The Kentucky Pharmacist Vol. 9, No. 5

Vol. 9, No. 5 September 2014

TTTHEHEHE KKKENTUCKYENTUCKYENTUCKY

PPPHARMACISTHARMACISTHARMACIST

News & Information for Members of the Kentucky Pharmacists Association

Get Involved - Stay Involved

Membership Matters in YOUR KPhA

Register today

at www.kphanet.org

September 2014

THE KENTUCKY PHARMACIST 2

Table of Contents

Table of Contents

Table of Contents— Oath— Mission Statement 2 President’s Perspective 3 KPhA Mid-Year Conference on Legislative Priorities 4 KPhA Open House 5 From your Executive Director 6 APSC 8 2014-15 KPhA Committees 9 Technician Review 10 Aug. 2014 CE — Evaluation of Eyes, Ears, Nose, Mouth &Throat 11 July Pharmacist/Pharmacy Tech Quiz 18 KPhA Emergency Preparedness 19

Sept. 2014 CE — CPE Monitor 20 Sept. Pharmacist/Pharmacy Tech Quiz 24 Oct. 2014 CE — Evaluation of the Respiratory and Cardiovascular Systems 25 Oct. Pharmacist/Pharmacy Tech Quiz 32 Kentucky Renaissance Pharmacy Museum 33 KPhA New and Returning Members 34 Pharmacy Law Brief 36 Pharmacy Policy Issues 38 Pharmacists Mutual 40 Cardinal Health 41 KPhA Board of Directors 42 50 Years Ago/Frequently Called and Contacted 43

Oath of a Pharmacist

At this time, I vow to devote my professional life to the service of all humankind through the profession of

pharmacy.

I will consider the welfare of humanity and relief of human suffering my primary concerns.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy

outcomes for the patients I serve.

I will keep abreast of developments and maintain professional competency in my profession of pharmacy.

I will embrace and advocate change in the profession of pharmacy that improves patient care.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

Kentucky Pharmacists Association

The mission of the Kentucky Pharmacists

Association is to promote the profession of

pharmacy, enhance the practice standards of the

profession, and demonstrate the value of pharmacist

services within the health care system.

Editorial Office:

© Copyright 2014 to the Kentucky Pharmacists Association. The Kentucky Pharmacist is the official journal of the Kentucky Pharmacists Association published bi-monthly. The Kentucky Pharmacist is distributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association.

Editorial, advertising and executive offices at 1228 US 127 South, Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email [email protected]. Website http://www.kphanet.org.

The Kentucky Pharmacy Education and Research

Foundation (KPERF), established in 1980 as a non-profit

subsidiary corporation of the Kentucky Pharmacists

Association (KPhA), fosters educational activities and

research projects in the field of pharmacy including career

counseling, student assistance, post-graduate education,

continuing and professional development and public health

education and assistance.

It is the goal of KPERF to ensure that pharmacy in Kentucky

and throughout the nation may sustain the continuing need

for sufficient and adequately trained pharmacists. KPERF will

provide a minimum of 15 continuing pharmacy education

hours. In addition, KPERF will provide at least three

educational interventions through other mediums — such as

webinars — to continuously improve healthcare for all.

Programming will be determined by assessing the gaps

between actual practice and ideal practice, with activities

designed to narrow those gaps using interaction, learning

assessment, and evaluation. Additionally, feedback from

learners will be used to improve the overall programming

designed by KPERF.

September 2014


One of the first responsibili-

ties as the President of

YOUR KPhA is to get the

leadership team assembled

for the coming year. The

team is more than just the elected officers and directors of

the Association. The leaders of KPhA also include all of the

volunteers who have agreed to serve as the chair or a

member of one of the many KPhA Committees and

Workgroups.

Why is this so important? It is important because it is the

committees of KPhA that give input and guidance to the

Executive Director, President and Board of Directors for

KPhA. Most committees are open to all pharmacists, phar-

macy technicians and pharmacy students who are mem-

bers of KPhA. I want to thank all of the members who have

volunteered to serve on these committees for the coming

year.

The roles and responsibilities of the Committees are out-

lined in the bylaws of the Association. Here is a list of the

committees and the key roles that they play for KPhA:

Organizational Affairs (OA) – This committee will be co-

chaired by Judy Minogue and Lewis Wilkerson. The OA

committee reviews and considers matters related to (but

not limited to) the internal affairs of the Association. These

matters also include soliciting and vetting nominations for

Officers, Board of Directors and all awards of the Associa-

tion except for the Meritorious Service Award.

Past Presidents Advisory Committee – Past President Ray

Bishop has volunteered his services as chairman of this

Committee of distinguished past leaders of the Association.

This committee serves in an advisory capacity to me as

President. Ray also will be a voting member of the Board.

Professional Affairs/ Public Affairs Committee – Cassy

Beyerle has agreed to serve again as chair this year. The

primary areas of responsibility for this committee are poli-

cies that relate to the practice of pharmacy and relation-

ships to the general public. The committee also vets appli-

cations for the Board of Pharmacy nominations.

Budget and Audit Committee – The committee is chaired by

the Treasurer, Glenn Stark. The other members of the com-

mittee include the officers of the Association and one or

more at-large member(s) of the Board. The Committee

shall provide guidance to the Board by assuring the adop-

tion of an annual operating budget, assure that an annual

audit of finances is performed, reviews and reports on fi-

nances quarterly and performs other duties as necessary to

oversee the financial health and viability of the Association.

Government Affairs (GA) Committee – Many thanks to Past

President Richard Slone, who has agreed to serve again as

chair. The GA Committee assists the Association with the

development and maintenance of a grassroots program to

support the Association’s legislative and regulatory initia-

tives that affect the practice of pharmacy. The committee

also helps to raise awareness of and contributions to the

Government Affairs fund which assists in our lobbying ef-

forts in Frankfort.

Membership Engagement Committee – This committee is

chaired by the President-Elect of the Association, Chris

Clifton. I view this to be one of the most vital committees to

the Association. Without members, we do not exist. My

goal for this committee is to continue to identify strategies

that will engage and thereby grow membership by helping

to identify, communicate and demonstrate the value of

KPhA to new and existing members. The committee will

promote the core message that MEMBERSHIP MATTERS

in YOUR KPhA.

New Practitioner Committee – This committee will be co-

chaired this year by Chris Harlow and Briana Kocher. This

committee represents and provides service to new pharma-

cists with the goal of increasing the visibility of KPhA and to

help the next generation of pharmacists get involved and

stay involved in KPhA following graduation from pharmacy

school.

There are also several work groups that are formed by the

Association to help provide additional guidance to the lead-

ership of KPhA. These are formed on an ad hoc basis.

There are currently three workgroups. They are:

Emergency Preparedness Workgroup – John Evans has

agreed to step up to the plate to chair this workgroup. This

committee will work with Leah Tolliver from KPhA staff in

developing and working with the Kentucky Department for

Public Health (KDPH) and in other related emergency pre-

paredness activities for the Association.

PRESIDENT’S

PERSPECTIVE

Robert Oakley

KPhA President

2014-2015

President’s Perspective

Continued on Page 7

September 2014


2014 Mid-Year Conference on Legislative Priorities

Friday, November 14, 2014

KPhA Student Legislative Day in partnership with Sullivan University College of Pharmacy

and University of Kentucky College of Pharmacy

8:30 a.m. Registration Opens

**9-10 a.m. Federal and State Regulatory issues in the pipeline

— Board of Pharmacy Executive Director Mike Burleson & BOP President Cathy Hanna

**10:15-11:15 a.m. Substance Abuse in Kentucky: The Impact of House Bill 1

— Maryellen B. Mynear, Inspector General, Kentucky Cabinet for Health and Family Services

11:30a.m. Lunch

**12:30-2 p.m. Pharmacy and the Pursuit of Provider Status

— Stacie Maass, APhA Senior VP, Pharmacy Practice and Government Affairs

**2:15-3:15 p.m. Effective Legislative Involvement

— Trish Freeman, Director of the Center for the Advancement of Pharmacy Practice

& Jan Gould, Senior Vice President - Government Affairs, Kentucky Retail Federation

3:15-5 p.m. Legislative Presentations

- How the Legislature Works — Sen. Julie Denton

- Legislative issues briefing — Government Affairs Committee Chair Richard Slone

- House of Delegates Meeting

- Kentucky PBM Transparency Act Update

Saturday, November 15, 2014

7:30 a.m. Registration Opens/Continental Breakfast

**8:15-9:15 a.m. Ebola Crisis

– Doug Thoroughman, PhD, MSCAPT, US Public Health Service,

CDC Career Epidemiology Field Officer, Kentucky Department for Public Health

**9:30-10:30 a.m. Protecting Your Pharmacy: Financial/Patient Data and Store Security and Liability

— Bruce Lafferre, CLU, ChFC, LTCP, MSFS, MSM, RHU, REBC, Pharmacists Mutual

**10:45-11:45 a.m. An Introduction to Poison Control in the 21st Century

— Ashley Webb, MSc, PharmD, DABAT, Director, Kentucky Regional Poison Control Center

**Continuing education credit

4.5 Contact Hours Available Friday

3 Contact Hours Available Saturday

Register today:

www.kphanet.org

Pharmacists: $95

Technicians: $35

Students: FREE

or $5 for lunch

Additional Certification Programs **9 a.m. – 5 p.m. MTM Certification Program **Noon – 6 p.m. Adult Immunization Training

Additional Registration Required. Lunch will be provided.

September 2014


Kentucky & American Pharmacists Month

Open

House

2014

YOUR KPhA opened

it’s office to members

and dignitaries Oct. 2

to kick off Pharma-

cists Month. Check

out KPhA’s Youtube

for videos of the pro-

gram.

Also, visit the KPhA

Website to read the

Proclamation from

Gov. Steve Beshear

and for a toolkit on

how you can develop

your own promotion!

September 2014


From Your Executive Director

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR

Robert “Bob” McFalls

There are more ways to celebrate American and Kentucky

Pharmacists Month than there are days in the year. To as-

sist you in your endeavors, KPhA has developed a toolkit

as a resource. Some of the tips are in boxes on this page

and the next. For more content, visit the KPhA website un-

der Resources.

We look forward to hearing from you on how you are pro-

moting the profession and connecting with your peers, pa-

tients and community about YOUR special month. And,

don’t forget to email information, clips and event photos to

Scott at [email protected].

2014 KPhA Mid-Year Conference

In 2012, YOUR KPhA resurrected its “Winter Workshop” in

a revised Mid-Year Conference on Legislative Priorities

format. Mark your calendar and plan to participate with

more than 200 student pharmacists from SUCOP, UKCOP

and UCCOP. We have an exciting couple of days planned.

I am pleased to report that Stacie Maass, Senior Vice Pres-

ident for Pharmacy Practice and Government Affairs with

APhA, will be in attendance to provide us with the latest

news from the federal level on our pursuit of provider status

for pharmacists. Senator Julie Denton is scheduled to talk

about the legislative process, and Jan Gould will help us

understand how to make it all happen in terms of our grass-

roots advocacy. Worried about the Ebola Crisis? Attend

and hear the latest from Dr. Doug Thoroughman, repre-

senting CDC and the Kentucky Department for Public

Health, who recently returned from West Africa. Concerned

about how you would continue your business operations

after a disaster? Hear from Bruce Lafferre on ways to man-

age risk and protect your pharmacy. We’ll also learn about

how we plan to advance our Collaborative Care Agreement

authority in the 2015 legislative session from Dr. Trish

Freeman along with a report from Government Affairs

Chairman Richard Slone on other parts of our legislative

agenda. And we will be spending time together on the MAC

Transparency bill passed in 2013 — we will be reviewing

the legislation that passed, discussing what it was intended

to do and addressing what is needed to ensure compliance

by the pharmacy benefit managers. To round out our edu-

cational time together, we will learn about how we can im-

prove poison control efforts and learn how Kentucky is ad-

dressing substance abuse issues with our new Inspector

General Maryellen Mynear. Other plans are in the work—

suffice it so say that YOU do not want to miss the 2015 Mid

-Year Conference. See you there!

Ideas for Getting out into the Community for Pharmacists Month

Senior Citizen Centers are always looking for new, exciting educational events. Set up a brown bag

medication review event at a local Senior Citizen Center.

Hold a healthcare event in your community or get involved in your local health fair.

Present information on pharmacy to people in the community. Promote the event in advance and invite the

public.

Speak with the local school nurse on educating high school teachers about pharmacy. Ask the guidance

counselor if you can set up a presentation on careers in pharmacy for career day.

Contact the media in your area, write a news release and talk with the media about Kentucky & American

Pharmacists Month.

Use social media!

September 2014


From Your Executive Director

Health Information Technology (HIT) Workgroup – This

group will be led by Jennifer Barker. The HIT workgroup

assists KPhA in its mission to advance the profession of

pharmacy by monitoring the development of HIE via a for-

mal committee interface with the state. They also help build

awareness of and educate pharmacists about HIE and ed-

ucate other provider networks what pharmacists are capa-

ble of doing. KPhA is fortunate that the past chair, Larry

Blandford, has been appointed to the KHIE Coordinating

Council.

Provider Status/Collaborative Care Workgroup – The chair

of this group is once again Trish Freeman. The primary role

of this group will be to advise KPhA in the Association’s

efforts to expand the definition of collaborative care prac-

tice in Kentucky. The profession was close to seeing this

happen in the legislature this year, but it did not. This group

will redouble its efforts in this area for the next legislative

session. I also have asked this group to take on the addi-

tional challenge of improving the transitions of care be-

tween the institutional and community pharmacy practice

for the benefit of our patients.

