Keliana O’Mara, PharmD, is a Pharmacist and the Neonatal Intensive Care Unit Pharmacy Specialist at WakeMed Health and Hospitals. Keliana is a graduate of UNC Eshelman School of Pharmacy. She completed her PGY1 at Moses Cone Health System and a neonatal pharmacotherapy research fellowship at Women’s Hospital of Greensboro. Her areas of research interest include neonatal pain and sedation management, dosing accuracy of medication delivery devices in neonates and pediatrics, neurodevelopmental impact of medication use in neonates, and individualized pharmacokinetic/pharmacodynamics dosing in neonates.
You can reach out to Keliana for collaboration and questions at: email@example.com
The transcript of today's episode can be found below 👇
pharmacist, pharmacy, nicu, baby, neonatal, working, medications, talking, patients, dosing, unit, day, tpn, physicians, wondering, mom, pediatric, projects, high risk, kids
Daphna, Keliana O'Mara, Ben
Hello, everybody, welcome back to the podcast. Daphna. How you feeling today?
I'm good. How are you feeling today?
I'm exhausted. I had the longest call ever, with the most random problems I have ever seen from machines malfunctioning to babies malfunctioning. It was long. But I'm very happy. I mean, I was actually looking forward throughout my call to this interview, because that's something that we had in mind to schedule and to record for a while. So do you want to introduce our guests for the listeners?
Sure. And you don't fall asleep on us. I don't think you'll be able to fall asleep on s3. So it's my distinct honor pleasure to introduce Kellyanne O'Meara farm D so she's a pharmacist, obviously and she is the neonatal intensive care unit pharmacy specialist at Wake Med, Health and Hospitals. Kellyanne is a graduate of UNC Eshelman School of Pharmacy She completed her PGY one year at Moses Cone Health System and the neonatal pharmacotherapy research fellowship at the Women's Hospital of Greensboro Kelly Anna Kalyana and I work together at the University of Florida. But now in her current role at week she oversees the pharmacy needs in their NICU and also trains pharmacy residents. Her areas of research interest include neonatal pain and sedation management dosing, accuracy of medication delivery devices, neurodevelopmental impact of medication use in neonates and individualized pharmacokinetic pharmacodynamic dosing in neonates. So that was a mouthful, you are doing a lot of things. Kelly, Anna, welcome to the podcast. Thank you. So I guess just to start, you have lots of options for what you would do with your career in pharmacy. So, so why neonatology?
Keliana O'Mara 02:44
Yeah, I kind of accidentally fell into it, I kind of accidentally fell into pharmacy as well, because I started out college thinking I wanted to do business. And had that first econ class, not put me into sleep as hopefully you guys will not be today. I may be in business school right now or be in business. But actually, my dad had recommended pharmacy initially, and I was like, ah, that's always some old white guy and a white coat. Counter. I don't want to count pills for a living. But he encouraged me to look a little more into it. And I realized that there were a lot more different career opportunities within pharmacy. So then I went to pharmacy school, and I was in my second summer rotation after my second year of school. And the person I was supposed to be with her the day had called out and so my preceptor was like, Wow, just go find something to do. So off, I went to go caffeinate as most of us do, and we have some downtime, and actually ran into a woman that knew my mom. And my mom had previously been a neonatal respiratory therapist, before she had retired from that role. And so this woman knew me from pictures that she had seen of me growing up and somehow recognize me in the hallway, and she said, You gotta be curious daughter. And she asked what I was doing, and I said, I was kind of homeless for the day. And so she said, Do you want to come to the NICU? So I said, Sure, why not? And so my first NICU pharmacy experience was with a neonatal respiratory therapist. So I have I have them to thank for me falling. Wow. Yeah, and yeah, and so I ended up there was a pharmacist in the NICU, but she so she kind of let me round with her for the day. And we saw a baby that had caught it off their line, and they were talking about getting TPA and I just learned about in school so that's the code. I know all about this. Didn't know anything actually. What? They let you go and find the dose and come up with the labs to monitor and then it works for the baby. And so at that point, I was like, Okay, this is definitely what I want to do and I loved it and you I pretty much gear the rest of my school and training around doing the ontology. And then I even, I found my fellowship, director on accident as well. So I was interviewing in the pre residency program, which is your fourth year of pharmacy school, and I've done a pre residency track, and we were interviewing for different spots. And I actually wanted to go where his wife was, which was at Baptist in Winston Salem. And she's like, Oh, well, if you come to my area, I happened to have a really good in with the guy who has the neonatal fellowship. So yeah, that just all kind of lined up nicely.
Well, you're a lucky lady.
Keliana O'Mara 05:42
It kind of makes me look like I'm way more gonna go with the flow type B, and really not the case love my decimal points. But it all kind of lined up nicely.
Well, you've definitely been already in your career at a few hospital systems. And obviously, our listeners are in all kinds of units, all kinds of systems. What do you think is kind of maybe the optimal role if you think you could have it your way for pharmacists to engage with the team in the NICU?
