Learning Objectives (cont.) - ACCP

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PRESENTED AT:

2017 Critical Care Preparatory Review and Recertification Course – Critical Care Pharmacy Evolution and Validation, Practice Standards,

Training, and Professional Development

Bradley A. Boucher, Pharm.D., FCCP, MCCM, BCPSUniversity of Tennessee Health Science Center

Memphis, Tennessee

Curtis E. Haas, Pharm.D., FCCP, BCPSUniversity of Rochester Medical Center

Rochester, New York

Workbook Page PRESENTED AT:

Conflict of Interest Disclosures

• Boucher

– Nothing to Disclose

• Haas

– Nothing to Disclose

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PRESENTED AT:

Learning ObjectivesAfter the presentation, the participant should be able to:

1. Describe key landmark events in the evolution of critical care pharmacy as a specialty.

2. Summarize key published documents and evidence validating critical care pharmacy as a specialty for validation to other health care professionals and stakeholders.

3. List the core knowledge areas for pharmacists caring for critically ill patients.

4. Identify the elements of fundamental, desirable, and optimal pharmacist practice and pharmacy service components.

5. Summarize the findings from key studies documenting the association of critical care pharmacy services with favorable health care outcomes.

6. List the criteria for credentialing and training of pharmacists providing critical care services at the desired and optimal levels as outlined in the 2011 ACCP Critical Care PRN Opinion Paper in addition to critical care training opportunities and growth.

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Learning Objectives (cont.)After the presentation, the participant should be able to: 7. Apply the standards of practice for clinical pharmacy to the critical care practice environment

using a standard process of care.8. Develop an approach to conducting a gap analysis relative to the principles and values of

team‐based care in a local critical care practice environment.9. Differentiate between the conventional and nontraditional pathways of training to obtain

knowledge, skills, and attitudes for critical care pharmacy practice.10. Define the key features of a mentor‐mentee (protégé) relationship and the important role of

mentoring in developing and training critical care clinical pharmacists.11. Develop an approach to lifelong professional learning to maintain competency in critical care

pharmacy practice using the principles of continuing professional development.12. Identify the many educational components or techniques that can be incorporated into a

personal development plan.13. Identify the avenues and processes for contributing to the critical care body of knowledge as a

presenter, author, or peer reviewer.

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PRESENTED AT:

SAQ

In what decade did clinical pharmacists begin to establish practices in a wide variety of ICU settings?

A. 1950’s.

B. 1960’s.

C. 1970’s.

D. 1980’s.


SAQ

A. Incorrect

B. Incorrect.

C. Correct. Clinical pharmacists began to establish practices in a wide variety of ICUs in the 1970’s.

D. Incorrect.

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LANDMARK EVENTS IN CRITICAL CARE MEDICINE/PHARMACY.

First ICU: 3 Bed Neurosurgical Unit in Baltimore, MD (1930’s).

First pharmacists assigned to ICUs in a limited number of hospitals (late 1960’s).

Several critical care pharmacists ICU practices established in or around the 1970’s, clinical research conducted in a wide array of therapeutic specialty areas (e.g., pharmacokinetics, infectious diseases, nutrition support, ACLS).

• Cardiovascular ICUs

• Pediatric/neonatal ICUs

• Medical ICUs

• Emergency Medicine

• Trauma

• Surgical ICUs

• Neurosurgical ICUs

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• Formation of Society of Critical Care Medicine (SCCM) with 100 members (1970).

• Multidisciplinary model stressed by founding SCCM President Dr. Max Harry.

• Subsequent inclusion of pharmacist as permanent member of SCCM governing council.

• Emergence of critical care specialty journals and publications.

• Heart and Lung (1972), Intensive Care Medicine (1972)

• Critical Care Medicine (1973), Critical Care Clinics (1984)

• Critical Care Therapeutics Column in Drug Intelligence and Clinical Pharmacy(1982)

• First critical care pharmacy textbook: Critical Care Pharmacy, Majerus TC and Dasta JF, eds. (1985)

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PRESENTED AT:


Formation of critical care pharmacists specialty groups

• SCCM Clinical Pharmacy and Pharmacology Section (1989)

• ACCP Critical Care PRN (1992) (N=2340)

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Learning Objectives1. Describe key landmark events in the evolution of critical care pharmacy (CCP)

as a specialty.

2. Summarize key published documents and evidence validating CCP as a specialty for validation to other healthcare professionals and stakeholders.

3. Summarize the findings from key studies documenting the association of critical care pharmacy services with favorable healthcare outcomes.

4. Outline the major critical care pharmacist activities within the three levels of clinical services as defined by ACCP/SCCM.

5. List the criteria for credentialing and training of pharmacists providing critical care services as outlined in the 2011 ACCP Critical Care PRN Opinion Paper; also outline critical care training opportunities.


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SAQ #2The scope of pharmacy practice within the ICU was outlined by two task forces focused on models of critical care delivery, the definition of an intensivist, and the practice of critical care medicine in 2001. Which organization formed these two task forces?

