In the next couple days, you will receive your "official" WMSHP ballot in the mail! The ballot may be mailed back to Brad Miller, WMSHP Secretary; handed in to an Executive Board member; or turned in at the November WMSHP meeting in Kalamazoo. There won't be extra ballots available at the monthly meeting, so keep that in mind. Also, note that we cannot accept votes that are faxed or emailed.

Try to make it to the MSHP Annual Meeting being held November 6^th at Rock Financial Showplace in Novi. There are a variety of topics including and adult, child, and infant CPR course for both Pharmacy Technicians and Pharmacists. You can register on-line at http://www.michiganpharmacists.org.

Join us at our next monthly meeting where Sandra Chase will be discussing "Recent Developments in the Treatment and Management of Atrial Fibrillation” at the Food Dance Café in Kalamazoo.  

See you then

President Elect

Adam Drzewicki graduated with his Pharm.D. from the University of Michigan in 2000.  After graduation, he completed a Pharmacy Practice Residency at Parkview Hospital in Fort Wayne, Indiana.  He then accepted a clinical pharmacist position in cardiology at Borgess Medical Center in Kalamazoo.

Board Members 

Ben Mgboh is a graduate of Purdue University. He completed a PGY1 residency in pharmacy practice at Spectrum Health. He is currently employed at Spectrum Health and his interest areas include cardiology, critical care and emergency medicine. Ben is currently an associate member of ACCP and is looking forward to more involvement with WMSHP. 

Kym Moline (Incumbent) works as a clinical pharmacist at St Mary's Health Care in Grand Rapids.  Kym is an adjunct instructor for Ferris and a precepts pharmacy externs and residents. She received her B.S and Pharm.D. degrees from Ferris and M.S.A. from Central Michigan University. 

Sarah Paulson (Incumbent) attended Ferris State University and graduated with her Pharm.D. in 2005.  She completed a pharmacy practice residency at St. Mary's Health Care in 2006.  She is currently a clinical pharmacist at Saint Mary's Health Care.  Sarah has been a member of WMSHP since 2005 and has served as a board member since June 2007.  She also has membership with ACCP, ASHP, MPA, MSHP, Phi Lambda Sigma, and Lambda Kappa Sigma. 

Kristina Rowley completed her Pharm.D. training at Ferris State University.  She completed her PGY1 residency at Borgess Medical Center in Kalamazoo, MI.  Then, she completed her PGY2 residency with a specialty in Ambulatory Care at William Beaumont Hospital in Royal Oak, MI.  She looks forward to joining her practice site at the Kalamazoo Center for Medical Studies Clinic as an Assistant Professor of Pharmacy Practice with Ferris State University.   

Abby Sturm graduated from Butler University with her Pharm.D. in 2004. Post-graduation she completed a PGY1 residency and PGY2 residency in Internal Medicine/Family Medicine at Clarian Health Partners in Indianapolis. After residency, Abby worked as a clinical pharmacist on a med/surg unit and adjunct faculty at Mercy Mt. Airy Hospital and the University of Cincinnnati - College of Pharmacy in Cincinnati. Over the past few years, she has enjoyed participating in a variety of teaching environments, precepting students, and working in a Coumadin clinic.  Abby and her husband moved to Michigan in the spring of 2008.  She is currently a inpatient pharmacist at St. Mary's Health Care in Grand Rapids.  

Technician

Aaron Britton began working as a Pharmacy Technician at Kay Pharmacy in 2000 and became a Certified Pharmacy Technician in 2003. In 2006, he began working as a technician at St. Mary's Healthcare where he was trained in sterile products and hazardous medication compounding and served on several committees. He recently joined Spectrum Health Butterworth Pharmacy as the Sterile Products Technician Supervisor. In 2008, he began pre-pharmacy coursework at Grand Rapids Community College.

Wendy Benkert is a lifelong resident of West Michigan, Wendy completed her pharmacy technician training at Baker College of Muskegon in 2000. She has been employed at Mercy Health Partners as a Certified Pharmacy Technician since. Wendy primarily works as an IV Technician, but also assists with peer interviewing, technician competencies, and USP 797 compliance processes.  

Marijke Rathke has been employed as a pharmacy technician at Bronson Methodist Hospital since 1998.  In 2004, she became a Certified Pharmacy Technician and in 2005, advanced to a Level III pharmacy technician in which she began working on the nursing unit as a decentralized technician.  Marijke is currently taking pre-mortuary courses at Kellogg Community College and is a member of the Everest Institute Advisory Board for Pharmacy Technicians.

