CSE Step-by-Step Guideline

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Clinical Skills Event

International Pharmaceutical Students’ Federation

Step-by-Step Guideline How to Run an Event

Clinical Skills Event

IPSF 2012©

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face Dear IPSFers,

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I am Eric So, from Canada. I have been involved in IPSF for the past five years, one year as the coordinator for Patient Counselling Event (PCE), then one year as the Clinical Skills Event (CSE) coordinator, then three years as the Chairperson of Professional Development. Through running CSE workshops and contests around the world for four years I would like to share with you the experiences and insight gained through shepherding the establishment and growth of CSE in IPSF.

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I sincerely hope you will find this useful and share in the passion of our common profession, Pharmacy.

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Eric. H. L. So B.Sc. (Pharm), RPh Pharmacist

Chairperson of Professional Development 2009-2011

table of

contents 6 Introduction

What exactly is a Clinical Skills Event?

What can a CSE look like?

8 Individual Clinical Skills Event 9 Team Clinical Skills Event 11 Examples of cases 14 Where to start when organizing a CSE?

Set up a suitable date

Define your participants

Find a proper location for your event 16 Case preparation for

Individual CSE

Team CSE 18 Walk-through

Individual CSE

Team CSE 2 Important things you definitely should NOT forget about

Patrons, Auspices, Fundraising and Support

Training of actor

Press relation/Advertisement Evaluation

Step-by-Step Guideline - How to Run an Event

Intro duction

Clinical Skills Event (CSE) was first introduced formally into the International Pharmaceutical Students’ Federation (IPSF) at the 56th World Congress in Ljubljana, Slovenia, with the first ever IPSF individual CSE competition. Since then, it has evolved into both an individual event and also a team event during IPSF’s 57th World Congress in Hat Yai, Thailand. The concept of Clinical Skills, that of using our clinical knowledge to solve drug related problems in the field of pharmaceutical science, is not new, and our American and Australian counterparts have had their own clinical skills competition for a few years now.

This booklet shall help you to first of all get a clear image of what exactly CSE is. Its second aim is to make clear the logistical issues surrounding running a clinical skills event, the cases, other insights, and/or possible concerns that you might have.

WHAT EXACTLY IS A CLINICAL SKILLS EVENT? The Clinical Skills Event (CSE) was a concept developed by the American Society of Health-Systems Pharmacists (ASHP). It was created to encourage pharmacy students to develop their clinical problemsolving, verbal and written communication skills, and to promote the role of the pharmacist in patient care.

Clinical Skills Event (CSE) focuses on helping you to use your clinical knowledge to solve and to improve your patient’s drug therapy. As the world of pharmacy is constantly updating, keeping your clinical skills up-to-date is paramount. Getting involved in CSE is not only rewarding in terms of expanding your clinical knowledge and reviewing clinical guidelines, but also to see how other countries are doing in terms of updating their clinical skills and practice.

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Step-by-Step Guideline - How to Run an Event

individual CSE What can a CSE look like?

Individual Clinical Skills Event A CSE can be held in two ways. First of all, the original way: The lndividual Clinical Skills Event. Here, you have seven participants per session and seven stations where everyone has seven minutes to solve the cases. In general, a contestant must complete all seven test stations. So you see, seven is the magic number in a clinical skills event!

Imagine those boxes as the stations you have prepared. Every participant starts at a station, and then circles around until everyone has completed all stations. If there is an oral station where participants have to interact with an actor physician/patient, you will need a separate room, to ensure that other contestants do not hear. In general, if you have only written stations, all the stations can be staged at one room.

Every participant has seven minutes at each station, so the time you need for the event is at least 49 minutes. If you want to have more than seven participants sessions are repeated as many times as needed or run parallel sessions at the same time. For example for the latter situation, imagine that you have 14 stations setup in the room, two sessions of seven stations can be running simultaneously.

If there is a number of contestants that is not a multiple of seven, eight for example, a 14 stations setup could still be run with only 1 person rotating in one session, and the other seven at the other session.

The time roughly works out to one hour per round, including time to get prepared and time for participants to circle from one station to the next one.

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team CSE Team Clinical Skills Event The second option you have when you organize a CSE is the Team Clinical Skills Event.

Scenario one with no patient/physician interview This is a little different than the individual CSE. Teams are formed in pairs or up to a group of four people. The team receives, on a set date, tthe case, and all instructions and references they need electronically or in hard copies. Then give the groups about 36 to 48 hours to solve the case and submit their answers. During this time the groups can search the internet, read references, and do whatever they want to solve the case. Of course these cases are more complex than the individual CSE cases.