A. Institute of Medicine (IOM).

B. American College of Clinical Pharmacy (ACCP).

C. American College of Critical Care Medicine (ACCM).

D. Clinical pharmacy and pharmacology section of the Society of Critical Care Medicine (SCCM).


SAQ #2

A. Incorrect

B. Incorrect.

C. Correct. The two task forces were established by the ACCM.

D. Incorrect

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VALIDATION OF CRITICAL CARE PHARMACY AS A SPECIALTY

Chapter Titled “The Role of the Pharmacist in Caring for the Critically Ill Patient,” published in The Pharmacologic Approach to the Critically Ill Patient, 3rd ed., Bart Chernow, ed. (1994).

Publication of “Position Paper on Critical Care Pharmacy Services,” (Rudis MI, BrandlKM, and The Joint SCCM/ACCP Task Force on Critical Care Pharmacy Services, Crit Care Med 2000); establishment of three levels of pharmacy services (Fundamental, Desirable, Optimal) for the provision of pharmaceutical care in critically ill patients.

SCCM recognition of critical care pharmacist as an integral member of the multidisciplinary team along with physicians, nurses and respiratory therapists as outlined by two ACCM taskforces (Brilli RJ, et al. Crit Care Med 2001).

Scope of pharmacy practice within ICU outlined by the two ACCM taskforces; critical care pharmacy and pharmacists services deemed “essential” within Level I critical care centers (Haupt MT, et al, Crit Care Med 2003).

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• Awarding of FCCM status by ACCM: over 80 pharmacists of overall total of 1014 (2015); 6 MCCM (Master of Critical Care Medicine) (2016).

• Receipt of numerous honor and awards by critical care pharmacists within SCCM, ACCM, and ACCP.

• SCCM/ACCM: Distinguished Investigator Award, Shubin‐Weil Master Clinician, Excellence in Bedside Teaching Award, Distinguished Service Award.

• ACCP: Russell R. Miller Award, Paul F. Parker Medal, Clinical Practice Award, Robert M. Elenbaas Service Award, Education Award.

• Creation of the Joseph F. Dasta Critical Care Pharmacy Outcomes Research Grant by the Clinical Pharmacy and Pharmacology Section of SCCM (2000).

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• Leadership roles in major multidisciplinary and pharmacy organizations

• SCCM: President Judi Jacobi (2010).

• ACCP: Presidents Robert Elenbaas, Barbara Zarowitz, Bradley Boucher, Curtis Haas, Judi Jacobi.

Prescriber perceptions of pharmacist provided patient care related clinical functions: decreased efficiencies between 40% and 65% in absence of pharmacy services (Maclaren R, et al., 2013).


CRITICAL CARE PHARMACY GROWTH

SCCM Membership: ∼15,900,CPPMembership∼2377 14.9 %.ACPCriticalCarePRN:∼23402016

Provision of direct patient care services: 62.2% of ICUs responding to hospital survey (MacLaren, et al. Ann Pharmacother 2006;40:612‐8).

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PRESENTED AT:


as a specialty.







SAQ #3

Which best depicts the medical event for which there is a higher mortality in ICUs without clinical pharmacists compared with ICUs with clinical pharmacists been documented?

A. Corrected QT (QTc)‐interval prolongation.

B. Preventable adverse drug interactions.

C. Drug‐drug interactions.

D. Nosocomial‐acquired infections.

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SAQ #3

A. Incorrect: No reduction in mortality related to correction of QTc interval prolongation.

B. Incorrect. No reduction in mortality related to prevention of ADEs.

C. Incorrect. No reduction in mortality in related to decreasing drug‐drug interactions.

D. Correct. Significant reduction in mortality in ICUs with CCPs versus without CCPs.


STUDIES DOCUMENTING THE ASSOCIATION OF CPP SERVICES WITH FAVORABLE HEALTHCARE OUTCOMES

• Reduction in Drug Costs in ICU with Inclusion of a Pharmacist as a Member of the Multidisciplinary Team.

• Medical‐Surgical ICU: annual savings $67,664 in 1994 dollars (Montazeri M and Cook DJ, 1994).

• Neurosurgical ICU: reduction in pharmacy acquisition costs from $4833 to $3239/patient after addition of pharmacist to neurosurgery team; reduction in ICU days from 8.56 to 7.24 days (p=.003) (Weant KA, et al. 2009).

• Numerous other studies in wide range of ICU settings (See Kane S, et al. 2003).

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PRESENTED AT:


• Reduction in Adverse Drug Effects/Drug‐Drug Interactions

• Decreased in preventable adverse drug effects after inclusion of pharmacist on interdisciplinary medical ICU rounds: 66%, p<0.001 (Leape LL, et al, 1999).

• Supported by meta‐analysis (3 studies), OR 0.23 (0.11, 0.48)(J Crit Care 2015).

