- Email: [email protected]
An interprofessional clinical toxicology advanced pharmacy practice experience
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
An interprofessional clinical toxicology advanced pharmacy practice experience
T
Valerie B. Clinarda, , Thomas E. Kearneya,b, Daniel J. Repplingerb, Craig G. Smollinb, Sharon L. Youmansa ⁎
a
Department of Clinical Pharmacy, University of California San Francisco, School of Pharmacy, 513 Parnassus Avenue, S-126, San Francisco, CA 94143-0403, United States b California Poison Control System – San Francisco Division, Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, Suite 6A, San Francisco, CA 94110, United States
ARTICLE INFO
ABSTRACT
Keywords: Advanced pharmacy practice experience Clinical toxicology Poison control center Interprofessional
Background and purpose: Clinical toxicology is a blend of science, research, and patient management practices involving human poisonings from exposure to natural and synthetic toxins. The objective of this study was to describe the components of an elective advanced pharmacy practice experience (APPE) in clinical toxicology at California Poison Control System (CPCS). Educational activity and setting: The APPE requirements included a mix of active participation in case management and supplemental educational exercises, case presentations and consultations, and a structured self-study component consisting of readings and on-line modules. In addition, there were two active learning activities, high acuity poisoning simulation scenarios utilizing a high-fidelity mannequin, and an antidote tasting session. Findings: From April 2012 to October 2017, 82 student pharmacists completed this APPE. Pharmacy students completed 85 pre-simulation surveys and 80 post-simulation surveys. Survey results showed an increase in pharmacy student beliefs that a clinical pharmacist should be involved in the differential diagnosis and management of patients (60% pre-simulation vs. 78.8% post-simulation, p = 0.009). APPE pharmacy students completed an evaluation of the preceptors (s), site, and learning experience. The average score for all areas on the preceptor and site evaluations was > 4.5 on a 5-point Likert scale. Qualitative data themes included student satisfaction with opportunities, feedback, and the interprofessional and collaborative environment. Summary: An APPE in the CPCS was successfully designed and implemented. The APPE provides an interprofessional collaborative learning environment that allows student pharmacists to understand the unique role of the pharmacist in this setting.
Background and purpose Clinical toxicology is a blend of science, research, and patient management practices involving human poisonings from exposure to natural and synthetic toxins. Several pharmacist career opportunities in this field include hospital-based practices in emergency medicine, critical care, industry-based drug safety, academia, forensic consultants, and specialists and consultants in poison control centers (PCCs). The American Board of Applied Toxicology (ABAT) administers an exam to credential and board certify non-physician Corresponding author. E-mail addresses: [email protected] (V.B. Clinard), [email protected] (T.E. Kearney), [email protected] (C.G. Smollin), [email protected] (S.L. Youmans). ⁎
https://doi.org/10.1016/j.cptl.2019.02.002
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
clinical toxicologists, including pharmacists. The California Poison Control System (CPCS) provides a platform for interprofessional collaboration and education in a clinical setting for advanced pharmacy practice experiences (APPEs). The CPCS, with four interconnected divisions – San Francisco, Sacramento, Madera, and San Diego – are all managed by the Department of Clinical Pharmacy at the University of California, San Francisco (UCSF) School of Pharmacy. The CPCS is accredited by the American Association of Poison Control Centers (AAPCC), operates on a 24 hour 7 day per week basis to all residents of the state of California, and is staffed predominately by pharmacists with specialty training and certification as Specialists in Poison Information. Interprofessional education (IPE) enables students from varying disciplines to learn with, from, and about each other to improve collaboration.1 This intentional component of the doctor of pharmacy curriculum prepares students to be a member of an interprofessional collaborative practice team. IPE is a priority for all health professional programs nationally and is a requirement outlined in the accreditation documents of each discipline.2 The Accreditation Council for Pharmacy Education (ACPE) “Standards 2016”3 describe IPE as an important component of pharmacy education. The San Francisco Division of the CPCS has served as a site for student APPEs since its inception in 1997 and provides a platform for active learning within an interprofessional setting. An average of five to six learners (medical students, emergency medicine residents, pediatric fellows, pharmacy residents, APPE pharmacy students, international physicians, and pharmacists training to develop PCC services abroad) rotate through the PCC at any given time. Two pharmacy students are assigned to a six-week block rotation. The service also includes full-time medical toxicology fellows, physicians typically trained in emergency medicine that participate in a two-year training program. As a component of their training, the medical toxicology fellows serve as daily coordinators for the students. The managing director of the PCC serves as an attending and consultant for the hospitalized patient consult service one day per week and along with a cadre of attending physicians, conducts teaching rounds with the students and medical toxicology fellows. The managing director, board certified by ABAT, is a faculty member of the UCSF School of Pharmacy and the preceptor of record for the APPE students. The objective of this study was to describe the components of the elective APPE associated with this PCC. Educational activity and setting The APPE requirements at the PCC include a mix of active participation in case management and supplemental educational exercises. Students must actively participate in all conferences and case discussions. Daily rounds are conducted on patients hospitalized for toxic exposures. Weekly grand rounds are conducted at the San Francisco Division, consisting of presentations by the medical toxicology fellow. These presentations usually include problematic or illustrative poisoning cases, are used to solicit opinions from the audience, and serve as a teaching tool for the audience. Statewide rounds are another opportunity for collaborative learning. These rounds occur bi-weekly via teleconference between each of the four divisions of the CPCS on a rotating basis. These presentations also typically include problematic or illustrative poisoning cases. Students are assigned to perform follow-up call to previously hospitalized patient to assess status with the guidance of the medical toxicology fellows and specialists. Specialist staff are pharmacists licensed by the California State Board of Pharmacy who are certified as Specialists in Poison Information by the AAPCC and/or board certified by ABAT. The students are responsible for creating follow-up notes and presenting the case verbally during daily group rounds among all other clerkship students, medical toxicology fellows, and an attending clinical toxicologist. The case presentations are structured in a subjective, objective, assessment, plan (SOAP) format, and students are expected to provide an assessment and treatment plan for the patient. Upon resolution of cases (e.g., patient discharged from hospital), learners are responsible for completing a discharge summary that includes a brief description of the case with patient demographics, age, sex, substance(s) taken or exposed to with amounts or doses, presenting symptoms, relevant laboratory findings, hospital course with progression of signs and symptoms, all treatments, and final medical outcome. Students may also accompany the medical toxicology fellow performing bedside consultations on hospitalized patients at the hosting hospital for the PCC. Additionally, students are assigned shadowing experiences with the specialist staff of the PCC to observe case management techniques while conferencing on incoming hotline calls. The students initiate follow-up calls on home-managed cases to gain experience in communicating with public callers, providing poison prevention advice, and understanding the spectrum of circumstances and outcomes of poisonings that are entirely managed by a PCC service. The primary educational goals for this experience include the ability to retrieve and document relevant information and case histories by telephone from healthcare providers on hospitalized poisoned patients throughout the service region of the PCC, to develop a working understanding of information retrieval systems used by poison center staff for case management, to construct an evidenced-based treatment plan for a hospitalized patient, to present patient cases to an interprofessional group, and to defend assessments and treatment plans. The students are expected to integrate underlying principles of basic and clinical sciences (e.g., pharmacology, pharmacokinetics, pathophysiology, physical and laboratory assessment) into their case management assessments and plans. Student pharmacists are also responsible for researching and presenting a contemporary topic on a poisoning-related issue that emerged from a case managed by the CPCS. The topics may broadly span such issues as newly marketed drugs, designer or illicit drugs, antidotes, natural toxins, decontamination and enhanced elimination of toxins, poisoning case management, forensics, and emerging public health problems. This activity meets the educational goal of demonstrating a foundation of knowledge regarding the discipline of clinical toxicology. This includes the ability to describe the indications, advantages and disadvantages of modalities to decontaminate a poisoned patient and enhance the elimination of poisons, and the use of antidotes. Additionally, learners given a hypothetical poisoning should be able to devise the initial approach to differential diagnosis and management of life-threatening symptoms (e.g., seizures, coma, hypotension) and describe the key features of the clinical presentation and management of the most 506
