Pharmacy News

Entries for July 2017

July Issue of Michigan Pharmacist!
Click here to access the journal on your computer, tablet or phone!

What's Inside:
  • 2016 Michigan Pharmacy Economic Survey
  • Michigan Society of Health-System Pharmacists (MSHP) Focus Articles including Healthcare System and Community Pharmacy Partnership in mCare Bedside Delivery, Combating Opioid Overdose with Naloxone Education and Distribution and a message from MSHP President, Dana Staat, Pharm.D. 
  • Upcoming Continuing Education events and offerings
  • And much more!

In this digital issue, be sure to click on links and URLs to navigate directly to information on the MPA website, use the back and forth arrows to "flip" through the pages and view in full screen to catch all the details. Don't forget to bookmark the issue page to access this valuable content anywhere you go!


Find it all http:here

Posted in: Member News
Anemia in Critically Ill Patients
By Jennifer Gregory, Pharm.D., PGY1 pharmacy resident, St. Joseph Mercy, Ann Arbor

Anemia 
Anemia is defined as a hemoglobin (Hg) concentration of less than 13 g/dl or less than 12 g/dl for adult males and females, respectively.1 Less than optimal Hg levels can result in insufficient tissue oxygenation.2 Blood transfusion remains the main stay of treatment for anemic patients, although there are risks. For example, transfusion has been shown to increase nosocomial infection risk, trigger an allergic reaction and even cause immunosuppression.3 In addition, transfusion-related circulatory overload may occur when patients are over transfused.2 This can cause an increase in blood viscosity, impeding blood flow and hindering tissue oxygen delivery.2  

Anemia and Critically Ill Patients
The incidence of anemia in the critical care setting is quite common. Approximately 40 to 60 percent of critically ill patients become anemic during their intensive care unit (ICU) stay.3,4 Various contributors of anemia exist in the ICU setting. Blood loss is one main etiology, and may be attributed to trauma, surgery or injury sites.5 Furthermore, critically ill patients tend to require more frequent lab monitoring and therefore end up with a higher amount of blood draws per day as compared to general medicine patients.4 This extensive lab testing can correlate to an estimated average daily blood loss of up to 70 mL from phlebotomy alone.4 Of note, blood loss may additionally be associated with considerable iron depletion.6 Iron is a necessary component for proper Hg production, and a potential iron deficit could further exacerbate the development of anemia.1 Since iron is mostly obtained via dietary sources, critical care patients are at even greater risk, as it is more difficult for them to meet the daily recommended nutritional requirements.7 Acute inflammation may also contribute to anemia and in critical illness inflammation is common.8 Inflammatory processes induce the amino acid hepcidin.4 Hepcidin degrades ferroportin, a transporter protein responsible for the exportation of iron from intracellular stores.6 Increases in hepcidin ultimately decrease cell iron liberalization. Additionally, inflammatory cytokines have been shown to suppress red blood cell formation via another mechanism involving interactions with erythroid progenitor cells.

Transfusion Thresholds 
The 2017 Society of Critical Care Medicine Surviving Sepsis Guidelines strongly recommend a transfusion threshold of 7 g/dl in most critically ill patients.9 Higher Hg targets of 8-10 g/dl have been suggested for certain subsets of critically ill patients, such as those diagnosed with coronary disease.2,3 

Consider the following equation:

Oxygen Delivery [DO2] = Cardiac Output [Q'] x Arterial Oxygen Content [CaO2]*

*Arterial Oxygen Content= Amount of Oxygen Dissolved in Blood + Amount of Oxygen Bound to Hg 

Arterial oxygen content decreases with declining Hg.2 Tissue oxygen delivery becomes deficient if cardiac output fails to adequately compensate for a loss in arterial oxygen content.2  Higher Hg transfusion thresholds have been hypothesized to be beneficial in patients with cardiac disease, such as heart failure or acute myocardial infarction, as damaged myocardium may prevent adequate compensatory cardiac output. It should be noted, however, that data is currently limited to suggest the safety and efficacy of this practice.2,3,6,10  

Summary 
Anemia is commonly associated with critical illness. The general accepted threshold for transfusion is an Hg concentration less than 7 g/dl. More research is needed to define the optimal transfusion Hg ‘threshold’ in critically ill patients with greater risk factors for hypoxia, especially considering the complex pathophysiologic mechanisms and disease state concerns that exist within this population. It is important to weigh the risks and benefits of red blood cell transfusions, as well as specific patient characteristics and disease state concerns, when making these treatment decisions.   

