Reflections on Evidence-based Medicine

It was really great to see the other residents, both hospital and community alike. Although by the end of a Friday afternoon it was tough to sit in one spot for 7-8 hours, there are many things to unpack and revisit throughout the residency year when it comes to appraising the literature, always having a critical lens, and (what I found to be an important talk) keeping your patient’s wishes in mind. So, how did I do on my goals?

Goal #1: Develop an efficient process for appraising a variety of literature, including RCTs, observational studies, meta-analyses, systematic reviews, and guidelines. I’d like to believe I have achieved this in that I have a good foundation and framework for approaching a variety of literature. For all the “checklists” and “scores”, I don’t think I’ll be using them for every single study I come across, but they are good for keeping in mind what elements make up a quality study.
– For observational studies, I have the STROBE checklist
– For guidelines, I have the AGREE II scoresheet
– For meta-analyses, there is the PRISMA checklist and AMSTAR score. I liked AMSTAR because it is fast, and a quick hit on what “big-picture” things to look out for in a meta-analysis.

Goal #2: Develop a process to approaching clinical dilemmas and treatment choice with patients. Achieved. Dr. Slavik provided us the 10 step workflow to doing this. The main idea I got from this was to start big when explaining medication choice, such as:
Condition (what it is) –> Drug class options –> Individual drugs –> Tangible risks (don’t give an NNT) –> Tangible benefits –> side effects, cost, other factors

Overall, the surprising thing I learned during this week was that meta-analyses are not as necessarily bulletproof as I’d like to believe. I think during undergrad, it was drilled into our heads that RCTs have a lot of areas where investigators can improve on, but I was part of a large group of my colleagues who imagined that as we were told that meta-analyses are at the “top of the evidence food chain”, they have to be of a higher quality.

Another thing that made me reflect and give me more pause was that certain research questions may be better answered by a cohort or case-control study, such as in the cases of rare adverse events, hypothesis-generating studies, or ones where larger studies may be impractical or too expensive.

Nuggets of Knowledge – Intro to Infectious Diseases

Few tidbits from the ADS on ID.

  • Presence of polymorphonuclear cells (PMNs) indicates inflammation
  • Beware of epithelial cell contamination in a sample
  • Coagulase-negative Staphylococcus spp is often a contaminant of blood cultures
  • A C&S will NEVER have PO susceptibility data due to concerns with bioavailability. Consult microbiology if you need direction.
  • Eosinophilia increases suspicion of allergic reactions or parasitic infections
  • Lymphocytosis increases suspicion of malignancy or bacterial infections
  • Acute phase reactants are non-specific but add to the overall picture
  • Pearl: cellulitis treated with ABX will appear to worsen for 2-3 days due to killing of bacteria and subsequent release of endotoxins
  • Some antibiotics perform poorly in acidic environments, so therefore will not penetrate and treat an abscess.
  • When do you consult microbiology?
    • Need more specific identification on an organism
    • Need additional susceptibility or MIC data
    • Need guidance on which test to use to identify a bug

And of course, this fun gem:

10commandmentsID

Goals and objectives: Clinical Orientation Rotation

Looking forward to my first foray into patient care this residency year. I will be working with Dr. Michael Legal and I will be paired up with my fellow resident, Puneet (follow the link to his blog!). I hope that I will develop somewhat of a foundation to tackle my next clinical rotation, which is oncology…and should be a steeeeeep learning curve indeed.

Goal #1: Holistically incorporate radiographic findings and be able to apply them to rationalize diagnoses to better develop a pharmacotherapeutic plan.
Objectives to meet this goal:
– Look up any words that do not make sense on a dictated interpretation of any radiographic investigations
– Present any radiographic findings as: what was found, and why that points towards a diagnosis (or why not)

Goal #2: Become proficient at performing medication reconciliation, and proactively take action to resolve any discrepancies.
Objectives to meet this goal:
– Obtain a relatively simple BPMH (5-10 medications +/- 1-2 OTCs) in under 10 minutes
– Be able to rationalize to my preceptor any action to resolve discrepancies
– Be able to write a succinct (<1 page) clinical note in the patient record on a MedRec clarification

Goal #3: Be able to work up a relatively simple patient (<6 medical conditions) in under 3 hours.
Objectives to meet this goal:
– Develop a flow to gathering information, starting with the chief complaint and HPI first
– By the end of the rotation, develop my personal workup sheet for further clinical rotations
– Continue to keep a notebook outlining conditions I do not know and to be transcribed to electronic form later (repetition solidifies knowledge for me!)