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
common drugs, chemicals, and natural toxin-induced poisonings. It was surmised that due to the capricious and unpredictable types of cases that may be discussed and managed during a four to six week period coincidental with a scheduled APPE, a structured self-study component was necessary. Students complete assigned readings from a textbook, Poisoning and Drug Overdose, created and authored by the CPCS and available online as a component of AccessMedicine. The text is a concise clinical guide for the diagnosis and management of poisonings. Additionally, APPE students complete online modules with associated quizzes and final comprehensive examinations. In 2014, a Massive Open Online Course (MOOC) was developed in conjunction with a partnership of an educational technology company, Coursera, the University, and the UCSF School of Pharmacy. The course was entitled Poisonings in the Home and Community: Assessment and Emergency Response. It was constructed as a six-module course in which each module was 60 to 90 min in duration with one to three integrated case-based quizzes per lecture and a final cumulative examination. The topics included general principles and household hazards, plants and mushrooms, venoms, stimulants, depressants, and emergency department management of the poisoned patient. The course is no longer a MOOC and has since been transferred to our collaborative learning environment (CLE) Moodle and is entitled Toxicology Video Course. All APPE students are required to complete all six modules, take the interactive case quizzes, and pass the comprehensive final examination attached to the course. The learning objectives of the online modules overlap with the overall learning objectives for the APPE. There are six additional modules posted as recorded lectures on the CLE platform that cover additional topics of urine drug screens, anion gap acidosis, decontamination, toxic alcohols, hyperthermia, antidepressant poisoning, cardiac glycoside poisoning, party drugs at raves, botulism, seafood poisoning, mushrooms, and snakebites. These additional modules are common topics for poisonings and are supplemental to the modules provided in the course described above. The final component of the APPE involves two active learning activities, a full environment simulation utilizing a high-fidelity mannequin with high acuity poisoning scenario and an antidote tasting session. The learners participate in a three-hour simulation exercise consisting of two to three scenarios that may include a hypotensive and bradycardic patient presentation, an agitated and hyperthermic patient, a pesticide exposure, or a pediatric patient with bloody emesis. The learning objectives for the simulation include demonstration of an appropriate understanding of the general approach to a patient with an acute overdose, recognition of signs and symptoms for toxidromes, understanding the management of a patient with life-threatening symptoms, and identification of specific therapies for a drug or chemical-induced poisoning. The pharmacy students work within an interprofessional team that includes medical students, emergency medicine residents, and pediatric physician residents. One primary goal is for each participant is to understand and practice closed-loop communication techniques. Prior to the simulation, the pharmacy students are provided a drug formulary of 75 antidotes (Table 1) and supportive care medications (e.g., paralytics and sedatives for rapid sequence intubation) to review with specific generic and brand name product listings and stocking levels. Students utilize the provided formulary to become familiar with the antidotes and medications that may be needed during the simulation. While access to the formulary list and other drug information databases is available during the simulation, the pace of the cases included in the exercise requires baseline knowledge and an information retrieval plan. The students must be prepared to administer any of these formulary medications into a cannulated portal system for the mannequin with a bar coding system that can record the time of administration of the drug during the simulation. The participants of the simulation exercise may vary depending on the timing and availability of students. Generally, two pharmacy students, one to two medical students, and one to two emergency medicine residents participate. One pharmacy student recommends the choice and dosing of the antidote(s) and draws up the antidote(s) into a syringe for administration. The other pharmacy student confers with the first pharmacy student, provides consultation to the team on medication-related issues, records all medications administered on a medication administration record, and is responsible for reciting a summary of the record upon request at any time during the simulation. The medical students assist with monitoring the vital signs while the emergency medicine residents serve as the team leader and primary case assessor. In this manner, the simulation offers an opportunity for IPE. The timing of the simulation within the rotation varies due the constraints of the availability of the simulation facilities that house the simulation setting and high fidelity mannequin. Student feedback and assessment are conducted via a pre- and post-survey. Additionally, the simulations are videotaped for review upon request, and a debriefing is conducted after each scenario. The medical toxicology fellows and managing director of the PCC incorporate student simulation performance comments into the final APPE assessment. The learning objectives related to the use of the formulary drugs during the simulation include the ability to provide the correct indication, dose, route of administration, infusion rate, volume, diluent for administration, duration, and end-point of therapy. Students are expected to identify potential contraindications, significant adverse effects to monitor, and potential drug or laboratory interactions. The video recordings and each participant is surveyed pre- and post- simulation exercise. Emergency medicine pharmacists coordinate the antidote tasting activity (Table 1). All students and residents completing a learning experience at the time this activity is scheduled participate. The educational goal is to expose the student to issues of antidotes commonly used in poisonings. Exposure allows hands-on experience with the product, including personal handling and tasting. The value of this opportunity is to provide a student a real-life perspective on issues of dosing and palatability. The educational objectives for the antidote tasting include providing the indication, dosing, role, and mechanism of each antidote in addition to examining the actual product. A timed comprehensive final examination is administered at the end of the rotation that includes questions on the indications, dosing, and end-points of antidotal therapy. Questions on case-based causation analysis and mechanisms of action of toxins, as well as their medical management, are also included. Several assessment and evaluation tools were utilized to ensure quality improvement and quality assessment for the learning 507
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 1 Antidote formulary. Generic/Brand name
Stocking level
Activated charcoala Atropine Antivenom, Crotalidae Polyvalent Immune Fab (ovine)/CroFab® Antivenom, Black Widow Spider/Antivenom Latrodectus Mactans® BAL (Dimercaprol)/BAL in oil 10% Bicarbonate, sodium
4 × 50 g each bottles 13 vials (0.4 mg/mL, 20 mL each) 12 vials 1 vial 2 amps (100 mg/mL, 3 mL each) 750 mL of 8.4% sodium bicarbonate solution and 3 × (1 mEq/mL, 50 mL each) ampules 10 vials (10 mL, 10%) 1 × 100 g powder bottle 30 vials (10 mL, 10%) 6 × 25 g tubes 10 × 1 g vials 2 × (150 mg/mL, 2 mL each) vials 2 50 × (20 mg each) vials 6 × 2 g vials 6 × prefilled injectors (50%, 50 mL each) and 3 × bottles or bags (10%, 1 L each) 4 × (5 mg/mL, 10 mL each) vials 15 vials of either product 3 × (50 mg/mL, 1 mL each) ampules 10 × 100 mg capsules 1 × (160 mg/mL, 5 mL each) vial 1 × 1 g ampule
