Pharmacy Services

Pharmacy Services Residency

Neurosurgery and Neurology

 (PGY1 Rotation - Acute Care)

 
Preceptors:

Gary Davis, PharmD
Chad Condie, PharmD

 
Site Description:

The Neuro Critical Care Unit (NCCU) located on the third floor of University of Utah Hospital is a 15-bed critical care and step-down unit including neurology and neurosurgery patients.

 
Rotation Description:

The pharmacist functions as part of a multidisciplinary team comprised of a Neurointensivist, neurology and neurosurgery residents, nurse  practitioner, medical students, 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, seizure prophylaxis, status epilepticus, brain tumors, myasthenia gravis, epilepsy, Guillain-Barre syndrome, anticoagulation management, and other medical and neurological disorders.  In addition, training will include DVT prophylaxis, stress ulcer prophylaxis, nutritional support, antibiotic therapy, increased intracranial pressure monitoring, cerebral physiology, neuromuscular blockade, etc.

 
RLS Goals:

  1. R1.4  Demonstrate ownership of and responsibility for the welfare of the patient by performing all necessary aspects of the medication-use system.
    1. OBJ R1.4.1  Display initiative in preventing, identifying, and resolving pharmacy-related patient-care problems.
  2. R2.2  Place practice priority on the delivery of patient-centered care to patients.
    1. OBJ R2.2.1  Choose and manage daily activities so that they reflect a priority on the delivery of appropriate patient-centered care to each patient.
  3. R2.6  Design evidence-based therapeutic regimens.
    1. OBJ R2.6.1  Specify therapeutic goals for a patient incorporating the principles of evidence-based medicine that integrate patient-specific data, disease and medication-specific information, ethics, and quality-of-life considerations.
    2. OBJ R2.6.2  Design a patient-centered regimen that meets the evidence-based therapeutic goals established for a patient; integrates patient-specific information, disease and drug information, ethical issues and quality-of-life issues; and considers pharmacoeconomic principles.
  4. R2.9  Implement regimens and monitoring plans.
    1. OBJ R2.9.1  When appropriate, initiate the patient-centered, evidence-based therapeutic regimen and monitoring plan for a patient according to the organization's policies and procedures.
    2. OBJ R2.9.2  Use effective patient education techniques to provide counseling to patients and caregivers, including information on medication therapy, adverse effects, compliance, appropriate use, handling, and medication administration.
  5. R2.11  Communicate ongoing patient information.
    1. OBJ R2.11.1  When given a patient who is transitioning from one health care setting to another, communicate pertinent pharmacotherapeutic information to the receiving health care professionals.
    2. OBJ R2.11.2  Ensure that accurate and timely medication-specific information regarding a specific patient reaches those who need it at the appropriate time.

Activities Evaluated:

Objective Number  (Level of Learning Required) & Description

Teaching Method(s)

Related Rotation Activities & Minimum Number of Times the Activity is Repeated to Ensure Completion of the Objective.

Goal R1.4: Place practice priority on the delivery of patient-centered care to patients.

OBJ R1.4.1  Display initiative in preventing, identifying, and resolving pharmacy-related patient-care problems

Direct Instruct.
Coaching
Facilitating
Modeling

The rotation will emphasize the delivery of patient care over all other aspects of the rotation experience.  Residents will independently identify medication issues in the Neuro-ICU patients assigned to their care. Residents will work with the interdisciplinary team to both identify and resolve issues in a timely fashion. During the course of the rotation, residents will learn skills that will help them identify risk factors for common preventable medication issues in the Neuro-ICU. Residents will use this information to prevent errors, disease-related problems, and develop proactive plans in the care of NCC patients.

Goal R2.2: Place practice priority on the delivery of patient-centered care to patients.

OBJ R2.2.1 (Organization) Choose and manage daily activities so that they reflect a priority on the delivery of appropriate patient-centered care to each patient.

Direct Instruct.
Coaching
Facilitating
Modeling

The rotation will emphasize the delivery of patient care over all other aspects of the rotation experience.  All topic discussions, formal presentations, meetings, etc. will occur only when all other patient care services have been delivered.

Goal R2.6: Design evidence-based therapeutic regimens.

OBJ R2.6.1 (Synthesis) Specify therapeutic goals for a patient incorporating the principles of evidence-based medicine that integrate patient-specific data, disease and medication-specific information, ethics, and quality-of-life considerations.

Coaching
Facilitating
Modeling

During this rotation, there will be opportunities to incorporate evidence-based medicine into the creation of patient-specific plans with specific therapeutic goals.  On a daily basis the resident will utilize information obtained from patient and topic discussions, journal reviews, and previous experiences to formulate individualized patient plans.  In particular, the resident will experience discussions with preceptors, the neuro team, and most importantly, patient and family members on a daily basis on most patients.

BJ R2.6.2 (Synthesis)  Design a patient-centered regimen that meets the evidence-based therapeutic goals established for a patient; integrates patient-specific information, disease and drug information, ethical issues and quality-of-life issues; and considers pharmacoeconomic principles.

Direct Instruct.
Coaching
Facilitating
Modeling

The resident is expected to 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 will be incorporated into the individualized therapeutic 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 considerations will be addressed.  It will be expected that residents 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), and lastly monitoring parameters.

