PHRM 251 UPDATED QUESTIONS WITH COMPLETE SOLUTIONS

1. Tips for delivering a successful oral report? - ANSWER 1) Systematic and organized 2) Look up things that are unknown to you 3) Highlight abnormal findings 4) prioritize problems list (ACUTE, THEN CHRONIC) 5) Make executable recommendations 6) Be prepared to answer questions 2. Define: Inpatient care - ANSWER Medical care where pateitns have at least one overnight stay at a medical institution for ongoing treatment and monitoring. 3. Acute Care Hospital - ANSWER patient admitted for treatment over a short period of time WHY? -> 1) assessment/treatment/monitoring not able to be done as outpatient HOW? Publically funded ; operated under regional HA. GOAL? To discharge patients out of facility as soon as they are medically stable Ex: Teaching/community/rural hospitals 4. Long-Term Care - ANSWER Patients admitted to facility for ongoing 24 hour care WHY? Patient unable to be cared for in their own home/assisted living. HOW? Publically funded/subsidized under regional HA , OR privately operated. GOAL? Transition back home, OR, indefinite management of the patient. EX: Residential care facility/hospital, high-intensity rehabilitation centre, tertiary mental health institution, hospice. 5. Teaching Hospitals/tertiary - ANSWER Associated with a medical school Higher involvement in training of HCPs Contain highly-specialized patient care areas serve as research institutes Eg bc Vancouver general, St. Paul's,rch 6. Community/Rural Hospitals - ANSWER Serve a region Fewer speciality services compared to teaching hospitals May not have as many integrated healthcare teams 7. 5 regional HA's in BC? - ANSWER 1) FHA 2) Northern Health 3) Vancouver Coastal Health 4) Interior Health 5) Island Health 8. Ministry of health is head - ANSWER 1. PHSA (works with regional health authorities to coordinate provincial programs) - REGIONAL HEALTH AUTHORITY 2.FNHA 9. Patient pathway through acute care (inpatient) - ANSWER 1) arrive to ER 2) Assessment in ER/Triage 3) Admission (as required) 4) Healthcare interventions (i.e., treatment) 5) Discharge (when patient is stable) 10. Patient care goals in ACUTE setting - ANSWER 1) To send patients home to be managed independantly. Treat patient and stabilize medical issues Improve patient functionality to baseline Initiation of care plans to prevent readmission. 11. Attending Physician/Most Responsible Physician (MRP) - ANSWER Responsible for Dx and overall direction of patient care 12. Inpatient = admitted under the attending physician/primary medical team 13. Physicians in Training - ANSWER 1) Med students (MS 3,4) not yet completed degree 2) Resident (R1-5) degree completed in residency training 3) Fellow (residency completed, training to become expert specialist) 14. Consult services - ANSWER Physician specialist in a topic area, providing expert opinion/diagnostics, and treatment recommendations to the primary medical team 15. May "sign-off" patient when consult request is resolved. 16. Care Management Leader (CML) / Patient Care Coordinator - ANSWER RN responsible for coordinating patient care disposition (how it is operated) Ex: Transfers, discharges, liaising with community services 17. Charge Nurse - ANSWER RN responsible for coordinating and supervising nursing services 18. Patient Care Nurse - ANSWER All aspects of daily patient care (med administration, monitoring of patient progress) 19. Allied HCPs - ANSWER RPh SW PT/OD RD SLP Recreational Therapist 20. Unit Clerk - ANSWER Clerical/administrative support for all patient care activities Submits and coordinates orders for investigations/tests/meds Manages communications with external groups (ex: consult note requests, sending discharge documents) 21. RPhT - ANSWER Many roles Clinical: Report compilation, Med Recs 22. RPh roles and duties in acute inpatient setting - ANSWER ID & resolve DTPs Approve/Verify DPOs Respond to DIR Manage dispensary workflow Enter & progress Medication Ordrs Prepare products Final prodcut check Inventory purchase/receiving Delivery of medications to patient