Pharmacy Services

Pharmacy Services Residency

Acute Pulmonary Internal Medicine

 (PGY1 Rotation - Acute Care)

 
Preceptor:

Zubin Bhakta, PharmD

 
Site Description:

The pulmonary internal medicine service at the University of Utah Hospital currently consists of one team. The team will consist of one attending physician, one medical resident, one potential 3rd year medical student, 1 potential PGY2 Internal medicine pharmacy resident. The pulmonary internal medicine team consists of up to 12 patients. The majority of pulmonary internal medicine patients are located on the Acute Internal Medicine B unit (AIMB), however patients can be located throughout the hospital. All patients will have an underlying pulmonary disease and are often followed by our outpatient pulmonologists; however we are a primary team so we will be responsible for all aspects of the patient’s care. Common reasons for admission include infection, coagulopathies, pulmonary dysfunction, liver dysfunction, and renal failure. Patients often present with multiple disease states and complicated drug regimens.

 
Rotation Description:

The pharmacist functions as part of a multidisciplinary team. Primary responsibilities include daily review of medication profiles, patient educations, reconciliation of home medications and improving medication dosing and utilization in all patients.

Residents contribute to patient care by monitoring patients, making recommendations to the medical team to improve care, and by facilitating the delivery of medications. Residents will round with one of the internal medicine teams.

Presentations include daily patient presentations, bi-weekly topic discussion, weekly formal case presentations, one journal club, and one educational presentation/in-service.

 
RLS Goals:

  • Goal R1.1 In collaboration with the health care team, provide safe and effective patient care to a diverse range of patients, including those with multiple co-morbidities, high-risk medication regiments, and multiple medications following a consistent patient care process
    • OBJ R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy
    • OBJ R1.1.2 Interact effectively with patients, family members, and caregivers
    • OBJ R1.1.3 Collect information on which to base safe and effective medication therapy
    • OBJ R1.1.4 Analyze and assess information on which to base safe and effective medication therapy
    • OBJ R1.1.5 Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans)
    • OBJ R1.1.6 Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions
    • OBJ R1.1.7 Document direct patient care activities appropriately in the medical record or where appropriate
    • OBJ R1.1.8 Demonstrate responsibility to patients
  • Goal R1.2 Ensure continuity of care during patient transitions between care settings
    • OBJ R1.2.1 Manage transitions of care effectively
  • Goal R1.3 Prepare, dispense, and manage medications to support safe and effective drug therapy for patients
    • OBJ R1.3.2 Manage aspects of the medication-use process related to formulary management
  • Goal R3.1 Demonstrate leadership skills
    • OBJ R3.1.1 Demonstrate personal, interpersonal, and teamwork skills critical for effective leadership
    • OBJ R3.1.2 Apply a process of on-going self-evaluation and personal performance improvement
  • Goal R3.2 Demonstrate management skills
    • OBJ R3.2.4 Manage one’s own practice effectively
  • Goal R4.1 Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and group)
    • OBJ R4.1.1 Design effective educational activities

Activities Evaluated:

midterm and final

RLS Objective

Rotation Activity

Teaching Method

OBJ R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy

Residents will act as an effective member of the medication-use safety team to ensure the safety and welfare of the patient. Examples: assisting physicians with medication dosing/route, assisting nursing staff with questions such as IV compatibility.

Residents will round daily with one of five internal medicine teams.  Residents will have the option of rounding with the preceptor the first day but will round independently for the remainder of the rotation, which will allow the resident to establish a collaborative, professional relationship with members of their medical team.  The number of patients will vary daily, but each internal medicine team can have a maximum of 20 patients. 

Direct Instruction
Modeling
Coaching
Facilitation

OBJ R1.1.2 Interact effectively with patients, family members, and caregivers

Residents will complete admission medication histories, provide anticoagulation educations and provide medication counseling to patients and their families when appropriate.

Coaching
Facilitation

OBJ R1.1.3 Collect information on which to base safe and effective medication therapy

Residents will collect and update daily pharmacy progress notes with the newest laboratory results, microbiology results, pertinent imaging results and review any pertinent progress notes related to the patient’s care.  Residents are expected to update daily pharmacy progress notes prior to the start of rounds each day.  Residents will complete accurate medication histories and provide appropriate documentation.

Modeling
Coaching
Facilitation

OBJ R1.1.4 Analyze and assess information on which to base safe and effective medication therapy

Residents will take into account each patient’s comorbidities, allergies, weight, laboratory values, vitals, renal function, hepatic function, and current medications prior to recommending a new drug therapy.

Modeling
Coaching
Facilitation

OBJ R1.1.5 Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans)

Residents will adjust medication recommendations based on changes in patient’s conditions (ie. Cr, BP, BG, drug levels, labs, cultures)

Modeling
Coaching
Facilitation

OBJ R1.1.6 Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions

Residents will be responsible for implementing the medication changes discussed during rounds and subsequent medication monitoring (efficacy, side effects).  Residents will follow-up with their team daily after discussing patients with their preceptor.

Modeling
Coaching
Facilitation

OBJ R1.1.7 Document direct patient care activities appropriately in the medical record or where appropriate

Residents will document anticoagulation educations, medication histories, pain management, iVents, and pharmacokinetic notes (when applicable) on patients.

