Pharmacy Services

General Surgery Rotation

 
Preceptors:

Daniel Lee, PharmD
David Canann, PharmD
Ryan Nielsen, PharmD

 
Site Description:

Residents will rotate through two different units during this rotation: The Ortho & Trauma Surgical Specialty Unit (OTSSU) and The Surgical Specialty & Transplant Unit (SSTU).

The Ortho & Trauma Surgical Specialty Unit (OTSSU) is located on the 6th floor of the University of Utah Hospital and is a 41 bed unit. The majority of patients on OTSSU are admitted after the OR for post-surgical care. Other patients are admitted from the emergency department, onsite outpatient clinics, or direct admit from other health care facilities (hospitals, skilled nursing facilities). Some patients are transferred from the intensive care units or other floor units. A variety of medical and surgical teams follow OTSSU patients. The majority of patients are under the care of the orthopedic surgery and trauma surgery.

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 patient population on SSTU is similar but slightly more acute than OTSSU. The majority of patients are under the care of the general surgery, vascular surgery, trauma surgery, transplant surgery, and internal medicine teams. Other teams/services involved with patient care on OTSSU and SSTU include infectious disease, urology, otolaryngology, gynecology, dermatology, ophthalmology, nephrology, gastroenterology, and plastic surgery.

 
Rotation Description:

Pharmacists on OTSSU and SSTU function as part of a team comprised of the attending surgeon or internist, surgical and medical fellows and residents, the nursing staff, nutritionists, social workers, respiratory therapists, and physical therapists. Pharmacists are available to other hospital staff and patients to answer questions, identify and resolve medication-related problems, and facilitate medication delivery.  Primary responsibilities include conducting patient interviews to obtain accurate medication and allergy histories, analyzing patient data daily, reviewing inpatient medication profiles, watching for adverse drug reactions, conducting drug-therapy monitoring, making drug-therapy recommendations, and documenting appropriate data.

The resident will spend 2 weeks rotating on OTSSU, and 2 weeks on SSTU.  On OTSSU and SSTU, mornings are usually spent conducting medication reconciliations, working-up patients, making pharmacy interventions, and answering medication questions. Topic discussions will be held in the afternoon, in addition to new patient work-ups.  The resident will be responsible for one journal club presentation and a nursing in-service.  The resident will lead a whiteboard topic discussion every Friday with the preceptors.  Also, trauma and OR experiences will be integrated by attending a trauma arrival in the ED, and observing an operation in the OR.   

 
RLS Goals:

  1. Goal R1.4:  Demonstrate ownership of and responsibility for the welfare of the patient by performing all necessary aspects of the medication-use system.
    1. OBJ R1.4.1  (Characterization)  Display initiative in preventing, identifying, and resolving pharmacy-related patient-care problems.
  2. Goal R2.1:  As appropriate, establish collaborative professional relationships with members of the health care team.
    1. OBJ R2.1.1  (Synthesis)  Implement a strategy that effectively establishes cooperative, collaborative, and communicative working relationships with members of interdisciplinary health care teams.
  3. Goal R2.4:  Collect and analyze patient information.
    1. OBJ R2.4.1  (Analysis)  Collect and organize all patient-specific information needed by the pharmacist to prevent, detect, and resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations as part of the interdisciplinary team.   
    2. OBJ R2.4.2  (Analysis)  Determine the presence of any of the following medication therapy problems in a patient's current medication therapy:
      1. Medication used with no medical indication
      2. Patient has medical conditions for which there is no medication prescribed
      3. Medication prescribed inappropriately for a particular medical condition
      4. Immunization regimen is incomplete
      5. Current medication therapy regimen contains something inappropriate (dose, dosage form, duration, schedule, route of administration, method of administration)
      6. There is therapeutic duplication
      7. Medication to which the patient is allergic has been prescribed
      8. There are adverse drug or device-related events or potential for such events
      9. There are clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test interactions or potential for such interactions
      10. Medical therapy has been interfered with by social, recreational, nonprescription, or nontraditional drug use by the patient or others
      11. Patient not receiving full benefit of prescribed medication therapy
      12. There are problems arising from the financial impact of medication therapy on the patient
      13. Patient lacks understanding of medication therapy
      14. Patient not adhering to medication regimen
  4. Goal R2.12:  Document direct patient care activities appropriately.
    1. OBJ R2.12.1  (Analysis)  Appropriately select direct patient-care activities for documentation.
    2. OBJ R2.12.2  (Application)  Use effective communication practices when documenting a direct patient-care activity.
    3. OBJ R2.12.3  (Comprehension)  Explain the characteristics of exemplary documentation systems that may be used in the organization’s environment.
  5. Goal R2.8:  Recommend or communicate regimens and monitoring plans.
    1. OBJ R2.8.1  (Application)  Recommend or communicate a patient-centered, evidence-based therapeutic regimen and corresponding monitoring plan to other members of the interdisciplinary team and patients in a way that is systematic, logical, accurate, timely, and secures consensus from the team and patient.
  6. Goal R5.1:  Provide effective medication and practice-related education, training, or counseling to patients, caregivers, health care professionals, and the public.
    1. OBJ R5.1.5  (Application)  Use public speaking skills to speak effectively in large and small group situations.