Susan Thomas: After returning to her hometown of Kalamazoo in 2002 and working as a CENA, she enrolled in Olympia's Pharmacy Technician Program. She graduated at the top of her class, earning the opportunity to extern at Bronson Hospital. She became certified and took a full time position with Bronson upon completion of her externship in November of 2004. While working in the inpatient setting she was able to train in multiple areas of the pharmacy and be a part of the peer interviewing team. In April of 2006 she moved into a position in Bronson's Outpatient setting. She continues to attend education seminars and pharmaceutical dinners to further her knowledge, and is an active technician preceptor.
 
Stephen Wolthuis has been employed as a Pharmacy Technician at Bronson Methodist Hospital inpatient pharmacy since 2004 and has been a certified technician since 2007.  He recently obtained Technician Level III status.  He is trained in a number of areas including unit dose, IV, supply (Pyxis), decentralized technician, and medication reconciliation.  His primary role is as an emergency room medication reconciliation technician.  In this capacity he has helped develop and further Bronson Pharmacy's role outside of pharmacy. Along with that he frequently precepts both pharmacist and pharmacy technician students in the medication reconciliation process.  He is currently taking nursing prerequisite classes at Kalamazoo Valley Community College.  As well, he is the co-chair of the department's Shared Governance Council and anticipates chairing the council in 2010.

Soon we will be electing new officers for the 2010 year.  Each active WMSHP member will be mailed an official ballot. The ballot may be mailed back to Brad Miller, WMSHP Secretary, handed in to an Executive Board member, or turned in at the October WMSHP meeting in Grand Rapids or the November WMSHP meeting in Kalamazoo. To eliminate the possibility of voting multiple times, there will not be extra ballots available at the monthly meetings. Please do not attempt to fax the ballots. To verify that WMSHP has your current address, log in to our website at wmshp.net and select "Update Address". 

In October, please join us at the Lacks Grand Room at Saint Mary’s Health for a talk on Dyslipidemia.  Kristin Smith and Matt Moran will be presenting an overview of lipid physiology, guidelines and pharmacotherapy.

Even though some of us may feel that summer has barely begun, August is coming to a close! It is hard to believe that it is time to ‘prepare’ ourselves for cooler days and evenings even though we seem to have not ‘heated up’ this summer!

This year, WMSHP completed our First Annual Summer Outing! Ryan Bickel, general member, organized and facilitated this event that occurred on Wednesday 7/29/09. Over 80 people (WMSHP members, prospective members, and their families) attended a baseball game at Fifth-Third Ballpark in Grand Rapids. The West Michigan Whitecaps hosted the Burlington Bees. I loved this outing because we all had a chance to catch up on peoples lives, see how their summer’s were going, and meet their family members! I am hopeful that an event like this can continue year after year. I would also like to take this time to thank Ryan Bickel for his efforts in organizing this event

During the summer the WMSHP Executive Board has been busy preparing for the year ahead. We are currently seeking nominations for Executive Board members. According to the WMSHP bylaws, only active members of WMSHP may be nominated for executive board positions. If you are interested in being a board member or know of other interested candidates, please submit their name, contact information, and a brief description of current practice and professional interests to WMSHP Secretary, Brad Miller, at email: webmaster@wmshp.net.

Happy final days of Summer and I look forward to re-convening in the Fall with our first meeting scheduled September 10th, 2009.

Spring has sprung and with the arrival of Spring comes the hustle and bustle of Spring time activities!  Please try to fit our April meeting into your busy schedule as we have two great topics from two of our area Pharmacy Practice Residents:  These topics are:  "Evaluation of Haloperidol Continuous Infusions in Critically Ill Patients" and "The Relationship Between Cumulative Aminoglycoside Doses and Renal Impairment in Adults with Cystic Fibrosis". 

Also, we are currently holding nominations for an open board member position as we have had a member of our board resign due to relocation reasons.  This would be an 18 month commitment.  If you have someone you think would be a great candidate, please contact myself or another board member. 

Thanks and Happy Spring!

On Monday Feb 2nd, 2009 the bucktoothed rodent known as Punxsutawney Phil saw his own shadow, which means, if you believe in this sort of thing, we can expect six more weeks of wintry weather. For us in Michigan, I have a feeling this will come to be a truth!

Greg Baron, our Director of Governmental Affairs for MPA, is looking for individuals in each local and regional association that he can send information regarding proposed rules, legislation and fundraising events that should and would be of interest to pharmacists. His hope is that these individuals would then share the information with their membership and help formulate responses with him. If interested in being a contact for Greg, please let me know.

