American Society Of Health-System Pharmacists Research Articles

Parenteral Nutrition Trace Element Product Shortage Considerations.

Parenteral Nutrition Trace Element Product Shortage Considerations.

Discrepancy in Vancomycin AUC/MIC Ratio Targeted Attainment Based upon the Susceptibility Testing in Staphylococcus aureus.

This study demonstrated a statistically significant difference in vancomycin minimum inhibitory concentration (MIC) for Staphylococcus aureus between a common automated system (Vitek 2) and the E-test method in patients with S. aureus bloodstream infections. At an area under the serum concentration time curve (AUC) threshold of 400 mg∙h/L, we would have reached the current Infectious Diseases Society of America (IDSA)/American Society of Health System Pharmacists (ASHP)/Society of Infectious Diseases Pharmacists (SIDP) guideline suggested AUC/MIC target in almost 100% of patients while using the Vitek 2 MIC data; however, we could only generate 40% target attainment while using E-test MIC data (p < 0.0001). An AUC of 450 mg∙h/L or greater was required to achieve 100% target attainment using either Vitek 2 or E-test MIC results.

Leadership Book Club: An Innovative Strategy to Incorporate Leadership Development into Pharmacy Residency Programs

Purpose: To describe an innovative strategy for incorporating leadership training and development across multiple postgraduate year 2 (PGY2) pharmacy residency programs at a single institution. Background: Tampa General Hospital has 7 pharmacy residency positions: 4 postgraduate year 1 (PGY1) residents and a single resident for each of the 3 PGY2 programs (critical care, emergency medicine, and solid organ transplant). Administrative topics are incorporated across the PGY1 and PGY2 residency programs, with each PGY2 program having additional administrative topics specific to their specialty area. Summary: What began as an elective administrative topic discussion for the PGY2 emergency medicine resident has evolved over time into a longitudinal leadership book club. The leadership book club is utilized to meet the residency goals and objectives related to leadership development for all 3 PGY2 programs. Each year a single book is identified through the American Society of Health-System Pharmacists (ASHP) Leadership Academy book list or by participant suggestion. The book is then divided into 4 sections with corresponding hour-long discussions that occur quarterly throughout the residency year. The residency program directors (RPDs) and co-RPDs lead the initial discussion, and each PGY2 resident leads 1 of the subsequent 3 discussions. Based on resident feedback, the leadership book club is an innovative and effective strategy to incorporate leadership training and development into residency training. Conclusion: It is imperative to foster the development of leadership skills in pharmacy residency programs to prevent a future leadership gap in health system pharmacy. Leadership book club is a unique strategy to incorporate leadership training longitudinally across multiple PGY2 residency programs at a single institution.

Overuse of proton pump inhibitors for stress ulcer prophylaxis in Jordan.

To determine the frequency of inappropriate proton pump inhibitor (PPI) prescriptions during hospitalization for stress ulcer prophylaxis on the general medical ward in a tertiary Jordanian hospital. A retrospective chart review was executed on 236 patient admissions prescribed any PPI in a tertiary Jordanian hospital. For each patient, a detailed range of demographic and clinical variables was recorded. Patient's clinical variables were clustered into major vs. minor criteria for using PPIs in stress ulcer prophylaxis according to the American society of health-system pharmacists' (ASHP) therapeutic guidelines on stress ulcer prophylaxis. The 236 patients (51% females) had a mean age of 52 ± 18.1 years. Approximately 56% of the patients were using PPIs before admission. All our patients started PPI use for stress ulcer prophylaxis. Of these, 86% were unnecessary and should be avoided since they do not have at least 1 major or 2 minor indications. Previous PPI use before admission or the presence of one risk factor for stress ulcer motivated initiation of therapy predominately. Recent gastrointestinal (GI) ulcer/bleeding (23%) and coagulopathy (8%) were the main major indications. High-dose corticosteroid (24%) was the most frequent minor indication. The high frequency of inappropriate PPI prescriptions in stress ulcer prophylaxis for inpatients is a major issue in Jordan. Following the current recommended therapeutic guidelines of stress ulcer prophylaxis could minimize the overuse of PPIs in inpatient settings and thus decrease both the possible safety issues of PPIs and the economic burden on the health-care system.

