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.

10 Rules of Email Etiquette at Work

One of the most frustrating things about pharmacy jobs today, for me at least, is the lack of email etiquette at work.  I know it sounds crazy to even bring this up, but I have been pondering this post for years.  You see, I have been guilty of not being the best at email, but over the years it is becoming crystal clear the errors people make every single day that not only make the sender look badly, but can actually fracture a team.  Without further ado, the email changes I would like to see in the pharmacy and hospital world with a disclaimer that since I have been practicing for almost 15 years, these examples go way back in time. 1.  REFRAIN FROM REACTIVE EMOTIONAL EMAILS.  If you find yourself getting worked up over what you are reading, do your best to avoid pressing reply and firing off a response.  Avoid sending emails when you’re feeling any type of negative emotion. These types of emails will ALWAYS make you look unprofessional and maybe even unstable.  Before you send off that email rant or reply to an email that angers you, try cooling off overnight.  Or, write an uncensored draft that you never actually send. Remember that all emails are forwardable.  If you don't want your whole department to read it, do not send it.

2.  RESIST THE REPLY ALL BUTTON.  This is the one that literally will make my entire head explode at work.  I have seen coworker after coworker make this mistake and it is not pretty.  This can make you look totally clueless all the way up the chain.  Coworkers don't let coworkers reply all.  In fact, I would love to see the day when reply all is no longer an option in Outlook, Gmail, or any other email client.  Why?  Because it creates mindless replies when all of the discussion could be tabled and then ONE single email sent out to a team.  Time after time in all of my jobs have seen emails go out - an official type declaration of what we are going to be doing - and someone else will reply all and jump in with something else essentially calling out critically all the things wrong with the initial.  Take the time to call the person that sent the email and give them the professional courtesy to make any corrections.  Don't shoot the messenger!

3.  UNDERSTAND WHAT CC AND BCC MEAN.  The recipients listed in the To field are the direct addressees of your email. These are the people to whom you are writing directly.  CC, which stands for “carbon copy” or even “courtesy copy,” is for anyone you want to keep in the loop but are not addressing directly in the email. The person(s) in the CC field is being sent a copy of your email as an FYI. Commonly, people CC their supervisors to let them know an email has been sent/an action has been taken or to provide a record of communications. The general rule of thumb is that recipients in the To field are expected to reply or follow up to the email, while those in the CC field do not.  So many times I see the ones in the CC field adding in their two-cents and then the whole thing becomes a reply-all festival.

4. IF YOU ADD SOMEONE IN THE CC OR TO FIELD, LET THE OTHERS KNOW.  Guess what?  There are times when people are added willy-nilly for no good reason and you look back and notice it a couple of emails later.  Let people know.  Professional courtesy and politeness go a long way.

5.  BCC IS GOOD FOR ONE THING ONLY.  Let's say that only half in your department contributed to the annual walk fund.  Rather than sending out an email to all those that contribute in the TO field where each of them can see who did contribute and who did not, put your own name in the TO and the rest in the BCC.  That way, gossip about who gives and doesn't is stopped before it can even begin.  Don't use the BCC field to add someone random to eavesdrop on the email.

6.  PICK UP THE PHONE.  If you notice that you are going back and forth on an email and getting nowhere, the phone still works.  Guess what?  Voices can convey so much more than words and rarely are misinterpreted as much as typed words.  I remember an email I saw that was sent for the third time.  The second time it was heavily highlighted with quotes from the manager's email weeks before.  The third send apologized for resending the email yet again but someone was not doing it correctly.  Because of the sender's frustration, more time was wasted from the entire department reading about some small piece in the whole operation, and worse, half of the department had nothing to do with the infraction.

7.  DON'T PUT A QUOTE IN YOUR SIGNATURE.  There is no reason for it.  From The Wordsmith:

******Avoid quotes, witty sayings and colors in the signature.

8.  DON'T ASSUME EVERYONE READS THEIR EMAIL IMMEDIATELY.  If something is important and needs to be communicated quickly, pick up the phone.