 

 

Objective Number  (Level of Learning Required) & Description

Teaching Method(s)

Related Rotation Activities & Minimum Number of Times the Activity is Repeated to Ensure Completion of the Objective.

Goal R2.9: Implement regimens and monitoring plans.

OBJ R2.9.1 (Application) When appropriate, initiate the patient-centered, evidence-based therapeutic regimen and monitoring plan for a patient according to the organization's policies and procedures.

Direct Instruct.
Coaching
Facilitating
Modeling

The resident will participate daily in multidisciplinary rounds.  Prior to daily rounds the resident will create an individualized pharmacotherapy plan for each of their patients and discuss these plans with the preceptor.  Early in the rotation the resident will first observe how/when the preceptor initiates a therapeutic plan.  The pre-rounds discussions with the resident will provide time for feedback and appropriate of the resident’s plan prior to implementation during rounds. 

OBJ R2.9.2 (Application)  Use effective patient education techniques to provide counseling to patients and caregivers, including information on medication therapy, adverse effects, compliance, appropriate use, handling, and medication administration.

Direct Instruct.
Coaching
Facilitating
Modeling

The resident will act as the primary pharmacy liaison with the Neurocritical Care Unit.  They are expected to answer drug information, policy, regulatory, and provide counseling to patients and their family members. 

 

                                                             

Goal R2.11: Communicate ongoing patient information.

OBJ R2.11.1 (Application)  When given a patient who is transitioning from one health care setting to another, communicate pertinent pharmacotherapeutic information to the receiving health care professionals.

Direct Instruct.
Coaching
Facilitating
Modeling

The resident is expected to compose a pharmacy specific transfer summary for each of the patients that they follow when that patient has been in the NCCU longer than 24 hours.  The summary note will include:  a brief synopsis of why the patient was initially admitted to the hospital in addition to why they were admitted to the Neurocritical Care.  They will also provide a pharmacy specific problem list with a history of what happened in the NCCU and follow up requirements for each of these problems.  They will also provide a detailed antibiotic history for each patient.  The resident will also include what the patient is receiving for DVT prophylaxis and if the patient’s medication/vaccination history is incomplete a reason why it was not completed.  All notes will be reviewed by the preceptor before being entered in the medical chart. 

OBJ R2.11.2 (Application)  Ensure that accurate and timely medication-specific information regarding a specific patient reaches those who need it at the appropriate time.

Direct Instruct.
Coaching
Facilitating
Modeling

The resident is expected to communicate any modification of the therapeutic plan to the team.  The resident will communicate any modifications with the preceptor who will also assist the resident in determining the optimal communication strategy, including how urgently the modification needs to be addressed.

 
Typical Day

0700-0830 Work up patients, resolve questions / medication related issues that arose overnight (Residents should arrive earlier if additional time is need to be fully prepared for rounds.)
0830-1200 Round on all neurosurgery/ neurology patients in the NCCU, IMCU
1200-1230 Lunch
1230-1600+ Complete medication reconciliations, topic discussions and teaching, attend meetings, perform patient  education (eg, anticoagulation, new meds), enter pharmacy progress notes, resolve medication related issues that have arisen throughout the day, work up new patients

*Note that patient care may require additional hours to ensure adequate follow-through on care issues and medication problems.

 
Topic Discussions

  1. Introduction to neurosciences
    1. Neuroanatomy and physiology (Greenberg Ch. 3)
    2. CSF physiology (Greenberg Ch. 7)
    3. Rating scales (GCS, NIX, Riker)
    4. Imaging (CT, CTA, MRI)
    5. Drains and lines (EVD, LD, PEG, DHT)
    6. NCC order sets (Bowel, electrolyte)
  2. Subarachnoid hemorrhage (SAH)
    1. Vasospasm
    2. Triple H therapy
  3. Other hemorrhages
    1. IVH
    2. IPH
    3. SDH
  4. Traumatic brain injury (TBI)
    1. Elevated ICP (CPP= MAP-ICP)
    2. Cerebral edema
    3. Hypertonic therapy (3%, 23.4%)
  5. Stroke
    1. Ischemic
      1. Post tPa management
      2. Secondary stroke prevention
    2. Hemorrhagic
  6. Status Epilepticus
    1. Initial management
    2. Pentobarbital
    3. Seizure prophylaxis
  7. CNS infections
    1. Meningitis
    2. Cerebral abscesses
    3. Shunt infections
  8. SIADH/ Salt wasting
  9. Diabetes Insipidus
  10. Chiari malformations
  11. Brain death/ donor patient management
  12. Gliomas/ brain tumors
  13. Spinal cord injury
  14. Autoimmune diseases
    1. MG
    2. GBS
    3. AIDP
  15. Afib with RVR

Evaluations Strategy

Residents will be provided with verbal feedback on a frequent (at least every other day, possibly several times daily) basis. ResiTrak will be used for documentation of scheduled evaluations. For all evaluations completed in ResiTrak, the resident and the preceptor will independently complete the assigned evaluation and save as draft.  The resident and the preceptor will then compare and discuss the evaluations.  This discussion will provide feedback both on performance of the activities and the accuracy of the resident’s self-assessment skills.  Evaluations will be signed in ResiTrak following this discussion.


What type of evaluation

Who

When

Midpoint

Preceptor, Resident

End of week 2

Summative

Preceptor

End of learning experience

Summative Self-evaluation

Resident

End of learning experience