Rachel Phillips

[Rachel Phillips]

Big heart, big dreams, small expectations!
Firstly, ask the patient about his real sexual life expectations! Then, teach your patient about the real sex life expectations when having to live with HF! The heart may be pumping ok at rest but will be definitely jumping out of his chest with strenuous physical activity! Prepare the patient, help him face his real strengths and possibilities!
Then do some labs.

[Rachel Phillips]

Please follow the Below link that describes new model that improves estimation of glomerular filtration rate (GFR) that could replace seven previously published models as the new standard of care for calculating the dose of platinum-based chemotherapy

http://www.medscape.com/viewarticle/883119?src=soc_fb_170723_mscpedt_news_onc_chemo

Warm Regards,

[Rachel Phillips]

As mentioned, the key is the type of label and ink (or thermal). We have been using IPA 70% resistant label/ink for years now inside the isolator after spraying or wiping down. There is an important note too, try to minimize the glove touching to the sticky part of the label because this is the area where antiseptic doesn’t reach to.

Regards,

[Rachel Phillips]

My responses below are based on our workflow in the US. However, I am very confident that it can serve as a benchmark for other institutions as well. Please feel free to let me know if you have any other question or require further clarification. My answers are included below your questions.

1- what’s the standard time for preparing one iv dose ?

At our hospital, it depends on what is the medication. For non-controlled small or large volume parenteral, it may take 5 to 10 minutes. If a medication requires careful swirling or gentle shaking, it will take 25 to 45 minutes per dose. For controlled medications, it takes 10 to 15 minutes, from removing medication from our automated dispensing cabinet and preparing the dose. We are using scanning process for each step of preparation and dispensing and that is why it may take 3 to 5 minutes more than other places. However, we strongly believe on the safety aspect of scanning and have buy in from all stakeholders at the hospital.

2- what’s the benchmark for number of IV doses prepared by each technician ?

8 to 10 doses per hour

3- what’s the standard time taken by each pharmacist for verifying the physician order ( from sending fax to printing labels) ?

5 to 6 minutes to verify an order once entered by physician. This has been our average since we opened in 2015. We verify approximately 1100 orders per day or 115 to 175 orders per pharmacist per 8 hour shift.

4- what’s the standard time for checking one prepared IV dose ?

1 to 2 minutes after preparation.

Respectfully,

[Rachel Phillips]

Thanks for this interesting question. Here are my thoughts:

1. We cannot deprive Diabetic patients from Dextrose. Every patient should receive at least 120g of dextrose that is crucial for brain function and renal medulla homeostasis.

2. It is recommend to hold all sources of Sugar i.e. LVP, minibags, PO, EN in case of severe/acute glucose intolerance until insulin therapy is initiated and glucose level is controlled. This happens during Acute Phase response in metabolically stressed patients

3. If the patient is receiving LVP containing D5W, calculate sugar content per day, insulin need per day and use your clinical judgement if meds are to be diluted with D5W or NS

4. Normal intake for sugar in diabetic patients is 200g/day while not exceeding 100 units of exogenous insulin per day

In conclusion, it is not wrong to use D5W in minibags for diabetic patients assuming we take above factors in consideration!

Hope this helps

[Rachel Phillips]

We have had similar shortages over the last couple years here in USA (west coast) for the manufacturers Hospira, Baxter, and B-Braun. I currently have B-Braun. We also have a secondary compounding company PharMEDIUM that does a lot of other various products, so just including one of theirs (5,000 units/1000mL) but they do make numerous other concentrations.

Our current Heparin is 25,000 units/500 mL D5W (50 units/mL). While it is in a non-PVC and DEHP bag it does not necessarily have to be. I have also been to another local hospital using 25,000 units/250 mL D5W (100 units/mL). A couple weeks ago we were out of our manufactured 5,000 units/1000 mL NS bags so we had to batch ourselves. See image of those. I strongly suggest making safety stickers for “high alert” meds such as HEPARIN ADDED, and placing them on the bags, otherwise if the main compounded label were to fall off the bag could look like a plain bag and get mistakenly used in a busy situation.

When I run out, I do batch compounding using 500 mL D5W bags to match our usual product, and using heparin of 1000 units/mL concentration (adding 25 mL total to the bag). We have had to make our own heparin 25,000 unit/500 mL bags in batches about 10 times in the last 6 months.

