The Kentucky Pharmacist - September/October 2020 by Kentucky Pharmacists Association

Official Journal of the Kentucky Pharmacists Association

TABLE OF CONTENTS FEATURES

Mission Statement: To advocate and advance the pharmacy profession to improve the health of Kentuckians.

Editorial Office: ©Copyright 2020 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. Publisher: Mark Glasper Managing Editor: Sarah Franklin Editorial, advertising and executive offices at 96 C Michael Davenport Blvd., Frankfort, KY 40601. Phone: 502.227.2303 Fax: 502.227.2258. Email: info@kphanet.org. Website: www.kphanet.org.

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KPhA Virtual Annual Meeting & Convention Agenda |10|

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COVID-19 Vaccine Update |29|

On the Cover KPhA VIRTUAL Annual Meeting & Convention November 13-14, 2020

IN EVERY ISSUE President’s Perspective |3| My KPhA Rx |6| September CE Article |12| September Quiz |18| September CE Answer Sheet |19| October CE Article |21| October Quiz |26| October Answer Sheet |27| Pharmacy Law Update |30| Pharmacy Policy Issues |32| New KPhA Members |33| Rx And the Law |38| Financial Forum |40|

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APSC |5| PTCB |20| EPIC |33| CMP Pharma |35| Pharmacists Mutual |36| Cardinal |37| APMS |Back Cover|

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All times are Eastern Time Zone

Annual Meeting & Convention Agenda Friday, November 13, 2020

7.0 CPE total hours (6.0 CPE available on-demand post meeting)

9:00 – 10:00 AM Kick off with Miss America Camille Schrier, PharmD Student 10:00-10:15 AM BREAK

The Importance of CBD in the New Healthcare Paradigm Clinical | 1.0 CPE Meroe Rabieifar, PharmD, President, My Community Pharmacy, PharmaCanna

2:00 – 2:30 PM Exhibit Break Check out the virtual exhibit hall

10:15 – 11:15 AM General Session

2:30 – 3:30 PM Concurrent Session

Practice Transformation: The Flip the Pharmacy Team Kentucky | Live | 1.0 CPE | Clinical Chris Harlow (Moderator), Martika Martin (panelist), Paula Miller (panelist), Clark Kebodeaux (panelist)

Advocacy Panel Law/Advocacy | Live | 1.0 CPE Shannon Stiglitz, Rep. Danny Bentley, Rep. Steve Sheldon

Law Review Law/Advocacy | 1.0 CPE (live, not recording) Ralph Bouvette, APSC

11:15 – 11:30 AM BREAK 11:30: 12:30 PM Concurrent Session 1.

New Drug Update Clinical | 1.0 CPE Clark Kebodeaux, Pharm.D., BCACP, UK College of Pharmacy Financial Planning for Young Professionals (Non-CE) | Live Lifetime Financial Group

12:30 – 12:45 PM BREAK 12:45 – 2:00 PM House of Delegates/Concurrent Session 1.

Basics of Pharmacogenomics Clinical | 1.0 CPE Amber Cann, PharmD, MBA - Owner, Venus Vitality

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3:30 – 3:45 PM BREAK 3:45 – 4:45 PM General Session 1.

Empowering Pharmacists to Care for Patients Law/Advocacy | Live | 1.0 CPE Scott J. Knoer, MS, PharmD Executive Vice APhA President and CEO Designate

4:45 – 5:45 PM Happy Hour/Networking/Students with Miss America Camille Schrier, PharmD Student 6:00 – 7:00 PM Awards Ceremony

Saturday, November 14, 2020

10.0 CPE total hours (10.0 CPE available on-demand post meeting) 9:00 – 10:00 AM Kickoff with President Joel Thornbury 10:00 – 10:15 AM BREAK

1:45 – 2:15 PM Exhibit BREAK Check out the virtual exhibit hall 2:15 – 3:15 PM Concurrent Session 1.

Crossing the Gap: Improving Workforce Relations Across Generations | 1.0 CPE | Kyle Bryan, PharmD, Executive Fellow, NACDS Foundation, Kelsie Skaggs, PharmD, PGY1 Community Pharmacy Resident, American Pharmacy Services Corporation

New Directions in Influenza Management: The Pharmacist’s Guide to Patient Identification, Testing, and Antiviral Use | Clinical | 1.0 CPE Karen Lusardi, PharmD, Clinical Pharmacy Specialist, Antimicrobial Stewardship, UAMS Medical Center, Little Rock, AR

10:15 – 11:15 AM Concurrent Session 1.

KBOP Update | Law/Advocacy | 1.0 CPE | Live Larry Hadley, Executive Director, KBOP

Diabetes Update 2020 | Clinical | 1.0 CPE | Brooke Hudspeth, PharmD, CDCES, MLDE, Chief Practice Officer, University of Kentucky College of Pharmacy

11:15 – 11:30 AM BREAK 11:30 – 12:30 PM Concurrent Session 1.

The Work-Life Integration Conundrum: Preposterous, Improbable, or Plausible? | Clinical | 1.0 CPE Stacy Taylor, PharmD, MHA, BCPS, Clinical Associate Professor, UK College of Pharmacy Pharmacy Technicians: Expansion of Roles in Community and Acute Pharmacy | Clinical | 1.0 CPE Devin Wallace CPhT CSPT RPhT PRS, Founder and President of Wallace Ventures Medical Sales and Consulting

12:30 – 12:45 PM BREAK 12:45 – 1:45 PM Concurrent Session 1.

Understanding the Kentucky Board of Pharmacy’s Investigative and Administrative Process | Law/Advocacy | 1.0 CPE Luke Morgan, JD, McBrayer

COVID-19 Vaccine Update | Clinical | 1.0 CPE Michele Pinkston, PharmD

3:15 – 3:30 PM BREAK 3:30 – 4:30 PM Concurrent Session 1.

Advances in Pharmacy Practice-Bridging Community and Ambulatory Care Practices | Clinical | 1.0 CPE Chris Harlow (moderator), Brooke Hudespeth (panelist), Paula Miller (panelist), Erica Neff (panelist), and Madison Poteet (PGY1 pharmacy practice resident)

Update to USP Compounding Affairs -Current Status and The Road Ahead | Law/Advocacy | 1.0 CPE Devin Wallace CPhT CSPT RPhT PRS, Founder and President of Wallace Ventures Medical Sales and Consulting

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September CPE Article Fall Risk Increasing Drugs and the Pharmacist’s Role in Fall Prevention Authors: Taylor Elliott, PharmD/MPH Candidate 2021; Asmita Shrestha, MPH; Mark Huffmyer, PharmD, BCGP, BCACP, CACP; Lynne Eckmann, PharmD, BCGP; Daniela C. Moga, MD, PhD; University of Kentucky College of Pharmacy The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-20-009-H05-P &T 1.0 Contact Hours (0.1 CEU) Expires 10/30/23 Learning Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1.

Describe the healthcare burden of falls

Identify risk factors for falls and complications of falls

Define fall-risk-increasing drugs, explain how fall risk is measured, and identify relevant medication classes for intervention

4. Describe the pharmacist’s role in preventing falls in the elderly population Introduction

independently. In addition, the fear of falling a second time may cause the person to be less active, Falls are a major public health problem that disprowhich in turn causes weakness, thus increasing the portionately affects adults older than 65 years of risk for another fall.(3) age. Every 11 seconds, an older adult is treated in the emergency room for a fall; every 19 minutes, an Injurious falls lead to three million emergency deolder adult dies from a fall.(1) partment visits and over 800,000 hospitalizations per year. The majority of these hospitalizations are The World Health Organization defines a fall as “an related to a head injury or a hip fracture.(3) These event which results in a person coming to rest ininjuries often have a lasting cascade effect that furadvertently on the ground or floor or other lower ther debilitates the person. For example, a hip fraclevel.”(2)Pharmacists can play an important role in ture caused by a fall most often requires orthopefall prevention in this patient population, which dic surgical repair. The surgery itself comes with can subsequently decrease fall-related injuries and multiple acute risks, including infection and bleedthe associated emotional and economic costs. ing. Furthermore, the surgery also immobilizes the Healthcare Burden of Falls patient for a prolonged period of time, putting him/her at increased risk for a deep venous thromAccording to data from the Centers for Disease boembolism (DVT). The prolonged immobilization Control and Prevention (CDC), millions of people can also result in muscle atrophy and further aged 65 and older experience a fall each year. This weakness, which could contribute to a subsequent equates to more than one out of four older adults fall. In addition, the frequent prescribing of opioids in the United States. Approximately 20 percent of for post-surgical pain control also increases risk for these falls results in a serious injury, such as a fraca subsequent fall. tured or broken bone or a traumatic brain injury (TBI). These injuries often inhibit the person’s abilThe total associated medical costs are exponential ity to perform activities of daily living (ADLs) or live – each year about $50 billion is spent on non-fatal |12| Kentucky Pharmacists Association | September/October 2020