Goal 1 was borne out of a weakness that I found during my hospital rotation in undergrad based on feedback I received, and goals 2 and 3 were due to them being necessary competencies I must carry forward in my residency training. I look forward to starting my clinical rotations!

Goals and Objectives: Evidence-based Medicine Rotation

Goal #1: Develop an efficient process for appraising a variety of literature, including RCTs, observational studies, meta-analyses, systematic reviews, and guidelines.
Objectives to meet this goal:
– Remain engaged during the didactic sessions and ask questions of my colleagues and the facilitator where necessary
– Develop a “hit-list” of 3-5 elements to look for in a paper or guideline to determine whether the evidence is applicable to a patient under my care, and whether I should continue appraising a paper before moving on to the next one
– Develop a “hit-list” of 2-3 elements to look for bias or systematic weaknesses in a paper or guideline to efficiently triage papers for more extensive review

Goal #2: Develop a process to approaching clinical dilemmas and treatment choice with patients.
Objectives to meet this goal:
– Develop an approach to elucidating patient values within the first 2 minutes of a patient interaction
– Endeavour to use zero medical jargon during each patient interaction, and to explain medical jargon not previously clarified
– Present at least 2 alternatives and 2 pros and cons for each treatment option, and develop a process to develop these pros and cons based on patient values

ADS – Community-acquired and hospital-acquired pneumonia

I quite enjoyed this session. Going back to Dr. Nishi’s session on an intro to ID, where she kept saying that for undergraduates, we are trained to treat ID as a cookie cutter system. Cellulitis gets cephalexin or cefazolin, full stop! However, real life is never that black and white, and this session revealed that. Dr. Brown introduced a case where the medical resident asks you what is good to treat someone with fever and cough. This was a good session to follow the morning one as we got into the mindset of first asking if there was an infection or not. It was a bit like a general workup. Vitals, ROS, med Hx, conditions, labs, and HPI. Once we were convinced it was a pneumonia, it turned to a roundtable discussion where we each had to provide a regimen and defend it! In total there were almost 30 regimens. After, we went through each and every choice, and the pros and cons of each regimen.

This was a great reminder of what to consider when recommending a medication (or not) for an ID patient. Definitely not cookie cutter. It also made us recall knowledge from the bugs and drugs table from undergrad, along with more up to date antibiograms. 

The process was repeated, albeit abridged, for HAP and VAP. The main point I got was that >48 hours exposure to the hospital setting or health care setting coupled with S/S suggestive of pneumonia increases your suspicion of HAP. In addition, there is much to keep in mind including if they had surgery and what type of surgery they had, prior exposure to broad spectrum ABX…kind of like a regular workup! The biggest pearl I got was that generally, double covering for Gram-negatives is not necessary. This encouraged me to think beyond the guidelines, while also thinking about the usual hospital bugs you’d be worried about such as Enterobacteriaceae, Acinetobacter, and MRSA pneumonia.

This session provided a good framework by which to approach other types of infection I will encounter, including UTIs, intraabdominal infections, meningitis, and others.

ADS – Introduction to Infectious Diseases

I’m writing this on public transit so I don’t forget most of the things (it’s amazing what you think you retain right after but then lose shortly thereafter!). Here are some of the more pertinent points I got from today’s morning session:

– Always be skeptical of a specimen: when it was obtained, where the sample was taken from, and (where I think I’d miss the most) how the sample was obtained. Harking back to my hospital rotation, I know that I’d skip to the C&S.

– The white blood cell count (and sometimes the temperature) can be deceiving: but a fever and leukocytosis indicate infection, I cry! It was a good reminder that there are multiple causes for these signs.