I look forward to working with the Committees and

Workgroups this year. I am excited about the opportunities

before us as a profession. Please look at the KPhA website

to learn more about the Committees and their members.

Even if you are not a member of one of the Committees or

Workgroups, I know they would like to hear from you.

Please do not hesitate to forward your ideas or suggestions

for KPhA to me or one of the Committee chairs. After all,

THIS IS YOUR KPhA.

Continued from Page 3

Ideas for the Community

Pharmacy! Record a special answering message

promoting Kentucky & American Pharmacists

Month when you answer your phone, “Thank

you for calling. We are celebrating Kentucky &

American Pharmacists Month. Pharmacists are

your medication experts! How can I help you?”

Conduct an Immunization Day/Week— hold

a flu clinic, blood pressure clinic or

osteoporosis screening.

Decorate your pharmacy for the month of

October with banners and posters highlighting

Kentucky & American Pharmacists Month.

Hold a medication educational session with

snacks at a convenient time, and invite the

public.

Hold an “open house” at your pharmacy and

hand out goody bags with an informational

brochure inside.

Give an OTC “tour” to your patients on how

to select the best OTC products for their

individual condition.

Invite local students to visit your pharmacy

for a class trip and give them a tour of the

pharmacy.

Ideas for Health Systems and

LTC Facilities! Place information in your facility’s

newsletter about Kentucky & American

Pharmacists Month.

Decorate the hospital or institution lobby

with posters or displays. Create a lunch tray

tent card explaining the goals of the

pharmacy and services you offer.

Hold an “open house” for all employees to

visit the pharmacy.

Host a visit for your senator or

representative and provide him/her with a

view of the role of the pharmacist.

Ideas for Students/Colleges

of Pharmacy! Create a YouTube video promoting

pharmacists!

Spread the word on social media!

Create a banner and ask your school to dis-

play the banner to promote Kentucky &

American Pharmacists Month.

Work with pharmacies in your area to hold

wellness events!

September 2014


2014 KPERF Golf Scramble

September 2014


2014-15 KPhA Committees

2014-15 KPhA Committees Executive Committee Duane Parsons - Chair

Bob Oakley - President

Chris Clifton

Glenn Stark

Brooke Hudspeth

Matt Carrico

Past Presidents Ray Bishop – Chair

Ron Poole – Vice Chair

Donnie Riley

Johnny B. Anneken

Joe Carr

Jessika Chinn

Leon Claywell

Kim Croley

Dwaine Green

George Hammons

Melinda Joyce

Clay Rhodes

Richard Slone

Joel Thornbury

Lewis Wilkerson

Organizational Affairs Judy Minogue – Co-Chair

Lewis Wilkerson – Co-Chair

Ralph Bouvette

BC Childress

David Collins

Shane Fogle

Matt Harman

Ryan Hatfield

Brooke Herndon

Pat Mattingly

Lance Murphy

Joel Thornbury

Bradley Browning

Professional Affairs/

Public Affairs Cassy Beyerle – Chair

Anne Policastri – Vice-Chair

Heather Bryan

Justin Chafin

Danielle Corbett

Candace Robinson Cottle

Allison Cubit

Cathy Hanna

Jennifer M. Jaber

Amy Larkin

Jill Lee

Jeff Mills

Elizabeth Moore

Misty Stutz

Lisa Tang

Sonia Erfani

Michael Tucker

Megan Reynolds

Christopher Sissle

Ad Hoc Committees Budget & Audit Glenn Stark – Chair/Treasurer

Chris Clifton

Brooke Hudspeth

Chris Killmeier

Bob Oakley

Duane Parsons

Sam Willett

Government Affairs Richard Slone – Chair

Ralph Bouvette

Matthew Burke

Peggy Canler

Matt Carrico

Leon Claywell

Barry Eadens

David Figg

Larry Hadley

Ryan Hatfield

Katie Herren

Steve Hill

Chris Killmeier

Ethan Klein

Christian Polen

Anne Policastri

Jill Rhodes

Leah Tolliver

Jonathan Van Lahr

Kelly Whitaker

Michelle DeLuca Fraley

Hanna Burgin

New Practitioner Briana J Kocher – Co-Chair

Chris Harlow – Co-Chair

Amanda Jett

Alex Brewer

Amanda Burton

Khaai Lee

Megan Pendley

Molly Trent

Stacie Silvers

Mark Huffmyer Kelli Carpenter

Membership Engagement Chris Clifton – Chair

Kim Croley

Kyle Harris

Kevin Lamping

Benjamin Mudd

Duane Parsons

Brent Simpkins

Mallory Megee

Work Groups Emergency Preparedness John Evans – Chair

Donna Johnson

Andrea Kirchner

Joanne Taheri

Jonathan Hughes

Brian Ferguson

Len Gore

Jacob Wishnia

Susan L. Victor

Health Information

Technology Jennifer Barker – Chair

Barry Eadens

Kyle Harris

Ryan Hickson

Patricia Robinson

Joel Thornbury

Leon Claywell

CCA/Provider Status Trish Freeman – Chair

Nancy Barker

Cassy Beyerle

Ralph Bouvette

Sarah Brouse

Leon Claywell

Holly Divine

Barry Eadens

Jan Gould

Bill Grise

Cathy Hanna

Brooke Hudspeth

Chris Killmeier

Katie Lentz

Duane Parsons

Bob Oakley

Jill Rhodes

Alyson Schwartz

Carolynn Horn

Joan Haltom

September 2014


Technician Review

KPhA Technician members are eligible for Free CE modeled on PTCB standards by becoming a member of the KPhA Pharmacy Technician Academy. All KPhA Technician Members are eligible for Academy Membership at no additional cost.

FREE

CE

KPhA Member Pharmacy Technicians

The mission of the KPhA Academy of Pharmacy Technicians is:

To unite the pharmacy technicians throughout the Commonwealth to have one

voice toward the advancement of our profession.

To follow what is currently happening with your profession please read our

newsletter articles and become involved.

For more information contact Don Carpenter via email at [email protected]

Technician Review From the KPhA Academy of Technicians

The Academy welcomes Megan Reynolds as the newest

Academy delegate. Megan is the Assistant Director of the

Pharmacy Technician program at Sullivan University and

has several years of experience as a technician. She will

make a great delegate for the Academy with her experi-

ence and dedication to the advancement of pharmacy tech-

nicians.

The KPhA Pharmacy Technician Academy continues to

work toward the advancement of the pharmacy technician

profession. We are involved in discussions with the Adviso-

ry Council to the Board of Pharmacy promoting change for

pharmacy technicians. Our goals are to improve patient

safety and play an important role in the evolving pharmacy

profession.

The Pharmacy Technician Certification Board (PTCB) has

announced some new initiatives and we want to make sure

the KPhA technicians are well informed. As many of you

know, starting in 2014 if you had to re-certify, 1 hour of pa-

tient safety continuing education along with the 1 hour of

law is required. PTCB plans to start a background check on

anyone taking the certification test. The exact starting date

has not been released yet. All continuing education must

be technician specific for 2015. It is not required that all CE

be ACPE, but it will have to be technician specific. The

amount of in-service hours will drop to five hours and by

2018 it will be zero. There is a lot of movement for advanc-

ing technicians coming from the national scene and we are

hopeful that Kentucky will become a leader for change in

the Pharmacy Technician profession. We will keep you in-

formed on the changes coming from PTCB and within Ken-

tucky.

The Academy also is seeking new members. We continu-

ously strive to increase our strength of numbers. The more

technicians represented in the Academy the stronger our

message will be. By joining the KPhA Pharmacy Techni-

cian Academy you are eligible to join the Collaborative Ed-

ucation Institute (CEI) which provides up to 10 hours of

technician specific CE every year. If you are interested in

finding out more about the Academy please contact Don

Carpenter at [email protected].

September 2014


Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat

Pharmacist Patient Assessment Skills for

Optimizing Self-Care, Part 2 of 4: Evaluation

of Eyes, Ears, Nose, Mouth and Throat By: Kimberly A. Messerschmidt, PharmD; Professor of Pharmacy Practice, SDSU College of Pharmacy. Clinical

Pharmacist, Sanford USD Medical Center and Kelley J. Oehlke, PharmD; Residency Program Director, Clinical

Pharmacy Specialist, Ambulatory Care, Sioux Falls VA Health Care System

Reprinted with permission of the authors and the South Dakota Pharmacists Association where this article originally ap-

peared. This activity may appear in other state pharmacy association journals. There are no financial relationships that

could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-9999-14-008-H04-P&T

2.0 Contact Hours (0.2 CEU)

Goal: To enhance pharmacists’ knowledge regarding patient assessment.

Objectives

At the conclusion of this article, the reader should be able to:

1. Assess the eyes, ears, nose, mouth and throat to identify common self-treatable medical conditions. 2. Recognize common ocular complaints and know which symptoms require physician referral. 3. Differentiate between symptoms associated with a common cold, influenza and allergic rhinitis. 4. Recognize symptoms that indicate a potential sinus infection. 5. Identify symptoms that may be useful in differentiating between viral and streptococcal pharyngitis.

KPERF offers all CE

articles to members

online at

www.kphanet.org

Introduction

In the first installment of this series we introduced the

QuEST process, which is a tool designed to help pharma-

cists elicit the information needed to provide appropriate

recommendations regarding self-care1. In this next section,

we continue to explore opportunities for utilizing basic pa-

tient assessment skills in the ambulatory care setting, with

a focus on assessment of the eyes, ears, nose, mouth and

throat.

EYES

The eyes can be affected by a number of medical condi-

tions, some of which are amenable to self-treatment while

others may require immediate medical attention. The po-

tential risk to vision from ophthalmic problems requires the

pharmacist to accurately distinguish between the two sce-

narios.

When examining the eyelids and surrounding areas, note

the quantity, distribution and texture of the eyebrows; also

check the eyelids for masses, drooping, redness and swell-

ing. A chronic inflammatory condition of the eyelid margins

is called blepharitis. Inflammation and infection of a gland

in the eyelid or the follicle of an eyelash may result in a

hordeolum (sty).

In addition to local conditions, sometimes systemic disease

can alter the appearance of the external eye. For example,

renal impairment can cause excessive fluid retention result-

ing in periorbital edema, and hyperthyroidism can cause an

abnormal protrusion of the eyeball known as exophthal-

mos. The unintentional loss of the lateral portion of the eye-

brows may indicate untreated hypothyroidism, and slowly

growing light-yellow plaques on the inner eyelids called

xanthelasmas are frequently associated with dyslipidemia.

One of the more common ocular problems a pharmacist

encounters is redness of the eye. Although most cases are

relatively benign, some require immediate medical atten-

tion. Conjunctivitis, an inflammation or infection of the clear

mucous membrane lining the eye, can be the result of in-

fectious or noninfectious etiologies.

Noninfectious causes most commonly stem from seasonal

or perennial allergies. Hallmark symptoms include bilateral

redness, a profuse watery discharge, puffiness and itching.

In more severe cases, a mucoid discharge may be noted.

To help identify allergies as the cause of the symptoms,

ask the patient about the presence of any non-ocular symp-

toms of allergic rhinitis such as rhinorrhea (runny nose),

sneezing, nasal congestion, post-nasal drip, itching of the

ears, nose, throat, or palate and systemic symptoms such

September 2014



as malaise and fatigue.

Conjunctivitis secondary to viral infection is the most com-

mon infectious cause of a red eye. This condition usually

occurs during, or shortly after an upper respiratory tract

infection and is characterized by a “pink eye”, swollen eye-

lids and a profuse watery discharge. Patients also may

complain of light sensitivity, itching and/or a mild foreign-

body sensation or scratchiness. Symptoms associated with

viral conjunctivitis are usually self-limiting and tend to re-

solve over a period of one to three weeks.

The symptoms typically start out in one eye, but commonly

spread to the other eye within a day or two. Cold com-

presses and lubricating eye drops may help control mild

symptoms. Since pink eye is highly contagious, patients

should be counseled regarding good hygiene practices to

minimize the spread of infection2 (Table 1).

If the patient is experiencing severe eye pain it may indi-

cate corneal trauma, in which case the patient should be

referred to their physician in order to rule out a corneal

abrasion.

Bacterial conjunctivitis also presents with a red eye and is

usually accompanied by tearing and ocular irritation. Within

one to two days a purulent, yellow-green discharge may be

noted, often resulting in crusting and matting of the eyelids

that develops overnight. Patients should be referred to a

physician for antibiotic drops whenever a bacterial infection

is suspected.

Another common ocular complaint is dry eye; this condition

is especially problematic in the elderly population. Patients

with dry eyes typically complain of general ocular discom-

fort, itching, burning or stinging, redness and a foreign body

sensation3. Medications that can exacerbate dryness in-

clude diuretics and those drugs with anticholinergic side

effects such as antihistamines, tricyclic antidepressants

and phenothiazines.

Self-treatment with artificial tears and/or ocular emollients

(during the night) can be recommended for up to three

days. Likewise, the use of ocular vasoconstrictors should

be limited to three days in order to prevent rebound con-

junctivitis; these products should also be avoided in pa-

tients with narrow-angle glaucoma.

Patients should not self-treat most ophthalmic conditions

for longer than 72 hours without consulting a physician.

Other indications for physician referral include symptoms of

ocular pain, blurred vision that does not clear with blinking,

photophobia, or any history of trauma, or chemical or ther-

mal exposure. A patient complaining of a unilateral red eye

that is accompanied by severe ocular pain, visual defects

or nausea and/or vomiting should be referred to a physician

for immediate evaluation to rule out acute angle-closure

glaucoma.

