Pharmacy Services

General Surgery

Acute Care

 
Preceptors:

Daniel Lee, PharmD - primary
David Canann, PharmD
Ryan Nielson, PharmD
Brian Bothwell, PharmD
Brian Spence, PharmD

 
Site Description:

Residents will rotate through 2 different units during this rotation: the Ortho & Trauma Surgical Specialty Unit (OTSS), and the Surgical Specialty & Transplant Unit (SSTU). OTSS is located on the 6th floor of the University of Utah Hospital and is a 41 bed unit. The majority of patients are under the care of the orthopedic surgery, trauma surgery, and general surgery teams. The Surgical Specialty & Transplant Unit (SSTU) is located on the 5th floor of the University of Utah Hospital and is a 26 bed unit. The majority of patients are under the care of the general surgery, urology, vascular surgery, trauma surgery, and transplant surgery.

 
Rotation Description:

Pharmacists on OTSS and SSTU function as part of a team comprised of the physicians, mid-level providers, nursing staff, nutritionists, social workers, case managers, respiratory therapists, and physical therapists. The clinical pharmacist is responsible for ensuring the appropriateness and safety of all medications prescribed for admitted patients and providing clinical support for nurses and providers. Additional responsibilities include analyzing patient data daily, reviewing inpatient medication profiles, writing pharmacy progress notes, performing patient and staff education, conducting drug-therapy monitoring, making drug-therapy recommendations, documenting appropriate data, and conducting patient interviews to obtain accurate medication histories. The hours of the rotation are traditionally 7-15:30. There is one pharmacist for OTSS and one pharmacist for SSTU from 7-15:30. One pharmacist of the two stays until 19:30 to care for afternoon admits. Based on this staffing model, flexibility with time requirements may be an option.

The resident will spend 2 weeks rotating on OTSS and 2 weeks on SSTU. Surgery has traditionally been a non-rounding service, but we are implementing rounding with a few different teams including General Surgery/Trauma. So, there will be an opportunity for rounding, but it will be a work in progress for 2016-17. The resident will also have the opportunity to observe cases in the operating room, and to learn the role of the OR pharmacist. Residents can also respond to trauma cases in ED with the trauma team. Students are often on rotation the same time as residents (maximum of one student and one resident), giving residents the opportunity to hone their precepting skills and complete the precepting requirement of the teaching certificate program. The resident will spend the first few hours of the day working up new patients, preparing for rounds when applicable, and addressing time sensitive patient care issues. The remainder of the day will be spent rounding when applicable, working up existing patients, performing medication reconciliations, writing progress notes, going over patients and leading and/or participating in topic discussions with preceptors.

Recently, the Surgery Services Pharmacy Department has started a new pre-op medication history process completed by pharmacy interns. And, we have hired a medication reconciliation pharmacy technician to help with medication histories as well. So, this will help free up time for the preceptors, residents, and students to expand our clinical role. Residents will be responsible for leading two topic discussions, presenting one journal club, and presenting one staff in-service or case presentation.

 
RLS Goals:

  1. Acute-1 Rotation:
    1. 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.
      1. OBJ R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy.
      2. OBJ R1.1.2 Interact effectively with patients, family members, and caregivers.
      3. OBJ R1.1.4 Analyze and assess information on which to base safe and effective medication therapy.
      4. OBJ R1.1.5 Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans).
      5. OBJ R1.1.7 Document direct patient care activities appropriately in the medical record or where appropriate.
      6. OBJ R1.1.8 Demonstrate responsibility to patients.
    2. R1.2 Ensure continuity of care during patient transitions between care settings.
      1. OBJ R1.2.1 Manage transitions of care effectively.
    3. R3.1 Demonstrate leadership skills.
      1. OBJ R3.1.1 Demonstrate personal, interpersonal, and teamwork skills critical for effective leadership.
  2. Acute-2 Rotation:
    1. 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.
      1. OBJ R1.1.1 Interact effectively with health care teams to manage patients’ medication therapy.
      2. OBJ R1.1.3 Collect information on which to base safe and effective medication therapy.
      3. OBJ R1.1.6 Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions.
      4. OBJ R1.1.8 Demonstrate responsibility to patients.
    2. R1.3 Prepare, dispense, and manage medications to support safe and effective drug therapy for patients.
      1. OBJ R1.3.2 Manage aspects of the medication-use process related to formulary management.
    3. R3.1 Demonstrate leadership skills.
      1. OBJ R3.1.2 Apply a process of on-going self-evaluation and personal performance improvement.
    4. R3.2 Demonstrate management skills.
      1. OBJ R3.2.4 Manages one’s own practice effectively.
    5. R4.1 Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and groups).
      1. OBJ R4.1.1 Design effective educational activities.