References 
1. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney inter., Suppl. 2012;2:279-335.
2. Du Pont-Thibodeau G, Harrington K, Lacroix J. Anemia and red blood cell transfusion in critically ill cardiac patients. Ann Intensive Care. 2014;4(16).
3. Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. J Trauma. 2009;67(6):1439-1441.
4. Hayden SJ,  Albert TJ, Watkins TR, et al. Anemia in critical illness: Insights into etiology, consequences, and management. Am J Respir Crit Care Med. 2012;185(10):1049-1057. 
5. Debellis RJ. Anemia in critical care patients: Incidence, etiology, impact, management, and use of treatment guidelines and protocols. Am J Health Syst Pharm. 2007;64:S14-S21. 
6. Prakash D. Anemia in the ICU: Anemia of chronic disease versus anemia of acute illness. Crit Care Clin. 2012;28:333-343.
7. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr. 2016;40(2):159-211.
8. Preiser JC, Ichai C, Orban JC, et al. Metabolic response to the stress of critical illness. British J Anaesthesia. 2014;113(6):945-954.
9. Rhodes A, Evans LE, Waleed A, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486-552.
10. Retter A, Wyncoll D, Pearse R, et al. Guidelines on the management of anemia and red cell transfusion in adult critically ill patients. Br J Haematol. 2013;160:445-464.
Posted in: Professional Practice
Northern Michigan Society of Health-System Pharmacists Regional Society Update
By Tammy Busch, R.Ph., staff pharmacist, Otsego Memorial Hospital, University of Florida-WPPD Pharm.D. candidate, northern regional representative

We had a very busy spring this year in northern Michigan. Our first ever Northern Michigan Society of Health-System Pharmacists (NMSHP) Annual Meeting took place in April in Gaylord and was a success with four live continuing education (CE) credits offered on the topics of Transitions of Care presented by Annie Ottney, Pharm.D., BCPS; Neonatal Abstinence Syndrome presented by Emily Kearney, Pharm.D., BCPS; Toxicology: Overdoses and Antidotes presented by Trevor Warner, Pharm.D., BCCP and Antimicrobial Stewardship jointly presented by Derek Vander Horst, Pharm.D., BCPS, PGY2 pharmacy resident and Katelin Anderson, Pharm.D., PGY1 pharmacy resident. Our April monthly meeting offered two live CE credits on the topic of Managing Pain in Patients with Cancer presented by Claire Saadeh, Pharm.D., BCOP. Finally, our local PGY1 residents presented their research projects at the May meeting. John Robinson, Pharm.D. provided insight on optimal management of Clostridium difficile infections; Allie Wasik, Pharm.D., conducted research on high-risk medication management, specifically sotalol, amiodarone, and DOACs in an outpatient cardiac clinic; Joseph Zerka, Pharm.D., explored the management of delirium in mechanically ventilated patients and Bradley Haan, Pharm.D., developed an alcohol withdrawal protocol for the hospitalized patient.

We have transitioned to our summer hiatus now and will resume our meetings in September. We are planning two additional meeting dates and new venues for this year, which will include Alpena along with Traverse City, Gaylord and Petoskey; thankfully, we have the capability to connect remotely with these venues so attendance is not dependent on driving three hours one-way for each meeting. In the meantime, we hope to gather for some fun events this summer at a Traverse City Beach Bums baseball game. Enjoy your summer!

Posted in: Member News
Resident Self-Assessment: What is New in the ASHP Standards?
By John S. Clark, Pharm.D., M.S., BCPS, FASHP, associate chief pharmacy officer, Michigan Medicine, Ann Arbor and clinical associate professor, University of Michigan College of Pharmacy, Ann Arbor

One of the most important items a pharmacy resident can learn is accurate and critical self-assessment. Once a resident enters practice, feedback will most often be provided formally one or two times per year. In an environment with seemingly scarce feedback, a pharmacist must be able to assess one’s own knowledge, skills, abilities and attitudes on a timely basis. The self-assessment objective in the post graduate year one (PGY1) pharmacy residency standard is designed to meet this important need. A change was made from the 2006 PGY1 Pharmacy Residency Standards regarding self-assessment versus the 2014 PGY1 Pharmacy Residency Standards. 

