Pharmacy Services

Pharmacy Services Residency

Solid Organ Transplant

 (PGY1 Rotation - Transitions of Care)

Preceptors:

Lonnie Smith, PharmD, FAST
Crystal Truax, PharmD, BCPS
Nicole Kenyon, PharmD, BCPS
Adrian Carlson, PharmD, BCPS

 
Site Description:

The solid organ transplant rotation offers both inpatient and ambulatory exposure to kidney, pancreas, liver, heart and lung transplant. The resident will have the unique opportunity to participate in transitions of care from pre-transplant evaluation, post-surgical care, discharge counseling, and post-transplant clinic follow-up. Practice sites include surgical and medical intensive care units, general medicine and surgical floors, and outpatient transplant clinics. Outpatient clinics may include:

  • Adult Kidney and Pancreas Pre- and Post-transplant
  • Adult Liver Pre- and Post-transplant
  • Adult Heart Pre- and Post-transplant
  • Adult Lung Pre- and Post-transplant

The transplant pharmacists operate as an integral part in the multidisciplinary transplant team that includes attending physicians, transplant surgeons, fellows, residents, nurse practitioners/physician assistants, nurse coordinators, social workers, financial counselors, and other important team members. Care of transplant patients is multifaceted and patients often have several comorbidities that expose the resident to different areas of internal medicine including, but not limited to, infectious disease, diabetes, and cardiology.

 
Rotation Description:

The primary focus of the rotation is for the resident to develop a comprehensive approach strategy to patient care. The resident will be responsible for direct patient care of post-transplant patients in both the inpatient and outpatient setting. Topics stressed include monitoring and management of immunosuppressive agents including toxicities and interactions, proper management and control of opportunistic infections, and prevention and treatment of rejection. By the end of the rotation the resident should have a strong understanding of transplant pharmacotherapy and current limits to graft and patient survival. By the end of the rotation, the resident will be expected to participate in transplant rounds, to efficiently work-up a patient in the outpatient setting and to complete a patient discharge counseling session.

The resident will also have the opportunity to participate in clinical research and transplant evaluation meetings, and may have the opportunity to aid in management of investigator-initiated and multicenter clinical trials. Weekly topic discussions will be held on a routine basis with the clinical pharmacists and transplant resident. Additional opportunities include journal club presentations and presentations to pharmacy and transplant staff. The resident may also have the opportunity to observe a transplant surgery, if desired.

 
RLS goals to be evaluated:

  • 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 comorbidities, high-risk medication regimens, and multiple medications following a consistent patient care process
    • R1.1.1 (Applying) Interact effectively with health care teams to manage patients’ medication therapy
    • R1.1.2 (Applying) Interact effectively with patients, family members, and caregivers
    • R1.1.3 (Analyzing) Collect information on which to base safe and effective medication therapy
    • R1.1.7 (Applying) Document direct patient care activities appropriately in the medical record or where appropriate
  • R1.2 – Ensure continuity of care during patient transitions between care settings
    • R1.2.1 (Applying) Manage transitions of care effectively
  • R3.1 – Demonstrate leadership skills
    • R3.1.1 (Applying) Demonstrate personal, intrapersonal, and teamwork skills critical for effective leadership
  • R4.1 – Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and groups)
    • R4.1.2 (Applying) Use effective presentation and teaching skills to deliver education

Solid Organ Transplant Rotation Activities and Teaching Methods Linked to Objectives:

Rotation Activity

Teaching Method(s)

Objective

At minimum, conduct 5 thorough patient interviews to determine current drug therapy and relevant medication history.

  • Evaluate medication therapy for post-transplant recipients in ambulatory and inpatient settings
  • Identify medication-related problems
  • Communicate recommendations for modifying drug therapy directly to the provider

Modeling
Coaching
Facilitating

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

 

Round with transplant team, and individual medical and surgical teams when appropriate.  In doing so, provide recommendations to the team regarding medication therapy issues, based on analysis and assessment of collected information.

