How to master shooting in the dark

Posted by Kendra Yum at Saturday, August 22, 2009

My first rotation is an institutional rotation at a hospital pharmacy. I wanted to see the operations of a hospital pharmacy at a different setting, so I have been commuting to Detroit’s John D. Dingell Veterans Affairs Medical Center (VAMC). The VAMC is a large medical facility that services some 300,000 veterans in the Michigan area. They provide primary care, surgical and specialty care, as well as medical research programs and community-living (nursing home) centers. The VAMC has an inpatient pharmacy, an outpatient pharmacy and processes prescriptions for mail-order services. Pharmacists also run an anticoagulation clinic and a hypertension clinic at Detroit’s VAMC.

Most of my time is spent at the inpatient pharmacy, reviewing patients’ records for therapeutic duplications or checking IV doses. I also help with filling orders, stocking the patients’ medication carts and compounding IV preparation in the clean room. All the inpatient medications are bar-coded, so that prior to administration, the nurse has to scan the medication barcode to verify that the correct medication is being given.

At the outpatient pharmacy, the most commonly used drugs are filled by a ScriptPro machine, with the other orders filled manually by technicians. In both cases, the pharmacist scans the bar-code on the bottle to a computer SP Station, which displays a photo of the pill for the pharmacist to verify. I have never worked with ScriptPro before, but it seemed like an efficient and effective way to catch medication errors.

On Wednesday, I had the chance to shadow the anticoagulation clinic pharmacist, Carol. Most patients have atrial fibrillation, past cardiac valve replacement, or a history of thromboembolism (DVT, PE) that requires continual anticoagulation with warfarin. It was exciting to see patients coming in every month just to see and speak with the pharmacist.

Most of the patients completed INR testing in the morning and then receive an assessment of and counseling on diet, bleeding, and medication adherence from the pharmacist. Patients on warfarin require extensive monitoring due to the unpredictability of patient’s response to warfarin and the potential danger of bleeding episodes if too much is given. It seems like warfarin dose titration can sometimes be a “shot in the dark”, since there are so many variables that can affect a patient’s INR. Is the patient’s INR too low because (a) he is not responding to the dose, (b) he is non-compliant (despite not admitting it), (c) he ate a lot more broccoli than he remembered this week, or (d) all of the above? Should we then increase the dose, not really knowing if the answer was (a), (b), (c), or (d)? That’s the type of question that requires the experience of the pharmacist and his/her knowledge of the patient. My day at the anticoagulation clinic definitely showed me how important it is to polish your patient counseling skills to get the most information from the patient to make the best clinical decision.