Welcome to AJHP Voices, a series of discussions with AJHP authors and interviews focused on contemporary practice issues. AJHP is the official journal of ASHP, and its mission is to advance science, pharmacy practice, and health outcomes. Hi, this is Daniel Coba, the editor-in-chief of HHP. Thanks for joining us in this episode of HHP Voices. Human errors that occur during resuscitation efforts during cardiac arrest have been reported to increase further the likelihood of patient harm and death in this setting. Joining me here today to discuss their article entitled "Farmacy Residency Training Program Increases Residence Confidence in Inpatient Medical Emergency Response." For Dr. Amanda Jo Shigel, Medical ICU and Emergency Medicine Clinical Pharmacy Specialist at WVU Medicine, and Dr. Blake Hayes, Clinical Pharmacy Team Lead at Indiana University Health. Amanda Jo, Blake, thanks so much for joining me today, and welcome. Thank you so much for having us. We're so excited to be here. Definitely glad to be here. Well, as we start off, I'm wondering, Amanda Jo, if you could frame the issue here. And really give listeners a sense of the magnitude of the problem of inhospitable cardiac arrest. What is the incidence in the United States? Absolutely. In 2019, the American Heart Association estimated that about 290,000 adults will suffer from inhospitable cardiac arrests per year, and that's specifically in the United States. And more recently, when looking in terms of percentages, data from 2022 showed an incidence of 8.5 per 1,000 adult admissions. Now, after reviewing these papers, one important piece of information that really stuck out to me was that these patients are just such high acuity. And so when compared to previous reports, it's actually been shown that the public health burden of adult cardiac arrest has increased by about 38%. And that to me just really shows the importance of proficiency in this acute setting and when taking care of these really sick patients. What do you mean by that when you say the public health burden of caring for individuals who experience cardiac arrest and inpatient setting has increased? What do you mean by that public health burden? The American Heart Association specifically mentioned the costs, the resources in terms of the amount of in-hospital arrests we're seeing and that it's almost comparable to out-of-hospital cardiac arrest. So I found that paper interesting, the fact that they noted that and they also focus on the pediatric portion as well. Got it. And Blake, there's been work done in this area, probably some of the more prominent work by lip shots and colleagues related to the likelihood of patient harm and death when a medication error occurs during resuscitation. You and Amanda Jo make reference to that in your article. Can you talk about those numbers? What does that look like when an error does occur during a resuscitation? That paper was published in the early 2000s and the authors in this study pulled data from MedMARKs, which is a national anonymous medication error reporting system that's managed by the United States Pharmacopia. So what they did was they took all of that data, it was from 2000 to 2005, and all the medication errors that were input with a selection of "code situation" having some association with a "code situation" as a contributing factor were evaluated. And so they did qualitative and quantitative analyses on that data and ultimately compared med errors that occurred that were code related to non-code related errors. And what they found was that code related errors were 39 times more likely to result in patient harm than non-code related errors for in-hospital errors. In addition to that, they also found that code related medication errors were over 50 times more likely to result in death, which is just so significant and really highlights how significant medication errors are when they're associated with these code events. And that's a great segue really into my next question, Blake, which is around the evidence of the pharmacist's value as a participant in the resuscitation efforts. And that's also a growing evidence base. When you talk about that, so you have this scenario where we know that if a medication error occurs during resuscitation, that there's a significant increase in the incidence of patient harm, how does bringing a pharmacist into that setting change those numbers? What's the evidence of the pharmacist's value? That's a great question. When you think about those numbers, there are a handful of studies that have evaluated specifically in cardiopulmonary resuscitation. And the outcomes of those studies showed that when you introduce a pharmacist into a specifically CPR-related, cardiopulmonary resuscitation-related efforts, there's a reduction in the amount of adverse drug events and medication errors that occur. So super important that because of what we just talked about, that we're reducing medication errors when we're present, in addition to that, a pharmacist's presence is associated with increased compliance with ACLS algorithms, which is also super important because other studies have shown that deviations from those ACLS algorithms are associated with decreased rates of RASC or return of spontaneous circulation, as well as decreased rates of survival to discharge. And then finally, the literature shows that pharmacist involvement in the CPR team is associated with reductions in patient mortality. So really significant. You know, I also wanted to highlight a systematic review that we didn't highlight in our paper because it just got published this year. It was published in the American Journal of Emergency Medicine by Curie and colleagues, and they discussed the benefit in this systematic review of having a pharmacist on the team, not just in CPR events, but in multiple different types of medical emergencies. And so in that, in addition to all of the associations with CPR teams and CPR efforts, they