fall injuries and $754 million on fatal falls. For nonfatal falls, greater than 50 percent of the economic cost is paid by Medicare. This percentage is expected to increase as the number of Americans aged 65 and older continues to grow.(4) Risk Factors for Falls and Complications of Falls Researchers have identified numerous risk factors for falls, many of which are modifiable. In general, these risk factors can be subclassified as extrinsic or intrinsic. Extrinsic causes are related to the physical environment, whereas intrinsic causes are related to patient-specific factors.(5) However, extrinsic and intrinsic causes frequently interact with one another, often making it difficult to pinpoint the primary precipitating factor. For example, depression has been shown to be an independent intrinsic risk factor for falls. Unfortunately, some classes of antidepressants used to treat depression have also been shown to be an extrinsic risk factors for falls. These medications are classified as fall risk increasing drugs, or FRIDs. In addition to the extrinsic and intrinsic risk factors for falls listed above, there are also factors that put patients at high risk for complications of falls. Specifically, patients who utilize long-term oral anticoagulants for comorbid conditions such as atrial fibrillation or DVT treatment/prevention are at increased risk for traumatic intracranial hemorrhage and subsequent mortality.(8) These patients may also be more susceptible to significant bleeding and/or bruising in comparison to their counterparts not on long-term anticoagulation. In addition, patients with osteoporosis are at high risk for compli-

cations after a fall. This is because healing can take longer than normal due to the impaired condition of the bone, which leads to prolonged reduction in activity and subsequent weakness.(9) Lastly, patients with dementia are also at increased risk for complications such as exacerbated symptoms or delirium due to immobility and lengthy hospitalizations. Considering the probability of a fall is positively correlated to the number of risk factors present, modifying as many risk factors as possible and minimizing potential complications of falls is essential. For pharmacists and pharmacy technicians, understanding how fall risk is measured and being able to identify fall risk increasing drugs is crucial to preventing falls in older adults. How is Fall Risk Measured? There are different parameters of gait which help identify and minimize fall risk. The parameters that should be clinically examined include walking speed, cadence (number of steps per unit of time), step width (measured from midpoint to midpoint of both heels), step length (measured from the point of foot contact to the point of contralateral foot contact), stride length (linear distance covered by one gait cycle), arm swing, freezing, turning, gait initiation, step symmetry, trunk, and walk stance.(10,11)

Extrinsic Causes: (3,5)

Intrinsic causes: (4,6,7)

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Slipping

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Advanced age

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Uneven floor surfaces, including steps

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Altered mental status

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Tripping or stumbling

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Dizziness/vertigo

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External forces, such as being pushed

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Frequent toileting

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Insufficient illumination

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Lower body weakness or deficits

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Broken chairs

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Vitamin D deficiency

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Failure of walking aids

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Vision or hearing problems

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Lifting or carrying heavy objects

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History of falls/fear of falling

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Poor footwear

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FRIDs and polypharmacy

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Alcohol use

Comorbidities (angina, arrhythmias, stroke, asthma, cancer, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), arthritis, depression, diabetes and associated neuropathy, Parkinson’s disease, Huntington’s disease) |13| www.KPHANET.org

Fall risk is measured using multiple tests, including the Tinetti Mobility Test (TMT), Timed up and Go Test (TUG), the Romberg Test, and the Five Times Sit-to-Stand Test (5TSST). See Table 1 below for more detailed information. Table 1 Test Tinetti Mobility Test (TMT) (11)

Description of Test

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Also known as the Tinetti Balance and Gait Test or the Tinetti PerformanceOriented Mobility Assessment

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Assesses balance and gait using a 16item test

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There are 28 total points possible, 16 for balance and 12 for gait <19 = high fall risk 19-24 = medium fall risk 25-28 = low fall risk

Timed Up and Go Test (TUG)/Get Up and Go Test (12)

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Measures the time period required by the patient to stand up from a chair with arm rests, walk three meters (using usual walking aids if necessary), turn around, walk back, and sit down

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Can be scored qualitatively on a scale from 1 to 5 1- No fall risk. Well-coordinated movements, without walking aid 2- Low fall risk. Controlled but adjusted movements 3- Some fall risk. Uncoordinated movements 4- High fall risk. Supervision necessary 5- Very high fall risk. Physical support or stand by physical support necessary

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Can also be scored quantitatively An older adult who takes ≥12 seconds to complete the TUG is considered at risk

Romberg Test (12)

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Identifies balance impairments in order to detect fall risk

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The Romberg sign is present in patients who have significant swaying or a break in position when standing with their feet together, arms by their side, and their eyes closed

Medication Classes of Concern Several medications and medication classes are known to independently impair an individual’s normal physical characteristics, including balance and gait. These changes in balance and gait have been associated with an increased risk for falls. The CDC has designed a program called Stopping Elderly Accidents, Deaths, & Injuries (STEADI). STEADI-Rx provides pharmacists guidance on assessing medications associated with fall risk.(13) Similarly, the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults also lists medications and medication classes to avoid in patients with a history of falls or fractures.(14) Table 2 below summarizes which medication classes of concern are listed by these two organizations. Table 2 Medication Class

STEADI-Rx

Beers Criteria

Anticonvulsants Antidepressants Antihypertensives Antipsychotics Antispasmodics Benzodiazepines Opioids Sedative hypnotics

The Pharmacist’s Role in Fall Prevention

Step 1: Medication Therapy Review

As one of the most accessible healthcare providers, pharmacists can play an important role in preventing falls in the elderly population. Prevention can take place through one or more of several mechanisms, including medication therapy management (MTM), subsequent patient counseling and deprescribing of potentially inappropriate medications, and recommendation of gait-stabilizing therapy when appropriate.

A medication therapy review (MTR) is conducted between the patient (and/or caregiver) and the pharmacist. In a comprehensive MTR, the pharmacist collects specific patient-related information, including all prescription and nonprescription medications, herbal products, and other dietary supplements. The pharmacist then assesses each of the patient’s medications for indication, safety, efficacy, and adherence. When medication-related problems are identified, the next step is to develop a plan for Medication Therapy Management resolution. Resolution can take place through paMedication therapy management (MTM) is a service tient education, communication with other that can be performed by pharmacists to ensure healthcare providers, or both. the best therapeutic outcomes for patients. MTM Step 2: Personal Medication Record includes five core elements: medication therapy review, a personal medication record, a medication- After completion of the MTR, the patient receives a related action plan, intervention or referral, and comprehensive record of his or her medications documentation and follow-up.(24,25) (prescription and nonprescription medications, |15| www.KPHANET.org

herbal products, and other dietary supplements). This comprehensive record, called the personal medication record (PMR), is intended for patients to use as a perpetual document for medication self-management. Ideally, the patient will carry his or her current PMR at all times and share it with other healthcare providers in order to reduce medication-related errors and adverse events. Step 3: Medication-Related Action Plan

Finally, while being cognizant of fall risk increasing drugs and the effects of polypharmacy are both of utmost importance, mitigating the fall risk is even more crucial. This can be done through patient counseling and/or collaboration with other members of the interprofessional healthcare team. Patient counseling can include education on both pharmacologic and non-pharmacologic therapy.

