Pharmacy Services

Pharmacy Services Residency

Thrombosis Clinic

 (PGY1 Rotation - Ambulatory Care)

 
Preceptors:

Sara Vazquez, PharmD
Vicky DiGregorio, PharmD
Jacob Hampton, PharmD

 
Site Description

The Thrombosis Center (TC) at University of Utah Health is a pharmacist-based anticoagulation management service located in the University of Utah Hospital. The TC pharmacists provide point-of- care INR testing, anticoagulation drug therapy selection and education (including the direct oral anticoagulants), and management for approximately 500 outpatients within U of U Health system via collaborative practice agreement with the referring provider. Patients are referred for treatment of acute thrombosis (deep vein thrombosis, pulmonary embolism, stroke) or prevention of thrombosis in high-risk conditions (atrial fibrillation, mechanical heart valve replacement, left ventricular assist device, thrombophilias, cancer, etc.).

 
Rotation Description

The resident will function as a clinical pharmacist in the TC. The daily patient schedule may include several different types of visits or encounters:

  • For an initial therapy selection consult, the pharmacist will review the patient’s history, perform clinical screening and medication reconciliation, discuss potential anticoagulant therapy options and education points for each drug with the patient/caregiver (warfarin, low-molecular weight heparins (LMWH), direct oral anticoagulants (DOACs)), initiate the chosen anticoagulant, and coordinate a follow-up plan. The pharmacist will communicate the anticoagulation plan back to the referring provider.
  • For patients newly enrolled in the TC, if the initial anticoagulant therapy has already been initiated, the pharmacist will review the patient’s history, perform medication reconciliation, and provide drug-specific education to the patient/caregiver.
  • Follow-up visits for warfarin patients include performing a point-of-care INR fingerstick test and conducting a brief patient interview that includes assessing compliance to warfarin, dietary and/or medication changes, changes in health status, need for periprocedural planning, bleeding or thrombotic complications. The pharmacist will communicate a plan for warfarin dosing and follow-up INR to the patient/caregiver. As the situation arises, the pharmacist will create, communicate, and initiate an individualized periprocedural anticoagulation plan.
  • Follow-up for non-warfarin anticoagulants (LMWH, DOACs) could include close follow-up during the first 3 months, then at least yearly follow-up as needed to assess appropriate medication dosing, compliance or need for medication refill, recent pertinent laboratory parameters, upcoming procedures and designing periprocedural anticoagulation plans, medication interactions, ED visits or hospitalizations, changes to health, bleeding or thrombotic complications.

With every patient encounter, the pharmacist is responsible for assessing the safety and efficacy of anticoagulation therapy. This includes assessing time in therapeutic range (TTR) on warfarin, and if poor TTR, making recommendations for ways to improve anticoagulation therapy.

The pharmacist is responsible for identifying, managing, and reporting medication interactions and/or adverse events.

 
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 regimens, and multiple medications following a consistent patient care process.
    • OBJ 1.1.1 (Applying) Interact effectively with health care teams to manage patients’ medication therapy.
    • OBJ 1.1.2 (Applying) Interact effectively with patients, family members, and caregivers.
    • OBJ 1.1.3 (Analyzing) Collect information on which to base safe and effective medication therapy.
    • OBJ 1.1.4 (Analyzing) Analyze and assess information on which to base safe and effective medication therapy.
    • OBJ 1.1.5 (Creating) Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans).
    • OBJ 1.1.6 (Applying) Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions.
    • OBJ 1.1.7 (Applying) Document direct patient care activities appropriately in the medication record where appropriate.
  • Goal 2.2: Demonstrate ability to evaluate and investigate practice, review data, and assimilate scientific evidence to improve patient care and/or the medication-use system.
    • OBJ 2.2.5 (Creating) Effectively develop and present, orally and in writing, a final project report.
  • Goal R3.1: Demonstrate leadership skills.
    • OBJ 3.1.2 (Applying) Apply a process of on-going self-evaluation and personal performance improvement.
  • Goal R3.2: Demonstrate management skills.
    • OBJ 3.2.4 (Applying) Manages 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 groups).
    • OBJ 4.1.2 (Applying) Use effective presentation and teaching skills to deliver education.

 
Thrombosis Clinic Rotation Activities and Teaching Methods Linked to Objectives

Rotation Activity Teaching Method(s) Objective

Conduct an initial anti-thrombotic therapy selection consult.

  • Perform a review of the patient’s history including concomitant disease states, prior thrombotic and bleeding events, current medications, laboratory results, and cost for potential therapy options.
  • Perform medication reconciliation during patient visit.
  • Provide education about appropriate therapy options.
  • Design a plan for initiating drug therapy including appropriate follow-up monitoring.
  • Communicate the drug therapy and monitoring plan to the patient/caregiver and the referring provider.
  • Document the clinical screening, education, and therapy plan in the electronic medical record (EMR).

Coaching
Facilitation

OBJ 1.1.1 (Applying) Interact effectively with health care teams to manage patients’ medication therapy.
OBJ 1.1.2 (Applying) Interact effectively with patients, family members, and caregivers.
OBJ 1.1.3 (Analyzing) Collect information on which to base safe and effective medication therapy.
OBJ 1.1.4 (Analyzing) Analyze and assess information on which to base safe and effective medication therapy.
OBJ 1.1.5 (Creating) Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans).
OBJ 1.1.6 (Applying) Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions.
OBJ 1.1.7 (Applying) Document direct patient care activities appropriately in the medication record where appropriate.

Conduct a new patient education visit.

  • Perform a review of the patient’s history including concomitant disease states, prior thrombotic and bleeding events, current medications, and laboratory results.
  • Perform medication reconciliation during patient visit.
  • Provide drug-specific education to the patient/caregiver.
  • Document the education session in the EMR.

