What's the Deal with the Vitamin C in the ICU?

I am noticing more physicians using Vitamin C and thiamine infusion along with steroid for patients with sepsis in the ICU. At first glance, the obvious issues are small sample study, retrospective study, and all patients at one hospital.

NPR's take

Another good one...

Another report

Need More Studies

He wants there to be a comprehensive study, and he said that Stanford University has expressed some interest. But he said it will be difficult to fund because it uses drugs that have been on the market for decades: “We are curing it for $60. No one will make any money off it.”

It will be interesting to see where this leads... if anywhere. But, in the meantime, a little Vitamin C never hurt anyone, right?

Pharmacy Forecast 2016-2020

The ASHP Foundation released a "Pharmacy Forecast: 2016-2020" Strategic Planning Advice back in December. My first thought is a pause thinking how long I have been out of pharmacy school. I start counting on my fingers from '99 and think, wait, what? SEVENTEEN years. I am officially the pharmacist I stood beside in one of my first pharmacy jobs. I considered him wiser. Maybe I am wiser, but I still sometimes feel like school was not too terribly long ago.

This is the fourth edition of this particular report, and I generally try to read every edition. This one somehow slipped by until this past week when I found it and read it rather quickly. There are some applicable topics for today's healthcare pharmacist that I want to dive into.

Strategic Planning versus Reactive Planning

I have not seen a lot of strategic planning within the hospital pharmacy model. We do a lot of reactive planning based on other departments mostly in line with cost management and saving money. We plan operations in how we staff our departments based solely on how many patients are in the hospital but do not use other metrics such how complicated medically is the patient? What if the patient comes in with a chronic infection versus the patient who comes in as a first-time infection? What if the patient has 20 or more home medications on board? Census is more than just number of patients. What if it is measured by a formula of disease states both acute and chronic along with number of hospital admissions in the past 5 years plus number of medications? A patient doesn't equal a patient. Maybe this applies in a surgical patient, but not in a patient with COPD, ARDS and decompensating on a ventilator due to a hospital-acquired infection.

Opening the report is a timely introduction:

"Since the start of the pay-for-performance movement1 and passage of the Patient Protection and Affordable Care Act (ACA), there has been intense pressure on healthcare organizations to improve quality while reducing costs. The stress created by this pressure has been exacerbated by proliferation of expensive specialty medications, egregious price increases for some sole-source drug products, and the escalation of generic drug prices. In response to this environment, many healthcare organizations are pursuing mergers and acquisitions in an attempt to create economies of scale without the cost of new construction. Another tactic is to partner with outside entities such as chain pharmacies."

Specifically what caught my eye this time was the section on work force. Change in practice models claim a shift from inpatient to ambulatory type practice.

"THE SHIFT TO AMBULATORY CARE As healthcare organizations respond to payment reforms that aim to lower costs and improve patient outcomes, health-system pharmacy practice leaders are challenged to optimize the role of the pharmacy work force in new models of care. One area of challenge is the shift in emphasis from inpatient to ambulatory care.1 Reflecting this change, three-fourths of Forecast Panelists (FPs) agreed that over the next five years, in at least 25% of health systems, patient care pharmacists will have umbrella responsibilities for both inpatients and outpatients (survey item 1). Further, 69% agreed that at least 25% of health systems will reallocate 10% or more of inpatient pharmacy positions to ambulatory-care positions (item 2). Consistent with anticipated growth in ambulatory care, 65% of FPs predicted a vacancy rate of greater than 10% for ambulatory-care pharmacy leadership positions over the next five years (item 5). Pharmacy staff development programs should ensure that there are adequate opportunities for education and training in management of ambulatory care pharmacy practice, transitions of care, and medication management of chronic illnesses. "

How do we lose money? Readmissions, using more inpatient days than necessary due to reasons in and out of our control, and not following certain standards that are attached to payment or removed when standards are not met while in-patient. 

Did you notice one thing? The salaries of newly hired entry-level pharmacists will decline by 10% while pharmacist technician salaries will increase?