also showed a pharmacist's presence with a patient with acute ischemic stroke. There's a reduction in dorda needle times. For hemorrhaging patients, there was reduced time to PCC, reduced hospital and ICU length of stay. For STEMI patients, there was increased guideline compliance. And then a number of other positive impacts of having a pharmacist on the team for trauma resuscitation, sepsis, status epilepticus. So outside of CPR efforts, I wanted to highlight all of the medical emergencies that have been studied in a literature and the positive impact of adding a pharmacist at those teams. Amanda Jo, I was about to ask you that exact question. You talk about this in your paper. What other emergency situations are pharmacists responding to at WVU medicine? So at WVU, when we specifically look at Ruby Memorial, which is our large academic medical center within the hospital, within our inpatient setting, when a medical emergency is page, this can include cardiac arrests, but it can also include respiratory failure for patients requiring rapid sequence intubation or any acute scenario deemed by the bedside nurse as needing immediate attention. So some situations that come to mind for this are anaphylaxis, seizures, tacky arrhythmias. So we have that as the inpatient component. And then we also are fortunate at WVU to have 24/7 emergency medicine pharmacist coverage. So in the ED, we have a pharmacist at bedside 24/7 for all acute scenarios. Now with ICU medical emergency specifically, those are not page overhead, but we did have those added to all of the pharmacist pagers, including the resident pagers, so they have the opportunity to also respond to ICU codes where the appropriate personnel is already there. And so that's what's really unique about our program is that, yes, they are medical emergencies, but they do encompass so many different disease states. So as the responding pharmacist and trainee, you know, really making sure they're equipped to handle those patient populations. So I would imagine with 24/7 coverage in the emergency department with a pharmacist, then that includes all of the trauma resuscitations. Correct. And that is specifically just our clinical pharmacy specialists that doesn't include our residents. They only respond to ED if they are on that rotation. But yes, they respond to all traumas, strokes, STEMIs, all those things Blake had highlighted where a pharmacist is just crucial in that patient care. We're gonna get into a discussion in a few minutes about the specifics of the PR MERT program. But I'm reflecting on a day when pharmacists were not allowed to go through ATLS training. We could go through ACLS, but we weren't allowed to go through ATLS. Are your pharmacists at Ruby Memorial? Are they going through ATLS training as well today? That's not something that's required. It was optional for me when I started at WU Medicine, but right now currently the biggest thing we focus on is ACLS, BLS, and then also PAL certification if we take care of pediatric patients. You mentioned responding to situations where there's a need for rapid sequence intubation. In that situation, is the pharmacist managing the drugbox? Yeah, this has actually changed over the course of my five years here. We initially were the ones noticing all the medications, but with COVID times it was really dangerous for us to be inside the room, so we tried to stay outside the room. That's where we let anesthesia start managing the induction and paralytic, but where we have such an important role, and I think throughout my years at WVU is something that I want to improve upon is the post-intubation situation. Anesthesia picks the induction med for paralytics, and then they oftentimes have to leave and go to the OR. When they're utilizing paralytics with such a long half-life, we've seen that we're not really good at providing that post-sedation, and so when I trained pharmacists and residents, that's a piece where we're vital in. We obtain fentanyl, medazolam, and ketamine, and we're right there on bedside with the team ready to ensure that they have appropriate sedation, so they're not awake while paralyzed, which we've seen in ED literature specifically is a common issue. Well, let's talk about the PR MERT program specifically, Blake, what is it? The PR MERT program stands for Pharmacy Residency Medical Emergency Response Training Program. In this program, it's a comprehensive longitudinal training program that's designed to provide pharmacy residents with the evidence, the skills, the confidence to be able to provide excellent patient care during medical emergencies, really to give those residents those skills and confidence to also, after they're finished participating in those medical emergencies, also being able to step back, reflect, and take care of themselves after the medical emergencies, and then whatever they choose to do after their PGY1 residency training, to be able to take those skills with them and to be successful in what they do, whether it's a PGY2 or a career, wherever they go from that residency training. Let me ask you, Amanda Jo just sort of ran through the list of its ACLS, if it's pals, maybe it'll be ACLS as an elective. If the pharmacist's training has an opportunity to go through all of this other training, why is PR MERT necessary or what additional value does PR MERT bring? You know, that's a good question and something that we've had some discussion around as it relates to this program. I think first and foremost, the PR MERT training program solidifies the pharmacy residents' understanding of how important their role is in code response. That's kind of one initial step is that, you know, all the stuff we just talked about of the benefit of a pharmacist in medical emergency response, it's important that the residents understand that, and you know, that's kind of the first step. But in addition to that, similar to pharmacy residency training as a whole, the PR MERT