Prior to residency, I had the opportunity to get involved with research through directed studies project and work. It was definitely a very different, but great experience to work on and help lead a research project from beginning to end. Mark was a fantastic project investigator, guiding me through this process yet also providing me with the independence to make this project my own. Additionally, for me, the project was helping to answer a very meaningful clinical question. I am sure that in my practice, I will frequently encounter questions that could be answered with a DUE study, and am glad that my experiences will help me conduct clinical research to answer future questions of my own! 🙂
Some things that I have learned from working on this project are:
- Have a clear idea of my clinical question and objectives – and when deciding on what data I should be collecting, consider how I will also be (1) using (e.g. stats, descriptive analysis?), (2) interpreting and (3) presenting the data to answer my clinical question and meet my objectives.
- It wasn’t until mid way through my data collection that I started putting dates to all my data collection sheet…Initially, I had saved all my changes on one file…but as I made changes to my data sheet and my analysis, it was challenging to keep track of my progress and figure out where I had left off. Despite having multiple versions of my data collection in the end, it was much easier, at least for me, to refer back and understand my data when writing my manuscript.
- When presenting my research, figure out the main points I want my audience to take away and ensure that the data I present helps highlight these points. Also consider what data would be the most meaningful and interesting to pharmacists currently in practice.
I really enjoyed this rotation at SPH and learned so much from Linda and the rest of the team on how to manage total parenteral nutrition. During this week, the team also had a new gastroenterology fellow and dietitian intern starting and it was a nice experience to be learning and working together with them!
With the help of Linda, I was able to build on a systematic approach to working up and assessing patients for TPN:
- Identify if there is an indication to TPN
- Surgery progress notes/reports (e.g. length of bowel resected) and imaging often provide the indication for TPN (e.g. anastomotic leak)
- Generally don’t give “pre-operative TPN”, but there are exceptions to this (e.g. had a patient who lost ~20kg over the last yr and surgery wanted pre-op TPN for malnutrition)
- This will also help you identify how to assess when your patient should be off TPN!
- Generally ideally would like to see pts tolerate solid foods for 24 hours prior to coming off TPN…generally TPN → PO intake and if can’t tolerate PO → EN (unless in ICU, generally don’t go from TPN → EN)
- If TPN indicated, assess the risk for refeeding syndrome and nutrition status
- Information gathering:
- current weight (assess fluid status → is this a dry or wet weight?)
- Calculate BMI, IBW and do adjBW if overweight
- usual weight at home
- weight change
- nutrition status
- intake during hospital admission
- intake prior to hospital admission
- signs of muscle wasting
- hx of organ failure (kidney, liver, cardiac)
- IV maintenance fluids and replacement fluids
- Provides you an idea of their volume status, tolerance to fluids and need for electrolyte replacements
- Check how long they have been on it and whether they have been any recent rate changes
- IV access
- Inputs and outputs
- Consider what patient is losing (e.g. diarrhea, vomiting, NG suction output, stoma output, urine output) + insensible losses
- Diarrhea → lose bicarb, sodium, chloride
- Vomiting → lose chloride
- Electrolytes → should get a baseline Mg and PO4 prior to starting TPN
- Order any electrolyte replacement orders
- TPN changes and starts tonight (reach the wards from VGH at 1830h)
- Electrolyte replacements would be given prior to TPN start
General monitoring parameters:
- Main Labs: Na, K, Ca, Phos, Mg, urea, sCr, glucose
- Other labs: bicarb, Cl, alb, prealbumin, LFTs
- Weights today and then q Mon + Th
- Ins and outs
- Can choose to order strict ins and outs – good to specify if want to record PO intake even if you specify “strict”
- If no ins and outs → checking with patient to get a sense of that (e.g. frequency and volume of diarrhea, vomiting, etc.)
