Got BK?

Posted by Jody at Sunday, August 29, 2010

“What is BK?” I asked the same question when I found out my patient had “BK”.

As I am rounding with the team one day I hear the attending mention my patient has BK. I immediately start racking my brain, what in the world is “BK”? I have no idea. I turn to my classmates and ask them. They respond, “BK? I thought he said PK.” Well then, “What does PK mean?” (This is the reason you ALWAYS stand as close to the attending as possible – they’re quiet talkers.) Whatever my patient has I know one of the symptoms they are experiencing is hematuria and they are going to be treated either cidofovir or leflunomide. My classmates and I are completely lost and ask our preceptor. He informs us that the attending was talking about “BK”. But our preceptor would not give us any further information. He told us we should research it tonight and gave us one clue, to start with renal transplant patients.

Returning to answer the question: “Do you have BK?” The answer: Yes, you most likely do have BK.

What is BK?

BK refers to the BK virus (BKV), and up to 90% of healthy adults are infected with the virus. The virus was first reported in 1971 in a renal transplant patient, and thus the virus was named after the patient’s initials. BK is a polyomavirus that is transmitted via the respiratory tract, especially during early childhood. The initial infection is usually asymptomatic, but it can result in a mild fever or upper respiratory symptoms. After the initial infection the virus remains latent for years in the kidneys and does not reactivate until a state of immunosuppression. In renal transplant patients BK virus manifests as nephritis (i.e. BKV nephritis), however in bone marrow transplant the clinical manifestation is hemorrhagic cystitis (HC). The presentation of HC is hematuria, bladder spasms, frequent urination, and dysuria due to inflammation of the bladder mucosa.

Diagnosis and Treatment of BK

Once symptoms of HC occur a qPCR of the plasma and urine is ordered. If results are positive the patient is then treated. However, there is no approved treatment for BKV. Clinical trials have been investing various drugs to combat the virus. Currently, trials with cidofovir and leflunomide have shown positive outcomes yet further research is warranted in both the virus itself and treatment options.

After my basic search of BKV it was time to tackle articles on clinical trials. In rotation, when a preceptor asks you to “look-up” or research something it doesn’t just mean hit Wikipedia and get the general information. We are pharmacy students, soon to be pharmacists, once we understand the condition/disease state we need to understand the treatment options and know what works (or doesn’t) and why. (A helpful hint my preceptor gave me, read the literature and know it because no one else will)

Bottom line: The learning never stops.

Witnessing the Michigan Difference through Conversations

Posted by Shelley Ling at Sunday, August 29, 2010

At a conference table, four pairs of eyes focused on one person as he described to us his roles and responsibilities in the UMHS pharmacy administration. As I listened to him talk, many questions popped into my head. What is his background? Who or what inspired him towards this career path? Were there untold stories of struggles or fruitless efforts? What is his vision for pharmacy...

I just finished a month-long institutional hospital pharmacy rotation at none other than the University of Michigan. Each week, we were assigned mini-rotations from operations to decentralized pharmacy services, all of which helped us to gain a bigger picture of how the hospital pharmacy system works. One of my favorite is definitely the week when we got to meet and to converse with pharmacists in administration. Despite the differences in roles, I have found admirable qualities shared by all of them.

1. Very few of them wanted to go into administration at first. This is not surprising since administration is a pretty nontraditional field in pharmacy. But ultimately, they have stayed in administration and love what they are doing, because they feel that it is the most effective way for them to impact patient care.
2. They are extremely diligent. Many of them work as much as 70 to 80 hours a week to meet the demands of their responsibilities.
   
3. Most of all, they are patient advocates. "How can we offer better care for our patients?" is a question they constantly ask themselves, because they want to offer the best care possible. For example, when Dr. Pam Walker saw a crucial role that can be played by pharmacists in the emergency room, she fought for that to happen despite initial setbacks. Sometimes, she would have to wait or to change her approach, but her vision kept her moving persistently forward. "Be aggressive, but not too aggressive. Not right now. Wait for the proper timing," was a piece of advice for her from her mentor.

Listening to their stories, their passion for pharmacy and for their patients is unmistakable and contagious. They are great role models for us because they not only embody so much knowledge and experience, but so much heart. And we wonder, what will our stories be? As long as we uphold the same attitude as they do and have a vision we are willing to strive for, we can only begin to imagine the possibilities... what a great way to start off P4 year!

