Pharmacy Services

Pharmacy Services Residency

Oncology

(PGY1 Rotation - Ambulatory Care)

 
Preceptors:

Variable (Makala Pace, PharmD, serves as the primary coordinator for this rotation)

Office: 50174
Hours: 8 am to 5 pm

 
Site Description:

The Ambulatory Oncology Pharmacy rotation includes two primary areas: the Huntsman Cancer Institute infusion pharmacy and the Huntsman Cancer Institute ambulatory clinics.

The Infusion Room has 32 chairs and six beds where 65 to 80 patients receive treatment on weekdays and around 10-15 patients are treated on Saturdays. The Infusion Pharmacy is also the main location for all outpatient clinic needs including outpatient infusion treatments given in clinic, injections given in clinic, and drug information questions when the clinic pharmacist is unavailable. There are currently three clinical pharmacists that are assigned to work in the infusion area. Technicians in this area are proficient in PhaSeal®, inventory management, and engaged in double check processes for safety.

The Huntsman Cancer Institute Ambulatory clinics are the location in which outpatients are seen at the Huntsman Cancer Institute. The ambulatory clinics have over 100,000 patient visits per year. Currently there are 10 clinical service lines (i.e. BMT, breast cancer, etc) that have clinical pharmacists are assigned to work in the outpatient clinics.

Pharmacists ensure safety and appropriateness of chemotherapy regimens, educate patients about chemotherapy, train residents and students, and participate in process improvements including but not limited to treatment plan development/optimization, clinic injections flow, and turn-around time advances.

 
Rotation Description:

The pharmacist works with oncology nurse practitioners, physician assistants, oncologists, and hematologists to optimize pharmaceutical care of hematology and oncology patients. The resident’s primary focus is to develop the knowledge and skills needed to achieve competency in the provision of patient care and practice management in an outpatient hematology/oncology infusion center. This includes clean room training specific to chemotherapy processes and completion of institutional chemotherapy certification. Residents will also spend time with clinic pharmacists specializing in nausea/vomiting and hematology to discuss supportive care topics related to outpatient chemotherapy.

 
RLS Goals:

  • R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy
  • R1.1.2 Interact effectively with patients, family members, and caregivers
  • R1.1.3 Collect 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)
  • R1.1.7 Document direct patient care activities appropriately in the medical record or where appropriate
  • R1.2.1 Manage transitions of care effectively
  • R3.1.2 Apply a process of on-going self-evaluation and personal performance improvement
  • R4.1.2 Use effective presentation and teaching skills to deliver education

Activities Evaluated and Taught:

Rotation Activities

RLS Objectives

Teaching Methods

Residents are expected to establish and maintain a respectful relationship with nurses, physicians, midlevel practitioners, and other members of the health care team.

If nursing schedule permits, residents will spend a half-day in the infusion room with nursing staff.

The resident will spend at least 8 hours in the chemo prep area learning to adequately prepare chemotherapy and related medications.  Instruction will also be provided in use of PhaSeal closed systems and compounding of investigational products.

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

IMCF

The resident is expected to see a minimum of 20 patients (or separate counseling episodes) during the 4 week rotation. 

These visits may be for medication histories, new medication counseling, supportive care (nausea, vomiting, alopecia, anorexia, pain control, constipation, diarrhea, stomatitis, etc)

After each patient interaction the resident will discuss with the preceptor what went well vs what could have been improved on in the interaction.

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

IMCF

Residents are required to review chemotherapy-related policies during the first week of rotation, and after completion of the chemo certification process are allowed to dispense chemotherapy within the confines of the organization’s policies and procedures.

Residents are responsible for ensuring the accuracy of medication profiles for chemo patients they review.  All medications related to each cycle of chemo (including oral chemotherapy) will be reviewed prior to commencement of IV chemotherapy.

Each chemotherapy patient is evaluated for appropriateness of doses based on patient parameters (lab values, weight), clinical guidelines, intent of therapy (palliative vs curative), interacting medications and their effects on chemotherapy dosage, compliance (physical barriers vs financial burdens), and any other factor that may reduce optimal outcomes.

The resident is required to read and understand all of the institution’s policies related to chemotherapy.  Each time the resident initiates a chemotherapy-related care plan, it will be done in accordance to those policies.

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

IMCF

Residents are responsible for ensuring the accuracy of medication profiles for chemo patients they cover.  All medications related to each cycle of chemo (including oral chemotherapy) will be reviewed prior to commencement of IV chemotherapy.

Based on his/her assessment of the factors discussed in R1.1.3, the resident will decide to proceed with chemotherapy as ordered or recommend changes appropriate to the patient situation.  The preceptor supervises this process and provides the resident with feedback after each patient is discussed

Use of tertiary references, primary references, PubMed, and guidelines (NCCN, ASCO, etc) will be covered on this rotation.  Each time the resident responds to a question or prepares for topic discussion the preceptor and resident will discuss which references are most appropriate for the task at hand.