- Calorie counts if progressing with diet
- Plan with diet (decided by surgery)
- Plan with surgery
- s/s associated with indication for TPN → e.g. vomiting, presence of gas, abdominal discomfort, tolerance to PO intake
- when changing orders, write delta signs to any change (helps pharmacy identify if there are any unintended mistakes)
This was my first non-clinical rotation, and I think the timing of this rotation at the half-way mark of my residency is very fitting. It was very eye-opening to see the layers of management and leadership behind ensuring that all the operations, clinical services and strategic plans run smoothly.
Through shadowing Mits, and having discussions and daily reflections with Mits, I had the opportunity to learn and observe about his management and communication styles.
Some clinical pearls I learned were:
- Communicating with SBAR
Prior to this rotation, SBAR was something I had only seen on a nursing communication sheet at MSJ. SBAR stands for Situation, Background, Assessment and Recommendation – it follows a similar order that SOAP does. When addressing a management issue, Mits had me practice how I would explain this particular issue through SBAR and I was also able to observe how Mits used SBAR to explain the same issue to a medical director. One difference between the way I explained SBAR and Mits was that he included parts of the “R” in my “S” to allow the receiving end to understand the purpose of the conversation. I think this tool will be a very systematic and effective way for me to communicate issues to other health care team members and my colleagues.
- Communicating with OWTF and using “I” language
OTFW is communicating by talking about what I observed, what I think, what I feel and want. The order doesn’t have to exactly follow OTFW, but the key is to touch on all of them when bringing up an issue. Communicating with OWTF and using “I” language will help others understand your perspective, communicate in a non-confrontational manner and provide others with the choice of helping you (versus demanding for assistance on the matter).
Implementing and ensuring successful change requires going through all 5 steps of ADKAR. On my last day, we attended a leadership forum at Burnaby Hospital where managers, coorindators, PCCs, LPNs and executive directors presented and discussed about the health care report card, different initiatives taking place at BH, the successful patient stories and steps to take and are being taken to ensure successful change. This forum was also great example of another communication tip that Mits taught me and that was to ensure that everything communicated does a 360. If there is an issue, ensure that those who brought up the issue are made aware of the status of the issue (e.g. email, verbal communication, interim reports). This forum provided an opportunity for the leaders in BH to provide feedback and input, as well as, ask questions to president of Fraser Health, Michael Marchbank. Overall, it was a great end to my rotation to see ADKAR being applied in practice!
- The Donut Model
The Donut Model consists of 3 layers – the inner most represents what you can directly affect (e.g. what you can wear)?, the second layer represents what you can influence and the third layer represents what you can’t control (e.g. weather, the past). It is important, in my residency year and the rest of my career, to be aware of these different layers and avoid putting my energy into things I cannot control.
The following are my objectives for surgery:
- Continue to develop a systematic thought process to assessing and managing infectious diseases
- Continue to develop my ability to practice antimicrobial stewardship (e.g. assessing when therapy can be narrowed, for IV to PO stepdown)
- Continue to develop my ability to effectively perform therapeutic drug monitoring on medications such as vancomycin, aminoglycosides and anticoagulation
- Develop my ability to effectively manage anti-coagulation (e.g. pre- and post-op management, duration of treatment or prophylaxis)
- Continue to develop my ability to write concise and clear chart notes
Another great rotation at RCH! Bruce was incredibly knowledgeable and helped to build my thought process regarding patients in surgery. This rotation definitely gave me a lot of experience with infectious diseases, especially intra-abdominal infections. Bruce also helped schedule a shadowing opportunity for me with one of the antimicrobial stewardship pharmacists. One key thing I will always keep in mind when managing infections is the importance of source control! Unfortunately, I was not able to get any experience with aminoglycosides…but was able to get lots of experience with anticoagulation (e.g. VTE prophylaxis for patients who have abdominal surgery for cancer – requires 28 days of LMWH). Generally, VTE prophylaxis is started on POD 1 with dalteparin if eGFR > 10. With Bruce’s guidance, I was able to write clearer chart notes. Writing concise and clear chart notes will definitely be a goal that I will continue in future rotations.
