Application of the Layered Learning Practice Model in an Academic Medical Center.

The layered learning practice model (LLPM) is a teaching strategy designed to train residents to precept students and other residents with the oversight of a seasoned clinical pharmacist. This model serves as a tool for residency programs to implement quality precepting opportunities and learning experiences as they look for new ways to integrate multiple learners into the practice setting. The levels of the LLPM include a senior preceptor, resident, and student. It is best implemented through utilization of 4 steps: orientation to the LLPM, preexperience planning, implementation, and postexperience evaluation. Orientation introduces preceptors and residents to the LLPM and outlines expectations for each precepting level. Preexperience planning allows the resident to take a leadership role in developing calendars, rotation activities, rubrics, and activities that match goals and objectives. For implementation, the senior preceptor maintains an active role with all learners; the resident serves as the student's primary preceptor and is responsible for incorporating the student into clinical activities, evaluating student work, and providing feedback. Postexperience evaluation is designed to solicit and provide feedback to the resident and student and to identify recommendations for improvement of the LLPM. Overall, the LLPM is a multilayered model incorporating the expertise and unique learning positions of the senior preceptor, resident, and student. Redistributing components of the senior preceptor's responsibility amongst learners may result in expansion of patient care and clinical services and help satisfy the increasing demands placed on pharmacists.

Evaluation of pharmacy services in emergency departments of Veterans Affairs Medical Centers.

OBJECTIVE: In 2008, the American Society of Health-System Pharmacists (ASHP) published a national survey that revealed only 6.8% of hospitals surveyed had a pharmacist assigned to the emergency department (ED) for any period of time. This survey was distributed among general and children's medical-surgical hospitals in the United States and did not include any Veterans Affairs (VA) Medical Centers. To date, there have been no identified survey studies describing the prevalence of pharmacy services within VA EDs. The objectives of this study are to determine the prevalence of dedicated pharmacy services within VA EDs, categorize the types of pharmacy services, determine if interventions/outcomes related to pharmacy services were collected, and assess the desire for pharmacy services in facilities that did not currently have dedicated pharmacy services. METHODS: The study was designed as a cross-sectional survey study conducted between January 14, 2010 and March 29, 2010. The study population included Pharmacy Clinical Coordinators employed at a VA facility. An initial email containing a link to the web-based survey was distributed via the national Pharmacy Clinical Coordinator listserv. Results of the survey were analyzed using descriptive statistics. RESULTS: The survey was distributed to 153 VA Medical Centers and a total of 33 (21.6%) responses were received. Of the responses, 24 facilities (72.7%) documented the presence of an ED, and of those, 5 (20.8%) indicated that they had a pharmacist dedicated to providing pharmacy services to the ED. The most common pharmacy services provided included medication reconciliation, patient education/ counseling, pharmacotherapy recommendations, ED staff education, precepting activities, adverse drug reaction (ADR) reporting, and ensuring formulary compliance. Three of the 5 facilities documented interventions, with 1 facility documenting ADRs prevented and cost avoidance in addition to interventions. Of the 19 facilities that did not have a pharmacist dedicated to the ED, 16 (84.2%) indicated a desire for such services. CONCLUSION: A greater prevalence of ED pharmacy services was reported in VA facilities compared with a national sample of non-VA facilities. Despite the high prevalence and variety of dedicated pharmacy services provided to the ED, documentation of these services remains an area in need of improvement.

Combination of inhaled corticosteroid and bronchodilator-induced delirium in an elderly patient with lung disease.

Steroid psychosis has been well described with oral glucocorticoids, however, our search of the literature did not identify an association between delirium and the combination of inhaled glucocorticoids and long-acting beta-agonists. We describe the occurrence of delirium with the combination of an inhaled glucocorticoid and bronchodilator. An elderly male described confusion and hallucinations within 1 week after initiation of budesonide/formoterol for chronic obstructive pulmonary disease. The combination inhaler was discontinued with resolution of symptoms. Several weeks later, the patient was hospitalized and restarted on the combination inhaler. The patient was alert and oriented on admission, however, confusion and hallucinations progressed throughout his hospital stay. The combination inhaler was discontinued and his confusion and hallucinations resolved by discharge. The temporal relationship of these events and a probable Naranjo association allows for reasonable assumption that the use of the budesonide/formoterol combination inhaler caused or contributed to the occurrences of delirium in this elderly patient. The onset of delirium was likely due to the systemic absorption of the glucocorticoid from lung deposition, complicated in an individual with several predisposing risk factors for delirium. Health care providers should be aware of this potential adverse drug reaction when prescribing inhaled medications to older patients at risk for delirium.