A 4-year study of the correlation between numbers of clinical rotations completed before ASHP midyear to being selected for a residency

PurposeCompetition for pharmacy residencies has drastically increased in the past decade. It is not known if there is a correlation between the number of clinical advanced pharmacy practice experiences (APPEs) completed before the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting (Midyear) and an increased likelihood of matching to a residency program. Exposure to clinical experiences has many benefits. We examined here if there is a relationship between the number of clinical APPEs completed prior to Midyear and overall, and matching for a PGY1 residency in the University of Maryland School of Pharmacy Classes of 2012–2015. MethodsBoth the type and timing of APPEs for 238 students in the identified cohort who applied for residencies were analyzed. Statistical analyses were performed to determine if there is a significant effect of the number of clinical APPEs completed prior to Midyear, or an effect of the number of clinical APPEs completed during pharmacy school on matching for a PGY1 residency. ResultsThere was no significant effect of the number of clinical APPEs completed before Midyear on matching for a PGY1 residency (p = 0.214). The total number of clinical APPEs completed by graduation had no significant effect on matching for a PGY1 residency (p = 0.240). ConclusionWhile students may find great value in clinical APPEs as a strong foundational base for pursuing a PGY1 residency, there was no significant effect of the timing of clinical APPEs and matching to a residency. Further study into other contributing variables is warranted.

Impact of Pharmacy Residency Research Training on Residents’ Actual Versus Perceived Ability and Interest to Identify and Solve Practice-Related Problems

Purpose: The American Society of Health-System Pharmacists (ASHP) requires that accredited residency programs provide pharmacy residents the opportunity to perform a practice-based project. The objective of this study was to evaluate the impact of pharmacy residency research training on residents’ actual versus perceived ability to solve practice-related problems in their professional careers. Methods: This cross-sectional study surveyed postgraduate year 1 (PGY1) pharmacy practice residents who completed training at a large academic medical center between 2007 and 2013. The survey consisted of 3 areas of assessment, that is, (1) general demographics, (2) perceived research abilities, and (3) self-reported research productivity. Results: A total of 39 residents were eligible; of those, 27 completed the survey (69.2% response rate). Participants reported low perceived ability for conductance of some research activities including study design development, implementation, and publication. No association between perceived research ability and self-reported research productivity was found. Research experience prior to residency training strongly predicted for subsequent publication after completion of PGY1 residency training (P < .0001). Conclusions: New training mechanisms may be needed to optimize research training that will provide residents with greater emphasis on areas of perceived deficiency.

Professional Organizations for Pharmacy Students on Satellite Campuses

Objective. To evaluate the structure and impact of student organizations on pharmacy school satellite campuses. Methods. Primary administrators from satellite campuses received a 20-question electronic survey. Quantitative data analysis was conducted on survey responses. Results. The most common student organizations on satellite campuses were the American Pharmacists Association (APhA) (93.1%), American Society of Health-System Pharmacists (ASHP) (89.7%), Christian Pharmacists Fellowship International (CPFI) (60.0%), state organizations (51.7%), and local organizations (58.6%). Perceived benefits of satellite campus organizations included opportunities for professional development, student engagement, and service. Barriers to success included small enrollment, communication between campuses, finances, and travel. Conclusion. Student organizations were an important component of the educational experience on pharmacy satellite campuses and allowed students to develop professionally and engage with communities. Challenges included campus size, distance between campuses, and communication.

Impact of the Pharmacy Practice Model Initiative on Clinical Pharmacy Specialist Practice.