Keliana O'Mara 06:18
I think that I'm hoping in most places now, pharmacists are out on the floors and actively rounding with the teams, I have had a couple of different roles since I got out of fellowship. My first job was in an area, a hospital that had not had clinical pharmacist yet. And so I was new to the NICU and new to a clinical pharmacist role. So they hired about six of us right out of training. And so that was very challenging, because you're not only trying to show the NICU, what you're capable of, but you're also having to show the department, the pharmacy department, what you're capable of. So they weren't really had not adjusted to what a clinical pharmacy specialist was. And so there were growing pains for all of us in that role. My role at my next job was going into an established role that had been vacated on a to pharmacists team in a unit where they had had clinical pharmacy. And then after that I worked at University of Florida where they had established clinical services. But the NICU had not had somebody in many, many years. And, and that's kind of similar to my role now. And that's, I think one of the easier ways as an actual pharmacists or clinical pharmacist, as you are able to come in and get a fresh slate. And you can kind of build services from the ground up. But in an area where you have the support of the pharmacy department as you're trying to do that, because it's something that they've seen before. I do think that ideally, the type of job I like this is where you're able to come in, you're rounding with the team, engaging with learners, and then that leaves you some time in the afternoon, usually to work on different projects. I think there's a lot of capability for pharmacists to be involved in, whether it's classic research projects, or quality improvement or things that can help propel the service forward. And so I think that that's certainly an important piece that I hope people embrace and want to be a part of all over.
So I don't know if I've ever told you this stuff. No, but I come from a proud family of pharmacists. I didn't know. mother and my sister both are now my mother is retired, but my sister is not obviously, and their pharmacist and I did spend a few summers working in my mom's pharmacy. And so I think what you're mentioning Kellyanne, where the presence of the pharmacist at the bedside is something to me, that's very exciting, because I remember when I was in high school, and I was working at my mom's sort of pharmacy just like putting away boxes and stuff. People would come in and seek advice from their pharmacist right saying, This is what I feel. What could you do for me and in the NICU in most NICUs? At least I feel like the pharmacist is really disconnected. Not by default. Right. It's not their wishes, obviously, but from the patients and from the families. And Kellyanne I'm wondering if we had to open this door for the pharmacist and all around the country to enter not just round, but the interaction with the with the families. What would that look like? In your opinion? Where does the pharmacists role really gets fulfilled in that in that setting?
Keliana O'Mara 09:30
I think I have a decent amount of family interaction actually in my wedding in 2020. My flower girls were twins that were former patients of mine. Yeah. And so I mean, I think there's definitely the ability for pharmacists to interact with families. And where I find that it's often helpful is helping to explain the medications to the parents and the treatments in ways that makes sense. It's not uncommon that they'll go on Google and say oh, Do you want to give my baby even if it's Tylenol, you know, if you read something on the internet that's unfiltered without the full understanding of what that looks like in their baby, it can seem very scary. And so I spend a lot of time where, when they're on the sicker side of things, explaining to families, what the medications are, how we would use them, how we assess whether or not it's working, what we know of in terms of long term outcomes and data. And then certainly as I start to get closer to home, I spend time helping to do discharge counseling, any of our babies that go home on Wiens of medications, whether it's for neonatal abstinence, Lovenox, occasionally, seizure meds, I tried to get in there and teach the families and counsel them and make sure that they completely understand the medications, making sure that they have the meds in hand before they go home. They understand how to give them how to give them if the baby throws them up, what to do if they miss a dose, and so all those kind of key normal kind of outpatient pharmacy counseling aspects, I do get on my side of things, as they're well and getting ready to go home.
That's really cool. And do you think that just the way most NICUs are constituted these days, that would represent sufficient pharmacists sort of men women power to do that type of discussion and interaction at the bedside? Or do you think that that would mean that the Pharmacy Departments will need to invest in more people to actually expand to that area?
Keliana O'Mara 11:33
I have noticed that pharmacy with NICU usually tends to have I think our our patients, a pharmacist ratio is much higher than most units. So that is definitely an issue. You heard you request? Well, no, I'm just saying like So normally, if you think an adult ICU pharmacist may have 15 to 20 patients, and like I'm the only one for 50 patients right now. So it's just I think, certainly resources, I think with the NICU can tend to be a little bit more limited from a pharmacy perspective. I don't know if the perception is that they're, you know, since you're tiny, no more of them. But I think that it would be difficult to cover every baby in a NICU across the country that that is in the neonatal unit with a pharmacist to that degree. But I think in light of having limited resources, certainly there are ways that you can kind of pick up which kids need the most attention. And I think there's definitely ways with you know, the electronic medical records, and there's different systems that we've been able to put in place have certain target medications, or other things that you can kind of pull through and quickly say, This one needs a little more TLC than, you know, this baby who's going home on a multivitamin, so
So I've had the pleasure of working with you, Kellyanne, I'm learning from you, because Because Admittedly, I was a trainee during the time that we work together. And I, maybe I can expand a little bit, and you've talked a little bit about it about what that system looked like, because I felt like that was a potentially very optimal working relationship. And then maybe you can agree or disagree. But you know, you're a special person, right? You're super efficient, one of the most efficient people that I have ever worked with, and you just get it done, whatever was asked of you, you just got done. And if that meant talking to the nurse, and the parent, in whoever, you, you made it happen. So, you know, I can't pretend that we can put one of you in every unit. But potentially, you know, through our discussions, maybe some of our listeners will have ideas about how they can better engage with the pharmacists situation that they do have. And so if I recall correctly, and you you know, you rounded with us on rounds every single day, and during that time you reviewed every medication the baby was on, you gave us concerns about interactions, you gave us concerns about, you know, the baby's GFR was changing, the weight was changing, and the clinical status was changing. So in real time, how we could make adjustments to improve kind of the medication. And then if the parent was at bedside, you stuck around in you updated them just like the rest of the team did. And then by the time rounds were done, you had done most of that kind of verifying the orders work. And you were the lead helper, and getting TPN written with trainees and learners. And then by afternoon you were working with pharmacy residents and pharmacy students and your own clinical projects. So I wonder if maybe You can just give us some advice on on how we can, you know, engage pharmacists. And maybe we can employ some of our listeners by you maybe telling us some stories of how, you know, you've you've been impacted some of those teams in a way that's different than a pharmacist who's who's not really on the floors in the unit.