9.  DO NOT FORWARD AN EMAIL UNTIL YOU ASK PERMISSION.  This is just plain common professional sense.

10.  DO NOT USE UNPROFESSIONAL FONTS OR BACKGROUND PAPERS.  They only distract.  This means NO comic sans.

Hope that helps.  And, by the way, I do mess up on some of these myself.

Ativan Drips and Precipitation

If you happen to run short of the lorazepam 2 mg/mL vials to compound your ativan drips, be mindful of the possibility of precipitation when using the lorazepam 4 mg/mL vials.  AHFS Drug Info states:

Precipitation-- The choice of commercial lorazepam concentration to use in the preparation of dilutions is a critical factor in the physical stability of the dilutions. Both the 2- and 4-mg/mL concentrations utilize the same concentrations of solubilizing solvents. On admixture, the solvents that keep the aqueous insoluble lorazepam in solution are diluted twice as much using the 4-mg/mL concentration than if the 2- mg/mL were used, resulting in different precipitation potentials for the same concentration of lorazepam. Care should be taken to ensure that the compounding procedure that is to be used for lorazepam admixtures has been demonstrated to result in solutions in which the lorazepam remains soluble.

Lorazepam concentrations up to 0.08 mg/mL have been reported to be physically stable, while occasional precipitate formation in admixtures of lorazepam 0.1 to 0.2 mg/mL has been reported. The precipitate has been observed in both containers and in administration set tubing.

In one case, a visible precipitate formed in a lorazepam 0.5-mg/mL admixture in sodium chloride 0.9% in a glass bottle.  However, a 0.5-mg/mL concentration may remain in solution longer if prepared from the 2-mg/mL concentration, yielding a higher concentration of organic solvents in the final admixture.

Concentrations of 1 and 2 mg/mL have been reported to be physically stable for up to 24 hours as well as concentrations below 0.08 mg/mL.

Concentrations in the middle range of 0.8 to 1 mg/mL may be problematic.  In one report, use of lorazepam 2 mg/mL to prepare lorazepam 1-mg/mL admixtures in dextrose 5% or sodium chloride 0.9% was acceptable but use of the lorazepam 4-mg/mL concentration to prepare the same solutions resulted in almost immediate precipitation.

Lorazepam solubility in common infusion solutions has been reported. Its solubility in sodium chloride 0.9% is approximately half that found in the other tested solutions. This result was attributed to the pH of the sodium chloride 0.9% (pH 6.3) being essentially the same as the isoelectric point of lorazepam (pH 6.4), where aqueous solubility would be the lowest. Dextrose 5% was the best diluent for lorazepam.

If you are a hospital or facility that mixes the middle range of 0.8mg to 1 mg/mL you have to be more mindful of other factors.  This is the reason I had no idea of this problem since other facilities where I have worked we mixed a much less concentrated solution.  I found out the validity of this information and wasn't too pleased.

The bottom line is that it would be nearly impossible for a pharmacist to know every single intricacies of different hospitals and compounding practices.  If knowledge like this is indeed something we should all 100%  know, then someone somewhere dropped the ball on training and/or education.  I am mostly wondering, how does your facility compound ativan drips?  What scenarios caused precipitation?

For more about this issue read here.

How One Patient Pharmacist Relationship Can Change Your Life

One patient can completely change your life.  Brenda was her name.   The website where there is an online cemetery mirroring how it looks in real life.  There are moments in my career where I sit back and remember the impact she had on my life.  Not only was she so vibrant (even over the phone) but she was also inspiring.  We were in the same generation though my life was about a young man I had met (and later married) and hers was about fighting for her life.  I was her pharmacist while she was at home battling breast cancer.  She had a boyfriend with the same maiden name as me, and well it was cool Brenda and I had the same initials. I always want to connect with patients, but unfortunately my current job does not afford me the opportunity very often.  I lingered outside one patient's room at the hospital yesterday wanting to go in and introduce myself letting him know I wished him the best with his new situation and just say hello.  I have to do this more often.  There is nothing at work keeping me from opening the door and saying hello.  I guess I worry the patients are bothered enough all day and night by nursing and physicians and lab techs and all.  They get little rest, and they are sick.  Perhaps some would want a friendly face just saying hello and asking them if they need anything.