In regard to pharmacologic therapy, the pharmacist can place notes on the patient’s PMR indicatLike the PMR, the medication-related action plan ing which medications may contribute to falls. The (MAP) is a document completed after MTR and is a pharmacist can also place items on the patient’s list of actions for the patient to use in tracking promedication-related action plan such as, “Because gress for self-management. The patient MAP this medication lowers your blood pressure, you should include only items the patient can act on or may feel dizzy when standing or sitting up quickly. that are within the pharmacist’s scope of practice. Be sure to rise slowly.” Pharmacists can also collabStep 4: Intervention and/or Referral orate with other members of the interprofessional team to help lower fall risk. For example, when apFor medication-related problems that cannot be propriate, the pharmacist can suggest deprescribresolved by the patient and are not within the ing of potentially inappropriate medications (PIMs) pharmacist’s scope of practice, the pharmacist to the respective provider(s). PIMs are defined as should collaborate or refer the patient to another “medications that should be avoided due to their member of the interprofessional healthcare team. risk which outweighs their benefit and when there This helps to improve medication use and adherare equally or more effective but lower risk alternaence and also eases transitions of care. tives available.”(28) In fact, one study showed that Step 5: Documentation and Follow-up withdrawal of fall-risk-increasing drugs is effective as a single intervention for fall prevention.(29) Also, The last step of the MTM process is completing in many cases, patients have multiple providers documentation and scheduling follow-up. The pawho are unaware of the patient’s complete meditient-specific record should include documentation cation regimen and therefore the potential risks of all patient visits in chronological order in a conassociated with drug-drug interactions, duplicate sistent format. Follow-up should occur regularly to therapy, and polypharmacy. Raising awareness ensure continued resolution of medication-related when this issue occurs can prove beneficial. Incorproblems and identification of new issues. porating other members of the interprofessional In regard to fall prevention, MTM can be utilized in healthcare team, such as physical and/or occupaseveral ways. First and foremost, the pharmacist tional therapists, can also decrease a patient’s fall can use MTR to identify which of the patient’s med- risk and improve quality of life. ications are individually classified as fall-riskWhile the pharmacist’s role in fall prevention most increasing drugs. The pharmacist can also use MTR commonly involves minimizing a patient’s medicato analyze the patient’s medications for potential tion regimen in instances of PIMs and polypharmadrug-drug interactions. In fact, analyzing for potency, recommending addition of gait-stabilizing thertial drug-drug interactions becomes increasingly apy in patients with movement disorders can also important as the total number of medications in a be of assistance. For example, in a small study of patient’s regimen increases. One study reported patients with Huntington’s disease, tetrabenazine that for every one increase in number of medicawas found to reduce chorea, which contributes to tions, participants had a seven percent higher risk balance problems and walking difficulties that lead for incident falls.(26) Another study analyzed the to higher fall rates.(31) Similarly, rivastigmine can risk of impaired balance in community-dwelling improve gait stability and might reduce the freolder adults taking medications versus those not quency of falls in patients with Parkinson’s disease. taking any medications to assess fall risk. After ad(32) justment for age, depressive symptoms, cognitive impairment, vision and hearing impairments, num- The pharmacist can also suggest simple, nonber of chronic diseases, and number of hospitaliza- medication related tips to prevent falls such as betions in the previous year, participants taking five ing physically active and wearing sensible shoes. In or more medications were 80% more likely to expe- addition, the pharmacist can counsel on modificarience impaired balance as opposed to those not tions to the patient’s physical residence and sugtaking any medications.(27) gest durable medical equipment (DME) like a cane or a walker. Some of the physical interventions |16| Kentucky Pharmacists Association | September/October 2020

might include illuminating stairs, removing throw rugs on the floor, placing a nightlight in the path from the bedroom to the bathroom, and placing grab bars near the toilet and the shower.(30)

Medication Use in Older Adults: 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL. J Am Geriatr Soc. 2019 Apr;67(4):674–94.

In addition to the pharmacologic and nonpharmacologic interventions mentioned above, the pharmacist can also play an important role in general patient education. Ensuring patients understand the risks of injurious falls as well as the cascading effects that can ensue after falls (such as loss of personal independence) is essential to prevention.

16. Landi F, Onder G, Cesari M, Barillaro C, Russo A, Bernabei R, et al. Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. J Gerontol A Biol Sci Med Sci. 2005 May;60(5):622–6.

Conclusion In conclusion, falls are a major public health problem that can lead to serious negative health outcomes, especially in adults aged 65 and older. The subsequent burden on individuals’ quality of life, as well as the financial costs on the health care system are enormous. Pharmacists can play a crucial role in fall prevention in this patient population by 1) understanding and recognizing risk factors for falls, 2) identifying medications of concern and polypharmacy, and 3) appropriately managing medication therapy with other members of the interprofessional healthcare team. References 1. Falls Prevention Facts [Internet]. NCOA. 2015 [cited 2020 Sep 21]. Available from: https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-preventionfacts/ 2. Falls [Internet]. [cited 2020 Aug 17]. Available from: https://www.who.int/newsroom/fact-sheets/detail/falls 3. Important Facts about Falls | Home and Recreational Safety | CDC Injury Center [Internet]. 2019 [cited 2020 Jun 29]. Available from: https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html 4. Falls Data | Home and Recreational Safety | CDC Injury Center [Internet]. 2019 [cited 2020 Jun 29]. Available from: https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html 5. Bueno-Cavanillas A, Padilla-Ruiz F, Jiménez-Moleón JJ, Peinado-Alonso CA, GálvezVargas R. Risk Factors in Falls among the Elderly According to Extrinsic and Intrinsic Precipitating Causes. European Journal of Epidemiology. 2000;16(9):849–59. 6. Callis N. Falls prevention: Identification of predictive fall risk factors. Applied Nursing Research. 2016 Feb 1;29:53–8. 7. Paliwal Y, Slattum PW, Ratliff SM. Chronic Health Conditions as a Risk Factor for Falls among the Community-Dwelling US Older Adults: A Zero-Inflated Regression Modeling Approach. Biomed Res Int [Internet]. 2017 [cited 2020 Jul 8];2017. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387801/ 8. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Use of Long-Term Anticoagulation is Associated With Traumatic Intracranial Hemorrhage and Subsequent Mortality in Elderly Patients Hospitalized After Falls: Analysis of the New York State Administrative Database. Journal of Trauma and Acute Care Surgery. 2007 Sep;63(3):519–524.

15. Williams LJ, Pasco JA, Stuart AL, Jacka FN, Brennan SL, Dobbins AG, et al. Psychiatric disorders, psychotropic medication use and falls among women: an observational study. BMC Psychiatry [Internet]. 2015 Apr 8 [cited 2020 Aug 31];15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4394398/

17. Galik E, Resnick B. Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents. Journal of Psychiatric and Mental Health Nursing. 2013;20(3):244–52. 18. Donoghue OA, O’Hare C, King-Kallimanis B, Kenny RA. Antidepressants are independently associated with gait deficits in single and dual task conditions. Am J Geriatr Psychiatry. 2015 Feb;23(2):189–99. 19. Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, et al. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others. J Am Med Dir Assoc. 2018;19(4):372.e1-372.e8. 20. M M, F C, T P. Risk of falls associated with antiepileptic drug use in ambulatory elderly populations: A systematic review. Can Pharm J (Ott). 2017 Mar 1;150(2):101–11. 21. Tinetti ME, Han L, Lee DSH, McAvay GJ, Peduzzi P, Gross CP, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014 Apr;174(4):588–95. 22. Kahlaee HR, Latt MD, Schneider CR. Association Between Chronic or Acute Use of Antihypertensive Class of Medications and Falls in Older Adults. A Systematic Review and Meta-Analysis. Am J Hypertens. 2018 10;31(4):467–79. 23. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc. 1999 Jan;47(1):40–50. 24. CDC. Using Medication Therapy Management to Treat Chronic Disease [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Aug 17]. Available from: https://www.cdc.gov/dhdsp/pubs/guides/best-practices/pharmacist-mtm.htm 25. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003). 2008 Jun;48(3):341–53. 26. Gnjidic D, Hilmer SN, Blyth FM, Naganathan V, Waite L, Seibel MJ, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify communitydwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012 Sep;65(9):989–95. 27. Agostini JV, Han L, Tinetti ME. The relationship between number of medications and weight loss or impaired balance in older adults. J Am Geriatr Soc. 2004 Oct;52(10):1719–23. 28. Alhawassi TM, Alatawi W, Alwhaibi M. Prevalence of potentially inappropriate medications use among older adults and risk factors using the 2015 American Geriatrics Society Beers criteria. BMC Geriatrics. 2019 May 29;19(1):154. 29. van der Velde N, Stricker BHC, Pols HAP, van der Cammen TJM. Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br J Clin Pharmacol. 2007 Feb;63(2):232–7. 30. US Department of Health & Human Services; Centers for Disease Control (CDC); National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Check for Safety: A Home Fall Prevention Checklist for Older Adults [Internet]. American Psychological Association; 2004 [cited 2020 Sep 21]. Available from: http://www.crossref.org/deleted_DOI.html 31. Kegelmeyer DA, Kloos AD, Fritz NE, Fiumedora MM, White SE, Kostyk SK. Impact of tetrabenazine on gait and functional mobility in individuals with Huntington’s disease. J Neurol Sci. 2014 Dec 15;347(1–2):219–23. 32. Henderson EJ, Lord SR, Brodie MA, Gaunt DM, Lawrence AD, Close JCT, et al. Rivastigmine for gait stability in patients with Parkinson’s disease (ReSPonD): a randomised, double-blind, placebo-controlled, phase 2 trial. The Lancet Neurology. 2016 Mar 1;15(3):249–58.

