Pharmacists in the ER Equals Better Patient Care

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One of the biggest impacts a pharmacist can make in the hospital setting is in the emergency department (ER). There has been a growing interest and trend in placing pharmacists in the ER to review medications, both reconciliation of home medications and medications administered in the ER to ensure correctness and cut down on medication errors and drug interactions that contribute up to 7,000 yearly deaths in the US. A pharmacist in the ER can review real-time orders that are typically bypassed by staff pharmacists due to the urgency of an ER patient.

Pharmacists can also improve flow of patients through the ER, educate prescribers and staff development about medications and their costs and also utilize the ER as a place to precept and mentor students and residents. Pharmacists can participate in codes, help with admissions in home medications and help with discharge medication reconciliation. Pharmacists in the ER can also be involved with the ER department in providing presentations, publications and other activities to the department. Pharmacists can monitor the use of expensive medications to make sure use is consistent with approved criteria (Factor VII, alteplase, etc.) and conduct MUEs in the emergency room setting. These pharmacists could also be involved with microbial culture follow-up. The emergency department is usually a place of unpredictability in acute illnesses and patient volume. High risk medications are used more often and a greater chance of a medication error reaching the patient.

Currently in most hospital settings, hospitals use a clerk to fill out a home medication sheet which typically can include errors in drug name, drug strength and directions. Many times staff pharmacists are clarifying home medications days later than what is optimal. I have personally witnessed mistakes in high-risk medications like warfarin that are discovered days later. In short, when a patient is admitted, they are prescribing for themselves with no oversight from a pharmacist, and physicians do not want to take ownership of what the patient takes at home since they are presenting with something acute that may have nothing to do with the herbals they take on the side.

The American Society of Health-System Pharmacists (ASHP) believes every hospital pharmacy department should provide its emergency department with the pharmacy services that are necessary for safe and effective patient care. The Joint Commission also has compliance requirements that can be met with a pharmacist in the emergency department (MM.4.10. which requires that all medication orders be evaluated by a pharmacist prior to administration of the first dose and MM 7.10 which identifies high-risk or high-alert medications and all the processes involved from procuring to monitoring and medication reconciliation). One of the National Patient Safety Goals is to accurately and completely reconcile medications across the continuum of care which would include the first stop in the emergency department.

One of the most common reasons most hospitals do not employ emergency room pharmacists is due to cost. Small hospital pharmacies are staffed at a bare minimum. Most hospitals do not realize that pharmacists working in the emergency room can reduce readmissions, medication errors and drug interactions to save money but more importantly increase patient safety while being treated for an acute illness.

 

 

1.       Impact of a prescription review program on the accuracy and safety of discharge prescriptions in a pediatric hospital setting. J Pediatr Pharmacol Ther. 2008 Oct;13(4):226-32. doi: 10.5863/1551-6776-13.4.226.

2.       Levy DB. Documentation of clinical and cost saving pharmacy interventions in the emergency room. Hosp Pharm. 1993;28:624-627,630-634,653.

3.       American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health Syst Pharm. 2003; 60:1993-5.

4.       Cohen V, et al. Effect of clinical pharmacists on care in the emergency department: a systematic review. – Am J Health-Syst Pharm. 2009;66;1353-1361

National Patient Safety Goals: The Joint Commission

ACCP: Update in Therapeutics (my thoughts)

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Well, here I sit in the Reno airport waiting on my flight to LAS.  My brain hurts a bit, but really enjoyed my stay at the Peppermill with my friend.  She is taking the exam for the first time, and if you have been following me for any amount of time know its my second attempt at this certification.  I feel what the in-person attendance vs the audio recordings can provide is the dedicated time to only listen to pharmacy all day for four days.  I really have my days mixed up so forgive me if I quoted that wrong.  The instructors for the most part were more than adequate presenting their material save for the always dry statistics lecture that made more sense since it's probably my 21st time hearing it. I can quote that infectious disease lecture almost verbatim at this point.  Maybe even in Dr. Smith's accent.

I enjoyed the changes in cardiology.  The material seemed much more organized and flowed better.

What my plan is for the next few months is to really learn the guidelines and as soon as the new lectures arrive (CDs), I will be the soccer mom in a van not listening to Top 40 but the lectures ad nauseum.  I guess there comes a point where all of this material coalesces and makes sense.  It was such a treat, I might add, to see Shannon Finks present since we attended UT Memphis School of Pharmacy together.  I love seeing UT students make such huge impacts in our profession.

So for now, I am reviewing cardiology at the moment.  And my friend and I did spend some time in the hotel room listening to the High Yield Med Reviews online lectures.  The stats one, she remarked, made more sense of the ACCP material... if that helps any.  I also purchased a couple of books.

Good luck to all of you who are now going to study like never before.  Do NOT wait.  Start now.  We have 5-5.5 months left.  That's really just around the corner considering I just received last years results 4 months ago.  Time flies.

