Pharmacy Services

Pharmacy Services Residency

Neurosurgery and Neurology

 (PGY1 Rotation - Acute Care I & II)

 
Preceptors:

  • Gary Davis, PharmD
  • Chad Condie, PharmD, BCCCP
  • Ryan McTish, PharmD

 
Site Description:

The Neuro Critical Care Unit (NCCU) located on the third floor of University of Utah Hospital is a 23-bed critical care and step-down unit including neurology and surgery critical care patients.

 
Rotation Description:

The pharmacist functions as part of a multidisciplinary team comprised of a Neurointensivist, neurology and neurosurgery residents, nurse practitioner, medical students, respiratory therapist, clinical dietician and neuroscience nurses. Pharmacists in the NCCU are expected to round daily on all patients, provide drug information, counsel patients, and facilitate medication delivery. Didactic and experiential training includes a focus in the following areas: ischemic and hemorrhagic stroke, meningitis, closed head injury, spinal cord injury, status epilepticus, brain tumors, myasthenia gravis, epilepsy, Guillain-Barre syndrome and other medical and neurological disorders. In addition, training will include DVT prophylaxis, stress ulcer prophylaxis, seizure prophylaxis, anticoagulation management, nutritional support, antibiotic therapy, increased intracranial pressure monitoring, cerebral physiology, neuromuscular blockade, etc.

 
Role of the Pharmacist:

The role of the Neurocritical Care pharmacist includes rounding with the multidisciplinary team in the critical care unit, reviewing appropriateness of therapy, addressing adverse drug reactions, reviewing labs and recommending drug therapy as indicated. The pharmacist completes a comprehensive treatment plan for each patient and documents interventions appropriately. The pharmacist ensures that a medication reconciliation has been completed on each patient and recommends appropriate home medications as indicated.

 
RLS Goals: ICU 1

  • R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy
  • R1.1.3 Collect information on which to base safe and effective medication therapy
  • R1.1.4 Analyze and assess information on which to base safe and effective medication therapy
  • R1.1.5 Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans)
  • R1.1.6 Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions
  • R1.1.8 Demonstrate responsibility to patients
  • R1.2.1 Manage transitions of care effectively
  • R3.1.1 Demonstrate personal, interpersonal, and teamwork skills critical for effective leadership

 
RLS Goals: ICU 2

  • R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy
  • R1.1.3 Collect information on which to base safe and effective medication therapy
  • R1.1.6 Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions
  • R1.1.8 Demonstrate responsibility to patients
  • R1.3.2 Manage aspects of the medication-use process related to oversight of dispensing
  • R3.1.2 Apply a process of on-going self-evaluation and personal performance improvement
  • R3.2.4 Manages one’s own practice effectively

 
Expectations of the Resident:

The pharmacy resident is responsible for identifying and resolving medication therapy issues for patients on the NCCU unit throughout the learning experience. The resident will provide therapeutic drug monitoring services for all assigned patients and work toward documenting all activities and pharmacist pass-off. Good communication and interpersonal skills are vital to success in this experience. The resident must devise efficient strategies for accomplishing the required activities in a limited time frame.

Teaching Methods include: I=direct instruction, C=coaching, M=modeling, and F=facilitation

NCCU Rotation Activities and Teaching Methods Linked to Objectives: The activities assigned to this learning experience reflect the activities a resident working in this environment are expected to be able perform. It is not expected that any particular resident be able to fulfill all of the necessary behaviors and actions of a pharmacist that regularly serves in this unit. It is expected that the resident demonstrate proactiveness and accountability in patient care. There is not usually one discrete activity assigned to help achieve an objective and/or goal.

Rotation Activity

RLS Goal

Teaching Method

Participate in interdisciplinary team rounds

R1.1.1

C, M, F

The resident is expected to compose a pharmacy pass-off using the “handoff” note in EPIC for each of the patients that they follow.

The note will contain the following at a minimum:

  • A brief synopsis of why the patient was initially admitted to the hospital in addition to why they were admitted to the Neuro ICU (NCCU).
  • A pharmacy specific problem list with a history of what happened in the NCCU and follow up requirements for each of these problems
  • A detailed antibiotic history for each patient
  • DVT prophylaxis
  • If the patient’s medication/vaccination history is incomplete, the reason why it was not completed and the information needed to complete the medication reconciliation.

The resident is expected to update these notes on a daily basis. A section at the bottom of the handoff will include interventions/discussion that is initiated by the resident. It is also expected that the resident will note pertinent issues for follow-up.