This paper describes the goals of the American Society of Health-System Pharmacists' Pharmacy Practice Model Initiative (PPMI) and its recommendations for health-system pharmacy practice transformation to meet future patient care needs and elevate the role of pharmacists as patient care providers. PPMI envisions a future in which pharmacists have greater responsibility for medication-related outcomes and technicians assume greater responsibility for product-related activities. Although the PPMI recommendations have elevated the level of practice in many settings, they also potentially affect existing clinical pharmacists, in general, and clinical pharmacy specialists, in particular. Moreover, although more consistent patient care can be achieved with an expanded team of pharmacist providers, the role of clinical pharmacy specialists must not be diminished, especially in the care of complex patients and populations. Specialist practitioners with advanced training and credentials must be available to model and train pharmacists in generalist positions, residents, and students. Indeed, specialist practitioners are often the innovators and practice leaders. Negotiation between hospitals and pharmacy schools is needed to ensure a continuing role for academic clinical pharmacists and their contributions as educators and researchers. Lessons can be applied from disciplines such as nursing and medicine, which have developed new models of care involving effective collaboration between generalists and specialists. Several different pharmacy practice models have been described to meet the PPMI goals, based on available personnel and local goals. Studies measuring the impact of these new practice models are needed.

No Shot: US Vaccine Prices and Shortages

In 2004 an Institute of Medicine report warned of vaccine shortages, raising concerns about disease outbreaks. More than a decade later, we looked for progress in reducing vaccine shortages. We analyzed data on vaccine sales and shortages reported by practitioners and patients to the Food and Drug Administration and the American Society of Health-System Pharmacists in the period 2004–13. We found that the number of annual vaccine shortages peaked in 2007, when there were shortages of seven vaccines; there were only two shortages in 2013. There were no shortages of vaccines with a mean price per dose greater than $75 during the study period. Furthermore, we found that a 10 percent increase in price was associated with a nearly 1 percent decrease in the probability of a shortage. Government payers should carefully consider the benefits of averting shortages when evaluating prices for vaccines, including older vaccines whose prices have been subject to congressional price caps.

Advancing Professional Development Through Virtual Mentoring.

*PGY1 Pharmacy Practice Resident, University of North Carolina Health Care, Chapel Hill, NC; †Critical Care Pharmacist, Medical Intensive Care Unit/Pulmonary, Assistant Professor (Adjunct), College of Pharmacy, University of Kentucky HealthCare, Lexington, KY. Corresponding author: Timothy D. Lewis, PharmD, University of North Carolina Health Care, 101 Manning Drive, CB #7600, Chapel Hill, NC 27514; phone: 984-974-1701; e-mail: timothy.lewis@unchealth.unc.edu To the Editor: Advances in technology have made it possible to communicate in real time with individuals, regardless of geographic location. With these advances, mentorship has taken on new forms, including virtual mentorship, which allows individuals in different networks to connect instantly. It is logical for pharmacists and trainees to leverage technology and embrace virtual mentorship as a viable mechanism of professional development and networking. Numerous professional organizations, including the American Society of Health-System Pharmacists (ASHP) and the American College of Clinical Pharmacy (ACCP), offer opportunities for students and residents to connect with pharmacists across the country and electronically establish a mentoring relationship. It is easy to see the potential value this type of program offers to students and new practitioners who are interested in pursuing residency, developing their professional practice, or searching for other postgraduate opportunities as positions become increasingly competitive. The electronic mentor match programs allow students and new practitioners to create a profile, then search and request a specific mentor based on their professional interests. Establishing a mentoring relationship with a stranger may feel uncomfortable for some, but the potential benefit is worth any transient uneasiness. One of the most valuable services a mentor can provide to a student or new practitioner is a different perspective. Having a mentor in a different region, institution, or area of practice encourages a mentee to consider alternative viewpoints and ways to accomplish tasks. For example, whereas one institution may teach a certain format for presenting a journal club, a mentor outside this environment may have a different method that offers the mentee an alternative way to convey the information. A different set of eyes on a curriculum vitae (CV) can give insight into whether the CV is descriptive enough for individuals outside the school of pharmacy or health care facility’s local faculty and preceptors who are familiar with the mentee’s activities. In addition, a mentor who is external to the mentee’s sphere of influence can be a tremendous resource for expanding the mentee’s professional network. This connection could prove invaluable as the mentee applies for residency or employment, becomes involved in professional committees, or seeks to implement change in their school or workplace. Similar to many other endeavors, the success of a mentoring relationship is contingent on a strong foundation being established on a clear purpose. The mentee should allocate time to reflect on what he or she would benefit from at that specific point in their career and identify genuine needs, which will fuel conversations with mentors. One of the most helpful conversations in establishing purpose is to discuss goals for the mentorship relationship. Although they will vary for each pair, common goals include the following: expand professional network, take steps to become a more competitive residency or employment candidate, and learn ways to prepare for residency applications and/or interviews. It is wise to make these goals as specific as possible, however, they should not serve as a checklist of tasks to complete. Rather, these goals should be expanded upon throughout the relationship in order to further strengthen the mentorship and benefits gained from the experience. The mentor may assist in the creation of additional goals and topics to discuss based on their understanding of the mentee’s shortand long-term goals. Mentorship is most often a process that continues over an extended period of time. By exchanging dialogue multiple times on important topics, the pair can ensure that a well-rounded and thoughtful discussion takes place. The most vital action a mentee can take is to ensure regular communication with the mentor. Taking initiative and being proactive in maintaining the connection is a sign to the mentor that the mentee seeks to optimize the relationship. Once