ward 23. RPhT - ANSWER All of the above, EXCEPT: 1) ID/resolve DTP 2) Approve/verify DPOs 3) Responding to DIR 4) Managing dispensary workflow 24. Pharmacist roles - ANSWER Grade 1 primary dispensary Grade 2 primary clinic, some responsibility dispensing, 1 year residency Grade 3 clinical pharmacy specialist, year 1-2 residency Grade 4/5 clinical and or dispensary coordinator (supervisor), year1/2 residency, MBA 25. Drug Distribution Processes in acute care inpatient settings - ANSWER 1) Pharmacy receives copy of medication order from ward 2) Order = entered 3) RPh reviews patient profile and order for the DTP 4) Medication label = generated ; medication is made available for the nurse to administer. 26. Inpatient Medication Supply Considerations: - ANSWER !) Is the medication available (formulary? in stock?) 2) Does the medication need to be sent from DISPENSARY? ward stock? -> readily available for nursing access Patient specific? send from dispensary/automated dispensing system 3) How quickly does medication need to be sent? STAT/URGENT: Must deliver first (ex: IV ABX in septic patient) ROUTINE: Make available by the next scheduled dosing time. 27. Clinical Pharmacy Services - ANSWER 1) Comprehensive patient workup 2) Targeted clinical pharmacy services 28. (TDM, renal dose adjustments, ABX stewardship, PO stepdown, warfarin dose adjustments) 3) Continuity of Care 29. (Med Recs, Discharge Medication Planning and Arrangement) 4) Education (services and presentations to staff Educational presentations to visiting public practice education of pharmacy students/residents Conducting research projects) 30. What are the different ways that drugs may be supplied for use in hospital dispensary? - ANSWER 1) Unit-dose (individiually labelled PO doses sent for each patient) 2) Automated Unit Dose STrips - Strip of meds ; pouch containing all medications for a specific tiem of administration for a specific patient 3) Automated Dispensing Systems (Electronic cabient locker - provides timely medication access, reduces dispensary workload, reduces med errors, tracks med access/usage) 4) Parenteral services IV medications (preparation of med doses in IV fluid bag) TPN (macro/micro-nutrients for patients where enteral feeding is inappropriate) Parenteral chemotherapy - for administration in specialized oncology care area) 31. How does a clinical pharmacist prioritize patient care? - ANSWER Dispensary services = core function of hospital pharmacy services. 32. Main limiting factor for Inpatient Clinical Pharmacy Services? - ANSWER Resource and Staffing constraints 33. Other limiting factors? - ANSWER 1) Academic teaching hospital vs community/rural hospital 2) Type of care setting (acuity of patients, type of ward) 34. Pharmacists must find balance between... ______ and ______. - ANSWER 1) comprehensive care for all 2) Reactive care 35. Comprehensive Pharmaceutical Care - ANSWER 1) full work-up, BPMH 2) Daily drug therapy review and monitoring 3) Daily patient assessment and education 4) Proactive drug therapy interventions 5) Discharge planning and counselling 36. Reactive Pharmacy Care - ANSWER "must-do's" ex: Troubleshooting of problem orders ; responding to urgent requests for pharmacy involvement. 37. What shifts Clinical Pharmacy from Comprehensive Care TOWARDS Reactive Care? - ANSWER 1) Increasing patient workload 2) Staffing shortages 3) Competing demands (dispenary duties, administrative duties, teaching, research) 38. How does RPh prioritize their work? - ANSWER 1) TROUBLE SHOOTING ORDERS = #1 2) Clinical Pharmacist-Identified Issues 39. What are trouble shoot orders? - ANSWER -> Orders flagged by dispensary that require involvement/resolution by clinical pharmacist 40. HIGH PRIORITY beacuse the patient may not receive a required medication until the pharmacist assesses therapy or resolves the issue. Ex: - nonformulary medications -unclear orders - orders that require clinical pharmacist follow-up - consults/other requests for clinical pharmacist involvement. 41. SA requests, counselling, IV medication compatibility... 