Pharmacy Services

Pharmacy Services Residency

Thrombosis Service

 (PGY1 Rotation - Transitions of Care)

 
Preceptors:

Heidi Weber, PharmD
Beth Young, PharmD

 
Site Description:

The University of Utah Healthcare (UUHC) Thrombosis Service is a nationally recognized anticoagulation management service, which consists of 11 FTE pharmacists and 7 FTE technicians who manage ~2,500 patients throughout the intermountain states, and specializes in safely, effectively, and seamlessly transitioning high-risk patients on high-risk anticoagulant therapy, into and out of the hospital, into and out of skilled nursing facilities, and into and out of the care of home health nurses, outside physician practices, and other hospital systems. The Thrombosis Service pharmacists and technicians all work together to provide exceptional patient-centered care by using unique communication tools and strategies across 3 physical locations. Also, several pharmacists, including the rotation preceptors, rotate working both inpatient and outpatient, rotating between the Hospital Thrombosis Team (located on the University Hospital Cardiovascular Medical Unit (CVMU)) and one of the two Thrombosis Clinics (located at the University Hospital Thrombosis Center and the Redwood Health Center).

 
Role of the Pharmacist:

The clinical pharmacists manage anticoagulation throughout the health-system, for inpatients, outpatients, and patients transitioning between care settings. Inpatient duties includes managing anticoagulation for patients who present to the ER or vascular clinic with an acute clot, patients on the Ortho Trauma Surgical Service (OTSS), patients with a Left Ventricular Assist Device (LVAD) for end-stage heart failure, patients at the Huntsman Cancer Hospital, patients on the rehabilitation unit at the University Hospital, and various other inpatient consults. Pharmacists also work in the outpatient Thrombosis Clinic at the University Hospital where patients are referred for treatment of acute thrombosis (deep vein thrombosis, pulmonary embolism, and stroke) or prevention of thrombosis in high-risk conditions (atrial fibrillation, mechanical heart valve replacement, LVAD, thrombophilia, cancer, etc.).

 
Resident Expectations:

The resident will learn to function as a clinical pharmacist on the Hospital Thrombosis Team, located on CVMU of the University Hospital. The resident will also rotate through the on-site Thrombosis Clinic at the University Hospital, where they provide point-of-care INR testing, anticoagulation drug therapy selection and education (including the direct oral anticoagulants (DOACs)), and management for outpatients within the UUHC system via collaborative practice agreement with the referring provider. Resident will be responsible for providing transition of care from the hospital to the outpatient clinic, or transition to providers outside of the University system. The daily activities may be customized based on the resident’s interest, experience, and progression.

 
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 R1.1.1 (Applying) Interact effectively with health care teams to manage patients’ medication therapy.
    • OBJ R1.1.2 (Applying) Interact effectively with patients, family members, and caregivers.
    • OBJ R1.1.3 (Analyzing) Collect information on which to base safe and effective medication therapy.
    • OBJ R1.1.7 (Applying) Document direct patient care activities appropriately in the medication record where appropriate.
  • Goal R1.2: Ensure continuity of care during patient transitions between care settings.
    • OBJ R1.2.1 (Applying) Manage transitions of care effectively.
  • Goal R3.1: Demonstrate leadership skills.
    • OBJ R3.1.1 (Applying) Demonstrate personal, interpersonal, and teamwork skills critical for effective leadership.
  • Goal R4.1: Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and groups).
    • OBJ R4.1.2 (Applying) Use effective presentation and teaching skills to deliver education.
Goal/Objective Methods Rotation Activities
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 R 1.1.1 (Applying)
Interact effectively with health care teams to manage patients’ medication therapy.

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

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

OBJ R1.1.7 (Applying)
Document direct patient care activities appropriately in the medication record where appropriate.

Coaching
Facilitation
Manage anticoagulation therapy and transitions between care settings.

Pre-surgery

  • Perform a review of the patient’s history including concomitant disease states, prior thrombotic and bleeding events, current medications, laboratory results
  • Design a plan for initiating drug therapy

During inpatient visit

  • Conduct patient/caregiver interview to confirm patient’s history
  • Provide daily warfarin management

Prior to discharge

  • Provide anticoagulant education to the patient/caregiver
  • Communicate the drug therapy and monitoring plan to the patient/caregiver, home health nurse, skilled nursing facility, and/or responsible outpatient provider

Post-discharge

  • 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, 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 pre-surgery workup, assessments, plans, and anticoagulant education in the electronic medical record (EMR)

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.
Goal R1.2: Ensure continuity of care during patient transitions between care settings.

OBJ R1.2.1 (Applying)
Manage transitions of care effectively.

Coaching
Facilitation
Goal R3.1: Demonstrate leadership skills.

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

Coaching
Facilitation
Goal R4.1: Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and groups).

OBJ R4.1.2 (Applying)
Use effective presentation and teaching skills to deliver education.

Coaching
Facilitation
Conduct a practice-based project.

 
Readings and Preparatory Work:

 
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:

Schedule 8:00am – 4:00pm, Monday through Friday
Thrombosis Clinics meetings (teleconference) every 4th 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 November 2017