An excerpt from the 2014 American Society of Health-System Pharmacy (ASHP) PGY1 standards relating to self-evaluation reads:

“Objective R3.1.2: (Applying) Apply a process of ongoing self-evaluation and personal performance improvement.
  • Criteria:
      --   Accurately summarizes own strengths and areas for improvement (in knowledge, values, qualities, skills, and behaviors).
      --   Effectively uses a self-evaluation process for developing professional direction, goals and plans.
      --   Effectively engages in self-evaluation of progress on specified goals and plans.
      --   Demonstrates ability to use and incorporate constructive feedback from others.
      --   Effectively uses principles of continuous professional development (CPD) planning (reflect, plan, act, evaluate, record/review)."
As a major contributor to the development of the new ASHP Pharmacy Residency Standards, I am very aware that a primary goal of the group was to simplify opportunities for programs to be compliant with the standards. The 2006 standards created a lot of work for residents, preceptors and residency program directors (RPDs) alike. As such, the group decided to make the self-assessment strategy for residents an objective rather than an obligatory self-evaluation matching for each preceptor evaluation provided.

The outcome is a simpler approach. For any evaluation, an RPD may add an evaluation through PharmAcademic for the resident to complete. At Michigan Medicine, for the PGY1 pharmacy program, I have chosen to add self-evaluations for some required experiences. In a strategy to assist in ensuring achievement of the objective, self-assessments are included in more than one required rotation. 

In conclusion, an attempt was made to reduce the number of self-evaluations in the 2014 PGY1 pharmacy residency standards while continuing the high quality development of skill in the residents. The change was made by being more selective about when self-assessments would be completed and reducing the number of self-evaluations required. If you have additional questions, please feel free to contact me at johnclar@umich.edu.

Reference:
1. American Society of Health-System Pharmacists. Accreditation Standards for PGY1 Pharmacy Residents. ASHP website. https://www.ashp.org/Professional-Development/Residency-Information/Residency-Program-Directors/Residency-Accreditation/Accreditation-Standards-for-PGY1-Pharmacy-Residencies. Accessed June 2017. 

Posted in: Member News
Gearing Up with Students and Residents
By Michelle Dehoorne-Smith, Pharm.D., patient care services manager, St. John Hospital and Medical Center, Detroit, MSHP Board of Directors

Since the start of 2017, we have taken a critical look at how each of us and our organizations can prepare for the challenge of gearing up for our evolving role in improving patient care through increased access to pharmacists’ healthcare services. As described in the Journal of the American Pharmacists Association’s 2017 pharmacy forecast, there will be a significant shift in the pharmacy work force, and in particular, in our role and training.1  

In addition, as we respond to payment reform, we will be continuously challenged to improve patient outcomes with lower costs and more efficient pharmacy services. Smaller work forces, decreased healthcare spending, improved outcomes and increased demand for high quality experiential education will be some of the future challenges. To assure the necessary skill set for our expanded direct patient care roles, we need to continue to increase the number of sites providing high quality experiential training for students and residents. Providing a greater number of sites with high quality experiential training while requiring less staff and providing expanded services that improve patient outcomes with overall lower cost of care are two of the greatest challenges facing our clinical practice. 

Improved integration of students and residents into our practice model may be a key step in accomplishing these seemingly unbalanced demands with our goals. For example, building interdependent student-pharmacist teams that focus on transitions of care, patient education and decreased readmissions may be a good first step. Integration of students into the practice model traditionally has been resisted as inclusion of students is often seen as an increased workload on supervisors as well as the belief it is a lower quality educational experience. Currently only 20 percent of forecast panelists predict a high likelihood that health-systems will have a formal plan within the next five years of achieving a cost-benefit balance in advanced experiential education and only 38 percent predict this to be somewhat likely.  Without more creative scheduling by organizations and universities and greater student accountability for quantifiable workload, we may be missing the forest amongst the trees. Students value direct patient care and the responsibility for improved patient outcomes. As future practitioners, these increased responsibilities may enhance students’ feeling of ownership for their future patients. 

Healthcare experiential sites need to be willing to forgo models that resist student ownership of workload and provide primarily shadowing and observational training. Rather than be perceived as a drain on the staff, high quality training sites should include greater integration of students and residents into the practice model and greater consistent provision of direct patient care. This will offset pharmacist workload as well as prepare our future practitioners with the appropriate skill set, hands-on experiences and accountability for outcomes.  We know students and residents can provide many benefits to our staff, patients and assist with workloads if we are willing to empower them and change the way we integrate them in our practice models. In turn, we may better prepare our future pharmacy practitioners with the skills to meet the goals of improved services at a lower cost in an efficient practice model. 

Reference: 
1. Zellmer WA, ed. Pharmacy forecast 2017: strategic planning advice for pharmacy departments in hospitals and health systems. Am J Health-Syst Pharm. 2017;74:27-53. 


Posted in: Member News
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