Calcium Chloride Injection Calcium Gluconate powder Calcium Gluconate Injection Calcium Gluconate Gel/Calgonate 2.5% gel® Carnitine (L-carnitine)/Carnitor® Cimetidine Cyanide antidote packages Dantrolene sodium Deferoxamine/Desferal® Dextrose (also see sodium chloride below) Diazepam (Valium®) Digoxin Immune Fab (ovine)/Digibind® or DigiFab® Diphenhydramine (parenteral) DMSA (Succimer)/Chemet® Dopamine hydrochloride DTPA-Calcium (Diethylenetriamine pentaacetate)/Pentetate Calcium Trisodium Injection DTPA-Zinc (Diethylenetriamine pentaacetate)/Pentetate Zinc Trisodium Injection EDTA-Calcium/Versenate® Epinephrine hydrochloride Esmolol hydrochloride, (Brevibloc®) Ethanol IV 10% with 5% Dextrose Ethanol oral/Vodka Etomidate (Amidate®) Flumazenil/Romazicon® Fomepizole (4-MP)/Antizol® Glucagon Haloperidol Hydroxycobalamin/Cyanokit® Insulin, regular Intralipid 20% Isoproterenol Hydrochloride Labetalol Hydrochloride Leucovorin calcium Lidocaine Hydrochloride Lorazepam, (Ativan®) Magnesium sulfate Methylene Blue Midazolam, (Versed®) Metoclopramide hydrochloride, (Reglan®) Morphine sulfate N-Acetylcysteine (NAC)/Mucomyst® or generic (oral preparation)* N-Acetylcysteine (NAC)/Acetadote® (IV preparation) Naloxone/Narcan® Nitroprusside sodium Norepinephrine bitartrate Octreotide acetate/Sandostatin® Olanzapine Ondansetron hydrochloride/Zofran® D-Penicilliamine/Cupramine® Pentobarbital sodium Phenobarbital sodium Phentolamine mesylate Phenylephrine/Neosynephrine® Phenytoin sodium Physostigmine/Antilirium® Potassium chloride Pralidoxime (2-PAM)/Protopam® Propofol Propranolol hydrochloride
1 × 1 g ampule 1 ampule 4 × (1:1000 or 1 mg/mL, 1 mL each) ampules 2 × (250 mg/mL, 10 mL each) ampules 2 bottles (1 L each) 1 pint 2 × (2 mg/mL, 20 mL each) vials 6 × 1 mg/10 mL vials 1 × 1.5 mL (1 g/mL) vials 90 × 1 mg kits 2 × (5 mg/mL, 10 mL each) vials 2 kits 1 × (100 U/mL, 10 mL each) vial 3 × (100 mL each) bags plus 6 × (500 mL each) bags 5 × (1:5000, 10 mL each) vials 3 × (5 mg/mL, 20 mL each) vials 1 × (100 mg each) vial 3 × prefilled 100 mg syringes and 2 × 1 g vials for infusions 2 × (4 mg/mL, 1 mL each) vials 2 × (500 mg/mL, 2 mL each) vials 4 × 10 mL (10 mg/mL) amps 2 × (5 mg/mL, 5 mL each) vials 4 × (5 mg/mL, 50 mL each) vials 10 × (0.5 mg/mL, 10 mL each) ampules 5 × 30 mL (20%) vials 1 carton of 4 × 30 mL (20%) vials 50 × 0.4 mg/2 mL amps 8 × (50 mg each) vials 2 × (1 mg/mL, 4 mL each) ampules 2 × 1 mL (0.1 mg/mL) amps 3 × 10 mg vials 8 × (2 mL) vials (2 mg/mL) 2 × 250 mg capsules 1 × (20 mL) vial (50 mg/mL) 16 × (1 mL) ampules (130 mg each) 8 vials (5 mg each) 4 × (1 mL) vials (10 mg/mL) 8 × (50 mg/mL, 5 mL each) vials 2 × 2 mL (1 mg/mL) amps 5 × (30 mEq, 15 mL each) vials 7 × 1 g (20 mL) vials 5 × (100 mL) vials (10 mg/mL) 6 × (1 mg/mL, 1 mL each) vials
(continued on next page) 508
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 1 (continued) Generic/Brand name
Stocking level
Prussian Blue/Radiogardase® Pyridoxine (Vitamin B6) Rocuronium bromide (Zemuron®) Sodium Chloride (normal saline)
25 bottles (30 capsules each) 3 vials (100 mg/mL, 30 mL each) 8 × (10 mL) vials (10 mg/mL) 0.45% (1/2 normal saline) and 0.9% (normal saline) with and without 5% dextrose in 250, 500, and 1000 mL bags 1 × (10 mL) vial (20 mg/mL) 1 vial 3 × multiple-dose vials (100 mg/mL, 2 mL each) 1 × (20 U/mL, 1 mL each) vial 10 × 5 mg tabs and 5 × 10 mg/mL amps
Succinylcholine chloride (Anectine®) Tetanus toxoid 5 LF U/0.5 mL in combination with diphtheria toxoid Thiamine hydrochloride Vasopressin Vitamin K1 (Phytonadione)/Mephyton® or AquaMephyton®
g = gram; mg = milligram; mL = milliliter; U = unit; mEq = milliequivalent. a Tasted during antidote tasting and handling exercise.
experience. Learners completed a simulation specific assessment pre- and post-simulation (survey shown in Table 2). Questions on this survey were formatted using five-point Likert scale (1 = not at all valuable/comfortable, 5 = highly valuable/comfortable) and free-text responses. Data analysis was conducted using statistical software Stata 12.4 In analysis of these data, chi-square, Fisher's exact test, and one-way analysis of variance (ANOVA) were utilized when appropriate. Statistical significance was defined as p ≤ 0.05.The UCSF IRB deemed this project exempt. Findings Simulation evaluation and assessment From October 2011 to October 2017, pharmacy students completed 85 pre-simulation surveys and 80 post-simulation surveys. Although data were collected on all types of learners, only the pharmacy students were required to complete all aspects of the APPE; therefore, only their responses are presented. However, it should be mentioned that the responses of other learners largely mirrored those of the pharmacy students. Of interest, only 29 (34.1%) pharmacy student participants had previously participated in a simulation exercise. Prior to simulation, the vast majority of pharmacy students (90%) agreed that “supportive care measures” are the most common interventions in the management of acutely poisoned patients. An increase in participants who believed a clinical pharmacist should be involved in the differential diagnosis and management of patient scenarios increased from 51 (60%) presimulation to 63 (78.8%) post-simulation (p = 0.009). In addition, the participants who understood the term “closed-loop communication” before and after simulation increased (29.4% vs. 83.8%, p < 0.001). The majority of trainees viewed the simulation experience as “valuable” or “highly valuable” (95%). APPE assessment As part of ongoing curriculum assessment, APPE pharmacy students completed an evaluation of the preceptors(s), site, and learning experience. The UCSF School of Pharmacy transitioned to an online evaluation management system starting May 2012. From April 2012 (the start of the APPE cycle for the cohort entering APPEs) to October 2017, 82 student pharmacists rotated through the PCC. Qualitative and quantitative assessment data were collected via preceptor and site/experience evaluations completed by each student pharmacist. The average scores on a five point Likert scale for each area on the preceptor evaluation tool and site evaluation tool are described in Table 3. The average scores for the areas assessed was > 4.5, revealing high satisfaction with the experience. Qualitative data was provided as part of the end of APPE evaluation set completed by each student. Two faculty members independently reviewed the qualitative feedback provided by 76 students, and the comments were analyzed for thematic content. The faculty discussed similarities and differences of the analyses and reached final consensus on the theme descriptors. Table 4 includes common key themes and selected quotes that illustrate the themes. Discussion This article discusses a specialty pharmacy practice APPE. As part of this elective APPE, students participate in various activities in an interprofessional setting. Since its inception, the structure of the APPE has adapted to ensure a positive learning environment. The development of online modules allows for a thorough review of toxicology topics while not detracting from active learning opportunities during rotation hours. The implementation of the high-fidelity simulation resulted in a statistically significant increase in the number of respondents who understood the term “closed-loop communication” (29.4% vs. 83.8%). This was used as a surrogate marker of respondent's comprehension of teamwork and communication skills. A significant increase in pharmacy students who believed a clinical pharmacist should be involved in the differential diagnosis and management of patient scenarios was documented. This change in perception of a clinical pharmacist's role suggests improved understanding of the pharmacist's available knowledge and skill-set among the interprofessional team. Similar results have been documented in previous studies in a variety of 509
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 2 Learner simulation survey. Survey questions:
Response field:
What is your area of training?
-Pharmacy student -Medical student -Internal medicine resident -Emergency medicine resident -Pediatrics resident -Other -PGY-1 -PGY-2 -PGY-3 -PGY-4 -PGY-5 -Yes -No -Week 1 -Week 2 -Week 3 -Week 4 -Week 5 -Week 6 (Check all that apply) -Acetaminophen -Acute alcohol withdrawal -Acute alcohol intoxication -Antidepressant overdose (i.e. SSRI) -Acute stimulant intoxication (i.e. cocaine, amphetamines) -Beta blocker overdose -Calcium channel blocker overdose -Carbon monoxide exposure -Cyanide exposure -Digoxin toxicity -Drug-related hyperthermia (including serotonin syndrome, malignant hyperthermia) -Environmental envenomations (i.e. black widow spider, rattlesnake) -Lithium overdose -Opiate overdose -Pesticide exposure -Salicylate (aspirin) overdose -Toxic alcohol ingestion (ethylene glycol, methanol) -Tricyclic antidepressant overdose (5 point Likert-type scale) -Management of critically ill adults -Management of critically ill children -Management of adults with overdose -Management of children with overdose -Management of patients with altered mental status -Management of severely agitated patients -Decontamination with whole bowel irrigation -Administration of an antidote -Supportive care measures -Forced emesis -None of the above -Yes -No (Check all that apply) -Reduce medication errors -Help in the selection of appropriate medications -Assist in the differential diagnosis and management of acutely ill patients -Recognition and prevention of adverse drug events -Provides an educational resource -Surveillance of medication orders (Free text response)
If applicable, what is your PGY level?