It was a little easier for me in home health because I had to call to find out how they were doing on their supplies, how nursing was handling things with the home IV antibiotics or TPN and it made it easier for me since I have this southern accent that sounds more southern even TO a southerner.  Ha!  That in itself was always an easy icebreaker.  "Where are you from?"  It always went from there.

Brenda wanted to go to Florida and jet ski.  With her pain pump.  We made it happen.  I'm proud of that memory.  I'm proud that I finally went out to meet her in person though I should have gone earlier when she was not in the final stage of life.  I saw a picture of her healthy.  Beautiful and full of life... same as most of us now.  We just can't waste this life we have!

I may have blogged about her before.  I haven't gone back to look because today I am thinking about her... it's been ten years, but I still think about how her life focus shifted with knowing she had little time left.  I am guilty of complaining quite a bit about my current job at times.  There are so many things that bug me mostly dealing with how things are handled, how pharmacists have those in control snowed, and how there's very little incentive (promotion, opportunities, salary increases, etc...) to even go above and beyond.  A new schedule comes out and I think why in the hell did I decide to do this job?  I mean, yes, it could be worse.  I know this.  But, could it not be better?

I think I am going to try to make these interactions with patients happen more often somehow.  If you have any ideas on how I can at the hospital, let me know... or if you have made it happen let me know.  These moments define major influences in my life (in the past), and I don't want to lose them by allowing my current situation to completely stifle who I am as a pharmacist.  Don't let your job dumb you down professionally or personally.

Should you be recommending a proton pump inhibitor (PPI) or H2-receptor antagonist (H2RA) for stress ulcer prophylaxis in critically ill patients?

We know that PPIs are better than H2RAs at raising intragastric pH, but we don’t know whether this higher pH value translates to superior clinical outcomes.  In fact, there is some debate whether a higher pH could actually cause problems, like nosocomial pneumonia or Clostridium difficile infection.  Given that clinically important GI bleeding has been associated with a high mortality rate (48.5% vs. 9.1% in non-bleeders), it seems that selecting the best agent for stress ulcer prophylaxis is an important decision. This hotly-debated topic, reinvigorated by the 2012 Surviving Sepsis Campaign Guidelines’ grade 2D recommendation in favor of PPIs, has again been examined with a recent meta-analysis by Alhazzani et al published in the March 2013 issue of Critical Care Medicine.

Actual .pdf of meta-analysis.

Of course, this is not the first meta-analysis to examine the topic.  In fact, three other meta-analyses have been published since 2009.  Here, here, and here. Naturally, the authors of this most recent meta-analysis claim that their statistical analysis was superior, they included more relevant trials, and they excluded more inappropriate trials to make this analysis a more pure, scientifically-valid view of the data.

This meta-analysis combined 14 randomized controlled trials with 1,720 total patients.  The analysis concluded that PPIs were associated with a reduction in clinically important upper GI bleeding (1.2% vs. 6.4%, NNT 19, RR 0.36, p=0.002) and overt upper GI bleeding (3.8% vs. 15.7%, NNT 9, RR 0.35, p<0.0001).  There was no difference in nosocomial pneumonia, ICU mortality, or ICU length of stay.

Is it time for famotidine and ranitidine to hang up their hat in the ICU?  The evidence from this meta-analysis appears compelling at first glance, but diving deep into the manuscript reveals some troubling issues.

First, the included trials were not comparing similar treatments of H2RAs.  Some trials used continuous infusions, some used once daily dosing, and one did not report dose at all.  It is scientifically questionable to pool a variety of different H2RAs with different dosing strategies together into a single group and categorize the treatments as being the same.

Second, the included trials did not have consistent definitions for “clinically important bleeding” and “overt bleeding”.  Some trials used very strict definitions where bleeding had to be confirmed with EGD, others has very loose criteria (eg, hemodynamic instability not explained by other causes), and some did not even provide definitions.  Indicative of the questionable criteria, 5 of the 12 included trials had an event rate of 0% in both arms, whereas one trial had an event rate as high as 31%.

