Pharmacy Services

Pharmacy Services Residency

Surgical Intensive Care Unit (SICU)

 (PGY1 Rotation - Acute Care)

 
Preceptors:

Nick Lonardo, PharmD
Kimberly Terry, PharmD
Wayne Shipley, PharmD, BCPS

 
Site & Rotation Description:

The Surgical Intensive Care Unit (SICU) is a 12-bed inpatient unit serving trauma, vascular, transplant, and general surgery patients. Patients in the SICU are managed by an attending physician, surgical, anesthesia, emergency medicine, and OB/GYN residents and fellows, clinical nurses, medical students, dieticians, pharmacists, and respiratory therapists. The acuity is very high and it is not unusual for patients to stay greater than 30 days.

The clinical pharmacist on the SICU is responsible for ensuring the clinical appropriateness and safety of all medications prescribed for admitted patients, verifying the accuracy and appropriate dispensing of physician orders, performing medication reconciliation upon admission, and daily documentation in the electronic medical record. The clinical pharmacist actively participates in multidisciplinary rounds daily or multiple times daily depending on patient acuity and attending preference and is responsible for medication-related education of patients and their family members, physicians, nurses, and pharmacy trainees. The pharmacist functions in a decentralized capacity and works directly with the SICU team and patients’ primary services as well as centralized pharmacists and pharmacy technicians to optimize pharmaceutical care for these units. The pharmacist also works with the SICU team on pertinent research projects and updating and maintaining standards of practice and protocols for the SICU. The pharmacist also participates in pharmacy department educational activities and meetings as much as time allows based on the needs of the SICU service. The resident will also have the opportunity to participate in the weekly interdisciplinary meeting for SICU.

SICU is a required, 4-week learning experience at the University Hospital at the University of Utah. The pharmacy resident is responsible for identifying and resolving medication therapy issues for patients and will work toward assuming care of all patients on the unit throughout the learning experience. The resident will provide therapeutic drug monitoring services for patients on their team receiving drugs requiring monitoring including, but not limited to, warfarin, aminoglycosides, and vancomycin. The pharmacy resident will work toward documenting all activities on all patients on the SICU, but assistance will be provided by the preceptor as needed to complete notes. 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.

 
Disease States:

Residents will be exposed to many types of surgery and disease states during rotation (i.e. specialized nutrition support, abdominal injuries and surgeries, management of trauma patients, etc). Disease states reviewed during rotation depend highly on the variable patient population. The resident will be expected to gain proficiency through literature review, topic discussion, and/or direct patient care experience. Pertinent articles to be chosen from are in a separate reading list. Since this type of learner will presumably be well versed in general topics, readings will be aimed at providing broad exposure to critical care-based topics, with emphasis on those encountered in the Surgical ICU setting.

 
SICU Rotation Activities and Teaching Methods Linked to Objectives:

Rotation Activity

Teaching Method(s)

Objective

Throughout the course of the rotation, the resident is expected to become competent and comfortable assuming the role of the rounding pharmacist. 

The resident will:

  •  Learn to collect patient data, review medication profile for appropriate therapy, design therapeutic plans and monitoring, and implement the plan with redesigning as necessary.
  • Be responsible for discussion/integration of all patient data during daily pre-rounds and post-rounds discussions with the preceptor and during multidisciplinary rounds with the team.  Initially, the resident will perform these functions with the close supervision of the preceptor, but as comfort and competency improve, the resident will be expected to take on more and more of the direct patient care activities and ultimately assume care of the patients.
  • Participate in multidisciplinary rounds daily and multiple times daily based on patient needs and attending preferences.
  • During rounds, present and implement the regimens created from earlier review of the patient specific data, evidence-based literature, and direct discussion with preceptor prior to rounds. 
  • Become proficient in speaking with confidence and efficiency to the medical team, utilizing pertinent information and communicating only pertinent data. 
  • Become an excellent listener and learn from the medical team so as to collaborate on patient specific care plans and regimens. 
  • Become a facilitator of patient care at all times. The resident will also be respectful and personable at all times, and is anticipated to gain the confidence of their team over the course of the rotation through daily interaction. 
  • Gain perspective of the various ways to solve patient care issues in the ICU setting based on interpretation of patient data, literature, and various experiences from members of the ICU team.
  • Strive to become the primary pharmacy liaison with the
    SICU team and patients by the conclusion of the rotation. 
  • Answer drug information questions, policy questions, regulatory questions, and provide any necessary counseling to patients and their family members.