And, I got the great opportunity to meet the winner of the giveaway -- Yvonne!  Like me, she sees the value in getting this, especially if you have been out of pharmacy school for any amount of time.  Jobs are more scarce, guidelines change and if you don't show that you have kept or are keeping up (demonstrated by passing this test), then you may be in trouble.  Just do it!!!

BCPS 2013: Some Pharmacoeconomics

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Pharmacoeconomics are on the test more than I would have thought.  Some notes for you.  Enjoy! Definitions

A. Pharmacoeconomics—the description and analysis of the costs and consequences of pharmaceuticals and pharmaceutical services and its effects on individuals, health care systems, and society. These costs and consequences typically include both economic and humanistic assessments.

1. A division of outcomes research; however, NOT all outcomes research is pharmacoeconomic research.

B. Outcomes research—broadly defined as studies that attempt to identify, measure, and evaluate the end results of health care services in general

1. Clinical effects as well as economic & humanistic outcomes (i.e. functional status, well-being, satisfaction w/ care).

2. Proposed that evaluation of drug therapy and related services should always include assessments of economic, clinical, and humanistic outcomes.

 

A. Economic, clinical, and humanistic outcome (ECHO) model

1. Economic outcomes—direct, indirect, and intangible costs compared with the consequences of medical treatment alternatives.

2. Clinical outcomes—medical events that occur as a result of disease or treatment

3. Humanistic outcomes—consequences of disease or treatment on patient functional status, or quality of life, measured along several dimensions, e.g., physical functioning, social functioning, general health perceptions and well-being.

B. The ECHO model recognizes intermediary outcomes

1. Economic intermediaries à introduced from the clinical and humanistic side of the model.

a. Clinical à direct costs of medical care assoc’d with each treatment, not just the direct cost of the pharmaceutical products (i.e. lab testing, ED visits, inpt hospitalizations, and costs of retreatment from product failure)

b. Humanistic à

i. Indirect, or productivity costs assoc’d with the time lost from work

ii. Direct nonmedical costs à transportation to the hospital, or physician’s office for treatment

2. Humanistic intermediaries à affect the indl’s subjective evaluation of outcomes

a. Examples: side effects; efficacy/effectiveness; patient’s willingness or ability to pay; adherence to drug regimen (compliance); patient’s knowledge; drug dosing schedules

Economic outcomes assessment

**Balance cost vs consequences

A. Costs

1. Direct medical costs—costs incurred for medical products and services used for the prevention, detection, and treatment of a disease.

a. Examples: hospitalization, drugs, laboratory testing, supplies

i) Fixed costs represent overhead costs

ii) Variable costs—vary as a function of volume

2. Direct nonmedical costs—costs for nonmedical services that are the result of illness or disease, but do not involve purchasing medical services.

b. Examples: special food, transportation for health care, family care

3. Indirect costs—costs of morbidity and mortality resulting from illness or disease.

a. Examples: lost productivity, premature death

4. Intangible costs—costs of pain, suffering, grief, and other nonfinancial outcomes of disease and medical care

5. Incremental costs—additional costs incurred to obtain an additional unit of benefit from an alternative strategy.

6. Opportunity costs—the value of the next best use that is forgone

B. Consequences

1. Positive versus negative

a. Full evaluations must measure both desirable and undesirable outcomes.

2. Intermediate (“surrogate outcomes”) versus final

a. Intermediate outcomes are commonly used to demonstrate clinical efficacy because their usage reduces the costs and time required to conduct a clinical trial.

C. Perspectives: The pharmacoeconomic question being asked usually determines the appropriate perspective or viewpoint to be used.

1. Patient—costs are what they pay for a product or service (the portion not covered by insurance).

2. Provider—the health care professional or care organization; costs are the actual costs of providing a product or service, regardless of the charge

3. Payer—insurers, government, or employers; the costs are the charges for health care products and services allowed (reimbursed) by the payer.

4. Society—costs include patient morbidity and mortality costs, and the overall costs of giving and receiving medical care (**PREFERRED FOR CEA)

 

Economic Assessments

A. Full economic evaluation helps to assess the economic benefit of a program, service, or treatment

a. Requires (1) comparison of  >2 treatment alternatives and (2) BOTH costs and consequences of the alternatives are examined

Methodology

Cost Unit

Outcome Unit

Example

COI

$

Not assessed

Yields total cost of a disease

CMA

$

Comparative groups assumed to have = outcomes

Determine the least costly alternative

CBA

$

$

Net cost or benefit usually* or cost:benefit ratio

Used to decide how to allocate scarce resources

CEA

$

Natural units or units of effect

Used to compare competing programs or tx alternatives that differ in therapeutic outcome**

CUA

$

QALY

Used to compare txs or programs using terms of patient preference, quality of health care, or when outcomes can’t be expressed in monetary terms

COI = Cost of illness, CMA = Cost-minimization analysis; CBA = Cost-benefit analysis; CEA = Cost-effectiveness analysis; CUA = Cost-utility analysis; QALY = Quality-adjusted life years

*Example: if cost for treatment is $100 and value of outcome of treatment is $1000, cost-benefit ratio is:

benefit ÷ cost = $1000 ÷ $100 = 10/1 benefit of $1 million and cost of $100,000 also yields cost-benefit

ratio of 10/1 VS. net benefit = $900 ($1000 - $100)

**Results are expressed as average cost-effectiveness ratios, or as the incremental cost of using one alternative

over another.