Prior to today, have you ever participated in a simulated patient exercise? Which week are you in of your toxicology rotation?
Up to this point in your training, which of the following toxicologic exposures have you been involved in managing?
Please indicate your comfort in managing the following situations:
Which of the following do you think is the most common intervention in the management of acutely poisoned patients?
Do you have a clinical pharmacist available in the clinical setting in which you practice? (i.e. dedicated pharmacist in your emergency department) What do you believe is the role of a clinical pharmacist?
What is meant by the term, “closed-loop communication”?
PGY = post-graduate year; SSRI = selective serotonin reuptake inhibitor.
510
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 3 Student pharmacists' evaluations of CPCS APPE learning experience and preceptor(s). Area assessed
Applicable answers (N)
Average score Scale 1–5 (with 5 the highest/desired score)
Creation of supportive learning environment Provides feedback Role model for student pharmacists Promotion of Critical Thinking Orientation Learning objectives Availability of Resources Practice environment
82 81 80 81 76 76 76 76
4.56 4.54 4.88 4.74 4.25 4.58 4.87 4.78
CPCS = California Poison Control System; APPE = advanced pharmacy practice experience. Table 4 Student pharmacists qualitative feedback regarding the APPE at the CPCS, categorized by common (frequency > 5) key themes. Assessment area: theme (frequencya) Learning objectives successfully achieved Basic principles of toxicology (23) Communication (16) Interprofessional education (13) Patient care/patient management (12) Foundational science integration (11) Areas of improvement for future students Orientation (14) Additional opportunities (8) Elements that factored into practice environment score Collaborative and supportive (IPE) environment (28) Learning opportunities (25) Preceptors (22) Resources and work stations (8) Rotation structure (8)
Illustrative quote(s) “Learned the basics of toxicology and overdose based on readings and case review” “How to communicate with team, writing notes and discharge summaries, and presenting patients on rounds” “I developed the ability to work as part of an interprofessional team…” “I really had the chance to learn how to assess the patient, not only gather important information for the patient but also to come up with an assessment plan” “Understanding deeply mechanisms of action and pharmacology” “First day orientation could be better organized” “Please make ED experience more readily available (perhaps once/week).” “Environment facilitates collaboration and learning across disciplines.” “Site offers and creates opportunities to practice and strengthen skills necessary for pharmacy practice in the toxicology setting.” “The staff at this site are some of the most impressive that I have ever worked with. Their dedication to lifelong learning, constant publications, and fascinating discussions are truly inspiring.” “This site certainly provides the resources and opportunities to develop the skills necessary for pharmacy practice in this setting.” “Site was very hands on and allowed us to make recommendations to physicians in a controlled environment.”
APPE = advanced pharmacy practice experience; CPCS = California Poison Control System. a Number of times appeared in student comments out of 76 student responses.
clinical settings. Garbee et al.5 found high-fidelity simulation as an effective method for IPE in undergraduate learners from nursing, respiratory therapy, nurse-anesthesia, and medical students. An increase in interprofessional teamwork and communication skills with retention of skills over a five-month period was demonstrated. Similarly, improvement in team-based attitudes and behaviors was noted in another study investigating operating room IPE.6 Literature including pharmacy learners also shows encouraging results, specifically related to communication, from studies using high-fidelity patient simulation for IPE.7–10 Smithburger et al.7 found improved Communication and Teamwork Skills (CATS) scores in a cohort of pharmacy, medical, nursing, social work, and physician assistant students. APPE evaluations completed by students revealed high satisfaction with the experience. As documented in Tables 3 and 4, student feedback regarding this APPE suggests that the learning objectives are clear and appropriate for student learning and that student progress is tracked through regular feedback. Based on student feedback, the APPE creates opportunities to practice and strengthen skills necessary for this practice setting, with 82% of students rating the practice environment at the highest level (5 out of 5). The qualitative feedback provided additional insight into the student's perceptions of the overall experience. For example, the interprofessional and collaborative learning experience was the most commonly mentioned factor that students considered when ranking the practice environment score. Students felt that the structure of the APPE allowed for learning opportunities not available in other practice settings. The application of foundational and basic sciences into patient care was noted as a benefit. One theme identified in the student assessment tool is related to the site and experience orientation. Based on student feedback, the preceptors at the site enhanced the orientation program by providing an introductory email with links to an updated orientation PowerPoint and internal website that allowed for the storage and sharing of rotation materials. A student coordinator was also identified. This coordinator schedules all learners at the site and is responsible for ensuring all materials for orientation are up to date. The coordinator greets students upon their arrival and oversees the orientation process on the first day. In addition, to address the comments by students about a desire for additional opportunities, the medical toxicology fellows are encouraged to invite all pharmacy students for bedside 511
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
consults. The CPCS is affiliated with an academic institution, and thus has access to resources that may not be available to all PCCs. For example, the simulation center and development of modules may not be available to all centers. These learning activities are important for the success of this learning experience. An additional limitation includes the change in APPE assessment tools in 2012. Therefore, we were not able to conduct an analysis of pre- and post-changes that were implemented as part of the continuous quality improvement process for the experience. Summary An APPE in the CPCS was successfully designed and implemented. The APPE provides an interprofessional collaborative learning environment that allows student pharmacists to understand the unique role of pharmacist in this setting. The addition of the simulation activity enforced interprofessional teamwork, specifically communication skills. Student feedback documents the positive learning environment for this elective experience. Conflict of interest None. Disclosure(s) None. References 1. Framework for action on interprofessional education and collaborative practice. Health professions networks nursing & midwifery human resources for health. World Health Organization; 2010 http://www.who.int/hrh/resources/framework_action/en/ Accessed: 13 April 2019. 2. Core competencies for interprofessional collaborative practice: report of an expert panel. Interprofessional Education Collaborative Expert Panel https://members. aamc.org/eweb/upload/Core%20Competencies%20for%20Interprofessional%20Collaborative%20Practice_Revised.pdf; May 2011 Accessed: 13 April 2019. 3. Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree (“Standards 2016”). Accreditation Council for Pharmacy Education; February 2015 https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf Accessed: 13 April 2019. 4. Stata Statistical Software [computer program]. Version 12. College Station, TX: StataCorp LP; 2011. 5. Garbee DD, Paige J, Barrier K, et al. Interprofessional teamwork among students in simulated codes: a quasi-experimental study. Nurs Educ Perspect. 2013;34(5):339–344. 6. Paige JT, Garbee DD, Kozmenko V, et al. Getting a head start: high-fidelity, simulation-based operating room team training of interprofessional students. J Am Coll Surg. 2014;218(1):140–149. 7. Smithburger PL, Kane-Gill SL, Kloet MA, Lohr B, Seybert AL. Advancing interprofessional education through the use of high fidelity human patient simulators. Pharm Practice (Granada). 2013;11(2):61–65. 8. Meyer BA, Seefeldt TM, Ngorsuraches S, et al. Interprofessional education in pharmacology using high fidelity simulation. Curr Pharm Teach Learn. 2017;9(6):1055–1062. 9. Bolesta S, Chmil JV. Interprofessional education among student health professionals using human patient simulation. Am J Pharm Educ. 2014;78(5) https://doi.org/ 10.5688/ajpe78594. 10. Kim TE, Shankel T, Reibling ET, et al. Healthcare students interprofessional critical event/disaster response course. Am J Disaster Med. 2017;12(1):11–26.