– Source control is sometimes the most important way to treat an infected patient: it’s great that you treat an intraabdominal abscess with cipro and metronidazole, but antibiotics don’t penetrate that well into abscesses. It shows how medicine and pharmacy can work together.

– The fundamental question is “does my patient have an infection?”: Again, it was good to build upon undergraduate knowledge and it gave me some tools to critically assess the culture, physical findings, and antibiotic choice that may be on board already. Just because an organism grows (and sometimes heavily) on a C&S does not mean that organism is causing the infection.

This was a great primer (full of clinical pearls that I will update with in Nuggets of Knowledge) to my upcoming ID/AMS rotation, which I am really looking forward to. It allowed me to rustle through the depths of 2nd year knowledge, and should prove to be a good background by which to base further learning from.

Reflections on Drug Distribution

It certainly feels good to have the 1st rotation under my belt…although it seems like the calm before the storm. All in all, I feel that I got more out of my drug distribution rotation than I had preconceived. Apart from doing the various drug distribution-y things such as “prepare and dispense medications safely and accurately according to institutional policies and procedures” and “accurately transcribe orders onto the patient’s medical record”, I had the opportunity to branch out a bit too. So one does not have to go back to the original post, here were my goals:

1. Develop an efficient process to processing and verifying drug orders – I think I have developed a flow for doing this. Name, 2nd identifier, allergies… then the rest is clinical. Screen the order – and NESA each order.
2. Become familiar with preparation and distribution procedures for parenteral medications in the hospital setting – which ones come premade from PDDC? Which ones need to be mixed? IVP, MED, or MEDM? Doesn’t only apply to parenterals…but I’ve been told it comes from experience.
3. Appreciate the role of pharmacy technicians and the impact of their scope of practice in the hospital pharmacy dispensary – see below.
4. Become familiar with reporting medication incidents from the hospital pharmacy dispensary – see procedure log. Reporting a PSLS was an interesting exercise.

And here were my objectives to meet those goals. Were they met?
– Prepare and dispense 3 medications safely and accurately according to institutional policies and procedures: ACHIEVED. See procedure logs. I got to be with a technician in various steps of preparing medications.
– Accurately transcribe 3 medication orders onto the medication profile of an inpatient: ACHIEVED. See procedure logs. Reflecting on my experiences, I think one week of order entry is way too short to have a working competency given the various idiosyncrasies of individual hospitals, but I can safely say that I have achieved this.
– Clarify 3 orders with physicians and other prescribers: I did not fully achieve this objective but it highlighted the difficulty in making completely informed clinical decisions from the dispensary. At least it encouraged me to be mindful of what I should find out in order to make a decision!
– Demonstrate the safe preparation of 1 IV medication: ACHIEVED (sort of?). I observed the preparation of various IV medications, including a few chemotherapy agents during my visitation to Burnaby Hospital. I do have some tissue culture (asceptic) technique experience in the past, but my muscle memory must be terrible and the technicians do it so quickly…that dexterity! Everything was very protocol based, and all your calculations, prep work, etc was done OUTSIDE of the hood. HOWEVER, if for some reason I was the only pharmacist on call who could do it and it was 2am…I think I could plug through it.
– Name 3 logistical barriers to providing clinical pharmacy care when pertaining to drug distribution: Only 3?? ACHIEVED. Not to say that it isn’t an efficient system. The hospital dispensary is like a well-oiled machine. However, things do happen. Unclear orders, porter delivery times, pass medications and the requirement for 24 hours notice, patient’s own medication ambiguities, incomplete/incorrectly filled out MedRecs… there are many things to keep in mind.
– Name 3 unique roles that the hospital pharmacy technician assumes to expedite safe and effective drug distribution: ACHIEVED. More like, “name a role the hospital pharmacy technician does NOT assume in the dispensary”. Ward stock, inventory, IV prep, you name it, they do it. My preceptor was mentioning that Fraser Health was moving towards centralized order entry. Not sure how that would work out, as it comes with the advantage of standardized order entry procedures, but some drawbacks as well. The techs or pharmacists who would be entering orders would not be following the patient, would not be screening for more subtle DTPs given the Hx of the patient, etc. However, the technicians basically run the show. They do the product check, preparation, most of the order entry (at least at ERH)…the pharmacists mainly deal with order verification in the dispensary, and most pharmacists are on the ward.