Keliana O'Mara 15:22
Yeah, I mean, I think that I think that from a pharmacy perspective, having specialists in the NICU is one of the more it can be one of the more rare areas. Because a lot of times there's a perception, and I've heard this in different spaces across where I've done projects and worked with people, but it's like, oh, babies don't have that many medications, right? They get Caffee, what's the big deal. And so it can be challenging if people don't truly understand all of the special needs and considerations that should go into this kind of population. I think that if they have if you're talking about institutions where you don't have someone that's trained to be in the NICU, but that you have staff that are willing to try to help out in ways I think some of the easy bread and butter things are with pharmacokinetics. So gentamicin and vancomycin. I think that that's a really easy way to get pharmacists to feel a little bit more comfortable quickly. Because it's the same, you know, the kinetics, the calculations are the same, regardless of which patient population that we're talking about. That's one of the things that very early when I started at Florida and vancomycin dosing, and definitely I've talked about this as well, but we were getting so many sub therapeutic trough levels. And it was taking us significant durations of time if we had a baby that truly needed to be on bank to get them therapeutic. And so one of the first projects I did there was, let me show you guys how I can do individualize kinetics, and we can draw two levels. And then we can be done checking them unless the renal function changes significantly. So
now, after the first dose of after the
Keliana O'Mara 17:17
first dose, yep. And so then we were able to basically show that we could get the kids therapeutic within the first 24 hours with two lab draws, instead of having to get three to five to seven lab draws and never truly achieving therapeutic levels. And so I think that that's certainly an area where pharmacists can have a big impact. There's more stuff coming down the pipeline, I think in terms of switching away from trough based therapy to a UC to MIT based therapy, the neonates right now are not being necessarily pushed forward by the IDSA recommendations, but I assume that that will be the next piece as it rolls out in adults in pediatrics. So I think that that's something that we all need to be prepared to think about is how that dosing looks different. One of the things that I started working on when I first got here, was working with the team to develop more standardized parenteral nutrition formulations. So this population, I'm over three different neonatal ICU is within the week med health and hospital system. And so in the other two units at the other sites, they're mostly kind of that 32 weaker that maybe needs a couple of days of French nutrition. And so we actually moved towards some standardized bags that are stocked over there that have, they're designed to give an optimal amounts of calcium, phosphorus, protein, and dextrose. And those bags, from a pharmacy operational standpoint, cut back the time it takes to make them by two thirds, it cuts back on the amount of time for the providers to have to order and reorder every day. So that cut the provider process from about an 11 step process to a two step process. And then from what we're seeing, as far as the growth outcomes and electrolytes, there's been no negative impact, and we're hoping as we amass more patients, we'll be able to show that it actually did better provision of nutrition, since we're able to kind of make sure that we're really pushing the protein and the glucoses. So, I mean, that's certainly something that pharmacy can be involved with that is mutually beneficial if you're able to make it more efficient and more productive and then provide better nutrition. So certainly lots of room there.
Yeah, that's, that's fascinating. And this, this individualized, Farmer cook pharmacokinetic that you mentioned, among other things, I like that description that you made of vancomycin troughs were two levels and unless kidney function changes dramatically, then you can pretty much to know, what their trends are going to look like, was that something that is original and that you came up with? It was? Or is that data out there? And can other pharmacists find it somehow, some way?
Keliana O'Mara 20:12
That data is out there, that was what, how we did all dosing of I mean, it's like a science and bank and my fellowship. So there's kind of Zacky pharmacokinetics. He's kind of the grandfather of that style. But yeah, so there are a couple of papers published in the neonatal population talking about that.
And I feel like sometimes the pharmacists are supposed to be the Swiss Army knife of the unit, right? Do this make this magically happen so that we don't have to do XYZ? How do we engage with our pharmacist colleagues in a way that strikes the tone of productivity and improvement rather than delegation? Right? How do we generally if we have a pharmacist that is overwhelmed, and that doesn't feel maybe appreciated? Because all they do is check doses and adjust this and adjust that, but how do we create, in your opinion, an environment where the pharmacist can actually take ownership of such projects as the one as you mentioned, to actually provide outcomes that are better for our patients? I'm wondering, what would that look like?