• Decreased incidence of QTc‐interval prolongation with ICU monitoring by pharmacist using standard algorithm: 19% vs. 39%, p=0.006 (Ng TM, et al. 2008).

• Reduction in drug‐drug interactions by 65% (p < 0.01) in medical ICU with pharmacist (Rivkin A and Yin H, 2011).



• Improvement in infectious diseases morbidity, mortality and costs (MacLaren R, et al. 2008).

• Mortality higher in ICUs without clinical pharmacists compared with ICUs with clinical pharmacists: 23.6% for nosocomial‐acquired infections, 16.2% for community‐acquired infections, 4.8% for sepsis, p < 0.008.

• Length of stay longer for ICUs without clinical pharmacists compared with ICUs with clinical pharmacists: 7.9% for nosocomial‐acquired infections, 5.9% for community‐acquired infections, 8.1% for sepsis, p < 0.03.

• Medicare bills increased patients in ICUs without clinical pharmacists compared with ICUs with clinical pharmacists: 12% greater for nosocomial‐acquired infections, 11.9% greater for community‐acquired infections, 12.9% greater for sepsis, p < 0.001.

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PRESENTED AT:


• Improvement in thromboembolic and infarction‐related event (TIE) Clinical and Economic Outcomes (MacLaren R and Bond CA, 2009).

• Mortality increased 37% in TIE ICU patients without clinical pharmacy services compared with ICU patients with clinical pharmacy services, p <0.0001.

• Bleeding complications increased by 49% (p<0.001) with 39% more patients receiving transfusions (p<0.001) in ICUs without clinical pharmacy services.

• Length of ICU stay and costs significantly higher in TIE patients in ICUs without clinical pharmacy services.



• Impact of ICU protocols on patient outcome

• Significant improvement in sedation and analgesia monitoring targets with use of protocol vs. empiric therapy (p<0.01); no difference in ICU stay (MacLaren R, et al. 2000).

• Pharmacist‐enforced ICU sedation protocol reduced mechanical ventilator duration as well as ICU, hospital length of stays (p<0.001) (Marshall, et al. 2008)

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PRESENTED AT:


as a specialty.







SAQ #4

Which most accurately describes a service listed uniquely within the “optimal” level of critical care pharmacy services according to the “Position Paper on Critical Pharmacy Services” published in 2000?

A. Securement of funds for clinical research studies.

B. Response to resuscitation events.

C. Pharmacokinetic monitoring.

D. Publication of critical care case reports.

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PRESENTED AT:

SAQ #4

A. Correct: Listed for the first time under Optimal level of CCP services.

B. Incorrect. Listed for the first time under

Desired level of CCP services.C. Incorrect. Listed for the first time under Fundamental level

of CCP services. D. Incorrect. Listed for the first time under Desired level of

CCP services.

Workbook Page 2‐11, 2‐33, 2‐34PRESENTED AT:

MAJOR PHARMACY SERVICE ACTIVITY CATEGORIES FOR CRITICAL CARE PHARMACISTS

• Clinical

• Educational

• Scholarly

• Administrative (e.g., business models, policy development)

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PRESENTED AT:

FUNDAMENTAL CCP SERVICES (SCCM/ACCP TASK FORCE RECOMMENDATIONS, 2000).

Predominant time commitment.

Evaluation of parenteral nutrition.

Pharmacokinetic monitoring.

Drug therapy info to ICU team members.

Implementation/monitoring of drug use policies and procedures.

• Prospective evaluation of drug therapy for safety/efficacy; intervention as needed.

• Identification of ADEs.

• Provision of drug info, IV compatibility data.

• Documentation of activities.

• Committee service.


DESIRED CCP SERVICES (SCCM/ACCP TASK FORCE RECOMMENDATIONS, 2000).

Interdisciplinary team rounding. Provision of formal nutrition

consultations. Didactic lectures to professional

students, postdoctoral trainees. Development/implementation of

drug therapy protocols and critical care pathways.

• Active engagement in critical care research.

• Conduct of medication histories, possible continuance of therapy.

• Response to resuscitation events.

• Experiential training of students, residents and fellows.

• Advanced outcomes, economic documentation.

• Publication of case reports, other practice insights.

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PRESENTED AT:

OPTIMAL CCP SERVICES (SCCM/ACCP TASK FORCE RECOMMENDATIONS, 2000).

Assist physicians, patients to make informed decisions regarding treatment options.

Development of critical care training for personnel working in ICU.

Securement of funds for clinical research studies through investigator initiated grants and contracts.

Publication of original critical care clinical research, outcome and administrative research or laboratory analyses.

• Provision of formal accredited educational sessions to other team members.

• Development/coordination of CCP residencies and/or fellowships.

• Teaching of ACLS.

• Proactive involvement in designing, prioritizing and promoting new pharmacy program and services.



as a specialty.