program allows residents to take what they learn in the classroom, whether it's the ACLS room, their pharmacy education or their rotations that they've been on in pharmacy school and apply it to real patients and to learn the why behind the treatment algorithms. We talked about deviations from the algorithms, but there are some instances where not all patients completely fall within the algorithm or understanding why the algorithm was created the way it was created super important so that when a pharmacist encounters a patient case that's complex and not a straightforward ACLS algorithm, they can utilize critical thinking skills, which is one of the biggest things that we're trying to teach through this program is critical thinking skills, utilize those skills, utilize the evidence that they've learned of why those things are in place, and then address it and apply it to those really complex patients. Finally, in addition to the ACLS piece in the cardiopulmonary resuscitation, you know, this program goes far beyond ACLS, and so as Amanda Joe was saying, we respond to all different types of medical emergencies, and we have a hand and a roll in all different types of medical emergencies, and so the program exposes the residents to all of those other medical emergencies, which is extremely beneficial to making it generalizable to all of the different roles that they might take on in their future career. What's your sense, Blake, of what's happening in other pharmacy residency programs? Is this becoming something that's more common across pharmacy residency programs, or is it still pretty unique offering? You know, I think it's pretty unique, and I think what makes it unique is how comprehensive it is. A lot of pharmacy residency programs have some type of an emergency response component, or a code pager, or some type of that component, but what makes it unique is, first off, that it's longitudinal, and then second off, that it's so comprehensive that we are really trying to dig deeper into understanding the literature behind why we're doing all of the things we're doing for all the various, you know, medical emergencies. Do you have any sense of in medical residency training? Is there anything similar or longitudinal, comprehensive approach to responding to emergencies that's done in medical residency training? You know, I think there is, when we sat down as a group to create this program, so many of the components of it are not original components. These are things that exist that are happening in other programs, but specifically things that are happening in medical training that, you know, our physician colleagues are already doing. So, things like simulation. Our physician colleagues do simulation longitudinally on topics that are maybe less encountered, and so to stay fresh and to stay up on those topics, they'll do simulation. Even the kind of model for how physicians respond to medical emergencies, you know, it's pretty rare that a first-year intern is going to be the person running a co-blue situation. Typically that resident, that intern would be there, there's going to be some type of either fellow or attending oversight, and so we wanted to mirror that and provide that for our pharmacy residents as well, where we're able to provide that kind of longitudinal oversight. And then, you know, weekly conferences. Our physician residents are so good at creating time to have those conferences and those didactic series on various things that they might see or that they have seen, whether it's M&M or evidence-based teachings on different disease states. So, you know, I absolutely think that this is occurring in various formats, you know, in medical training, and our physician colleagues are doing this. So Amanda Jo, walk us through the components of the program. What does the experience look like for these residents? Before I jump into the components, I think it's easiest if I break down a couple of roles that you'll see or hear me talk about throughout the program. So, the program has what's called the Code Blue Coordinator. Currently, this is myself. This individual is in charge of coordinating the program every year, setting up all the meetings, and is really responsible with the residency program director for handling any issues that you can see come up throughout the year. And then we have code preceptors. So, these are the clinical pharmacist present at the actual medical emergency with the training. They're there to provide, you know, direct instructions, modeling, coaching, facilitating based off of where the training is in their year of learning. Do those code mentors tend to be primarily emergency medicine and critical care medicine pharmacists? That's actually the third role I was going to explain. Those are called code coaches. We thought it was a creative title. So, those are the preceptors you're referring to that are actually that one-on-one mentorship throughout the year. And they're there to meet with those trainees after their week of response and really go through what they're seeing. A majority of them are emergency medicine and critical care trained, but we also have had preceptors with internal medicine training or just PGY1 training who are really interested in medical emergencies and brought such value to the program that they have also asked to be code coaches. So, it's a variety of preceptors, but that is definitely one of the biggest strengths of our program is that continual mentorship throughout the year. So, now that we understand those different roles between the coordinator code preceptors and code coaches, in July, we start with an orientation month. This is really meant to build a solid foundation for the learners. So, we have three lectures during this month. The first reviews the syllabus and schedule. The second goes into those ACLS algorithms really focusing on the medication piece. The doe saying things that they're going to see at these codes. We also review