I will write a short compounding formula with notes below….

COMPOUNDED STERILE PRODUCT: Heparin 25,000 units/500 mL D5W bag (when premix is out of stock)

PROCEDURE: remove 25 mL of D5W from the 500 mL bag, then add 25 mL of 1,000 units/mL (25,000 units) into the bag for a total volume of 500 mL. Of note, these solutions can be made in NS.

EXPIRATION: 30 hours room temp or 9 days refrigerated (797 medium risk BUD when making from multiple vials and/or multiple punctures to the bag’s port).

STABILITY NOTES: Many concentrations ranging from 1 unit/mL to 500 unit/mL have been studied and reported stable at both the room temp and refrigerated stability beyond the USP 797 BUD’s but must keep to those 797 maximums. Some of these studies confirmed physical stability of the compounded formulations up to 12 months in either D5W or NS at fridge and room temps. This very stable physical stability is also also evident by the product’s availability as a manufactured premix with expiration dates out 2 years in some cases. While the actual 50 unit/mL or 100 unit/mL concentrations being used are not specifically listed in this first reference by Bing, those concentrations are within the ranges studied and of course, available already as premixes with long stabilities so this should give confidence to make them yourself if you have to. If you do not have a place to store them, or just have low volume of use, then only make each one when needed.

LABELING: standard batching label with lot numbers, HEPARIN ADDED sticker, any additional alert stickers per local policy.

REFERENCES REVIEWED: (and attached)
Bing’s Extended Stability for Parenteral Drugs 2013 (see multiple references within the entry)
Lexi-Comp Heparin Monograph 2017
Trissel’s Handbook of Injectable Drugs 2017 (not attached)

https://mega.nz/file/GwJDQKYS#SAQeLti4ovlsf5N8dbtm3u4Bli1hqRKOnD-TYeHDgCw

[Rachel Phillips]

In addition to Naveed best reference; I would recommend as starter to review the appropriate use of PN and Neonatal Considerations (Attached ASPEN recommendation on the appropriateness of PN released in March, 2017). The review intended to guide evidence based decisions regarding appropriate PN use for all age group including Neonatal. Furthermore, attached clinical practice guideline; from Ireland and ASPEN review on optimizing PN for neonates.

Enhancing Parenteral Nutrition Therapy for the Neonate.pdf

Guideline-on-the-Use-of-Parenteral-Nutrition-in-Neonatal-and-Paediatric-Units.pdf

When PN is appro 0148607117695251.pdf

Hope this will help.

[Rachel Phillips]

We never use pest controls in the clean room.

Pest control materials, if left to volatilize or float in the air, can be as bad or even worse than the pests. But again it is a challenge, and we need to deal with it case by case, by conducting pros and cons analysis.

Below are some hints:

· Focus on preventing pests from getting into clean rooms in the first place.

· Take appropriate supplemental non-chemical steps to eliminate the source or the pest’s route of access to the building and the clean room.

· PMPs must act as consultants for their clients, advising them on sanitation, design, construction, and maintenance improvements that can be made in the building’s surroundings, on the building itself, and inside the building to make the whole area as unfriendly to pests and as impervious to pest invasion as possible.

· The central principle of clean-room Integrated Pest Management is to start from the facility’s outer surroundings; identify pest-conducive conditions and pest populations that are present; and then, working from outside in — from least-sensitive to most-sensitive — block and thwart a pest’s progress into the clean room.

· When it is necessary to apply a pest control device or, in rare cases, a pesticide, inside the clean-room environment, it must be done using materials and methods that reliably preclude the possibility that any contaminants will be added to the particulate load of the air in the clean room.

[Rachel Phillips]

1- whom will do the counseling?

all medication counselling at the adult and children hospital are done by a pharmacist, pharmacy interns and students can also do this under the supervision of a pharmacist.

2- whom will be eligible to be counseled? Any criteria?

Due to the chronic shortage of pharmacists in our hospitals, we tend to prioritize who gets counselling, by that i mean ideally the ward pharmacist is responsible for carrying out all discharge counselling, he or she will at their discretion determine who needs this service, if they are on leave or absent and their ward is covered by someone else (rarely happens as we don’t have the staff to do this), then the replacement pharmacist will do the counselling based on handover discussion.