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PRESENTED AT:

SAQ #5According to the 2011 ACCP Critical Care Practice and Research Network (PRN) opinion paper, which best describes the credentialing criterion that is included uniquely under “Optimal” credentialing for pharmacists providing critical care pharmacy services?

A. Critical care fellowship training.

B. Board of Pharmacy Specialties (BPS) certification.

C. Advanced cardiac life support certification (ACLS).

D. Postgraduate year two (PGY2) training in critical care.


SAQ #5

A. Incorrect. Critical care fellowship training is not listed under Desired or Optimal credentialing.

B. Incorrect. BPS certification is listed as Desired training.

C. Incorrect. ACLS certification is listed as Desired training.

D. Correct: PGY2 critical care training is Listed as Optimal credentialing for providing CPP services.


PRESENTED AT:

CCP TRAINING AND CREDENTIALING

• First critical care pharmacy residency described: 1981 (The Ohio State University).

• ASHP Critical Care Pharmacy Residency Standards published in 1990.

• 116 ASHP accredited critical care residencies in 2014; Increase from 8 in 2001, from 39 in 2005 (Note: 67,357 adult ICU beds in U.S. as of 2009).

• Majority of PGY2 critical residents somewhat or very satisfied (91% and 76%, respectively) with their program and mentorship based on 2012 survey.



• ACCP Critical Care PRN Opinion Paper: Recommendations for “Desirable” credentialing of pharmacists providing critical care services includes:

– Pharmacy degree, active state licensure

– PGY1 residency

– BPS certification

– ACLS certification

• “Optimal” credentialing: all of above criteria in addition to PGY2 training in critical care (or related practice area e.g., emergency medicine, transplant, etc.).

• Critical care pharmacists traditionally sought credentialing through pharmacotherapy or nutrition support BPS certification.


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PRESENTED AT:


• Critical care pharmacy research training: long history of fellowship training.

• ASHP Research and Education Foundation Critical Care Traineeships.

• SCCM Clinical Pharmacy and Pharmacology Section mentoring services: practice, education, administration, scholarship.

• Implications for new ACCP Clinical Pharmacy Standards on critical care pharmacy specialty (?).



as a specialty.




5. List the criteria for credentialing and training of pharmacists providing critical care services as outlined in the 2011 ACCP Critical Care PRN Opinion Paper; also critical care training opportunities and growth.


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PRESENTED AT:

SAQ #6

Which best describes what is deemed a core knowledge base area for pharmacists caring for critically ill patients?

A. Infectious diseases.

B. Oncology.

C. Transplantation.

D. Obstetrics.


SAQ #6

A. Correct: Core knowledge area based on BPS Critical Care Content Outline

B. Incorrect. Not a core knowledge area based on BPS Critical Care Content Outline.

C. Incorrect. Not a core knowledge area based on BPS Critical Care Content Outline.

D. Incorrect. Not a core knowledge area based on BPS Critical Care Content Outline.

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PRESENTED AT:

CORE KNOWLEDGE BASE AREAS FOR PHARMACISTS CARING FOR CRITICALLY ILL PATIENTS

• Pulmonary

• Cardiovascular

• Neurology and Neurological Injuries

• Psychiatry

• Renal

• Hepato‐Gastrointestinal

• Immunology

• Endocrine


Learning ObjectivesAfter the presentation, the participant should be able to: 7. Apply the standards of practice for clinical pharmacy to the critical care practice environment








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SAQ #7Which organization has published a practice standard for clinical pharmacy?

A. American Pharmacists Association.

B. American Society of Health‐Systems Pharmacists.

C. American College of Clinical Pharmacy.

D. American Association of Colleges of Pharmacy.


SAQ #7A. Incorrect.

B. Incorrect.

C. Correct. (Pharmacotherapy 2014; 34:794‐7)

D. Incorrect.


PRESENTED AT:

Standards of Practice – Clinical Pharmacy (Pharmacotherapy 2014:34:794‐7)

• Defines expectations of clinical pharmacists delivering comprehensive medication management in team‐based, collaborative settings.

• Qualifications:– Advanced education, training and experience

– Clinical and personal competencies to practice in team‐based environment

– Board Certification



Pharmacist’s Process of Care

www.pharmacist.com/sites/default/files/JCPP_Pharmacists_Patient_Care_Process.pdf


PRESENTED AT:


• Additional Expectations– Collaborative, team‐based care and privileging– Professional development and maintenance of competence

– Professionalism and Ethics– Research and scholarship– Education and training/mentorship– Management and leadership– Policy and service development– Consultation


Scope of Critical Care Pharmacy Services (Crit Care Med 2000;28:3746‐50)

• Six Domains– Clinical activities– Drug Distribution– Education– Research– Documentation– Administration

• Two Areas– Pharmacist Activities– Pharmacy Services

• Three Gradations– Fundamental– Desirable– Optimal


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PRESENTED AT:


• Important elements of this document:– Expressed the need for clinical pharmacists in the management of complex ICU patients

– Promoted a team‐based approach to care

– Pharmacists have shared responsibility and accountability for patient outcomes.