Keliana O'Mara 21:17
I think that there's a lot of things that pharmacy can bring to the table, even if you're talking about people that may be a little bit more centralized in the pediatric pharmacy, they may have things where they know, you know, we are always having to do XYZ to manipulate this dose or, you know, figure out a way to overcome this in the computer system, or this type of AB, this always happens, and they may not feel competent coming to the physicians with that, and they'll just a lot of times to make it work. So they'll say like, oh, this is something that's weird, or we're constantly having to manipulate or change. But especially if it's an area they don't understand as well. And they're like, well, it's for the babies, so we're just going to make it work. Whereas I think asking getting them to the table and asking them, are there any things that like we're having, we're seeing this issue, or we're having this problem? What are you guys experiencing? on your end? What sort of operational impact does that have on your end, and trying to kind of meet in the middle? And I think that, certainly, if there are things that we on the NICU side can do to help on the operational side of the pharmacy to lighten that load. It also frees up their ability to do more clinical activities and less of the more mechanical, you know, checking of things. That's a good point.
Yeah, that's great. So better communication is what I hear you say,
Keliana O'Mara 22:46
to me dialogue.
That's right. That's right. I, you know, a lot of the work that you do is about individualizing, medication, TPN, pain management, Nas management, things like that. And so I'd like to hear a little bit more about some of those projects, but also what kind of you think, I mean, obviously, the future is individualizing medication therapies. But But what does that, you know, what does that mean? What does that actually look like?
Keliana O'Mara 23:17
I think so I've come to the point in my career, where I realized that it needs individualization is great. But I think a standardized approach to individualization is probably the best way to do that. Because we know that if we have too much deviation, it can certainly cause issues. So I think having a bit of a, this is you with our new NAS protocol, we have some flexibility and choices that people can make, based off of the types of symptoms that babies are still having. And so we're looking at the scores and individualizing adjunctive therapies based off the scores that baby is seen. But those adjunctive choices are standardized. So I think that that is probably the best way to do that. Because you don't want to get so out in the weeds, that every baby is treated differently. And then you don't know if what you're doing is actually working in a more systematic manner. But I think allowing the flexibility to individualize when it's needed is probably very important.
Yeah, I liked, I think the example you gave about the TPN based on kind of the gestational age, so you like you said you know what the needs are going to be and so it's not the same TPN for a 23 weaker as a 25 weekers a 32 weaker, but we can cut the efficiency, you know, improve the efficiency by by by standardizing it a little bit. Right by some patient characteristics. I think that's really cool. And there's a lot of opportunity there.
Keliana O'Mara 24:54
Yeah, we're hoping to go ahead. Sorry. No, no, I'm sorry. Yeah, we're hoping to roll out even more have that going forward, we kind of started with where's our biggest use of kind of where everyone's already intrinsically writing a very similar TPN. And who are we going to capture the most with and then doing some fine tuning for kids on either end of falling out of that spectrum. So we have some that we're planning on rolling out in the smaller kids. And by that token, also some that we can roll out and some of the bigger babies that may have some extended nutritional needs from TPN as well.
I'm wondering if in for physicians in neonatology, there's, there's this big movement, right towards really collaborative and networking with other institutions to really generate more usable data, especially when, when we're talking about individualization of care, you suddenly narrow down the group of patients you really want to study and provide better care to that collaboration becomes paramount. And I'm wondering if there is such a movement in pharmacy as well, where pharmacists from certain centers, or certain regions of the US and of the world probably collaborate on projects and initiatives that you're aware of.
Keliana O'Mara 26:12
I see a lot of that and more kind of a grassroots movement amongst the pharmacist, because we don't have a formal network or pathway for that. But you always hear that, you know, we always hear pharmacies, a very small world, and then pediatric pharmacies and even smaller worlds. And neonatal pharmacy is a very small world. And so most of us do have contacts throughout everywhere. And so as we're looking to do things, or potentially roll out new projects, I was asked to help with one a few years ago, looking at use of Zosyn versus Flagyl, and NEC and trying to decide if Flagyl had neurotoxicity risk in babies the way that they see in other patient populations, which is a bit controversial. And so a couple of different places are looking at that. So I do feel like there is an effort is just not a formalized effort at this point, specifically as it relates to neonatal pharmacy. It would be great if we could do that, though. Yeah, that's interesting.
Well, it's never too never too late to start. Right. Yeah. Well, and I think that's the exciting thing about being in, you know, big institutions where they're already collaborating with other institutions. I know we have some listeners, though, that are at small places, right. So their resources are very limited, especially in the pharmacy kind of arena. I wonder if you have any recommendations for resources for people who might not have, you know, a real expert like yourself? Kind of at their, at their disposal?
