me that I not only need to be aware of who’s writing the content, but also actively appraising the content itself.
My thought summary:
- The quality of a guideline can vary substantially – are there sources of bias?
- No guideline is perfect no matter who writes it, therefore, the importance lies in being aware of those potential biases
- Surrogates…why are we chasing them? There could be better hard endpoint. Do the surrogates correlate with the hard endpoint?
- Our responsibilities should lie in our primary interest (our patients); however, we can sway due to our secondary objectives (maintaining our professional relationships)
- Mitigation lies in patient-informed decision-making
- Subconscious biases to be aware of:
- confirmation bias
- anchoring bias
Session 2 – Parenteral Therapy
Resources, resources, resources…use the resource. Also, use the right resource – the health authorities are divided with regard to the correct resource. Did I mention the word resource enough?
- Peripheral – short term use (<7 days)
- Central >7 days
- PICC, Hickman’s, IVAD, Port-a-cath
- 1 to 3
- Y site = 2 drugs to 1 lumen
- Line Volume: the drug may still be in the patient
- Complications and considerations:
- Phlebitis –> ensure full treatment administered
- Hematoma –> able to change route of medication?
- Extravasion –> check the extravasion protocol for management, PDTM
- Catheter related infection –> line vs. blood culture…which comes back first?
- Occlusion: CVC = alteplase, Peripheral = change the line
- Complications/solutions –> Trissels/PDTM
- SC –> slower absorption (good for increasing frequency)
- The PDTM:
- safety document
- Cytotoxic? –> BCCA
- Concentrating a bag:
- Pt’s clinical status
- Medication stability –> Trissels
- Infusion Rate
- Catheter Type
- reconstitution chart
- Drug assessment:
- L x 3
- Type of line
- Location of patient
- Length of administration
Day 1 – MUE and Infectious Diseases
It was wonderful seeing everyone after …what…3 weeks? It’s really crazy how fast time flies.
Today we had 2 separate sessions – MUE and Infectious Diseases. There are so many takeaways that I almost don’t know where to start. Every moment in this program just shows me that I have so much more to learn and that I will never be done learning.
Day 1, Session 1 – MUE :
Seems simple, but of course, ignorance is bliss! My biggest takeaway is to know what I’m looking for. There is so much information available, but if I don’t know my outcome, I will go down so many unnecessary rabbit holes – just like we did with this iron MUE assignment. Although not perfect, I now have a better general idea of my process/tips for conducting research.
- PICO question – if it’s well laid out and detailed, it’ll make my research easier to conduct. Although this may take more time initially (must resist the urge that says “you should be reading articles!”), it’ll give me a better result.
- Know the background – with an example of drug therapy comparison, how do we normally treat this disease? Do surrogates matter? Are there studies which demonstrate a correlation between surrogates and hard endpoints. Having this information will help build a foundation for relevant research.
- Guidelines – a good starting point, but who wrote them? It could be a drug company in disguise…always. be. suspicious.
- Outcomes – so much to consider! But most importantly, what am I looking for? This should be done before I even look at the articles – it relates back to my PICO
- And of course, Dr. Tejani’s quick summary:
- Develop a strong question
- What type of study would answer my question?
- How should the study be designed to achieve this outcome
Day 1, Session 2: Infectious Diseases
- Pediatric: AAP Redbook, Bugs/Drugs, Pedmed (references section)
- General treatment overview: Dipiro, Mendell, IDSA guidelines (though treatment can be aggressive)
- ABX to site penetration: Sandford
- BC Centre for Excellence in HIV/AIDS
- Toronto General Hospital – Immunodeficiency Clinic (Good for ICU -> oral forms available)
- TB: Canadian TB Standards
- Antibiograms – there’s one for community! (Lifelabs)
- Easy bacterial preliminary classification: VHpharmsci.com
- Approach to a patient with an infection:
- Does the patient need an agent? What are the risks of no treatment?
- Choosing an agent
- likely pathogens
- Pt factors
- Organism factors
- Antimicrobial factors
- Source Control
- Risk Factor Management
- Narrow when possible
- Pt not improving? Consider reasons for treatment failure