Methods to Promote Preceptor Scholarship through Resident Collaboration.

Preceptor participation in scholarly endeavors is recognized in the American Society of Health-System Pharmacists's (ASHP) residency accreditation standards as a method to demonstrate commitment and contribute to the profession of pharmacy. Although workplace demands and position responsibilities may not allow adequate time for preceptors to pursue scholarly activities, collaboration with pharmacy residents in a structured environment can be mutually beneficial and aid in the professional development of the resident and preceptor. The goal of this article is to provide preceptors with a description of activities suitable for collaboration with residents and with tips to ensure success within the residency year.

Modafinil for the treatment of multiple sclerosis-related fatigue.

OBJECTIVE: To review the efficacy and safety of off-label use of modafinil in the treatment of multiple sclerosis (MS)-related fatigue. DATA SOURCES: Literature was accessed via MEDLINE (1966-January 2010) and International Pharmaceutical Abstracts (1960-2010), using the medical subject heading terms modafinil, multiple sclerosis, and fatigue. STUDY SELECTION AND DATA EXTRACTION: All English-language, peer reviewed publications were analyzed for relevance. Studies appropriate to the objective were evaluated, including 3 open-label trials, 1 single-blind trial, and 2 randomized placebo-controlled trials. DATA SYNTHESIS: Fatigue symptoms, assessed by a variety of self-reported symptom scales, improved in each of the uncontrolled studies reviewed when participants with MS received modafinil 200 mg or less daily for up to 12 weeks. These benefits were not maintained, however, in one uncontrolled study when modafinil was increased to 400 mg daily. Of the 2 randomized, controlled trials, 1 study found that modafinil 200 mg once daily resulted in a reduction in fatigue symptoms measured by the Fatigue Severity Scale at 8 weeks. The other study found no difference in the reduction of fatigue symptoms, measured by the Modified Fatigue Impact Scale at 5 weeks, between the placebo group and patients who received modafinil 100-200 mg twice daily. The most common adverse reactions associated with modafinil use in all studies included gastrointestinal and central nervous system effects. CONCLUSIONS: Based on the available data, use of modafinil for the treatment of MS-related fatigue has demonstrated benefit in all uncontrolled studies but has conflicting results from 2 controlled studies. Modafinil is a reasonable therapeutic option in this patient population, although larger, long-term, randomized controlled studies are necessary to further elucidate the appropriate dose of modafinil, its effects on MS-related fatigue, and adverse effects associated with its use.

Class effect of erythropoietin therapy on hemoglobin A(1c) in a patient with diabetes mellitus and chronic kidney disease not undergoing hemodialysis.

In patients with diabetes mellitus, hemoglobin A(1c) (A1C) is commonly interpreted as a measure of long-term glycemic control, reflecting a mean glucose level over the previous 2-3 months. Although some reports suggest that treatment with recombinant erythropoietin may affect A1C values in patients undergoing hemodialysis, we know of no evidence to support this interaction in patients with chronic renal insufficiency who are not undergoing hemodialysis. In addition, we know of no evidence specific to the treatment effect of epoetin alfa and/or darbepoetin alfa on A1C. We describe a 64-year-old man with diabetes, chronic kidney disease, and anemia who was treated consecutively with epoetin alfa and darbepoetin alfa and experienced a temporal reduction in A1C level to a nadir of 4.4%. Throughout approximately 3 years of treatment with these erythropoietin analogs, the patient's total daily dose of insulin was reduced in response to his decreasing A1C values, despite elevated blood glucose levels and the absence of patient-reported hypoglycemic events. Five months after the patient's erythropoietin therapy was discontinued, his A1C value increased to 8.8%, leading us to conclude that management of the insulin dose may have been different without the falsely lowered A1C levels. Use of the Naranjo adverse drug reaction probability scale indicated a probable association between this patient's reduced A1C levels and erythropoietin therapy. This case demonstrates that both epoetin alfa and darbepoetin alfa may artificially lower A1C levels in a patient with diabetes who is not undergoing dialysis, and therefore this finding can be interpreted as a class effect. Clinicians should be aware of factors that affect A1C values, specifically erythrocyte life span. In patients receiving erythropoietin, therapeutic decisions should be based on A1C and glucose levels, as well as patient symptoms suggestive of hypo- or hyperglycemia, to avoid therapy changes that could complicate disease management.