Third, one must question whether the endpoint of “clinically important bleeding” is a surrogate or a clinically relevant outcome.  Given the questionable definitions and criteria used, a firm endpoint like ICU mortality would be a definitive approach to concluding a victor.  Unfortunately, there was no difference in ICU mortality demonstrated in this meta-analysis (17.5% PPI vs. 21.2% H2RA, p=0.91).

Given the paucity of high-quality data examining PPIs versus H2RAs for stress ulcer prophylaxis, it can be extremely temping to favor meta-analyses to find an answer to this compelling question.  The fallacy in this approach, however, is that you cannot take a multitude of poor-quality trials (many with fewer than 50 patients in the H2RA arm) and somehow combine the data into a valid, reliable, unbiased manuscript on which you base your clinical practice.

So how should we interpret this meta-analysis?  In my view, until better quality evidence comes out, there is no proven difference in the prevention of stress ulcer prophylaxis between PPIs and H2RAs.  The decision should be made based on formulary considerations (cost and availability), formulation considerations (ability to be crushed), the patient’s history of using a particular agent prior to admission, and potentially drug interactions (although I believe the PPI/omeprazole debate has not been concluded).

Sean P. Kane is a critical care clinical pharmacist and the author of ClinCalc.com -- an evidence-based website with clinical tools and calculators for medical professionals.

Nexium photo:  Photo credit: License Some rights reserved by Rennett Stowe

BCPS 2013: Infectious Disease (Pneumonia)

Infectious Disease.  The topic that I like but loathe.  At the same time. Pneumonia

1. Community Acquired Pneumonia (CAP) - not hospitalized 2 days or more within the past 90 days, not in a LTC facility/residence, no IV antibiotic therapy, IV chemo, or wound care in the past 30 days, or attendance at a hospital or dialysis clinic.  Must have at least two of the following symptoms:  fever or hypothermia, rigors, sweats, new cough (with or without sputum), chest discomfort, onset of dyspnea, or fatigue, pain, headache, myalgias, anorexia.CURB-65 - predictor of complicated course and whether to admit to the hospital.  Give a point for each of the following:  age > 65, comorbid illnes (DM, CHF, lung dz, renal dz, liver dz), high temp > 101F, Bacteremia, altered mental status (think elderly), immunosuppression (cancer, steroid use), High-risk etiology (S. aureus, legionella, G- bacilli, anaerobic aspiration), multilobe involvement or pleural effusion.
2. Nosocomial Pneumonia:  Hospital Acquired Pneumonia (HAP) (48 hours or more after admission), Ventilator Assoc Pneumo (more than 48–72 hours after intubation), Health care Assoc Pneumo (2 or more days within 90 days of the infection) - know risk factors of nosocomial pneumonia.  Pretty common sense.
3. CAP Organisms:  Unidentifiable (40-60%), M.pneumo, S. pneumo, H.flu, C.pneumo, viruses, S. aureus, Moraxella cat,
4. Alcoholics - S. pneumoniae, oral anaerobes, gram negative bacilli
5. Nursing Home - S. pneumoniae, H. influenzae, gram negative bacilli, S. aureus
6. COPD - S. pneumoniae, H. influenzae, M. catarrhalis
7. Postinfluenza: H. influenzae, S. aureus, S. pneumoniae
8. Exposure to water: Legionella
9. Poor oral hygiene: oral anaerobes
10. HIV infection: P. jiroveci, S. pneumoniae, M. pneumoniae, Mycobacterium

HAP Organisms:  S. aureus, Pseudomonas aeruginosa, Enterobacter spp., Klebsiella pneumoniae, Candida, Acinetobacter spp., Serratia marcescens, Escherichia coli, S. pneumoniae

P. aeruginosa is transmitted by health care workers’ hands or respiratory equipment S. aureus is transmitted by health care workers’ hands Enterobacteriaceae endogenously colonize hospitalized patients’ airways (healthy people seldom have gram negative upper airway colonization) Stress changes respiratory epithelial cells so that gram-negative organisms can adhere Up to 70% of patients in the intensive care unit have gram-negative upper airway colonization, and 25% of them will become infected through aspiration

