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Systematic Approach
( 7steps)

Step 1: Identify the requestor and establish timeframe
Step 2: Obtain background information and define informational need
Step 3: categorize the ultimate question
step 4: develop and conduct an efficient search strategy
step 5: evaluate, analyze and synthesize relevant literature into a response
step 6: communcation response
step 7: conduct follow up


Step 1: Identify the requestor and establish timeframe

a. Requestor
i. Healthcare professional vs. Consumer
ii. Information should be appropriate for requestor’s level of understanding
b. Timeframe for response
i. Urgency of request
ii. Determine how to deliver response


Step 2: Obtain background information and define informational need

a. Establish context of the question
i. General information vs. patient specific
ii. If patient specific, consider the following:
• patient demographics ex) age, gender, weight, height, race, ethnicity, etc
• health problems or conditions; primary diagnosis
• end organ function
• allergy history
• prescription and OTC medications
b. Determine why the question is being asked
i. Gather as much information as possible
ii. Sufficient backgrounds is definted by the situation
c. Important to have a clear understanding of situation
d. “Real” question being asked may be buried in original question- determine the "ultimate" question
e. Type of questions ask depend on the request - Sample Background Questions/Considerations by Classification Type
• Drug Identification
 Where the patient is from?
 Has there been an ingestion?
 Who wants this information and why do they want the information?
 Where did they get the product?
 What does the patient believe they are taking it for?
 What is the dosage form, color markings, size, etc?

• Pharmacokinetics or Dosing
 Patient compliance
 Patient’s age and gender
 Patient’s weight (fluid overload vs obesity)
 Patient’s end-organ function
 Concomitant medications/disease states
 Nutritional status – What are the patient’s dietary (and alcohol) habits?
 Patient’s condition
 Previous drug concentrations and timing of the concentrations
 Route of administration, dose of the drug, and administration schedule

• Adverse Drug Reaction
 Route of administration, dose of drug, diluent, duration of therapy, and administration schedule
 A list of all other medications which the patient has taken during the previous 2 weeks
 Onset, duration, severity of reaction
 Changes in soaps, lotions, perfumes
 Changes in diet
 Concomitant diseases and other health conditions
 Known allergies and their manifestations

• Stability or Compatibility
 Number of peripheral lines, central lines, etc.
 Y-sites, IV piggyback, in-line filters
 Diluents of each medication
 Type of tubing
 Suspected contact time of the agents

• Drug-drug Interactions
 Description of the interaction – What event(s) suggest that an interaction occurred?
 All current medications including dose, route, duration, and sequence of administration
 Has the patient received this combination or similar combination in the past?
 OTC medications
 Patient’s condition and other health problems


Step 3: Categorize the ultimate question

a. Serves to refine and understand the request
b. Also serves to define the scope of the search needed
c. Example classifications below (this is NOT a comprehensive list)

• Adverse Drug Reaction
• Availability/Cost- do you have it in the pharamcy
• Compounding/Stability/ Formulation
• Dosing and Administration
• Drug-drug, Drug-food, Drug-lab Interactions
• Drug Identification
• IV Compatibility/Stability
• Method of Administration- how should i give this
• Natural Products
• Patient Education
• Pediatrics
• Pharmacoeconomics
• Pharmacokinetics
• Pharmacology
• Pregnancy/Lactation
• Special Populations
• Therapeutic Consult
• Toxicology


Practice Question – Select the BEST category for the question below

Q: What dose of oral clonidine is equivalent to the patch form?

dosing and administration


Practice Questions
Which category?
1. What is the dose for Zosyn® (piperacillin/tazobactam)?

dosing and adminstration


Which category?
2. What is this white, oval tablet used for?