EARS

Examination of the ears begins with the inspection of the

outer ear and surrounding skin, looking for any redness,

swelling or lesions. Special attention should be given to

non-healing skin lesions, which may indicate a squamous

cell carcinoma. This condition occurs most frequently in fair

QuEST Process1

Quickly and accurately assess the patient (e.g., symptoms, current medications and medical conditions,

allergies)

Establish that the patient is an appropriate candidate for self-care

Suggest appropriate strategies for self-care

Talk with the patient about:

√ The medication’s actions, proper administration, and potential adverse effects

√ What to expect from treatment

√ Appropriate follow-up

Thoroughly wash hands on a regular basis.

Avoid touching eyes with hands.

Avoid close contact with other individuals.

Use a clean towel and washcloth daily.

Change pillowcases frequently.

Avoid sharing objects that may be contaminated (e.g., towels, washcloths, eye cosmetics).

Throw away eye cosmetics and disposable contact lenses (and lens supplies) that may be contaminated.

Table 1. Patient counseling tips to prevent the

spread of pink eye

September 2014



-skinned individuals who have had frequent sun exposure.

The lesion is usually located on the upper rim of the ear

and results in a raised, crusted lesion with a central ulcera-

tion.

The entrance to the ear canal also should be examined for

drainage, excessive earwax (cerumen) and redness or

swelling. Some patients have a tendency to accumulate

and retain excessive moisture in the ear canal, especially

after bathing, swimming, sweating or just being exposed to

a humid environment. This may result in a condition called

water-clogged ears. The patient may complain of a feeling

of wetness or fullness, which can be accompanied by grad-

ual hearing impairment. Ear drops containing isopropyl al-

cohol in anhydrous glycerin can be used to dry out the ears

after each exposure to water, but these products should be

avoided in children less than 12 years of age, and in those

with other exclusions for self-treatment (Table 2).

If left untreated, water-clogged ears may develop into acute

otitis externa, or “swimmer’s ear”, which is an inflammation

or infection of the outer ear canal. This occurs when contin-

ued water exposure, along with the patient’s attempts to

remove the excess moisture, results in the breakdown of

the ear’s natural defenses and allows inflammation and

infection to take place.

If the patient complains of pain or itching in the ear canal,

or if any discharge or inflammation is noted, perform the

“tug test”. To do this, gently tug on the ear to move it up

and down, and press on the tragus (the piece of cartilage

that protects the opening of the ear canal). Movement of

the external ear is painful in acute otitis externa, and these

patients, as well as any other patient with a suspected ear

infection (otitis media), should be referred to his/her physi-

cian.

Problems with ear wax are another common otic complaint,

especially in patients over the age of 65. If excessive or

impacted wax causes bothersome symptoms, such as a

feeling of pressure, fullness or itching, or if it interferes with

hearing or causes trapping of moisture, it should be re-

moved. Options for removal include over the counter ear

wax softeners, or manual removal by a physician.

The use of cotton-tipped swabs, or other foreign objects

such as bobby-pins, should be avoided due to the potential

for pushing the hardened wax further into the ear canal or

causing trauma. A summary of the symptoms of the most

common otic disorders is provided in Table 3.

Pharmacists also should be aware of the potential effect of

medication use on the ear and its functions. Drug-induced

ototoxicity can present itself in a number of ways, and it

very commonly goes unrecognized. Medications may im-

pair the auditory function of the ear (hearing) by affecting

the eighth cranial nerve, and as a result, patients may no-

tice a muffling of sounds, or they may complain of fullness

in the ears or hearing loss. Tinnitus frequently precedes or

coincides with hearing loss and may be described as a

ringing, buzzing, ticking or roaring sound.

Medications also may result in vestibular toxicity. Since the

vestibular system influences balance and equilibrium, ves-

tibular toxicity can result in symptoms of lightheadedness,

Table 2. Otic symptoms and conditions requiring

physician referral

Signs or symptoms of potential infection (i.e., ear

pain, drainage, or fever)

Tinnitus

Dizziness

Perforation of the ear drum (including tympanosto-

my tubes, recent ear surgery or trauma)

Loss of hearing

Lightheadedness, loss of balance, vertigo, nausea or

vomiting

Foreign objects in the ear canal

Table 3. Selected symptoms of common otic disorders

Water-clogged ears Otitis externa Otitis media Impacted cerumen

Pain No Often Usually Rarely

Hearing difficulty Possible Possible Usually Often

Purulent discharge No Common If perforation No

Bilateral symptoms Possible Possible Possible Fairly common

Appropriateness of

self-treatment

Yes In selected cases# Never In selected cases*

# Only if individual has a history of swimmer’s ear and can reliably recognize recurrences

*For adults only, self-treatment for up to four days is appropriate.

September 2014



loss of balance, vertigo, nausea and vomiting. Most often

these effects are reversible upon discontinuation of the of-

fending drug. Medications associated with potential ototoxi-

city include antibiotics (e.g., erythromycin, aminoglyco-

sides, vancomycin), loop diuretics, quinine, cisplatin, salicy-

lates and NSAIDs. Any patient with symptoms suggestive

of drug-induced ototoxicity should be referred to a physi-

cian for further assessment.

NOSE AND SINUSES

When inspecting the nose, start by examining the external

surface for skin lesions, erythema or drainage. Check the

patency of the nasal passages by occluding one nostril at a

time and asking the patient to inhale through the other nos-

tril. Air passage should be noiseless and unobstructed. If

significant congestion is noted, question the patient about a

recent upper respiratory tract infection such as a common

cold, or any allergic symptoms like itching, puffy or watery

eyes, or a watery nasal discharge. Symptoms of a common

cold can vary slightly depending on which one of over 200

viruses is causing the cold, but most commonly it starts

with a scratchy, sore throat, followed by a runny nose,

sneezing and watery eyes. A mild headache, malaise and

fatigue also may be present. Towards the end of a cold, the

runny nose typically turns into a stuffy nose, and up to 20

percent of patients develop a nonproductive cough. Over

the counter cold products containing antihistamines and

decongestants can help ameliorate symptoms, but do not

“cure” or shorten the duration of the cold. With influenza,

the symptoms are generally more severe and often are ac-

companied by a high fever and muscle aches (Table 4).

Allergic rhinitis also may be difficult to distinguish from a

common cold, but in general, patients suffering from aller-

gies are more likely to complain of itching of the eyes, ears,

nose and palate, and the duration of symptoms usually ex-

ceeds one week. Make sure to specifically ask patients

about the recent use of topical nasal decongestants, since

the use of these drugs for more than three to five days, or

at doses which are higher than recommended, can cause

rebound nasal congestion. Allergy patients should be re-

ferred to their physician for suspected complications (e.g.,

ear, sinus or pulmonary infection) or co-morbidities (e.g.,

asthma, obstructive sleep apnea) that need medical evalu-

ation, or if they are not responding adequately to non-

prescription treatment.

If nasal drainage is present, note the color and consistency

of the discharge. Clear, watery drainage is often associated

with allergic rhinitis or the first stage of a common cold. Yel-

low, green or blood streaked discharge indicates a possible

sinus infection. To assess for sinus problems, ask the pa-

tient about any symptoms of nasal congestion, facial pain,

pressure or tenderness, and about any recent upper respir-

atory tract infections. To detect tenderness, use your

thumbs to press upward under the eyebrows and under

both cheekbones. Excessive discomfort or pain suggests

sinusitis.

With sinus congestion, the patient’s speech will have a na-

sal quality. A patient is more likely to have a sinus infection

(rather than just a cold) if symptoms have not improved

after about 10 days, or if symptoms worsen (rather than

improve) after five to seven days.

Other symptoms indicating a potential sinus infection in-

clude, but are not limited to, the following: a low-grade fe-

ver, cough, malaise, nasal congestion that is unresponsive

to nasal decongestants, a preceding upper respiratory in-

fection, toothache, headache or facial pain (especially upon

awakening or bending over) and purulent nasal drainage.

Individually, each of these signs or symptoms has poor

prognostic value, but when seen in combination they can

be highly predictive of a sinus infection. When a sinus in-

fection is suspected, the patient should be referred to a

physician for further evaluation and treatment.

Table 4. Differentiating between a cold and influenza

Symptom Common Cold Influenza

Fever Rare Sudden onset,

often > 102o F

(38.9°C)

Headache Mild or absent Prominent

Myalgias/

arthralgias

Mild or absent Prominent

Fatigue, weakness Mild or absent Extreme, up to

2 weeks

Runny nose,

sneezing

Common Less common

Nasal congestion Common Less common

Sore throat Common Common

Cough (usually

non-productive)

Less common

Usually mild,

hacking

Common,

persistent

Can be severe

Ocular Watery eyes Pain, burning,

photophobia

Duration 7 days 7 days

Complications Sinus

congestion,

earache

Bronchitis,

pneumonia

September 2014



MOUTH AND THROAT

Mouth

When inspecting the mouth, use a tongue blade and pen-

light to examine the lips, gums, cheeks, tongue, teeth and

palate. Have the patient remove any lipstick or dentures in

order to facilitate your examination. Also note any unusual

odor to the patient’s breath. A sweet odor, similar to rip-

ened bananas, may indicate diabetic ketoacidosis, while a

foul or putrid odor may be a sign of a dental or pulmonary

infection.

Observe the lips for color, moisture, swelling, asymmetry or

presence of lesions. Common findings include herpes sim-

plex lesions (cold sores or fever blisters) which are recur-

ring lesions that are usually located on the border of the lip.

These painful lesions usually start as a small cluster of

vesicles that rupture and form a yellowish-brown crust.

Healing generally occurs over a period of 10 to 14 days.

Any non-healing lesion should be examined by a physician

to rule out carcinoma. Dry, cracked or inflamed lips can be

a sign of sun or wind exposure, dehydration or poorly fitting

dentures. An asymmetrical drooping of one side of the

mouth may be the result of Bell’s Palsy (inflammation or

dysfunction of the facial nerve) or a cerebrovascular acci-

dent and should be promptly referred to a physician to de-

termine the cause.

Next, ask the patient to open her mouth. Note the state of

dental hygiene and observe for any signs of inflammation

of the gums (gingivitis) or easy bleeding, both of which may

be an early symptom of periodontal disease. Gingival hy-

perplasia (enlargement of the gums) may be associated

with pregnancy, leukemia or exposure to certain drugs

(e.g., calcium channel blockers, phenytoin, cyclosporine).

A yellowish to brown discoloration of the teeth from tobac-

co, coffee, tea or prior tetracycline use is a fairly common

but benign finding.

Inspect the gums, cheeks and palate for erythema, lesions

or swelling. The normal oral mucosa should be pink and

moist. A lack of saliva under the tongue may be an indica-

tion of dehydration. Aphthous ulcers (canker sores) are

small, painful pale yellow to white spots or ulcerations that

are often surrounded by a reddened halo. They are a fairly

benign finding and usually heal within seven to 10 days

without treatment. Leukoplakia presents as a thickened

and painless white patch and may occur anywhere on the

oral mucosa. This finding is usually the result of chronic

irritation such as from chewing tobacco and is considered a

pre-malignant condition that should be further evaluated.

Oral thrush is a yeast infection of the mouth that results in

creamy-white, curd-like patches. The area under the patch-

es is often reddened and sore. These lesions may be

found on the cheeks, tongue, throat, hard and soft palate

and gums. Patients more susceptible to oral thrush are

those on certain medications such as inhaled or systemic

steroids, antibiotics or other immunosuppresants, as well

as those who smoke, are diabetic or have an immunosup-

pressive disorder. Patients with suspected thrush should

be referred to a physician for further evaluation and treat-

ment.

Throat

To inspect the throat, use a tongue blade and penlight to

visualize the posterior portion of the oral cavity and the

tonsils. Insert the tongue blade posteriorly, no further than

the uvula to avoid provoking the gag reflex. Moistening the

tongue blade with warm water may help avoid triggering

this reflex. While pressing gently downward on the tongue,

ask the patient to say “aaah”. This raises the soft palate

and allows for better visualization of the oropharynx and

tonsillar area. Observe the surrounding region for inflam-

mation, erythema, exudate or lesions. Small, irregular

spots of pink or red lymphatic tissue and small blood ves-

sels are commonly present.

The color of the tonsils usually blends in with the pink color

of the pharynx and they normally should not project be-

yond the limits of the tonsillar pillars. If the tonsils are red-

dened, swollen or covered with whitish spots, or exudate,

an infection may be present. A yellowish, mucoid drainage

in the pharynx is typical of postnasal drip.

A sore throat, or pharyngitis, is one of the most common

reasons a patient seeks medical attention. This condition is

usually caused by the invasion of the pharyngeal tissue by

a pathogen, although non-infectious etiologies (e.g. gas-

troesophageal reflux disease, post-nasal drainage) also

are possible. Both bacterial and viral organisms can pro-

duce a sore throat.

Approximately 50 to 80 percent of pharyngitis is due to viral

pathogens, while Group A streptococcus is by far the most

common bacterial pathogen. Since untreated streptococcal

pharyngitis (strep throat) may lead to complications such

as rheumatic fever, one of the most important tasks in eval-

uating a patient with a sore throat is to decide whether or

not they may have strep throat.