Scenario two with live patient/physician interview You can also add a live session with an actor in the event. This was done in the 58th IPSF World Congress in Egypt. The actor plays a role according to your case (let’s say the doctor or the patient) and in the live session the groups can ask questions in order to get the necessary information that is missing to solve the problem. It is best to have this session in the middle of the given time. That way, participants have half of the time to find out what answers they still need, and after this session they can still include those answers in their solution of the case.

For example, the team CSE at the World Congress in Egypt had the following structure. The teams were given a written case (see appendix) with patient information and information about the chief compliance and lab work. They were given 3 days to do research about the disease and possible treatment. On the third day each team booked a time, 10 minutes each, with the actor-patient and actor-doctor to interview and ask any further questions. Through this, the teams were able to obtain more information that could affect their suggested treatment and /or catch any drug related problems.

Afterwards the teams were given 24 hours to write the chief recommendations and identify the drug related problems they had encountered.

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Step-by-Step Guideline - How to Run an Event

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Clinical Skills Event

Examples of cases

Case 5: 1 Additional Reference Many medications commonly interact with grapefruit juice and grapefruit products. For the following list of medications, please indicate whether or not you, the pharmacist, would warn the patient about the consumption of grapefruit juice or grapefruit products. Please mark yes or no in the following table.

Medication

Yes

Simvastatin

x

Captopril Metformin Felodipine Carbamazepine

No x x

x x

Bonus: Cicle the correct answer and fill in the blank.

Grapefruit juice and grapefruit products will inhibit/induce the enzymes in the intestines and liver, specifically the __cytochrome (CYP) 450 3A4__. Due to this interaction, this will increase/decrease the drug levels any medications that interact with grapefruit juice, leading to increased/decreased effects of the medication.

As you can see with this case, the subject involved is pharmacokinetics, specifically with drug metabolism. The objective here is for the candidate to identify which of the listed drugs interacts with grapefruit. In the bonus question section, the concept of why grapefruit does interact with medications is probed. grapefruit does interact with medications is probed.

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Step-by-Step Guideline - How to Run an Event

Examples of cases Case 6: 1 Reference and calculator Stephanie Brown has come by the pharmacy with the following prescription for her daughter: Global Medical Clinic #502-1152 6th Street Patient: Erika Brown Address: 1949 London Street Rx Date: August 3, 2011 Amoxicillin 100mg TID x 10 days Dr. H. Lee # 5311

She explains to you that her daughter has been extremely irritated and says that she complains of going to the washroom all the time. When speaking with Erica, she tells you that when she does go to the washroom, there’s a burning sensation and it’s really uncomfortable. She is also quite embarrassed, but she is unable to swallow tablets or capsules.

The following is her most updated medical profile: Name: Erica Brown (female)

Notes:

Date of Birth: October 23, 2002

Medical Condition

Weight: 36 kg, August 2011

Healthy

Height: 128 cm, August 2011 Allergies: penicillin, anaphylaxis when she was 3 years old

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Present Drug Therapy: None

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Clinical Skills Event Case 6: 1.

Please identify any drug-related problem(s), both potential and actual.

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Potential (1) : risk of anaphylaxis (1) secondary to previous reaction to penicillin (1)

● Potential (1): risk of ongoing urinary tract infection (1) secondary lower than recommended dose of amoxicillin (1)

2. If there were drug-related problem(s) identified in part 1, please provide recommendations to resolve the drug-related problem(s). If you would like to recommend a different therapy, please include drug name, dose, dosing regimen, duration. This is the only answer accepted for full marks: ●

Change the amoxicillin to sulfamethoxazole/trimethoprim 40mg/8mg (1) suspension (1)

● Dose range: sulfamethoxazole 450 – 800 mg/trimethoprim 90 mg – 160 mg equivalent to 11.25 ml – 20ml of the suspension for each dose (do marks for giving a range, must provide a specific dose within the range(1) ●

Dosing regimen: twice daily (1)

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Duration: 7 – 10 days (1)

● No marks for this question at all if the dose exceeds 160 mg trimethoprim (20mL) as this would exceed adult dose

This case revolves around paediatric concerns in pharmaceutical practice such as therapeutics and dosing. The subject being paediatric therapeutics, the case has several objectives: (1) to identify the drug related problem of drug allergy (2) dosing by weight (3) therapeutic alternatives.

Some of you might think that the cases are easy to solve and that they can be solved without any help from references.

However, IPSF does provide all relevant references and background information regarding the case since there are participants from around the world with different levels of clinical exposure and different comfort levels for English. To make it more challenging for the participants, you could choose not to provide references.

For all cases with answers from past IPSF World Congress Individual CSE, please see Appendix I.