Example: drug A has 90 percent cure rate, drug B has 95 percent cure rate; drug A costs $50,000 to

treat 100 patients, drug B costs $100,000 to treat 100 patients

-Calculation of average cost-effectiveness ratios:

drug A costs $50,000/100 patients ÷ 90 cures/100 patients = $555/cure

drug B costs $100,000/100 patients ÷ 95 cures/100 patients = $1053/cure

-Calculation of incremental cost-effectiveness ratio:

$100,000 - $50,000

95 cures - 90 cures      = $10,000/additional cure with drug B

 

Techniques for analysis

A. Discounting

1. Definition—an analysis that adjusts (reduces) future costs and consequences to reflect present fiscal value.

2. Discounting costs—based on the time value of money; because the value of money decreases over time, future costs must be adjusted (discounted) to present time values.

3. Discount rate of 3–8 percent should be used (often reflective of current interest rates used by banking institutions). Health care uses 5%.

B. Sensitivity analysis

1. Definition—an analysis that tests robustness of study conclusions; sensitive variables (or assumptions) are varied over a range of plausible results and the impact on study results is observed.

2. Variables include percent efficacy (or effectiveness), incidence of specific adverse drug reactions, and dominant costs.

C. Incremental cost analysis

1. Definition—an analysis that examines the extra cost of one program or treatment alternative relative to the additional effect provided by that alternative.

2. Formula: _Cost B – Cost A_

Effect B – Effect A

 

Applied Pharmacoeconomics

A. Definition—putting pharmacoeconomic principles, methods and theories into practice to assess the value of pharmaceutical products and services used in “real-world” practice settings

B. Primary application—to inform local decision making. Examples:

a. Formulary management

b. Clinical guidelines

c. Drug use policies

d. Service or program evaluation

e. Individual patient treatment decisions

BCPS 2013: Infectious Diseases

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My infectious disease review.  I've already talked about pneumonia and may be revising these to go from the direction of the bugs and then the drugs again.  One thing I will say:  Invanz is not active against MRSA, ampicillin-resistant enterococci, Pseudomonas aeruginosa or Acinetobacter species.  Hear me?  :)

BCPS ID Review

Pneumonia

CAP

HAP
Organisms M. pneumonia, S. pneumonia, H.flu, C. pneumonia, Legionella, Viruses S. aureus, Pseudomonas, Enterobacter, Klebsiella pneumo, Candida, Acinetobacter, Serratia, E.coli, S.pneumonia
Treatment Healthy no Abx in previous 3 months

Macrolide (clarith or azith) OR doxycycline

Cormorbidity or Abx in previous 3 months

FQ (moxi, gemi, levo 750mg)

Macrolide (or doxy) + [High-dose amox 1g

tid OR amox/clav 2g bid OR ceph ]

(ceftriaxone, cefuroxime, cefpodoxime)

 Early onset (< 5 days)

3rd ceph (ceftriaxone, cefotaxime)

FQ (levo, moxi, cipro)

Amp/sulbactam

Ertapenem

Late onset (> 5 days or RF for MDR)

   Ceftazidime OR cefepime + AG or FQ (cipro, levo)

Imi, mero, or dori + AG or FQ (cipro, levo)

Pip/taz + AG or FQ (cipro, levo)

   + Vanco/linezolid only if MRSA risk factors
Duration At least 5 days 7 days (14 days for Pseudomonas)

 

Influenza: Type A (Annual, H1N1, H1N2), Type B

Prophylaxis:  if outbreak and cannot receive vaccine

1. Amantadine, Rimantadine 5-7 weeks

2. Neuraminidase inhibitors: Oseltamivir 75-150mg daily x6wks; 75mg daily x7days within 2 days of contact

Zanamivir 10mg daily through inhalation x4wks

Treatment: only if severe symptoms or at risk for complications

1. Amantadine, Rimantadine- only against Type A, decreases symptoms 1 day  *do NOT use for at risk for complications

Dosing: 100mg bid x3-7 days [Elderly 100 daily]; ADJUST FOR RENAL DISEASE (amantadine> rimantadine)

AE: CNS, GI, peripheral edema, orthostatic hypotension

2. Oseltamivir- decreases symptoms 1-1.5 days

Dosing: 75mg bid x5days [CrCl <30 75mg daily]