– Promoted investment in departmental and institutional infrastructure and human resources to support a safe and effective drug use process in the ICU.



• Many pharmacy service standards are outdated:

– Information systems – meaningful use and other incentives make EMRs more widespread.

– Distribution systems have evolved

– Sharp‐end technologies not included

• Several fundamental recommendations not practical for small, community institutions.


PRESENTED AT:

ICU Pharmacist as EducatorTeaching Methods/Techniques

• Clinical Training• Point‐of‐Care• Demonstrations• Clinical Conferences• Topic Discussions• Assigned Readings• Journal Club

• QI Projects• Writing Assignments• Didactic Teaching• Collaboration on

Guidelines/Protocols• Competency‐based

programming• Patient‐Family education

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ICU Pharmacist as EducatorMultiple Audiences

• Pharmacy Students and Residents (may or may not have primary interest in critical care)

• Critical Care Team (primary interest in critical care – greater ICU therapeutics focus)

• Pharmacist Colleagues (may or may not have primary interest in critical care – competency development)

• Other trainees (mixed backgrounds and interests)

• Patients and families (not a traditional educational focus for ICU pharmacists)


PRESENTED AT:

ICU Pharmacist as EducatorSimplifying the Preceptor Process

• I do….you watch (Role Modeling)

• I do….you help (Coaching)

• You do…..I help (Coaching/Facilitating)

• You do…..I watch (Mentoring)


Critical Care Service Standards (Crit Care Med 2003;31:2677‐83)

• Level I:– Comprehensive critical care for a wide variety of patient populations with a high level of specialization

• Level II:– Comprehensive critical care but may not provide care for certain patient populations.

• Level III:– Provides stabilization, but limited ability to provide comprehensive critical care.


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PRESENTED AT:

Critical Care Service Standards (Crit Care Med 2003;31:2677‐83)

• Emphasized importance of clinical pharmacists as required members of the team

• Qualifications and competence of the ICU pharmacist was defined as essential.

• ICUs with an academic mission should provide protected time for pharmacist contribution to scholarly activities

• Non‐academic centers should provide time for ICU pharmacists to maintain competence.










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PRESENTED AT:

SAQ #8Which attribute of highly functional teams serves as the foundation for all others?

A. Shared goals.

B. Mutual trust.

C. Effective communication.

D. Clear roles.


SAQ #8A. Incorrect.

B. Correct. With mutual trust, all other issues are easy to address. In the absence of trust, it is much more difficult!

C. Incorrect

D. Incorrect.


PRESENTED AT:

Principles and Values of Team‐Based Health Care

• Definition of Team‐Based Care:Team‐based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high‐quality care.

www.iom.edu/Global/Perspectives/2012/TeamBasedCare.aspx


Principles and Values of Team‐Based Health Care

• Personal Values (Highly Functioning Team Members)

– Honesty

– Discipline

– Creativity

– Humility

– Curiosity

• Principles of Team‐Based Care– Shared Goals

– Clear Roles

– Mutual Trust

– Effective Communication

– Measurable Processes and Outcomes

www.iom.edu/Global/Perspectives/2012/TeamBasedCare.aspx


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Critical Care Team – Gap AnalysisHow is your team doing?

• Shared Goals:– Are the patient and family goals for critical care routinely incorporated in the plan?

– Are the patient and family viewed as active members of the team?

– Are there clearly articulated and understood goals agreed upon by all team members?

– Is progress towards the goals routinely re‐evaluated in light of the changing course and evolving perspective of the patient and family?

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• Clear Roles:– Are each team member’s functions, responsibilities and accountabilities clearly defined?

– Are the roles and responsibilities focused on the shared goals of the team and patient?

– Is there clear respect for the contributions of each team member (non‐hierarchial, interdependent perspective)?

– Does each member go about his or her responsibilities with a reasonable degree of autonomy and a balance of collaboration?

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• Mutual Trust:– Does an environment of mutual trust and support exist among the ICU team?

– Does the hiring process include a focus on the personal and professional values that support mutual trust?

– Is the team effective at establishing and maintaining mutual trust with patients and families?

– Does the team regularly participate in non‐patient care activities to develop greater trust?

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• Effective Communication:– Has the team established a high priority for open, direct, clear,

consistent professional communication between team members (regardless of traditional hierarchial structures)?

– Does communication take advantage of all potential modes and technologies for efficiency and convenience?

– Do members of the team use effective listening skills?

– Are signs of tension and unspoken conflict regularly recognized and addressed?


PRESENTED AT:


• Measurable Processes and Outcomes:– Has the team identified and implemented reliable, timely and

ongoing measures of performance?

– Are these measures focused on both process/outcomes of care provision and team function?

– Are measures of patient and family satisfaction included?

– Does the team regularly report its measures of success and failure?