I can’t believe how quickly this rotation flew by! I’m very fortunate to have been able to work with such a supportive preceptor and health care team at the Short Stay Medical Unit (SSMU).
These were my objectives for this rotation:
- Develop and strengthen my systematic approach to assess and work up patients
- Develop my ability to clearly and concisely document my soap notes and important patient interactions
- Develop my ability to effectively perform therapeutic drug monitoring on medications such as vancomycin, aminoglycosides, digoxin and anticoagulation
- Develop my ability to practice antimicrobial stewardship (e.g. assessing when therapy can be narrowed, for IV to PO stepdown)
During this rotation, my preceptor helped to build on my approach and when I presented on my patients, he would help map it all out on the whiteboard. This made it easier for me to view my patient as a whole and connect their medications to their indications and medical conditions. The importance of matching medications to medical conditions, vice versa was emphasized with this rotation. Additionally, I feel that I was able to improve on my documentation, especially on my soap notes for therapeutic drug monitoring (e.g. for vancomycin). Unfortunately, I was not able to get much experience with monitoring of digoxin or aminoglycosides. I was able to see various patients with pneumonia, and had more experience assessing for narrowing of therapy and IV to PO stepdown.
For the past week, Dr. Ensom went over pharmacokinetics for vancomycin, aminoglycosides, phenytoin and digoxin, as well as, gave us a brief overview of other drugs that have TDM. On our last day, we also had clinical pharmacists share real-life cases and how to apply pharmacokinetics in real life. The sessions were incredibly useful, especially since I didn’t take the pharmacokinetics electives. During my general medicine rotation, I hope to get more experience with interpreting levels, applying my pharmacokinetic knowledge and writing concise and comprehensive chart-notes/documentations.
Some things I took away from the sessions:
- For future chart notes on TDM, I will document if possible on: individual pharmacokinetic parameters, population estimates (if clinically useful)
– check if this is the first or follow-up note
– write chart notes in bullet points
– check infusion times, timing of level relative to dose, previous doses and their timing
– keep in mind that my audience is the health care team and other pharmacists
- Patient can only be toxic if they are alive!
- Population estimates are like clothes off the clothing rack. Whenever possible, want to get individual PK parameters
This was definitely a jam-packed week of statistics and critical appraisal. It was very valuable to have the opportunities to not only learn about the different critical appraisal tools, but also apply and use it for patient cases. Even with the time allotted for us to use the tools, I was not able to finish going over the entire checklist and was able to truly appreciate how long a full and comprehensive critical appraisal can take. The big thing that most of our presenters emphasized was the need to practice, practice practice before you can expect to be efficient in this skill. As residency progresses, I aim to refine this skill as I prepare for my future journal clubs, project and literature searches.
Some points that I took away were:
- Make evidence synopses! Always question the evidence of what you are recommending or counselling (e.g. no alcohol while taking antibiotics — this belief actually came about because people were dying from STIs and they were still infective while taking ab treatment, and alcohol increased the likelihood they would have more intercourse)
- Cochrane reviews: as unbiased as you can get, but still have bias
- Search: drug name meta-analysis systematic review, RCTs
- Even if it is a small study where SS cannot be achieved (e.g. pilot studies), statistics can still be used to tell you about variance, mean, population size
- Talking to patients about evidence
1. Set the stage (WOW Intro: Who you are, Occupation, Why you are here)
2. Use Framing language
3. Understand the Patient’s Experience and Expectations
4. Build partnerships
5. Explain disease
*Why they were at risk
*Disease and symptoms
*Impact of having that disease and complications
6. Explain medications
7. Provide Evidence on Benefit and Risk
(Benefits, Risks, Characteristics)
8. Elicit patient’s benefits, values and preferences
9. Discuss a shared recommendation
10. Check for understanding and agreement
11. Talk about follow-up