Modeling
Coaching
Facilitating

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

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

 

Provide effective discharge counseling for at least one newly transplanted patient with appropriate documentation, including information to help with pharmacist pass off for efficient transition of care.

Direct instruction
Modeling
Coaching
Facilitating

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

R1.2.1 Manage transitions of care effectively

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

Establish a working relationship with transplant multidisciplinary team, including physicians, nurses, and others to effectively manage transplant patients medication.

Modeling
Coaching
Facilitating

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

Minimally present at least one each of the following to the transplant team:

  • “Lunch and Learn” in-service
  • Topic discussion
  • Journal club

All presentations should be appropriate for the intended audience, with a handout to reinforce key concepts, and inclusive of relevant and up to date information. 

Modeling
Coaching
Facilitating

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

Participate in the education and assessment of pre-transplant patients

  • Attend and then present medication education during pre-transplant patient education session
  • Evaluate a pre-kidney transplant patient for consideration of listing based on pharmacologic criteria

Modeling
Coaching
Facilitating

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

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

R1.2.1 Manage transitions of care effectively

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

 
Expectations:

  • On non-clinic days, inpatients will be worked up and ready for discussion with preceptor prior to 10 AM. If able, round individually on all patients prior to this meeting.
  • Patient care is a priority throughout the day.
  • Plans will be communicated with preceptor prior to implementation, including recommendations for immunosuppressive drug monitoring.
  • Communicate plan of care and changes in therapy as appropriate with floor/central pharmacists.

Orientation:

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

Presentations

  • Pre-transplant kidney patient education (observe ≥1 session prior)
  • One journal club
  • One "lunch and learn" presentation (Topic: Resident’s Choice)
  • One formal topic discussion (Topic: Resident’s Choice)

Optional activities

  • Observe a kidney transplant:  Date TBD
  • Observe a kidney transplant biopsy:  Date TBD

Core discussion topics

  • Immunology
  • Immunosuppressive agents
    • Induction
    • Maintenance
  • Infections
    • Post-transplant prophylaxis
    • Opportunistic infections
    • Immunizations
  • Acute and chronic rejection
  • Long-term complications
  • Elective topics led by the resident
  • Additional topics determined by the resident/preceptors

Evaluations

  • Evaluations will be documented in PharmAcademicTM. At the midpoint of the evaluation, the preceptor will evaluate the resident. At the end of the rotation, the resident will self-evaluate, the preceptor will evaluate the resident, and the resident will evaluate both the preceptor and the learning experience.

Suggested readings

  • Halloran PF. Immunosuppressive Drugs for Kidney Transplantation. NEJM 2004;351:2715-29.
  • Hardinger K, Koch M, Brennan D. Current and Future Immunosuppressive Strategies in Renal Transplantation. Pharmacotherapy 2004;24(9):1159-1176.
  • Soave R. Prophylaxis Strategies for Solid Organ Transplantation. CID 2001;33(S1).
  • Danovitch GW. Handbook of Kidney Transplant. Lippincott Williams & Williams. 2010.
  • Fishman J. Infection in Solid-Organ Transplant Recipients. NEJM 2007;357(25):2601-14.
  • Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009;9(Suppl 3):S1-155.
  • Allen U, Humar A, Limaye A et al. Infectious Diseases Guidelines, 2nd Ed. Am J Transplant 2009;9(Suppl 4):S1-281.
  • Alloway RR, Dupuis R, Gabardi S, et al. Evolution of the Role of the Transplant Pharmacist on the Multidisciplinary Transplant Team. Am J Transplant 2011;11:1576-1583.
  • Maldonado AQ, Tichy EM, Rogers CC, et al. Assessing Pharmacologic and Nonpharmacologic Risk in Candidates for Kidney Transplant. Am J Health-Syst Pharm 2015;72:781-93.

Updated March 2016