Corticosteroids, Contagions, and Creatinine Clearance

Posted by Salem at Saturday, August 28, 2010

I spent the first month of my P4 year with Dr. Cesar Alaniz. He is the clinical pharmacist in University Hospital’s critical care medicine unit (CCMU). The CCMU is an intensive care unit that takes care of U of M’s most critically ill patients. Unfortunately, most of the patients were so sick, that we couldn’t speak to them. Sepsis, hospital-acquired pneumonia, and GI bleeds were some of the common chief complaints of the patients we cared for. This made for an intense (no pun intended), but excellent 4 weeks.

Week 1

I remember being very nervous on the first day. Practically sweating through my freshly ironed white coat, I wondered if I had reviewed my list of antibiotics thoroughly enough. Dr. Alaniz told us to look at the charts of a few patients, and then join him on patient care rounds the next day. I did this, and by the time we finished rounding on Tuesday, I was totally bewildered…

Why are these physicians spending so much time discussing ventilator settings?

What on earth is a galactomannan assay?

Why are so many of these patients on hydrocortisone?

What is the pharmacist’s role in all of this?

How do I use all these computer programs?

Whenever the attending physician, or any of the other members of the medical staff had a drug question, they would turn to Dr. Alaniz. He was able to quickly and confidently answer their esoteric questions like...

“How much Precedex is lost during hemodialysis?”

“What’s the dose of an ampho B bladder wash?”

“How should we redose tobramycin after a one-time of 340mg with a 4 hour random level of 6.8?”

Would I ever be prepared for these types of questions? For the rest of the first week I found myself waking up at 4 AM just to keep up with everything that was happening with our patients. Early!

Week 2

By week 2, Dr. Alaniz had us analyzing the aminoglycoside and vancomycin blood levels of the patients on our service. He wanted us to evaluate the levels and see if the dose of drug the patients were receiving was appropriate. This was not nearly as straightforward as it had been in class. All of the patients were in some stage of renal failure. So the numbers we would use for our calculations would fluctuate up and down, up and down. Curveball!

Week 3

During week 3, we only had a few patients on our service. Dr Alaniz decided that due to the “paucity of patients” he would let me start rounding without him. This totally changed my experience. Any drug-related questions now came to me - and there were some hard ones...

“Do we need to continue vancomycin in this patient?”

“How do we taper methylpred after anaphylaxis?”

It was great when I was able to provide an answer, but it was a little embarrassing when I couldn’t. Pretty thrilling!

Week 4

By week 4, I was a part of the team. I could make recommendations, and answer questions much more comfortably. I could definitely have learned much more from a few more weeks at the CCMU.

A NICU Experience

Posted by Karen at Saturday, August 28, 2010

I cannot believe these past 4 weeks just flew by!

My first rotation was at the UM Neonatal Intensive Care Unit (NICU). Most of our patients were premature (less than 37 weeks gestational age), and some of them weighed less than 1 kilogram.

It was an unforgettable experience, not only was it the first time that I worked with the neonatal population, I also had a lot of other “first times.” Some of these were…

1. Going on rounds by myself
2. Making an intervention
3. Applying pharmacokinetics in real patients
4. Looking at patients’ flowcharts 2 hours before rounds started
5. Preparing for topic discussions using only primary literature

Throughout the four weeks, we met with our preceptor, Dr. Mehta, where we had our topic discussions on neonatology and patient case presentations. Although we were working with a very unique patient population, the thought process that we learned on working up patients is applicable to any patient, no matter how young or old. Dr. Mehta also emphasized the importance of transitioning from our role as a student to a health care professional:

1. Talk like a healthcare professional-in order to effectively communicate with other health professionals, we have to know the correct medical terminology. Dr. Mehta asked us how caffeine worked for the treatment of apnea of prematurity, and after struggling for the right term, our final answer was “something in the brain” (the correct answer was the brain stem).

2. Know your drugs (one thing that Dr. Mehta constantly stressed to us)-just knowing the doses, side effects and mechanism of action is not enough. Since we are the drug experts, we cannot forget about the pharmacokinetic and pharmacodynamic profile, routes of administration, compatibility with other drugs (if the drug is administered intravenously), relative cost, therapeutic effect, and monitoring parameters. Yes, most of this is memorizing, but once you have mastered this knowledge, you will appreciate why a drug is dosed every 24 hours versus being infused continuously or why one drug can be immediately discontinued versus another that has to be tapered down for a week. Everything will start to make more sense.

