Is a FASTHUG enough? Going beyond mnemonics for the next generation of pharmacy learners

Mnemonic devices are acronyms, abbreviations, or other learning tools that have been used for decades to memorize basic concepts. They are ubiquitous in teaching settings, including among intensive care unit (ICU) pharmacists, where the mnemonic FASTHUG (Feeding, Analgesia/Sedation, Thromboembolic prophylaxis, Head of bed, Ulcer prophylaxis, Glucose) is commonly cited. FASTHUG has existed since 2005 and serves as a reminder for key components of care for a critically ill patient. Due to the popularity of this acronym, multiple iterations have been created, where creative authors update, change, and/or add to the mnemonic. While FASTHUG is a unique learning tool with strengths for the entire care team, it has clear pitfalls when used in the pharmacy learning setting (i.e., during advanced practice rotations or for a postgraduate year 1 resident). This has led to the implementation of distinct mnemonic tools which are more specific to pharmacy interventions. The result is a myriad of published tools available for preceptors with limited data supporting their use in practice. A thorough understanding of the educational benefits of mnemonic devices paired with a recognition of their pitfalls can improve learning experiences. This review is designed to help preceptors understand the role of mnemonic devices and deploy them strategically for pharmacy learners. Furthermore, current pharmacy learners have different needs and characteristics when compared with other generations. This may alter the current students' level of comfort with utilizing mnemonics. Alternative teaching strategies that may be more beneficial for today's learners include technology and media utilization, scenario‐based discussions, and hands‐on application of mnemonics. Pharmacists who understand these variables can optimize their rotations and improve the learning experience for both themselves and their learners.