42. Daily medication Profile Review - ANSWER Pharmacist reviews pt's medications profile daily to identify potential and actual DTPs (all patients) 43. Health Care Record Review - ANSWER RPh reviews pt's chart/labs/pharmanet/other records to ID potential/actual DTPs 44. (all/most patients) 45. Focused Patient Interviews - ANSWER RPh interviews patients to clarify and resolve DTPs identified through other methods (PRN) 46. Comprehensive Care - ANSWER RPh identifies selected patients to receive more comprehensive care... e.g., those with multiple DTPs, complex drug therapy, and very elderly patients. (As many as possible) 47. Type of drugs that may be seen on computer-generated target drugs report? - ANSWER 1) Broad-spectrum ABX 2) High-risk drugs (Digoxin, Warfarin) 3) TDM-requiring meds (Vanco/AMG/PHT/CBX/Tacrolimus) 4) Expensive medications 5) IV medications that may be stepped down to PO alternatives (ex: PPI, ABX) 6) Non-formulary medications listed as "medication not available" 48. Specialized reports - ANSWER Computer-generated reports combining drug/lab/other to make it easier to identify DTPs. ex: - Renal dosing report - Drug level report - Positive C. Diff toxin report - Warfarin/INR report 49. What is the rationale for "Targeted Pharmacy Services"? - ANSWER Intended to provide a consistent approach and reliable service in regards to some specific high-priority drug therapy issues. 50. RATIONALE: 1) Pharmacists are uniquely equipped to provide the service (or assess/resolve DTPs) 2) All patients with target drug therapy issue in question will receive a similar approach/level of service by the pharmacy. 51. What are 3 examples of Targeted Pharmacy Services? - ANSWER 1) TDM 2) Renal dosing service Pharmacists dose-adjust all renally-eliminated medications for ALL PATIENTS WITH eGFR < 50mL/min RPh has authority to independantly change dose +/- interval for medications to account for renal functoin 3) ABX stewardship 4) PO stepdown 5) Warfarin dosing services 52. Key considerations related to renal dose adjustment of medications? - ANSWER 1) Are the medications indicated? 2) Is renal function acutely changing? (what is the patient's baseline renal function? is the patient's current renal function worsening or improving? is the change in renal function due to a reversible insult?) 3) Is a dose adjustment necessary? (risk of under-dosing? Risk of accumulation?) 53. eGFR vs CrCl? - ANSWER eGFR = lab-calculated ; reported along with SCr. 54. CrCl: Hand-calculated Most drug dosing tables are based on CrCl (hence - use CrCl for renal dose adjustment) 55. Define: Antimicrobial Stewardship - ANSWER The practiceo f minimizing emergence of ABX-resistant organisms by using ABX only when necessary, and selecting appropriate ABX at right dose/frequency/DOT to opimize outcomes, while minimizing ADE's. 1) Recommend ABX with narrowest spectrum of activity (based on likely empiric organisms OR on C&S data) 2) D/C ABX when no longer indicated OR when adequate course of Tx completed 3) PO stepdown at earliest feasible opportunity. 56. When is PO stepdown NOT APPROPRIATE? - ANSWER 1) acute illness 2) No PO formulation available 3) 100% F(PO) required for achievement of maximum tissue concentration 4) Patient NPO 57. Downsides of parenteral medications? - ANSWER 1) Invasive (injectable...) 2) risk of infection/complication 3) Patient comfort/mobility 4) Delayed discharge 5)$$$ 58. When is PO stepdown FEASIBLE? - ANSWER 1) Continued requirement of a particular ABX 2) Patient = clinically stable 3) Patient = able to tolerate PO dosage form 4) Patient has NO GI ABNORMALITIES/DDI that would adversely affect F(PO) 59. Group 1&2 drugs - ANSWER pharmacist may independantly initiate PO stepdown. Group 1: Similar AUC achieved between PO and IV dosage forms. Group 2: Lower AUC achieved with PO dosage form compared to IV ; patient must be clinically improving prior to stepdonw. 