Coaching
Facilitation

OBJ 1.1.2 (Applying) Interact effectively with patients, family members, and caregivers.
OBJ 1.1.7 (Applying) Document direct patient care activities appropriately in the medication record where appropriate.

Conduct a follow-up visit for a warfarin patient.

  • Perform point-of-care INR blood test.
  • Conduct patient/caregiver interview to obtain appropriate information about medication compliance, dietary or medication changes, changes in health status, upcoming procedures, bleeding or thrombotic complications.
  • Assess the efficacy and safety of warfarin therapy via TTR, and formulate an alternative therapy plan as appropriate.
  • Analyze the information obtained in the patient interview to design a warfarin dosing and monitoring plan.
  • Communicate the dosing and monitoring plan to the patient/caregiver.
  • Document the assessment and plan in the EMR.

Direct instruction
Modeling
(for POC INR testing)

Coaching
Facilitation

OBJ 1.1.2 (Applying) Interact effectively with patients, family members, and caregivers.
OBJ 1.1.3 (Analyzing) Collect information on which to base safe and effective medication therapy.
OBJ 1.1.4 (Analyzing) Analyze and assess information on which to base safe and effective medication therapy.
OBJ 1.1.5 (Creating) Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans).
OBJ 1.1.6 (Applying) Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions.
OBJ 1.1.7 (Applying) Document direct patient care activities appropriately in the medication record where appropriate.

Design a peri-procedural anticoagulation plan.

  • Determine the bleeding risk associated with the procedure and patient.
  • Determine the thrombotic risk associated with the procedure and patient.
  • If applicable, design a plan for discontinuing anticoagulation pre-procedure.
  • If applicable, employ a bridging strategy using heparin or LMWH.
  • Design a plan for re-initiating anticoagulation post-procedure.
  • Coordinate a plan for follow-up monitoring.
  • Communicate the plan to the patient/caregiver, proceduralist, and referring provider.
  • Document the assessment and plan in the EMR.

Coaching
Facilitation

OBJ 1.1.1 (Applying) Interact effectively with health care teams to manage patients’ medication therapy.
OBJ 1.1.4 (Analyzing) Analyze and assess information on which to base safe and effective medication therapy.
OBJ 1.1.5 (Creating) Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans).
OBJ 1.1.7 (Applying) Document direct patient care activities appropriately in the medication record where appropriate.

Conduct a follow-up encounter for a non-warfarin anticoagulant (LMWH or DOAC).

  • Follow-up call
  • Review progress notes from recent clinic visits/ED visits/hospitalizations, assess for upcoming procedures, interacting medications, review appropriate laboratory parameters, and need for medication refill.
  • Call the patient/caregiver to inquire about medication compliance, appropriate dosing, and any other changes that may not have been reflected in the EMR.
  • Document the assessment and plan in the EMR.

Coaching
Facilitation

OBJ 1.1.2 (Applying) Interact effectively with patients, family members, and caregivers.
OBJ 1.1.3 (Analyzing) Collect information on which to base safe and effective medication therapy.
OBJ 1.1.4 (Analyzing) Analyze and assess information on which to base safe and effective medication therapy.
OBJ 1.1.6 (Applying) Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions.
OBJ 1.1.7 (Applying) Document direct patient care activities appropriately in the medication record where appropriate.

Submit an adverse event report.

Coaching
Facilitation

OBJ 1.1.4 (Analyzing) Analyze and assess information on which to base safe and effective medication therapy.

Use and incorporate feedback from preceptors to continuously improve patient care interactions and dosing/monitoring decision-making.

Coaching
Facilitation

OBJ 3.1.2 (Applying) Apply a process of ongoing self evaluation and personal performance improvement.

Manage the patient schedule efficiently.

  • See patients at their scheduled times and within the allotted time frame.
  • Adapt seamlessly to unexpected patient schedule changes.

Coaching
Facilitation

OBJ 3.2.4 (Applying) Manages one’s own practice effectively.

Conduct a practice-based project.

Coaching
Facilitation

OBJ 2.2.5 (Creating) Effectively develop and present, orally and in writing, a final project report.
OBJ 4.1.2 (Applying) Use effective presentation and teaching skills to deliver education.

 
Readings and Preparatory Work:

Review the Outpatient Thrombosis Service Collaborative Practice Agreement.
https://pulse.utah.edu/policies/Lists/Policies/DispForm.aspx?ID=2361

Review the Thrombosis Service Anti-thrombotic Therapy Guideline.
https://pulse.utah.edu/policies/Lists/Policies/DispForm.aspx?ID=2936

Review the Thrombosis Service Direct Oral Anticoagulation Resources.
https://pulse.utah.edu/site/throserv/Pages/DOAC.aspx

 
Orientation Materials:

Your preceptor will meet with you on the first day of rotation to make an individual orientation plan with you.

 
Project Description:

  • Conduct a practice-based project, topic tailored to resident’s interest and needs of the Thrombosis Service.

 
Typical Daily/Weekly/Monthly Activities:

Clinic patient schedule 8:30am – 4:30pm, Monday through Friday
Thrombosis Clinics meetings (teleconference) every other Wednesday, noon-1pm
Thrombosis Service team meeting first Wednesday of the month, 3-4pm
Attend quarterly Anticoagulation Safety subcommittee meetings (to be determined)

 
Evaluations:

Evaluations will be documented in PharmAcademic™.
At the midpoint of the rotation, the preceptor will evaluate the resident. At the end of each rotation, the resident will self-evaluate, the preceptor will evaluate the resident, and the resident will evaluate both the preceptor and the learning experience.

Updated March 2016