Otherwise if pharmacist is absent or a ward is not covered, we tend to rely on the medical team or the nursing staff to flag those patients that require counselling. Having said that we do ensure that wards like renal, cardiology etc always have pharmacy cover. Again this also depends on the patient and their medical complexity, e.g. post renal transplant patient versus surgical post appendectomy patient. For renal and cardiac and to some degree respiratory and some infectious disease wards have a standard discharge template whereby a pharmacist needs to sign off that they have done medication counselling for some patients. In the pediatric setting, the process is more or less the same but with a less structured format (currently being reviewed).

3- when the physician write a discharge medications, do the clinical pharmacist review those medications before being dispensed by pharmacist.

Since we do not have the distinction between pharmacist and clinical pharmacist in Australia, yes all discharge medication scripts are screened and reviewed by a pharmacist to ensure they are correct (med rec wise, labs checked, supply etc). Scripts are subsequently entered/typed by a pharmacy technician and further checked by pharmacist (double check system), but the pharmacist checker does rely on the ward pharmacist to ensure all that the discharge script is clinically sound. Again this process is less defined in our paediatric hospital and is being reviewed.

[Rachel Phillips]

Refrigerators can be placed in ISO classified areas, especially in negative-pressure HD buffer rooms. It is important to check any condenser pans monthly to avoid standing water and to wipe down the coils. If you can place it near or in front of low-wall returns, this be helpful. CriticalPoint has completed a couple of studies (to be published) showing no negative environmental impact when refrigerators are located in ISO classified rooms. I hope this helps.

[Rachel Phillips]

We are currently experiencing shortages of D50% premix syringes, intermittent shortages of D70%. Our current practice is to make our own syringes of D50% from either a D50% 500mL bag we are able to acquire, or by diluting D70% with SWFI. The D50% syringes may be difficult to store in the fridge (little data on fridge storage at that concentration), so we send out from the pharmacy via the pneumatic tube or hand delivery when nursing calls for a hypoglycemic patient.

Here is my compounding formula for making D50% from D70% and SWFI (rounded to nearest 1 mL on the figures)

COMPOUNDING (#20 syringes): add 714 mL of D70w to 286 mL of SWFI in a sterile empty container to make 1000 mL of D50w stock solution. Further unit dose this solution into 50 mL syringes.

COMPOUNDING (#10 syringes): add 357 mL of D70w to 143 mL of SWFI in a sterile empty container to make 500 mL of D50w stock solution. Further unit dose this solution into 50 mL syringes

[Rachel Phillips]

Epoxy-painted walls are fair enough according to the USP 797.

[Rachel Phillips]

Well, if that is what happened, it is not considered allergy, but it is a lipid intolerance, you have now to rule out pancreatitis and/or liver dysfunction, also what was the last lab for serum triglycerides?

After all, and if you can’t define the reason of intolerance, you may now try the SMOF, as a test dose like you did before, and if it is not working again, you may consider the MCT oil, but this will be a caloric source only, not essential fatty acids source, then you may need also to rub the patient’s skin every 2 or 3 days by the external oil.

I have a question to you, if the patient can tolerate oral MCT? why not encouraging enteral feeding then?

[Rachel Phillips]

First, you have to make sure it was an allergy due to that lipid, usually hypersensitivity to any of TPN components is rare. Once confirmed, so any lipid containing LCT oil will not be applicable for use (including SMOF), unless you want to try any other lipid to confirm the allergy itself!

Also Omegaven (which is 100% refined fish oil) should not be used alone, it has to be mixed as well with LCT oil for use. Also, it has no linoleic acid and alpha linolinec acids (essential fatty acids), so can’t substitute Intralipid.

So, I suggest (again, after you make sure allergy is due to lipid emulsion) that you can rub the patient’s skin by safflower oil (or any oil rich in essential fatty acids), here you don’t give calories, but you only avoid Essential Fatty Acid Deficiency Syndrome.

I hope it helps.

[Rachel Phillips]

There is a good reference at the ASPEN portal dealing with product shortages, it explains some strategies to save the remaining little stock for certain patient categories, also alternatives if applicable.

http://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Clinical_Practice_Library/Product_Shortage_Recommendations/

I think being proactive against product shortages is one of the biggest challenges we face all the time.

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