Keliana O'Mara 27:53
Yeah, that's, that's hard. Because a lot of times, there's not a great one reference book or paper that can describe what we see in the NICU. Since you know, sometimes you may have things that occur over and over again, and then other times, it's a one off, and you may see it one time in a career and not see it again. I do think that there are different listservs. So if people are even kind of peripherally involved in the care of neonates, they can join some of those pediatric listservs. And you can put out a question and people get back to you very quickly. Those are especially useful when we are navigating drug shortages, which seem to always be a problem. And so there is from that aspect, you can kind of quickly say, Hey, what is everyone doing with the small slippage shortage? Or what are people doing with the pediatric multivitamin, intravenous preparation shortage? So I think that if people just kind of need a quick, has anybody seen this? What do you guys do about this? I used one when we were working on one of the fellows projects with Avastin to see how Avastin was being used other centers so you can get some, maybe less of the specific, you know, I have this one patient that's doing this, what do I do about it, but at least from a more broad spectrum of how to address a lot of the issues in the NICU, the listservs are a great reference to kind of put a pulse what others are doing around the country.
It gets you a nice consensus of you know, what's what's right, but like, what are people doing? I was you was following up on that question, right of physicians working with resource limited institution and that doesn't mean that they have nothing but maybe they have a pharmacist, maybe they have a pediatric pharmacist, but they don't have a neonatology dedicated pharmacist. I always thought when I was a fellow that I should spend some time with the pharmacist and my training my training program, never are instituted anything of that sort. But I'm wondering if we were together right now to implement a, a, a rotation where a future neonatologist, a physician would rotate in the pharmacy? What are the things you would like to show them that you think would be very valuable for them to take way to their attending careers?
Keliana O'Mara 30:21
Yeah, I think that would be a very interesting thing. I think, seeing kind of the workflow day to day of what that looks like. So some places, the pharmacist may round in the morning, and they go back to staffing in the afternoon, where I did my fellowship, that's what the decentralized pharmacists did. So I was around clinically all day, but they had to go back and then staff in the actual pharmacy.
What does that mean to staff,
Keliana O'Mara 30:46
so they're actually going in and running the pharmacy. So going in and verifying the orders verifying that all the medications are correct checking the actual product, I see managing that side of things, I think it's definitely helpful if a physician can know the actual process from putting in the order to verification to seeing how it's actually prepared, because I think that helps you understand, Oh, I'm ordering this medication, it has to go into solution. So it has to sit there for 15 to 20 minutes before it can even go into solution as an IV, then it has to be pulled up, then it has all these other checks. And so I think that understanding what that looks like can help when you're like I put in this order, and nobody got it to me. And it's because it's just one of those things where physically it takes time to actually go into solution. And we can't give you you know, crystals.
So if you're not modifying discontinuing all the within 30 seconds of putting in the order,
right, we would probably call less.
Keliana O'Mara 31:50
Yeah, yeah. And then I think even seeing that production piece of the parenteral nutrition bags and seeing how, because a lot of times, the common Whoa, that I've seen everywhere that I've worked is the order gets put in labs come back, or a blood sugar came back, and it's a little higher low, and it's been, you know, 30 or 45 minutes since the order was put in. So then you're like, Oh, let me just change this real fast. It's really quick in the computer, right? And then pharmacy is like, No,
I just need that. Yeah,
Keliana O'Mara 32:25
yeah, no, we just pump the bag. Yeah, so seeing kind of what that process looks like. And you know, they have to actually go through and it's kind of a robot typing and most places have, and they have to calibrate it all and set it all up and run all these different things. And then if you have you here, we have one compound ER for the neonatal, pediatric and adult TPN. And so a lot of times places will do all of the will get the NICU done first, and then switch out all the components on the compound or to the adult concentrations. So if you get that in late, and all of the neonatal ones have already been done, now you've taken away a safety layer, because the stuff that's hanging on the compound or is no longer meant for the neonatal population. And so I think understanding those sort of operational things where it's, you know, easy when you make the phone call, and you're like, why
are we asked to push back the TPN timeline, right? Yeah, yeah, get it in a little later. Required.
Keliana O'Mara 33:30
TPN time creep, where it's like 30 more minutes, 30 more minutes. But that's also where I think it helps to have the pharmacist that may not and this is something I did when I worked in Florida when I first started there, because they hadn't had someone in the NICU. I had most of the TPN pharmacists come round with me, I had all of the pediatric satellite pharmacists come round with me so that they also had a better understanding. Because I think sometimes pharmacy is like, Oh, are they sitting down and eating snacks? Why aren't they getting these orders? And, and it's like, in reality, we just had, you know, hypoplastic get bored, and we're running around. We're trying to do this. We're going and we're grabbing that. And so I think it helps both sides to see what the other side is doing so that everyone understands we're all busy.
Running into the pharmacist before TPN deadline.
Yeah. You mentioned how the pandemic is kind of affecting our lives and surely we've all felt that way. Like I'm still not sure why I can't get sweeties. Maybe you could tell me about that. But you've been knowing you've had a problem. But you were mentioning to us before we got started about some of the other ways that the pandemic has been affecting your work.