9. General Information about Pain After A Fracture | Osteoporosis Canada [Internet]. [cited 2020 Sep 21]. Available from: https://osteoporosis.ca/bone-healthosteoporosis/living-with-the-disease/after-the-fracture/general-information-aboutpain-after-a-fracture/ 10. Vaught SL. Gait, balance, and fall prevention. Ochsner J. 2001 Apr;3(2):94–7. 11. Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr. 2017 Feb;129(3–4):81–95. 12. Nordin E, Lindelöf N, Rosendahl E, Jensen J, Lundin-Olsson L. Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff’s global judgement and fall history in evaluating fall risk in residential care facilities. Age Ageing. 2008 Jul;37(4):442–8. 13. STEADI-Rx | STEADI - Older Adult Fall Prevention | CDC Injury Center [Internet]. 2020 [cited 2020 Aug 31]. Available from: https://www.cdc.gov/steadi/steadi-rx.html 14. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate

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September 2020 â&#x20AC;&#x201D; Fall Risk Increasing Drugs and the Pharmacistâ&#x20AC;&#x2122;s Role in Fall Prevention 1. Which of the following most accurately describes a fall? A.

An event which results in a person coming to rest inadvertently on the ground or floor or other lower level

An event which results in a person coming to rest inadvertently on the ground or floor or other lower level AND leads to injury

An event which results in a person coming to rest inadvertently on the ground or floor or other lower level AND has a clear, inciting cause

2. Which of the following are false regarding the healthcare burden of falls â&#x20AC;Ś A.

Millions of people aged 65 and older experience a fall each year.

Injurious falls lead to three million emergency department visits and more than one million hospitalizations.

The percentage of economic costs paid by Medicare related to falls is expected to decrease in the future.

D. Approximately 20 percent of falls in people aged 65 and older results in a serious injury.

3. Which of the following is NOT a risk factor for falls? A.

Insufficient lighting

Fear of falling

Altered mental status

It measures the time period required by the patient to stand up from a chair with arm rests, walk three meters (using usual walking aids if necessary), turn around, walk back, and sit down.

It assesses balance and gait using a 16-item test AND classifies fall risk as high, medium, or low.

7. Which of the following choices is not correct based on data from the primary literature? A.

Users of any psychotropic drugs had an increased fall risk of nearly 47%.

The time-risk analysis did not demonstrate a significantly elevated risk of falling 0-24 hours after antihypertensive initiation, change, or dose increase.

Opioid and antiepileptic use and polypharmacy were significantly associated with increased risk of falling in the meta-analyses.

8. Which of the following choices most accurately describes the steps in medication therapy management? A.

Medication therapy review, personal medication record, medication-related action plan, intervention and/or referral

Intervention and/or referral, personal medication record, medication-related action plan, medication therapy review

Personal medication record, medication therapy review, medication related-action plan, intervention and/or referral

D. All of the above are risk factors for falls

4. Which of the following medication classes are not associated with increased fall risk? A.

Antipsychotics

Opioids

Benzodiazepines

D. Statins

5. Polypharmacy is a significant risk factor for falls. A.

True

False

6. Which of the following choices most accurately describes the Tinetti Mobility Test? A.

The Tinetti Mobility Test is positive if significant swaying exists when a patient stands with their feet together, their arms by their sides, and their eyes closed.

|18| Kentucky Pharmacists Association | September/October 2020

9. Which of the following is NOT a strategy for pharmacists to prevent falls? A.

Provide patients with nonpharmacologic safety tips such as proper footwear, appropriate lighting, etc.

Educate patients on the presence of fall-risk increasing drugs and/or polypharmacy

Assist with appropriate de-prescribing of potentially inappropriate medications.

D. All of the above are strategies for pharmacists to prevent falls.

10. Gait stabilizing therapy is recommended for all patients taking a fall risk increasing drug. A.

True

False

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, 96 C Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: 10/30/23 Successful Completion: Score of 80% will result in 1.0 contact hour or .1 CEUs. TECHNICIANS ANSWER SHEET September 2020 — Fall Risk Increasing Drugs and the Pharmacist’s Role in Fall Prevention Universal Activity #0143-0000-20-009-H05-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C 3. A B C D 5. A B 7. A B C 9. A B C D 2. A B C D 4. A B C D 6. A B C 8. A B C 10. A B Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved 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 If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #__________________________ Birthdate _______ (MM)_______(DD)

PHARMACISTS ANSWER SHEET

September 2020 — Fall Risk Increasing Drugs and the Pharmacist’s Role in Fall Prevention

Universal Activity #0143-0000-20-009-H05-P Name _______________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C 3. A B C D 5. A B 2. A B C D 4. A B C D 6. A B C

7. A B C 8. A B C

9. A B C D 10. A B

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved 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 If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy

Quizzes submitted without NABP eProfile ID # and Birthdate cannot be accepted. |19| www.KPHANET.org

Have an idea for a continuing education article? WRITE IT! Continuing Education Article Guidelines

The following broad guidelines should guide an author to completing a continuing education article for publication in The Kentucky Pharmacist. 



Average length is 4-10 typed pages in a word processing document (Microsoft Word is preferred). Articles are generally written so that they are pertinent to both pharmacists and pharmacy technicians. If the subject matter absolutely is not pertinent to technicians, that needs to be stated clearly at the beginning of the article.



Article should begin with the goal or goals of the overall program – usually a few sentences.



Include 3 to 5 objectives using SMART and measurable verbs.



Feel free to include graphs or charts, but please submit them separately, not embedded in the text of the article.

|20| Kentucky Pharmacists Association | September/October 2020



Include a quiz over the material. Usually between 10 to 12 multiple choice questions.



Articles are reviewed for commercial bias, etc. by at least one (normally two) pharmacist reviewers.



When submitting the article, you also will be asked to fill out a financial disclosure statement to identify any financial considerations connected to your article.



Articles should address topics designed to narrow gaps between actual practice and ideal practice in pharmacy. Please see the KPhA website (www.kphanet.org) under the Education link to see previously published articles.



Articles must be submitted electronically to the KPhA director of communications and continuing education (info@kphanet.org) by the first of the month preceding publication.

OCTOBER CPE Article ICU Recovery Challenges Authors: Ariana N.Chambers, PY4 Pharm.D candidate 2021 and Jimmi Hatton Kolpek, Pharm.D. The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-20-010-H05-P &T 1.0 Contact Hours (0.1 CEU) Expires 10/30/23 Learning Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: Pharmacist Objectives: 1.

Define Post-ICU Syndrome

Identify the components of the ABCDEF bundle

Recognize the role of a pharmacist during and post-ICU stay in both in-patient and community or ambulatory settings

4. Obtain/access resources that can be given to patients possibly suffering from PICS Pharmacy Technician Objectives: 1.

Define Post-ICU Syndrome

Identify the components of the ABCDEF bundle

Recognize possible signs of PICS in your patient population that can be referred to the pharmacist for additional resources

We all know someone who has been in a severe car accident, suffered from a stroke or heart attack, had post-operative complications, pneumonia, coronavirus, and the list of emergency situations that could lead to an intensive care unit visit continues. According to the Society of Critical Care Medicine (SCCM), there are approximately 5 million individuals admitted to the ICU yearly in the United States. Unfortunately, around one-third of these patients will be placed on mechanical ventilation [1]. However, did you know that anywhere from 30 to 70% of these 5 million individuals will go on to develop a new syndrome because of their ICU stay? [2] What is Post-Intensive Care Unit Syndrome? Post-Intensive Care Unit Syndrome (PICS) was first defined by the Society of Critical Care Medicine in 2010. It presents as a change or worsening of cognition, physical or psychological function after criti-

cal illness. Symptoms include ICU-acquired weakness, cognitive or brain dysfunction such as memory problems, inability to organize thoughts or complete tasks, sleep disturbances, anxiety and posttraumatic stress disorder (PTSD) [3]. PICS can occur within 2 days to weeks or months following an ICU stay. No definitive timeline for onset or duration has been reported, although most ICU recovery clinics evaluate patients within three months of ICU discharge and follow them up to one year. When patients are in the ICU, it is important to manage risk factors associated with developing PICS. They can be separated into ICU-related risk factors such as delirium, immobility, failed communication, systemic corticosteroids, sepsis, acute respiratory distress syndrome, renal replacement therapy, sedative use, and prolonged mechanical ventilation greater than seven days [2,4]. As stated |21| www.KPHANET.org