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Step-by-Step Guideline - How to Run an Event

Where to start?

1. CHOOSING A DATE The first thing after you have decided to organize a local or national CSE is deciding when to do so.

Maybe you have a national congress where you have an afternoon full of workshops where the CSE will fit wonderfully.

It could also first be organized on a local level in your school of pharmacy. Another option is to talk to your teachers and include the event in the schedule and have every student participate in it, or else make it an optional class in the afternoon or on a weekend.

Be creative! But also keep in mind that there might be events that people don’t want to miss, like a soccer game on TV or anything else that is important in your area. Please check the dates carefully before you organize your CSE. If you don’t, you might end up without enough participants!

2. DEFINING YOUR PARTICIPANTS After you have found a suitable time, you have to decide who shall participate in your event. It makes a huge difference if you want to organize an event for students who are in their first or second year of pharmacy, or if they are about to be finished. Depending on who you want to address, you have to adapt your cases.

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3. FINDING A LOCATION The location should be a quiet place and large enough where you can have a set of tables for the 7 stations. If you do want to have “live” station(s), with a live actor, then you will need to have a quiet soundproofed room, preferably close to the main room.

Each station is allotted 7 minutes.

Equipment required: ●

A person to be the timer

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A bell

● Invigilator to keep watch and herd people from station to station; more may be needed if stations are spread out in different forms (several oral cases for example) ●

Printed cases and references

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Stationary (pencils or pens)

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Numbered stations

Ensure that all your required equipment and the set up of the stations are all well prepared and ready to go before the event begins. Example for oral case station setup:

For Team CSE

A quite private room for the patient interview is all that is needed in terms of logistics. You may also consider establishing a central location, such as a right after any works to handout the case, either electronically, or by paper form. It is highly suggested that you make participants submit their final answers in electronic format to an email account set up for the purpose.

For the patient interview, if you do choose to have one, you could provide the participant with some new data if needed, for example any new laboratory data. This, however, is not mandatory.

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Step-by-Step Guideline - How to Run an Event

Case

preparation 1. INDIVIDUAL CSE The case and the structure of the contest are based on principles of Objective Structured Clinical Examination (OSCE) used in Canada. Each case should revolve around a clinical subject and have clear objectives in what drug-related problems the contestants need to identify and solve.

Considering each case is only 7 minutes long, it is highly suggested that one case should only revolve around one clinical subject, such as: pharmacology, therapeutics, paediatrics, geriatrics, pharmacokinetics, etc. You may consider having multiple choice answers, and/or written response.

Also consider who your main participants are. Write cases that are suitable for their knowledge level.

Do vary the difficulty of the 7 cases. From experience, have one or two “simple” cases and one very challenging case to stimulate your participants.

Another aspect in the case preparation is that you can have written cases as well as “oral” cases with live actors presenting the case and the contestant will provide the answer verbally. For consideration regarding training the actor, please see IPSF Actors Guideline.

And of course you have to remember that there is a CSE Coordinator who is always here to help you with the cases.

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2. TEAM CSE Overall, the creation of the team event case is similar to the individual event cases. The case should be based on principles of Objective Structured Clinical Examination (OSCE); each case should revolve around several clinical subjects and have clear objectives, in which the contestants need to identify and solve the drug-related problems presented.

Mirroring cases in clinical setting, set up a patient profile with clinical information (medication history, current and past medication list, weight, laboratory value, allergy profile etc.) You may wish to release all these information at the onset or reserve some information for the patient actor interview.

There should be several drug related problems in the case, to which each team should be able to (1) identify the drug related problems, (2) state the problem in a professional manner (considering pharmacists do work with other health professionals, and will need to defend our suggestion), (3) rank the priority of each drug related problem from the most severe/urgent to the least and (4) suggest the most suitable solutions that are safe, effective and supported by clinical literature and guidelines.

Also consider what resources you use. It is easier to use the most up-to-date therapeutic guideline as the baseline. As different guidelines from different nations have different therapeutic approaches and recommendations, use references that come from your national health association to be consistent with therapeutic guidelines of your nation, or if the event is multinational, use international and reputable journals such as the New England Journal of Medicine or The Lancet.

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Step-by-Step Guideline - How to Run an Event

Walk-through individual CSE

Organise a sign-up sheet of those who are interested and set a deadline for students to sign up.

Assign the time for the participants, taking into consideration that 7 participants will require a 1-hour block. All relevant materials shall be provided, contestants should not be allowed to bring in their own resources or materials for the event.

Once they walk in, they should be seated in 7 “stations” where the printed cases are laid out with pencils, references and calculators if needed.