AE: GI

3. Zanamivir- decreases symptoms 1-1.5 days

Dosing: 2 inhalations (5mg/inhalation) bid x5days

AE: bronchospasm, cough

 

UTIs Treatment Other Comment
Uncomplicated cystitis Nitrofurantoin 100mg bid

     X 5 days

TMP/SMX DS bid x 3 days

Or Fosfomycin 3 gm once

Duration: 3 days vs 5

 Alternatives:

Amox-clavulanate, cefdinir, cefaclor, or cefpodoxime x 3-7d or FQ x 3 d

  
Pregnancy Amoxicillin

Nitrofurantoin

Cephalexin

TMP/SMZ

Duration: 7 days

 AVOID:

FQ

Tetracyclines

AG

TMP/SMZ (esp 3rd trimester

 Pregnant women should be screened for UTI even if asymptomatic
Recurrent cystitis Relapse: treat 2-6 weeks Reinfection

<2/yr: pt initiated x3days

3+/yr: post-intercourse

TMP/SMZ SS, cephalexin 250mg, nitro 50-100mg

3+/yr: daily or 3x/wk

 3+/yr other can also use TMP 100mg, or Norfloxacin 200mg
Uncomplicated Pyelonephritis Not requiring hospital:

Cipro 500mg BID x 7d

Cipro ER 1000mg daily x 7d

OR Levo 750 mg daily x 5d

OR TMP-SMX DS bid x 14d

 

Hospitalized:

IV FQ

Aminoglycoside with or w/o ampicillin

OR extended-spectrum cephalosporin or an extended-spectrum pcn with or without an aminoglycoside or carbapenem

 

 Not requiring hospital:

Or Oral beta-lactam (less effective) plus initial IV ceftriaxone 1gm OR IV 24-hour dose of aminoglycoside

 

 For pts without N/V and not immunocompromised
Complicated UTIs FQ levo x 5 days

AG x 5-14 days

 Extended spectrum Beta lactam  
Catheter-related UTIs Symptomatic pts x 7-10 days and cath removal Assymptomatic pts should NOT be treated E.coli, Candida, Enterococcus, Pseudo, Kleb pneumo, Enterobacter
Prostatitis Acute: Duration 4 weeks TMP/SMZ

Cephalosporins

FQ

 Chronic: 1-4 months

TMP/SMZ

FQ

  
Epididymitis >35 yr: TMP/SMZ, FQ

x 10 days- 4 weeks

 < 35 yr: Ceftriaxone 250mg IM AND doxycycline 100mg bid

x 10 days

  

Skin and Soft Tissue Infections

Cellulitis Nafcillin, Oxacillin, Dicloxacillin x5-10 days Alternatives: Clinda, BL combos, 1st ceph Vanco/Linezolid for MRSA

PCN G if streptococcal
Erysipelas Penicillin G, Clindamycin

x 7-10 days

    
Necrotizing Fasciitis B lactam combo + clinda  + cipro

Carbapenems

Cefotaxime + clinda OR metron

 Streptococcal: High dose IV PCN + clindamycin ABX not curative, surgical debridement necessary!
DM Foot Infection Deep:  1-2 weeks

Amp/sulbac, Ticar/clav, Pip/taz

Ertapenem

FQ + [clindamycin OR metron]

Cefoxitin

3rd ceph + [clinda OR metron]

 Shallow: treat like cellulitis

PCN, 1st ceph, etc.

 Topical: Becaplermin 0.01%

Human platelet derived growth factor, improves healing from 35-50%

 

Surgery also important

 

Osteomyelitis: treat for 4-6 weeks (chronic IV 6-8 weeks + 3-12 months PO)

1. Neonates: Nafcillin + [cefotaxime OR AQ]

2. Infants: Cefuroxime OR ceftriaxone OR [Nafcillin + cefotaxime]

3. Peds (>3yr): Nafcillin OR Cefazolin OR Clindamycin

4. Adults: Nafcillin OR Cefazolin OR Vancomycin

5. Pts with Sickle Cell Anemia: Nafcillin + Ampicillin

6. Prosthetic Joint Infections: Vancomycin + rifampin OR Nafcillin + rifampin

 

CNS Infections: Meningitis

Empiric: 7-14 days

1. Neonates: Ampicillin + AQ OR + cefotaxime

2. 1 month- 50 yrs: 3rd ceph (cefotaxime, ceftriaxone) + Vanco

3. >50 yrs: 3rd ceph +Vanco + ampicillin

4. penetrating head trauma: Vanco + cefepime, ceftazidime, meropenem

Pathogen Known: MOSTLY PCN G 4mill units IV q4h OR Ampicillin 2g q4h, alt: 3rd ceph, vanco, mero, FQ

Corticosteriods: Dexamethasone 0.15 mg.kg q6h x2-4 days; give 10-20 mins before (or at time of ) Abx

