IPSA I – Exam 1

Role of Pharmacists in POCT

- gather patient history/information regarding illness

- determine if patient is candidate

- collect vitals, testing specimen, and process it

- interpret test results and determine next steps

- prescribe medication based on protocol, recommend OTCs for symptom management, give vaccines, or refer to other providers

What are the steps pharmacists need to complete prior to POCT?

1. assess population need/ability to do particular test

2. CLIA certificate

3. bloodborne pathogen standards

4. policy and procedures manual

5. forms

6. consent

What are waived CLIA tests?

- simple tp perform

- low risk medical diagnostic tests (if done correctly)

- high accurarcy

- not error-proof

- some can be used at home (ie. COVID, pregnancy)

Identify the Referral Criteria for POCT: BP

hypertensive urgency or emergency (> 180 and/or >110 mmHg)

Identify the Referral Criteria for POCT: Temperature

> 104 ºF

Identify the Referral Criteria for POCT: Oxygen Saturation

< 90%

What happens with the use of a too-small cuff in BP reading?

overestimates BP

What happens with the use of a too-large cuff in BP reading?

underestimates BP

What happens when the cuff is too loose in BP reading?

underestimate BP

Steps for Using Temporal Thermometer:

- brush hair aside and center on forehead

- make T and touch behind the ear

- keep button depressed throughout measurement

Steps for Using Pulse Oximeter:

- clean oximeter with alcohol (let dry)

- clean finger before and after each test

- insert fingertip before releasing clamp

- press powerbutton once on front panel

- keep finger still during measurement

- read corresponding data

Reasons for Inaccurate Pulse Ox Measurements:

- excessive patient movement

- poor circulation, dark skin pigmentation, thick or cold skin

- current tobacco use

- fingers are not clean

- dark fingernail polish or fake nails

- low hemoglobin

- placement of sensor on extremity wheh BP cuff, arterial catheter, or IV line

Identify the Normal Reading Value: Pulse

60-100 bpm (regular)

Identify the Normal Reading Value: Respirations

12-20 rpms (regular depth and effort)

Identify the Normal Reading Value: BP

< 120/80 mmHg

Identify the Normal Reading Value: Tympanic

97.5 - 99 ºF

Identify the Normal Reading Value: Temporal

97.9 - 100.1 ºF

Identify the Normal Reading Value: Oxygen Saturation

95 - 99%

Steps for Lymph Node Inspection:

- palpate in circular motion

- use pads of most sensitive fingers (middle)

- perform assessment bilaterally

Vaccine Confidence Tips:

- discuss importance (friends, family, active listening)

- answer questions, educate (keep clear)

- reach diverse communities

- tailor outreach

- reach out to the community

What is the pharmacist's role in educating about vaccinations?

- routine vaccinations

- destination specific vaccinations

- other medications

- considerations for routine or controlled meds

The need for travel vaccines is based on:

- travel destination

- length/stime of timing of stay

- planned activities

- prior immunization history

- patient health history

Vaccination Resources:

- APhA Certificate Course

- CDC Yellow Book

- Travax

HALO Tool:

- indicates possible need for adult vaccinations

- includes health, age, lifestyle, and occupational factors

The items that are needed in an emergency kit include:

- emergency protocol

- BP cuff

- epinephrine

- diphenhydramine (if in protocol)

- CPR mask or shield

- VAERS

Adverse Reaction Management:

- review management of adverse reactions

- instruct patients to remain in pharmacy for at least 15 minutes

- report adverse reactions to VAERS

VAERS

- Vaccine Adverse Event Reporting System

- web submission, mail, or fax

- vaccine injury table required in report

- any possible AEs can be reported here

SMBG (Self Monitoring Blood Glucose)

- OTC meters regulated by FDA

- 95% of readings must be within ±15% of true value (lab measurement)

POC Glucose Monitoring

- healthcare facilities

- 95% of readings must be within ±12% of true value (lab measurement)

- accuracy impacted by many factors

Provide reasons for inaccurate results/errors:

- physiological variables

- interference from medications (depending on test strip)

- technical variables

- mechanical variables

- environmental variables

What physiological variables can cause inaccurate results/errors?

- low hematocrit

- high hematocrit/polycythemia

- hypoxia/high altitude

- oxygen therapy

What medication interference can cause inaccurate results/errors?

- ascorbic acid

- APAP

- alcohol (if not dried prior to testing)

What technical variables can cause inaccurate results/errors?

- testing unclean skin

- not enough blood applied to strip

- improper storage

- outdated/wrong test strips

- incorrectly calibrated

- test strip not fully inserted

- excessive squeezing of finger

What mechanical variables can cause inaccurate results/errors?

- equipment malfunction

- battery failure

What environmental variables can cause inaccurate results/errors?

- temperature

- humidity

- altitude

What should you do if a control test is out of range?

- check expiration dates (test strips, control solution)

- consider storage conditions

- try new bottle of test strips

- was the meter recently dropped?

- contact company if there is no explanation

Glucose testing should be done at what age?

adults any age who are overweight and have at least one additional risk factor

Glucose testing should be performed at what age if the adult patient is overweight and has at least one additional risk factor?

any age

Glucose testing should begin at what age if the patient is asymptomatic (regardless of weight/risk factors)?

35 years old

When should a patient do repeat testing if their glucose results were normal?

repeat every 3 years

When should a patient do repeat testing if their glucose results were abnormal?

repeat testing with doctor ASAP (diagnosis requires 2 abnormal screenings)

What are some risk factors for patients who may qualify for glucose testing?