Keliana O'Mara 34:54
Yeah, it's it's definitely as I think we all know, been a very different Time, one of the things that we are seeing a lot of in our unit is in our babies that have opioid exposure, we're seeing a lot more polypharmacy of prescription medications, psychiatric medications, a lot of the atypical antipsychotics, high dose antidepressants and things of that nature. And so that has really impacted what these kids look like when they come out. And it's really made it much more difficult to treat these babies, they often have really terrible neurologic symptoms. And so even if we feel that we've treated the opioid withdrawal piece, we're still seeing a lot that's making their management difficult. And one of the things that's really impacted our abilities to do non pharmacologic measures in our unit is not being able to have the volunteers in house. And so with the restrictions for visitors, the volunteers have not been allowed in. And so it has definitely created some interesting challenges, because these babies that normally would have at least had somebody holding them. And I don't know how busy your guys's units have been, but ours has just been bursting at the seams. I think we all know what everyone was doing during quarantine. And that was really nice. Because the sense is all around this area in the state isn't sky high for months. And so it certainly makes it very challenging where you have nurses that have high patient assignments, and then these babies that are not always the happiest of children, and then not having the volunteers available to help with that nonpharmacologic. And we don't really have the population here that supports fully transitioned to the eat sleep console. We just don't have the parental engagement thus far here to be able to really push forward with out having some sort of pharmacologic management. And so that's where we kind of had to take a look at our whole neonatal abstinence protocol. And we did not have any standardization to adjunctive treatments, we weren't really choosing our adjunctive medications based off of the symptoms that babies are presenting with it was just this attending prefers being a BB. So if they got through their opioid piece, and this was felt to be non opioid, you get fino BB, and this one prefers quantity. So this baby got quantity. And so we were able to kind of pull through and look at all of our data, and really get into what the points look like what, as far as you know, having more autonomic symptoms versus neurologic versus Gi. And we sat down and pulled through the literature and looked at other people's protocols. And we're able to kind of say, we think we can at least have some standardization based off of the meds that mamas taking the symptoms that babies are presenting with and making standardized types of targeted choices for the symptoms that we're seeing versus just kind of having it be all over the place, or just provide your preference. And with that, with the babies that we treated Thus far, we've been able to really cut down on that length of stay from about three weeks, to a little over a week. And so that's been an that's just a three to four months worth of data that we've had about 10 kids. So that's been exciting. But it's definitely been challenged with trying to figure out how best to deal with these babies, especially in light of some of the lack of nonfarm resources available to us right now.
It's inspiring how you can make something positive and a bit of a negative situation. This is this is this is a hopeful message for all of us. I think you mentioned something, obviously, regarding a culture of safety. And I feel like this is the one thing I'm always amazed with our pharmacy colleagues, right. I mean, it's the, the attention to detail, obviously. But every pharmacist I've worked with has implemented on top of hospital mandated protocols to prevent medication errors, the number of redundancies to make sure they themselves don't make mistakes. And, and I'm quite jealous of of your guides, I feel like I wish I had that, that diligence to do all these things to make sure that everything is perfect all the time. And I'm wondering if you have some tips or some tricks, or some software's or tools that you use, that you found to be extremely helpful in making you a more efficient clinician, and decreasing the amount of errors you do. And I'm not talking about the scanning of the meds and the patient labels, which I think most hospitals in the US at least have, but I'm talking about these little Excel worksheets that you guys have, where you make sure everything is good. Yeah.
Keliana O'Mara 39:49
We do love numbers and decimals and excels. Yes, um, I think that the evolution of the electronic medical records has definitely helped To fine tune some of these sort of things. So I, we worked last fall with building a neonatal and pediatric scoring tool that would pick through as medications were ordered, or labs were changing. We kind of figured out what our most important points were. And we have a scoring tool that will generate a patient acuity score, basically, based off of the things that we thought would need the closest pharmacy attention so that fino BB level came back, that score pops up, and we know that we need to go look at that patient. And so that has really helped. And I think that is helpful too, even if you don't have a dedicated neonatal pharmacist. So when I am not on on the weekends, and somebody else is working, they're able to sort by the score, and they're like, Okay, this baby has the most points, I need to look at them first. And then just the way that the the dosing references are built within epic, so we have it so that it'll pull through the correct dose and interval based off the gestational age or corrected gestational age. And that certainly helps. And we have some stuff that we've utilized with a pharmacist handoff tool so that if I can leave on Friday, or when I leave at the end of the day, I've got at eight o'clock, this level comes back if the bank level is greater than 15, do this if it's 10 to 15 do that. And so the pass off between shifts, and just being very precise and specific so that plans are communicated appropriately. So everyone will get a blast of information for me, I will put in the physician sticky note and like here's what you do for levels XYZ, the pharmacists gets the same information. And so everybody has the same information and can assure that the right thing is being done. So those are some of the
like working with parents, right. anticipatory guidance.
Keliana O'Mara 42:03
I know that you have been very involved with, like, projects in your unit, like you've mentioned, and some of those have also included trainees, residents and fellows. And so we do have lots of listeners who are trainees, and probably some of them haven't found an area of interest yet. And so I wonder, you know, what are some areas where we really need to do the work? And if somebody was interested in a project that related to pharmacotherapy pharmacodynamics, you know, dynamics? Where would they start? Where should they go? Who should they talk to you?