Benefit in: Peds with H.flu and Adults with S. pneumo

Brain Abscess: Treat based on source: mostly metron + 3rd Ceph                               Unknown source: Vanco + Metron+ 3rd ceph

 

Endocarditis: Strep, Staph, Entero, HACEK    Duration: 4-6 weeks (8+ weeks with VRE)

Strep: PCN G ± gent, Ceftriaxone ± gent, Vanco

Staph: Oxa/nafcillin ± gent (+ rifampin if prosthetic valve), Cefazolin ± gent (+ rifampin if prosthetic)

MRSA: Vanco (+ rifampin if prosthetic); may also use Vanco in severe PCN allergy

Entero: [PCN G or ampicillin or vanco]  + [gent or streptomycin]                 VRE: linezolid, Quin/Dalf

HACEK: ceftriaxone, Amp/sulbactam, FQ

PPx: dental and resp tract procedures: Amoxicillin 2g PO 1 hr prior                          PCN Allergy: Clinda, azith/clarith

Perotonitis/ Intra-Abdominal Infections

Mild-Mod: cefoxitin, Ticar/clav, ertapenem, moxifloxain,tigecycline;  [cipro/levo +metronidazole],

[cefazolin/ cefuroxime/ceftriaxone/cefotaxime + metronidazole]

Severe, healthcare acquired, High-risk: Pip/Taz, [ceftazidime/cefepime +metronidazole], imi/cil, mero, dori, [cipo/levo +

metronidazole (not for healthcare acquired)]

Duration: 4-7 days, [injuries repaired in 12hr can be treated for only 24 hr]

 

C. difficile: diagnose by presence of endotoxins

Initial Therapy:  Mild to moderate initial episode:  Metronidazole 500mg PO/IV tid x 10-14days OR Vanco 125mg PO QID x 10-14days

Severe initial episode:  Vancomycin 125 mg PO QID for 10-14 days

Severe complicated CDI: Vancomycin 500mg PO plus Metronidazole IV 500mg Q8H

Recurrences:  First recurrence:  Same as for initial episode

Second recurrence: Vancomycin tapered/pulsed

 

Medical/Surgical PPX

Procedure Treatment Comment
Gastric/duodenal Cefazolin 1-2g Indicated: morbid obesity, esophe obstruction, decreased gastric pH or motility
Biliary Cefazolin 1-2g Indicated with (without?): acute cholecystitis, obstr. jaundice, common duct stones, >70yr
Appendectomy Cefoxitin 1-2g

Cefazolin 1-2g  + metronidazole

OR amp/sulbactam

 If perforated treat x 3-7 days
Colorectal Cefoxitin 1-2g

Cefazolin + metronidazole OR amp/sulbacam

Gent/tobra 1.5mg/kg + clinda 600mg/metron 0.5-1g

± neomycin +erythromycin/

metronidazole

 PO/IV may be better bc PO only may cause Cdiff

Mechanical bowel prep is not recommended
Obstetrics/GYN Hysterectomy: Cefazolin/cefoxitin 1-2g

Caesarian: cefazolin 1-2g

  

Caesarian: administer AFTER cord clamped
Cardiothoracic Cardiac surg/Pulm resection:

cefazolin/cefur oxime 1-2g

Vascular surg: cefazolin 1g q8h x3doses

 For all: Use Vanco if MRSA risk

 
Orthopedic Cefazolin 1-2g (or cefur or vanco) Indicated: surgery involves prosthetics
Head/Neck Cefazolin 1-2g

Amp/sul 1.5-3g

Gent 1.5mg/kg + clinda 600-900mg

 Indicated: major surgery when incision through oral or pharyngeal mucosa
Urologic NOT recommended If (+) urine culture, treat then operate

Pseudomonas Putida BacteriaAnd because pseudomonas is always mentioned:

Pseudomonas aeruginosa
Drugs of Choice:  Piperacillin-tazobactam, Imipenem, Meropenem, Ceftazidime, Cefepime, Amikacin, Gentamycin, Tobramycin, Ciprofloxacin
Alternatives:  Timentin, Aztreonam, Levofloxacin
Third-Line agents: 
Comments:  (Gram-negative bacilli).   Consider using two agents from two different classes as empiric treatment in critically ill patients if P. aeruginosa is suspected. Once susceptibilities known, narrow to one drug according to susceptibility report. 

 

BCPS Study Schedule 2013: Who is With Me?

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The Study Schedule is posted in the menu above for those interested!  Basically I'm following a similar format as listed on Dr. Ted Williams BCPS Study Group.  