You know I get excited about this one:

"PHARMACISTS AS PROVIDERS Nearly 80% of FPs predicted that at least 25% of health systems will have a formal plan for including pharmacists, along with nurse practitioners and physicians assistants, in advanced roles that allow primary-care physicians to care for more patients (item 4). Supporting the high level of agreement with this statement is the shortage of primary-care physicians, proposed federal legislation to grant provider status to pharmacists, and the large number of states that authorize pharmacists to establish collaborative practice agreements with physicians. 2 Recent changes in reimbursement rules related to complex chronic care and transitional care management3 support the addition of pharmacists to primary-care teams. Many health systems will be establishing a privileging process for pharmacists to ensure that those with expanded patient care roles have the necessary competence for those roles."

I suggest you read through the report. It is mostly put together through surveys, but has some very timely information for the next 4-5 years in pharmacy.

PHARMACY FORECAST 2016-2020

Rejection Can Be a Good Thing

Have you ever thought of rejection as being something that can be utilized for greatness? While no one actively enjoys rejection on the job or in life, it is at least something that can propel you to another level in how you view its role in your expertise and willingness to continue moving forward despite what is usually considered a personal failure with the usual negative results.

Usually when most people face rejection the first impulse is to withdraw and criticize the methods; however, what if we turned it into an opportunity to learn? What if we sought out opportunities to be rejected to learn how to minimize the emotional reaction and criticism and turned it into something else?

Take for example the issue that comes up with a medication where you have to make the phone call to the prescriber about a prescriber’s choice in medication. How does a pharmacist approach it to not look like someone who is pointing out mistakes the prescriber made and at the same time can convince a change if you really believe it? I hear pharmacists in the field make comments about physicians’ personalities and how one physician always says no to any recommendation and another physician is just plain “not nice.” What one pharmacist may think as “not nice” another pharmacist may interpret in a different way. Hospitals many times are using clinical pharmacists to manage medications with a cost savings plan in mind and that aspect can sometimes clash with what the prescriber believes when medicine was more of an art and less money, or it could mean that the pharmacist is bringing a valuable piece of knowledge to the table that the prescriber will appreciate. Whatever the reason, learning how to approach the physician and using it as an opportunity to improve the approach and delivery can make rejection turn into a positive rather than a negative.

Overcome the fear of rejection: One of the reasons why we have such fear of rejection is that we take rejection personally. Rejections are not personal. The prescriber or manager did not reject YOU but the proposal or effort was rejected. Of course rejection should not make you feel less, but it somehow can. Don’t let it, dive in and ask why the recommendation isn’t accepted, move on. The more you ask and are rejected (or accepted!) the less it will sting. If a pharmacist can learn how to detach emotions from the results, whether a yes or a no, it will help gain real confidence in the face of possible rejection. Building a relationship with the prescriber by actually being physically on the floor and picking up the phone helps as well. Leaving a note on a chart doesn’t help build a relationship and can easily be ignored but asserting yourself helps not only improve your relationship with the prescriber but also gives the prescriber a chance to hear and respond in real-time to a request. And the more you are rejected, the less it will sting and in the meantime the prescriber is getting to know you better.

What if a prescriber responds with a no? What if you asked the right questions to find out about the no? You could learn a lot as to why your idea to change something was rejected or you could just learn it is the prescriber’s prerogative. If all of this is handled well, you could use that no to help build a relationship and eventually trust.

This is a study that reviewed inpatient pharmacy recommendations and their acceptance rate. Perhaps if we focused a little more on approach and building a relationship with the prescribers, the number of acceptances would increase and make more of a difference. In the meantime, don’t let a rejection keep you from asking and asking well. Those rejections help teach you how to handle rejection better which could be the very thing keeping you from excelling as a clinical pharmacist.

Top 8 Traits of Highly Effective Pharmacy Technicians

Behind every good pharmacist is a great pharmacy technician. Things run more efficiently, staff relations are better and ultimately the patient receives better care with a good pharmacy technician. Here are my top 8 traits I look for in a good pharmacy technician.

1.      Team Player

A team player is willing to go above and beyond the normal job description and help with other job roles of the team when there is a deficit in the team. They will not worry about what others are doing on the team but be a positive team player helping serve the patient.

