by Samantha LaRocque & Jacalyn Gualtieri, Pharm.D. candidates 2017, Eugene Applebaum College of Pharmacy and Health Sciences

Finally, after three years of didactic learning, it was fourth year of pharmacy school, and time to put our knowledge to practice. The first day of rotation is the most intimidating of them all. You will have questions like, “What do I need to know?” or “Where do I need to be?” and “How am I going to get there?” As each day and each rotation proceeds, you are seemingly unaware of the transformation you are undergoing. But what does it take for a student and a preceptor to be successful in a clinical rotation?

From a student’s perspective, there are a few strategies that can help make a rotation successful. First, set measurable goals for yourself at the beginning of each rotation. Make sure you arrive early to allow yourself enough time to prepare for daily activities. Be confident: you may view your interventions as insignificant, but remember that you are the expert of pharmacotherapy. Other members of the multidisciplinary healthcare team, as well as the patient, are counting on you to identify and resolve drug-related problems. Without confidence, your critical interventions may be overlooked. Whether you are talking to a patient about medication adherence, or discussing an alternative therapy choice with a provider, be confident. Despite knowing the information, if you cannot deliver it in an effective and efficient manner, then you are not optimizing patient care. Also, we have learned that prioritization of clinical interventions is essential to patient success. Talk to your patients. It may seem easier to look at a patient’s EMR to perform a medication reconciliation, but you would be surprised the valuable information that you can get from simply talking to your patient. In our experience, taking the extra step to engage the patient has led to positive feedback from our preceptors, even in the ICU. Lastly, one of the most important aspects of a clinical rotation is building a student-preceptor relationship. This requires communication throughout the rotation in order to ensure that expectations and goals are mutually understood.

For preceptors starting a rotation with a new student, it is helpful if goals are set and expectations are discussed up front. Additionally, doing a weekly (or more frequent) recap is especially helpful to students in order to allow for growth and continual improvement throughout the rotation. It is extremely advantageous to familiarize the student with the practice site, including patient care areas, equipment, chart navigation and key providers. We will never forget the first day of our Medical ICU rotation when our preceptor set aside 20 minutes to help us navigate the EMR, including showing us how to prioritize data collection for critically ill patients. This relieved so much anxiety and allowed for more time to focus on a patient’s pharmacotherapy rather than getting lost in the chart. It is also important to be flexible and individualize your rotation to each student. We want to be challenged, but we also want a safe and effective learning environment. For example, students are easily overwhelmed with patient numbers. It is often more effective to first have a student follow a few patients, and then build up from there. With regards to interventions, we appreciated a constructive approach, where each idea was discussed and the student was encouraged to “dig deeper” and gain confidence in the decision-making process. If possible, we also enjoyed having some autonomy on rotations (when the student is ready and the preceptor is comfortable with the student’s knowledge and confidence). We were able to make the most effective interventions and impact on several rotations when we were the ones on the “front line.”

 Overall, the P4 year is challenging, but a rewarding learning experience.

by Gladys Dabaja, Pharm.D., SMSHP president-elect, director of pharmacy, Henry Ford Wyandotte Hospital, southeastern regional representative

The Southeastern Michigan Society of Health-System Pharmacists (SMSHP) is off to a busy start this year. We had two productive Board meetings so far, and the energy and excitement around membership growth continues to develop. The SMSHP Membership Committee has been working diligently on increasing pharmacist and pharmacy technician membership. We have seen a surge in pharmacy technician membership in large part due to live CE requirement for licensure renewals, which was mandated by the State of Michigan in 2015. Additionally, The University of Michigan (UM) Hospitals and Health Centers have encouraged their pharmacy technicians to join SMSHP. UM has agreed to reimburse SMSHP membership fees to all their pharmacy technicians. A special thank you to Denise Propes for helping to facilitate and take the lead on this initiative.