- age ≥ 35 yrs

- overweight/obese

- first degree relative with diabetes

- history of CVD

- HTN (or on meds for HTN)

- HDL

- physical inactivity

- high risk race/ethnicity (basically anyone but white)

What weight classification can patients be to qualify for glucose testing?

- BMI ≥ 25 in most adults

- BMI ≥ 23 in most individuals of Asian descent

Blood Sugar Goals in Patients w/o Diabetes:

Fasting:

Blood Sugar Goals in Patients w/ Diabetes:

Fasting Plasma Glucose: 80-130 mg/dl

Postprandial Glucose:

A blood sugar reading (in all patients) of < 70 mg/dl indicates what?

hypoglycemia

Criteria for Pre-Diabetes:

Fasting Glucose: 100-125 mg/dl

Criteria for Diabetes Diagnosis:

Fasting Glucose: ≥126 mg/dl

Random Glucose (ie. not fasting): ≥200 mg/dl + symptoms

- in the absence of symptoms, two abnormal tests are required for diagnosis

Alternative Glucose Testing Sites:

- upper arm

- thigh, calf

- fleshy parts of hand

- fingertips

Alternate site testing is acceptable when...

glucose is stable

- fasting/before meals

- more than 2 hrs after meals

- more than 2 hrs after exercise

Avoid alternate site testing when...

glucose is rapidly changing

- hypoglycemia or prone to hypoglycemia

- within 2 hrs after meals

- at least 2 hrs after injecting bolus insulin

- during or within 2 hrs of exercise

- during illness or pregnancy

Goals of Cholesterol Screening:

- determine risk of ASCVD

- determine need for statin therapy

Who should be screened for cholesterol levels?

- children 9-11 yrs not previously tested

- adults 19+ yrs not on lipid lowering therapy

Who does not qualify for a cholesterol screening?

- adults already on statin

- patients with ASCVD

If a patient's cholesterol screening results are normal, what is their recommended screening frequency?

screen every 5 yrs

If a patient's cholesterol screening results are abnormal, what is their recommended screening frequency?

follow-up with doctor ASAP

Name applicable risk factors for cholesterol screening:

- ASCVD, statin use

- gender, BMI

- eGFR, diabetes

- BP (medication for BP)

- current smoker

The ASCVD Risk Calculator is not for these patients:

- patients w. ASCVD

- patients w. LDL ≥190 mg/dL

- patients

What is the primary prevention in most patients?

goal is LDL < 100 mg/dl

What patients qualify for lower treatment goals?

- patients w. 10-year risk ≥10%, LDL < 70 mg/dl

- patients w. ASCVD (secondary prevention), LDL < 70 or < 55 mg/dl

What patient groups may qualify for a statin?

- ASCVD (secondary prevention)

- LDL ≥ 190 mg/dl

- diabetes (40-75 yrs)

- primary prevention if 10-yr risk ≥ 5%

LDL Goal for Primary Prevention

< 100 mg/dl for patients w. risk score < 10%

< 70 mg/dl for patients w. risk score ≥10%

Clinical Guidelines:

- "statements that include recommendations intended to optimize patient care"

- systematic review of literature (foundational)

- set of recommendations (involving evidence and judgement regarding benefits/harms of options)

Benefits of Guidelines:

- recommendations for providing optimal patient care

- systematic review of evidence, synthesize vast bodies of literature

- literature synthesized by experts

- undergo review process

- developed or endorsed by national organizations

Limitations of Guidelines:

- can take years to develop/update

- potential for conflicts of interest

- must inform but never replace clinical expertise (suggestions for care, not rules)

- practice changing updates may not be incorporated into guidelines

- lack of coordination among development groups (causes differing recommendations)

What should you look at when determining which guideline to use?

- US Guidelines preferred over Interational/Local Guidelines

- Who created the guideline (is it credible?)

- Who is the intended audience

- When was it published (is it current?)

- What patient population does the guideline address

- Does the guideline match the question be asked

Classes of Recommendation: Class I

- strong

- benefit >>> risk

Classes of Recommendation: Class IIA

- moderate

- benefit >> risk

Classes of Recommendation: Class IIB

- weak

- benefit ≥ risk

Classes of Recommendation: Class III

- harm/no benefit

- risk ≥ benefit

Levels of Evidence: Level A

high quality of RCTs

Levels of Evidence: Level B-R

moderate-quality RCTs

Levels of Evidence: Level B-NR

non-randomized studies

Levels of Evidence: Level C-LD

limited data

Levels of Evidence: Level C-EO

expert opinion

Levels of Evidence Pyramid:

system used to rank studies based on the quality and reliability of their designs

Levels of Evidence: Filtered Information

systematic review and meta-analyses

Levels of Evidence: Unfiltered Information

- RCTs

- cohort studies

- case controlled studies

- case series and reports

4 Strategies to find Guidelines:

1. DynaMed

2. Clinical Guidelines Research Guide (via Cowles Library)

3. PubMed (MEDLINE)

4. Google (only if given exact name of source)

Evidence-Based Medicine:

the conscientious, explicit, and judicious development and use of the current best evidence in making decisions about the care of individual patients

Three Pillars of EBM:

- best external evidence

- clinical expertise

- patient values and circumstances

EBM - Best External Evidence

systematic review, clinical trials, and clinical practice guidelines

EBM - Clinical Expertise

incorporates clinical judgement to determine if/how external evidence applies to a specific patient case

EBM - Patient Values & Circumstances

considers the individual patient's unique medical history, beliefs, and preferences