3. Know the current literature-information changes all the time. Everything that we do has to be evidence-based. We have to know the current literature on drug therapies or else we cannot make any recommendations without evidence-based medicine. Time after time, whenever we asked Dr. Mehta about drug-related questions, she would refer to current studies that supported her answer.

4. Be confident :)

I took away some good lessons from this rotation. From learning how to communicate more effectively to evaluating drug therapy based on systems (respiratory, cardiovascular, etc), I can see the improvement in my abilities today as compared to my first day four weeks ago. As my colleagues and I stepped out of the NICU yesterday after rounds, we were sad that we had to leave. For me, this was a place where I began my transition to becoming a pharmacist.

First Rotation Completed??

Posted by Zhe Han at Friday, August 27, 2010

I could still remember feeling nervous and uncertain when P4 orientation ended. Yet one month had since gone by and I completed my first P4 rotation today! My first rotation was institutional at Providence Park Hospital in Novi. After a 3-month summer, waking up at 5:30am was the last thing that I was ready for. I was really glad that I adapted quickly and I once said to a friend, I watched sunrise every morning when heading east on M14.

The first week of my rotation focused on the distributive activities of an inpatient pharmacy. Everyone in the pharmacy was incredibly busy that week because Joint Commission surveyors were onsite. In fact, even before my preceptor brought me to the pharmacy on my first day, we went up to the floors to do a "sweep".

I was on the anticoagulation and pharmacokinetics service throughout my second week. One important lesson I learned was it is always important to go up to the floors to talk to the nurse, to see the patient and to verify pump settings.

The third week was the most interesting and the most challenging. I attended MICU rounds. My preceptor wanted me to work up at least 3 patients, understand their disease states, know what drugs they were on, whether the drugs were dosed appropriately, and what patients should be monitored for. Even though I had plenty of time to work up patients before rounds, I still felt lost. On the fourth day, I had a patient with CrCL~5 on milrinone and I caught that the infusion rate was not adjusted for the patient's renal function. After discussing with my preceptor, I recommended decreasing the rate to 0.2mcg/kg/min. So that was my first recommendation on rounds! Finally, things started to come together a little after several days of feeling lost and overwhelmed.

Like Father, Like Son

Posted by Jim Stevenson at Thursday, August 19, 2010

I may have gone to “Take your son/daughter to work day” once during elementary school, but I don’t recall it too well. I’d like to think that my understanding of and appreciation for my father’s job has progressed a bit since second grade. Really though, entering P4 year, I still didn’t have a good idea of what my father, or the rest of the large pharmacy administrative staff, did on a day-to-day basis. Are their roles something I could see myself doing? Are administrative skills genetically heritable? These are the questions I set out to answer during my first rotation.

Aside from honing my clinical skills and preparing myself for a potential residency, one of my main objectives of my P4 year was to get a better idea of how I might best apply myself in the field of pharmacy. I also considered administration to be one of the practice areas that you experience “now or never”. After speaking to the administrators at the hospital, I’ve learned that I was wrong about this “now or never” mentality, as many of them started out in other areas and didn’t even initially consider management. But that’s the spirit of P4 year – being wrong and then learning the truth.

My preceptor is Dr. Paul Walker, the Assistant Director of Pharmacy Clinical Services at UMHS. To my surprise, his meetings and projects to not overlap very much with my father’s (my father has his own P4 student this month, Doug Ritchie). I spend about half of my time each day attending meetings with Dr. Walker and about half of my time working on independent projects that I later relay to Dr. Walker.

One of the expectations for students on the administrative rotations is to meet with each of the Assistant Directors. We then find out what they do, how they got there, and how their role interplays with the other administrators. That’s been an interesting aspect of this rotation, as I now know who is in charge of what and the career paths they took to get there.

Another aspect of the rotation I have enjoyed is information on quality improvement in our hospital pharmacy. I’ve always enjoyed research and interpreting numbers, and administrative quality improvement takes those concepts and uses them to improve patient care and the financial efficiency of our services. In the Information Age, we have a lot of numbers at our fingertips, and this will only grow as our health system continues to advance Computerized Physician Order Entry and our software systems.

One Jim Stevenson has already chosen the administrative path. Will there be another? That remains to be seen – I’m barely half way through my first rotation!