Teach
Evaluate

R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy (early, late).

R1.1.8 Demonstrate responsibility to patients (early, late).

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

The resident will:

  • Begin data collection by using current well-established SICU standard monitoring Ivent to collect pertinent patient information for SICU patients utilizing current form of electronic medical record (Epic).  Data collection includes labs, system-based organ assessment of all organ systems, drug levels, ventilator settings, nutrition care, antibiotic choice and duration, and all other current medications (analyzed for appropriate dosing based on organ function). 
  • Glean data from trips to the bedside to discuss (or care for) patient with nurses, physicians, and other care providers.
  • Collect and analyze patient information and create a general problem list from evaluation of patient data and medication profile.
  • Bring pertinent medication issues/concerns/additions to multidisciplinary rounds as all partners in the patient’s care discuss and further dissect patient information.
  • Review patient profiles multiple times daily for the presence of all appropriate therapies and absence of necessary therapies using data collected from electronic medical records.  Common problems the resident may be exposed to include medication or specialized nutrition support with no indication; absence of medication necessary for acute or chronic disease state management; inappropriate prescription of medication or nutrition support; inappropriate dosing, dosage form, schedule, or route/method of administration; therapeutic duplication; medication prescribed which patient is allergic to; adverse drug reactions, etc. 
  • Participate in cardiac arrests, intubations, and acute resuscitations.

 

R1.1.3 Collect information on which to base safe and effective medication therapy (early, late).

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

 

The resident will:

  • Create an individualized pharmacotherapy plan for each of their patients prior to daily rounds and discuss these plans with the preceptor.  Early in the rotation the resident will first observe how/when the preceptor initiates a therapeutic plan.  As the preceptor observes appropriate interactions with the healthcare team they will facilitate the resident’s involvement in the initiation of individualized therapeutic regimens.  The pre-rounds discussions with the resident will provide time for feedback and appropriate changes to the resident’s plan prior to implementation during rounds. 
  • Participate daily in multidisciplinary rounds and communicate pharmacotherapy changes/issues/concerns with multidisciplinary team. 
  • Communicate any post-rounds modifications of the therapeutic plan with at a minimum the resident/intern responsible for the patient but optimally the entire 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. 

Teach
Evaluate

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

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

The resident will have ample opportunities for both written and verbal pass off as patients change in the ICU setting and also as they transition out of the ICU to the floor or LTAC settings. 

The resident is expected to:

  • Keep up written pass off in the form of daily documentation in the electronic medical record.
  •  Perform verbal pass off when written documentation is not possible, when written documentation requires supplementation, or when receiving provider requests verbal pass off. 
  • Communicate both written and verbal information in logical, complete, and concise manner.
  • The resident will be instructed at the beginning of rotation how to determine which medical resident/intern is responsible for the each patient in the CVICU.  The resident is expected to communicate any modification of the therapeutic plan with at a minimum the resident/intern responsible for the patient but optimally the entire 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.  The resident will further communicate pass off on transitioning patients to the appropriate floor pharmacist in a timely manner to prevent lapses in care.

Teach
Evaluate

R1.2.1 Manage transitions of care effectively.

During rotation, there will be ample opportunities to use judgement and prudence in 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. 
  • Be cognizant of supply and shortage issues prior to recommending therapies. 
  • Help address wastage issues in the ICU setting by working closely with physician and nursing staff (discussing stop dates/times to avoid wasting already made bag, returning IV medications to central pharmacy earlier to attempt to reallocate the medications, being aware of stability issues that might make administration a higher priority, etc.).
  • Participate in SICU multidisciplinary meeting.

Teach
Evaluate

R1.3.2 Manage aspects of the medication-use process related to formulary management (late only).