A national survey of emergency pharmacy practice in the United States

The results of a survey to characterize pharmacy practice in emergency department (ED) settings are reported. An electronic survey was sent to all members of the American Society of Health-System Pharmacists' Emergency Medicine Connect group and the American College of Clinical Pharmacy's Emergency Medicine Practice and Research Network. Approximately 400 nontrainee pharmacy practitioners were invited to participate in the survey, which was open for 30 days. Descriptive statistics were used for all analyses. Two hundred thirty-three responses to the survey that were at least partially completed were received. After the removal of duplicate responses and null records, 187 survey responses were retained. The majority of respondents were from community hospitals (59.6%) or academic medical centers (36.1%). A pharmacist's presence in the ED of more than eight hours per day on weekdays and weekends was commonly reported (68.7% of respondents); 49.4% of institutions provided more than eight hours of coverage daily. Nearly one in three institutions (34.8%) provided no weekend ED staffing. The most frequently reported hours of coverage were during the 1 p.m.-midnight time frame. The distribution of ED pharmacist activities, by category, was as follows (data are median reported time commitments): clinical, 25% (interquartile range [IQR], 15-40%); emergency response, 15% (IQR, 10-20%); order processing, 15% (IQR, 5-25%); medication reconciliation/history-taking, 10% (IQR, 5-25%); teaching, 10% (IQR, 5-15%); administrative, 5% (IQR, 3-10%); and scholarly endeavors, 0% (IQR, 0-5%). Pharmacists from academic and community EDs perform a variety of clinical, educational, and administrative activities.

Determining the Need for Standardized Infusions and Concentrations at Hospitals within North Carolina.

In 2013, the American Society of Health-System Pharmacists (ASHP) endorsed a policy recommending the development of nationally standardized drug concentrations and dosing units. Although many hospitals have started standardizing their intravenous (IV) solutions, few have taken the practice beyond their institutions or local geographical areas. This project evaluates the current IV standardization practices for adult patients across hospitals in North Carolina and compares them with each other. In addition, this project proposed standards and evaluated them for their impact on reducing observed variability. In the fall of 2013, an e-mail request was sent to select hospital pharmacy leaders in North Carolina asking them to voluntarily submit a copy of their adult IV standard concentrations and dosing guidelines. From these lists, the data were summarized and compiled to evaluate trends and compare the various policies. A total of 18 different hospitals and health systems responded. Survey results showed more than 255 concentrations for 84 unique drugs. Of these, 37 were high-risk medications, with 135 unique drug concentrations. From this list, a single proposed concentration was developed for each medication. If utilized, this standardization would result in a greater than 65% reduction in potential drug concentrations in use. A single dosing unit was also proposed for all medications reviewed, resulting in a greater than 21% reduction in variation. Standardization of IV drug concentrations and dosing units statewide could reduce the variability in IV therapies and promote safer and more consistent practices in medication administration.

