Development of a pharmacy educational environment questionnaire.

INTRODUCTION: A robust instrument for measuring the educational environment in a pharmacy patient care setting is currently lacking. The authors aimed to develop a person-reported outcome measure to gauge trainee pharmacists' perceptions of their clinical workplace-based educational environment. This paper reports the various sources of validity evidence. METHODS: A preliminary, three-domain (system, relationship, and personal), 36-item measurement instrument was developed by incorporating results from literature review, focus group interviews, iterative discussions among educators, and cognitive interviews. The preliminary instrument, together with the Dundee Ready Educational Environment Measure (DREEM) and Orientation to Happiness Scale (OHS), were administered to trainee pharmacists recruited from one pharmacy school and one healthcare cluster in Singapore. Rasch analysis was conducted on the overall instrument as well as three domains: System, Relationship, and Personal. RESULTS: The 36-item instrument was administered to 145 learners, of which 66 were trainee pharmacists and 79 undergraduate interns. Upon removal of the middle "neutral" category to resolve poorly functioning categories and removal of five poorly functioning items, the overall instrument and its domains generally showed good fit with the Rasch model. Moreover, the overall 31-item Singapore Pharmacy Educational Environment Questionnaire (SPEEQ) and its three domains showed moderate to high convergent correlation with all the five DREEM domains and low to non-significant divergent correlation with the OHS Pleasure of Life subscale. CONCLUSIONS: Among one sample of pharmacy trainees, the 31-item SPEEQ and its three component domains demonstrated notable validity evidence to gauge trainees' perceptions of their learning environment.

A correlation of thrombin generation assay and clot waveform analysis in patients on warfarin.

OBJECTIVES: Thrombin generation assays and activated partial thromboplastin time (aPTT)-based clot waveform analysis (CWA), are some examples of global coagulation assays. Each modality evaluates different aspects of the clot forming process to globally define haemostasis with exclusive measurement parameters. Data on CWA are emerging, but its performance against other haemostatic assays is yet to be ascertained. This study evaluates the correlation between aPTT-based CWA and CAT parameters across a range of INR in warfarin-treated patients. PATIENTS/METHODS: A prospective study consisting of patients on warfarin anticoagulation with varying INR levels. CWA and CAT were performed for the study subjects. RESULTS: 54 samples were included covering an INR range from 1.33-6.89, with a mean of 4.31 +/- 1.13. For CAT parameters, endogenous thrombin potential (ETP) and peak thrombin were assessed. Both unadjusted and adjusted (adjusted for final plateau transmittance) aPTT-based CWA were evaluated for parameters min1 (maximum velocity), min2 (maximum acceleration) and max2 (maximum deceleration). Peak thrombin showed significant correlation with all CWA parameters (min1: r = 0.435, P<0.001; min2: r = 0.485, P<0.001; max2: r = 0.578, P<0.001; adjusted min1: r = 0.734, P<0.001, adjusted min2: r = 0.693, P<0.001; adjusted max2: r = 0.751, P<0.001). ETP correlated significantly with all CWA parameters except unadjusted min1 (min1: r = 0.235, P = 0.087; min2: r = 0.326, P = 0.016; max2: r = 0.437, P<0.001; adjusted min1: r = 0.610, P<0.001, adjusted min2: r = 0.563, P<0.001; adjusted max2: r = 0.642, P<0.001). CONCLUSION: We demonstrated a modest correlation between CAT and CWA parameters. Adjusted CWA improved this correlation. These findings provide additional understanding of CWA and it's role in the evaluation of global haemostatic function.

The use of portfolio to support competency-based professional development of pharmacists in a Singapore tertiary hospital.

This article was migrated. The article was marked as recommended. Competency frameworks is implemented to support continuing professional development in an academic medical centre, with the aims of establishing and retaining a competent pharmacist workforce; and is described using Kotter's change management framework. The desire to provide a clear developmental route with defined criteria to identify and bridge competency gaps through systematic training of our pharmacists and meeting JCI requirements for documented continued competence gave impetus to the establishment of the General and Advanced Level Frameworks. To aid implementation, a series of roadshows were organized to communicate the vision to pharmacists and experts from the UK were invited to share experience and to "train-the-trainers". Clinical groups were set up to provide learning platforms for the advanced pharmacist practitioners to coach the pharmacists. Competency assessment was conducted biyearly using workplace based assessment tools. Formative feedback was provided post-assessment and learning objectives and training plan for the next assessment cycle would be discussed. The implementation of competency frameworks provides an opportunity for pharmacists to identify competency gaps and plan their training and development to achieve higher standards of practice. The portfolio and competency-based developmental frameworks enable systematic approach to evaluate and facilitate performance management.

Validity of current recommendation for peri-operative interruption of warfarin in Asians.

Temporary interruption of anticoagulation therapy is usually recommended for anticoagulated patients undergoing invasive procedures to minimize their bleeding risks. We validated the current consensus recommendation on warfarin interruption which were based on Western population studies to determine if they could safely be applied to Asians. The international normalized ratios (INR) in twenty warfarinised patients with a stable INR of 2-3 were prospectively measured at days 0, 3 and 5 after stopping warfarin for procedures or at completion of treatment. The median INR at days 0, 3 and 5 were 2.30 (95% CI 2.16-2.43), 1.32 (95% CI 1.22-1.57) and 1.06 (95% CI 1.05-1.13) respectively (P < 0.001 for trend). All patients were below therapeutic INRs by day 3 with 14 patients (70%, 95% CI 49.92-90.08) achieving INR readings below 1.5. By day 5, all INRs were below 1.5 and only 2 patients (10%, 95% CI -3.15 to 23.15) had INRs above 1.2. There were no significant peri-procedure bleeding or thrombotic events in the 1 month following interruption of warfarin. Our results suggest that the current international recommendation of stopping warfarin for 5 days prior to procedure can safely be applied to Asians without compromising risk of bleeding or thrombosis.

The use of fondaparinux for the treatment of venous thromboembolism in a patient with heparin-induced thombocytopenia and thrombosis caused by heparin flushes.

Heparin-induced thrombocytopenia (HIT) is an immunologic drug reaction characterized by paradoxical association with venous and arterial thrombosis. The syndrome is caused by IgG antibodies that are reactive against complexes of platelet factor 4 and heparin. Fondparinux does not bind to platelet factor 4, is structurally too short to induce an antibody response, and could in theory be a useful agent to treat HIT. A 69-year-old white female presented with a lower extremity extensive iliofemoral deep vein thrombosis after a right total knee arthroplasty and was subsequently found to have a pulmonary embolism. The patient was noted to have heparin flushes during her operation. Her platelet drop decreased >50% from baseline during initiation of antithrombotic therapy. She was started on subcutaneous fondaparinux 7.5 mg once daily injection. Her serotonin release assay and enzyme-linked immunosorbent assay for heparin antibodies were positive for HIT. Her platelet count nadir was 60 x 0(3)/mm(3) on day 5 and the platelet count rebounded after 8 days of fondaparinux therapy. No recurrent thrombotic or bleeding events were noted throughout her therapy. Anecdotal reports have shown that fondaparinux can be a useful agent to treat HIT with or without thrombosis.