A Public Option

Posted by Brandon at Wednesday, August 18, 2010

I came into pharmacy as somewhat of an idealist. I never understood why there were so many hurdles for patients needing medication. Shouldn’t community pharmacy be a component of a simple transaction that brings patients better health – patient sees physician, physician issues prescriptions if necessary, patient sees pharmacist who gives him medications and valuable advice?

...Then I worked retail, got familiar with insurance, saw patients weep at the cost of their drugs and had my utopian vision shattered.

This emotional rollercoaster through the world of healthcare drove me to pursue a nontraditional public health rotation at the City of Detroit Department of Health and Wellness Promotion.

The pharmacy is located in the basement of the Herman Kiefer Health Complex, which is not much to look at. The halls are dark and dingy, and the building, like much of Detroit, needs some serious renovating. But when I learned about the work being performed there by the various health clinics, social programs and pharmacy, the place brightened up considerably.

So let’s talk about the pharmacy and why my idealistic side is so grateful it exists. The Herman Kiefer pharmacy is a very important part of the Detroit community because it provides an outlet for many patients to receive vital medicines they otherwise would not be able to afford.

If a patient is an uninsured resident of the city of Detroit, he or she is able to get a prescription filled for a $6 flat processing fee. Seniors age 65 and older meeting these criteria pay only $2 per prescription! The pharmacy and its patients benefit from generous pricing from manufacturers as well as public funding sources.

As future healthcare providers, we have to appreciate the service being provided here. This was explained to me by one of the pharmacists I’ve been working with. He said that our number one priority must be the patient and the most rewarding part of his job is filling prescriptions that may otherwise go unfilled. The particular patients we see - those that are uninsured, likely unemployed and certainly struggling with financial difficulties - are some of the most challenging in terms of compliance.

This pharmacy is somewhere they know they can go and will not be turned away. Prices will be consistent and affordable, and they will not be treated differently for being without insurance. And in turn, I have found the patients here to be among the most appreciative of pharmacy services.

While the work here has not differed tremendously from other community experiences, the unique lessons learned will last forever.

In need of stem cells?

Posted by Jody at Tuesday, August 17, 2010

I am starting my first rotation at UofM in bone marrow transplant (BMT) with Dr. Frame.

On the first day, of my first rotation, I was quite nervous – I had no idea what to expect. All I knew was that I would be with two other students from my class which helped ease by nerves a little. My classmates and I were to meet Dr. Frame in the cafeteria. We all thought, “Here we go, our FIRST rounds ever.” When Dr. Frame came he sat down with us and explained how we wouldn’t be attending rounds until tomorrow. He explained that with no knowledge of BMT we would feel lost and overwhelmed. (However, this feeling of lost and overwhelmed lasted the entire first week). Dr. Frame gave us an overview of BMT, described the different types of transplant and the common diseases that needed transplant. I was able to understand beyond the basics (allogenic transplant = a donor and recipient, and an autologous = the patient’s own stem cells). We talked in detail about the actual process of transplant, and In the simplest terms (for either an allo and auto), the patient receives chemo in order for the primary disease to go into remission, next the stem cells are mobilized for collection (either the patient’s or a donor’s), the patient receives a conditioning regimen of chemo and then the actual transplant occurs.

After our quick overview of BMT, he gave each of us a list of 5 patients and told us to take the rest of the day to thoroughly learn two patients in detail. By 11am we were free to go. My classmates and I thought it was awesome; we’d go home, spend a few hours learning our two patients and be done for the day. Little did we know, that when Dr. Frame said, “take the rest of your day to learn two patients” he really meant the rest of the day. As I read the patient charts I had to continuously stop and look up almost every other word. There were so many terms and acronyms I had never seen before, things like “BK virus”, “ECP held due to bleeding” or “PCA (0.4/10/14)”. I literally spent the rest of the day trying to decipher the H&P and progress notes.

The second day came and finally we were able to attend rounds. Needless to say, even after my day of studying and researching I was still lost. Dr. Frame did a great job explaining the terminology we didn’t know and the different procedures. As the first week went on things started to come together, especially since there were discussion sessions at the end of each day. All students on rotations for oncology/hematology/BMT would come together for the last 1-2 hours for a discussion session lead by one of the preceptors. Each topic came with a reading assignment to help facilitate the discussion (or to help those of us who had forgotten the topic from therapeutics). The topics that were focused on were specific conditions commonly seen in cancer patients, such as, tumor lysis syndrome, febrile neutropenia, anemia, WBC growth factors, nausea/vomiting, and pain.