Table 5 lists common findings associated with both strepto-

coccal and viral pharyngitis. Although individual signs and

symptoms are not accurate enough to make a clear diag-

nosis, patients with one or fewer of the cardinal findings

(i.e., tonsillar exudate, swollen tender anterior cervical

September 2014



nodes, absence of cough, history of fever) have a relatively

low risk of strep throat.

It is important to refer any patient with suspected strep

throat to his/her physician for further assessment, diagno-

sis and care. A low grade fever and malaise often accom-

pany the viral sore throat. Although distressing to the pa-

tient, this condition is usually benign and self-limited. Dur-

ing the acute phase of pharyngitis, most patients will bene-

fit from rest, adequate fluid intake, antipyretic/analgesic

therapy and warm salt water gargles.

CONCLUSION

Patients commonly present to their community pharmacy

seeking a recommendation for the treatment of symptoms

involving the eyes, ears and upper respiratory tract. While

many of these conditions can be self-treated, some require

physician referral, and it is imperative for the pharmacist to

be able to distinguish between the two.

By utilizing basic patient assessment skills, the pharmacist

is able to guide the patient regarding the most appropriate

treatment to pursue, whether it be self-treatment or further

evaluation by a physician. Using these skills, along with

effective communication techniques, allows the pharmacist

to build long-term, trusting relationships that optimizes pa-

tient care.

REFERENCES

1. Leibowitz K, Ginsburg D. Counseling self-treating pa-

tients quickly and effectively. Proceedings of the APhA

Inaugural Self-Care Institute; May 17-19, 2002.

2. Pink eye (conjunctivitis). Available from URL: http://

www.mayoclinic.com/health/pink-eye/DS00258. Updat-

ed May 22, 2010.

3. Pray, SW. Minor eye problems in the elderly. US Pharm

2009;34(6):12-17.

SUGGESTED READINGS

Berardi RR, Ferreri SP, Hume AL, Kroon LA, Newton

GD, Popovich NG et al, editors. Handbook of Nonpre-

scription Drugs: An Interactive Approach to Self-care.

16th ed. Washington DC: The American Pharmaceuti-

cal Association; 2009.

Dipiro JT, et al (eds): Pharmacotherapy: A Pathophysi-

ologic Approach. 7th ed. McGraw Hill; 2008.

Jones RM and Rospond RM. Patient Assessment in

Pharmacy Practice. 2nd

ed. Baltimore (MD): Lippincott

Williams & Wilkins; 2006.

Longe RL and Calvert JC. Physical Assessment: A

Guide for Evaluating Drug Therapy.1st ed. Vancouver:

Applied Therapeutics, Inc; 1994.

* cardinal symptoms of strep throat

Signs and symptoms suggestive of streptococcal pharyngitis

Sudden onset of severe throat pain

Pain on swallowing

Fever > 101° F (38.3°C)*

Headache and malaise

Abdominal pain (especially in children)

Nausea and vomiting

Rash

Enlarged or tender cervical lymph nodes*

Pharyngeal erythema, exudate

Tonsillar erythema, enlargement, exudates*

Bad breath

Lack of cough*

Table 5. Characteristic findings associated with pharyngitis

Signs and symptoms suggestive of viral pharyngitis

Cough

Temp ≤101° F (38.3°C)

Runny nose

Hoarseness

Conjunctivitis

Pharyngeal vesicles and/or ulcers

Malaise

September 2014



August 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 2 of 4:

Evaluation of the Eyes, Ears, Nose, Mouth and Throat

1. Which of the following statements best describes symptoms typically associated with allergic conjunctivitis? A. Unilateral redness, irritation and purulent discharge B. Bilateral redness, watery discharge and ocular itching C. Severe ocular pain and redness D. Crusting and matting of the eyelids, particularly upon

awakening 2. A patient presenting with a unilateral red eye and severe ocular pain should be: A. Instructed to self-treat with acetaminophen for up to five

days. B. Referred to a physician if the symptoms do not improve

on their own within 72 hours. C. Referred to a physician for immediate evaluation. D. Told to practice thorough hand washing and to avoid

sharing contaminated objects with others. 3. Which of the following statements regarding the self-treatment of common ocular problems is FALSE? A. Patients should not self-treat most ophthalmic condi-

tions for longer than 72 hours without consulting a phy-sician.

B. The use of ocular vasoconstrictors should be limited to three days in order to prevent rebound conjunctivitis.

C. Patients experiencing severe eye pain should be re-ferred to their physician as it may be a sign of a corneal abrasion.

D. Patients who have experienced a chemical exposure to the eye should be instructed to flush well with water and call their physician if the pain and/or vision problems do not resolve within 72 hours.

4. Which of the following otic conditions is potentially appro-priate for self-treatment? A. Symptoms of ear pain, fever and drainage B. Suspected drug-induced ototoxicity C. A repeat case of swimmer’s ear D. Impacted cerumen in a patient with dizziness and tinni-

tus 5. Pain associated with the “tug test” is most suggestive of: A. Otitis externa (swimmer’s ear). B. Ear wax impaction. C. Ototoxicity. D. Otitis media. 6. Clear, watery nasal discharge accompanied by an itchy nose and eyes is most consistent with : A. A bacterial sinus infection. B. A common cold. C. Influenza. D. Allergic rhinitis.

7. Symptoms that suggest a patient has influenza rather than a common cold include: A. Nasal congestion. B. Myalgias and arthralgias. C. Runny nose and sneezing. D. Sore throat. 8. Symptoms of purulent nasal discharge, cough, nasal con-gestion, facial pain or tenderness, and a headache are most consistent with: A. Influenza. B. Strep throat. C. A sinus infection. D. Seasonal allergies. 9. Leukoplakia is a pre-malignant condition found on the: A. Oral mucosa. B. Nose. C. Scalp. D. Eyelids. 10. Painful, creamy-white, curd-like patches in the oral cavi-ty are due to: A. Chronic irritation. B. A viral infection. C. A bacterial infection. D. Yeast. 11. Which of the following symptoms are more likely to be suggestive of viral pharyngitis rather than streptococcal pharyngitis? A. Enlarged cervical lymph nodes and a high fever B. Tonsillar exudate C. Sudden onset of severe throat pain D. Low grade fever, runny nose and a cough 12. Which of the following are signs and symptoms of strep-tococcal pharyngitis that should alert you to recommend a prompt referral to a physician? A. Pain on swallowing, temperature < 101° F (38.3°C) B. Runny nose and cough C. Temperature >101° F (38.3°C) with tonsillar exudate D. Low grade fever, runny nose and a cough

September 2014



This activity is a FREE service to members of the Kentucky Pharmacists Association. The

fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South,

Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

The Kentucky Pharmacy Education & Research Foundation is

accredited by The Accreditation Council for Pharmacy

Education as a provider of continuing Pharmacy education.

Quizzes submitted without NABP eProfile

ID # and Birthdate cannot be accepted.

PHARMACISTS ANSWER SHEET August 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 2 of 4: Evaluation of the Eyes, Ears, Nose, Mouth and Throat (2.0 contact hours) Universal Activity # 0143-9999-14-008-H04-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 7. A B C D 9. A B C D 11. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B C D 12. A B C D Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

Personal

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD)

Expiration Date: September 27, 2017 Successful Completion: Score of 80% will result in 2.0 contact hour or 0.2 CEU.

Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. August 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 2 of 4: Evaluation of the Eyes, Ears, Nose, Mouth and Throat (2.0 contact hours) Universal Activity # 0143-9999-14-008-H04-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 7. A B C D 9. A B C D 11. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B C D 12. A B C D Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

Personal


September 2014


KPhA Pharmacy Emergency Preparedness

KPhA Pharmacy Emergency Preparedness Initiative Interest Form

Name: ______________________ Status (Pharmacist, Technician, Other): ___________________

Email: ______________________________ Phone: ___________________________

For Pharmacists: Interest in serving as a volunteer: Yes____ No _____

If yes, please go to KHELPS link on KPhA Website to register (www.kphanet.org under Resources)

Please send this information to Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness via email at

[email protected], fax to 502-227-2258 or mail at KPhA, 1228 US 127 South, Frankfort, KY 40601.

For more Emergency Preparedness

Resources, visit www.kphanet.org,

click on Resources and Emergency

Preparedness.

Pharmacy Personnel Training Program KPhA Director of Pharmacy Emergency Preparedness Leah Tolliver, PharmD, is developing a training program for

Pharmacy Personnel on preparing for a disaster, both in the pharmacy and at home. Watch the KPhA eNews and the

calendar on www.kphanet.org for dates and more information.

Make a plan and practice

Disasters and other emergencies occur with very little warning, so make sure that you and your family have a plan in

place to handle several types of emergencies. For more information on developing emergency plans, visit http://

www.ready.gov/make-a-plan.

Once you have your plan, be sure to practice it until all members of your family are comfortable with the plan!

Drop, Cover and Hold On

With a major fault line near the western end of Kentucky, a major earthquake is possible. For more information on

earthquake drills, visit http://quake.ualr.edu/schools/guide/section6d.htm.

September 2014


Sept. 2014 CE — CPE Monitor

CPE Monitor – A New Continuing

Education Tracking System for Pharmacy By: Bernie Hendricks, RPh, Continuing Education Coordinator, South Dakota State University

College of Pharmacy






Pharmacist Objectives


1. Describe the CPE Monitor mechanism for tracking / verifying continuing education credits. 2. Name two primary benefits of the new CPE Monitor program. 3. Describe the process for pharmacists to obtain an e-Profile ID. 4. Identify the two key pieces of information that a pharmacist must submit to be properly credited for successful

completion of continuing education programs. 5. Describe the process of a pharmacist reviewing / verifying information on earned continuing education credits.

Pharmacy Technician Objectives

1. Describe the CPE Monitor mechanism for tracking / verifying continuing education credits. 2. Name two primary benefits of the new CPE Monitor program. 3. Describe the process for pharmacy technicians to obtain an e-Profile ID . 4. Identify the two key pieces of information that a pharmacy technician must submit to be properly credited for

successful completion of continuing education programs. 5. Describe the process of a pharmacy technician reviewing / verifying information on earned continuing education

credits.

Background – Continuing Pharmacy Education (CPE)

Continuing pharmacy education is required for re-licensure

in all 50 states, along with the District of Columbia, Guam,

and Puerto Rico.

CPE requirements vary from state to state re-

garding the number of contact hours required

(annually or biennially), the composition of the

CPE and the format (live or home study).

The number of CPE “contact hours” required for re-

licensure ranges from 10 – 20 per year, depending on the

state or territory. The most common requirements are “15

hours per year,” or “30 hours biennially,” or “12 hours per

year.” Some states express their requirements in terms of

continuing education units (CEUs), in which 1 CEU is

equivalent to 10 “contact hours.”

Certain states require a set number of CPE hours in speci-

fied topic areas such as pharmacy law, or AIDS/HIV, safety

or pain management. And numerous states require that a

specified number of hours must be completed as

“live” (didactic) CPE.

Some states allow a “carry-over” of hours, where extra

hours of CPE earned in a given year are allowed to be car-

ried over into the next reporting period.

Kentucky law requires pharmacists to earn 15

hours of CPE each year. Extra hours do not

carry over to the next year, and one hour of

HIV/AIDS CPE is required every 10 years.

Newly licensed pharmacists do not have to complete CPE

hours the year they graduate, but must complete the stand-

ard 15 hours the next year.

CPE credit – tracking and verification

The CPE Monitor program is a new tracking service for

continuing pharmacy education which is a “national collab-

orative effort between the National Association of Boards of

Pharmacy® (NABP®) and the Accreditation Council for

Pharmacy Education (ACPE).”

This program will electronically “store and authenticate data

for completed CPE units,” for pharmacists and pharmacy

KPERF offers all CE

articles to members

online at

www.kphanet.org

September 2014



technicians. To accomplish this, ACPE-accredited provid-

ers of continuing pharmacy education programs will upload

verification to a participant’s e-Profile account, following

successful completion of a given continuing education pro-

gram.

Data will be stored in a central repository managed by

NABP. Individual pharmacists and pharmacy technicians

will be able to access the information in their own accounts,

and Boards of Pharmacy will be able to verify CPE infor-

mation of those seeking re-licensure. This electronic stor-

age and authentication process should efficiently stream-

line subsequent tracking and verification of continuing phar-

macy education credit.

Paper copies of ACPE Statements of Credit for continuing

pharmacy education units (CPE units) earned by pharma-

cists and pharmacy technicians have been eliminated in

this new, stream-lined process.

Testing – implementation

By April of 2012 an NABP-ACPE pilot program had been

completed, and nearly 50 ACPE-accredited providers had

“transitioned their systems to transmit data” to the CPE

Monitor database. These 50 providers were the first to re-

quire participants to provide “e-Profile ID number” and

birthdate in “MM/DD” format in order to earn CPE credit.

The balance of ACPE-accredited providers transitioned

their systems during 2012, with full transition of all provid-

ers required by Dec. 31, 2012. KPERF transitioned as of

September 2012.

ACPE noted that by April 2012 “more than 142,000 phar-

macists and 62,000 pharmacy technicians” had set up their

NABP e-Profiles for electronic transmission and tracking of

their CPE units earned.

NABP has affirmed, “All information is maintained in a

highly secure environment.” And, “CPE Monitor will not

track CPE from non-ACPE-accredited providers. Until this

feature is provided in Phase 2, non-ACPE-accredited CPE

will need to be submitted directly to the Board of Pharma-

cy.” This includes CPE earned that is accredited by the

Kentucky Board of Pharmacy.