The resident will:

  •  Use and incorporate all feedback suggestions from preceptor and medical team continuously 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 getting 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 their patients.
  • Utilize and learn from the preceptors’ styles during rotation, but they are encouraged to begin 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 ICU.  The purpose of our rotation is not to create more pharmacists who think exactly like us, but to develop and create unique pharmacists who share our knowledge and processes and challenge us to become better.

Teach
Evaluate

R3.1.2 Apply a process of ongoing self-evaluation and personal performance improvement (late only).

R3.2.4 Manages one’s own practice effectively (late only).

The resident will be expected to:

  • 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.
  • Present patients to preceptor daily in concise and logical manner.
  • Precept students or younger residents (as able based on rotation timing) including helping with patient workups and notes, educating about general ICU practice and specific disease states, and mentor the younger residents or students in becoming an ICU pharmacist.
  • Participate in development of ICU protocols and research as needed.

 

R4.1.1 Design effective educational activities (late only).

 
Preceptor Interaction (daily):

0600-0730 Preceptors available while resident and preceptor work up patients
0715-0730 Pre-rounds with resident (assuming rounds start at 0730)
0730-1200 Daily rounds with resident and team (and preceptor until resident and preceptor comfortable with resident rounding independently)
1200-1530 Preceptor available for topic discussions, reviewing progress notes, patient updates, etc.

 
Communication:

  1. Daily scheduled meeting times: Residents to prioritize questions and problems to discuss during scheduled meeting times as listed above (pre-rounds best time to maximize efficiency in implementing patient care during rounds).
  2. E-mail: Residents are expected to read e-mails at the beginning, middle and end of each day at a minimum for ongoing communication. This is appropriate for routine, non-urgent questions and problems, however, most communication is done in person verbally since preceptors are always available and usually on the unit.
  3. Office extension: Appropriate for urgent questions pertaining to patient care.
  4. Pager: Residents will carry unit-based pager once appropriate and would no longer be able to contact preceptor via this method (use preceptor personal phone #).
  5. Personal phone number: Provided to resident at time of learning experience for issues that arise and the preceptor is not reachable on the unit (in person or telephone).

Typical Daily/Weekly/Monthly Activities:

Pharmacists start at 0600 by working up all patients admitted to the SICU to prepare for daily rounds at 0730. Residents should arrive around or before 0600 to work up patients before rounds. Rounds typically last 1-3 hours, depending on the patient census, acuity, and attending physician. Time after rounds is occupied by medication reconciliation, following up on planned interventions discussed in rounds, working up new patients admitted that day, attending educational activities and meetings, writing daily progress notes, and topic discussions.

Expected progression of resident responsibility on this learning experience:
(Length of time preceptor spends in each of the phases will be customized based upon resident’s abilities and timing of the learning experience during the residency training year)

Day 1: Preceptor will review SICU learning activities and expectations with resident.
Week 1: Resident to start by working up at least half of the SICU patients and progress to work up all SICU patients by the end of the week. Resident must present patients to preceptor daily. Preceptor to attend and participate in team rounds with resident, modeling pharmacist’s role on the health care team.
Week 2: Resident to work up all SICU patients at beginning of week. Preceptor still in workroom available for questions and to continue modeling behaviors. Expect daily patient discussions daily. Preceptor to attend team rounds with resident, but encourage and coach the resident to take on more responsibilities as the pharmacist on the team (preceptor sitting at a very short distance away with team able to see preceptor).
Weeks 3-4: Resident expected to work up all patients and round independently without team able to see preceptor (but possibly sitting somewhere to be able to eavesdrop and provide direct, specific feedback). Resident expected to write as many notes as possible for all SICU patients, and delegate those notes they are unable to write in a reasonable amount of time to preceptor. Continue to discuss identified problems with preceptor daily.

 
Evaluation Strategy:

Residents will be provided with verbal feedback on a frequent (at least every other day, possibly several times daily) basis. Feedback will be used for documentation of scheduled evaluations. For all evaluations completed in PharmaAcademic, 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 PharmAcademic 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

Preceptor, Learning Experience Evaluations

Resident

End of learning experience

Updated March 2016