2.      Self-starter

Taking the initiative on getting things completed is a very desirable trait with a pharmacy technician. Noticing where help is needed and jumping in without being told is one of my favorite traits of a technician.

3.      Problem Solving/Critical thinking

Improving process and making things better is not just for the pharmacist but for the technician as well. Many times the pharmacy technician has a unique view into operations that the pharmacist may not recognize.

4.      Committed to Learning

Medicine is a fluid field of study. Not only do guidelines change for the patient, but patient care and pharmaceutical delivery changes happen as well. A good technician will be committed to the process of improvement and making things better by keeping up-to-date with the field.

5.      Customer Service/Communicator/Conflict Resolution/Empathy

Rather than showing defensiveness and pointing out errors with nursing, a good technician will be able to problem solve as mentioned above but also be able to deliver the message in a kind way. The pharmacy technician will be able to help when needed and be able to help diffuse emotional issues and be a “go to” person for the nursing staff when medication help is needed.

6.      Accuracy, Focus and Detail Oriented in a Busy Environment

Being able to focus on details with a lot of external stimuli is a plus! I know from first-hand experience how difficult this can be, but someone who can focus well and be very accurate is a trait I find important in a pharmacy technician.

7.      Prioritization, Organization and Time Management

When someone on the medical team needs something STAT, being able to prioritize and manage requests and know the timing is very important to flow and getting things done. Knowing that a medication is due later in the day and can wait versus loading a medication on the floor that will be needed at morning meds is part of knowing how to prioritize and organizing the day to complete tasks. It is also important to know how to manage the day when things are not as busy and going above and beyond to do the things that are normally on the bottom of the list.

 8.      Computer Skills

Last but not least, every technician needs to know how to work a computer and be able to quickly learn how to problem solve with a computer to help triage and manage problems.

Should Pharmacists Become Board Certified?

I enjoy brainstorming with other pharmacists on becoming board certified.

I remember back in 1998-1999, the assistant dean of my alma mater, the University of Tennessee at Memphis, stressed how important it was to consider residency and board certification. At the time, I was 25 years old and making decisions that would impact me for life.

I decided back then to decline that path. I only saw the dollars that were before me in retail pharmacy and the student loan debt approaching 6 figures. So, I quipped, "Why would I want to work for half pay or less for a whole year?" and "Why would I want to spend money and time to become board certified when there are no immediate financial rewards?"

Hindsight is 20/20. Fast forward to a 40-something in the profession for more than 14 years experiencing all sorts of different pharmacy experiences. After trying most, I have regrets regarding my earlier decisions. I regret not doing a rotation overseas. I regret not doing a residency. I regret that I dismissed it all for more money.

I know that not everyone feels like me, and that is understandable. Perhaps I am just a different sort who realized fairly quickly that I was falling behind. Whatever the reason, I decided to pursue a Board Certified Pharmacotherapy Specialist (BCPS) certification a couple of years ago. I work in a small community setting in a smaller city, and although it is nothing like Memphis in terms of clinical opportunities, such opportunities can be found with a little luck. Passing the test was probably up there with my other personal accomplishments.

Why should you become board certified?

1. According to the Board of Pharmacy Specialties (BPS) website, "From patient to provider, the value of the BPS-certified practitioner registers throughout the health care continuum. For pharmacy professionals, documentation of specialized experience and skills yields the additional benefits of personal satisfaction, financial rewards and career advancement." I definitely agree, but most BCPS-certified pharmacists I have spoken with did not receive a raise unless they changed jobs. While BCPS certification may have helped with landing a clinical job in the past, it might just be something to separate you from a PharmD without BCPS on any pharmacist job interview today.

2. If you have been out of school for more than 5 years, I bet you have already forgotten some of what you have learned. You can either depend on your local hospital's computer system to remind you of every little thing OR you can take charge of what you know and remain committed to being the best pharmacist you can be. Think of it like this: if you work in a hospital and are commanding larger salaries than new graduates with fresher knowledge, there comes a point at which you are replaceable. Remain competitive in your field, which means using continuing education to really learn something, rather than last-minute cramming to renew your state license.