– Are data regularly used for process improvement?

Workbook Page 2‐14 – 2‐16 PRESENTED AT:

Other Relevant Standards• Joint Commission

– Medication Management Chapter– National Patient Safety Goals

• CMS Conditions for Participation– Quality Assurance and Performance Improvement– Preparation and administration of medications– Medical Records requirements– Pharmaceutical Services

• Other (e.g. Pay for Performance, HACs)


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PRESENTED AT:










SAQ #9What is the preferred pathway for the training of critical care pharmacists?

A. Mentored clinical experience.

B. PGY1 and Mentored Clinical Experience.

C. ASHP Critical Care Traineeship.

D. PGY1 followed by PGY2 Critical Care residencies.


PRESENTED AT:

SAQ #9A. Incorrect.

B. Incorrect.

C. Incorrect

D. Correct. The preferred but not sole pathway.


Qualifications of Clinical Pharmacists (Pharmacotherapy 2013;33:888‐91)

• Board certification (or board eligible) is the cornerstone of eligibility

• Postgraduate residency training preferred pathway for clinical pharmacists providing direct patient care

• Alternatively, 3‐4 years of relevant experience with at least 50% of time in specialty area

• Valid CDTM agreement or formally granted clinical privileges


PRESENTED AT:

Training Recommendations• Graduate of ACPE‐accredited school of pharmacy

• Licensure and registration

• Conventional– PGY‐1 Pharmacy Practice

– PGY‐2 Critical Care or Fellowship(116 programs; 145 residents; 4 fellows)

• Unconventional/Alternative Pathways– Pathway not clearly defined / Variable

– Declining in relevance (?)


Nonconventional Training Paths

• Mentored clinical practice experience– Hands‐on, team‐based experience– Mentors – different backgrounds/disciplines; multiple mentors may be needed

– Reinforced by reading and analysis of the primary and secondary literature; topic discussions; point‐of‐care learning

– Minimum of 3‐4 years of mentored/supervised experience for level I and II ICU practice competency


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PRESENTED AT:

Nonconventional Training Paths• PGY‐1 with mentored/supervised training

– Mentored clinical experiences similar to above– Mentors – different backgrounds/disciplines– 2‐3 years of mentored/supervised experience to gain competency for

Level I and II ICUs.

• Critical Care Traineeship (ASHP Foundation)– 4‐month distant education– 2‐week on‐site experiential training– Post‐experiential training activities– Not a comprehensive training program – consider it a component of a

broader experience


Nonconventional Training PathsOther potential components

• Graduate degree (e.g. Masters Degree)• CE Programming• Attendance at CCM meetings• Fundamentals in Critical Care (SCCM)• ACLS/ATS/PALS training and certification• SCCM CPP National Journal Club• SCCM CPP Mentor program – long‐distance• Experiential rotations at peer institutions• Visiting professor or scholar programs• Guideline/Protocol/Guideline development


PRESENTED AT:










SAQ #10Critical Care Pharmacists should have just one mentor during their professional development?

A. True.

B. False.


PRESENTED AT:

SAQ #10A. Incorrect.

B. Correct. It is typical and expected to have several mentors during various stages of training and development.


Mentor – Protégé Relationship(Am J Pharm Educ 2003;67:Article 82)

• Mentor Qualities– Strong Interpersonal skills– Technical competence/expertise– Knowledge of organization and profession– Status/Prestige within organization and profession– Willingness to be responsible for protégé’s growth and development

– Ability to share credit– Patient


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PRESENTED AT:


• Protégé Qualities– Self‐perceived growth needs

– A record of seeking/accepting challenging assignments

– Receptivity to feedback and coaching

– Willingness to assume responsibility for own growth and development

– Ability to perform in more than one skill area



• Relationship Qualities– Voluntary

– Mutual benefits perceived and derived from the relationship

– No conflicts of interest/competition between mentor and protégé

– Not confined to professional or business interests


PRESENTED AT:

Phases of Mentor‐Protégé Relationship (Am J Pharm Educ 2003;67:Article 82)

InitiationWeeks‐MonthsBegin workMentor Coaches

Cultivation2‐5 yearsMutual BenefitsIntimate Bonds

SeparationMonthsProtégé autonomyMentor desertedResentment

TransformationYearsPeer relationshipMutual sense of gratitude


Mentoring and Critical Care

• Mentor‐Protégé relationships are essential to formal development of critical care pharmacists

• Seek mentors who can fill gaps in knowledge, skills and attitudes relative to critical care practice, research and education

• Over time, ICU pharmacists should have several mentor‐protégé relationships.

• Critical care pharmacists should mentor junior colleagues and trainees


PRESENTED AT:

Mentoring

Who is carrying who at what point in the relationship?