New VTE Guidelines Favor NOACs Over Warfarin

New VTE Guidelines Favor NOACs Over Warfarin

Optimizing the Clinical Use of Vancomycin.

The increasing number of infections produced by beta-lactam-resistant Gram-positive bacteria and the morbidity secondary to these infections make it necessary to optimize the use of vancomycin. In 2009, the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Disease Pharmacists published specific guidelines about vancomycin dosage and monitoring. However, these guidelines have not been updated in the past 6 years. This review analyzes the new available information about vancomycin published in recent years regarding pharmacokinetics and pharmacodynamics, serum concentration monitoring, and optimal vancomycin dosing in special situations (obese people, burn patients, renal replacement therapy, among others). Vancomycin efficacy is linked to a correct dosage which should aim to reach an area under the curve (AUC)/MIC ratio of ≥400; serum trough levels of 15 to 20 mg/liter are considered a surrogate marker of an AUC/MIC ratio of ≥400 for a MIC of ≤1 mg/liter. For Staphylococcus aureus strains presenting with a MIC >1 mg/liter, an alternative agent should be considered. Vancomycin doses must be adjusted according to body weight and the plasma trough levels of the drug. Nephrotoxicity has been associated with target vancomycin trough levels above 15 mg/liter. Continuous infusion is an option, especially for patients at high risk of renal impairment or unstable vancomycin clearance. In such cases, vancomycin plasma steady-state level and creatinine monitoring are strongly indicated.

Pharmacy technician accreditation standards updated

P technician accreditation standards have been updated by the American Society of Health-System Pharmacists (ASHP) and the Accreditation Council for Pharmacy Education (ACPE) boards of directors to expand flexibility in training programs to meet the requirements of different experiential practice settings and compounding activities. ASHP and ACPE adopted the new standards on the recommendation of the Pharmacy Technician Accreditation Commission (PTAC). The changes took effect on January 1.

Quality Improvement Initiative and Safety of Insulin Pen Usage in a Small Hospital.

The Institute for Safe Medication Practices (ISMP) has stressed the need for hospitals to re-evaluate their methods of insulin delivery in an effort to minimize complications of insulin pen use. Improper use of insulin pens can lead to adverse effects, such as hypoglycemia or blood-borne infections. This study was an American Society of Health-System Pharmacists (ASHP) quality improvement activity focused on insulin pen safety in the hospital. The objective of this study was to improve insulin pen delivery and patient health and to reduce adverse effects related to insulin pen use. The purpose of the impact activity was to utilize pharmacist experts to evaluate processes related to the use of insulin pens within the hospital and then implement quality improvement efforts to address potential safety concerns. Baseline and postintervention questionnaires were administered to all nursing personnel (N = 400) to assess their analytical and procedural knowledge regarding insulin pen use and administration. Insulin administration observations and insulin pen storage and labeling audits were also conducted at the same time points in 3 patient care areas where insulin administration was common. Process improvements were made after the baseline data were collected. An overall improvement in insulin pen use was determined after implementation of the quality improvement plan. The greatest improvements were seen for insulin pen administration. The proper storage of insulin pens had 69% compliance at baseline that rose to 98% compliance post intervention, an improvement of 29% (P < .01). Similarly, compliance with the return of insulin pens to proper storage areas increased by 16%, from 78% at baseline to 94% post intervention (P < .05). An improvement in insulin pen usage was promoted by a quality initiative in a small hospital setting. Periodic education about safety procedures along with yearly reviews for all nurses will improve the ongoing safety of insulin pen usage within the hospital.

No Shot: US Vaccine Prices And Shortages.

In 2004 an Institute of Medicine report warned of vaccine shortages, raising concerns about disease outbreaks. More than a decade later, we looked for progress in reducing vaccine shortages. We analyzed data on vaccine sales and shortages reported by practitioners and patients to the Food and Drug Administration and the American Society of Health-System Pharmacists in the period 2004-13. We found that the number of annual vaccine shortages peaked in 2007, when there were shortages of seven vaccines; there were only two shortages in 2013. There were no shortages of vaccines with a mean price per dose greater than $75 during the study period. Furthermore, we found that a 10 percent increase in price was associated with a nearly 1 percent decrease in the probability of a shortage. Government payers should carefully consider the benefits of averting shortages when evaluating prices for vaccines, including older vaccines whose prices have been subject to congressional price caps.