60. AHFS-DI (American Hospital Formulary Service - Drug Information) - ANSWER Most comprehensive evidence-based drug information reference 61. Therapeutic guidelines, off-label use, citations *best for: most comprehensive drug information resource - complex dosing, off-label use* 62. DynaMed - ANSWER Online All information contained in one place. Epidemiology, Etiology/Pathophysiology, Dx/Assessment, Management *Best for: In-depth diagnostic and treatment information on a clinical topic* 63. UpToDate - ANSWER - Referenced primary/tertiary sources & guidelines - Drug monographs from Lexi-Drug *Best for: In-depth diagnostic and treatment on a clinical topic* 64. Basic Skills in Interpreting Lab Data - ANSWER - Lab information from pharmacist perspective - Reference ranges reported in the USA (may need to convert to SI units) *Best for: Laboratory data information and information* 65. Handbook of Clinical Drug Data - ANSWER Brief drug monographs, drug comparison charts 66. Drug use in special populations Pregnancy/Lactation/Pediatrics/Geriatrics 67. Information on drug-induced diseases *Best for: Special populations & Drug-induced diseases - drug specific clinical information* 68. Sanford's Guide to Antimicrobial Therapy - ANSWER updated yearly ; use in conjunction with hospital-specific antibiogram (if available) WHY? USA RESISTANCE PATTERNS. 69. *Best for: All things antimicrobial related* 70. Bugs and Drugs - ANSWER OLD CANADIAN Sections divided by colour: Yellow = antibiotics Blue = treatment Orange = prophylaxis Purple = dentistry Red = pregnancy/lactation Green = organisms *Best for: All things antimicrobial related* 71. Spectrum [app] - ANSWER App with local antibiotic resistance data Hospital-specific Antimicrobial stewardship guidelines Dosing information 72. Handbook on Injectable Drugs - ANSWER Injectable Drug Reference ; updated every 3 years 73. Provides information (for parenteral drugs) on: - compatibility - stability - storage and preparation *Best for: Parenteral drug questions* 74. Parenteral Drug Therapy Manual - ANSWER - parenteral monograph [compatibility, stability, preparation, indications, toxicities, interactions, adverse reactions] 75. Ordering restrictions and parenteral administration that are SITE/WARD-specific [SC/IM max doses, IVB, etc.] *Best for: institutional parenteral policies* 76. BC Cancer Website - ANSWER - online - cancer drug manual (drug-specific) - cancer drug protocols (protocol-specific) - patient information (can also be printed) 77. *Best for: All information that is cancer/chemotherapy-related* 78. Lexi-Comp ONLINE - ANSWER Drug-specific ; therapeutic information Lexi-Drugs and AHFS-DI monographs Lexi-Interact DDI Lexi-Drug ID (medication identification tool) Trissel's IV compatibility Toxicology ; pregnancy/lactation 79. Patient education available in many languages. *Best for: Point of care quick searches* 80. Drug Prescribing in Renal Failure - ANSWER - Online/Paper - Dose adjustments for renal failure and HD/PD patients. DRUGS GROUPED BY CLASS 81. *Best for: Most comprehensive renal adjustment of drugs* [A]: Human trials larger than a case study [B]: Human case study [C]: In-vitro data [D]: Author's educated assessment based on PKPD of the drug. 82. Louisville Kidney Disease Program - ANSWER website for renal dose adjustments 83. Providence Health Care () - ANSWER website for renal dose adjustments Created by BC nephrology pharmacists at providence health 84. Outpatient - ANSWER a medical setting in which patients receive care but are not admitted (community pharmacy and primary care clinic)- funded independent or corporate owner 85. Group 3 Drugs - ANSWER No PO alternative available ; drug selection is based on pathogen susceptibility and LACK OF contraindication to the therapeutic alternative. 86. DEFINE: Continuum of Care - ANSWER Attempts to tie-in healthcare team to provide comprehensive care 87. 3 components: 1) Informational 2) Relational 3) Management continuities. 88. 