the crash cart layout. We bring out the medication drawer. We show them for the first time what they're going to be seeing when they're standing in front of the crash cart, which is vital for them when they're preparing those meds. And then we discuss pharmacist's roles, you know, what you're going to be doing when you're responding to these cardiac arrests. The third lecture focuses on rapid sequence intubation. As this is a majority of our medical emergencies, focusing on the pharmacokinetic and dynamic dosing and literature of the medications used and also orienting a learner to an automated medication dispensate cabinet. I know before I started residency, I had never used those and that's so important in obtaining the meds within these scenarios. So after those lectures, the next portion of orientation, they go and get certified through American Heart Association and BLS and ACLS. And then we take them to what's called our WV Step Center, which stands for simulation training and education for patient safety, but we just often refer to it as our SimLab. And this is a really unique piece of WVU medicine. It's a state of the art center where we can actually bring trainees in to an ICU bed scenario with real life mannequins and have them prepare meds, run through those algorithms and just tie in all those pieces that we taught them through the lectures that we went over. And then the last piece of orientation is a mock code medical emergency scenario. So when learners are on rotation or orienting at this time, we actually page them. So it feels like they're going to feel when they get that page of going to a medical emergency. And what they walk into is a crash cart in front of them where they are asked to prepare meds, review those ACLS medication dosing algorithms and just show that they're proficient in those areas. And then the second portion that focuses on a rapid sequence intubation. We put them in front of what we have as an omnesal machine, ask them to pull out medications, review the dosing side effects, everything that they can see when intubating a patient. And this piece is a pass fail, but the learner has to pass before they're able to go ahead and longitudinally respond to codes. Now moving on beyond orientation is the longitudinal piece. And when I think of this, I break it down into three areas. So the first piece is obviously the resident holding the pager. They rotate this weekly and they hold it during day shift hours. And when they respond to these medical emergencies, those code preceptors are there to give them coaching and feedback in the moment. The learner is also responsible for logging these responses and sharing them with their code coaches when they meet with them after their week of response. And this we found is just so valuable because the code coach not only can give them feedback, to brief with them what they did, but also what they can do is if the learner didn't get an experience, this happens some weeks, they can review situations so that they're fresh on those skills because we find that that's valuable with having them longitudinally respond. The second big component of the longitudinal response is feedback. To all programs, feedback is so important. We've adapted a lot based level of feedback. And so throughout the year, the learners will get feedback at the medical emergencies with the code preceptor, monthly with their code coach, and then quarterly via farm academic. They also meet with the code blue coordinator myself at the midpoint and final to ensure everything is appropriate and if we need to alter anything, that's where we discuss changing components of the program. And then lastly, the third piece of the longitudinal component, which I think is so fun to be a part of is the lecture series. So the first half of the year, we use our code coaches to review the medical emergency disease states that we had mentioned previously, status, anaphylaxis, stroke, massive PE, so that we're really increasing the knowledge of our trainees when they're responding to these scenarios. And then the second half of the year, the trainees present to us clinical scenarios or a tough clinical patient case that came up during the response. Some of my favorites that I've seen be presented on these topics are eCPR, you know, ecomo during CPR, lidocaine versus amia, when to pick one or the other. And one of my most recent favorite presentations was actually looking at the weight of the patient. When do you use pediatric versus adult ACLS algorithms? And so, you know, the program is, there's a lot of different pieces that come to it and we're really proud of it. And the last really important piece that we focus on is a wellness portion where we talk about death and dying and how to cope with the mortality seen in the hospital. So I want to get into a bit more detail there and Blake, I'd like to bring you into this discussion as well, although you're now at IU Health, you were so involved in the establishment of this program. So I'd like to bring your perspectives in as well. And one place maybe Amanda Joe that I'd like to start and Blake, it relates to something that you said earlier when you were talking about the evidence around the value of the pharmacist and adherence to the ACLS guidelines and specifically the uses of drugs as they are laid out in the guidelines. But I think we all know all three of us having been at the bedside in these settings that there are times when those controversies arise, Amanda Joe, you made reference to Leidocaine versus amiodarone, I'm going to really date myself here, but I recall so clearly the days of high dose epinephrine and what should be used, how are the residents, how did they navigate through those very fast discussions when you have a critically ill patient, a patient who really is an extremis, how did they learn to navigate through those complex decision making processes in real time? That's a great question. And I think