Basically this is it.  I have already started studying prior to today of course, but since it would do me good to have a written plan, I went ahead and added this.  I always worry that the BCPS studygroup website will go down.  Just in case:  (hope you don't mind Ted ;))

Ted's BCPS Study Tips (after passing in 2010)

Study Schedule

Things to know

  • Know the basic statistics cold.  (I agree 100% with this!!!)
    • You can't fake these and there are a lot of questions
    • Knowing wont guarantee passing, but not knowing will guarantee failing
  • Know treatment algorithms - know guidelines -- FIRST, SECOND, and some THIRD LINE THERAPY
  • Know indications for therapy
  • Know contraindications to therapy
  • Know therapeutic window for drugs with narrow/targeted window (e.g. Lithium)
  • Know ADRs of significance
    • And if that ADR arises, how to change therapy (e.g. cough from lisnopril, switch to ARB)
  • Know basic kinetics (e.g. volume of distribution, half life, dose adjustments based on plasma concentration, etc)
  • Know major CYP interactions
    • know the drugs that strongly induce or inhibit
    • Know drugs which are major substrates, especially when inducers and inhibitors are likely to be co-administered (e.g. Seizures)
    • Know which way the plasma concentrations will go

Things not to worry about

  • Exact doses for complex regimens (e.g. ICU insulin drip rate protocols)
  • Complex statistical calculations
  • Complex Kinetics (e.g. Vancomycin initial dose)
  • Minutia of side effects (ie if you wouldn't change therapy, it's not a big deal)
  • Obscure treatments for very obscure disorders

Final thoughts

  • Just like NAPLEX, you can miss a bunch of questions and still pass (2010 passing was 67%) - 2011 was a 111/200 and last year 2012 was higher 123/200 I think?
  • Test is designed to test practical application, not minute details, so focus on patient treatment
  • The BCPS study group schedule will definitely prepare you.
    • I only did the first two cycles through and I was fine
    • Even if you get off schedule, if you go through the material twice, you'll definitely have a fighting chance
    • Spending 1 hour a night on the schedule will get you ready, don't stress
    • The Sample questions in the PSAPs,on the BPS website, and most in the study guide are NOT helpful
      • Not structured like the questions on the exam
      • Content is not validated
      • If you haven't taken an exam for a while, they might be helpful to get you back in the groove. But if you are taking the exam immediately after a residency and pharmacy school, don't worry about them. They will stress you out.

BCPS Topic Areas 2010

Key Statistical Tests to Memorize

Statistics

Clinical Trials

Included from Clinical Trials

Bone Joint Rheumatology

Pediatrics

Geriatrics

Kinetics?

Describe Kinetics? here.

Neurology

BCPS Psychiatry

Affective Disorders

Psychoses

Miscellaneous

Fluid and Electrolytes & Nutrition?

Acute Cardiac Care

Critical Care

Endocrine

Infectious Disease

BCPS HIV

Gender Health Issues

Ambulatory Cardiology

Ambulatory Care

Gastrointestinal Disorders

Nephrology

Oncology Support

Hematology

Oncology

Dermatologic Disorders

Eyes Ears Nose Throat

Immunologic

Pulmonary Disorders

BCPS 2013: Pediatrics Otitis Media

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Such a fun topic!  Who loves it when the kid says his/her ear hurts?  I cringe just thinking about this one: Otitis Media:  The Bane of all Daycare and all School-aged Youngsters

Common Pathogens

  • Viral
  • S. pneumoniae
  • Nontypeable H. influenzae
  • Moraxella catarrhalis

Treatment

  • Watch and wait if > 2 yo and pain/fever less than 48-72 hours
  • Bulging tympanic membrane/perforation = antibiotics
  • Always antibiotics if < 6 months old 4. Middle ear fluid does not indicate repeated treatment unless persists > 3 months
  • Corticosteroids, antihistamines, and decongestants are not recommended

Antibiotic regimens a. Amoxicillin (high dose: 80–90 mg/kg/day): Recommended by AAP as the first-line therapy for acute otitis media b. Amoxicillin/clavulanate c. Cefuroxime d. Other antibiotic options (e.g., cefdinir, cefpodoxime) may be effective. e. Duration i. The most appropriate duration is unclear. ii. In general, 7–10 days, but a shorter course (5 days) has been used in children older than 2 years iii. For confirmed cases of acute otitis media not responding to the initial antimicrobial regimen within 48–72 hours, a change in antibiotic regimen is warranted. Failure of the the above warrants ceftriaxone IM for 3 days or tubes i. Intramuscular ceftriaxone may also be considered if adherence is a concern. ii. Tympanostomy with tube placement may be most beneficial for children with persistent otitis media with effusions and significant hearing loss (e.g., greater than 25-dB hearing loss in both ears for more than 12 weeks).