Keliana O'Mara 42:47
Yeah, I can always come up with projects about drugs, because they're fun, and we don't have enough information on the vast majority of them. I think that neonatal abstinence will continue to be a big one that people can look at, I think that there's a big push from pharmacy and medicine as well for transitions of care, and things of that nature. So I think finding ways to better improve transitions of care, it's a little bit more challenging in the NICU population. But again, if we can look at maternal to neonatal transitions of care, and things that we know that mom may have, or see or do that impacts baby, you can make a more concerted effort to have that piece started before the babies are even born. And so that's one of the things that we're working on with HIV positive moms and making sure that we know exactly which regimen which risks the baby falls into. And so a lot of times, here we have me working with the antimicrobial stewardship pharmacist, the the Duke peds ideas, who we work with for our HIV babies, and so that conversations happening before the baby is even born, sometimes weeks to months before they're born. And then when the babies are here, it's a very seamless transition to make sure that everything is lined up.
So no middle middle of the Knights scrambling
Keliana O'Mara 44:13
for right. Yeah, we have a little thing put in right there so they know exactly what to order. And then it flows through pretty seamlessly. So I think anything where we can engage high risk for baby disease states before the babies are even born, that certainly I think potential for ways of helping to have a positive impact for as far as neonatal transitions of care. I think another area of people are at centers, where they see these little beep EDS and chronic kids bouncing back and forth, and having a good solid transitions of care as they're leaving the NICU so that they know them. When this baby gets sick. They often need hydrocortisone they tend to grow and persist in E. coli when They get their UTI every six weeks there, there's pieces of information that we can more kind of firmly give that would help. When our colleagues are getting these graduates, I think that pain management is always a good one that we can look at where we can have an impact. So a lot of places are trying to move towards, especially in the post op population, e RAs and opioid avoiding or opioid sparing management of pain. We're actually rolling out one of those now in our post op kids for gi surgeries. So I think that that's something that pharmacy and physicians can definitely work on together and utilizing things like IV acetaminophen, and other things that may help help spare opioids.
Go back to the HIV discussion that you were just having soy. So I'm wondering what practically does that look like? Because I guess it means optimizing the mother's HIV regimen so that the baby is at the lowest possible risk of contracting the disease through the delivery process? And if that's the case, what is how does the pharmacist really change what's supposed to be already what's supposed to be already done by I guess, the infectious disease specialist. And I'm saying this not as a rebuttal, but I want people to grasp what the impact could be, obviously.
Keliana O'Mara 46:28
Right. So we are building an order panel that will have high risk versus low risk and kind of that moderate risk in the middle, which are all different regimens. So many times, we'll know ahead of time if this mom is being seen by the Health Department and hasn't picked up their meds and there'll be a known potential high risk. And so we can go ahead and say Mama's high risk, and then when they go on, they'll just put in HIV high risk for the baby. And it will blow through all the cracks, medications and the timing of what all of those look like. Because otherwise we're all going was it two per kilo on day one, and this dose on day four. So all of that's already kind of we know, high risk, Mom equals high risk baby for this, and then that directs them to the classes. So this
is more than that, right? I mean, you're describing something where you would potentially know if a mother is adherent to her regimen as well, by following her in terms of the medication she's picked up and so on, to know that even if she is at high risk, is she taking her supposedly prescribed regimen? And how does that then, in turn, categorizes the baby at birth, which is which is really cool.
Keliana O'Mara 47:39
Yeah, yeah. And that's definitely my antimicrobial stewardship. Pharmacists colleagues are highly involved on that. And they are the ones who manage all that side. So we have a very close working relationship where she'll say, hey, we just got notified, this mom is brewing and we'll go Okay, let's go we kind of plot it all out and are able to make sure that everything is ready to go once the babies are born.
But the, the possibilities are endless, right? thyroid medications, moms with you know, myasthenia gravis things, things that we could anticipate, that are always kind of a last minute. What do we do when the baby gets here kind of looking at our algorithms problem? So yeah, very cool.
What's your take on antibiotic stewardship? Why are we so bad at it?
Keliana O'Mara 48:36
Now, okay, I, I think we have Frank gotten better. So when I started this, I finished my fellowship in 2010. So back in the days where I was a little pharmacy fellow, and every kid got seven to 10 days of AMP and gent, when they came out whether they needed it or not, they were at risk or not, everybody got it. I got really good at calculating kinetics, because every baby got individualized gent dosing. So I've done probably 1000s of those by now. So it was it serves that purpose. For me. I used to be really good at calculating. But I think it has gotten better. But I think it's just it's that one time you were wrong, right? So it's the one time you don't start antibiotics or you start the wrong antibiotics. And then that's what sticks with you. I think there is definitely more of a push towards towards making people understand that antibiotics are not benign. And so having to be choosy with with that I think I think we have gotten better. But yes, I think it is still definitely a struggle,
I think, and it goes back to what you were saying. I think the, in my opinion, it relates to what you were describing with the HIV scenarios that you mentioned, where it's risk stratification. over and over again, not just on admission, but doing risk stratification every 12 hours. And that's the only way where you can have the sense of seeing things evolve, trending patient's clinical status, and hopefully then having some positive feedback to withhold anti microbials. So yeah,
Keliana O'Mara 50:18
yeah, no, it is definitely, especially with the little ones. I think that is always going to be the struggle. I think ideally, if we had a great marker, right, or sepsis, I think that would help. And I think
we're working on that by any chance, right.