previously, one-third of ICU patients require mechanical ventilation which then exponentially increases their risk for the development of PICS. Additionally, there are some unmodifiable patientspecific risk factors to consider as well including patient personality, life experiences, previous medical history (alcoholism, prior stroke, COPD, etc.), ability of the patient to handle ICU stress, baseline impairments, depression, anxiety, PTSD, lower educational level, and female sex [2,4]. Given the wide range of risk factors at play, it is crucial that the patient’s interdisciplinary team delegates team members to assess patient progression each day. Fortunately, a few studies have occurred in the past few years to assess how to best do so. The prominent model is the ABCDEF or ICU Liberation bundle per the SCCM (Table 1). One prospective, cohort study found that the ABCDEF bundle “showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma and delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition [5].” Thus, let us delve into each component further to assess the role of the pharmacist particularly in the in-patient critical care setting and then in the community or ambulatory setting as well. What are the components of the ABCDEF Liberation Bundle? The first component of the ABCDEF bundle is assess, prevent, and manage pain per SCCM [6]. Other models list the first component as airway management. As a clinical pharmacist in the critical care inpatient setting, recommending IV opioids and nonopioid analgesics and assessing pain via speaking with nursing staff, family, and reviewing documentation can be helpful. This component can be difficult to assess given the likelihood that the patient will be sedated and/or intubated, so team communication is vital. Due to the high probability that these patients are going to need intubation, the airway management component will likely already have been assessed and implemented prior to pharmacist involvement with the team. The next component of the ABCDEF bundle is spontaneous awakening and spontaneous breathing trials [6]. This component is essential for evaluating the patient’s respiratory function at scheduled intervals to potentially wean the patient from mechanical ventilation as early as possible. As we have learned, prolonged ventilation use places a patient at increased risk of developing PICS. Pharmacist are not likely to have a direct impact during these breathing and awakening trials. However, pharmacist can always assess patient home medications for inhalants as these may be useful to have |22| Kentucky Pharmacists Association | September/October 2020

during the time of the trial. Additionally, it is important to note that the use of a patient’s native language during breathing and awakening trials is an important and often under-utilized facet that can help orient the patient. The third component of the ABCDEF bundle is choice of analgesia and sedation as well as coordinated communication and care. This component goes hand-in-hand with the “A” component of the bundle. Pharmacy can play a role here as recommendations for desired level of sedation can be made to the team. For example, pharmacy could recommend dexmedetomidine or benzodiazepines for lighter sedation if a breathing trial is anticipated to be attempted soon versus the use of propofol or a combination of sedatives if deeper sedation is desired. Pharmacy can also play a role in analgesia here in terms of patient home medications. If the patient is taking a medication for pain or neuropathy at home, pharmacy could suggest restarting this medication and has the expertise to review medications for dual use while in-patient. Additionally, coordinated communication and care is vital for ICU patients and their families. Regarding the patient, updates on their progression once stable and candid conversation about their journey, if requested, can help the patient begin to process what they are experiencing, improve memory, and understand nightmares and terrors as a result of their ICU stay particularly if the patient keeps a ICU diary or journal [7]. The family component of coordinated care will be mentioned later. The fourth component of the ABCDEF bundle is assess, prevent, and manage delirium. Unfortunately, the cause of delirium in many ICU patients is an anomaly. Per DSM-IV, delirium can be defined as a disturbance of consciousness or change in cognition that develops over a short period of time and caused by the direct physiological consequences of a general medical condition [8]. Symptoms of delirium can vary based on the type of delirium the patient is experiencing. First, hyperactive delirium includes symptoms of irritability, anger, nightmares, and easy startling. Secondly, hypoactive delirium symptoms include depression, slurred speech, anorexia, and altered sleep patterns. Lastly, mixed delirium includes symptoms of both hyperactive and hypoactive as listed above. Delirium has been found to be an independent predictor of higher 6month mortality and longer hospital stay especially in mechanically ventilated patients [9]. Pharmacist intervention could be made for the delirium component when assessing patient medications that could lead to its development. These medications could include anticholinergics, stimulants, dopamine agonists, high-dose benzodiazepines, corticosteroids, and sedatives as examples.

Also, pharmacists can help interpret and trend the patient’s Confusion Assessment Method in the ICU (CAM-ICU) scores and assess electrolyte changes or imbalances which could lead to total parenteral nutrition (TPN) or enteral feeding adjustments. Lastly, someone from the team should speak with the patient’s family to assess their normal routine and needs for improved sensory stimulation. These nonpharmacologic interventions include obtaining patient glasses or hearing aids, opening and closing the patient’s blinds in the room at certain times each morning and evening, and having family present during the day [10]. The fifth component of the ABCDEF bundle is early mobility and exercise. The team should consult physical and occupational therapist as soon as the patient is medically stable and able to ambulate. Early movement shows improvement in both cognitive and psychiatric symptoms [4]. As a clinical pharmacist, the focus of this component would likely include assessing the in-patient medications for sedative/drowsiness side effects and attempting to adjust order times that are going to best coincide with the patient’s physical therapy to allow the patient to have optimal performance.

It is important to note that family can also experience changes in mood, depression, fatigue, anxiety, and PTSD from seeing their loved-one’s experience in the ICU. Thus, family members can experience PICS-family (PICS-F) and should seek help from their primary care physician to be referred for appropriate care as needed [4]. There are also peer support groups available online for patients and families to connect with others who have had an ICU experience as an individual or a family member. One easily accessible resource is https://sccm.org/MyICUCare/THRIVE/Patient-andFamily-Resources via SCCM and can be given to patients and family members or caregivers who would like additional information about PICS [3]. What are ICU Recovery Clinics?

Intensive care unit recovery clinics are slowly emerging across the United States. These centers are designed to improve the patient’s quality of life after a stay in the ICU and assist patients with any adjustments to their “new normal” as they recover. Many patients will need individualized care after their ICU stay and an ICU recovery center usually has an interdisciplinary team that may include a physician, nurse practitioner, pharmacist, physical The final component of the ABCDEF bundle is fami- therapist, dietitian, occupational therapist, and/or ly engagement and empowerment and prove to be social worker [11]. Each of these professionals can a vital piece of the recovery process for the patient. assist in a patient’s recovery in specific areas which Family can be utilized in many ways including obwill ultimately provide optimal patient care. Vantaining baseline information such as medication derbilt’s ICU recovery clinic “identified a high prevahistory, allergies, mental status, and outpatient lence of cognitive impairment, anxiety, depression, pharmacy information. Clinical pharmacists can physical debility, lifestyle changes, and medicationprovide clarity and comfort to the family by updat- related problems warranting intervention [11].” As ing them on medication changes and answering data continues to be collected regarding the utility questions related to medications as they arise each of ICU recovery centers, hopefully this will lead to day. Additionally, reviewing medication discharge expansion of these services to millions of patients instructions and changes that were made with the who are suffering from PICS. patient and their family is an essential duty of the In the setting of an ICU recovery clinic, pharmacist pharmacist as several changes may have been can play several roles. For starters, pharmacists are made due to the patient’s ICU stay. trained to assess patient medications for adverse Furthermore, patient families are likely going to effects, drug-drug interactions, safety and efficacy. identify or notice changes in the patient postIn a small study, it was found that the median numdischarge and can be extremely helpful in asber of pharmacy interventions at an ICU recovery sessing if the patient needs to be seen for PICS. clinic was 4 per patient [12]. These pharmacy interNew symptoms that would indicate the possibility ventions led to the treatment of many medicationof PICS in a post-ICU patient could include new on- related problems as well as the recommendation set confusion, poor sleep patterns, nightmares, for preventive measures such as immunizations. mood changes, and increased difficulty completing Pharmacist can also be useful in recommending activities of daily living [3]. Once again, there is not a medications for newly developed PICS symptoms definitive timeline of when and how symptoms will as treatment of PICS is complex and individualized appear in patients, so logging of changes by family based upon the patient’s symptomology. Accordcan be great tool for the patient’s follow-up apingly, pharmacists can be utilized as an essential pointments. Inevitably, patient recovery is going to member as ICU recovery clinics continue to grow. be a journey that will depend on several factors, but the support of family can certainly improve both outcomes and motivation. |23| www.KPHANET.org

Currently, the only ICU recovery clinic in Kentucky is located at the University of Kentucky in Lexington. Patients who are admitted to the University of Kentucky’s medical intensive care unit (MICU) are screened by the ICU recovery team for risk factors of PICS. If a patient is at risk, a member of the team meets with the patient and family to determine if they are interested in scheduling a follow-up appointment in the ICU recovery clinic [13]. This clinic is also open to referrals from other ICU teams within the University of Kentucky hospital system. At the clinic, the patient is seen by a physician, nurse practitioner, pharmacist, and physical and occupational therapist to assess for PICS and address any concerns that may have arisen since the patient’s ICU discharge.

the pharmacy. In these instances, technicians can inform the pharmacist in order to provide the patient or family with additional resources regarding PICS, if requested.