Prophylaxisotitis media 1. Reserved for patients with recurrent acute otitis media 2. Reduces occurrence by about one episode per year 3. The risk of promoting bacterial resistance may outweigh the slight benefit

The Power of Quizlet and Studying for the BCPS 2013

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Quizlet is an amazing online flashcard storage site where there are many many sets of different types of collections of cards or "sets" to study.  I do not remember exactly how I found Quizlet, but suffice it to say that it is a great resource.  I am "lofgrenb" on there if you are looking for me.  I have tons of sets that are mostly set to private, but would be glad to share.  Just message me. Basically you create a profile either by hand or like everything else out there on the interwebs, just link it to your Facebook, because you KNOW you want everyone to know your business.  (wink wink)

In the "search Quizlet" box, you will type in BCPS.  Right now it's 2012 and 2011 cards that pop up, but as more and more BCPS pharmacists-to-be (including me) start creating new sets, you will be able to see them.  There is a "copy" button where you can copy the entire set that the user spent hours on and make it your own.  I know, slick right?  I have done a bit of both:  making my own and copying others and then editing to my liking.  Since there isn't a lot of ACCP material on regulations and stats, I highly recommend taking a look at some sets I like at the moment.

This is a regulatory one.

 

 

See this user:  rx_jenn:  All of her sets are fabulous.

If anyone knows her, tell her Blonde Pharmacist thanks her.  I should have spent a little more time studying to pass rather than barely failing, but I'm ready to tackle the beast again.

Anyone want to join in on flashcard creating?

Anyone up for meeting in Reno, NV at the ACCP 2013 Update in Therapeutics?  I will be there!

Pharmacy Residency or Not?

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Pharmacy Resident Yes or No?If you were a manager or director of a hospital pharmacy, what candidate would be the most desirable for your team:

  1. A fresh-out-of-school pharmacist who just passed the boards
  2. A fresh-out-of-school pharmacist a year ago that just completed a residency
  3. A seasoned 5-10 year pharmacist in the same type of pharmacy

This is the question I have been thinking about in the past few months, and a follower here has mentioned I should do a post on it and try to lend some insight without bias.

That's the hard part because I fall into category 3 and you can better believe that I truly believe the seasoned 5-10 year pharmacist has a lot over the other two.  So, can I do this without bias?  At least I have gotten my opinion out of the way.

The pharmacist that just passed the boards is likely to have the most up-to-date knowledge at his/her fingertips... or rather brain.  He or she more than likely has just memorized a plethora of information since we cannot bring Lexi-Comp or any other reference into the boards exam to help us pass.  But is it true that knowing information is very different from applying it in practice?  I remember graduating with that same idea of knowing my stuff but the job I chose helped me quickly forget about 80% of what I learned (retail).  I did not need to know sterile technique.  Gone.  I memory dumped everything about IVs and anything else that I could and focused on classes of drugs commonly used in retail, the side effects, the interactions and giving flu shots.  I obtained my immunization certification and let those that graduated with me that wanted to do a residency to go for it.  Heck, they were making $40K to my 100K.  Seriously.  Easy decision with Sallie Mae knocking on my mailbox monthly for her piece of the pie.  I wanted a bigger pie to have left for ME.

The new grad has the knowledge, but the application is not there yet.  That's my point.

The residency trained pharmacist, on the other hand, has had the knowledge memorized and hopefully had the opportunity to apply that knowledge surrounded by professional pharmacists who helped them to grow both in learning and application.  It really depends on where you did your residency, but yes.  If you did one, kudos to you.  Would I do one now if I could do it all over again?  YES and YES.  Sorry, my opinion that your last rotation of clinicals being equal to a residency is not.  To arrive at a facility for one month and to move on doesn't even get you started on the nuances of the place much less dealing with the different personalities of physicians and nurses.  It doesn't matter if you did the same work as the resident.  He/she will be there for awhile.  It is just different.  Plus, they are sacrificing about 80,000 in pay probably.  Maybe less.  It is just different.

The seasoned pharmacist.  Big sigh.  He/she could be really over it, could be the type that wants to do more (me), or could just really be doing what they love.  The neat thing about experience is that it is priceless.  A pharmacist that has been in the field for over 20 years really has an appreciation for it all.  Yes, they may have moved on past order entry and clinical floor work.  They may be in management at this point, but some remain in a operational/clinical role.  I truly have more appreciation for this category because the truth is I'm heading there faster than I would like.

I have had this blog now for several years, and I remember when I started it I wanted to fall in the ranks with others that griped about retail.  I had a different story for most every HOUR of the day.  Things that you could never imagine were happening around me and it was so very entertaining.

I went through a conversion from retail to home infusion to LTC to hospital.  The last move was made for me because the LTC I worked on sold to another company and lay-offs were happening.  I had to find a place before it was my turn.  I would probably still be there had it not fallen on hard times running customer service, the IV program and maybe even PIC.  Who knows.  Things change all the time just like in every area of life and you have to take the bull by the horns and work with what you have.

The original question:  Pharmacy residency or not?  If you are graduating from pharmacy, please for the love of God do a residency.  There are too many pharmacists now and you have to differentiate yourself.  If you are not or cannot do one, find a niche.  Find something that doesn't have a glass ceiling.  Pass the BCPS exam after three years of experience.