After the first week things really started to come together, which also made rounds even more exciting. Each day there was at least one patient with a new condition or problem that we had never learned about in school. However, this also meant we’d be hitting the books once we left the hospital – talk about a fast learning curve!

LTACH...gesundheit?

Posted by Tiffany Pfundt at Monday, August 16, 2010

Not to worry, my allergies haven't flared up. LTACH refers to Long-Term Acute Care Hospital and happens to be my home for 1 month (less than two weeks now). I know it may sound oxymoronic, long-term acute care, but it's a real thing. The LTACH I have been placed at is CareLink in Jackson. LTACHs are designed to care for patients who are not well enough to go home, but aren't ill enough to remain in the critical care units at regular hospitals. A typical CareLink patient has multiple co-morbidities, including diabetes, CHF, hypercholesterolemia, and high blood pressure, in addition to more complex conditions like kidney failure requiring dialysis, infections requiring extended IV antibiotic therapy, or malnutrition requiring TPN. In order to remain an LTACH an average patient stay at CareLink must be greater than or equal to 25 days, so our patients are with us for extended periods of time. Upon discharge patients can be sent to nursing homes, assisted-living facilities, or home.

CareLink is staffed by 1.5 clinical pharmacists (one full-day, one half-day). Currently we are in charge of caring for 36 patients and the pharmacist I work with plays a critical role in providing care for every patient. The pharmacist I work with is immensely knowledgeable, yet humble. He juggles clinical, managerial, and staff pharmacist responsibilities daily. Doctors, nurses, and dieticians rely on his clinical judgement and recommendations when making recommendations of their own.

Each day begins by "rounding" on each of the two floors. Rounding consists of hanging out by the nurses station where all the action (and patient charts) is located. Being close to the action allows the pharmacist to tend to immediate needs that may arise on the floor. It also helps build a strong and trusting relationship with other health care providers. Given the relatively small number of patients, the pharmacist is able to tend to every patient's needs daily, even if they all have complex needs. Daily responsibilities include:

• Renally dosing medications for renally impaired and dialysis patients
• Monitoring for CNS active drugs and their propensity to potentiate falls
• Pharmacokinetic dosing of aminoglycosides and vancomycin
• Reviewing antimicrobial selection for treating complicated infections
• Starting and adjusting TPN and PPN for patients receiving parenteral nutrition
• Monitoring for and correcting electrolyte abnormalities
• INR monitoring, warfarin and heparin dosing
• Participating in and providing information for interdisciplinary team meetings
• Monitoring for excessive acetaminophen use
• Medication reconciliation for patients ready to be discharged
• And more...

Although I didn't select this rotation as one of my top picks, I feel very fortunate to have been placed here for my Internal Medicine rotation. After speaking to some classmates, I think my Internal Medicine experience will be more relaxed than some. Not to worry though, I don't feel like I am getting short-changed in regard to the quality of the rotation or the amount I am learning. My preceptor has perfected the balance between giving direction and letting students think independently. That coupled with the diverse and complex patient population has accelerated my hands-on learning experience.

The first day of rotation I shadowed him. That day he provided me with a general outline of what a pharmacist does at CareLink on a daily basis. On Day 2, he handed me the INR reports and instructed me to adjust our patients' warfarin dosing accordingly (with his final approval, of course). Since then my responsibilities have grown steadily. Also during the first week he assigned me an Antibiotic Therapy Monitoring project. The goal was to develop a way to keep a closer eye on high-cost antibiotics in hopes of reducing unnecessary use. Monitoring these drugs serves multiple purposes. Not only does it help keep costs down, it also reduces unnecessary bacterial exposure to more broad-spectrum antibiotics, and reduces unwanted side-effects associated with these agents. As soon as he assigned me the project he allowed me to take ownership of it and make needed adjustments I see fit. This has helped me build confidence in my abilities as a future pharmacist, and has instilled a sense pride.

Final words: I give this rotation two thumbs up!

Getting My Feet Wet

Posted by Omo at Monday, August 16, 2010

So after our long summer break (I say long because many other schools don’t have the luxury of three months break before they transition into their P4 year), I was pumped for my fourth/final year to start. After all, you often hear many positive things about the P4 year such as:

· “You learn more as a P4 than you will in all previous years of pharmacy school combined”

· “P4 year is cool, you get to meet a lot of pharmacists who will inspire you”

· “P4 year is a very humbling experience because you may have done well throughout pharmacy school but when you get on the floors to practice, you find out how little you know.”