Activities Evaluated and Taught:

Objective Number  (Level of Learning Required) & Description

Teaching Method(s)

Related Rotation Activities &
Minimum Number of Times the Activity is Repeated to Ensure Completion of the Objective.

Goal R1.4:  Demonstrate ownership of and responsibility for the welfare of the patient by performing all necessary aspects of the medication-use system.

OBJ R1.4.1 (Characterization) Display initiative in preventing, identifying, and resolving pharmacy-related patient-care problems.

Direct Instruction Modeling

  • The preceptor will discuss and emphasize the importance of the resident taking responsibility of the patient’s care

Goal R2.1:  As appropriate, establish collaborative professional relationships with members of the health care team.

OBJ R2.1.1  (Synthesis) Implement a strategy that effectively establishes cooperative, collaborative, and communicative working relationships with members of interdisciplinary health care teams.

Facilitation Modeling
Coaching

  • The resident will integrate themselves into the team of each unit, as well as various surgery teams
  • The resident will collaborate with all members of the team throughout the course of the rotation

Goal R2.4:  Collect and analyze patient information.

OBJ R2.4.1  (Analysis)  Collect and organize all patient-specific information needed by the pharmacist to prevent, detect, and resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations as part of the interdisciplinary team.   

Direct instruction
Modeling
Coaching
Facilitation

  • The resident will collect all pertinent data and present it to the preceptor in an organized manner  
  • The resident will work up and optimize therapy for a predetermined number of patients for a day.
  • The preceptor will go over each patient with resident talking about the areas of intervention identified, and how best to make the intervention.

  OBJ R2.4.2  (Analysis)  Determine the presence of any of the following medication therapy problems in a patient's current medication therapy:

  • The resident will make appropriate interventions based on a patient’s current medication regimen, after talking it through with the preceptor
  • The preceptor will facilitate independence of the resident  as the rotation progresses
  • The resident and preceptor will discuss trends in medication errors by surgery service

 

Goal R2.12:           Document direct patient care activities appropriately.

OBJ R2.12.1  (Analysis)  Appropriately select direct patient-care activities for documentation.

Modeling
Coaching
Direct instruction

  • The resident will provide recommendations in the medication history document
  • The resident will select  which patients to write electronic notes
  • The resident and preceptor will discuss each patient’s electronic note

OBJ R2.12.2  (Application)  Use effective communication practices when documenting a direct patient-care activity.

Coaching
Facilitation Modeling

  •  The resident will select appropriate language when documenting a potential intervention

 

OBJ R2.12.3  (Comprehension)  Explain the characteristics of exemplary documentation systems that may be used in the organization’s environment.

Facilitation
Coaching

  • The resident will be asked to develop a new process to optimize the manner in which a patient is worked up, and documented, and present this new method to the preceptor.

 

Goal R2.8:  Recommend or communicate regimens and monitoring plans.

OBJ R2.8.1  (Application)  Recommend or communicate a patient-centered, evidence-based therapeutic regimen and corresponding monitoring plan to other members of the interdisciplinary team and patients in a way that is systematic, logical, accurate, timely, and secures consensus from the team and patient.