Adherence to stress-related mucosal damage prophylaxis guideline in patients admitted to the Intensive Care Unit.

Objective:Concern about adverse effects of the inconsistent use of stress-related mucosal damage prophylaxis in intensive care unit (ICU) is increasing. Hence, this study was designed to prospectively evaluate the rate of inappropriate stress ulcer prophylaxis (SUP) administration upon ICU admission, at ICU discharge and determine the adherence to American Society of Health-System Pharmacists (ASHP) guideline during ICU stay.Methods:In this study, 200 patients were randomly selected from all ICU admissions during 9 months. Risk factors of stress ulcer were recorded daily during ICU stay and appropriateness of SUP administration was assessed according to the ASHP criteria.Findings:Of all 160 (80%) patients who received SUP, 44.4% did not have indication; and among 95 patients with an indication for SUP administration, 6.3% did not receive it upon ICU admission. Consequently, 77 (38.5%) of 200 patients received inappropriate prophylaxis on ICU admission. In addition, 53.5% of patients had appropriate adherence to ASHP guideline during all days of ICU stay (44% and 2.5% of patients received SUP more than 120% and <80% of appropriate SUP duration, respectively). Moreover, 81.2% were continued on inappropriate prophylaxis upon transfer from the ICU.Conclusion:We concluded that although SUP administration included both overutilization and underutilization in this ICU, but high prevalence of SUP overutilization caused unnecessary hospital costs, personal monetary burden, and may increase adverse drug reactions. Therefore, educating physicians and cooperation of clinical pharmacists regarding implementing standard protocols could improve patterns of SUP administration.

Attachment to stress ulcer prophylaxis guideline in the neurology wards of two teaching and non-teaching hospitals: A retrospective survey in Iran.

Objective:In this study, we aimed to evaluate the attachment to stress ulcer prophylaxis (SUP) guideline in the neurology wards of two teaching and nonteaching hospitals.Methods:A total of 243 patients were retrospectively reviewed in the neurology wards of two teaching and nonteaching hospitals. To assess the appropriate administration of SUP, an internal guideline was prepared using the American Society of Health-System Pharmacists (ASHP) protocol.Findings:SUP prescriptions were noncompliant with ASHP guideline in about 93.1% and 84.6% of cases in the nonteaching and teaching hospitals, respectively.Conclusion:SUP may be better practiced in teaching hospitals versus nonteaching ones.

病院薬剤師の職務満足度に関する多施設アンケート調査

Employee job satisfaction is strategically important to hospital organizations. However, current job satisfaction in Japanese hospital pharmacists has not been clarified. To examine the job satisfaction of hospital pharmacists, we conducted a questionnaire survey on 194 hospital pharmacists at eight hospitals in Kitakyushu-Chikuho, Fukuoka district.The job satisfaction instrument, which is structured on 12 job satisfaction facets and global job satisfaction, developed by the American Society of Health-System Pharmacists was used, and each satisfaction item was evaluated using a 5-point Likert scale. A total of 154 responses were used for analysis. As a result, more than half of the hospital pharmacists reported being highly satisfied (defined as score of 4 or 5) in terms of global job satisfaction. In the multiple regression analysis with all of the facet scores as independent variables and global job satisfaction as the dependent variable, the four most important job satisfaction facets associated with global job satisfaction were Management (t-statistic 3.91), Community (3.05), Pay (2.61), and Staffing (-3.80). In the logistic regression analysis with respondent characteristics as independent variables and highly satisfied measure as the dependent variable, hospital bedsize, gender and pharmacy specialist/certified pharmacist were most often significantly associated with being highly satisfied with a job satisfaction facet.These findings may provide useful information to improve job satisfaction in Japanese hospital pharmacists.