that the answer is that it first off, it varies resident to resident. Every resident is going to be a little different in how they do that. But I think the way that our program is designed is that first off for every medical emergency that the resident and the trainee responds to, there's a preceptor there. So ultimately, if it gets to the point of this is unsafe and the resident doesn't know the answer, that is the point of having a preceptor that is present. Now a lot of times that preceptor might be outside the door, just listening, just watching. But the goal is that over time that resident starts to gain a little more confidence, gain a little more experience, and then be able to say, "Hey, I don't think that's a great idea. And here's why." And it's because over time they've seen it now, or maybe they haven't seen it, but they've heard of another resident who has seen it. And you know, one example you talk about Hidos epinephrine, that's kind of the point of the lecture series, we had a resident do one of their lectures on epinephrine, the history of it, how we got to where we are, the evidence behind it, why we use it. And so as a result, the other residents are able to take that, and then at the bedside and say, "No, there's evidence that says that that's not wise for these patients, and here's why." There are adverse effects associated with those things. And so it's a process, it's something that happens over time, but it's something that we see. And so it's really neat to watch that happen, but definitely the model of the program is so that if they aren't able to make that decision in the first half of the year, that hopefully by the second half of the year, or even Q4, depending on how difficult of a situation it is that they can make that decision. But ultimately, for all four quarters of the year, there is someone that's there to be able to step in if something truly becomes not what's best for patient safety. Amanda, Joe, what would you add to that? Yeah, I was just going to say, it's been a joy to watch that kind of progression, as Blake has said. You know, in the beginning, I try to explain it to them, like the basics. You want to know the basics of the ACLS algorithm, but by the end, yes, standing up for what's right for the patient, and really talking about those controversial topics, some that comes in mind, and this is where I learn, you know, someone asks, can you push potassium in a coat? It's their hypokalemic, right? And we push potassium as we know to kill people. So that doesn't make sense, right? But there is data to show rapid administration of potassium. And so not only is the resident learning, but the preceptors are, right? Because that's a clinical controversy. And amongst ourselves, we're always learning. And so that's something that I think program brought to all of us as well, is that these clinical cases and these scenarios that come up, we're all learning through pharmacy. And so that's just been a joy as well. That's what I wanted to add. I have particular interest based on my own background of one specific scenario or really a whole constellation of scenarios, but those folks who go into some degree of distress, maybe it's respiratory arrest, maybe it's full cardiac arrest, but as a result of some type of exposure to a poison or a toxin. Is there any additional attention given to some of the unique characteristics of those particular types of cardiac arrest? And in many ways, you could make the analogy also to traumatic arrests that result from a traumatic injury. But can you talk about that a bit in terms of sort of the other, maybe not so common causes of cardiac arrest and how the trainees are acclimated to those? And that's the tough part about the program I think, right? You can't orient them to everything you're going to see. And that's the nice part of the case series, because we did, for example, have a lidocaine toxicity situation. And so I wish I could teach them everything they're going to see. And I think the residents often want that. They want to hear everything that they're going to walk into, but that's not always the case. And so exactly like you're mentioning traumatic cardiac arrest, toxicology situations, that's really good for when we review it in the case series and how to handle those patients and pharmacist roles and contacting poison control if we get Ross and things like that. So that's been a joy as well, something you can't prepare them for. But that piece I think is really important in the continual education, almost like Blake had mentioned, where one resident saw that. And so we share that case so all the residents can learn, but also the preceptors. Now, you mentioned that there's also a focus on death and dying. And I think that that's somewhat unique. And I would go as far as to say that in the profession, we probably do not prepare our students well enough and probably not a residence either, or what the experience of death and dying, both for the patient, but then also for the team members afterward exposure to the family. There are just so many dynamics that come into play. Can you talk a bit about what that component of the program looks like? Absolutely. This is one of my favorite pieces of the program. And it's something I hold really near to my heart. When we were looking at the training curriculum, we wanted to focus on wellness because like you had mentioned, this is such a tough topic. And it's not really covered well in the pharmacy curricula. And so in my mind, this can be one of the hardest pieces for residents is handling how you witness someone pass away. And so I had a similar experience during my PGY2 training and critical care, and I thought it helped me. And so when we were looking at our program, we definitely want to do include something like that. So Blake and I first started in about 2019. We invited all the residents over Blake's house. We make them a homemade meal. It's just a comfortable environment