Registration / e-Profile ID

For step one, pharmacists and pharmacy technicians are

required to register with CPE Monitor on the NABP website

(www.MyCPEmonitor.net ) to obtain their NABP e-Profile ID

(ePID). This unique ID number, along with a participant’s

MMDD (month/day of date of birth) will be needed for the

participant’s e-Profile account to be properly credited for

earned CPE units.

e-Profile Account

In step two, pharmacists and pharmacy technicians also

will create individual e-Profile accounts in order to track

their CPEs completed. e-Profile accounts can be created

by going to www.NABP.net, then “CPE Monitor,” and then

clicking on “create an e-Profile.”

Electronic tracking

Following the successful completion of a given continuing

education program, the ACPE-accredited provider of that

program will transmit verification by uploading the appropri-

ate credit award to the national database maintained jointly

by ACPE and NABP, where it will be posted to the partici-

pant’s e-Profile account.

Case example 1: A pharmacist goes to an ACPE approved

live program and earns credit for 3 separate CE sessions

(1.5 hours, 2 hours, 1 hour). The ACPE-accredited provid-

er, utilizing the participant’s e-Profile ID and MMDD, will

upload verification of that credit to the participant’s e-Profile

account citing the amount of credit, the Universal Program

Identification number for each session completed, and rele-

vant date(s).

The participant will then be able to log in to his/her account

with the “username” and “password” established during the

initial set-up to confirm the credit awards and comprehen-

sive listings of past CPE units successfully completed and

credited.

Note: If a participant logs in to his/her e-Profile account

and notices that he/she has not been properly credited in

the account, then the participant will need to contact the

provider of that program to reconcile that credit issue.

Case example 2: A pharmacy technician submits two sepa-

rate home study courses on pharmacy law (2 hours, 2 hours)

to an ACPE-accredited provider. The provider then corrects

the two post-tests submitted, and verifies completeness of

additional requirements (evaluation, needs survey). Once

successful completion of requirements has been determined,

the provider of the two CPE programs will need the partici-

pant’s e-Profile ID number and MMDD to properly upload the

appropriate credit, the Universal Program Identification Num-

ber, and the date(s) for the courses.

Note: If the participant has not obtained an e-Profile ID

(ePID) in advance, then the provider will be required to put

the credit verification ‘on hold,’ until the participant obtains

the e-Profile ID and provides that and the MMDD (month/

day of date of birth).

Records

Using their “username” and ‘password,” pharmacists and

http://www.MyCPEmonitor.net

September 2014



pharmacy technicians will be able to login to their e-

Profile accounts anytime to verify or confirm the number

of CPE units (CE credits) that have been earned in a given

period of time. They also will be able to print hard-copy rec-

ords if they wish. Any discrepancies will need to be recon-

ciled with the provider of a given program.

Boards of Pharmacy also will be able to access licensee

accounts to insure that CE requirements have been met for

re-licensure each year.

Note: A given Board of Pharmacy may independently veri-

fy information in e-profile accounts of those seeking re-

licensure. Or a Board may require a pharmacist or pharma-

cy technician to print a hard copy report from their e-Profile

account and submit with re-licensure application.

Benefits

Hard copy Statements of Credit will eventually be eliminat-

ed – thus avoiding the issue of lost copies and the subse-

quent tracking down of various providers for “replacement

copies.”

Boards of Pharmacy will be able to view e-Profile account

verification of CPE units earned for re-licensure applica-

tions.

Licensees also will be able to print a hard-copy statement

from their NABP e-Profile which verifies the accumulated

CPE units earned for a given time period. And certain

Boards of Pharmacy (or other “licensing jurisdictions”) may

require their pharmacists and pharmacy technicians to sub-

mit such a “hard copy” statement for re-licensure.

Reminders

Pharmacists and pharmacy technicians will need to keep a

good record of their e-Profile “Username” and “Password,”

in order to confirm that they have been properly credited for

CE.

Following each live program event or home study course

submitted, participants should verify on their individual e-

Profile accounts that they have received the correct num-

ber of CPE units (credits) for that event or course. Partici-

pants should also periodically verify that they are on track

for accumulating the proper number of credits for re-

licensure as those dates approach.

Pharmacy students: If a pharmacy student would happen

to establish an e-Profile account prior to becoming licensed

as a pharmacist, that student would later need to go back

into his/her e-Profile to update that account with the phar-

macist license number and state.

Pharmacists and pharmacy technicians who develop any

problems setting up or accessing their accounts, printing

statements or verifying accumulated credit, are urged to

contact NABP’s Customer Service at 847-391-4406 or

email them at [email protected] (or [email protected]).

Additional information on CPE Monitor may be obtained by

visiting www.MyCPEmonitor.net .

References:

1. NABP “Survey of Pharmacy Law 2012”

2. ACPE “Electronic Mailbag,” April 12, 2012

KPhA Government Affairs Contribution Name: _______________________________Pharmacy: _____________________________

Email: ______________________________________________________________

Address: _____________________________________________________________

City: ___________________________________________ State: _________ Zip: ____________

Phone: ________________ Fax: _________________ E-Mail: ______________________________

Contribution Amount: $_________ Check ____ (make checks payable to KPhA Government Affairs)

Mail to: Kentucky Pharmacists Association, 1228 US Highway 127 South, Frankfort, KY 40601

mailto:[email protected]



September 2014


The Kentucky Pharmacist is online!

Go to www.kphanet.org, click on Communications

and then on The Kentucky Pharmacist link.

Would you rather receive the journal electronically?

Email [email protected] to be placed on the Green list for electronic delivery.

Once the journal is published, you will receive an email

with a link to the online version.


September 2014 — CPE Monitor – A New Continuing Education Tracking System for Pharmacy

1. Pharmacists and pharmacy technicians may obtain their new e-Profile ID number by: A. Contacting their Board of Pharmacy. B. Logging in to the ACPE website. C. Logging in to the NABP website,

www.MyCPEmonitor.net. D. Automatically receiving it when they license. 2. In order for a pharmacist or pharmacy technician to ac-cess their existing “NABP e-Profile” account, they will need to log in with their: A. Username and Password. B. e-Profile ID Number and MMDD. C. Username, password, and e-Profile ID number. D. MM/DD and SSN. 3. At the time when all ACPE-accredited providers are re-quired to have fully transitioned to the CPE Monitor system, all pharmacists and pharmacy technicians will be required to obtain and submit their “e-Profile ID” number (ePID) and “MMDD” in order to insure the proper electronic transmis-sion of CPE unit (CE credit) to their accounts. A. True B. False 4. All ACPE-accredited providers will be required to fully transition to the CPE Monitor electronic tracking system by: A. April 2012. B. July1, 2012. C. December 31, 2012. D. December 1, 2013. 5. Continuing education credit earned that is not ACPE approved will automatically be included and properly credit-ed into the CPE Monitor system, beginning December 31, 2012. A. True B. False

6. Boards of Pharmacy or other “licensing jurisdictions” for pharmacist and pharmacy technician re-licensure applications: A. May access individual e-Profile accounts to confirm

that CE requirements have been met for a given time period.

B. May require pharmacists and pharmacy technicians to submit a paper statement from their e-Profile accounts for CE verification.

C. Either a or b. D. Neither a nor b. 7. Boards of Pharmacy may continue to accept continuing education credits for re-licensure from non-ACPE accredit-ed providers following the full implementation of CPE Moni-tor. A. True B. False 8. “Live” CPE and “home study CPE” credit earned by pharmacists and pharmacy technicians will both be treated the same by ACPE accredited Providers following full im-plementation of CPE Monitor – with all credit uploaded to the CPE Monitor database A. True B. False 9. If a pharmacist or pharmacy technician checks their e-Profile account and notices that he/she has not been properly credited for a CE program successfully completed, that person should contact: A. The Board of Pharmacy. B. Customer Service at NABP. C. Their local internet service provider (ISP). D. The ACPE accredited provider of that program who

would have been tasked with uploading the credit infor-mation.

10. If a person needs to submit an e-Profile ID (ePID) for a given CE program and has misplaced or cannot remember the number, then he/she should: A. Log in to their e-Profile account to access the ePID. B. Call their state Board of Pharmacy. C. Call their state Pharmacists Association. D. All of the above.


September 2014



PHARMACISTS ANSWER SHEET September 2014 — CPE Monitor – A New Continuing Education Tracking System for Pharmacy (1.0 contact hours) Universal Activity # 0143-9999-14-009-H04-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B 5. A B 7. A B 9. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B 10. A B C D Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

Personal


Expiration Date: October 22, 2017 Successful Completion: Score of 80% will result in 1.0 contact hour or 0.1 CEU.


TECHNICIANS ANSWER SHEET. September 2014 — CPE Monitor – A New Continuing Education Tracking System for Pharmacy (1.0 contact hours) Universal Activity # 0143-9999-14-009-H04-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B 5. A B 7. A B 9. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B 10. A B C D Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

Personal









ID # and Birthdate will not be accepted.

September 2014


Oct. 2014 CE — Respiratory & Cardiovascular Systems

Pharmacist Patient Assessment Skills for Optimizing

Self-Care, Part 3 of 4: Evaluation of the Respiratory

and Cardiovascular Systems By: Kimberly A. Messerschmidt, PharmD; Professor of Pharmacy Practice, SDSU College of Pharmacy. Clinical

Pharmacist, Sanford USD Medical Center and Kelley J. Oehlke, PharmD; Residency Program Director, Clinical

Pharmacy Specialist, Ambulatory Care, Sioux Falls VA Health Care System






Goal: To enhance pharmacists’ knowledge and skills regarding patient assessment.

Learning Objectives


1. Perform a basic assessment of the respiratory system. 2. Evaluate a patient for signs and symptoms of respiratory distress. 3. Identify symptoms associated with a cough that indicate the need for physician referral. 4. Perform a basic assessment of the cardiovascular system including pulse, respiratory rate and blood pressure. 5. Describe the proper technique for blood pressure measurement. 6. Identify the characteristics of the most common causes of chest pain.

KPERF offers all CE

articles to members

online at

www.kphanet.org

Introduction

SL is a 54-year-old male who approaches the pharmacy

counter with an over the counter (OTC) cough and cold

product. The patient explains that he has been taking this

multi-symptom cold formula for the past two days, but when

he actually read the product directions, he saw a warning

which recommended that patients with heart disease or

high blood pressure should consult a physician before us-

ing the product. He asks for your advice regarding an alter-

native treatment as his blood pressure has been elevated.

Recalling the QuEST/Scholar process (page 12)1 which

was introduced in the first installment of this series, you

begin your consultation by assessing the patient.

In this section, we will continue to explore opportunities for

utilizing basic patient assessment skills in the ambulatory

care setting, with a focus on assessment of the respiratory

and cardiovascular systems.

As you read this module, think about the case above and

how you would apply the QuEST process in order to formu-

late the best plan for this patient’s care.

RESPIRATORY SYSTEM

Typical respiratory symptoms such as shortness of breath

or cough may arise from a variety of pulmonary, as well as

non-pulmonary conditions (e.g., heart failure, gastroesoph-

ageal reflux). The initial assessment should start with eval-

uating the patient for any obvious signs of respiratory dis-

tress that indicate a need for physician referral (Table 1).

Observe the patient’s pattern and ease of breathing. It

should be smooth and even, and appear effortless, with a

rate of 12 to 20 breaths per minute. Note the depth of the

respirations and whether the patient is using accessory

muscles (i.e., neck, abdominal, or intercostal muscles).

These muscles are used to augment breathing when the

diaphragm cannot move sufficient air.

Next, listen to the patient’s breath sounds for any abnor-

malities. Wheezing is a high pitched, continuous, squeaky

sound that can sometimes be heard without the aid of a

stethoscope. It is caused by air flowing through narrowed

or partially obstructed airways. This narrowing may be due

to excessive secretions, inflammation or bronchospasm,

and it is commonly seen in lung diseases such as asthma

or chronic obstructive pulmonary disease (COPD), or in

acute bronchitis. Wheezing also may be induced by expo-

sure to certain medications (e.g., aspirin, NSAIDs, beta-

blockers) in susceptible individuals. Stridor is a serious,

high-pitched, wheezing type of sound that occurs when

there is a significant partial obstruction of the upper airway,

such as when a foreign object like food, or swelling due to

September 2014



an infection threatens to occlude the airway.

Next, evaluate the patient’s ease of breathing. A patient

with dyspnea may say they are short of breath, winded or

breathless. To help determine the severity of their symp-

toms, note whether they can speak in complete sentences

without being forced to stop for a breath. Also, ask how

their breathing is affecting their daily life. Can they carry

groceries into the house? Do they have any problems

dressing or bathing themselves? If the patient has dyspnea

that has not been formally evaluated, or if they have any

other signs or symptoms of respiratory distress, they

should immediately be referred to their physician.

If the dyspneic patient has a previous diagnosis of obstruc-

tive lung disease and is using an inhaler, the pharmacist

should always assess medication adherence; this includes

having the patient demonstrate their inhaler technique.

Studies have shown that a large percentage of patients do

not use their inhalers correctly. Providing oral or written

instruction on administration technique is not good enough,

as this approach results in only about one-half of patients

being able to use their inhaler correctly2. An actual demon-

stration of appropriate technique by the pharmacist, while

the patient observes and then repeats the demonstration, is

the most effective method of teaching this somewhat com-

plicated task. This approach results in 75 percent of pa-

tients using acceptable technique. Since the efficacy of an

inhaled medication is highly dependent upon proper admin-

istration, it is well worth the extra time it takes to teach the

correct administration method to make sure the patient is

getting the most benefit.