| INTRODUCTION
Pharmacists are integral members of the interdisciplinary intensive care unit (ICU) patient care team and have been shown to positively impact outcomes by decreasing health care costs, preventing adverse drug events, and reducing patient mortality. 1,2 Therefore, it is a top priority to educate and train pharmacy students and residents to become excellent critical care pharmacists. 3 Preceptors strive to provide quality experiential education and therefore utilize tools at their disposal to facilitate learner success. A few examples of these tools include patient workup forms, podcasts, pre-reading assignments, and instructional videos and recordings. One of the most commonly used concepts in didactic and experiential critical care are mnemonic devices, memory tools that reinforce broader concepts. 4,5 While critical care mnemonics can be useful, their broad implementation does not always meet the needs of an individual learner. Today's learners are particularly complex due to their variability of experience and their generational characteristics. Advanced pharmacy practice experience (APPE) students and postgraduate year 1 (PGY1) residents will have different exposure to critical care topics within their didactic curriculum, different opportunities for critical care-focused electives, and different levels of interest in acute care medicine. [6][7][8] Furthermore, these trainees are now commonly from "Generation Z," a generation observed to have distinct learning styles and needs. 9,10 These differences include a reliance on technology and a more kinesthetic approach to learning. This means that preceptors must be adaptable to the changing landscape of the learner when implementing teaching strategies.
Many preceptors have relied on common mnemonics such as FASTHUG (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head of Bed, Ulcer Prophylaxis, Glucose) to aid in learners' work-up of a critically ill patient. 4 Given its popularity, multiple iterations of the mnemonic have been published in the past two decades. But should preceptors be using a generalized mnemonic that was designed for a whole medical team in a pharmacy critical care rotation? Alternatively, are there other mnemonic devices that are better suited for these learners? The purpose of this review is to outline published and validated critical care mnemonics, while analyzing the strengths and drawbacks of using such tools in the ICU. Creative solutions for preceptors and the profession are presented to move beyond the basic use of mnemonic devices and enhance critical care rotations for both the learner and the preceptor. This knowledge can help preceptors make the most of their learners' experiences and implement a precepting strategy that will ensure both a smooth orientation to the unit and an emphasis on key areas for pharmacy interventions. The first widely utilized mnemonic developed for ICU patients was FASTHUG. Created by Dr. Jean-Louis Vincent in 2005, the FASTHUG mnemonic was designed to act as a tool that any member of the interdisciplinary ICU team can utilize to ensure essential elements of patient care are being addressed at least once a day. 4 The meaning of this and other critical care abbreviations are included in Table 1. The   author compared the ICU with an airplane cockpit, where the complexity and acuity of the patients demands attention to important var-iables each day. He postulated that patient care would be improved through the use of this tool each day by any ICU clinician. The FAS-THUG components are evidence-based observations, which lead to decreased length of stay and improved quality of care. 4 Although FASTHUG highlights several core elements of ICU care that can be applied to every ICU patient, it was never meant to be a comprehensive care plan. In 2009, an updated version of this mnemonic, called FASTHUGS BID, was proposed. 5 A second iteration of FASTHUG BID was later adapted to fit the needs of a surgical patient (Table 1). 17 A group of pharmacists noted that this type of abbreviation was highly effective in critical care recall, but that FASTHUG was missing key elements of the pharmacist's role. They created an adjusted mnemonic of FASTHUG-MAIDENS to better address drug-related problems including drug interactions, renal/hepatic dose adjustments, and adverse drug events. 12 Other clinicians have published other ICU mnemonic tools in editorials or blog posts. Many of these are not peer-reviewed and may be influenced by personal preferences, but they are quite creative. 11,14,18,19 Another major ICU mnemonic is the ABCDEF bundle for ICU liberation (Table 1). This mnemonic serves as an implementation tool rather than a memorization tool, and this bundle has shown to improve mortality, decrease delirium, and decrease ICU complications. 11,15 2.2 | The effectiveness of mnemonic tools in education and patient care Mnemonic tools have been used for decades to help organize disparate concepts into patterns that support recall. 20,21 These types of tools can be found in scientific papers in nearly every specialty and are seemingly more prevalent with the access of free, openaccess medical education through various media and social media outlets. The greatest strengths of mnemonic tools are that they reinforce foundational knowledge and improve recall. This has been displayed in both medical and educational literature. 20,[22][23][24] Although they improve recall, there is a distinct lack of higher order learning when mnemonics are used. 21,25 It is also uncertain whether mnemonic tools promote long-term memory formation or simply short-term support. While some psychology researchers have shown improvements with mnemonic tools in long-term memory, some studies have only displayed improvements in memory when tested within 24 h but not at 7 days after a learning event. 26,27 Putnam suggests that mnemonics are best used for educational purposes when they are directed at repetitive memorization tasks and when combined with other learning strategies. 20 Therefore, a critical care pharmacy learner likely will not experience long-term memorization benefits from the use of a mnemonic like FASTHUG. Rather, the mnemonic approach could improve the learner's adherence to items in the mnemonic; however, students may require additional support for patient assessment and recommendations.
Part of the reason that mnemonics translate well to the practice of critical care is that they have displayed improvement in patient care and outcomes in several research studies. Papadimos and colleagues conducted a retrospective study examining the rates of ventilator-associated pneumonia (VAP) in a surgical ICU before and after implementation of the FASTHUG mnemonic in 2005. 28 This process was also coupled with several procedural interventions, including oral care with chlorhexidine mouthwash, an early extubation strategy, and aggressive enforcement of hand washing.
The investigators discovered that the rates of VAP decreased sig- Masson and colleagues conducted a randomized, prospective study with pharmacy residents across four ICUs. 29 The pharmacy residents were randomized to use either the FASTHUG-MAIDENS mnemonic or standard monitoring practice to identify drug-related problems (DRPs). Utilization of FASTHUG-MAIDENS resulted in a greater mean proportion of DRPs identified per patient encounter compared with standard monitoring (73.2% vs. 52.4%, p = 0.008).
The most common DRP identified was related to medication reconciliation. Another retrospective, cross-sectional study evaluated the use of FASTHUG-MAIDENS to review ICU patients by a pharmacist. In total, 120 patients were retrospectively evaluated using FASTHUG-MAIDENS, which led to the identification of areas of improvement for feeding, analgesia, and sedation. 30 The most common issues identified were inadequate nutrition compared with the recommended daily caloric intake, sedation levels not being recorded, and use of non-validated tools to monitor pain and sedation. Based on these initial findings, the researchers then initiated a second phase of their experiment. The critical care pharmacist prospectively reviewed 20 patients with a FASTHUG-MAIDENS approach. The pharmacist identified 103 DRPs which led to 63 interventions being recommended by the pharmacist for these patients. The most common interventions pertained to antibiotics, feeding, stress ulcer prophylaxis, and drug dosing. 29 When critical care practitioners use these mnemonics, it can improve patient outcomes. The patient-specific improvements were achieved when combined with advanced knowledge of the critical care patient which is still developing in a pharmacy trainee. Therefore, the use of these tools in our learners may not translate to tangible success. To date, there is only a single study where pharmacy trainees were evaluated on the use of these mnemonic devices. 29 As such, more research needs to be conducted to validate the widespread use of a mnemonic in an APPE or PGY1 setting. Though mnemonics have a longstanding history of effectiveness in general education, it is still unknown whether ICU mnemonics adequately address the needs of pharmacy learners.