We are excited to have hosted American Society of Health-System Pharmacists (ASHP) President-Elect, Paul W. Bush, Pharm.D., M.B.A., FASHP. Dr. Bush is the chief pharmacy officer at Duke University Hospital, Durham, N.C. Dr. Bush presented on “Current Issues and Opportunities in Pharmacy Practice – Update from ASHP” on April 12. It was exciting to hear his thoughts and input about pharmacy practice and how we can continue to move the profession in the right direction. Additionally, our annual Pharmacy Technician CE event is scheduled for May 20 from 8 a.m. to noon at the Hellenic Cultural Center in Westland. The event will include breakfast and three live continuing education presentations that include pain. Information regarding registration and location will be available shortly on our website at www.SMSHP.org.

We have completed two educational activities this year. Our first was at our Jan. 11 meeting. At this meeting we learned about “Health Technologies: Pharmacists and Pharmacy Technician's View and Role.” The topic was presented by John S. Clark, Pharm.D., the director of pharmacy at the University of Michigan Hospitals and Health Centers. Dr. Clark did a great job discussing the major issues and opportunities facing the future of pharmacy and how technology can help or hinder its success. On Feb. 8, Angela Michael, Pharm.D., clinical pharmacy hematology/oncology specialist at Henry Ford Hospital, Detroit, presented “A Tough Pill to Swallow? A Practical Guide to the Management of Oral Chemotherapy.” We learned about the emergence and complexity of oral chemotherapy that includes high costs, side effects and adherence issues. For our March 8 meeting, Kyle Burghardt, Pharm.D, assistant professor of pharmacy practice at Wayne State University presented, “An Introduction to Clinical Pharmacogenetics and Personalized Medicine”. This presentation discussed how the landscape of healthcare continues to evolve and expand into new territories. 

by Syeda Maahin Mahmood, Pharm.D., PGY1 pharmacy resident, St. Joseph Mercy Hospital, Ann Arbor

Traumatic Brain Injury (TBI) is a serious health condition which contributes to almost one third of all injury-related deaths in the United States.¹ TBI cases can range from mild to severe and cause a wide variety of short and long-term effects on cognition.² TBI can also cause epilepsy and increase the risk of neurologic conditions such as Alzheimer's or Parkinson's disease.³ Because of the wide and lasting impact TBI can have, it is important to stay up-to-date on the management of this condition.

In September 2016, the Brain Trauma Foundation published updated guidelines on the management of TBI (previous guidelines were released in 2007).⁴ The updates to the guidelines included the addition of new sections such as decompressive craniectomy and cerebrospinal fluid drainage, limiting infection, and deep vein thrombosis (DVT) prophylaxis as it relates to concerns in TBI patients as well as adding more information regarding nutrition and the comparative effectiveness of different hyperosmolar agents. Pharmacists may have a variety of roles in managing patients with TBI. These include managing nutrition, optimizing DVT prophylaxis and recommending the use of appropriate pharmacologic therapy.

To start, monitoring labs in a TBI patient is similar to that of most critically ill patients with the goal of having electrolytes and glucose within normal limits. More specific to TBI, avoiding hyponatremia is especially important as this can lead to cerebral edema and increase intracranial pressure (ICP). Depending on the injury, TBI patients can also be at risk for hematomas or a hemorrhage, so decreasing the risk of bleeding is essential. This can be done by monitoring the complete blood count and targeting hemoglobin greater than 7 g/dL, platelets greater than 75 x 10³/mm³ and an INR of less than 1.4.⁵

Furthermore, maintaining ICP at goal of 20 – 25 mmHg is another important component in the patient with a TBI. Monitoring ICP has been shown to significantly decrease mortality, especially in younger patients.⁶ Maintaining ICP at goal includes using both non-pharmacologic interventions, such as keeping the head of the bed at 30 degrees, decompressive craniectomy, or placement of an external ventricular device, as well as pharmacologic interventions such as choosing short-acting sedatives or the appropriate agents in hyperosmolar therapy.^5,7 More severe cases of elevated ICP may require neuromuscular blockade or high anesthetic doses of propofol (if the patient responds to a bolus test dose of either agent respectively with successful lowering of ICP).^5,7 Because of the possible risk associated with these interventions, an informed pharmacist is essential to the safety of these critically ill patients.