Does the three year rule of working before you can take the BCPS equal one year of residency then?  Perhaps.  I can see how this is a good rule of thumb of knowledge.

Who would you hire of the three and why?

Read this article.  Seriously a good read from the ACCP.

All Things Vancomycin

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Believe it or not, vancomycin was first isolated in the fifties from an isolate of dirt in the jungles of Borneo by a missionary. It is a naturally occurring antibiotic made by the soil bacterium Actinobacteria. The name vancomycin comes from the word vanquish.  Initially it was used as a sort-of last resort for penicillinase-producing strains of Staphylococcus aureus.  Today, vancomycin is one of the most widely used antibiotics for the treatment of serious gram positive infections involving methicillin-resistant S. aureus (MRSA). Years ago, early use of vancomycin was associated with several different types of toxicities including infusion related effects (Red Man Syndrome), nephrotoxicity (kidney), and possible ototoxicity (damage to ears).  It was determined later that the majority of these adverse effects were due to the early formulations that contained impurities; however, by that time, its use was decreased with the development of other penicillin-type medicines like methicillin, oxacillin, and nafcillin).  Thanks to MRSA, Vancomycin is making a huge comeback, or has been since the early 1980s.

On a side note, Red Man Syndrome is not an allergic reaction.  This can be managed with a histamine blocker or slowing down the infusion.  Can't tell you how many times I have seen this listed as an allergy to vancomycin on someone's profile.

In monitoring Vancomycin, trough serum concentrations are the most accurate method.  Typically draw the trough level prior to the fourth dose (steady-state).  Keep trough levels above at least 10 mg/L to avoid development of resistance.  For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L.  For complicated infections, the optimal trough concentrations are 15-20 mg/L to improve penetration, increase optimal serum concentrations, and improve clinical outcomes.

How to dose?  Dosing vancomycin is a bit of an art, but start at 15-20 mg/kg using actual body weight.  Many hospitals encourage a maximum dose of 2 grams.  Definitely adjust dose in renal dysfunction.

 

Creatinine Clearance(based on Cockcroft and Gault and not eGRF) Dose*
>60 ml/min Uncomplicated Infections: 10-15 mg/kg q12h1 

Serious Infections: Consider loading dose of 25mg/kg IV x1, followed by 15-20 mg/kg q8-12h (45-60mg/kg/day divided q12h or q8h)2

 
40-60 ml/min 10-15 mg/kg q12h-q24h
20-40 ml/min 5-10 mg/kg q24h
10-20 ml/min 5-10 mg/kg q24h-q48h
<10 ml/min

10 - 15 mg/kg IV loading dose x1; redose according to serum levels
Hemodialysis 15-20 mg/kg load, then 500 mg IV post HD only
CVVH 10-15 mg/kg q24h

* round dose to 250mg, 500mg, 750mg, 1g, 1.25g, 1.5g, 1.75g or 2g (maximum: 2gm/dose)

Higher total daily doses of vancomycin have been associated with nephrotoxicity

1 For patients with uncomplicated infections requiring vancomycin, trough levels of 10-15 mcg/ml are recommended.

2 For patients with serious infections due to MRSA (central nervous system infections, endocarditis, ventilator-associated pneumonia, bacteremia or osteomyelitis) , trough levels of 15-20 mcg/ml are recommended.

Vancomycin troughs are not recommended in patients in whom anticipated duration of therapy is short (≤ 3 days)

Trough levels are recommended for routine monitoring (for intermittent hemodialysis, a pre-dialysis level should be drawn). Trough levels should be obtained within 30 minutes before 4th dose of a new regimen or dosage change.

Once weekly monitoring is reasonable in patients with stable renal function and clinical status. (Data supporting safety or prolonged troughs of 15-20 mcg/ml is limited.)

There is a great app out there I recommend called Vancomycin ClinCalc Full.  The author also has a website called ClinCalc you can check out to see if the dosing matches how your particular program wants you to do it.

I don't earn a dime for that link either, I just enjoy finding quality programs to work more efficiently.

I love Dr. Walter Crittenden, PharmD MD "An Infections Disease Compendium:  A Persiflagers Guide" on the iPad as well.

One of my biggest pet-peeves is when I hear someone say, "Oh I have blown their kidneys!" in regards to one serum creatinine level coming back higher.  Hey, let's wait until 2-3 consecutive high serum creatinine concentrations (increase of 0.5 mg/dL or 150% increase from baseline, whichever is greater) after several days before making such a claim.  Seriously.

And the "Rants and Screeds" of Dr. Crittenden, "Vancomycin is a shitty drug; mostly static, toxic, lousy pharmacokinetics, penetrates poorly into all tissues.  When compared to beta lactams, it is always worse."

Gotta love that!