All of the above statements prepared me somewhat for my experience. My first rotation is institutional and it is at the U-M hospital. I must add that having my P3 rotation in the hospital last semester helped me with getting acclimated with the system. The experience thus far has been remarkable. There is always something that needs to be done for a patient so you are always busy and hardly ever idle/bored.

Side note: I am never bored but sometimes I feel sleepy because these are very early morning shifts, definitely not what I am accustomed to but thank God for tea/coffee.

I will share a little bit of the top 3 things I have learned thus far. They are pharmacy and non-pharmacy related.

3. Assertion is a key in pharmacy

We have learned so much and it is easy to have a lot of information jumbled in one’s head especially when we are asked drug-related questions during rounds. Nonetheless, when dealing with patients, we need to be sure about what we are recommending/saying/doing. Being sure means over learning material pertaining to the patient so that we can deliver to the best of our abilities. In addition, it is important to remember that everyone you are working with is human so do not be intimidated (yes, I know it is easier said than done!) but try to be assertive!

2. Build networks and create healthy relationships in the workplace

Being immersed in the institution everyday for the past two weeks has really emphasized the need for us to establish a friendly relationship with co-workers including pharmacy technicians, doctors, physician assistants and nurses. I worked with a pharmacist at the Operating Room (OR) Pharmacy. Throughout the time I was with her, I could tell that she enjoyed every bit and made the most of her job. She was very lively, friendly and respectful to her technicians. Her positive interaction with the physicians on the floor was glaringly obvious. The friendly ambience reinforced the need to strive for a workplace like this because there is nothing better than enjoying your job!

1. Know the BUG-DRUG Sheet

Special thanks to Dr. Carver for this sheet! I can confidently say that I have at least one patient everyday with an Infectious Disease (ID) issue. Last week, I was in Motts Children Hospital and I got to round with the medical team every morning. We had about two to three patients on average everyday and at least 2/3 if not all the patients had an ID issue. It makes a lot of sense why we spent about 6 weeks on this section of therapeutics. Know the bug-drug sheet! I cannot emphasize this any more.

I hope my message/post was helpful. Feel free to leave comments or ask any more questions about my experienceJ

-Omonye

Out in the Community

Posted by Alex at Wednesday, August 11, 2010

My first rotation as a P4 is Sam's Club. Unlike many pharmacy students, I have never interned at a community pharmacy. My background is inpatient pharmacy, clinical research and managed care. Since I just completed a summer internship in managed care, I find it quite interesting to start off the year with my community rotation.

One of the biggest issues that patients face is insurance. "Your insurance won't cover your med until next week." "Your insurance will only cover a certain number of pills." As a result, quite naturally most people would think insurance companies are evil and don't look out for the good of patients.

As part of the rotation, we are required to do an educational poster. For my topic I'm thinking of doing a poster on basic managed care terms and principles: formulary, tier, co-pay, prior authorization, quantity limit. I really want to educate people on these topics so they can at least get some understanding of what happens when they are paying for their medicine.

A comment that one of the techs said resonated within me: "If the doctor writes a prescription for a drug, the insurance should just pay for it."

Doctors don't always put cost or the patient's insurance into account when selecting drug therapy. So I would have to disagree with that statement. Furthermore, the managed care organizations base their decisions on what gets covered or not on the very same clinical practice guidelines and primary literature that health care providers base their decisions on.

I believe if patients are aware of what meds their insurance covers and lets their doctor knows while the prescription is being written, a lot of hassle could be avoided. The patient does not have to wait around for their med to be filled only to find out the insurance does not cover it, and then have to wait longer for pharmacy to reach the doctor to change the med. Therefore, as part of my project I'd like to inform patients that they should really let their doctor know what insurance they have and what meds are covered.

Just now I googled Blue Cross Blue Shield's formulary indicating which meds are tier 1, tier 2, tier 3. It took me 5 seconds to pull up the list.

Through this project I believe I can be a true patient advocate in helping patients access their medications.

As cliche as this may also sound-- all experiences, regardless of what type of experience, really does enrich learning.

To bleed or not to bleed...