512
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
An interprofessional clinical toxicology advanced pharmacy practice experience
T
Valerie B. Clinarda, , Thomas E. Kearneya,b, Daniel J. Repplingerb, Craig G. Smollinb, Sharon L. Youmansa ⁎
a
Department of Clinical Pharmacy, University of California San Francisco, School of Pharmacy, 513 Parnassus Avenue, S-126, San Francisco, CA 94143-0403, United States b California Poison Control System – San Francisco Division, Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, Suite 6A, San Francisco, CA 94110, United States
ARTICLE INFO
ABSTRACT
Keywords: Advanced pharmacy practice experience Clinical toxicology Poison control center Interprofessional
Background and purpose: Clinical toxicology is a blend of science, research, and patient management practices involving human poisonings from exposure to natural and synthetic toxins. The objective of this study was to describe the components of an elective advanced pharmacy practice experience (APPE) in clinical toxicology at California Poison Control System (CPCS). Educational activity and setting: The APPE requirements included a mix of active participation in case management and supplemental educational exercises, case presentations and consultations, and a structured self-study component consisting of readings and on-line modules. In addition, there were two active learning activities, high acuity poisoning simulation scenarios utilizing a high-fidelity mannequin, and an antidote tasting session. Findings: From April 2012 to October 2017, 82 student pharmacists completed this APPE. Pharmacy students completed 85 pre-simulation surveys and 80 post-simulation surveys. Survey results showed an increase in pharmacy student beliefs that a clinical pharmacist should be involved in the differential diagnosis and management of patients (60% pre-simulation vs. 78.8% post-simulation, p = 0.009). APPE pharmacy students completed an evaluation of the preceptors (s), site, and learning experience. The average score for all areas on the preceptor and site evaluations was > 4.5 on a 5-point Likert scale. Qualitative data themes included student satisfaction with opportunities, feedback, and the interprofessional and collaborative environment. Summary: An APPE in the CPCS was successfully designed and implemented. The APPE provides an interprofessional collaborative learning environment that allows student pharmacists to understand the unique role of the pharmacist in this setting.
Background and purpose Clinical toxicology is a blend of science, research, and patient management practices involving human poisonings from exposure to natural and synthetic toxins. Several pharmacist career opportunities in this field include hospital-based practices in emergency medicine, critical care, industry-based drug safety, academia, forensic consultants, and specialists and consultants in poison control centers (PCCs). The American Board of Applied Toxicology (ABAT) administers an exam to credential and board certify non-physician Corresponding author. E-mail addresses: [email protected] (V.B. Clinard), [email protected] (T.E. Kearney), [email protected] (C.G. Smollin), [email protected] (S.L. Youmans). ⁎
https://doi.org/10.1016/j.cptl.2019.02.002
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
clinical toxicologists, including pharmacists. The California Poison Control System (CPCS) provides a platform for interprofessional collaboration and education in a clinical setting for advanced pharmacy practice experiences (APPEs). The CPCS, with four interconnected divisions – San Francisco, Sacramento, Madera, and San Diego – are all managed by the Department of Clinical Pharmacy at the University of California, San Francisco (UCSF) School of Pharmacy. The CPCS is accredited by the American Association of Poison Control Centers (AAPCC), operates on a 24 hour 7 day per week basis to all residents of the state of California, and is staffed predominately by pharmacists with specialty training and certification as Specialists in Poison Information. Interprofessional education (IPE) enables students from varying disciplines to learn with, from, and about each other to improve collaboration.1 This intentional component of the doctor of pharmacy curriculum prepares students to be a member of an interprofessional collaborative practice team. IPE is a priority for all health professional programs nationally and is a requirement outlined in the accreditation documents of each discipline.2 The Accreditation Council for Pharmacy Education (ACPE) “Standards 2016”3 describe IPE as an important component of pharmacy education. The San Francisco Division of the CPCS has served as a site for student APPEs since its inception in 1997 and provides a platform for active learning within an interprofessional setting. An average of five to six learners (medical students, emergency medicine residents, pediatric fellows, pharmacy residents, APPE pharmacy students, international physicians, and pharmacists training to develop PCC services abroad) rotate through the PCC at any given time. Two pharmacy students are assigned to a six-week block rotation. The service also includes full-time medical toxicology fellows, physicians typically trained in emergency medicine that participate in a two-year training program. As a component of their training, the medical toxicology fellows serve as daily coordinators for the students. The managing director of the PCC serves as an attending and consultant for the hospitalized patient consult service one day per week and along with a cadre of attending physicians, conducts teaching rounds with the students and medical toxicology fellows. The managing director, board certified by ABAT, is a faculty member of the UCSF School of Pharmacy and the preceptor of record for the APPE students. The objective of this study was to describe the components of the elective APPE associated with this PCC. Educational activity and setting The APPE requirements at the PCC include a mix of active participation in case management and supplemental educational exercises. Students must actively participate in all conferences and case discussions. Daily rounds are conducted on patients hospitalized for toxic exposures. Weekly grand rounds are conducted at the San Francisco Division, consisting of presentations by the medical toxicology fellow. These presentations usually include problematic or illustrative poisoning cases, are used to solicit opinions from the audience, and serve as a teaching tool for the audience. Statewide rounds are another opportunity for collaborative learning. These rounds occur bi-weekly via teleconference between each of the four divisions of the CPCS on a rotating basis. These presentations also typically include problematic or illustrative poisoning cases. Students are assigned to perform follow-up call to previously hospitalized patient to assess status with the guidance of the medical toxicology fellows and specialists. Specialist staff are pharmacists licensed by the California State Board of Pharmacy who are certified as Specialists in Poison Information by the AAPCC and/or board certified by ABAT. The students are responsible for creating follow-up notes and presenting the case verbally during daily group rounds among all other clerkship students, medical toxicology fellows, and an attending clinical toxicologist. The case presentations are structured in a subjective, objective, assessment, plan (SOAP) format, and students are expected to provide an assessment and treatment plan for the patient. Upon resolution of cases (e.g., patient discharged from hospital), learners are responsible for completing a discharge summary that includes a brief description of the case with patient demographics, age, sex, substance(s) taken or exposed to with amounts or doses, presenting symptoms, relevant laboratory findings, hospital course with progression of signs and symptoms, all treatments, and final medical outcome. Students may also accompany the medical toxicology fellow performing bedside consultations on hospitalized patients at the hosting hospital for the PCC. Additionally, students are assigned shadowing experiences with the specialist staff of the PCC to observe case management techniques while conferencing on incoming hotline calls. The students initiate follow-up calls on home-managed cases to gain experience in communicating with public callers, providing poison prevention advice, and understanding the spectrum of circumstances and outcomes of poisonings that are entirely managed by a PCC service. The primary educational goals for this experience include the ability to retrieve and document relevant information and case histories by telephone from healthcare providers on hospitalized poisoned patients throughout the service region of the PCC, to develop a working understanding of information retrieval systems used by poison center staff for case management, to construct an evidenced-based treatment plan for a hospitalized patient, to present patient cases to an interprofessional group, and to defend assessments and treatment plans. The students are expected to integrate underlying principles of basic and clinical sciences (e.g., pharmacology, pharmacokinetics, pathophysiology, physical and laboratory assessment) into their case management assessments and plans. Student pharmacists are also responsible for researching and presenting a contemporary topic on a poisoning-related issue that emerged from a case managed by the CPCS. The topics may broadly span such issues as newly marketed drugs, designer or illicit drugs, antidotes, natural toxins, decontamination and enhanced elimination of toxins, poisoning case management, forensics, and emerging public health problems. This activity meets the educational goal of demonstrating a foundation of knowledge regarding the discipline of clinical toxicology. This includes the ability to describe the indications, advantages and disadvantages of modalities to decontaminate a poisoned patient and enhance the elimination of poisons, and the use of antidotes. Additionally, learners given a hypothetical poisoning should be able to devise the initial approach to differential diagnosis and management of life-threatening symptoms (e.g., seizures, coma, hypotension) and describe the key features of the clinical presentation and management of the most 506