3 components of Continuity of Care are bridged by WHICH TWO CORE ELEMENTS, which BOTH MUST BE PRESENT for continuity? - ANSWER 1) how patients experience care provided by their healthcare providers 2) Care provided over a period of time 89. Define: information continuity - ANSWER Transfer of patient information required to make the appropriate healthcare decisions 90. INCLUDES: Specific data on patient's disease +/- personal values and preferences 91. Define: Management Continuity - ANSWER Established plan of care that is consistent and flexible to the patietn's needs minimizes duplication and conflicting care 92. Define: Relational Continuity - ANSWER Provides the patient with predictability in dealing with HCPs Emphasizes on consistency and coherence of care Allows for development of caring patient-provider relationship ; implies the provider's acceptance of responsibility for the patient's outcomes and satisfactions. 93. WHY is Continuity of Care important? - ANSWER Improved clinical efficacy, patient outcomes, and generally improved HCS pt-centered care. 94. How do pharmacists maintain Continuum of Care? - ANSWER 1) Collaboration to ensure appropriate coordination of care 2) Consideration of other HCPs 3) Understanding roles of HCPs ; working to build a well-functioning team that provides continuity of care 4) Evaluate medications for efficacy/safety 5) Documentation of interventions made 6) Communication of information to relevant HCPs 7) Ensuring patient has adequate med supply on discharge. 95. Define: Med Rec - ANSWER HCPs working together with patient/family/together to ensure accurate med info is communicated across transitions of care 96. Goal: to prevent ADR/ADE ; unintentional discrepancies. 97. Ex: Unintentional addition - HIV medications not ordered on admission b/c not on PharmaNet Ex: International D/C of a med - should DOCUMENT (ex: ACEi upon admission in AKI patient) 98. Outline the stepwise approach on how to facilitate a med rec - ANSWER 1) complete BPMH 2) Reconcile differences. Use BPMH to create admission orders, OR, compare BPMH against admission/transfer/discharge medication orders ; identify/resolve discrepancies. 3) Document and communicate any resulting changes in medication orders to the patient/caregiver/HCP. 99. Medication Reconciliation - ANSWER A PROCESS 100. Often involves >1 HCP 101. BPMH (Best possible medication history) - ANSWER Must be done in order to facilitate proper medication reconcilitation 102. 2 reasons why a Med Rec on discharge is beneficial? - ANSWER 1) Patients are at increased risk of medication discrepancies on discharge 2) Decreased return to ER & decreased readmission. 103. What are the resources you would compare when facilitating a med rec on discharge? - ANSWER 1) BPMH 2) Hospital medications (look at MAR from past 24h) 3) New post-discharge medications. 104. Who is at high-risk of medication discrepancies, and thus should receive Med Rec on DISCHARGE? - ANSWER 1) >5 meds 2) Multiple changes to medication regime 3) pt on high-risk medication (warfarin/insulin/digoxin) 4) Discharge without any home support 5) Dx = cancer/COPD/depression/CHF/stroke 6) Unanticipated hospitalization within the last 6 months 105. What are the 4 components of a Best Possible Medication Discharge Plan? - ANSWER 1) Accurate medication list that patients should be taking on discharge 2) Med info transfer letter to next care provider 3) Structured discharge Rx to next care provider/community RPh 4) patient information grid +/- wallet card 106. Define: Medical Record - ANSWER - Used for planning patient care - communication tool provided by MD/etc - research/education - LEGAL DOCUMENT 107. EMR - ANSWER - computer based ; accessed electronically - better pt care (d/t access) - Reduced duplicate tests/assessments - Improved confidentiality/privachy 108. Traditional Paper Chart - ANSWER Kept in nursing station - DO NOT REMOVE - EXCEPT IF PATIENT IS GOING FOR OPERATION/TEST - CHART WILL FOLLOW PATIENT. 109. What happens with OLD (medical) RECORDS? - ANSWER Patient's paper record = stored with health records When patient = admitted, request is made for old records to be sent to the nursing unit 110. Importance of OLD RECORDS for RPh? - ANSWER HIstorical therapeutic drug levels and response to therapy 111. Verification of drug allergy and timelines. 