TREATMENT

CAP - duration of treatment at least five days:

Empiric nonhospitalized - prev healthy and no abx in past 3 mos - macrolide or doxy (macrolide if H.flu suspected) and if comorbidities present or recent antibiotics in past 3 months - Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

-- OR -- Macrolide (or doxycycline) with high-dose amoxicillin (1 g 3 times/day) or amoxicillin/clavulanate (2 g 2 times/day) or with a cephalosporin (ceftriaxone, cefuroxime, or with cefpodoxime)

Empiric treatment of hospitalized patients with moderately severe pneumonia - Respiratory fluoroquinolone

--OR-- Ampicillin, ceftriaxone, or cefotaxime (ertapenem in select patients) plus a macrolide (or doxycycline)

Empiric treatment of hospitalized patients with severe pneumonia requiring intensive care unit treatment (may need to add other antibiotics if P. aeruginosa or MRSA is suspected)

• Ampicillin/sulbactam plus either a respiratory fluoroquinolone or azithromycin
• Ceftriaxone plus either a respiratory fluoroquinolone or azithromycin
• Cefotaxime plus either a respiratory fluoroquinolone or azithromycin

Treatment duration—at least 5 days, with 48–72 hours afebrile and no more than one sign of clinical instability (elevated temperature, heart rate, or respiratory rate; decreased systolic blood pressure; or arterial oxygen saturation) before therapy d/c

Hospital Acquired Pneumonia - Treatment duration—Efforts should be made to decrease therapy duration to as short as 7 or 8 days (14 days for pneumonia secondary to P. aeruginosa).

1. Early onset (less than 5 days) and no risk factors for multidrug-resistant organisms -  Common organisms include S. pneumoniae, Haemophilus influenzae, (MSSA), Escherichia coli, Klebsiella pneumoniae, Enterobacter spp., and Proteus spp. -- Treatment -- Third-generation cephalosporin (cefotaxime or ceftriaxone), Fluoroquinolone (levofloxacin, moxifloxacin, ciprofloxacin), Ampicillin/sulbactam, OR Ertapenem
2. Late onset (5 days or longer) or risk factors for MDR organisms - Common organisms include those listed above for early onset plus Pseudomonas aeruginosa, K. pneumoniae (extended spectrum β-lactamase positive), Acinetobacter spp., MRSA, and Legionella pneumophila. -- Treatment -- a.  Ceftazidime or cefepime plus aminoglycoside or fluoroquinolone (cipro-, levo-)  b.  Imipenem, meropenem, or doripenem plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin), OR c.  Piperacillin/tazobactam plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin)  ***Vancomycin or linezolid should be used only if MRSA risk factors (e.g., history of MRSA infection/colonization, recent hospitalization or antibiotic use, presence of invasive health care devices) are present or there is a high incidence locally (greater than 10%–15%).

Risk factors for MDR organisms -- Antibiotic therapy within the past 90 days, Hospitalization of 5 days or more, High resistance in community or hospital unit, Risk factors for health care–associated pneumonia, Immunosuppressive disease and/or therapy

A wonderful article published just last November that I love.  (Pharmacy Times)  Only thing is it doesn't go into the detail of the different antibiotics with Late vs Early Onset of Hospital Acquired.  Just CAP.  That's OK

And because guidelines haven't changed, my quizlet from last year.  Hope you enjoy:

Flu Vaccine or Fired

As hospital healthcare professionals, we stand at the frontline of patient care of very sick patients.  Our patients include those with cancer struggling with an infection, patients on the ventilator with sepsis and the list goes on.  Where does personal liberty end and responsibility to our patients begin? Eight employees were just fired from Indiana University Health Goshen Hospital in Goshen, Indiana for refusing the flu vaccine.

“As a hospital and health system, our top priority is and should be patient safety, and we know that hospitalized people with compromised immune systems are at a greater risk for illness and death from the flu,” explained hospital spokeswoman Melanie McDonald to the Elkhart Truth. “The flu has the highest death rate of any vaccine preventable disease, and it would be irresponsible from our perspective for health care providers to ignore that.”