Keliana O'Mara 50:34
I mean, I wish if I could, if I could do that I could retire tomorrow, right? No, but I think that it is, it's a lot of just the fear of people have had we've all seen where it goes not well. But I think that constant feedback piece that you mentioned, is is important to make sure that we're watching very closely. And it's certainly easy, because we just looked back at our early onset sepsis babies over the last few years. There are some questions should we be moving away from amp and Jen as our backbone of early onset sepsis, like Are we there yet? Have we arrived, where our bugs have evolved in such a way that this is no longer what we should be doing? Yeah. Terrifying. Yeah. Which is kind of my my thing back is you have the kids that probably don't need them at all right? And then you have the kids that may or may not need them. But everybody is like, good. I feel better. 3640 hours in the kids where you're like, yep, that is a definite. And I think there's there's probably some room and work to be done where we can stratify even those kids a little better. You We recently had a kid where the mom had an amp resistant gram negative UTI never picked up her antibiotic ruptured. And the baby after a couple of days ended up with gram negative Brad sepsis. And we're all kind of like a you know, but I think if there's, if we can get enough data to show who really is the most at risk for these more resistant gram negatives, maybe those are the kids that upfront, we make different choices on but leave the the middle of the road kids on their backbone, bread and butter and pungent.
That's interesting. Very cool.
We're getting we're getting close to the end of our hour together. And I think we've mentioned some, but I'm wondering what some of your pet peeves are working with providers in the NICU, other than us pushing the TPN timeline? Mmm hmm.
And provide any story as long as it's the identifier?
Keliana O'Mara 52:44
I mean, I don't have any real pet peeves about providers in general. I think therapy wise, using dopamine for everything is probably one of my pet peeves. Yeah, yeah. Not a big fan of just dopa for all that's,
we can. You're talking about a more rationalized approach to the symptom of hypotension and understanding what are we dealing with? Is it is it volume? Is it sepsis? Is it?
Keliana O'Mara 53:15
Okay? Yes, yes, I am a firm believer in pathophysiology based management of hypertension, not that dopamine is bad. I'm not saying definitely bad. Dopamine does not fit all all the time. Yeah, yep. So that is, that's one of my my bugaboos would be. Why, why are we hypotensive? And a lot of times when I ask that question, because I'll say, I'll get the question. Okay, you know, that space, so and so it was having maps in the teens, what do you want to do? And like, Why do I think the baby's hypertensive? And it's like, I don't know what they are. And let's think about it and then make some choices from there.
I guess for pharmacists, even more so than for physicians, there's always we all leave the unit wondering, did I do this correctly? Did I not forget that? Did I not miss this? How do you deal with these anxieties? And how do you maintain? what's your what's your personal trick to maintain a healthy work life balance where you sort of leave work at work and focus at home?
Keliana O'Mara 54:15
That took me a long time. And the thing that is both nice and somewhat of a challenge when you are in a position like mine, so I'm essentially on service 52 weeks a year. So I'm seeing these kids, you know, and that's it's part of what makes when you have pharmacists and dieticians and other people that are there every day. They're often really great historians. And they can say nope, nope, we did that back in January, and this is what happened. So it is hard, but you do get a lot of continuity. And so it is nice that we get to see the full picture. And we'll see those kids generally from the day that they come in until the day that they Go home. And we're there for the whole journey, which is, on many levels very rewarding, but can be very emotionally exhausting as well. I used to be the one that was like going home and peeping at night. And I still do that sometimes when I have a kid where I'm like, I don't trust you, I know, I know that you're doing something. And I'll go, and I'll keep and I'll look. But I have had to really focus on, I'm not the only one that can do my job, I leave really good sign out and communicate clearly and effectively. And that's why I communicate the same message to all of the people. So the nurse practitioner and the attending and the next up to the pharmacist are all getting the same message. And so it's just a matter of trusting your colleagues, taking that step back. And making sure that you don't let it drive you too crazy. But it is that is definitely a challenge. And I trust that communication, though. Yeah.
Well, I guess if you guys have the pharmacist can do it, then then I guess we can learn to do it, too.
Keliana O'Mara 56:07
I mean, it took me a solid decades.
All right. Well, we're on our way there. Well, Kellyanne, it's really been a pleasure connecting with you, again, had an event if you have any other questions, or Kellyanne,
I'm wondering, minute pearls for us. I'm wondering if it's okay with us to share your email address in our show notes. For anybody who's interested, like you mentioned, you mentioned so many cool projects, and whether it is to pick your brain or to participate. I hope that this is okay with you.
Keliana O'Mara 56:41
Yeah, absolutely. That's awesome.
Yeah. Well, one of our goals of the podcast is really just to connect people to information and to other people. And so our guests previously and thank you for taking on the charge had been so willing to be accessible that I think we can make some real change. Super cool.
That's right. Thank you, Eliana, thank you so much. Thank you. Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address, the queue firstname.lastname@example.org. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikhil spelled Dr. NICU. And Daphna is at Dr. Dafna MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you