Due to the rarity of ICU recovery clinics at this time despite the number of affected individuals by PICS, patients and their families can be directed to the Society of Critical Care Medicine Patients and Family portal at sccm.org/myicucare/home. As previously stated, this resource will allow them to connect with a support group. Additionally, there is a guide available to help them understand PICS and their ICU stay [3, 4]. Lastly, the site offers a glossary of terms and a patient communicator app to document PICS symptoms, medications and responses [4]. Hopefully, more resources and ICU recovery In a community or ambulatory setting, similar inter- clinics will continue to be made available. ventions can be made through medication assisted In conclusion, anyone can be affected by PICS as no therapy interventions when an ICU recovery center one anticipates a stay in the ICU. Fortunately, PICS is not feasible for the patient. In these situations, it is a defined syndrome and can be mitigated may be more difficult to ascertain the patient’s rethrough assessing patients for risk factors and the cent ICU stay, but the introduction of new medicautilization of the ABCDEF bundle. Patients and their tion or short fills for some could help the pharmafamilies can be directed to the SCCM website for cist in determining that the patient had a recent additional resources at any time. Additionally, there hospital stay. Also, technicians can be utilized in the are several books, podcasts, and videos available community or ambulatory setting. Many times, paonline to learn about personal journeys of those aftients are familiar with the technicians when pickfected by this syndrome (Table 2). Finally, pharmaing up medications. They may be more willing to cists across the United States can make an impact speak candidly with technicians about their recent on identifying and serving patients affected by PICS hospital stay especially if the patient is a regular at in a variety of patient-care settings. Table 2: ICU Recovery Resources Institution/Organization Society of Critical Care Medicine University of Kentucky ICU Recovery Clinic Lexington, KY Vanderbilt University Medical Center ICU Recovery Center Nashville, TN Eskenazi Health Critical Care Recovery Center Indianapolis, IN Pharmacy to Dose: The Critical Care Podcast (available on Apple Music, Spotify, and online) YouTube

Books

Contact information https://sccm.org/MyICUCare/THRIVE/Post-intensive-CareSyndrome https://ukhealthcare.uky.edu/wellness-community/blog/ critically-ill-patient-finds-heroes-icu Phone Number: 859-323-9555 https://www.icudelirium.org/the-icu-recovery-center-atvanderbilt Phone Number: 615-322-2386 https://www.eskenazihealth.edu/health-services/recoverycenter Phone Number: 317-880-2224 PICS – Aired January 15, 2020 Life After the ICU: A Personal Experience – Aired January 28, 2020 After the ICU: Nancy Andrews at TEDxDirigo Generate Recovering from the ICU: A Survivor's Story In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope by Rana Awdish You Can Stop Humming Now by Daniela Lamas

|24| Kentucky Pharmacists Association | September/October 2020

Table 1: Summary of ABCDEF Liberation Bundle Components Component

Management

Assess, prevent, and manage pain; airway

Potential Medication Considerations What type of analgesia should be used?

Is the patient being managed for pain in the outpatient setting?

Spontaneous awakening and breathing trials

Ex: IV opioids such as hydromorphone, fentanyl, morphine or nonopioid analgesics such as APAP, NSAIDs What medications could aid in helping the patient successfully complete the trials?

Review medications, dosing schedule, and labs (phosphorus, calcium, metabolic alkalosis) that may compromise patient breathing effort

Choice of analgesia and sedation

Consider patient home inhaler(s) or nebulization treatments What is the desired level of sedation and which agents could help?

Assess, prevent, and manage delirium

Ex: Dexmedetomidine, propofol plus component A medications What medications could be contributing to patient delirium?

Early mobility and exercise

Ex: anticholinergics, stimulants, dopamine agonists, high-dose benzodiazepines, corticosteroids, sedatives Evaluate pain control and medications that could increase fall risk.

Family Engagement and Empowerment

Ex: antihistamines, sedatives, benzodiazepines, opioids, antihypertensives Is family available to provide: allergies, medication history, mental status, pharmacy information?

Other Considerations

What is the patientâ&#x20AC;&#x2122;s native language? What is the desired duration of sedation? Will the patient need surgery? Is an awakening of breathing trial coming up? Non-pharmacologic interventions: patient glasses or hearing aids, opening and closing patient blinds at appropriate times of day, monitor noise levels and visual stimuli such as television, visitations with family When will the patient be extubated? Is the patient willing and able to begin to walk?

What is the dynamic of the family communication? Is team communication with the family effective, clear, and concise? Evaluate family coping and support needs

|25| www.KPHANET.org

October 2020—ICU Recovery Challenges 1. What is the estimated percentage of ICU patients who are affected by PICS each year?

7. When should the patient be encouraged to engage in mobility and exercise?

10 – 30%

Once they are medically stable and able to do so

5 – 40%

Within one week

30 – 70%

After being transferred out of the ICU

D. 70 – 95%

D. As soon as they are extubated

2. Which of the following components are included in the definition of PICS?

8. How many ICU recovery centers are located in Kentucky?

Change or worsening of cognition

1 in Louisville

Change or worsening of physical function

2 – 1 in Bowling Green, 1 in Covington

Change or worsening of psychological function

2 – 1 in Frankfort, 1 in Paducah

D. All of the above

D. 1 in Lexington

3. The “A” of the ABCDEF bundle is assess, prevent, and manage what?

9. What resources are available via the Society of Critical Care Medicine Patients and Family portal online?

Pain

Support groups

Sedation

PICS guide

Airway

Glossary of terms

D. A and B

D. Patient communicators app

Two of the above

All of the above

A and C

4. What is being assessed with the “B” of the ABCDEF bundle? A.

Awakening and breathing

Sedation and delirium

Breathing and mobility

D. None of the above

5. Which of the following examples is not relevant to the “C” component of the ABCDEF bundle? A.

Updating the patient family on medication changes

Assessing patient nutrition needs

Recommending analgesia and sedatives

D. Suggesting the patient or family keeps an ICU diary or journal

6. Which type of delirium includes symptoms of irritability, anger, nightmares, and easy startling? A.

Mixed

Hypoactive

Hyperactive

D. Reactive

|26| Kentucky Pharmacists Association | September/October 2020

10. In what practice settings can pharmacists and their technicians identify patients who may be experiencing PICS? A.

Community

Ambulatory

Recovery Clinics

D. In the ICU E.

All of the above

Expiration Date: 10/30/23 Successful Completion: Score of 80% will result in 1.0 contact hours TECHNICIANS ANSWER SHEET. October 2020—ICU Recovery Challenges Universal Activity # 0143-0000-20-010-H05-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D

3. A B C D E 4. A B C D

5. A B C D 6. A B C D

7. A B C D 8. A B C D

9. A B C D E F 10. A B C D E

Information presented in the activity:

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved 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 If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

PHARMACISTS ANSWER SHEET October 2020—ICU Recovery Challenges Universal Activity # 0143-0000-20-010-H05-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________

PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D

3. A B C D E 4. A B C D

5. A B C D 6. A B C D

7. A B C D 8. A B C D

9. A B C D E F 10. A B C D E

Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education. |27| www.KPHANET.org

|28| Kentucky Pharmacists Association | September/October 2020

COVID-19 Vaccine What Pharmacies Can Do Now to Prepare Author: Michele Pinkston, PharmD, KPhA Director of Pharmacy Emergency Preparedness To date, three COVID-19 vaccines have entered Phase III clinical trials in the United States. While it is unknown which, if any, of them will prove successful, there is increasing evidence that there will be an FDA approved or authorized COVID-19 vaccine sooner rather than later. Pharmacists across Kentucky will be looked to as frontline providers of the vaccine. There are many questions about the COVID-19 vaccine including regulatory approval, availability, number of doses, and final storage temperature. While we await answers to these questions, there are a few things that pharmacies can be doing now to prepare: 1. Enroll with the Kentucky Immunization Registry (KYIR) One requirement from DHHS/CDC for participation in the COVID-19 Vaccination Program will be participation in the state or jurisdiction immunization registry. This means that pharmacies must be enrolled with KYIR to order, receive, and document doses of COVID-19 Vaccine. If your pharmacy is already enrolled with KYIR, you do not need to enroll again. If your pharmacy is not enrolled and you want to participate in the COVID-19 Vaccine Program, now is the time to enroll. There are two options for enrolling:



Enroll with KHIE with access to KYIR at the KHIE/ KYIR enrollment Webpage (https://khie.ky.gov/ Get-Started/Pages/default.aspx). Enrolling with the Kentucky Health Information Exchange (KHIE) will establish an electronic connection from your pharmacy electronic health record (EHR) to KYIR. Data flows automatically to KYIR without the need to manually record doses.



This is the preferred method for connecting with KYIR as all data is electronically transmitted. However, this process takes longer to implement due to the testing phase. Most chain/ large retail pharmacies and hospitals are enrolled via a KHIE connection. Enroll directly with KYIR at the KYIR Enrollment Webpage (https://chfs.ky.gov/agencies/dph/ dehp/idb/Pages/kyir.aspx). This enrollment will give your pharmacy manual access directly to KYIR. This is the quickest enrollment as the turnaround time currently is two weeks. However, this option requires documentation be manually entered by pharmacy staff.