Discussion QuestionA young, bright clinical pharmacist who recently completed PGY‐1 training approaches you about her interest in developing clinical expertise in critical care at your 480‐bed community teaching hospital with Level II critical care services. What options would you discuss with this pharmacist concerning obtaining the necessary knowledge, skills and attitudes?Workbook Page 2‐18, 2‐19

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PRESENTED AT:

Discussion QuestionShe appreciates the advice to return for CCM PGY‐2 training, but last year she bought a new house…..

…..and this year, a new car.She wants advice on gaining “on‐the‐job” experience.










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PRESENTED AT:

SAQ #11What is the relationship between Continuing Pharmacy Education (CPE) and Continuing Professional Development (CPD)?

A. They are essentially equivalent processes.

B. CPD replaces CPE for most state requirements.

C. CPE can be an important component of CPD.

D. CPD is not recognized as relevant by ACPE.


SAQ #11A. Incorrect.

B. Incorrect.

C. Correct. A CPD personal development plan frequently includes CPE.

D. Incorrect.


PRESENTED AT:

Continuing Professional DevelopmentGeneral Considerations

• Necessity and obligation to multiple stakeholders• Multifaceted, self‐directed, holistic, outcomes‐focused

approach to learning• Career‐long, iterative process – continuous cycles, rather than a

defined start and end• Sustained career successes more dependent on CPD than early‐

career education/training• Should be closely integrated into daily practice and work

environment for success and sustainability (can’t be another thing to do)


Continuing Professional DevelopmentStakeholders

• Pharmacist‐Learner (Self)

• Employer

• Critical Care Colleagues

• Students, residents and fellows

• Patients

Each contribute to and benefit from CPD process.


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PRESENTED AT:

Continuing Professional DevelopmentProcess

ReflectionReflection

PlanPlanActAct

EvaluateEvaluate

Portfolio


Continuing Professional DevelopmentReflection

• Self‐Assessment Process

• Seek evaluation and feedback from others

• Conduct personal/professional SWOT

• Reflection should be both scheduled and episodic

• Goal is to identify 2‐3 specific, well‐defined, and achievable learning needs.


PRESENTED AT:

Continuing Professional DevelopmentPlan

• Develop a personal development plan (PDP) to address learning needs

• Include learning objectives that are SMART (specific, measurable, achievable, relevant, time‐bound)

• Identify resources needed to address the PDP

• Evaluate the availability and access to needed resources; modify PDP accordingly

• PDP should be regularly reassessed and modified


Continuing Professional DevelopmentAct

• Develop an action plan to implement the PDP

• Need to incorporate a variety of learning strategies and methods

• Incorporate into the daily practice activities

• PDP action plan should not be considered an “additional burden” (or it will never get done!)


PRESENTED AT:

Continuing Professional DevelopmentEvaluate

• Evaluate effectiveness of the action plan for achieving learning objectives of PDP:– Did activities provide content, depth and experiences to address

the learning objectives?– Did the activities stay focused on the objectives and were

timelines adhered to?– Were all competencies adequately addressed?– How did the CPD activities affect the learner and the patient?

• Evaluation should lead into next round of Reflection – restart continuous cycle…


Continuing Professional DevelopmentPortfolio

• Sometimes considered the 5th step of CPD, but is integral to each of the 4 steps.

• Process for documenting CPD process

• Format varies – may be standardized by employer, regulatory authorities, CE providers, etc.

• Is a dynamic, living document that reflects the continuous, iterative nature of CPD.


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PRESENTED AT:

Continuing Professional DevelopmentLearning Strategies and Methods

• Continuing pharmacy education (CPE)

• Short courses or seminars

• Participation in professional organizations

• Primary and secondary literature (“Foraging” and “Hunting”)

• Discussion and debate• Journal clubs/Clinical

conferences• Interprofessional, patient

care rounds• Guideline and protocol

development• Point‐of‐care learning

Workbook Page 2‐23 – 2‐25 PRESENTED AT:







personal development plan.13. Identify the avenues and processes for contributing to the critical care body of knowledge as

a presenter, author, or peer reviewer.

Workbook Page 2‐4

PRESENTED AT:

SAQ #12What is the primary purpose for scientific review of submitted manuscripts or primary research?

A. To assure scientific validity of the research.

B. To assure proper syntax and terminology.

C. To assure the authors are qualified.

D. To assure an absence of conflicts of interest.


SAQ #12A. Correct. Peer review is primarily focused on the

scientific value and validity of the research.