R1.1.3
R1.2.1

I, C , F

For each patient that the resident follows (up to 15 patients by the end of the rotation), the resident is expected to, at a minimum, create an individualized therapeutic plan that incorporates patient-specific information obtained from the patient, family members, other health care members, outpatient pharmacy records, and the medical record. Disease and drug information obtained from previous experiences, topic discussions, and literature reviews are also expected to be incorporated into the individualized therapeutic plan. The integration of the patient’s goals of care, ethical considerations, and quality of life concerns are expected to be included in each plan. The preceptor will assess the resident’s ability to perform adequate literature searches (primary, tertiary literature, various other medication databases, etc.) and assist the resident through direct instruction on how to improve in their ability to obtain answers for clinical questions. When applicable, pharmacoeconomic and formulary considerations will be addressed. It will be expected that the resident will evaluate every medication for appropriateness, dosing based on individualized pharmacokinetic/dynamic considerations, route of medication administration (including formulation since this is a significant issue in the critically ill patient), drug interactions, and monitoring parameters. The resident will prepare these therapeutic plans on a daily basis prior to rounds; however, these plans are dynamic and will change throughout the day based on the patient’s condition. These plans will be discussed with NCCU team during teaching rounds.

The resident will demonstrate reasonable competency in operation of Omnicells for medication administration during ordinary and emergency circumstances. The resident will also verify medication orders in urgent situations to facilitate rapid dispensing of medications.

R1.1.1
R1.1.3
R1.1.4
R1.1.5
R1.1.6
R1.1.8
R3.1.1

I, C, F

The resident will create patient-centered, evidence-based monitoring plans using their previous clinical experiences, review of the literature, and incorporation of consensus guidelines. The resident will be coached on ways to determine when it is feasible and useful to obtain laboratory markers for monitoring of their pharmacotherapy (Ex. Determining when it is appropriate to obtain a vancomycin level to assess dosing adequacy or when AED levels are appropriate). The preceptor(s) will aid the resident through direct instruction in regards to common problems the resident may be exposed to including: medication or specialized nutrition support with no indication; absence of medication necessary for acute or chronic disease state management such as adequate DVT prophylaxis in the Neuro population, seizure prophylaxis, and optimal blood pressure control to ensure maximal cerebral perfusion; inappropriate dosing, dosage form, schedule, or route/method of administration; therapeutic duplication; medication prescribed to which patient is allergic; adverse drug reactions, the appropriate use of steroids for managing cerebral edema, etc

R1.1.6
R1.1.8

I,C F

The resident will have ample opportunities to support the allocation of resources, particularly with regard to high-cost or high-risk drug items and wastage.

The resident is expected to:

  • Work with physicians and nurses to utilize high-risk or high-cost medications only when necessary and help recommend alternatives as necessary. Examples would be the appropriate use of IV Levetiracetam and Nicardipine.
  • Recognize supply and shortage issues prior to recommending therapies.

Help address wastage issues in the NCCU setting by working closely with physician and nursing staff to address the discontinuation of medications or the ability of the patient to utilize oral / feeding tube administration as opposed to intravenous administration.

R1.3.3

C, F

The resident will be expected to:

Present patients to preceptor daily (or more often if necessary) in concise and logical manner.

  • Prepare and lead at least 4 topic discussions on various disease states and management. The resident will present to the preceptors and be prepared for post-presentation discussion. The resident is expected to use a combination of tertiary and primary literature to create topic discussions.
  • Time permitting, prepare and present a formal topic to the NCCU team.

Participate in development of NCCU protocols and research as needed if opportunities arise.

R1.1.5

M, F

The resident will:

  • Continuously incorporate all feedback provided by preceptor and medical team to enhance performance and effectiveness in patient workups, rounds, communication, and other patient care activities.
  • Recognize patterns and attempt to utilize past feedback to develop current and future processes to avoid need for repeat feedback from preceptor.
  • Attempt answering patient care questions or general informational questions by exhausting tertiary and primary literature before asking preceptor for assistance, unless the situation is urgent and requires immediate action.
  • Provide responses in a timely manner and take full responsibility for patients.
  • Utilize and learn from the preceptors’ styles during rotation, while beginning to develop their own process during rotation in order to most effectively learn to care for patients.

Become self-sufficient and independent throughout the course of the rotation, essentially able to function as the rounding pharmacist in the NCCU.

R3.1.2
R3.2.4

M, F

 
Readings and Preparatory Work:

Readings will include relevant clinical studies which impact patient care as well as available clinical guidelines for stroke, epilepsy, meningitis, and other conditions. Other readings include: disease state reviews found within the medical and neurocritical care literature, chapters from Pharmacotherapy, as well as PSAP modules of interest.

 
Project/Presentation Description:

The trainee will present patient cases daily, inservices as needed, and conduct one journal club in which an article relevant to clinical practice is discussed and reviewed.

 
Typical Daily/Weekly/Monthly Activities:

Include following patients admitted to the Neurocritical Care service, participating in daily patient care rounds, outlining a pharmacotherapy care plan for a given disease states, patient medication education, and drug monitoring. The trainee will discuss patient cases daily and present one in-service and one journal club article.

 
Evaluations:

The resident will be assessed on their preparation for rounds and their use of the literature to develop recommendations. The preceptor will be available daily to observe the resident and will also receive feedback from the NCCU team. The resident will receive regular verbal feedback and a midpoint and final written evaluation.

Last updated September 2017