New Practitioners Forum

New Practitioners Forum

Responding to drug information ing DI queries. Although there have been

substantial changes in the available DI

requests references, as well as in their delivery

platforms, the logic behind the system-

A pharmacist is busy entering a compli-

cated order into the pharmacy com-
puter system when the phone rings. The
note that possessing the skills necessary
to properly answer DI requests is not the
sole domain of pharmacists practicing in
atic approach remains as true today as it
was 30 years ago.
The key elements incorporated
caller asks, “What is the dose of Lovenox?” DI centers; rather, these skills are essen- into any systematic approach to answer-
The pharmacist places the caller on hold tial for all practicing pharmacists regard- ing DI queries include (1) obtaining in-
and logs on to a computerized drug in- less of their practice settings. formation about the requester, (2) deter-
formation (DI) resource or opens up a The systematic approach. A five- mining the true DI need, (3) classifying
book, locates an answer, and provides a step systematic approach to respond- the request, (4) conducting an efficient
response to the requester. Once the con- ing to DI queries was introduced by search using available resources, (5)
versation is over, the pharmacist resumes Watanabe et al. in 1975.6 Watanabe’s evaluating the literature and disseminat-
entering medication orders. As simplistic method instructed student pharmacists ing the information to the requester, and
as this scenario may seem, responding to on how to manage DI requests. Over the (6) following up when appropriate.
DI requests is an intricate matter that re- past 30 years, modifications to this ap- Obtaining information about the
quires proper training. proach have been introduced5,7; however, requester. The initial step in the system-
Despite the fact that today’s graduates the basic concepts of Watanabe et al. have atic approach is identifying the requester.
from schools of pharmacy are exposed to remained the “gold standard” for answer- It is the responsibility of the recipient
a degree of DI instruction, a cri- of the call to request information about
tique of the appropriate manage- the caller, as well as provide identifica-
ment of DI requests is warranted. tion as the responder. In order to pro-
Several references have been pub- vide a response that meets the needs of
lished on the topic of DI.1-4 These the requester, demographics of the caller,
references, which include chapters including professional background (e.g.,
on the process of answering DI physician, nurse, physician assistant,
queries, are used to instruct stu- pharmacist) and contact information
dent pharmacists and are available must be obtained. The professional back-
for any pharmacist who wishes ground of the caller dictates the depth
to review the topic. Additionally, or focus of research to be conducted
in 1996, the American Society of and determines the language to be used
Health-System Pharmacists pub- in the formulation of the final response.
lished guidelines on the provi- Failure to obtain this information from
sion of medication information the requester may be problematic. For
by pharmacists.5 These guidelines instance, after the pharmacist has pro-
outlined a method for properly re- vided the requester with information and
sponding to a DI request. The aim completed the call, he or she may obtain
of this article is to provide phar- additional, or even contradictory, data on
macy practitioners with a practi- the topic. In such cases, it is the pharma-
cal guide on answering DI queries cist’s professional and legal obligation to
in an institutional setting; howev- contact the requester and update him or
er, many of these principles apply her with the new information. Similarly,
to pharmacists practicing in other the pharmacist may need to contact the
settings as well. It is important to requester for follow-up questions or ad-
ditional information that may modify
the response.
The New Practitioners Forum column features articles that address the special
professional needs of pharmacists early in their careers as they transition from students to Determining the true DI need.
practitioners. Authors include new practitioners or others with expertise in a topic of interest Oftentimes, the true DI need may not
to new practitioners. AJHP readers are invited to submit topics or articles for this column be the initial DI request. Consider the
to the New Practitioners Forum, c/o Jill Haug, 7272 Wisconsin Avenue, Bethesda, MD
20814 (301-664-8821 or [email protected]).
Continued on page 710