Pharmacists have an important role in optimizing seizure, DVT and infection prophylaxis for patients with TBI. Although the new guidelines discuss each of these topics, there is still a lack of definitive guidance. For seizure prophylaxis, the guidelines advise not using phenytoin or valproate for late post-traumatic seizures and recommend the use of phenytoin to decrease the incidence of early post-traumatic seizures depending on risk-benefit. Levetiracetam is another agent that is being used more often; however, more studies are needed to make evidence-based recommendations.⁴ For DVT prophylaxis, the guidelines report conflicting data evidence and simply state that low molecular weight heparin or low-dose unfractionated heparin may be used in combination with mechanical prophylaxis, but this may cause an increased risk for expansion of intracranial hemorrhage⁴. Therefore, the pharmacist can help inform the decision of when, or to even start, pharmacologic DVT prophylaxis based on a risk-benefit assessment thereby individualizing patient care.

Lastly, for infection prophylaxis, the guidelines no longer recommend peri-procedural antibiotics for intubation due to weak beneficial evidence and a lack of similar infectious disease policies, but recommend considering antimicrobial impregnated catheters to decrease catheter related infections.⁴ Pharmacists have an important role in infection prophylaxis and management through antimicrobial stewardship efforts.

Overall, the management of severe TBI patients is anything but simple. Pharmacists possess the capabilities and knowledge to help optimize and individualize pharmacologic therapy for these patients. With insight from the new guidelines, pharmacists can arm themselves with information and recommendations to make headway and improve the care of these patients. 

References:

1. National Center for Health Statistics. National Vital Statistics System. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/nvss/. Updated Feb. 16, 2017. Accessed March 2017. 
2. National Center for Injury Prevention and Control. Traumatic Brain Injury & Concussion. Centers for Disease Control and Prevention website. https://www.cdc.gov/traumaticbraininjury/outcomes.html. Updated March 30, 2017. Accessed March 2017.
3. National Institutes of Health. Traumatic Brain Injury: Hope Through Research. National Institutes of Neurological Disorders and Stroke website. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Traumatic-Brain-Injury-Hope-Through. Accessed March 2017.
4. Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM. Guidelines for the management of severe traumatic brain injury. Neurosurgery. 2016;80(1):6-5.
5. American College of Surgeons. ACS TQIP Best Practice Guidelines. American College of Surgeons website. https://www.facs.org/quality-programs/trauma/tqip/best-practice. Accessed March 2017.
6. Alali AS, Fowler RA, Mainprize TG, Scales DC, Kiss A, de Mestral C, Ray JG, Nathens AB. Intracranial pressure monitoring in severe traumatic brain injury: results from the American College of Surgeons Trauma Quality Improvement Program. J Neurotrauma.2013;30(20):1737-1746.
7. Meyer MJ, Megyesi J, Meythaler J, Murie-Fernandez M, Aubut JA, Foley N, Salter K, Bayley M, Marshall S, Teasell R. Acute management of acquired brain injury part II: an evidence-based review of pharmacological interventions. Brain Injury. 2010;24(5):706-21.

by Rebecca Maynard, Pharm.D., clinical pharmacist specialist – antimicrobial stewardship, Borgess Medical Center

Continuing the work of 2016, 2017’s first charge for the Michigan Society of Health-System Pharmacists (MSHP) Organizational Affairs Committee is to update the MSHP mission statement and goals and finalize the MSHP vision statement to align with the mission and goals of the Society. If you are at all like me, you may be wondering a couple things: “Don’t we already have a vision statement?” (Surprisingly, no), followed by, “Aren’t a mission and goals enough? Do we actually need a vision?” (To which I now argue yes, that the vision is a valuable and even fundamental part of any organization and differs from the Mission in its structure and purpose).

But what is the difference between a mission and a vision statement, and how does that impact our Society? Vision statements serve as the “North Star” for any organization—an overarching statement that defines and provides guidance and inspiration for what the organization dreams as its end-state.¹ Vision statements are all about what you want to achieve. Mission statements, on the other hand, answer the what-, who- and why- questions of the organization’s purpose; they define the current state of an organization and explain what it does, who it does this work for and how it accomplishes that work. In an organization where leaders change, the vision can help new or incoming leaders stay the course and focus on what is most important: our patients and our profession.