Another common respiratory complaint is cough. This

symptom can be classified in a number of ways: acute (less

than three week duration) or chronic, and productive

(associated with the expectoration of secretions from the

lower respiratory tract) or nonproductive (dry, hacking). It is

important to remember that the cough reflex is a vital res-

piratory defense mechanism designed to expel secretions

and debris from the respiratory tract; therefore, it can be

counterproductive to suppress.

The most common etiologies of a cough are postnasal drip

due to allergies or upper respiratory tract infection, ciga-

rette smoking, poorly controlled or undiagnosed asthma

and gastroesophageal reflux3. Other less common causes

include heart failure, malignancy, other pulmonary diseases

and drugs such as angiotensin converting enzyme (ACE)

inhibitors.

A typical ACE inhibitor induced cough can begin anytime

from hours to months after initiation of the offending drug. It

usually starts out as a tickling sensation in the back of the

throat, and the resulting cough is generally described as

being non-productive and poorly responsive to antitussives.

The typical ACE inhibitor induced cough generally resolves

within one to four weeks after drug discontinuation3.

A cough associated with a common cold is usually caused

by post-nasal drainage and may respond to the use of a

decongestant/antihistamine combination. Any cough that

lasts for more than one week, or is accompanied by symp-

toms suggestive of an underlying infection or more serious

condition should always be evaluated by a physician (Table

2).

VITAL SIGNS and CARDIOVASCULAR SYSTEM

The vital signs (pulse, respiration, blood pressure and tem-

perature) are considered to be the baseline indicators of a

patient’s health status. Pain assessment is often times con-

sidered the fifth vital sign. Evaluation of the vital signs may

be incorporated into any practice setting, measured togeth-

er or separately and obtained in a brief period of time.

Pulse

A person’s pulse represents the number of cardiac cycles

per minute. Because it is easily accessible, the radial pulse

(wrist) is most commonly taken. When determining the radi-

al pulse, the pharmacist should:

Table 1. Signs and symptoms of respiratory distress

Increased respiratory rate

Use of accessory muscles

Retractions of the intercostal spaces

Wheezing or stridor

Dyspnea

Pursed lip breathing

Cyanosis of the skin or lips

Changes in mental status (e.g., confusion, somnolence,

restlessness or anxiety)

Nasal flaring, especially in newborns

Table 2. Symptoms associated with a cough that indicate a

need for physician referral

Fever

Night sweats

Hemoptysis

Unintended weight loss

Productive cough with purulent sputum (e.g., thick, colored)

Increasing symptoms in a patient with underlying pulmonary

disease

Poor response to self-treatment

September 2014



Place the pads of the index and middle fingers on the

palmar surface of the wrist near the base of the thumb.

Press down until pulsation is felt, being careful not to

occlude the artery.

If the rhythm is regular, count the number of beats in

30 seconds and multiply the number by two.

If the rhythm is irregular, count the number of beats in

one minute.

Table 3. Guidelines for proper blood pressure measurement5

Ask the patient if he or she has smoked or ingested caffeine within the previous 30 minutes. If the patient

answers “yes”, record the information and recognize that it may impact the blood pressure.

The patient should be seated in a chair with his back supported, feet flat on the floor and bare arm

supported at heart level.

Make sure the patient has been allowed to rest for at least five minutes before measuring her blood

pressure.

Determine the appropriate cuff size.

Palpate the brachial artery along the inner arm near the crease of the elbow.

Center the bladder of the cuff over the brachial artery and wrap the cuff snuggly around the arm, placing

the lower edge of the cuff approximately one inch above the antecubital space (fold of the arm).

Position the manometer dial so it can be easily read.

Instruct the patient not to talk during the measurement.

Determine the maximum inflation level (how much to inflate the cuff). While palpating the radial pulse,

inflate the cuff to the point at which the radial pulse can no longer be felt, then add 30 mmHg to this

reading.

Rapidly deflate the cuff and wait 30 seconds before reinflating.

Insert the stethoscope earpieces, making sure they point forward when in place.

Place the bell of the stethoscope lightly, but with an airtight seal, over the palpable brachial artery. Note

that the diaphragm of the stethoscope also may be used; however, the bell is designed to detect

low-pitched sounds and should be used if possible.

Rapidly inflate the cuff to the maximum inflation level.

Slowly release the air, allowing the pressure to fall steadily at 2 to 3 mmHg/second.

Note the pressure at the first appearance of repetitive sounds and record this as the systolic pressure.

Continue listening, noting the pressure at which the last sound is heard. This is the diastolic pressure.

Continue listening until 20 mmHg below the diastolic pressure, then rapidly and completely deflate the

cuff.

Record the patient’s blood pressure in even numbers, along with the patient’s position (i.e., sitting,

standing, lying), cuff size (if a non-standard size is used) and the arm (right or left) used for

measurement.

Wait 1 to 2 minutes before repeating the pressure measurement in the same arm.

September 2014



Record the finding as beats per minute (bpm).

The normal resting adult pulse should be between 60 and

100 bpm. In an adult, a heart rate less than 60 bpm is

called bradycardia, and a heart rate greater than 100 bpm

is called tachycardia. However, a well-conditioned athlete

or patient on medications that may slow the heart rate

(e.g., beta-blockers) may have a normal, resting heart rate

of less than 60 bpm.

Respiratory Rate

Respirations are often counted and evaluated without the

patient’s knowledge because sudden awareness of this

measurement may alter the patient’s normal respiratory

rate and pattern. The pharmacist should observe the rise

and fall of the patient’s chest, and the ease with which

breathing is accomplished. For a normal adult, the rate is

expected to be 12 to 20 respiratory cycles per minute.

Count the number of respiratory cycles (i.e., inspiration and

expiration) that occur in 30 seconds and multiply by two.

Record the value as respirations per minute (rpm). For

adults, a respiratory rate of less than 12 rpm is called brad-

ypnea, and a respiratory rate of greater than 20 rpm is

called tachypnea. Also observe the regularity and rhythm

of the breathing pattern.

Blood Pressure

Blood pressure is a peripheral measurement of cardiovas-

cular function. It is the pressure placed on arterial walls by

the blood, and it is controlled by heartbeat force, blood vol-

ume and vessel tone. Blood pressure has two components.

Systolic blood pressure represents the maximum pressure

that is felt on the arteries during left ventricular contraction.

Diastolic blood pressure is the resting pressure that the

blood exerts between each ventricular contraction.

BP Measurement

Because signs and symptoms of hypertension are com-

monly absent or ambiguous (e.g., headache, dizziness),

accurate measurement is essential. Indirect measures of

blood pressure are made with a stethoscope and a sphyg-

momanometer. Each sphygmomanometer is composed of

a cuff with an inflatable bladder, a pressure manometer

and a rubber hand bulb with a pressure control valve to

inflate and deflate the bladder. Cuffs are available in a

number of sizes to accommodate the wide range of arm

circumferences. To determine the appropriate cuff size,

compare the length of the bladder with the circumference

of the patient’s upper arm. For the most accurate measure-

ment, the bladder length should be at least 80 percent of

the arm circumference.

Electronic sphygmomanometers, which do not require the

use of a stethoscope, also are available. The electronic

sphygmomanometer senses vibrations and converts them

into electrical impulses. The impulses are transmitted to a

device that translates them into a digital readout. The in-

strument is relatively sensitive and also is capable of simul-

taneously measuring the pulse rate. It does not, however,

indicate the quality, rhythm and other characteristics of a

pulse and should not be used in place of your touch in as-

sessing the pulse.

Identifying, treating and monitoring a patient’s blood pres-

sure are extremely important steps in reducing the risk of

cardiovascular disease, as 72 million Americans have high

blood pressure4. In addition, blood pressure is an estab-

lished parameter for initiating and adjusting medication

therapy. Guidelines for performing blood pressure meas-

urement are summarized in Table 3.

Measurement Errors

Many factors can affect a blood pressure reading including

age, race, time of day, weight, emotions and medications.

Table 4 contains a list of medications that have the poten-

tial to increase blood pressure. Patient position is another

important factor to consider to ensure accuracy. For exam-

ple, if the patient has her legs crossed during measure-

Table 4. Medications that have the potential to increase blood pressure4

Adrenal steroids (prednisone, fludrocortisone, triamcinolone)

Amphetamines/anorexiants (phendimetrazine, phentermine, sibutramine)

Antivascular endothelin growth factor agents (bevacizumab, sorafenib, sunitinib)

Calcineurin inhibitors (cyclosporin and tacrolimus)

Decongestants

Erythropoiesis stimulating agents (erythropoietin and darbepoietin)

Estrogens (usually oral contraceptives)

Nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors

Others: venlafaxine, bromocriptine, bupropion, buspirone, carbamazepine, clozapine, desulfrane, ketamine, metoclopramide

September 2014



ment, the result may be falsely elevated. Using a cuff that

is too small also may produce falsely elevated readings.

Conversely, a cuff that is too large can produce a falsely

low reading.

For the most accurate blood pressure assessment, two or

more readings, each separated by two minutes, should be

averaged. If the first two readings differ by more than 5

mmHg, additional readings should be obtained and aver-

aged. The Seventh Report of the Joint National Committee

on Prevention, Detection, Evaluation and Treatment of

High Blood Pressure (JNC VII)* provides guidelines for the

classification of blood pressure readings which are summa-

rized in Table 5.

Pharmacists who

participate in blood

pressure screenings

should be aware

that hypertension is

diagnosed by a phy-

sician only after a

patient has had ele-

vated readings on

two separate occa-

sions. Additionally,

pharmacists should be familiar with the

national guidelines that delineate indi-

vidual blood pressure goals and pre-

ferred pharmacological treatment

based upon each patient’s concurrent

disease states6,7

. Irregular blood pres-

sure measurements (high or low), in

which the patient is experiencing symp-

toms, should be referred for medical

attention. Both hypertensive urgencies

(with no signs of organ impairment) and

emergencies (with evidence of target

organ dysfunction) are characterized by

the presence of a very elevated blood

pressure (i.e., greater than 180/120 mm

Hg) and should be referred.

Cardiovascular System

Although few pharmacists routinely per-

form a complete cardiovascular assess-

ment, a basic understanding of how to

evaluate common cardiac symptoms

will help the pharmacist determine the

most appropriate course of action, in-

cluding referral to a physician.

Chest pain is probably one of the more

worrisome symptoms a pharmacist can encounter. Chest

pain occurring secondary to myocardial ischemia is termed

angina pectoris, but it also is important to remember that

similar pain may result from gastrointestinal, pulmonary,

abdominal or musculoskeletal disorders. Although each

may possess subtle differences in symptomatology (Table

6), it can still be quite difficult to determine the cause.

Therefore, most cases of new onset chest pain should be

referred to a physician for further evaluation, especially in

patients with underlying risk factors for cardiovascular dis-

ease (CVD).

Palpitations are an uncomfortable awareness of the heart-

beat that may be an indicator of a relatively benign or seri-

ous underlying condition. Patients may describe them as a

Table 5. Classification of blood pressure for adults ages 18 and older (JNC VII)6

Blood Pressure Classification Systolic Blood Pressure (mmHg)* Diastolic Blood Pressure (mmHg)*

NORMAL <120 <80

PREHYPERTENSION 120-139 80-89

Stage 1

HYPERTENSION

140-159 90-99

Stage 2

HYPERTENSION

>160 ≥100

*Treatment determined by highest BP category

Table 6: Characteristics of common causes of chest pain

Cardiac Gastrointestinal Musculoskeletal

Patient history Cardiac risk

factors

Gastritis or

indigestion

Trauma

Type of pain Heavy pressure,

crushing,

squeezing across

anterior chest;

often radiating to

arms, neck, jaw,

shoulder, back

Substernal

burning; may

radiate to the back;

may be squeezing;

may be hard to

distinguish from

cardiac pain

Sore, dull achy

feeling or sharp,

knifelike pain

Associated symp-

toms

Sometimes

dyspnea, nausea,

vomiting,

sweating;

dizziness,

lightheadedness or

fainting

Regurgitation,

dysphagia, nausea

May have local

tenderness

Aggravating fac-

tors

Physical exertion,

stress, cold

Large or fatty

meals, bending

over, lying down

Physical

movement,

coughing,

breathing

Relieving

factors

Rest, nitroglycerin Antacids Rest, heat, pain

medications

September 2014


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fluttering or pounding sensation in their chest. They may

say their heart is racing, skipping beats or having extra

beats. Patients with palpitations should have a complete

medication history taken, with special attention given to the

use of sympathomimetics, vasodilators, anticholinergics

and the withdrawal of beta-blockers. Non-prescription drug

usage, including caffeine and illicit drugs (e.g., cocaine,

amphetamines) also should be evaluated when appropri-

ate. These patients should be referred to a physician if pal-

pitations are persistent, or are accompanied by shortness

of breath, lightheadedness, dizziness or fainting, or if there

is a history of coronary heart disease (CHD). Patients with

known cardiovascular disease should always consult their

physician or pharmacist before initiating a new OTC medi-

cation or dietary supplement since many of these products

can cause cardiovascular side effects or interact with their

prescription medications8.

CONCLUSION

Patients commonly present to their community pharmacy

seeking advice regarding the treatment of their respiratory

and cardiovascular conditions. In the introductory case, SL

is concerned about the impact of his multi-symptom cough

and cold product on his underlying hypertension. A thor-

ough patient assessment would reveal that his only symp-

tom is a dry cough, and changing his multi-symptom cold

medication to a single ingredient cough suppressant would

eliminate any unnecessary medications, such as decon-

gestants, that may adversely affect his health.