706 Am J Health-Syst Pharm—Vol 66 Apr 15, 2009

 New Practitioners Forum

Continued from page 706 information. This practice may be coun- ture may be limited by the date of publi-
terproductive for two reasons. First, plac- cation and the depth and detail of infor-
example given at the beginning of the ing the caller on hold creates urgency. mation on the topic searched. When it is
article. This may seem like a simple re- The sense of urgency may prevent the suspected that more recent information
quest for a dosing recommendation of pharmacist from conducting a thorough is available on the topic, or when more
enoxaparin for a patient; however, it is search and may result in a response that detailed information is needed, it may
possible that the pharmacist will need to is incomplete or even inaccurate. Second, be necessary to search for additional in-
evaluate another aspect of this drug ther- depending on the length of the search, formation, which may be published in
apy. For instance, the requester may have the requester may not be able to hold un- journal articles. Since it is impractical
a patient who has been on unfractionated til the answer is found and subsequently or even impossible to search for jour-
heparin and developed heparin-induced will hang up the telephone before the nal articles directly, it is necessary to
thrombocytopenia (HIT). Knowledge of pharmacist can deliver a response. To use secondary indexing and abstracting
this information may introduce a differ- avoid these problems, the pharmacist services to locate the information pub-
ent angle to the search. At this point, the should tell the requester that he or she lished in journals. Making clinical deci-
request is no longer a simple dosing ques- will need to conduct a search and get sions based on the information found in
tion. Instead, the question is whether or back to the requester once a response is article abstracts is tempting but almost
not low-molecular-weight heparins can obtained. On occasion, an immediate always inappropriate. Abstracts provide
be used in a patient who developed HIT. response may be required and it may be a summary of the article and therefore
In general, the pharmacist should always necessary to conduct a quick search while do not necessarily provide all the de-
ask the requester why the question is be- the requester is on hold; however, this tails necessary to make a clinical deci-
ing asked and if the question is patient should be an exception rather than the sion. The abstract should only serve as
related. rule. In some cases, a follow-up search a tool to decide whether the article is
Once the pharmacist has determined may be necessary. pertinent to the search. If so, the article
the requester’s information needs, the Classifying the request. Classifying should be read in order to make a clini-
pharmacist may need to request patient- the request into a question category (e.g., cal decision. In years past, most second-
specific information in order to answer the dosing, adverse reaction, pharmacokinet- ary databases only provided citations of
question appropriately. This information ics) may be a part of a mental process or articles and abstracts, but today, when
may include the patient’s name, medical formal documentation of a DI response. searching MEDLINE through PubMed
record number, location, other patient Request classification assists the phar- (www.pubmed.gov), certain full-text
demographics (e.g., height, weight, age), macist in developing a search strategy articles are available for free download
and laboratory data (e.g., drug level, se- by identifying the appropriate references while others are available for download-
rum creatinine level, liver enzymes lev- that contain the information requested. ing for a fee. Furthermore, when prac-
els). Depending on the format of the Classification of the request also allows ticing in an institutional setting, such as
patient medical records at the institution, for assessment of the types of DI requests a hospital, full-text journal articles that
a pharmacist may be able to easily access received, which may be useful when al- would otherwise be available through a
the patient’s complete profile, in which locating financial resources for the pur- fee-for-use download may be available
case this information should always be chase of DI references. to the user through a contract with the
obtained. Since the pharmacist may not Conducting an efficient search institution’s library.
be aware of all the required informa- using available references. Once the When a journal article is obtained,
tion at the time of the original intake request is classified, a search for infor- it must be read carefully and evalu-
of the question, it may be necessary for mation should be initiated. Using a ated before making clinical decisions.
the pharmacist to call the requester back stepwise approach, most searches should It is important to note the publication
and ask for this information. Addition- begin by using tertiary literature (e.g., type (e.g., clinical trials, meta-analysis,
ally, the pharmacist may opt to reserve reference books, Micromedex Healthcare review, case report) in order to analyze
these questions until he or she replies to Series, Clinical Pharmacology), followed and interpret the data appropriately.
the requester when the response can be by secondary indexing and abstracting When evaluating a clinical trial, spe-
tailored to the patient’s specific needs. databases (e.g., MEDLINE, Internation- cific considerations must be given to the
Most requesters desire a quick response al Pharmaceutical Abstracts), leading to patient population discussed in the ar-
and may not understand the need to pro- primary literature (e.g., journal articles ticle in comparison with the patient for
vide additional information or to clarify describing original work) when neces- whom the information is needed. It is
the question being asked. The pharmacist sary. Tertiary literature provides a com- common for more than one article to be
must explain that this information is nec- pilation of information gathered from found on the topic searched, and some-
essary in order to provide an appropriate primary literature and other resources. times the information in the different
response. Turning to tertiary literature resources articles is conflicting. It is the pharma-
The pharmacist in the scenario at the first enhances the search’s efficiency by cist’s responsibility to evaluate both ar-
beginning of this article placed the caller readily providing a broad picture of the ticles and, when necessary, to report the
on hold while searching for the requested topic searched. However, tertiary litera- conflicting information found.