Direct Instruction
Modeling
Coaching
Facilitation

OBJ R1.1.8 Demonstrate responsibility to patients

Residents will evaluate each patient thoroughly and follow-up on recommendations and medication management of the patient throughout the day. 

Coaching
Facilitation

OBJ R1.2.1 Manage transitions of care effectively

Residents will update pharmacy pass-off notes daily to ensure continuity of care during transitions of care. If information needs to be communicated in a timely manner, resident will call or page the new pharmacist with the information.  Residents will also review patient’s discharge medication list to ensure proper medications are continued or stopped upon discharge.  

Modeling
Coaching
Facilitation

OBJ R1.3.2 Manage aspects of the medication-use process related to formulary management

Residents will learn to identify & resolve medication problems and formulate therapeutic regimens that are evidence-based for all patients on their internal medicine team.

Facilitation

OBJ R3.1.1 Demonstrate personal, interpersonal, and teamwork skills critical for effective leadership

Residents will make recommendations during rounds after formulating evidence-based therapeutic regimens for all patients on their internal medicine team.  Residents will present patients to the preceptor daily and make follow-up recommendations with their internal medicine team if needed after rounds. 

Modeling
Coaching
Facilitation

OBJ R3.1.2 Apply a process of on-going self-evaluation and personal performance improvement

Residents will be conscientious of their work and strive toward providing the best possible care at all times. 

Facilitation

OBJ R3.2.4 Manage one’s own practice effectively

Residents are expected to act as the primary pharmacist for their internal medicine team.  Residents will have the option of rounding with the preceptor the first day but are expected to round independently for the remainder of the rotation.  Residents are expected to update all pharmacy progress notes for patients on their internal medicine team daily before rounds and to complete all patient care activities prior to meeting with the preceptor in the afternoons.

Direct Instruction
Modeling
Facilitation
Coaching

OBJ R4.1.1 Design effective educational activities

Residents are expected to provide patient education as appropriate.  These include anticoagulation educations, medication education of an existing home medication, or new medication educations.

Residents will tailor education to their specific audience.  Patient educations, physician in-service, case-presentations, topic discussions, and journal clubs are examples of educational activities on rotation.

Residents will provide specific learning objectives during formal presentations.  i.e.  internal medicine physician in-service

When applicable, residents will serve as a role-model for DP4 students on their internal medicine rotation.

Residents will present weekly formal case presentations on Fridays.  The formal case presentation will focus on a topic related to a specific patient’s reason for admission and a formal handout will be required.

Residents will present a final in-service on an internal medicine topic to their internal medicine team. The presentation will include formal handouts.

Residents will provide a handout to their preceptor for topic presentations, journal club, and case presentations.  Residents will provide a handout to the internal medicine team during the final in-service.

Direct Instruction
Facilitation
Coaching

 
Readings and prep work:

Core topics that will be covered with assigned readings prior to topic discussions include the following:

  • Anticoagulation – ACCP Chest guidelines
  • Diabetes Mellitus
  • Fluid/Electrolyte Replacement & Management
  • Hepatic Disorders - alcohol-induced, autoimmune, cholecystitis, ascites, cirrhosis
  • Infectious Disease - pneumonia, UTI, cellulitis, opportunistic infections
  • Pharmacokinetics - vancomycin, aminoglycosides, beta lactams
  • Pulmonary - COPD, asthma, cystic fibrosis, lung transplant, pulmonary fibrosis, tuberculosis, pulmonary arterial hypertension (Since all of our patients will have an underlying pulmonary disorder, we will cover a variety of pulmonary topics)
  • Renal Disorders - acute and chronic

Residents are encouraged to request elective topics to be covered

 
Project description:

  1. Case presentation (weekly)
    • Patient presentation in SOAP note format
    • Topic presentation that focuses on a specific disease state relevant to a patient
    • Formal hand-out and presentation
  2. Topic discussion (weekly)
    • Formal hand-out and presentation
    • Examples of topics: AKI, alcoholic hepatitis, anemia, pneumonia
  3. Journal Club (1)
    • Topic must be related to internal medicine
    • Article published within the last year
    • Likely to impact patient care
    • Formal hand-out and presentation
  4. Inservice presentation (1)
    • Examples of past topics include: DVT prophylaxis, insulin review, bowel regimens, overview of QTc prolonging medications, antibiotic coverage, overview of NOACs
    • Formal hand-out and presentation

Typical Daily/Weekly/Monthly activities:

A typical day will be 0700-1530 but additional hours are usually necessary to complete projects, readings for topic discussions, journal club and attend meetings.
0700-0900 Round preparation- patient monitoring and med reconciliations
0900-1200 Internal medicine rounds
1300-1400 Patient presentations- identify and resolve follow-up issues with medical team
1400-1500 Topic discussion with preceptor
1500 + Additional time to work on medication reconciliations, projects, topic discussions and resolve any remaining follow-up issues with medical team

 
Evaluation:

The resident will receive feedback on their progress each day as they discuss patients with the preceptor. The preceptor will provide formative feedback for case presentations, journal clubs and in-service. There will be a snapshot of their progress at 2 weeks and a summative evaluation of strengths, areas for development, and specific feedback to take to the next rotation. A formal final summative evaluation will occur on the last day of rotation.

Updated March 2016