3. A paper published in 2006 states that "Future Clinical Pharmacy Practitioners Should Be Board-Certified Specialists.” In the past, clinical pharmacists have not made board certification a priority, but this is changing rapidly in both clinical and staff positions. As pharmacists move in the direction of becoming reimbursed professionals for optimizing medications, there will be a trend toward licensing agencies requiring board certification in certain scenarios. Sure, that is not the case today, but if you would have told me in 2000 that the market would be in its current shape with oversaturation and residency demand, then I would have done things very differently in 1999-2002.

4. The PharmD curriculum is not enough to get you in sync with other health care professionals. Experience in dealing with physicians and their assistance along with board certification will take you to the next level in recommending appropriate treatment. Placing new graduates in clinical positions without experience and expecting them to build relationships with clinicians is not the best-case scenario for building pharmacist clinical teams. Requiring board certification ensures a higher level of expertise and is moving toward becoming a requirement in many hospitals. The benefits in just preparing and studying for the test are immense, in my experience.

5. Last, but not least, you should become board certified to give your patients the best care possible. This was my number 1 reason. I remember the day when I sat at my desk years ago and realized I had no idea about new practice guidelines and that order entry had essentially turned me into a robot dependent on the computer. I realized that it was time to make some personal changes that would cost me both dollar and time, yet result in amazing benefits for my patients.  

Most pharmacists are reluctant to pursue BCPS certification because no one wants to fail, much less fail twice. Although it is humbling to fail once, it is euphoric to pass, even the second time.

I hope to inspire more pharmacists to be their best in our profession. If you fail, realize that any amount of learning will significantly change how you practice pharmacy. 

Pharmacy Distractions

Yesterday, I decided to record the number of distractions I faced on a regular work day. This proved to be a distraction in itself considering the pharmacy where I worked is in an open plan where technicians, phones, cubicles and door to the hospital hallway are all within ten feet of where I sit. There are four or five telephone lines which ring regularly. There are usually one to two other pharmacists sitting within five feet and two to three technicians in the same vicinity.

Yesterday I recorded over 150 interruptions. I even faulted myself for starting personal conversations which distracted others. 

What are some things we can do to make the pharmacy workplace have less distractions? Interruptions contribute to medication errors and having a dedicated space where interruptions are not allowed should be implemented. Chemotherapy entry, preparation and checking definitely falls into this category. The Institute for Safe Medication Practices found that each interruption is associated with a 12.7% increase in errors. I have personally attempted to enter new chemotherapy on a patient in the noisiest place where phones are ringing consistently, technicians are interrupting the workflow with issues on the phone that they cannot handle and other staff are just walking by to chat, all while the TV is reporting the news and a radio in the back is piping out 80s music. It is enough to cause me to go into panic mode. Ask for a dedicated space with less distractions or a no-interruption zone. You may not get it but it is on the record that you asked. In the meantime, one tip I have tried is headphones with something soothing to completely block out all noise when concentration is key. Bose makes great noise-canceling headphones that work! Though I would love to work in silence, blocking out everything but one sound is better than ten sounds all interrupting and distracting what you are trying to do safely. 

Another source of interruptions is when a medication is out-of-stock. This issue can completely lead a pharmacist into a rabbit hole of issues. First I have to ask if we have the medication which leads to comments of inventory failure and what process is to blame. Second we have to call other hospitals and ask to borrow a medication which interrupts them as well. We also have to call a courier service to deliver the medication which leads to delay in delivery of treatment to the patient. If we could reduce missing medications, we could reduce distractions and phone calls. This type of interruption falls under system distractions along with medication timing and other issues that causes distractions on how we handle system failures or deficits.

Alert fatigue is another source of distraction. It is common for me to receive five or more alerts per order when entering a medication with the majority being unnecessary. For example, when entering a sodium chloride IV fluid, I will routinely be alerted that the chloride in the IV fluid will be a duplication with the potassium chloride (chloride duplication). I will also receive an alert that sodium chloride is on national backorder. Most of the times medication alerts include what is formulary, nonformulary, to notify IT staff when medication is depleted, duplication of class that isn't clinically significant, insignificant labs that can include a time period longer than current hospitalization and even how to enter medications differently for a new process that can change quite often. It is used more times than not as an email to communicate inventory issues that should be saved for another time and not when entering a medication where the most important issues are drug, strength, indication, directions and allergies. All of the important stuff can be diluted quickly by things that are nowhere near as important than the task at hand.