The vision statement, while succinctly written, has been anything but brief in its crafting. The statement underwent multiple revisions with input from committee members and the MSHP Board of Directors and was finalized at the January Board meeting.

MSHP’s vision is that all people in Michigan have pharmacy care providers to ensure optimal, safe and effective medication use.

As we move forward with a formal vision to guide us, the Organizational Affairs Committee now turns its focus to refine the mission statement based on the changing landscape of pharmacy as a profession and healthcare as a whole. Our Mission must include the work we do in hospitals, health-systems, ambulatory clinics and other settings like individual practices. It also needs to consider the expanding roles of non-pharmacists as providers. We must also acknowledge the work that technicians have undertaken to become a vital part of our licensed profession. Our organization does so much to help us attain our goal of providing exceptional patient care, from the work of our committees and leadership to community outreach and coordination with the legislature. We want our Mission and Goals to reflect that.

Once the Committee’s work is completed and approved by the MSHP Board, we will move forward with amending the bylaws to reflect the new Mission Statement. The Organizational Affairs Committee will take up the torch again on May 11 at Committee Day, and we welcome anyone with an interest or passion in shaping how we portray our organization to its members and the community to join us.

References:

1. Evans J. Vision and Mission: Unleashing the power of vision and mission. Psychology Today. Posted Apr 24, 2010. https://www.psychologytoday.com/blog/smartwork/201004/vision-and-mission. Accessed August 2016.

by Shawna Kraft, Pharm.D., clinical pharmacist – hematology/oncology, University of Michigan Health System

How can you gear up for provider status? It is not necessary to wait until we have the official legislation as there is a plethora of resources available to begin optimizing your practice now and begin the steps toward being a recognized provider.

Resources for Pharmacists

For those practicing in ambulatory care, Michigan Pharmacists Association (MPA) has an Ambulatory Care Toolkit available here that provides excellent and extensive information on business models and clinical resources. Even those pharmacists working inpatient may find some of this information beneficial to their practice.

A few other states such as North Carolina have had a version of provider status since 2000 and can provide a best practice example for how we may be able to implement once we have similar status in Michigan.

Best practice examples are also available within our own state. We have a pharmacy practice model initiative in Michigan (PPMI2) that works toward advancing pharmacy practice. There are examples listed here from practices around the state detailing how efforts are already happening to advance our roles.

Resources for Other Healthcare Professionals

Dana Staat, MSHP president, stated in her “Gearing Up” article in January 2017 MSHP Monitor that it is important to get key stakeholders to further understand the impact pharmacists can have as providers. The MPA website has the Pharmacists As Providers resource which was created and is maintained by the MSHP/MPA Public Affairs Committee. This document contains quick overviews of information about different disease states and treatments and highlights the vital role of the pharmacist as it relates to those diseases. This information can provide a starting point for discussing, expanding or optimizing the services you are providing. Find the Pharmacist as Providers webpage here.

Resources for Patients

Patients can be powerful advocates for pharmacy. The MSHP/MPA Public Affairs Committee also created a Pharmacists As Providers resource specifically for patients. This document contains the same topics covered in the resource for pharmacists, but aims to explain to patients the pharmacist’s role in those disease states and treatment programs. Find that resource here.

Optimizing Roles of the Technician, Students and Residents

One component of optimizing our roles as pharmacists is ensuring we are supporting the development of pharmacy technicians, students and residents. Practices can work to expand their patient care model to rely on the use of technicians, as well as students and residents, as essential components to the workflow. This is an area we should all be implementing now so that we are primed and have the capacity to expand our provision of patient care when the time comes.

Lastly, I believe our best resource is each other. Networking and attending meetings and conferences to hear what others are doing and share your practice is the best way we can support one another to achieve ideal patient care. I would encourage you to reach out to those who are expanding their practices and share ideas. This is only the beginning of the impact we can have on our patients.