for them to open up. And what we do is as preceptors and residents, we sit in a roundtable discussion. We all talk about experience we've had inside and outside of work with death. And really ways we've all individually learned to cope. It's such a unique opportunity. And for the residents, I think it's so vital because they see that everyone's human. They see that preceptors have emotions. They can struggle with this piece of healthcare. And more importantly, I think it's good to see them bond to connect outside the hospital in this way by really opening up about death that they've witnessed. The preceptors do review resources that we have available for the residents throughout the year, because that's an important piece if they are ever emotionally struggling. And then at the end of the night, we actually watch a movie called Being Mortal, which focuses on the relationships that physicians have with patients as they're nearing the end of life. And so kind of like you highlighted after our first year, Blake and I reflected on this and we wished we had this as a student, because no one really prepared you as a trainee as you're standing at the bedside and hearing the words time of death for the first time. Amanda Jo, you mentioned the movie Being Mortal, and I believe that that's based on the work of Atul Gawande, who wrote a book by a similar name to really help people understand the entire end of life process. Can you talk a bit more about what that provides for the residents as part of their experience? Yeah, what I enjoy most about the movie is it shows them the physician's perspective. I think a lot of times pharmacy residents struggle with that and they don't understand that a lot of other health care colleagues do the same. And so it looks at it in the eyes of a physician, they walk through different patients scenarios in their end of life and their take on it, and also the patients take on it, which is I think really valuable to see how different people, you know, when they're nearing the end of life, the thoughts they have and the experience they have in our health care system. So I think it adds a lot of value in terms of looking at it through a different lens per se. Blake, what would you add to this? This is a very difficult component of the overall training experience. What would you add in terms of preparing residents for death? Well, you know, I just want to first reiterate that it's something that all of our colleagues and team members and various disciplines struggle with this in terms of how do we train people to deal with this? How do we help them understand that this is something they will experience? And we really can't know how they're going to feel until they do experience it. And I remember as a student, I was shadowing in the emergency department, and it was the first time. It was a traumatic arrest, and it was the first time that I heard time of death called. And so as years went by and my training is in emergency medicine, and you know, I was an emergency medicine specialist while I was at WVU, I began to think about, I have a resident who has probably never seen this, and I know they're going to. And so I read some editorials that are out there, but there's really nothing out there that's solid that provides guidance on how we should handle it. And so I think the biggest thing for people who are training learners of all disciplines is having a conversation with the learner. Before it happens, letting them know that this is going to happen, you're probably going to see this as you're providing patient care. As it's happening, you know, when I'm in a cardiac arrest with a learner and we're nearing the end of what looks like is going to be the time where, you know, maybe here to physicians say, we're going to do one more round of CPR, and if we don't get it, we're going to call it. And at that point, maybe starting to have conversations with the learner. And then maybe once a learner has experienced that end of life situation, and this goes for acute end of life situations where maybe it's a patient you've never even met before and they walk into your ED and kind of the more longitudinal ones you think about oncology patients who you know that patient and you know their family and you've met them and you've interacted with them. But I think having conversations that all steps in the road with the learners and being transparent that this isn't an easy thing, this shouldn't be an easy thing. I think if we learned anything from, you know, a couple years ago where the football game, the Bengals versus the Bills and Demar Hamlin, you know, had a cardiac arrest event on the field and they ended the game knows because the expectation of human beings isn't that we approach death and say, all right, time to get back to work. And so stopping, slowing down and really understanding what that learner is going through. And it might be that some learners need to go home for the day for the first time and seeking some counseling and things like that. And so I think every person's going to be different in how they handle that. But I think we as preceptors, we as educators need to be aware of that and need to have conversations about it. I would agree with you completely and emphasize that it really can occur in a variety of settings. I can recall being in the Poison Center setting as an intern and being involved with two cases, both of them pediatric deaths. And I remember them quite well to this day. One was an acetaminophen overdose and the other was as a result of Stevens Johnson syndrome. And even when you're at a distance by telephone and you're not in the room and other parts of my career, I was in the room, but it still can be quite impactful. And I really applaud you for including this component of the program, we have a little bit of time left. I'd like to really get a sense of your experience with the program both quantitatively and qualitatively. Amanda Jo, what's the