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
common drugs, chemicals, and natural toxin-induced poisonings. It was surmised that due to the capricious and unpredictable types of cases that may be discussed and managed during a four to six week period coincidental with a scheduled APPE, a structured self-study component was necessary. Students complete assigned readings from a textbook, Poisoning and Drug Overdose, created and authored by the CPCS and available online as a component of AccessMedicine. The text is a concise clinical guide for the diagnosis and management of poisonings. Additionally, APPE students complete online modules with associated quizzes and final comprehensive examinations. In 2014, a Massive Open Online Course (MOOC) was developed in conjunction with a partnership of an educational technology company, Coursera, the University, and the UCSF School of Pharmacy. The course was entitled Poisonings in the Home and Community: Assessment and Emergency Response. It was constructed as a six-module course in which each module was 60 to 90 min in duration with one to three integrated case-based quizzes per lecture and a final cumulative examination. The topics included general principles and household hazards, plants and mushrooms, venoms, stimulants, depressants, and emergency department management of the poisoned patient. The course is no longer a MOOC and has since been transferred to our collaborative learning environment (CLE) Moodle and is entitled Toxicology Video Course. All APPE students are required to complete all six modules, take the interactive case quizzes, and pass the comprehensive final examination attached to the course. The learning objectives of the online modules overlap with the overall learning objectives for the APPE. There are six additional modules posted as recorded lectures on the CLE platform that cover additional topics of urine drug screens, anion gap acidosis, decontamination, toxic alcohols, hyperthermia, antidepressant poisoning, cardiac glycoside poisoning, party drugs at raves, botulism, seafood poisoning, mushrooms, and snakebites. These additional modules are common topics for poisonings and are supplemental to the modules provided in the course described above. The final component of the APPE involves two active learning activities, a full environment simulation utilizing a high-fidelity mannequin with high acuity poisoning scenario and an antidote tasting session. The learners participate in a three-hour simulation exercise consisting of two to three scenarios that may include a hypotensive and bradycardic patient presentation, an agitated and hyperthermic patient, a pesticide exposure, or a pediatric patient with bloody emesis. The learning objectives for the simulation include demonstration of an appropriate understanding of the general approach to a patient with an acute overdose, recognition of signs and symptoms for toxidromes, understanding the management of a patient with life-threatening symptoms, and identification of specific therapies for a drug or chemical-induced poisoning. The pharmacy students work within an interprofessional team that includes medical students, emergency medicine residents, and pediatric physician residents. One primary goal is for each participant is to understand and practice closed-loop communication techniques. Prior to the simulation, the pharmacy students are provided a drug formulary of 75 antidotes (Table 1) and supportive care medications (e.g., paralytics and sedatives for rapid sequence intubation) to review with specific generic and brand name product listings and stocking levels. Students utilize the provided formulary to become familiar with the antidotes and medications that may be needed during the simulation. While access to the formulary list and other drug information databases is available during the simulation, the pace of the cases included in the exercise requires baseline knowledge and an information retrieval plan. The students must be prepared to administer any of these formulary medications into a cannulated portal system for the mannequin with a bar coding system that can record the time of administration of the drug during the simulation. The participants of the simulation exercise may vary depending on the timing and availability of students. Generally, two pharmacy students, one to two medical students, and one to two emergency medicine residents participate. One pharmacy student recommends the choice and dosing of the antidote(s) and draws up the antidote(s) into a syringe for administration. The other pharmacy student confers with the first pharmacy student, provides consultation to the team on medication-related issues, records all medications administered on a medication administration record, and is responsible for reciting a summary of the record upon request at any time during the simulation. The medical students assist with monitoring the vital signs while the emergency medicine residents serve as the team leader and primary case assessor. In this manner, the simulation offers an opportunity for IPE. The timing of the simulation within the rotation varies due the constraints of the availability of the simulation facilities that house the simulation setting and high fidelity mannequin. Student feedback and assessment are conducted via a pre- and post-survey. Additionally, the simulations are videotaped for review upon request, and a debriefing is conducted after each scenario. The medical toxicology fellows and managing director of the PCC incorporate student simulation performance comments into the final APPE assessment. The learning objectives related to the use of the formulary drugs during the simulation include the ability to provide the correct indication, dose, route of administration, infusion rate, volume, diluent for administration, duration, and end-point of therapy. Students are expected to identify potential contraindications, significant adverse effects to monitor, and potential drug or laboratory interactions. The video recordings and each participant is surveyed pre- and post- simulation exercise. Emergency medicine pharmacists coordinate the antidote tasting activity (Table 1). All students and residents completing a learning experience at the time this activity is scheduled participate. The educational goal is to expose the student to issues of antidotes commonly used in poisonings. Exposure allows hands-on experience with the product, including personal handling and tasting. The value of this opportunity is to provide a student a real-life perspective on issues of dosing and palatability. The educational objectives for the antidote tasting include providing the indication, dosing, role, and mechanism of each antidote in addition to examining the actual product. A timed comprehensive final examination is administered at the end of the rotation that includes questions on the indications, dosing, and end-points of antidotal therapy. Questions on case-based causation analysis and mechanisms of action of toxins, as well as their medical management, are also included. Several assessment and evaluation tools were utilized to ensure quality improvement and quality assessment for the learning 507
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 1 Antidote formulary. Generic/Brand name
Stocking level
Activated charcoala Atropine Antivenom, Crotalidae Polyvalent Immune Fab (ovine)/CroFab® Antivenom, Black Widow Spider/Antivenom Latrodectus Mactans® BAL (Dimercaprol)/BAL in oil 10% Bicarbonate, sodium
4 × 50 g each bottles 13 vials (0.4 mg/mL, 20 mL each) 12 vials 1 vial 2 amps (100 mg/mL, 3 mL each) 750 mL of 8.4% sodium bicarbonate solution and 3 × (1 mEq/mL, 50 mL each) ampules 10 vials (10 mL, 10%) 1 × 100 g powder bottle 30 vials (10 mL, 10%) 6 × 25 g tubes 10 × 1 g vials 2 × (150 mg/mL, 2 mL each) vials 2 50 × (20 mg each) vials 6 × 2 g vials 6 × prefilled injectors (50%, 50 mL each) and 3 × bottles or bags (10%, 1 L each) 4 × (5 mg/mL, 10 mL each) vials 15 vials of either product 3 × (50 mg/mL, 1 mL each) ampules 10 × 100 mg capsules 1 × (160 mg/mL, 5 mL each) vial 1 × 1 g ampule
