Thursday, July 19, 2012

The inpatient pharmacy at St. Joseph Mercy Hospital in Ann Arbor

Posted by Beejal at Thursday, July 19, 2012

Hi everyone! Here's another long post on day-to-day activities with a little bit of reflection!  Grab yourself a fro-yo and sit yourself down for 20 mins! :) 

I’ve gotten through 4 weeks at St. Joe's, and have gotten a pretty good handle on things.  This is not a stressful rotation, but you really do learn a lot about the staff pharmacist’s role.  You do a lot of multitasking and learn how to be efficient (in case you’ve missed that somewhere along your pharmacy experience)!  I think this might be a more difficult rotation if you haven’t seen the St. Joe’s system, but I had my IPPE at St. Joe's Livingston so things were pretty familiar.

A typical day…

There are some baseline responsibilities that define a P4’s day: F8s, Ancillary carts, ADEs, Duplicates, and ALS bags/boxes.  Dr. West will put out a schedule for which student is covering each responsibility each week (There are usually 2 P4s in the same block).  Some days you could be assigned everything, other days you could have split responsibilities, and a few days you could have no responsibilities.  

F8s are drugs to be checked first thing in the morning at 7:30am, so that the tech can deliver them at 8am.  My understanding is that they are the drugs that a) don’t fit in the pyxis b) are too expensive to stock in the pyxis and/or c) for patients who are day-to-day, ie they could be leaving anytime.  These “Short-Stays” for example could be referring to someone who just delivered a baby.  Ancillary carts have drugs being refilled in the pyxis, and are checked usually between 9 and 10am. 

Sentri7 is St. Joe's equivalent system for UofM’s Theradoc.  It has tabs for different drug alerts, and ADEs and Duplicates are a couple of examples.  ADEs are alerts that are triggered when a renally-eliminated drug is prescribed.  The intern must check out the patient’s CrCl and determine if the dose is appropriate.  There are usually 5-7 pages of patients to go through so this can be tedious; but you learn which drugs to look out for, where to find the information you need about the patient, and common physician prescribing practices.  I’ve seen a lot of these alerts for famotidine, loratadine, gabapentin, allopurinol, certain antibiotics, metoclopramide, and metronidazole.  If you are assigned this, it is your primary responsibility (besides F8s and Ancillaries if you’re assigned to those too) before any other projects are worked on.  Usually the first day you’re assigned this, you won’t even come close to finishing.  You should get through all of them after a few days, so it’s important to identify the poorest renal functions and the highest risk drugs.  Duplicates is also a tab on Sentri7.  This alert is triggered when a patient is prescribed two drugs that can be used for the same indication.  The intern needs to go through the patient’s notes to figure out if this is indeed duplicate therapy, or if the physician intended to use both drugs.  I usually see these for asthma inhalers, MVIs, and famotadine/omeprazole. There are usually no more than 10 duplicates daily, so this is one of the easier responsibilities.

ALS bags and boxes are emergency drug kits that are carried by EMTs.  The technician restocks the boxes, and the interns check for accuracy as the pharmacist.  These are to be checked by 4pm, so this is your last responsibility of the day.  Both P4s will do these every day because it can get overwhelming.  Our record so far is 11 boxes and 12 bags in one day. 

Other projects... 

There are side projects/tasks that we get assigned on a week-by-week basis, as well as a rotation-long project.  My rotation-long project is to look at a list of patients who are readmitted to determine if poor med reconciliation could have caused the readmission.  The patients on the list are those who were taking anticoagulants, so the goal is to determine if pharmacy presence in anticoagulation monitoring and dosing might prevent readmissions.  This requires you to learn about both of the patient’s admissions by reading through all of the notes.  It can be really tedious especially if the patient was admitted for a long time.  This is a project that one intern is assigned during each block, so usually you’re continuing the work of one of your classmates. 

We’ve also learned how St. Joe’s monitors vancomycin and warfarin.  These are both tabs on the Sentri7 system.  Guidelines are generally the same as UofM (because we all follow CHEST), so you’re just getting more comfortable taking on the PK responsibilities. We aren’t assigned these tasks all of the time; only about a week each.

One of the things I found unique to St. Joe's (though I haven’t been to many other hospitals) is the “Huddle.”  Once every shift we have a team meeting where the pharmacy manager goes through announcements, drug shortages, system outages for other locations where we’ll need to help verify orders, and acknowledgements.  During acknowledgements, different people take the time to thank a coworker that has been really helpful lately, stayed flexible to cover open shifts, etc.  Even when I was at St. Joe's Livingston, the general feel was very kind and appreciative.  Nobody’s hard work goes unnoticed, and there are always open lines of communication.


Dr. West wants you to see all parts of the hospital, so I’ve shadowed a technician, a nurse, an IV room pharmacist, and a Medical ICU clinical pharmacist.  The focus is to see the integration of pharmacists in the hospital system.  I like that there is a focus on being independent; I get taught something once and then I’m responsible for that task from that day forward.  All of the pharmacists and technicians are really nice and helpful.  I like feeling like I’m responsible and trusted, and relied upon.  My role has meaning, and I am becoming more confident in what I know (and realizing what I don’t know)!

It’s very cool to see the difference between a big academic institute and a large community teaching hospital.  I would definitely recommend this rotation to all students!

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