Amen and amen.

First do no harm reminds the health care providers that they must consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.

What about the harm of possibly transmitting the flu virus to a patient?  Yes, there is an argument that the flu vaccine doesn't always cover every strand of flu of the current year, but even in my case this year I was the one in my home that did NOT get the flu.  My husband and son were not vaccinated and they tested positive for Influenza A.  I know it's not always effective, but this year the going percentage I am hearing is 60% effective.  That is significant.

Among those who do have symptoms when they get flu, they may be shedding the virus up to 24 hours before the onset of symptoms.

American Academy of Pediatrics (AAP) became the latest organization to issue a policy promoting mandatory immunization against influenza for health care workers, with exemptions for health reasons. In July and August, the Infectious Diseases Society of America (IDSA) toughened its policy on flu vaccination for health care workers by removing an exemption for religious reasons and specifying that annual vaccination should be a condition of employment in health care settings and/or a requirement to receive professional privileges. The Society for Healthcare Epidemiology of America adopted a similar policy. In November 2009, the National Patient Safety Foundation had voiced its support for mandatory vaccination of health care workers.

My stance?  If you refuse the flu vaccine and work in a hospital, find another job.  You are putting your patients at risk.  Egg allergy?  Read this.

Pharmacy Residency or Not?

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.

The Perfect Medical Model

I have been doing a lot of thinking lately in regards to my career.  I am still in waiting mode about the BCPS exam, but in the meantime have spent some time making lists of how pharmacists are utilized and even on a smaller level within pharmacy departments.  You see, it is tough being on this side of a career.  I guess you could say I'm in the middle in regards to time and experience.  I have been a pharmacist now for thirteen years. I have watched, usually with protest unfortunately, as pharmacists are labeled and grouped depending on different criteria.  Back in 1999, it was about having a residency in order to be a "clinical" pharmacist.  That is still the case today except in the smaller hospital where residency trained pharmacists aren't in supply.  Other criteria is used at that point.

In a perfect medical model, especially in the small hospital, I think it would be beneficial if the physician handled diagnoses, testing, and collaborated with the clinical pharmacist for treatment.  It is fairly obvious when you study the medical school curriculum that the focus is on diagnosis.  Yes, it is important to know what we are treating, but it does no good if you throwing ertapenem at pseudomonas or if you are dosing vancomycin at 1 gm every 12 hours in a young obese man for MRSA.

Hospitals really should consider encouraging all their pharmacists, especially PharmDs to learn the material that the BCPS requires.  It has seriously helped me in the past several months personally.  It is worth the investment of money and time and makes a FABULOUS resume' builder.

And in the end, it's about the patient receiving the best care possible.  Wouldn't a collaboration encourage that?

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Fungal Meningitis and the End of Lackadaisical FDA Involvement in Compound Pharmacies

New England Compounding Center (NECC) is at the center of this quite horrific tragedy that has affected the lives of many with fourteen already dead. I cannot personally fathom such a loss over something so seemingly accidental. As a pharmacist my thoughts immediately go to sterile technique and the FDA's regulation of our industry. You see, the states oversee the pharmacies compounding and normally that should be enough. However, something went terribly wrong here. But what is coming out lately is the role of compounding pharmacies and how in this case, there was a grey area they were working in. Basically compound pharmacies can make patient specific medications, what is not allowed is these compounding pharmacies acting as manufacturing and bulk shipping repackaged medications without FDA oversight.

It's all about the dollar, but in this case many priceless lives have been lost.

There are two fungi involved: aspergillus and Exserohilum rostratum.

In the past, these pharmacies have been the heroes making things like bioidentical hormones and other specialty concoctions.

Under the FDA's definition, compounding pharmacies are supposed to mix drugs to order only on a specific patient in response to a prescription from a doctor. Under this definition NECC was not operating as a compounding pharmacy but as a large-scale production of a drug. The FDa should have stepped in before these lives were lost.