Calcium Chloride Injection Calcium Gluconate powder Calcium Gluconate Injection Calcium Gluconate Gel/Calgonate 2.5% gel® Carnitine (L-carnitine)/Carnitor® Cimetidine Cyanide antidote packages Dantrolene sodium Deferoxamine/Desferal® Dextrose (also see sodium chloride below) Diazepam (Valium®) Digoxin Immune Fab (ovine)/Digibind® or DigiFab® Diphenhydramine (parenteral) DMSA (Succimer)/Chemet® Dopamine hydrochloride DTPA-Calcium (Diethylenetriamine pentaacetate)/Pentetate Calcium Trisodium Injection DTPA-Zinc (Diethylenetriamine pentaacetate)/Pentetate Zinc Trisodium Injection EDTA-Calcium/Versenate® Epinephrine hydrochloride Esmolol hydrochloride, (Brevibloc®) Ethanol IV 10% with 5% Dextrose Ethanol oral/Vodka Etomidate (Amidate®) Flumazenil/Romazicon® Fomepizole (4-MP)/Antizol® Glucagon Haloperidol Hydroxycobalamin/Cyanokit® Insulin, regular Intralipid 20% Isoproterenol Hydrochloride Labetalol Hydrochloride Leucovorin calcium Lidocaine Hydrochloride Lorazepam, (Ativan®) Magnesium sulfate Methylene Blue Midazolam, (Versed®) Metoclopramide hydrochloride, (Reglan®) Morphine sulfate N-Acetylcysteine (NAC)/Mucomyst® or generic (oral preparation)* N-Acetylcysteine (NAC)/Acetadote® (IV preparation) Naloxone/Narcan® Nitroprusside sodium Norepinephrine bitartrate Octreotide acetate/Sandostatin® Olanzapine Ondansetron hydrochloride/Zofran® D-Penicilliamine/Cupramine® Pentobarbital sodium Phenobarbital sodium Phentolamine mesylate Phenylephrine/Neosynephrine® Phenytoin sodium Physostigmine/Antilirium® Potassium chloride Pralidoxime (2-PAM)/Protopam® Propofol Propranolol hydrochloride
1 × 1 g ampule 1 ampule 4 × (1:1000 or 1 mg/mL, 1 mL each) ampules 2 × (250 mg/mL, 10 mL each) ampules 2 bottles (1 L each) 1 pint 2 × (2 mg/mL, 20 mL each) vials 6 × 1 mg/10 mL vials 1 × 1.5 mL (1 g/mL) vials 90 × 1 mg kits 2 × (5 mg/mL, 10 mL each) vials 2 kits 1 × (100 U/mL, 10 mL each) vial 3 × (100 mL each) bags plus 6 × (500 mL each) bags 5 × (1:5000, 10 mL each) vials 3 × (5 mg/mL, 20 mL each) vials 1 × (100 mg each) vial 3 × prefilled 100 mg syringes and 2 × 1 g vials for infusions 2 × (4 mg/mL, 1 mL each) vials 2 × (500 mg/mL, 2 mL each) vials 4 × 10 mL (10 mg/mL) amps 2 × (5 mg/mL, 5 mL each) vials 4 × (5 mg/mL, 50 mL each) vials 10 × (0.5 mg/mL, 10 mL each) ampules 5 × 30 mL (20%) vials 1 carton of 4 × 30 mL (20%) vials 50 × 0.4 mg/2 mL amps 8 × (50 mg each) vials 2 × (1 mg/mL, 4 mL each) ampules 2 × 1 mL (0.1 mg/mL) amps 3 × 10 mg vials 8 × (2 mL) vials (2 mg/mL) 2 × 250 mg capsules 1 × (20 mL) vial (50 mg/mL) 16 × (1 mL) ampules (130 mg each) 8 vials (5 mg each) 4 × (1 mL) vials (10 mg/mL) 8 × (50 mg/mL, 5 mL each) vials 2 × 2 mL (1 mg/mL) amps 5 × (30 mEq, 15 mL each) vials 7 × 1 g (20 mL) vials 5 × (100 mL) vials (10 mg/mL) 6 × (1 mg/mL, 1 mL each) vials
(continued on next page) 508
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 1 (continued) Generic/Brand name
Stocking level
Prussian Blue/Radiogardase® Pyridoxine (Vitamin B6) Rocuronium bromide (Zemuron®) Sodium Chloride (normal saline)
25 bottles (30 capsules each) 3 vials (100 mg/mL, 30 mL each) 8 × (10 mL) vials (10 mg/mL) 0.45% (1/2 normal saline) and 0.9% (normal saline) with and without 5% dextrose in 250, 500, and 1000 mL bags 1 × (10 mL) vial (20 mg/mL) 1 vial 3 × multiple-dose vials (100 mg/mL, 2 mL each) 1 × (20 U/mL, 1 mL each) vial 10 × 5 mg tabs and 5 × 10 mg/mL amps
Succinylcholine chloride (Anectine®) Tetanus toxoid 5 LF U/0.5 mL in combination with diphtheria toxoid Thiamine hydrochloride Vasopressin Vitamin K1 (Phytonadione)/Mephyton® or AquaMephyton®
g = gram; mg = milligram; mL = milliliter; U = unit; mEq = milliequivalent. a Tasted during antidote tasting and handling exercise.
experience. Learners completed a simulation specific assessment pre- and post-simulation (survey shown in Table 2). Questions on this survey were formatted using five-point Likert scale (1 = not at all valuable/comfortable, 5 = highly valuable/comfortable) and free-text responses. Data analysis was conducted using statistical software Stata 12.4 In analysis of these data, chi-square, Fisher's exact test, and one-way analysis of variance (ANOVA) were utilized when appropriate. Statistical significance was defined as p ≤ 0.05.The UCSF IRB deemed this project exempt. Findings Simulation evaluation and assessment From October 2011 to October 2017, pharmacy students completed 85 pre-simulation surveys and 80 post-simulation surveys. Although data were collected on all types of learners, only the pharmacy students were required to complete all aspects of the APPE; therefore, only their responses are presented. However, it should be mentioned that the responses of other learners largely mirrored those of the pharmacy students. Of interest, only 29 (34.1%) pharmacy student participants had previously participated in a simulation exercise. Prior to simulation, the vast majority of pharmacy students (90%) agreed that “supportive care measures” are the most common interventions in the management of acutely poisoned patients. An increase in participants who believed a clinical pharmacist should be involved in the differential diagnosis and management of patient scenarios increased from 51 (60%) presimulation to 63 (78.8%) post-simulation (p = 0.009). In addition, the participants who understood the term “closed-loop communication” before and after simulation increased (29.4% vs. 83.8%, p < 0.001). The majority of trainees viewed the simulation experience as “valuable” or “highly valuable” (95%). APPE assessment As part of ongoing curriculum assessment, APPE pharmacy students completed an evaluation of the preceptors(s), site, and learning experience. The UCSF School of Pharmacy transitioned to an online evaluation management system starting May 2012. From April 2012 (the start of the APPE cycle for the cohort entering APPEs) to October 2017, 82 student pharmacists rotated through the PCC. Qualitative and quantitative assessment data were collected via preceptor and site/experience evaluations completed by each student pharmacist. The average scores on a five point Likert scale for each area on the preceptor evaluation tool and site evaluation tool are described in Table 3. The average scores for the areas assessed was > 4.5, revealing high satisfaction with the experience. Qualitative data was provided as part of the end of APPE evaluation set completed by each student. Two faculty members independently reviewed the qualitative feedback provided by 76 students, and the comments were analyzed for thematic content. The faculty discussed similarities and differences of the analyses and reached final consensus on the theme descriptors. Table 4 includes common key themes and selected quotes that illustrate the themes. Discussion This article discusses a specialty pharmacy practice APPE. As part of this elective APPE, students participate in various activities in an interprofessional setting. Since its inception, the structure of the APPE has adapted to ensure a positive learning environment. The development of online modules allows for a thorough review of toxicology topics while not detracting from active learning opportunities during rotation hours. The implementation of the high-fidelity simulation resulted in a statistically significant increase in the number of respondents who understood the term “closed-loop communication” (29.4% vs. 83.8%). This was used as a surrogate marker of respondent's comprehension of teamwork and communication skills. A significant increase in pharmacy students who believed a clinical pharmacist should be involved in the differential diagnosis and management of patient scenarios was documented. This change in perception of a clinical pharmacist's role suggests improved understanding of the pharmacist's available knowledge and skill-set among the interprofessional team. Similar results have been documented in previous studies in a variety of 509
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 2 Learner simulation survey. Survey questions:
Response field:
What is your area of training?
-Pharmacy student -Medical student -Internal medicine resident -Emergency medicine resident -Pediatrics resident -Other -PGY-1 -PGY-2 -PGY-3 -PGY-4 -PGY-5 -Yes -No -Week 1 -Week 2 -Week 3 -Week 4 -Week 5 -Week 6 (Check all that apply) -Acetaminophen -Acute alcohol withdrawal -Acute alcohol intoxication -Antidepressant overdose (i.e. SSRI) -Acute stimulant intoxication (i.e. cocaine, amphetamines) -Beta blocker overdose -Calcium channel blocker overdose -Carbon monoxide exposure -Cyanide exposure -Digoxin toxicity -Drug-related hyperthermia (including serotonin syndrome, malignant hyperthermia) -Environmental envenomations (i.e. black widow spider, rattlesnake) -Lithium overdose -Opiate overdose -Pesticide exposure -Salicylate (aspirin) overdose -Toxic alcohol ingestion (ethylene glycol, methanol) -Tricyclic antidepressant overdose (5 point Likert-type scale) -Management of critically ill adults -Management of critically ill children -Management of adults with overdose -Management of children with overdose -Management of patients with altered mental status -Management of severely agitated patients -Decontamination with whole bowel irrigation -Administration of an antidote -Supportive care measures -Forced emesis -None of the above -Yes -No (Check all that apply) -Reduce medication errors -Help in the selection of appropriate medications -Assist in the differential diagnosis and management of acutely ill patients -Recognition and prevention of adverse drug events -Provides an educational resource -Surveillance of medication orders (Free text response)
If applicable, what is your PGY level?