If you have questions about enrollment, contact the KYIR Helpdesk: Hours: 8 a.m. to 4 p.m. Monday – Thursday and 8 a.m. to 12 p.m. Friday Phone: 802-564-0038 Email: KYIRHelpdesk@ky.gov (use email option after 12 p.m. on Fridays) 2. Enroll as a Provider in the COVID-19 Vaccination Program (when agreement is available)



To enroll as a vaccine provider, pharmacies must sign a COVID-19 Vaccine Provider Agreement either directly with CDC via a federal pharmacy program or with the state department for public health. CDC/DHHS is currently negotiating with some retail chain pharmacies and independent pharmacy groups such as PSAOs. Any pharmacy not enrolled via this federal program will be asked to enroll in the KDPH COVID Vaccine Program if they want to participate. Currently, KDPH is only enrolling hospital Continued on pg. 41

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|31| www.KPHANET.org

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Welcome new Members We’re so happy to have you! The list reflects new memberships received from July 1, 2020— August 31, 2020.

If you see one of these new members, please welcome them to the KPhA family! Timothy Bailey, London New Practitioner 1st Year

Megan Mier, Buffalo Technician

Nicole Barratiere, Lexington New Practitioner 1st Year

Christina Schreiner Spille, Edgewood Pharmacist

Kathy Detraz, Hopkinsville Technician

Jessica Smith, Elizabethtown Technician

Zachary Grimmett, Belfry New Practitioner 1st Year

Christopher Whitman, Louisville New Practitioner 1st Year

Kayla Janbakhsh, Louisville New Practitioner 1st Year

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https://cmppharma.com/ |35| www.KPHANET.org

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|37| www.KPHANET.org

Rx and the Law This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

denied on September 22, 2020. However, the judge did acknowledge that his previous order was not intended to prescribe the actions that the pharmacy defendants should have taken. The question of whether the actions they did take were sufficient under the law is a question of fact for the jury to decide.

The Corresponding Responsibility regulation does specifically cite pharmacists. However, the assertion by the pharmacy defendants to say that they have no duty here seems to be an extreme position. Pharmacies are registrants too. As registrants under the Controlled Substances Act, pharmacies also have a duty to prevent abuse and The opioid crisis, and the multitude of court cases around diversion of controlled substances. The Administrator of the country that followed from it, have placed additional the DEA has the authority to suspend or revoke a pharmacy's registration if it appears to create a danger to the scrutiny on the duty of Corresponding Responsibility for public health or safety to allow the pharmacy to continpharmacists. This concept is not new. The regulation has been in effect for many years. The regulation states; ue. While the Corresponding Responsibility regulation refers to pharmacists, it seems unrealistic to leave the "A prescription for a controlled substance to be effective dispensing pharmacist unsupported in the performance must be issued for a legitimate medical purpose by an of their duty. The judge's initial ruling also seems to be individual practitioner acting in the usual course of his an extreme position. As is many times the case, the best professional practice. The responsibility for the proper solution is somewhere in the middle. prescribing and dispensing of controlled substances is Pharmacy owners need to be clear with their staff about upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the pre- diversion and addiction prevention. Establishing a culscription. An order purporting to be a prescription issued ture of judicious and sensible dispensing of controlled substances starts with owners and managers of the not in the usual course of professional treatment or in pharmacy. Owners who concentrate on volume will get legitimate and authorized research is not a prescription less discernment from their staff pharmacists as the staff within the meaning and intent of section 309 of the Act will likely feel pressure to fill all controlled substance pre(21 U.S.C. 829) and the person knowingly filling such a scriptions. The DEA believes that the law does not repurported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of quire a pharmacist to dispense a prescription of doubtful, questionable, or suspicious origin. The pharmacist is the provisions of law relating to controlled substancmaking a real-time decision with the conflicting preses." (emphasis added) sures of prevention of diversion or addiction and patient Recent activity in the Multi District Litigation (MDL) court care. It seems unreasonable that the pharmacy has no in Ohio focused on Corresponding Responsibility. Judge duty in this situation. Yes, the pharmacist is on the frontDan Polster issued an order on August 6, 2020 denying line and has to make the decision, but the pharmacy and the pharmacy defendants' motion to dismiss the comits owner create the environment where this decision plaint against them. The pharmacy defendants' motion must be made. The pharmacists canâ&#x20AC;&#x2122;t make these decito dismiss asserted that the duty of Corresponding Resions in a vacuum. Discussion with the prescriber will sponsibility falls on the pharmacist, not on the pharmacy. probably be necessary. Perhaps discussions with the Therefore, the pharmacies had no duty to take any action patient will also be necessary. The pharmacist can then during the opioid crisis. The judge disagreed and denied use this information in conjunction with their professionthe motion. al knowledge, experience and judgment.

CORRESPONDING RESPONSIBILITY

The judge then went on in his ruling to outline what steps the pharmacies should have taken and the information that should have been provided to their staffs. His opinion was very detailed and involved data mining and data analytics. The pharmacy defendants filed a motion to reconsider on August 25, 2020 because they believed the requirements outlined by the judge were excessive and beyond the requirements imposed by statute and DEA regulations. The motion to reconsider was

|38| Kentucky Pharmacists Association | September/October 2020

Another portion of the filings in this case discussed the pharmacy's duty to train their staff pharmacists to properly handle prescriptions for opioids and to establish policies and procedures to prevent their pharmacies from facilitating the diversion of opioids. While this duty is not explicitly spelled out in the DEA regulations, it seems to be implied in the pharmacy's duty to protect public health and safety. The judge's initial ruling went into a lot of detail on what he thought was acceptable

and went far beyond what someone could easily infer from the regulations. The judge stepped back from this initial position when he denied the motion for reconsideration. What can we learn from this case? There will be a continued focus on the doctrine of Corresponding Responsibility going forward. The law continues to evolve and yesterday's solution will not be sufficient for tomorrow. Pharmacists have an independent duty to the patient and are not merely order takers for the physician. Following the physician's orders is no longer a sufficient defense when a patient is harmed by a prescription when the pharmacist could have intervened. The pharmacy needs to create a team atmosphere and assist their pharmacists as they make these important patient care decisions.

Kentucky Professionals Recovery Network (KYPRN) is a free-standing organization that provides confidential monitoring of licensed professionals struggling with the disease of addiction.

www.kyprn.com

References: 1. 21 C.F.R. Section 1306.04(a) 2. https://www.ohnd.uscourts.gov/sites/ohnd/files/ MDL2804_2709.pdf ÂŠ Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company. This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

ATTENTION PHARMACISTS, STUDENT PHARMACISTS AND INTERNS, OR PHARMACY TECHNICIANS: The Kentucky Renaissance Pharmacy Museum Board is recruiting individuals who have interest in serving on our Board. The Board is looking for individuals who are interested in preserving the history of pharmacy in Kentucky (and beyond) and promoting and educating this history to the public. The Board requests individuals who are willing to ATTEND MEETINGS, WORK ON ADVANCING OUR MISSION, TELLING OUR STORY, AND BRING FRESH IDEAS. If you are interested in becoming a member of this Board or have questions, please contact us as noted below; if you have other interests in supporting our mission, please reach out to us as well as noted below: Mike Burleson, President: maburley@hotmail.com | 859-312-1182 Lynn Harrelson, Board Member: lharrelson@seniorpharmacysolutions.onmicrosoft.com | 502-425-8642 A Kentucky Renaissance Pharmacy Museum and Fountain, Inc |39| www.KPHANET.org

Financial forum This series, Financial Forum, is presented by PRISM Wealth Advisors, LLC and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

Rebalancing Your Portfolio Should investors make regular adjustments? Everyone loves a winner. If an investment is successful, most people naturally want to stick with it. But is that the best approach? It may sound counterintuitive, but it may be possible to have too much of a good thing. Over time, the performance of different investments can shift a portfolio’s intent as well as its risk profile. It’s a phenomenon sometimes referred to as “risk creep,” and it happens when a portfolio’s risk profile shifts over time. Balancing. When deciding how to allocate investments, many begin by considering their time horizon, risk tolerance, and specific goals. Next, individual investments are selected that pursue the overall objective. If all the investments selected had the same return, that balance – that allocation – would remain steady for a time. But if the investments have varying returns, over time, the portfolio may bear little resemblance to its original allocation.1 How Rebalancing Works. Rebalancing is the process of restoring a portfolio to its original risk profile. There are two ways to rebalance a portfolio. The first is to use new money. When adding money to a portfolio, allocate these new funds to those assets or asset classes that have fallen.1 The second way of rebalancing is to sell enough of the “winners” to buy more underperforming assets. Ironically, this type of rebalancing forces you to buy low and sell high. As you consider the pros and cons of rebalancing, here are a couple of key concepts to consider. First, asset allocation is an investment principle designed to manage risk. It does not guarantee against investment losses. Second, the process of rebalancing may create a taxable event. And the information in this material is not intended as tax or legal advice. It may not be used for the purpose of avoiding any federal tax penalties. Please consult a professional with legal or tax expertise regarding your situation. Periodically rebalancing your portfolio to match your desired risk tolerance is a sound practice regardless of the market conditions. One approach is to set

|40| Kentucky Pharmacists Association | September/October 2020

a specific time each year to schedule an appointment to review your portfolio and determine if adjustments are appropriate.