B. Incorrect.

C. Incorrect

D. Incorrect.


PRESENTED AT:

Dissemination of Critical Care Knowledge (Scholarship)

• Reasons to Disseminate Knowledge– Professional– Ethical obligation– Personal

• Venues– Peer‐reviewed publications– Non‐peer‐reviewed publications– Abstracts/Posters/Platforms– Presentations/CPE


Peer‐Reviewed Publication• Selecting a Target Journal

– Type and quality/importance of manuscript

– Target audience

• Manuscript

– Comply with journal requirements

– Succinct, focused, non‐repetitive

– Syntax and spelling

– Avoid common errors/weaknesses


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PRESENTED AT:

Common Manuscript WeaknessesOriginal Research

• Abstract and paper don’t match

• Weak introduction• Unclear objective(s)• Methods without results• Results without methods• Duplicate results in tables• Rambling, unfocused

discussion

• Failure to address weaknesses

• Conclusions beyond the data• Too many tables• Simplistic figures• Cite literature incorrectly• Exceed word limits


Peer‐Reviewed PublicationReview and Revision Process

• Editorial Review– Focus on relevance and general quality

• Peer or Scientific Review– Should focus on quality and impact of content– Recommend Accept, Revision, or Reject

• Editor Response• Revision process

– Respond to all comments, not necessarily agree– Revised manuscript by deadline

• After Acceptance


PRESENTED AT:

Abstracts and Scientific PresentationsSelecting a Meeting….

• Quality and relevance of presentation

• Prestige of meeting/Career goals

• Membership – desire to support organization

• Availability of funding for travel (or not…)

• Priorities of key collaborators

• Location of the meeting (sadly true….)

• “Encore” presentations an option


Abstracts and Scientific PresentationsPreparing the Abstract

• Succinct – greatest impact in the least space

• Title – brief and captivating

• Clearly state purpose (primary)

• Methods and analysis concise but clear

• Results may need to be just primary endpoint

• Conclusion – single brief sentence clearly tied to stated purpose

• Revise, revise, revise – engage all authors


PRESENTED AT:

Abstracts and Scientific Presentations

• Submission– All electronic now – reduces ability to cheat!

• Platform vs Poster– Depends on quality and relevance– Usually based on reviewers’ scores– Typically have to designate Platform status

• Review Process– 3‐5 reviewers typical– Decisions are final (no revisions, resubmissions)


Poster Presentations• Dos and Don’ts….

– Avoid wordy posters (nobody will read it…)– Use of tables, figures, concise bullet lists best– Font size readable from 5‐6 feet (with bifocals!)– Ease of readability more important than aesthetics– Unless required, don’t reprint abstract on poster– Watch out for the “logo police” – especially if printing at your

site– Walk‐rounds – be prepared and be succinct

• Virtual Posters – rising popularity…


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PRESENTED AT:

Platform Presentation

• Recognition of high quality, impactful work

• Presentation usual 10 minutes with 5‐10 minutes for questions

• Usually brief slide presentation – can not get into very granular presentation of work

• May involve peer review/judging

• Feedback may be written or verbal

• Often requires an accompanying poster


Dissemination of KnowledgeA conscious decision to swim with sharks

Actually, nobody wants to swim with sharks. It is not an acknowledged sport and it is neither enjoyable nor exhilarating. These instructions are written primarily for the benefit of those, who, by virtue of their occupation, find they must swim and find that the water is infested with sharks.• Rules for Swimming with Sharks

– Assume all unidentified fish are sharks– Do not bleed– Counter any aggression promptly– Get out of the water if someone else is bleeding– Use anticipatory retaliation– Disorganize an organized attack

Thorac Surg Clin 2011;21:441‐2


PRESENTED AT:

Being a Peer Reviewer/Referee

• Reasons to participate– Professional obligation (take and give back)– Professional service opportunity– Enjoy reviewing the “raw” product– Educational opportunity for trainees

• Reasons to decline an invitation– Conflict of interest– Lack of expertise in the subject matter– Lack of time to meet deadlines


Being a Peer Reviewer/Referee

• Getting on the list

– Publish in the journal

– Be recommended by a peer

– Being a recognized expert in the field

– Publishing in the field in a peer journal(s)

– Volunteering services


PRESENTED AT:

Tips for conducting peer review• Assumption of biomedical review skills….

• Focus on scientific quality and importance

• Grammar and word choices – leave to copyeditor

• “Connect the dots”

– Objective(s) ↔ Conclusions

– Methods ↔ Objective(s)

– Methods – valid, state‐of‐the‐art, statistically valid

– Method ↔ Result

– Result ↔ Method

– Conclusions ↔ Results

– Fair and complete discussion of the study weaknesses


Peer Review Recommendation• Reasons for Rejection Recommendation

– Fatal flaw– Extensive revision needed (total rewrite)– Valid research that is not important– Re‐publication of extensive portion of study– Serious ethical violations– Not relevant to target audience of journal

• Revision (minor or major) Recommendation– Quality paper that needs issues addressed– Major revision usually undergoes 2nd review

• Accept Recommendation– Unusual on first review – exceptional manuscript


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PRESENTED AT:

Peer Re‐review Process

• Receive detailed response to comments (yours and other reviewers) along with revised manuscript

• Restrict comments to responses to first review – “play fair”

• Confirm revisions have not materially altered the meaning of other parts of the manuscript

• Evaluate the validity of defense of comments not accepted (often valid)

• If extensive revisions still needed editor may reject.


Evening Sailing on Lake Ontario

Thank you for your attention!

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