In March, we look forward to meeting to discuss the topic of "Inpatient Glycemic Control". Please join us at the Bistro Bella Vita Downtown in Grand Rapids!

As we all continue to stay safe and warm in this bitter cold I had the pleasure of attending both my first MSHP Committee Day as well as my first MSHP Board Meeting! Areas of discussion at Committee Day included (but was certainly not limited to!) forming a list serve for Michigan Residents on the MPA website, organizing a networking location for residents at future ACE and ASHP meetings, as well as providing information for the underinsured residents in Michigan on where they may obtain assistance for both medical treatment and medication assistance. Participating in these events was extremely inspiring and I look forward to working with all of the great pharmacy colleagues we have in Michigan!

Our MSHP President Jim Lile discussed his theme for 2009 which includes "membership participation". This can mean anything from taking part in a small task needed to be completed to sharing and engaging others in MSHP. As a reminder, the ACE Meeting will be held this year from 2/27-3/1/09 at the Detroit Marriott at the Renaissance Center. What a great way to participate and network with other Michigan Peers!

Please join us on February 19th (note this is the 3rd Thursday of the month) at the Radisson in Kalamazoo Michigan. Laura Aykroyd, PharmD, BCPS will be discussing "Achieving Blood Pressure Control in Severe Hypertension".

Until then, please stay safe and warm!

In the January WMSHP Newsletter, Brenda (Schulz) McCracken, a PGY-1 Pharmacy Resident at Spectrum Health, writes about managing hyperglycemia at her institution using basal-bolus insulin order sets.

_________

Importance of Inpatient Hyperglycemic Management

Brenda J. (Schulz) McCracken, PharmD
_________

When insulin is ordered for a patient who has high blood glucose levels, practitioners tend to think that the patient must have a history of diabetes mellitus (DM). However, this is not necessarily true. In a study by Umpierrez et al (2002), hyperglycemia was present in 38% of patients admitted to the hospital, of which 12% had no history of DM before the admission.1 If the patients do not even have DM, why are their blood glucose levels elevated and why do practitioners bother initiating the patients on insulin therapy while in the hospital? Will high blood glucose levels for a few days really affect anything?

It has been shown that hyperglycemia may be an independent risk factor for an increased risk of infection.² In fact, patients with poor glucose control (at least one blood glucose value >220 mg/dL) undergoing major cardiovascular or abdominal surgery are at nearly 6 times the risk of serious postoperative nosocomial infections compared to patients with adequate blood glucose control (all blood glucose values ≤220 mg/dL).² Hyperglycemia can also lead to increased morbidity and mortality in patients undergoing coronary artery bypass grafting and in patients with stroke.^2-5

A landmark study by Van den Berghe et al (2001) showed that maintaining controlled blood glucose levels via insulin continuous infusions significantly improved clinical outcomes among critically ill patients.^6,7 This trial demonstrated a 43% reduction of intensive care unit (ICU) mortality and a 34% decrease in overall hospital mortality in patients whose average blood glucose levels were maintained at 103 mg/dL, with a target range of 80-110 mg/dL. The strict control of blood glucose was associated with fewer blood stream infections, reduced frequency of neuropathy, lower incidence of dialysis-dependent renal failure, fewer blood transfusions, and less need for mechanical ventilation. In addition, more recent studies have shown that poor blood glucose control is related to adverse outcomes, including mortality, infectious complications, longer hospital stays, and more costly care.⁶

Although attention is often focused on controlling blood glucose levels in patients undergoing major surgeries and patients in the ICU, hyperglycemia is actually a major issue for all other inpatients as well. In fact, it is normal for many patients to have what is termed “stress hyperglycemia,” which is elevated blood glucose levels associated with acute illness.⁶ The body naturally increases blood glucose levels in response to injury, stress, certain medications, severe illness, or surgery. Even though hyperglycemia may be a natural response to illness for some patients, numerous studies have clearly shown that uncontrolled hyperglycemia negatively affects patient outcomes.^2-7 As a result, tight glycemic control for all inpatients is becoming a healthcare priority and a standard of care.⁶ The recommended targets for blood glucose levels in hospitalized patients according to the American Diabetes Association are shown below in Table 1.⁹

Table 1⁹

Patient Population	Goal Blood Glucose Levels
Critically ill patients	As close to 110 mg/dL as possible and generally <180 mg/dL
Non-critically ill patients	Pre-meal (fasting): As close to 90-130 mg/dL as possible and generally around 110 mg/dL Postprandial: <180 mg/dL