Pat Reding and Bo Schnurr may be reached at 800-288-6669 or pbh@berthelrep.com. Registered Representative of and securities and investment advisory services offered through Berthel Fisher & Company Financial Services, Inc. Member FINRA/SIPC. PRISM Wealth Advisors LLC is independent of Berthel Fisher & Company Financial Services Inc.

This material was prepared by MarketingLibrary.Net Inc., and does not necessarily represent the views of the presenting party, nor their affiliates. All information is believed to be from reliable sources; however we make no representation as to its completeness or accuracy. Please note - investing involves risk, and past performance is no guarantee of future results. The publisher is not engaged in rendering legal, accounting or other professional services. If assistance is needed, the reader is advised to engage the services of a competent professional. This information should not be construed as investment, tax or legal advice and may not be relied on for the purpose of avoiding any Federal tax penalty. This is neither a solicitation nor recommendation to purchase or sell any investment or insurance product or service, and should not be relied upon as such. All indices are unmanaged and are not illustrative of any particular investment

COVID-19 Vaccine Continued

vide.

into the program. Enrollment will open for pharmacies soon. Please monitor your email and social media accounts for information regarding pharmacy vaccine provider enrollment.

5. Register your pharmacy on the Vaccine Finder website

3. Communicate with your Local Health Department or Emergency Manager



Health departments will be critical in local vaccine decisions. They need to know if your pharmacy would like to partner with them in the effort. If you want to be involved in local planning for the COVID-19 vaccination program, reach out to your local health department today.



A directory for local health departments with fax numbers can be found here: https:// chfs.ky.gov/agencies/dph/dafm/Pages/lhd.aspx

4. Gather Required Information



Each state will be required to collect vaccination site data from each provider pharmacy. This is information your pharmacy can determine now so you are ready when the time comes to report.



Number of Staff: Frontline pharmacy staff that provide vaccinations will likely be offered the vaccine in the early stages of availability. Be prepared to indicate the number pharmacists, technicians, and staff that want to receive the vaccine at each pharmacy.



Vaccine Storage Capacity: The storage temperature requirement could potentially be refrigerated (2°-8°C), frozen (-20°C), or ultra-cold (60° to -80°C). While it is not expected that individual pharmacies have storage capacity for all vaccines (especially ultra-cold), it is necessary to know how much refrigerated vaccine or frozen vaccine your pharmacy can safely store in compliance with CDC vaccine storage guidelines.



Patient Population: An understanding of the number of patients for whom you can or want to administer the vaccine during operating hours. It will be important to take into consideration your day to day operation as well as any extra vaccination clinics you may want to pro-



Every pharmacy providing ANY type of vaccination (flu, childhood, and eventually COVID) should be listed on the Vaccine Finder website: https://vaccinefinder.org/

Please note the following:  The site has been updated. So, if a pharmacy was previously listed, that information did not transfer to the new site.  All pharmacies must register and be approved to be listed on the site. The registration information is at the very bottom of the main page. Pharmacies will have to be registered if they plan on administering the COVID vaccine when available.  One downside is that any pharmacy approved/ listed must update their information no less than every 14 days or else they will be removed from the site. The process for updating is manual (for most) currently.

Please see the CDC Vaccine Finder Provider Fact Sheet for a brief overview of the Vaccine Finder program. As new information about COVID-19 vaccine is released from CDC and KDPH, KPhA will provide updates for pharmacists through multiple avenues, including email, social media, and the COVID-19 Update weekly e-newsletter. You can also find up to date information on the COVID Vaccine Resource Page of the KPhA website.

|41| www.KPHANET.org

KPhA BOARD OF DIRECTORS

KPERF BOARD OF DIRECTORS

Don Kupper, Louisville donku.ulh@gmail.com

Chair

Bob Oakley, Louisville rsoakley21@gmail.com

Chair

Joel Thornbury, Pikeville jthorn6@gmail.com

President

Secretary

Cathy Hanna, Lexington channa@apscnet.com

President-Elect

Clark Kebodeaux, Lexington clark.kebodeaux@uky.edu

Treasurer

Brooke Hudspeth, Lexington brooke.hudspeth@uky.edu

Secretary

Chris Killmeier, Louisville cdkillmeier@hotmail.com

Treasurer

Joel Thornbury, Pikeville jthorn6@gmail.com

President, KPhA

Lewis Wilkerson, Frankfort rphs2@aol.com

Past President Representative

Kevin Lamping, Lexington kevin.lamping@twc.com Paul Easley, Louisville rpeasley@bellsouth.net

Directors Ronnah Alexander, Providence ralexander@hfchc.net

Sarah Lawrence, Louisville slawrence@sullivan.edu

Jessika Chilton, Beaver Dam jessikachilton@ymail.com

Pat Mattingly, Lebanon pat@patspharmacy.com

Kyle Harris, London kyleharrispharmd@yahoo.com Jacob Barnett, Lexington jacobbarnett15@gmail.com

University of Kentucky Student Representative

Mark Glasper Executive Director mglasper@kphanet.org

Chad Corum, Manchester pharmdky21@gmail.com

Sarah Franklin Director of Communications & Continuing Education sarah@kphanet.org

Cassy Hobbs, Louisville cbeyerle01@gmail.com Thao Le Batovsky, Louisville tle3380@my.sullivan.edu

KPhA Staff

Sullivan University Student Representative

Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Martika Martin, Owensboro Speaker of the House 12marmar@gmail.com Nathan Hughes, Louisville Vice Speaker of the House njhughes1980@gmail.com Trevor Ray, Caneyville trevor@midwaypharmacy.com Cory Smith, Barbourville corysmith6155@gmail.com Misty Stutz, Crestwood mstutz@sullivan.edu

|42| Kentucky Pharmacists Association | September/October 2020

Angela Gibson Director of Finance & Administrative Services agibson@kphanet.org Jody Jaggers, PharmD Director of Public Health jjaggers@kphanet.org Kristen Blankenbecler, PharmD Director of Clinical Outreach kristen@kphanet.org Michele Pinkston, PharmD, BCGP Director of Emergency Preparedness michele@kphanet.org Lisa Atha Office Assistant/Member Services Coordinator latha@kphanet.org

-From The Kentucky Pharmacist, September 1970 Volume XXXIII, Number 9

Frequently Called and Contacted Kentucky Board of Pharmacy

Kentucky Society of Health-System Pharmacists

(703) 683-8200 www.ncpanet.org

P.O. Box 4961

info@ncpanet.org

(502) 564-7910

Louisville, KY 40204 (502) 456-1851 x2 www.kshp.org info@kshp.org

www.pharmacy.ky.gov

Kentucky Regional Poison Center

Pharmacy Technician Certification Board (PTCB)

(800) 222-1222

National Association of Chain Drug Stores (NACDS) 1776 Wilson Blvd., Suite 200 Arlington, VA 22209 www.nacds.org 703-549-3001

State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601

2215 Constitution Avenue

American Pharmacists Association (APhA)

Washington, DC 20037-2985

2215 Constitution Avenue NW

(800) 363-8012

Washington, DC 20037-2985

www.ptcb.org

(800) 237-2742 www.aphanet.org National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314

KPhA/KPERF HEADQUARTERS 96 C Michael Davenport Blvd. Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) info@kphanet.org www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc www.youtube.com/KyPharmAssoc |43| www.KPHANET.org

THE

Kentucky PHARMACIST 96 C Michael Davenport Blvd. Frankfort, KY 40601

Thank you for your support of the KPhA Virtual Annual Meeting & Convention Annual Sponsors



APSC – American Pharmacy Services Corporation



APMS – Alliance for Patient Medication Safety

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Cardinal Health



CMP Pharma

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Compliant Pharmacy Alliance



EPIC



Pharmacists Mutual

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SUNRx

The Kentucky Pharmacist - September/October 2020

Articles inside

Rx And the Law

October CE Article

October Answer Sheet

September CE Article

PTCB

September Quiz