Project week (with an interesting ADS coming up on one of my interests… infectious diseases!)…then UBC summer didactic week…then clinical orientation.

Vancomycin tapering for C. difficile

I found this one to be interesting, and involved some digging into EMR. The patient was in for C. difficile associated diarrhea (CDAD), and was the first instance that I could see on Meditech (since 2010 at least), and was on vancomycin 125 mg PO QID since the 28th (closing in on one week). The order read as follows:

vancomycin 125 mg PO TID x 2 days (starting Jul 5th) then
vancomycin 125 mg PO BID x 3 days then
vancomycin 125 mg PO daily x 2 days then stop.

Immediately I thought that I better look into it as I was unfamiliar with taper regimens for PO vancomycin. What I found was that there really is not that much evidence to support taper regimens despite it appearing on UpToDate and some clinical guidelines, and taper regimens are only recommended under guidelines for the 2nd recurrence. In addition, it was the patient’s first bout with C. difficile as far as we knew; in that case what is recommended is either metronidazole 500 mg PO TID or vancomycin 125 mg PO QID x 14 days, if severe (see the paper above for more details). I decided to write it in the clinical book that the pharmacy had, describing my concerns so that the clinical pharmacist could reassess and follow up. It was a good opportunity to delve a bit deeper into an order and try and make an intervention from the dispensary.

C3.2 R5: Complete the “Med Safety Game” and document in ePortfolio

I completed the game today via CCRS and attained a score of 4882. One thing that stood out for me was that a few of the questions I could answer much more easily now that I have had some exposure to the dispensary during my Drug Distribution rotation. One question was concerning how to process STAT orders. Very early on in my order entry/verification training, I would enter stat orders into Meditech. However useful that may be to the clinical pharmacist who would want to easily know if stat furosemide IV or midodrine PO was given, it is cumbersome and slows down order entry, and that information could be obtained from reading the MAR, nursing notes, or doctor’s orders. Now, that particular question was easy as I have gotten a better grasp on how orders are processed from the ward and to the pharmacy.

C3.2 R4(c): Clarify a medication order with a prescriber (#3)

This clarification has a bit more of a clinical slant to it. Truth be told, I was very happy to be able to make some interventions from the dispensary level as it does impact patient care, and adds some more checks and balances to medication safety.

Patient was a 39 yo female who was on quite a bit of antihyperglycemic medications:
– Metformin 1000 mg PO BID
– Linagliptin 5 mg PO BID
– Dapagliflozin 5 mg PO daily
– Gliclazide MR 60 mg PO daily

On her admission orders she was also ordered “continue Jentadueto 2.5 mg PO BID”. From my experience in community, this was an incomplete order as Jentadueto (a combination linagliptin/metformin product) comes in 2.5/500, 2.5/850, and 2.5/1000 mg tablets. In addition, the linagliptin was given at 10 mg a day, which is above the recommended daily dose, AND it didn’t appear on Pharmanet – it was handwritten into the MedRec. There was no A1c to go on while in hospital.

I decided that this was a complex situation that required clarification of how the patient takes her meds. Therefore, I liaised with the clinical pharmacist on the ward to clarify these aspects with her. This required some memory retrieval from undergraduate days (time flies!) as I learned that above 2 g/day, it is unlikely to gain much more benefit from maxing out the metformin dose. In addition, the trials that have to do with intensive A1c control (ACCORD and ADVANCE) do not apply to this patient, as she is 39 years old and ADVANCE and ACCORD included patients above 55 years old. The other medications could be reassessed by her GP/endocrinologist.

The linagliptin as it turns out was taken only once a day, as per the patient, and she had stopped taking Jentadueto “a while ago”. The clinical pharmacist on the unit eventually wrote the clarification orders, and it should show up on her discharge prescription, corrected and ready to go for her trip home.