drug identification


Select the BEST category for the questions below

1. Is Lamictal® (lamotrigine) available as a suspension?

compounding/ stability/ formulation


Select the BEST category for the questions below

2. Which antibiotic can be used to treat a sinus infection if the patient is allergic to penicillin?

therapeutic consult


Select the BEST category for the questions below

3. Can warfarin and metronidazole be taken together?

drug drug interaction


Step 4: Develop and conduct an efficient search strategy

a. General  specific
i. Tertiary  Secondary  Primary
• Tertiary – provide information that is collected and evaluated from multiple types of references and are organized in a useful way
 Examples: texbooks, lexicomp, micromedex, clinical practice guidelines, revew articles
• Secondary – abstracting and indexing services; allow for efficient access to primary literature. Do NOT interpret the primary literature
 Examples: pubmed, OVID, cochrane library, IPA
• Primary – introduces new knowledge or enhances existing knowledge on a subject; data are original
 Examples: clinical trials, case reports, conference proceedings
ii. Use general knowledge from tertiary references to narrow scope


Step 5: Evaluate, analyze and synthesize relevant literature into a response

a. Apply information to the given situation and synthesize a specific response

b. Questions to consider before formulating a response (Table 2-1)
i. Do you know the requestor’s name, profession, and contact information?
ii. Is the request in reference to a specific patient?
iii. Do you have a clear understanding of the question being asked?
iv. Do you know why the requestor is asking the question?
v. Do you understand the requestor’s expectations?
vi. Do you have enough background?
vii. Do you know the unique circumstances that generated the question?
viii. Do you know when the information is really needed?
ix. Do you know how the problem or situation has been managed to date?
x. Do you have an idea how the information supplied will be used?
xi. Do you know about alternative explanations or management options that have been considered or should be evaluated further?


step 5: c. Critical factors to consider

i. Patient factors
• Patient demographics
• History of present illness
• Past medical and surgical history
• Social history
• Family history
• Allergy history
• Prescription and OTC medications
• End-organ functions, physical examination, lab test, diagonostic tests
ii. Disease factors
• Definition
• Epidemiology
• Etiology
• Pathophysiology
• Risk factors
• clinical findings, diagonosis, treatment and prevention
iii. Medication factors
• Names
• Pharmacology
• Pharmacokinetics
• Indications
• Dosing and administration
• adverse effects, toxicity, drug interactions and monitoring parameters
iv. Pertinent background information
• Setting
• Context
• Rationale for the question
• Unusual or special circumstances
• scope of question, limitations of available information, applicability and generalization


Step 5: d analysis

critical assessment of the nature, ment and significance of individual elements, ideas and factors.
Review and evaluation of pertinent information and evidence.
Need to look negative and positive effects


Step 5: e Synthesis

careful, systematic and orderly process of combining or blending vares and diverse elements, ideals or factors into coherent response.
Integrate data from diverse sources


Step 5: f components of a DI response

f. Components of a DI response
i. Restate/summary of ultimate question
ii. Introduction or discussion of background information on topic
iii. Supporting evidence for the recommendation being made
iv. Conclusion
v. References


Step 5: g characteristics of DI response

g. Characteristics of a DI response (Table 2-4)
i. Timely
ii. Current
iii. Accurate
iv. Complete
v. Concise
vi. Well-referenced (evidence based)
vii. Clear and logical
viii. Objective and balanced
ix. Free of bias or flaws
x. Applicable and appropriate for specific circumstances
xi. Answers important related questions (anticipate the next question)
xii. Addresses specific management of patients or situations


Step 6: Communicate response

a. Should be appropriate for the requestor
b. Give the requestor time to ask questions (especially if verbal response)
c. Ask if the information was helpful or met their need
d. Repeat key concepts until you feel certain requestor understands what trying to communicate to them
e. Document response
i. DI Center – electronic database
ii. Clinical practice – electronic interventions, notes in chart, personal files, etc.


Step 7: Conduct follow-up

a. Determine the outcome of a recommendation
b. Re-evaluate a recommendation and modify if necessary
c. Allows provider to receive feedback and learn from the experience