experience been so far? Overall, we're just so proud of our program and what we've been able to do. It all started with five pharmacists that came together as a work group. You got to talk to myself and Blake today, but the other co-authors on the paper were vital with the program, Kara, Nick and Amber. And now it's expanded to have nine total code coaches. So it's so exciting to see the progression. But overall, I think if you talk to any of the code coaches or preceptors, the most rewarding part of the program has been watching the residents grow and their confidence and comfortability, which we discuss in our paper. A lot of trainees walk into their PGI one year, having never seen a code and intubation. So having the chance to see them grow throughout the year and become a vital piece of that medical emergency response team has really been such a joy. And you know, when we started this program, we looked for literature. We looked for papers on what people were doing because, you know, like you had mentioned, other residency programs are probably doing something similar, maybe different based off of their site and we couldn't find anything. And so we knew the mission of our program was to develop something that worked for us and hopefully publish it to show other sites ways to start a program and tailor it in and adapt whatever they felt necessary. As Blake had mentioned earlier, the most important thing is pharmacists have been shown to save lives in medical emergencies. And so we just wanted to create a program that made them confident and comfortable when at the bedside during a patient's highest acuity. Overall, I mean, I think our program adapts a lot and it's been such a joy to be alongside my colleagues, but looking at it, the residents have just grown such longitudinally in that comfortability and their confidence and that's the biggest takeaway for us is that joy in watching that. Blake, what would you add to that? From a quantitative perspective, we do describe in our paper that we surveyed the residents before and after the program and the residents have, year after year, demonstrated that they are more comfortable because of this training. They're more comfortable in those medical emergencies, which, as Amanda said, people are very uncomfortable in these types of settings and situations. And so our residents are year after year more comfortable, year after year feel more knowledgeable on the topics. But then, as Amanda said, it's extremely rewarding. We're really watching these residents grow over time, watching them gain knowledge and become better clinicians, but then also become more comfortable in other skills that translate to various other aspects of clinical pharmacy, things like just critical thinking and application of literature and education, there's a lot of education that goes on that the residents have to start doing and providing education. And so it's been extremely rewarding and really just awesome to see what has kind of happened year over year. Blake, what advice would you give to your colleagues in other areas of the country who were thinking about doing something similar as they start up a program like this? You know, I think it can be a big commitment when you sit down and look at all the components that our program had put in place is that it can be a big commitment to get it up and running and there's going to be trial and error, but it's totally worth it. And the residents really do see the benefit of it. So you know, I think in terms of like advice and implementing the program would be sit down and get a good group of team members to really do a lot of the planning and the working to lay it out so that the vision for your site can become a reality. And then listen to the residents, you know, they're going to have feedback, they're going to have pieces that they find helpful or not helpful, but adapt and change to make sure that you're offering those learners something that's really going to help them and the rest of their career. Amanda, Joe, what would you add to that? I totally agree. What I've learned through this experience and being the coordinator for the past several years is it really takes an army. The code coaches are vital to the program, so just really getting a group of preceptors involved that feel invested in this portion of the residents training. I know my medical emergency response training has got me where I am today. And so I think just having the right people at the table and making a program that works well for your individual hospital is key. And then like Blake had mentioned, feedback is just so vital. I have adapted the program probably every year slightly based off of feedback. You know, we've added second sim labs, we've changed the times of the response. So I take the feedback sessions very seriously and I tell the residents that, you know, this is your year, this is your opportunity to grow as a clinician. And this feedback is so important in making the best program we can have. And so that's probably another piece I would encourage programs is to just have a really solid group and enjoy watching the residents grow, get their feedback, and adapt along the way. And that's all the time we have today. I want to thank Dr. Amanda Jo Shiggle and Dr. Blake Hayes for joining me to discuss their article, Pharmacy Residency Training Program, increases residents' confidence in inpatient medical emergency response, which was recently published on agehp.org. Please join us here each month for discussions on contemporary pharmacy practice issues and interviews with agehp authors. If you enjoyed this podcast, please share it with your colleagues and via your social media of choice. Thank you for listening to AJHP Voices. For more information about AJHP, the premier source for impactful, relevant, and cutting edge professional and scientific content that drives optimal medication use and health outcomes. Please visit ajhp.org. ajhp.org.com.