Activities Evaluated and Taught:

Objective Number (Level of Learning Required) & Description

Rotation Evaluated

Teaching Method(s)

Related Rotation Activities

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

Acute-1
Acute-2

Direct instruction
Modeling
Coaching
Facilitation

  • Round with teams when applicable
  • Communicate appropriate recommendations for medication regimen changes or monitoring to various surgical teams
  • Work with case management on discharge to SNF patients 

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

Acute-1

Direct instruction
Modeling
Coaching
Facilitation

  • Talk with patient and family for medication histories, vaccine screening, and patient education

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

Acute-2

Direct instruction
Coaching 
Facilitation

  • Review patient data daily to help guide clinical decision making
  • Review labs for electrolyte repletion, TPN modifications, medication implications
  • Interpretation of drug levels and dose adjustments

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

Acute-1

Direct instruction
Coaching 
Facilitation

  • Review patient data daily to help guide clinical decision making and recommendations

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

Acute-1

Direct instruction
Coaching 
Facilitation

  • Customize plan due to patient specific data
  • Re-assess plan with new information, and adapt with regimen changes

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

Acute-2

Direct instruction
Facilitation

  • Ensure important changes get made through proper follow up and communication to surgery teams

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

Acute-1

Direct instruction
Modeling
Coaching
Facilitating

  • Write daily pharmacy progress notes
  • Write Vancomycin monitoring progress notes
  • Document patient education as appropriate

OBJ R1.1.8 Demonstrate responsibility to patients.

Acute-1
Acute-2

Modeling
Coaching
Facilitation

  • Take ownership for all patient care activities

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

OBJ R1.2.1 Manage transitions of care effectively.

Acute-1

Direct instruction
Modeling
Coaching
Facilitation

  • Review discharge to SNF orders to ensure proper therapy and transition of care
  • Work with surgery teams and case management to optimize transition to SNF
  • Provide pass off information to other pharmacists

R1.3 Prepare, dispense, and manage medications to support safe and effective drug therapy for patients.

OBJ R1.3.2 Manage aspects of the medication-use process related to formulary management.

Acute-2

Direct instruction
Modeling
Coaching
Facilitation

  • Assess non-formulary requests and take appropriate action
  • Use patient own med process when necessary
  • Use medication management policies to guide decision making

R3.1 Demonstrate leadership skills.

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

Acute-1

Direct instruction
Modeling
Coaching
Facilitation

  • Work effectively will all members of the multidisciplinary team to optimize patient care

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

Acute-2

Direct instruction
Modeling
Coaching
Facilitation

  • Confront areas of improvement and reassess progress frequently
  • Initiate discussions with preceptor to help guide feedback

R3.2 Demonstrate management skills.

OBJ R3.2.4 Manages one’s own practice effectively.

Acute-2

Direct instruction
Modeling
Coaching
Facilitation

  • Develop clinical practice based on different preceptors styles
  • Multitask effectively
  • Always take ownership of patient outcomes

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

OBJ R4.1.1 Design effective educational activities.

Acute-2

Direct instruction
Modeling
Coaching
Facilitation

  • Customize educational materials based on audience
  • Complete a staff In-service or case presentation

 
Readings and Preparatory Work:

Current topics include:

  1. Pain Management, Part 1: Basics of Pain Management
  2. Pain Management, Part 2: epidurals, nerve blocks, etc.
  3. DVT Prophylaxis and Treatment
  4. Enteral Nutrition/ Feeding Tubes and Formulations
  5. Medication administration through feeding tubes
  6. Antibiotics and Allergies
  7. Anti-emetic therapy
  8. Parental Nutrition
  9. Post-Operative Diabetes Management
  10. Bone and Joint infections
  11. Cellulitis
  12. UTI’s
  13. Transplant Overview
  14. Heparin Induced Thrombocytopenia
  15. Perioperative Medication Management
  16. Warfarin Teaching and Enoxaparin Teaching
  17. Surgical Antimicrobial Prophylaxis
  18. Bone and Joint Infections
  19. Dosing considerations for patients with renal insufficiency
  20. Bowel Regimens
  21. Transplant Overview
  22. Post-Op Ileus
  23. Stress Ulcer Prophylaxis
  24. Rapid Sequence Intubation Medications
  25. ACLS Medications
  26. Atrial Fibrillation

Current lists of required and recommended readings can be found on the shared drive – RxPharmacists/6th floor/Resident Rotation

 
Project/Presentation Description:

  1. Residents are required to present a formal journal club presentation to their preceptors.
  2. Residents are required to lead two topic discussions while on rotation.
  3. Residents present a minimum of one in-service to nursing or surgery team during the time of their rotation or present a formal case to a surgery team or preceptors.

Typical Daily/Weekly/Monthly Activities:

  1. Work up patients and write daily progress notes
  2. Round with teams or run the list with various services
  3. Review pressing issues with preceptor and make interventions
  4. Present patients/plans to preceptor
  5. Answer team questions
  6. Provide patient education on new meds and pain plan
  7. Sign pre-op med recs and complete medication histories
  8. Optimize admission orders or post op orders – timing, home meds, routes, etc.
  9. Communicate with multidisciplinary team to optimize patient care
  10. Respond to emergency situations on floor
  11. Review discharge to SNF medication orders
  12. Respond to pages from central pharmacy about issues with orders

Resident Evaluation:

The resident will receive verbal feedback daily and/or weekly from the various preceptors. The resident will have a formal written midpoint and final evaluation with Daniel Lee.

Updated March 2016