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

IMCF

Understand what interventions or issues are typically documented by oncology pharmacists based on the various audiences that read these notes, and at what point in the patient’s care (i.e. transfer, discharge, chemo counseling, medication histories, supportive care counseling, monitoring/assessment of adverse events).

Residents will be provided ample feedback on how to better communicate various medication-related issues so that their recommendations are well received by other health professionals and well understood by other pharmacists.

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

IMCF

As appropriate inform clinical pharmacists and other health-care professionals about follow up items from clinic or infusion encounters.

R1.2.1 Manage transitions of care effectively

CF

The resident will complete our institution’s chemo certification exam and practicum to establish baseline competency in this area.  Instruction and feedback will be provided throughout the rotation to help the resident further develop these skills.

Use and incorporate self-evaluation and feedback from preceptors to continuously improve performance on the rotation.

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

CF

Drug information requests will be assigned to the resident after details are taken by the preceptor.  As the rotation progresses, residents will be tasked with responding to drug information requests from ACC and HCI clinics and will be coached by the preceptor as they determine the “real” question and details required.

Use of tertiary references, primary references, PubMed, and guidelines (NCCN, ASCO, etc) will be covered on this rotation.  Each time the resident responds to a question or prepares for topic discussion the preceptor and resident will discuss which references are most appropriate for the task at hand.

Once the resident has established proficiency at retrieving information from appropriate sources, the resident will work on collating these references to generate a response.

Topics discussed in this process are:  when to use primary vs tertiary literature, what constitutes an “appropriate” primary reference, when guidelines should be used instead of primary literature

The resident will also have to respond to clinical questions where there isn’t enough information to answer without conjecture.  This process will be discussed as it arises.

By the end of the rotation, the resident should be able to appropriately respond to an information request and be aware of the limits of his/her own knowledge base

The resident should also be able to respond appropriately when the clinical question lies outside the limits of his/her knowledge base and requires further follow-up.

R4.1.2 Use effective presentation and teaching skills to deliver education

MCF

I: Direct Instruction, M: Modeling, C: Coaching, F: Facilitating

 
Readings and Preparatory Work:

Topic discussions will be tailored to the specific goals of each resident and planned working environment post-residency. Topic discussions may include, but are not limited to, nausea/vomiting, CBC interpretation, anemia, and erythropoietic agents, basic discussion of various cancers (lung, prostate, colorectal cancer, breast, etc).

  1. Review hospital policies related to chemotherapy prior to beginning of rotation
    1. Antineoplastic and immune modulating agents: ordering these medications
    2. Extravasation of anti-neoplastic agents
    3. Safe handling of hazardous drugs
      1. Overview and general procedures
      2. Preparing and reconstituting hazardous drugs
      3. Administration of hazardous drugs
      4. Handling requests for special dosage forms of hazardous medications
      5. Gene therapy products
      6. Medical surveillance of employees with occupational exposure to hazardous drugs
  2. Review basic pharmacology (ie reread chapter from DiPiro, Goodman and Gilman, or similar text)of the following classes of antineoplastic medications prior to beginning of rotation
    Taxanes Monoclonal antibodies
    Alkylating agents Platinums
    Anthracenediones/Anthracyclines Histone deacetalase inhibitors
    Antimetabolites Topoisomerase II inhibitors
    Camptothecin analogs Vinca alkaloids
    DNA Methylation inhibitors Chemoprotective agents
    Proteasome inhibitors Rescue/bio-modulating agents

Typical Daily/Weekly/Monthly Activities:

  1. Daily hours: 8am until 5pm (may vary)
  2. Daily tasks: patient chart review, review and manipulation of EPIC treatment plans and therapy plans, , compounding and checking of medications, and responding to clinical questions
  3. Patient education tasks: chemo counseling for new patients, review of OTC and herbal products, answering therapy-related questions from patients; the resident is expected to see a minimum of 20 patients (or separate counseling episodes) during the 4 week rotation
  4. Resident education tasks: attending weekly killer sessions, topic discussions, patient presentations
  5. Written project: resident will complete a written project to be determined based on the needs of the Infusion Room Pharmacy and the specific goals of the resident

Preceptor Interaction

Preceptors and residents share the same workspace for the majority of this rotation. However, the resident should check in with the preceptor upon arrival and notify the preceptor any time he/she leaves for meetings, educational sessions, etc.

 
Communication:

Communication will occur with preceptors daily, and any questions or rotation related issues may be emailed to the primary preceptor throughout the rotation. The resident may call the main office phone for sick calls/emergency issues.

 
Expected progression of resident responsibility on this learning experience:

Resident will complete BEACON training as part of residency orientation in July. Chemo certification via LMS will be assigned to resident and completed during the first week. Residents work up patients prior to patient arrival and discuss each patient with preceptor prior to dispensing. As the weeks progress, resident will work up more patients, and should be able to cover 4-5 patients a day by the end of the rotation.

 
Evaluations:

Residents will be provided with verbal feedback on a frequent (at least every other day, possibly several times daily) basis. PharmAcademic will be used for documentation of scheduled evaluations and should be completed within 1 week of rotation completion.

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