Coaching
Modeling
Facilitation

  • The resident will communicate interventions and monitoring plans to different members of the surgery teams
  • The resident will follow a defined number of patients daily, monitor the therapeutic plans, and follow up with the teams as appropriate. 

Goal R5.1  Provide effective medication and practice-related education, training, or counseling to patients caregivers, health care professionals, and the public.

OBJ R5.1.5  (Application)  Use public speaking skills to speak effectively in large and small group situations.

Coaching
Facilitation
Direct instruction

  • The resident will present  a journal club
  • The resident will present  an in-service to RNs or MDs
  • The resident will present a weekly whiteboard discussion to the pharmacist.
  • The pharmacist and resident will discuss all presentations and how to customize the information, based on the audience

 
Readings and Preparatory Work:

  • Clinical practice guidelines for antimicrobial prophylaxis in surgery.  Am J Health-Syst Pharm 2013; 70:195-283.  PMID:  23327981
  • Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):S381-S453.  PMID: 18574271
  • The perioperative management of Antithrombotic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):S299-S339.  PMID: 18574271
  • Discontinuation and Reinstitution of Medications During the Perioperative Period. Am J Health Syst Pharm 2004;61(9):899-912.  PMID: 15156966
  • Stopping and Restarting Medications in the Perioperative Period. Med Clin North Am 2001; 85(5):1117-1128.  PMID: 11565489
  • Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. Am J Surg 2005;189(4):395-404.  PMID: 15820449 
  • Adherence to Guidelines for Antibiotic Prophylaxis in General Surgery: A Critical Appraisal. Journal of Antimicrobial Chemotherapy 2008;61(1):214-218.  PMID: 17999981
  • Role of NMDA Receptor Antagonists in Postoperative Pain Management. Curr Opin Anaesthesiol 2009;22(5):618-622.  PMID: 19535974
  • Emerging Trends and New Approaches to Acute Pain Management. Pain Manag Nurs 2008;9(Suppl 1):S33-S41.  PMID: 18226793
  • Pharmacotherapy for Acute Pain: Implications for Practice. Pain Manag Nurs 2008;9(Suppl 1):S22-S32.  PMID: 18294591
  • Prevention and Treatment of Postoperative Nausea and Vomiting. Drugs 2000; 59(2):213-243.  PMID: 10730546
  • New Pharmacologic Findings for the Treatment of PONV and PDNV. Am J Health-Syst Pharm 2009;66 (Suppl 1):S11-18.  PMID: 19106333
  • A Comprehensive Review of Evidence-Based Strategies to Prevent and Treat Postoperative Ileus. Dig Surg 2009;26:265-275.  PMID: 19590205
  • Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416.  PMID: 15699079
  • Stress Ulcer Px in the Postoperative Period. Am J Health Syst Pharm 2004;61:588-596.  PMID: 15061430
  • Chapters to read in Pharmacotherapy (DiPiro): Assessment of Nutrition Status and Nutrition Requirements, Parenteral Nutrition, Renal impairment, Quantification of Renal Function, Drug Therapy Individualization for patients with renal Insufficiency, Skin and Soft tissue Infections, Bone and Joint Infections, Diarrhea and Constipation, Kidney and Hepatic Transplant

Project/Presentation Description:

  • Residents are required to present a formal journal club to preceptors.
  • Residents are required to present a topic on the whiteboard each Friday to the preceptors.
  • Residents will coordinate with the OTSSU and SSTU floor nurse educator to prepare and present  a minimum of one nursing in-service during the time of their rotation.

Typical Daily/Weekly/Monthly Activities:

  • Gather patient data and work up patients
  • Review pressing issues with preceptor and make interventions
  • Present patients/plans to preceptor
  • Perform medication histories
  • Write electronic progress notes
  • Answer team questions
  • Work on projects/ presentations
  • Attend a Trauma I in the Emergency Department
  • Observe a surgery in the OR
  • Integrate into team to optimize patient care

Resident Evaluation:

  • The resident will receive feedback from preceptors on a daily and weekly basis.  Formal evaluations will occur at the midpoint and conclusion of the rotation.