In response to research showing the significant benefits of controlling inpatient hyperglycemia, Spectrum Health has recently implemented new basal-bolus insulin order sets. In addition, all sliding scale insulin order sets have now been officially eliminated at Spectrum Health in order to provide tighter glycemic control for our patients through evidence-based medicine. Basal-bolus insulin regimens more closely mimic the body’s natural physiologic secretion of insulin (Figure 1) and provide continuous 24-hour coverage with basal insulin (i.e. insulin glargine). Also, basal-bolus regimens use a proactive rather than reactive approach to prevent future episodes of hyperglycemia. On the other hand, sliding scale regimens did not provide any insulin to patients until their blood glucose levels were already significantly elevated and the rapid-acting insulin doses often over-corrected the blood glucose level, resulting in undesirable frequent episodes of hypoglycemia.

Fear of hypoglycemia is the primary barrier to achieving target blood glucose levels in patients.⁶ Many healthcare providers are more concerned about avoiding hypoglycemia rather than detecting and controlling hyperglycemia, which is potentially the more profound threat to inpatient safety.⁶ Instead of reducing insulin therapy to avoid hypoglycemia, several strategies can be used to prevent it, such as increasing the frequency of blood glucose monitoring, establishing higher thresholds for withholding insulin doses, and adjusting for changes in the patient’s medical status and nutritional intake (i.e. new NPO status, interruption of TPN or IV dextrose infusions, tapering of steroid medications, etc).

With strict hyperglycemic management and the appropriate use of insulin therapy, Spectrum Health can reduce hospital lengths of stay, decrease costs, improve therapeutic outcomes, and prevent patient mortality.

 

References:

1. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002 Mar;87(3)978-82.
2. Pomposelli JJ, Baxter JK 3rd, Babineau TJ, Pomfret EA, Driscoll DF, Forse RA, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr. 1998 Mar-Apr;22(2):77-81.
3. Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003 May;125(5):1007-21.
4. Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ. 1997 May 3;314(7090):1303-6.
5. Jorgensen H, Nakayama H, Raaschou HO, Olsen TS. Stroke in patients with diabetes. The Copenhagen Stroke Study. Stroke. 1994 Oct;25(10):1977-84.
6. Hirsch IB, Braithwaite SS, Verderese CA. Practical management of inpatient hyperglycemia. Lakeville (CT): Hilliard; 2005.
7. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67.
8. Ergun-Longmire B, Ten S, Maclaren N. Management of type-1 and type-2 diabetes in children. In: New M, editor. Pediatric endocrinology. 2005 May 5. Available from: http://www.endotext.org/pediatrics/
9. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2005;28:S4-S36.

Once again, it is time for our second session of WMSHP. I hope you all had a good holiday season. I can’t believe how quickly 2008, and my term as WMSHP President, has passed. It has been a great experience to serve you, the members of WMSHP, this past year.

I’d like to welcome 4 new board members to the WMSHP Executive Board. Angela Green (Mercy Health Partners), Andrea Goodrich (Saint Mary’s Health Care), Kali Schulz (Ferris State University), and Bridgette Sharif (Borgess Medical Center) were all elected to the board in our general November election. Current board member, Natalie Paul (Spectrum Health) will serve as our President-Elect for 2009 and Brad Miller, also from Spectrum Health, will continue his role as WMSHP Secretary. Thanks to everyone who participated in the voting process.

Please join us at our January meeting. Please note that the January meeting has been scheduled for January 15. John Jameson, PharmD, Professor-Pharmacy Practice, from Ferris State University will discuss “Management Problems in Diabetes.”

Also, please see our website (www.wmshp.net) to determine if your membership is ready to expire. To do this, click on “Update Address” which you can find in the left-column, then enter your membership number. If you receive the newsletter via email, you can check your membership expiration date by clicking the link on the top of newsletter. 

Remember to Vote: The ballots are out! By now, you all should have received an official WMSHP ballot in the mail. The ballot may be mailed back to Brad Miller, WMSHP Secretary, handed in to an Executive Board member, or turned in at the November WMSHP meeting in Kalamazoo. There won't be extra ballots available at the monthly meeting, so keep that in mind.

MSHP Annual Meeting: Try to make it to the MSHP Annual Meeting being held November 14 at the Radisson Hotel in Lansing. There are a variety of topics for both Pharmacy Technicians and Pharmacists. You can register on-line at www.michiganpharmacists.org.

Join us at our next monthly meeting where Kevin Hess, MD will discuss "Similarities and Differences Among SSRI's for the Treatment of Depression." The meeting will be held at the Sol World Cafe inside the Radisson Plaza Hotel in Kalamazoo