The 7 stations are separated from each other, and are numbered 1 to 7. The printed case and the required references are placed faced down on the table.

Before contestant starts, the rules and procedures are explained: ●

Write down their name on the page (once they start - and can turn over the page).

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Do not start until the timer says so.

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Read the instructions clearly and answer on the page only.

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Do not write on the reference pages.

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For each case, the contestants will get 7 minutes.

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The timer will ring the bell to notify the contestant that they have 1 minute left.

● The timer will ring again at the 7 minute mark; at that time, the contestants will put their pen and paper down, remain seated, and hand the case to the invigilator. ● Once the volunteers have received all the cases, the contestants will get up and move to the next station. Contestant from station 1 will move to station 2, and contestant at station 2 will move to station 3, etc. ●

The stations are repeated until everyone has gone through all 7 stations.

After the contestants leave, you can begin with the next block, and/or you can begin marking.

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Walk-through team CSE

Here you also have to first organize a sign-up sheet where people have to sign up (best already in formed groups) before a certain date. When they have done so, arrange a meeting where you explain the rules and maybe also hand out the cases or, if you want to send out the cases electronically please collect the e-mail addresses there.

As soon as the teams have the cases and all the material you want to give them, the time starts and the groups have around 36 to 48 hours.

If resources allow for an actor, set up an allotted time (1 hour) for each team to ask questions from the patient actor like in a clinical setting. The time for this should be at least one day after the release of the case and at least one day before submission. This will allow for proper time for participants to research appropriate questions to ask the patient actor and process the answers received from the patient actor. You may wish to have all the teams gather in the same time so they can hear all the questions or answers, or you may have separate sessions. This will depend on how much time is available, and what kind of experiences you want the participants to have. Having a shared question period with the actor will help stimulate learning, while having separate question period is a more competitive format for CSE.

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Step-by-Step Guideline - How to Run an Event

Things

you definitely should NOT forget about 1.Patrons, Auspices, Fundraising and Support Approach your faculty, student pharmacy organization, professional pharmacy organization, and the government ministry to provide you with funding, judges, and/or material for CSE. Certain companies, such as pharmaceutics, or drug information companies are also good prospects for sponsorships.

Ensure a proper project proposal is written, entailing the goals of having CSE, and why you believe that CSE is important for pharmacy students.

To ensure participation of your patrons and to establish a relationship with them, invite them to be guest judges for CSE. If your faculty is involved, have the faculty write or review the case beforehand.

You can utilise the sponsors to provide the prizes of the event. Prizes can include reference books, a free registration to IPSF Congress (of course the winner then has to participate in the international CSE held there) or even a trophy.

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2. Training of actor If actors are needed, please select one, preferably one who is near graduation, or has already graduated for greater ease. However, if you choose to use a student or a professional actor please go over the clinical points of any verbal case to ensure the case is clear. For more insight please refer to IPSF’s actor’s guideline.

3. Press relation/Advertisement To generate more interest and response from your students and your faculty, advertise and promote the event at least one to two months in advance. Spread the word to students and your faculty through mediums like newsletters, student pharmacy organisation websites, flyers, notices etc. Promote the event along with the major prize. This will certainly entice participation.

After the event is completed, dedicate a newsletter edition to report on CSE. You can ask the winner of the event to write an article about their experience to be included into the newsletter. You can also ask the main organiser of the event to report on how they thought the day went. This will generate interest for future events. Include photos of the event and a list of all the participants.

If you plan to send the winner of CSE to the IPSF World Congress, it is also worth asking them to write an article reporting about their participation. This will promote CSE as an international event, enticing more sponsors in the future.

4. Evaluation For the benefit of the participants, the evaluators should provide written/verbal feedback to the participants, especially if it is an oral case or a team case. The answers should also be provided to give insight to the participants.

With written cases, no feedback is necessary as the adjudication is done point by point as seen in sample cases provided in Appendix I. With oral cases, contestants would benefit from written feedback about how well they: (1) identify the drug-related problem(s) (2) provide a therapeutic alternative that is necessary, safe, and effective, and (3) verbally transmit in a succinct, and professional manner.

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Acknowledgement Many thanks to the Melissa Teo, pharmacist and Clinical Skills Event Coordinator 2011-2012, for her valuable input and help. Also I would like to acknowledge the IPSF’s Editorial Board, and Alexandra Marques, Chairperson of Publication and Media 2012-2013, for their wonderful publishing and editorial work. Finally, I would like to thank all the past CSE participants who have participated and attended past CSE workshop and contest, without you, your enthusiasm and passion, this guideline would not be possible.

Viva la Pharmacie!

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International Pharmaceutical Students’ Federation