Prior to today, have you ever participated in a simulated patient exercise? Which week are you in of your toxicology rotation?
Up to this point in your training, which of the following toxicologic exposures have you been involved in managing?
Please indicate your comfort in managing the following situations:
Which of the following do you think is the most common intervention in the management of acutely poisoned patients?
Do you have a clinical pharmacist available in the clinical setting in which you practice? (i.e. dedicated pharmacist in your emergency department) What do you believe is the role of a clinical pharmacist?
What is meant by the term, “closed-loop communication”?
PGY = post-graduate year; SSRI = selective serotonin reuptake inhibitor.
510
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
Table 3 Student pharmacists' evaluations of CPCS APPE learning experience and preceptor(s). Area assessed
Applicable answers (N)
Average score Scale 1–5 (with 5 the highest/desired score)
Creation of supportive learning environment Provides feedback Role model for student pharmacists Promotion of Critical Thinking Orientation Learning objectives Availability of Resources Practice environment
82 81 80 81 76 76 76 76
4.56 4.54 4.88 4.74 4.25 4.58 4.87 4.78
CPCS = California Poison Control System; APPE = advanced pharmacy practice experience. Table 4 Student pharmacists qualitative feedback regarding the APPE at the CPCS, categorized by common (frequency > 5) key themes. Assessment area: theme (frequencya) Learning objectives successfully achieved Basic principles of toxicology (23) Communication (16) Interprofessional education (13) Patient care/patient management (12) Foundational science integration (11) Areas of improvement for future students Orientation (14) Additional opportunities (8) Elements that factored into practice environment score Collaborative and supportive (IPE) environment (28) Learning opportunities (25) Preceptors (22) Resources and work stations (8) Rotation structure (8)
Illustrative quote(s) “Learned the basics of toxicology and overdose based on readings and case review” “How to communicate with team, writing notes and discharge summaries, and presenting patients on rounds” “I developed the ability to work as part of an interprofessional team…” “I really had the chance to learn how to assess the patient, not only gather important information for the patient but also to come up with an assessment plan” “Understanding deeply mechanisms of action and pharmacology” “First day orientation could be better organized” “Please make ED experience more readily available (perhaps once/week).” “Environment facilitates collaboration and learning across disciplines.” “Site offers and creates opportunities to practice and strengthen skills necessary for pharmacy practice in the toxicology setting.” “The staff at this site are some of the most impressive that I have ever worked with. Their dedication to lifelong learning, constant publications, and fascinating discussions are truly inspiring.” “This site certainly provides the resources and opportunities to develop the skills necessary for pharmacy practice in this setting.” “Site was very hands on and allowed us to make recommendations to physicians in a controlled environment.”
APPE = advanced pharmacy practice experience; CPCS = California Poison Control System. a Number of times appeared in student comments out of 76 student responses.
clinical settings. Garbee et al.5 found high-fidelity simulation as an effective method for IPE in undergraduate learners from nursing, respiratory therapy, nurse-anesthesia, and medical students. An increase in interprofessional teamwork and communication skills with retention of skills over a five-month period was demonstrated. Similarly, improvement in team-based attitudes and behaviors was noted in another study investigating operating room IPE.6 Literature including pharmacy learners also shows encouraging results, specifically related to communication, from studies using high-fidelity patient simulation for IPE.7–10 Smithburger et al.7 found improved Communication and Teamwork Skills (CATS) scores in a cohort of pharmacy, medical, nursing, social work, and physician assistant students. APPE evaluations completed by students revealed high satisfaction with the experience. As documented in Tables 3 and 4, student feedback regarding this APPE suggests that the learning objectives are clear and appropriate for student learning and that student progress is tracked through regular feedback. Based on student feedback, the APPE creates opportunities to practice and strengthen skills necessary for this practice setting, with 82% of students rating the practice environment at the highest level (5 out of 5). The qualitative feedback provided additional insight into the student's perceptions of the overall experience. For example, the interprofessional and collaborative learning experience was the most commonly mentioned factor that students considered when ranking the practice environment score. Students felt that the structure of the APPE allowed for learning opportunities not available in other practice settings. The application of foundational and basic sciences into patient care was noted as a benefit. One theme identified in the student assessment tool is related to the site and experience orientation. Based on student feedback, the preceptors at the site enhanced the orientation program by providing an introductory email with links to an updated orientation PowerPoint and internal website that allowed for the storage and sharing of rotation materials. A student coordinator was also identified. This coordinator schedules all learners at the site and is responsible for ensuring all materials for orientation are up to date. The coordinator greets students upon their arrival and oversees the orientation process on the first day. In addition, to address the comments by students about a desire for additional opportunities, the medical toxicology fellows are encouraged to invite all pharmacy students for bedside 511
Currents in Pharmacy Teaching and Learning 11 (2019) 505–512
V.B. Clinard, et al.
consults. The CPCS is affiliated with an academic institution, and thus has access to resources that may not be available to all PCCs. For example, the simulation center and development of modules may not be available to all centers. These learning activities are important for the success of this learning experience. An additional limitation includes the change in APPE assessment tools in 2012. Therefore, we were not able to conduct an analysis of pre- and post-changes that were implemented as part of the continuous quality improvement process for the experience. Summary An APPE in the CPCS was successfully designed and implemented. The APPE provides an interprofessional collaborative learning environment that allows student pharmacists to understand the unique role of pharmacist in this setting. The addition of the simulation activity enforced interprofessional teamwork, specifically communication skills. Student feedback documents the positive learning environment for this elective experience. Conflict of interest None. Disclosure(s) None. References 1. Framework for action on interprofessional education and collaborative practice. Health professions networks nursing & midwifery human resources for health. World Health Organization; 2010 http://www.who.int/hrh/resources/framework_action/en/ Accessed: 13 April 2019. 2. Core competencies for interprofessional collaborative practice: report of an expert panel. Interprofessional Education Collaborative Expert Panel https://members. aamc.org/eweb/upload/Core%20Competencies%20for%20Interprofessional%20Collaborative%20Practice_Revised.pdf; May 2011 Accessed: 13 April 2019. 3. Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree (“Standards 2016”). Accreditation Council for Pharmacy Education; February 2015 https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf Accessed: 13 April 2019. 4. Stata Statistical Software [computer program]. Version 12. College Station, TX: StataCorp LP; 2011. 5. Garbee DD, Paige J, Barrier K, et al. Interprofessional teamwork among students in simulated codes: a quasi-experimental study. Nurs Educ Perspect. 2013;34(5):339–344. 6. Paige JT, Garbee DD, Kozmenko V, et al. Getting a head start: high-fidelity, simulation-based operating room team training of interprofessional students. J Am Coll Surg. 2014;218(1):140–149. 7. Smithburger PL, Kane-Gill SL, Kloet MA, Lohr B, Seybert AL. Advancing interprofessional education through the use of high fidelity human patient simulators. Pharm Practice (Granada). 2013;11(2):61–65. 8. Meyer BA, Seefeldt TM, Ngorsuraches S, et al. Interprofessional education in pharmacology using high fidelity simulation. Curr Pharm Teach Learn. 2017;9(6):1055–1062. 9. Bolesta S, Chmil JV. Interprofessional education among student health professionals using human patient simulation. Am J Pharm Educ. 2014;78(5) https://doi.org/ 10.5688/ajpe78594. 10. Kim TE, Shankel T, Reibling ET, et al. Healthcare students interprofessional critical event/disaster response course. Am J Disaster Med. 2017;12(1):11–26.
512