Educating the staff is very important in handling distractions and improving patient safety. Educating the staff to know when to interrupt with something important that cannot wait a second and when to write a note for the pharmacist to handle a few minutes later is important. Placing phones with multiple lines in a separate area to lower distractions while the pharmacist is entering orders or checking orders and/or having a designated technician to answer phones and not filling is an idea to consider. Also educating a technician on how to answer the phone and troubleshoot is invaluable!

The Institute for Safe Medication Practices has looked at this issue and has an invaluable write-up about things that can be done to help pharmacists and technicians focus on what matters most... patient safety.

California Pharmacists Will Soon Dispense Naloxone for Opioid Overdose

California legislation will soon allow pharmacists to dispense naloxone without a prescription for opioid overdose according to the Pharmacy Naloxone Bill (AB 1535).

Naloxone is an opioid antagonist that competes and displaces opioids at opiod receptor sites. In opioid overdose, adults would take 0.4 to 2 mg IV every 2-3 minutes as needed. Repeated doses may be needed every 20 to 60 minutes, bit if no response is observed after 10 mg, the diagnosis should be questioned. Adverse reactions are mostly related to reversal of dependency/withdrawal including GI, cardiovascular, CNS and respiratory effects. 

Beginning January 1, 2015, California pharmacists can furnish naloxone to family members of patients at risk for overdose, those who might be in contact with someone at risk for OD, or anyone who requests the drug. Guidelines will be developed by the state's boards of pharmacy and medicine.

This is a great step for pharmacists combating a problem: drug overdoses.  Drug overdoses kill more people each year than either cars or guns. In 2010, the CDC reported, 38,329 people died of drug overdoses (mostly opioid related).

Read this article from back in February by Maia Szalavitz with Time Magazine, "Wider Use of Antidote Could Lower Overdose Deaths by Nearly 50%."

A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition

Click on image to order A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition (no paid link on this, just for your information)

            As a pharmacist and a clinician at my local hospital, there have been times where I am starting a new PN (total parenteral nutrition) and needed help beyond the usual formula or write-up that we use. In the information age, we have a diverse amount of information online at our fingertips; however sometimes this information can be from sources that are not legitimate. I can google PN and a disease state and hope for something relevant, or I can seek out material that is tried, true and tested.

            The A.S.P.E.N. Parenteral Nutrition Handbook, 2nd Edition is a pocket-sized handbook or quick reference that covers many parenteral nutrition topics with students in dietetics, nursing, medicine and pharmacy in mind. There are 10 fully revised chapters from the 2009 1st edition including: 

1.  Chapter 1: Nutrition Screening, Assessment, and Plan of Care

2.   Chapter 2:  Overview of Parenteral Nutrition

3.   Chapter 3:  Parenteral Nutrition Access Devices

4.   Chapter 4:  Parenteral Nutrition Formulations and Managing Component Shortages

5.   Chapter 5:  How to Prescribe Parenteral Nutrition Therapy

6.   Chapter 6:  Review and Verification of Parenteral Nutrition Orders, Preparing Parenteral Formulations, and Ordering

7.   Chapter 7:  Parenteral Nutrition Administration and Monitoring

8.  Chapter 8:  Complications of Parenteral Nutrition

9.  Chapter 9:  Medication-Related Interactions

10.  Chapter 10:  Home Parenteral Nutrition Support

These chapters cover many of the relevant topics for the patient receiving parenteral nutrition (PN) including some newer topics on order review, compounding, and drug shortage management. Also this handbook contains evidence-based guidelines from the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (JPEN, March 2014) and A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing (JPEN, March 2014).

I have taken the time to utilize this handbook while dosing PNs in the past few weeks and have found this reference accurate while covering many of the topics I needed.  I especially enjoyed the chapter on parenteral nutrition complications.  I found the topics succinct and spot-on for finding quick information on a couple of questions I had on a patient’s PN.

If you are looking for a guide with a broad range of topics related to PN that will help your student, resident or even new pharmacist managing PN, this guide will help you tremendously.