Posted by BJ Opong at Sunday, August 08, 2010

My first rotation is at Crittenton Hospital in Rochester Michigan. On the first day of my rotation I was a little uneasy not knowing what to expect from an Anticoagulation Clinic. Aside from that, there was the mental adjustment that there would no longer be the late morning starts or half days as the days of class room lectures were long gone. In front of me stood long days working in the clinic and even shorter nights reading articles to build upon what I had learned during the day. I anxiously awaited my newfound challenge. One of the first things that I learned from my first few days in the clinic is that they have a very friendly and broad patient population. What I noticed is that these weren’t patients who were being forced by a doctor to be there, but patients who genuinely wanted the best therapy possible and who were very knowledge about there care. Let me get into what actually goes on at an anticoagulation clinic for those of you who don’t know. Patients are referred by their doctor for monitoring of their warfarin therapy for various reasons, be it long-term or short-term therapy. The patients who just started monitoring will have visits more frequently at the beginning of therapy. To make a long story short the patients come into the clinic (which is a typical doctors office/exam room) to have the INR monitored. This is done by the patients giving a drop of blood via a finger poke test similar to the one performed by diabetics. The blood is analyzed and an INR is produced. (I’m not gonna lie, but the 1^st time I had to poke a 90 year old lady’s finger I was nervous because I didn’t want to hurt her.) Given the patients admitting condition the range that we desire could vary but generally it is between 2-3. Depending on where the patient is the pharmacist will counsel the patient about various ways to either increase or lower their INR and alter the patients’ daily doses. It sounds simple enough but a lot more goes into than you would think. Aside from learning a lot of interesting stuff about anticoagulation and poking fingers all day the aspect that I have enjoyed the most from this rotation is the patient interaction. The patients’ are very friendly and are not hesitant at all to share their personal experiences, which makes for entertaining dialogue. I am looking forward to the rest of this rotation and the conversations that ensue.

The Joint Commision

Posted by Sarah Thiel at Thursday, August 05, 2010

My first rotation is at Providence Hospital in Southfield, Michigan for hospital pharmacy administration (nontraditional).

I was full of pre-rotation jitters Sunday night before my first day. I even picked out my outfit and made my lunch the night before - a habit I had left behind in high school! I got a good nights sleep and left Ann Arbor at 6:30am since I had never driven to Southfield before and wanted ample time to arrive.

I successfully maneuvered through morning rush hour traffic and even found a parking spot that was free of charge - which is a novel idea when one gets used to paying everywhere in Ann Arbor for parking.

My preceptor's administrative assistant met me at the employee entrance and showed me the way to the pharmacy department. She showed me around the department and introduced me to many people. My preceptor (the director of pharmacy) wasn't going to be in until Tuesday, so his manager took me under his wing for the day. When he arrived at 8am he had very interesting news for me - The Joint Commission (TJC) had arrived to survey our hospital system.

My tour of the nursing units was on the fly as the manager took me to every department to check all the medication room refrigerators for multi dose vial dating compliance before the surveyors began looking around. TJC now requires all multi dose vials be dated with a "beyond use date" of 28 days after it was opened or punctured (http://www.jointcommission.org/NR/rdonlyres/7DDACC46-9522-4DA6-B7A4-A41F52745A7E/0/jconlineJune910.pdf).

From there we went to "The Command Center" to get the latest scoop on what the surveyors' schedule would be. Here I was introduced to the two nursing directors as well as the Chief Medical Officer (CMO). One really great aspect of this institution is the level of support the Department of Pharmacy receives from nursing, the CMO, and other higher-up executives- and what a difference this support makes to developing and implementing pharmacy services!

I was then introduced to the Team Leader Surveyor and was able to tag along with the entourage of people accompanying her. What you will quickly find out about TJC surveyors is that they know how to get the information they need and that they are very good at their jobs - if there are any discrepancies in policies or procedures they will find it. They ask hundreds of questions and follow up on any issue of possible concern they find. All the employees at the hospital are basically told the same thing for how to interact with the surveyors: 1) Be polite but don't speak unless spoken to, 2) Be clear and concise when answering questions, and most importantly 3) Don't divulge or offer up any information that wasn't explicitly requested.

Having the Joint Commission here for an entire week has been a great way to kick-off my hospital pharmacy administration rotation. I have already attended several debriefing meetings, participated in conference calls regarding pharmacy technologies, presented information to physician and nursing surveyors, gave two summary overviews of the medication management tracer to the pharmacy staff, discussed the ongoing drug shortage issues, and even discussed initiatives to reduce departmental costs while improving patient care!

Now that week one is already close to an end, I am already very comfortable with this hospital and all the staff- everyone here is so friendly!

Who knows whats in store for next week!