Additionally, by measuring his current blood pressure, the

pharmacist would be able to reassure the patient and de-

termine whether or not any intervention was necessary.

By utilizing these basic patient assessment skills, the phar-

macist is able to recommend appropriate self-care treat-

ment and build a trusting relationship in the process.

*Editor’s Note: At the time of original publishing, JNC VII

guidelines were in use and now the more liberal JNC VIII

guidelines are available. Practitioners may be choosing to

follow the updated JNC VIII guidelines outlined in the table

in the July 2014 issue of The Kentucky Pharmacist, page

19.

REFERENCES

1. Leibowitz K, Ginsburg D. Counseling self-treating pa-

tients quickly and effectively. Proceedings of the APhA

Inaugural Self-Care Institute; May 17-19, 2002.

2. Kuehn BM. Education key to treating airway disease.

JAMA 2007;298(22):2601-7.

3. Irwin RS, Baumann MH, Boulet LP, et at. Diagnosis

and management of cough: Executive Summary.

Chest 2006; 129:1S-23S.

4. Dipiro JT, et al (eds): Pharmacotherapy: A Pathophysi-

ologic Approach. 7th ed. McGraw Hill;2008.

5. William JS, Brown SM, Conlin PR. Blood-pressure

measurement. N Engl J Med 2009;360(5):e6.

6. Chobanian AV, Bakris GL, Black HR, et al. Seventh

report of the Joint National Committee on prevention,

detection, evaluation, and treatment of high blood pres-

sure. Hypertension 2003;42(6):1206-52.

7. Rosendorff C, Black JR, Cannon CP, et al. Treatment

of hypertension in the prevention and management of

ischemic heart disease: A scientific statement from the

American Heart Association Council for high blood

pressure research and the Councils on Clinical Cardiol-

ogy and Epidemiology and Prevention. Circulation

2007;115(21):2761-2788.

8. Tachjian A, Maria V, Jahangir A. Use of herbal prod-

ucts and potential interactions in patients with cardio-

vascular diseases. J Am Coll Cardiol 2010;55:515–25.

SUGGESTED READINGS

Berardi RR, Ferreri SP, Hume AL, Kroon LA, Newton

GD, Popovich NG et al, editors. Handbook of Nonpre-

scription drugs: An Interactive Approach to Self-Care.

16th ed. Washington DC: The American Pharmaceuti-

cal Association; 2009.

Dipiro JT, et al (eds): Pharmacotherapy: A Pathophysi-

ologic Approach. 7th ed. McGraw Hill; 2008.

Jones RM and Rospond RM. Patient Assessment in

Pharmacy Practice. 2nd ed. Baltimore (MD): Lippincott

Williams & Wilkins; 2006.

Longe RL and Calvert JC. Physical Assessment: A

Guide for Evaluating Drug Therapy.1st ed. Vancouver:

Applied Therapeutics, Inc; 1994.


September 2014


October 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 3 of 4:

Evaluation of Respiratory and Cardiovascular Systems

1. The most effective method of assuring that a patient is using her inhaler correctly is to: A. Answer any questions they ask about their inhaler. B. Provide them with verbal instructions, then ask if they

have any questions. C. Provide them with written instructions and tell them to

call if they have any questions. D. Demonstrated the appropriate technique, then have the

patient show you how they are going to use their inhal-er; supplement with written instructions.

2. Wheezing is caused by air movement through narrowed airways. This narrowing can occur from: A. Inflammation and/or infection. B. Excessive secretions. C. An adverse drug reaction. D. All of the above. 3. Which of the following descriptions indicate the need for immediate physician referral? A. A respiratory rate of 18 breaths per minute in a 60 year

-old patient B. An asthma patient who is not wheezing, but looks

“blue” around his lips C. A COPD patient who complains of chronic shortness of

breath when he climbs the stairs D. None of the above 4. Which of the following scenarios describes a patient who would be an appropriate candidate for self-treatment of his cough? A. A 63 year-old COPD patient with a productive cough

and a new complaint of coughing up green sputum B. A 25 year-old with a cold, and a cough that kept him

from sleeping well last night C. An otherwise healthy 30 year-old who complains of a

cough associated night sweats fever, and unintended weight loss

D. An 18 year-old with a three week history of poor re-sponse to OTC cough suppressants

5. Age, race, time of day, weight, emotions, patient position and medications may affect which of the following? A. Proper beta-blocker dosing B. Blood pressure measurement C. Nasal congestion D. Treatment of cough 6. Proper blood pressure monitoring should include which of the following? A. Patient resting for at least 30 minutes B. Large cuff size C. Feet placed flat on the floor D. Slow inflation of the cuff

7. The normal resting adult pulse should be between ____ and ____ beats per minute. A. 12 and 20 B. 40 and 90 C. 60 and 100 D. 90 and 120 8. For a normal adult, the respiratory rate is between ____and ____ respiratory cycles per minute. A. 12-20 B. 16-20 C. 40-90 D. 60-100 9. For adults, a respiratory rate of less than 12 rpm is called A. Bradycardia. B. Bradypnea. C. Tachycardia. D. Tachypnea. 10. Chest pain associated with a musculoskeletal origin is most typically described as a: A. Heavy pressure radiating to the neck or jaw. B. Burning sensation that is worse when lying down. C. Sharp, knifelike pain that is exacerbated by physical

movement. D. A crushing pain associated with nausea and sweating. 11. Palpitations: A. Are always indicative of a serious underlying cardiac

condition. B. May be felt as a fluttering or pounding sensation in the

chest. C. Are usually benign and only need to be evaluated by a

physician if the patient experiences fainting. D. Are always considered a medical emergency. 12. Heavy pressure, crushing and squeezing across the anterior chest, often radiating to the arms, neck, jaw, shoul-der and back, may be indicative of which of the following? A. Cardiac chest pain B. Musculoskeletal chest pain C. Gastrointestinal chest pain D. GERD chest pain


September 2014



PHARMACISTS ANSWER SHEET October 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 3 of 4: Evaluation of Respiratory and Cardiovascular Systems (2.0 contact hours) Universal Activity # 0143-9999-14-010-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 7. A B C D 9. A B C D 11. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B C D 12. A B C D Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

Personal








Expiration Date: October 22, 2017 Successful Completion: Score of 80% will result in 2.0 contact hour or 0.2 CEU.


TECHNICIANS ANSWER SHEET. October 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 3 of 4: Evaluation of Respiratory and Cardiovascular Systems (2.0 contact hours) Universal Activity # 0143-9999-14-010-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 7. A B C D 9. A B C D 11. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B C D 12. A B C D Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

Personal



ID # and Birthdate will not be accepted.

September 2014


In 2009 the Centers for Medicare and Medicaid Services

(CMS) implemented Surety Bond Requirements for sup-

pliers of Durable Medical Equipment, Prosthetics and

Supplies (CMS-6006-F). This ruling requires that each

existing supplier must have a $50,000 surety bond to

CMS.

Pharmacists Mutual Insurance Company, through its

subsidiary Pro Advantage Services, Inc. d/b/a Pharma-

cists Insurance Agency (in California), led the way to

meet this requirement by negotiating the price of the

bond from $1,500 down to $250 for qualifying risks.

To see if you qualify for a $250 Medicare Surety Bond,

or would like information regarding our other products,

please contact us:

Call 800.247.5930 Extension 4260

E-mail [email protected]

Contact a Pharmacists Mutual Field Representative or Sales Associate http://www.phmic.com/phmc/services/ibs/Pages/Home.aspx

In Kentucky, contact Bruce Lafferre at 800.247.5930 ext. 7132 or 502.551.4815 or Tracy Curtis at 800.247.5930 ext. 7103 or 270.799.8756.

Pharmacists Mutual Insurance offers Medicare Surety Bond

Kentucky Renaissance Pharmacy Museum

2014 Mid-Year Conference on Legislative Priorities

Nov. 14-15, 2014

Griffin Gate Marriott Resort, Lexington, KY

The Kentucky Renaissance Pharmacy Museum offers several ways way to show support of the Museum, our state's

leading preservation organization for pharmacy.

While contributions of any size are greatly appreciated, the following levels of annual giving have been established

for your consideration.

Friend of the Museum $100 Proctor Society $250

Damien Society $500 Galen Society $1,000

Name______________________________________ Specify gift amount________________________

Address ____________________________________ City____________________Zip______________

Phone H____________________W________________ Email___________________________________

Employer name_____________________________________________________for possible matching gift.

Tributes in honor or memory of_____________________________________________________

Mail to: Kentucky Renaissance Pharmacy Museum, P.O.Box 910502, Lexington, KY 40591-0502 The Kentucky Renaissance Pharmacy Museum is a non-profit 501(c)(3) business entity and as such donations are tax deductible. A notice of your tax

deductible contributions will be mailed to you annually.

Questions: Contact Lynn Harrelson @ 502-425-8642 or [email protected]

For more information on the museum, see

www.pharmacymuseumky.org or contact Gloria Doughty at

[email protected] or Lynn Harrelson at [email protected].


http://www.phmic.com/phmc/services/ibs/Pages/Home.aspx

http://www.phmic.com/phmc/services/ibs/Pages/Home.aspx

September 2014


KPhA New and Returning Members

KPhA Welcomes New and Renewing Members

July-August 2014

Brittany Anderson Bulan Samuel Armes Crossville Elisha Bischoff Louisville Michael Blacketer Louisville Jacqueline Blair Mason, Ohio Larry Blandford Goshen Terry Box Cynthiana Stephen Britt Louisville Robert Buckner Campbellsville Mary Campbell Shepherdsville Peggy Canler Bowling Green William Chauvin Elizabethtown Lisa Clontz Prospect Lysette Daniels Smiths Grove Michael Daniels Taylor Mill Debra Dunaway Henderson James Dunaway Henderson Harold Ellis Frankfort Mary Enzweiler Covington Scott Ferguson Lexington

Veronica Foster Munfordville William Fugate Louisville Patricia Gooch Pikeville Wayne Gravitt Wheelwright Jennifer Grove Madison, Ind. William Hall Whitesburg Lisa Hart Frankfort Steve Hart Frankfort Shirley Henson Smithland Kevin Higgins Benton Ashley Hubbard Manchester Mark Huffmyer Lexington Robert Hughes Lexington Audrey Hurley Louisville Bill Hurley Simpsonville Jacob Hutti Louisville Donna Johnson Louisville Kim Jones Williamsburg Briana Kocher Lexington Andrea Kramer Covington

Amy Larkin Lexington Nick Ledgerwood Lexington Kelsey Lee Owensboro Joe Lewis Hyden Pamela Luebbe-Haeberlin Louisville Catherine Mcclish Louisville Velda McDaniel Georgetown Kristi McGregor Louisville Aaron Mcintosh Midway William Merrick Louisville David Morgan Manchester Ann Murphy Princeton Owen Neff Centerville, Ohio Meghann New Lexington Frank Nicks Bowling Green Ronald Nix Louisville Christopher Noetzel Flemingsburg Myron Pass Louisville Kenneth Pearce Danville Andrea Pearson Bowling Green

Charles Pearson Bowling Green Angela Pence Campton David Potts Louisville Thomas Ranz Louisville Judith Rech Mount Sterling James Rickett Williamsburg Brandy Robertson Barlow Denise Robison Louisville Bonnie Russell Elizabethtown Larry Russell Elizabethtown Tamara Schlensker Louisville Tara Schutte Louisville Jan Scott Earlington Janelle Seitz Mount Vernon William Sewell Utica Edwin Shelton Owensboro Sherri Short Richmond Joe Silvers Monticello Patricia Slone Hindman Jamie Stake Greenup

September 2014


KPhA New and Returning Members

Geneva Staten Louisville Drane Stephens Eminence David Stultz Greenup Terry Sutton Henderson Audra Swearingen Louisville Joanne Taheri Louisville Timothy Tracy Lexington Jonathan Van Lahr Webster

Stuart Waldman Louisville Norman Walton Bardstown Lewis Wilkerson Frankfort Kimberly Wilkerson Frankfort Franklin Wishnia Louisville David Wren Louisville Andrey Yazykov Lexington

Know someone who should be on this list?

Ask them to join YOU in

supporting YOUR KPhA!

MEMBERSHIP MATTERS:

To YOU, To YOUR Patients To YOUR

Profession!

KPhA Honorary Life

Members

Ralph Bouvette

Leon Claywell

Gloria Doughty

Ann Amerson Stewart

September 2014


Pharmacy Law Brief

Pharmacy Law Brief: New Data Breach Laws in Kentucky

Author: Peter P. Cohron, B.S.Pharm., J.D., Practicing pharmacist and attorney, Henderson, Ky.

Question: I understand that Kentucky has two new

data breach laws that went into effect in July 2014. I under-

stand that health care providers under the HIPAA rules are

exempt. Do these new laws have any effect on pharmacy?

Response: Kentucky enacted two new data breach

notification laws — HB 232 and HB 5 — in 2014. These

define the type of breach, the information that should have

been protected and notice requirements so that affected

individuals will be informed in a timely manner.

The practice of pharmacy is exempted as it is subject to

HIPAA. However, there are several aspects of business

that occur in many pharmacies, community and institution-

al, that are not covered by HIPAA. Thus, these business

activities, including but not limited to sales and purchase

contracts, sales transactions, provision of services, etc., fall

under these new laws.