710 Am J Health-Syst Pharm—Vol 66 Apr 15, 2009

 New Practitioners Forum

In general, Internet searches should to extrapolate the information found to Conclusion. Using the systematic ap-
be reserved for when primary, second- the presented scenario and integrating proach to answering DI questions is essen-
ary, and tertiary resources have been ex- information and experience. The phar- tial for providing efficient pharmaceutical
hausted; however, the Internet may be an macist may also consider consulting with care. Like other pharmacy functions, it
excellent resource for certain questions. other colleagues, because their input may is an acquired skill which improves with
For instance, for questions concerning be a valuable addition in terms of expe- proper training and experience.
immunization issues, the Centers for rience or interpretation of information.
Disease Control and Prevention web- The oral or written response should be 1. Gaebelein CJ, Gleason BL. Contemporary
site (www.cdc.gov) is a useful source of tailored to the requester’s needs, keep- drug information: an evidence-based
information. The U.S. Food and Drug ing language, depth, and scope of con- approach. Baltimore, MD: Lippincot
Williams & Wilkins; 2008.
Administration website (www.fda.gov) is tent in consideration. Acquiring proper 2. Malone PM, Kier KL, Stanovich J. Drug
another useful website. Similarly, when a literature evaluation skills is important information handbook: a guide for phar-
question arises concerning a formulation for practicing pharmacists; however, an macists. 3rd ed. Columbus, OH: McGraw-
Hill; 2006.
of a branded dietary supplement, the In- in-depth discussion of this topic is out of 3. Millares M. Applied drug information:
ternet may be the only resource available the scope of this article. strategies for information management.
to provide a list of the active ingredients in In general, the response should begin Vancouver, WA: Applied Therapeutics,
the formula. However, Internet searches with restating of the question, ensuring Inc.; 1998.
4. Galt AK, Calis KM, Turcasso NM. Clini-
may not target the types of literature that that the pharmacist’s understanding of cal skills program: drug information.
are necessary for making a clinical deci- the question was correct. This should be Bethesda, MD: American Society of
sion and reviewing the results obtained followed by describing the resources used Health-System Pharmacists; 1995.
through an Internet search may be time- for the search and the information found 5. American Society of Health-System Phar-
macists. ASHP guidelines on the provision
consuming. When the Internet is used as in each of the sources. When reporting of medication information by pharma-
a resource for medical information, the information obtained via a secondary re- cists. Am J Health-Syst Pharm. 1996; 53:
source of the information must be closely source, it is important to provide the ar- 1843-5.
scrutinized to ensure credibility and lack ticle’s citation. Likewise, when reporting 6. Watanabe AS, McCart G, Shimomura S et
al. Systematic approach to drug informa-
of bias. A noncommercial domain (e.g., information found through an Internet tion requests. Am J Hosp Pharm. 1975; 32:
.gov, .edu, .org), presence of references, search engine, it is important to provide 1282-5.
currency of information, contact infor- the specific website in which the informa- 7. Fischer JM. Modification to the systematic
approach to answering drug information
mation, authorship information, and tion is found. When a written response is requests. Am J Hosp Pharm. 1980; 37:
Health on the Net Code accreditation are prepared, it is advised that the response 470,472-6.
all things to consider when checking for be concise, focusing on the question
credibility. asked. Formulating a lengthy written re- Joseph P. Nathan, M.S., Pharm.D.,
Efficient searches depend on the abil- sponse may result in the response being Associate Professor
Pharmacy Practice
ity of the pharmacist to locate informa- lost among the other information pro-
Drug Information Specialist
tion quickly. This requires a pharmacist vided in the response letter. A requester International Drug Information Center
to be aware of the institution’s DI and is more likely to read a letter that is com- Arnold and Marie Schwartz College of
library resources, including availability prehensive and concise. A letter should Pharmacy and Health Sciences
of print and electronic tertiary referenc- be accompanied by complete references, Long Island University
es; familiarity with available secondary unless otherwise indicated. 75 Delkab Avenue
databases; and ability to access full-text Following up. While following up on HS509
Brooklyn, NY 11201
journal articles electronically, in print, or a completed response is not always feasi-
[email protected]
via interlibrary loan services. ble, it should be done when possible. One
Evaluating the literature and dis- example of a follow-up is when a dose Suzanna Gim, B.A., Pharm.D., Assistant
seminating the information to the of an antibiotic is recommended by the Professor
requester. It is a common practice for pharmacist and a follow-up is warranted Pharmacy Practice
pharmacists to simply forward the infor- to ensure that proper blood levels are at- Arnold and Marie Schwartz College of
mation found (e.g., review article, copy tained and that no modifications to the Pharmacy and Health Sciences
of the page from a reference, printout original recommendations are necessary. Long Island University and
Drug Information Specialist
from an Internet website) to the request- A pharmacist constrained by time may Brookdale University Hospital and Medical
er without proper analysis or descrip- need to provide an immediate response Center
tion of the information. This method of to a DI request; however, he or she may Brooklyn, NY
responding to DI requests may be most have to conduct (or request a colleague to
convenient and at times may be appro- conduct) a more extensive search when The authors have declared no potential con-
priate; however, it is always necessary for an opportunity arises. When additional flicts of interest.
the pharmacist to evaluate and analyze information is found, it is necessary to
the information found. This evaluation contact the requester and provide this DOI 10.2146/ajhp080363
and analysis include assessing the ability additional information.

Am J Health-Syst Pharm—Vol 66 Apr 15, 2009 711

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