| Mnemonics lack desirability for pharmacy learners
One significant challenge of mnemonic use is the disparity between their design and the desired learning environment of current pharmacy learners. Most current pharmacy students fall into Generation Z or "Gen Z," which is comprised of students born from 1995/1997 to 2012. 9,10 It is important to note that generational stereotypes are not exact but provide a framework for better understanding Gen Z learners and their motivations. Most current pharmacy learners are independent and prefer convenient learning modalities with more kinesthetic and visual teaching methods (as opposed to lecturing). They desire immediate, honest feedback, they are socially connected, and they view technology as a way to collaborate, create, and share knowledge. Additionally, Gen Z students report a desire to apply knowledge through scenario-based education, in order to better prepare them for real-world experiences. 9 Members of this generation are highly reliant on technology and social media but may experience more anxiety, depression, and feelings of inadequacy as a result. 39,40 This reliance on technology may also lead to more insecurity than previous generations. 39 Gen Z learners prefer individualized, hands-on learning experiences, customized feedback, and want to know what it takes to succeed in the moment, similar to their immediate and customizable experiences on social media. 39 Although they are hardworking, Gen Z students typically have short attention spans and may be less likely to ask questions when they are unsure, due to uncertainty and anxiety. 10,39 Based on these generational characteristics, further described in Table 3, a mnemonic device may be poorly matched to    44 Checklists have also been associated with decreased occurrence of ventilator-associated pneumonia (VAP) and improved compliance with sedation interruptions and head of bed interventions. 45,46 Even pharmacotherapy interventions, like stress ulcer prophylaxis, have been improved through the use of a checklist. 45 A checklist provides a tangible asset for learners to use in their evaluation of a patient, which is particularly fruitful for Gen Z learners.

| The clinician's approach for improving rotations
Additional strategies could be to implement a different process for patient assessment and evaluation. Common strategies utilized include both a systems-based approach or a problem-based approach.
The systems-based approach follows the standardly taught review of systems and commonly evaluates organ systems from the head and moving downward. Pharmacy learners could identify needs within T A B L E 3 Generation Z learners and commentary on mnemonic teaching tools.  51 The priority placed on competency-based education helps to ensure that a pharmacy learner not only memorizes pharmacotherapy facts, but can apply them to patient care. This is critical in the information age when drug therapies are expanding rapidly and learners must critically evaluate a vast array of literature for evidence-based patient care decisions. Furthermore, an emphasis on the PPCP during pharmacy school can facilitate a more natural transition into a clinical experience that demands learners develop and monitor pharmacotherapy patient care plans. As more schools of pharmacy incorporate the PPCP into their curriculum, it will be important that preceptors become familiar with this concept. Using the common language included in the PPCP will align with the learners training, pre-reading in common pharmacotherapy textbooks, and support success in the ICU. 52,53 Additionally, schools of pharmacy can leverage pedagogies and technology to facilitate learner success in the ICU. Generation Z responds well to active involvement in their learning, particularly in a setting associated with individual success. 9,10 Therefore, the use of the "flipped classroom" which engages the students directly with content can enhance learning in the didactic setting and better translate to the bedside. Critical care pharmacists who teach at schools of pharmacy are encouraged to deliver education via an active learning strategy. 54 Another educational initiative that may improve learners' ability to integrate into the ICU is the use of practice electronic health records (EHRs). Due to the prominence of technology in medical care, familiarization with health technology tools was emphasized as critical by a recent task force of the American Association of Colleges of Pharmacy. 55 One study found that the use of EHR technology for an order verification activity improved students' confidence and competence in managing a patient case. 56 Additionally, the use of a simulated EHR improved student perceptions of APPE-preparedness and efficiency when using a real medical chart. 57 The use of these products is encouraging, but further data are needed to determine whether these skills translate into success in an APPE experience.
Pharmacy and critical care professional organizations can also promote learner preparedness for the ICU setting. Networks of critical care pharmacists from across the globe have more access to one another than ever before through the use of list-servs and instant communication. Utilizing these resources to create a centralized precepting repository of resources could facilitate improved teaching strategies for younger preceptors and more efficient use of time for ICU pharmacists. Furthermore, a repository could organize tools that apply to both general and specialized ICUs to meet the needs of preceptors from a variety of ICUs. This could also be supported at annual meetings of clinical pharmacy organizations through preceptor development sessions dedicated to sharing tools that have been used successfully.
Finally, professional organizations can facilitate ICU preceptor teaching strategies through the development of a packet of review materials and pre-rotation readings that are written to the level of the learner. Professional journals could invite authors to outline a series of review papers that preceptors could use as pre-reading for their ICU rotations. Ideally, these review articles would be written at the level of a pharmacy learner and include overviews that are evidence-based, practical, and critical care pharmacotherapy-focused. Furthermore, leveraging the use of new technology, social media, video media, and podcasts could cater to the next generation of learners.
While these learners still need to know how to find and review guidelines, the use of interactive media to support learning this content can enhance a critical care rotation.

| CONCLUSION
Preceptors strive for excellent rotations, and the ICU provides a great learning environment for students. Mnemonics can be useful recall tools, but they must be strategically deployed in a pharmacy rotation in order to be effective. The current mnemonic tools, including FAS-THUG, can be enhanced when thoughtfully deployed by the preceptor and supported by strong background knowledge from the academy of pharmacy schools. Preceptors who identify the limitations of mnemonic tools and adapt them to their current learners can improve the experience for both themselves and their learners while providing excellent patient care.

ACKNOWLEDGMENTS
The authors thank Dr. Sandra Kane-Gill for her helpful comments and thorough review of the manuscript.

FUNDING INFORMATION
There was no external funding for this research.