The purpose and intent of the bills is to protect Personally

Identifiable Information, or PII (differentiated from the infor-

mation gathered in pharmacies for the proper preparing and

dispensing of prescriptions known as Protected Health In-

formation or PHI). PII includes a person’s name used in

combination with any one or more of the following: Social

Security Number, driver’s license number, credit or debit

card numbers and any other personal information obtained

in the normal course of business.

In order to meet the requirements of the bills, a business

must establish security policies and procedures, including

breach investigation policies and procedures. If the busi-

ness, as most pharmacies do, conducts business with any

governmental agency, these policies and procedures must

be in place by Jan. 1, 2015. Second, though not yet a re-

quirement, encryption of data is strongly suggested. Data

mapping, or knowing where the data is kept, is needed and

limiting access to the computers holding the data is again

strongly advised. Finally, the laws call for affected entities

to review business insurance policies for adequate cyber-

insurance coverage, with emphasis on apportionment of

costs when a breach occurs between the business and a

nonaffiliated third party.

If and when a breach occurs or the business is informed

that there is a reasonable belief that such has happened,

notice is required to every Kentucky resident where his or

her unencrypted data has been accessed by an unauthor-

ized entity. A reasonable belief is far less than a 100 per-

cent assurance but if a reasonable person with the same

information would reach the same level of suspicion of a

breach, acting on that belief cannot result in liability. Sub-

ject only to the needs of law enforcement (the police may

ask for a delay if they are investigating and notice may aid

the unauthorized party to escape), notice must be made in

an expedient manner and without undue delay.

HB 232 lays out in detail the notification methods, and I

refer the reader to those. In essence, for less than 1,000

affected persons, the notification must be done individually

though informing the media is permitted. For more than

1,000 persons, all consumer reporting agencies and credit

bureaus that maintain nationwide files also must be notified.

However, if existing business policies and procedures are

consistent with the timing requirements of HB 5, they may

be substituted and will be considered to be in compliance

with the law. This is important for multistate businesses

such as pharmacy chains that must meet the requirements

of data breach notification laws of several states.

In order to minimize the damage and costs aligned with a

breach, these bills suggest assembling all employees who

oversee and have access to PII and run drills to practice

and prepare for data breaches. The entities also should

have a breach investigation team named and prepared to

step in upon notification of a breach. The group’s job will be

to seek the source of the breach in a timely manner, as well

Submit Questions: [email protected]

Disclaimer: The information in this column is intended

for educational use and to stimulate professional discus-

sion among colleagues. It should not be construed as legal

advice. There is no way such a brief discussion of an issue

or topic for educational or discussion purposes can ade-

quately and fully address the multifaceted and often com-

plex issues that arise in the course of professional prac-

tice. It is always the best advice for a pharmacist to seek

counsel from an attorney who can become thoroughly fa-

miliar with the intricacies of a specific situation, and render

advice in accordance with the full information.

September 2014


Roamey visits University of Cincinnati COP

@KyPharmAssoc

@KPhAGrassroots

Facebook.com/KyPharmAssoc

KPhA Company Page

Are you connected

to YOUR KPhA?

Join us online!

as having the responsibility to, if necessary, notify the po-

lice and work with them.

Most Kentucky pharmacies do not limit their business with

the public to prescriptions and health services. “Out front”

buying and sales are a significant part of the business, and

these transactions are not covered by the auspices of

HIPAA. Thus, certain business conducted in a pharmacy

will fall under these new laws. Pharmacists should make

themselves aware of the need to protect PII and the steps

to take in the event of a breach. While the criteria for han-

dling a PHI breach under HIPAA and a PII breach under

these new Kentucky laws are not largely exclusive of each

other, pharmacists should not rely on one to cover the oth-

er. Roamey (and KPhA ED Robert McFalls and Director of

Communications and CE Scott Sisco) visited

University of Cincinnati College of Pharmacy

APhA-ASP chapter in September. Thanks for

the invitation, and YOUR KPhA looks forward

to strengthening this relationship!

September 2014


Pharmacy Policy Issues

PHARMACY POLICY ISSUES:

Freedom of Speech and Off-Label Promotion of Pharmaceuticals

Author: Devin Pence is a third professional year Pharm.D. student at the University of Kentucky College of Pharmacy

and also is pursuing a Master of Business Administration degree at the Gatton College of Business and Economics. A

native of Leitchfield, Ky., he completed his pre-pharmacy coursework at the University of Louisville.

Issue: A federal Court of Appeals ruled in the case of United States v. Caronia that a pharmaceutical sales representa-

tive engages in Constitutionally-protected free speech when discussing off-label use of a medication. This court decision

drastically changes governmental regulation of pharmaceutical promotional activities. What are the implications of this

for the future of drug promotion and education by pharmaceutical industry representatives?

Discussion: In December of 2012, the Second Circuit

Court of Appeals in Manhattan ruled in favor of Caronia in

the United States v. Caronia case. The judges ruled that

prosecuting Alfred Caronia, a pharmaceutical sales repre-

sentative, for promoting the legitimate, off-label use of

Xyrem®, a drug used to treat narcolepsy, for treatment of

insomnia was a violation of free speech.1 Pharmaceutical

companies and their representatives have long been pro-

hibited from discussing and promoting drug indications un-

approved by the FDA and therefore not in the labeling to

potential clients and prescribers, and have had to pay mil-

lions of dollars in settle-

ments to the U.S. gov-

ernment for doing so.

However, the court’s de-

cision in the Caronia

case could be a step in a

more lenient direction for

drug marketing and edu-

cation by drug compa-

nies. Using this ruling as

a foundation for their pro-

tection, pharmaceutical

manufacturers soon may be able to promote their drugs for

safe and effective off-label uses, as well as provide pre-

scribers with useful information that could improve use of

medications for off-label indications.

Some challengers to the ruling argue that permitting these

companies to promote unlabeled uses would be danger-

ous, stating that the firms would be free to make any claims

they wanted about their medications. This argument fails to

acknowledge that drug companies still would be required to

make truthful claims that were not intended to deceive the

prescriber or render the medication misbranded. On the

contrary, the ruling could have significant benefits for pa-

tient outcomes if pharmaceutical companies were now able

to provide prescribers with the most detailed and up to date

information available on off-label drug usage. Approximate-

ly 20 pecent of all prescriptions are intended for an off-label

use, proving the potential magnitude of this increased ac-

cess to information.2 Drug companies could provide pre-

scribers with helpful data that they’ve gathered on the safe-

ty and efficacy of these therapies, leading to better care for

millions of patients.

While the Caronia court ruling has potential for great im-

pact on the pharmaceutical industry, it is still unclear what

the magnitude of this impact will be. Since the Caronia rul-

ing, there have been at least two court cases involving

large drug companies, Amgen and Par, which have been

settled with both firms

paying large penalties to

the government. These

cases don’t offer much

evidence on the Caronia

case’s potential impact

because both lawsuits

already were well under-

way before the ruling of

the case was delivered.3

Only time will tell if phar-

maceutical companies will

begin utilizing the Caronia case ruling as a defense, and if

judges will see that defense as being sufficient to acquit

them.

With this newly acquired defense, pharmaceutical compa-

nies and their representatives may find themselves head-

ing toward a more open and profitable future, one where

they may be free to discuss and promote off-label drug us-

es and be free from the fear of lawsuits or FDA administra-

tive challenges, assuming what is said is truthful and safe.

If this were the case, patients also could benefit from in-

creased prescriber access to data on off-label medication

usage that would result in safer and more effective thera-

pies. The Caronia case has far-reaching potential and it will

be interesting to see what effects it will have on pharma-

ceutical industry in the coming years.

Have an Idea?: This column is designed to address timely and practical

issues of interest to pharmacists, pharmacy interns and

pharmacy technicians with the goal being to encourage

thought, reflection and exchange among practitioners.

Suggestions regarding topics for consideration are wel-

come. Please send them to [email protected].

September 2014


Consultant Pharmacists Dinner CE Event

References:

1. Fauber J. "Court: Off-Label Drug Marketing Is 'Free

Speech'." Medpagetoday.com. N.p., 4 Dec. 2012.

Web. 13 Jan. 2014.

2. Radley DC, Finkelstein SN, Stafford RS. "Off-label

Prescribing Among Office-Based Physicians FREE."

JAMA Internal Medicine 166.9 (2006): 1021-026. JA-

MA Network. JAMA Internal Medicine, 8 May 2006.

Web. 13 Jan. 2014.

3. Radick R. "Caronia and the First Amendment Defense

To Off-Label Marketing: A Six Month Re-Assessment."

Forbes. 29 May 2013. Web. 13 Jan. 2014.

KPhA Academy of Consultant Pharmacists Invite you to a Dinner CE Event! Napa River Grill

1211 Herr Lane Louisville KY Monday October 27th at 6pm TWO HOURS OF LIVE CE

“Bugs and Drugs” by Dr. Kim Croley, CGP, FASCP, FAPhA Clinical Pharmacist UAN 0143-0000-14-044-L01-P

Learning Objectives – At the completion of this program, the participant will be able to: 1) Compare and contrast the antimicrobial drug classes. 2) Understand the types of antimicrobial drug resistance that can occur. 3) Create treatment plans for which antimicrobial therapy can be managed successfully. 4) Relate prudent use of antimicrobial therapy to quality metrics.

Free for KPhA Academy of Consultant Pharmacists and/or ASCP (Kentucky Chapter) members, $5 for non-members

Also presenting: “Namenda XR (memantine HCl) and the treatment of moderate to severe dementia of the Alzheimer’s

type” Dr. Amita Patel, MD, Geriatric Psychiatrist

RSVP to Julie Owen at [email protected] by Oct 22th

September 2014


Pharmacists Mutual

September 2014


Cardinal Health

September 2014


KPhA BOARD OF DIRECTORS

Duane Parsons, Richmond Chair

[email protected] 502.553.0312

Bob Oakley, Louisville President

[email protected]

Chris Clifton, Villa Hills President-Elect

[email protected]

Brooke Hudspeth, Lexington Secretary

[email protected]

Glenn Stark, Frankfort Treasurer

[email protected]

Raymond J. Bishop Past President

[email protected] Representative

Directors

Matt Carrico, Louisville*

[email protected]

Tony Esterly, Louisville

[email protected]

Matt Foltz, Villa Hills

[email protected]

Chris Killmeier, Louisville

[email protected]

Mallory Megee, Nicholasville University of Kentucky

[email protected] Student Representative

Jeff Mills, Louisville

[email protected]

Chris Palutis, Lexington

[email protected]

Christian Polen Sullivan University

[email protected] Student Representative

Richard Slone, Hindman

[email protected]

Mary Thacker, Louisville

[email protected]

Sam Willett, Mayfield

[email protected]

* At-Large Member to Executive Committee

HOUSE OF DELEGATES

Ethan Klein, Louisville Speaker of the House

[email protected]

Chris Harlow, Louisville Vice Speaker of the House

[email protected]

KPERF ADVISORY COUNCIL

Kim Croley, Corbin

[email protected]

KPhA/KPERF HEADQUARTERS

1228 US 127 South, Frankfort, KY 40601

502.227.2303 (Phone) 502.227.2258 (Fax)

www.kphanet.org

www.facebook.com/KyPharmAssoc

www.twitter.com/KyPharmAssoc

www.twitter.com/KPhAGrassroots

www.youtube.com/KyPharmAssoc

Robert McFalls, M.Div.

Executive Director

[email protected]

Scott Sisco, MA

Director of Communications & Continuing Education

[email protected]

Angela Gibson

Director of Membership & Administrative Services

[email protected]

Leah Tolliver, PharmD

Director of Pharmacy Emergency Preparedness

[email protected]

Elizabeth Ramey

Receptionist/Office Assistant

[email protected]

KPhA Board of Directors/Staff

KPhA sends email announcements

weekly. If you aren’t receiving: eNews,

Legislative Updates, Grassroots Alerts

and other important announcements,

send your email address to

[email protected] to get on the list.

September 2014


Kentucky Pharmacists Association 1228 US 127 South Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org

Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org [email protected]

American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.org

National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 [email protected]

Drug Information Center Sullivan University College of Pharmacy 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu Kentucky Regional Poison Center (800) 222-1222

Frequently Called and Contacted

50 Years Ago/Frequently Called and Contacted

KPhA Remembers KPhA desires to honor members who

are no longer with us. Please keep KPhA informed by sending this infor-

mation to [email protected].

Deceased members for each year will be honored permanently

at the KPhA office.

50 Years Ago at KPhA RELIEF WORK

L.R. Hugg, R.Ph., a graduate of the University of Kentucky College of Pharmacy, Class of

1933, is interested in vacation and emergency relief work in any section of Kentucky. For

several years Hugg owned and operated his own store in Paducah, selling the store in

March, 1964. He has had experience in retail pharmacy, hospital pharmacy and an apothe-

cary shop. For a reference you can contact Kolb Brothers Drug Company, Paducah, or

L.S. DuBois Son & Company, Paducah.

- From The Kentucky Pharmacist, October 1964, Volume XXVII, Number 10.

September 2014


THE

Kentucky PHARMACIST

1228 US 127 South

Frankfort, KY 40601

For more upcoming events, visit www.kphanet.org.

Save the Date 137th KPhA Annual Meeting

& Convention June 25-28, 2015

Holiday Inn University Plaza and Sloan Convention Center

Bowling Green, KY

Mark your Calendar Or we’ll send Duane and Kim after you!

2014 Mid-Year Conference

on Legislative Priorities

November 14-15, 2014 Griffin Gate Marriott Resort

Lexington, KY

Documents

The Kentucky Pharmacist Vol. 9, No. 5