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!