112. DEFINE: Thinned Charts - ANSWER If a patient's hospital stay is VERY LONG - may remove some old charts (to facilitate management of records) 113. Importance of thinned charts for RPh? - ANSWER - access to old MAR - Access to old patient medication profile 114. Pre-admitting info - ANSWER Patient ID Allergy and Intolerances 115. Admitting data - ANSWER Record of admission (Hx and screening) Consent Interdisciplinary signatures Verification of family MD 116. Prescriber's Orders - ANSWER Allergy and Intolerance (CI/Caution) Prescriber Order form (including PPO) Med Recs Pharmacy patient medication profile 117. History - ANSWER ED record (including ER nurse assessment) Admission note by admitting service (IM/CTU) Pharmanet profile 118. Progress notes - ANSWER Hx and patient progress during admission Consult notes 119. Medication - ANSWER MAR Pain management flow sheet, BG record, anticoagulation record, etc. 120. Nurses' notes and graphic charts - ANSWER Vital signs record Fluid balance and IV therapy nurses' progress notes 121. Interdisciplinary - ANSWER Interdisciplinary referrals Collaborative care plans 122. Diagnostics, labs, and investigations - ANSWER Lab data MICB reports Dx reports (Ex: ECHO, ECG) 123. Surgery - ANSWER Surgical report 124. OTher - ANSWER Transcriptions (discharge summary) *may also be in "hx" 125. Define: Prescriber's Orders (aka DPOs) - ANSWER includes: ALL ORDERS FOR PATIENTS [not just medications] 1) blank ordres 2) PPO Pre-defined ; assist MD in choosing most appropraite care Built with evidence and best practice Approved for use through hospital committee with various stakeholders Often accompanies clinical pathway or practice guideline Saves prescribe from potential errors of re-writing (minimizing communication errors) 126. Pre-operative order - ANSWER All pre-operative orders are CONSIDERED DISCONTINUED FOLLOWING OPERATION. 127. Post-Operative Order - ANSWER All medications that need to be re-ordered post-operatively need to be re-ordrered. 128. POD 0 - ANSWER day of operation 129. POD #1 - ANSWER 1st day after operation (i.e., start med Y 1 day post-op) 130. Define: Automatic Stop Date - ANSWER Pre-determined duration of medication ordres that are programmed by the pharmacy computers system to STOP, *unless* a specific duration is written by the prescriber. Ex: FHA policy = ABX orders written without duration will default to stop after 5 days (EXCEPTION: ARV, anti-TB) 131. Define: Progress Note - ANSWER Note written by healthcare team detailing patient's treatment progress 132. INCLUDE: - name, title of HCP, signature, date, contact number # - SOAP/SBAR format 133. LEGAL DOCUMENT 134. Define: MAR - ANSWER Lists al medications ordered for a patient (BOTH regularly scheduled & PRN) OFFICIAL RECORD of whether a patient received their scheduled dose (HCP administering circles time ; initial beside it) 135. RPh & MAR? - ANSWER MUST LOOK AT MAR DAILY Identify PRNs given the night before Identify if any doses missed/held/not given Identify cumulative doses of medications Identify timing of certain medications (Ex: for assessment of drug levels) 136. Define: Working Up Paitent - ANSWER Capture work-up on an assessment form/patient monitoring form 137. Resources to aid with patient work-up? - ANSWER patient/family/caregiver PharmaNet, patient medication notes Community RPh Family MD Old charts from previous admissions Provincial lab results 138. Define: Reporting your Patient - ANSWER Once patient work-up completed - must REPORT the plan to the practice educator (usually verbal report) 139. Monitoring Plan? - ANSWER EFFICACY, SAFETY. 140. Must be: - pt-specific - appropriate frequency/durations - outlining expected changes - Including quantifiable targets and ranges (ex: lab values, date, and HCP responsible for monitoring) 141. SEPARATE EACH DRUG WITHIN YOUR MONITORING PLAN. 142. What are common pitfalls in a patient report? - ANSWER 1) missing/incomplete data 2) No time 3) illogical flow 4) failure to prioritize issues 5) Lack of executable plan 6) Challenges in communicating rationale