Sunday, October 6, 2013

Rotation 4: Health System/Hospital Pharmacy at St. Joseph Mercy Hospital

Posted by Rachel Lebovic at Sunday, October 06, 2013

I can’t say that I was looking forward to the health system/hospital (otherwise known as “institutional”) rotation, but at least it was nice to be back at St. Joe’s. All of the pharmacy staff there are so welcoming! I had my P3 institutional rotation at St. Joe’s last spring, and this fall I was assigned to St. Joe’s for my P4 institutional rotation. There were some pros and cons to having both of my institutional rotations in the same hospital. Pros included already being familiar with the computer systems, layout of the pharmacy, etc. Cons included seeing the same system twice instead seeing how different health system pharmacies function, as well as already completing many of the special activities that P4s usually complete on this rotation (such as “buddying” with a nurse for a few hours). At least the intention of the experience was different – the P3 experience was focused on teaching you how to do the work of the pharmacy technicians, while the P4 experience is focused on teaching you how to function as a pharmacist.
A typical day went something like this:
7:30am – check “F8s.” The term F8 comes from an old computer system in which you pushed the F8 key to perform this task. The task consists of checking 24-hour supplies of a specific medication for a specific patient that doesn’t get stocked in the Pyxis machines on the patient’s floor. My job was to verify that the medication in the Ziploc bag matched what was on the label, and that there was the correct quantity to last the patient 24 hours.
9:00am – check the ancillary cart. Unlike the F8s that are for specific patients, the ancillary cart contains medications that are going to be stocked on a floor, then can be used for any patient when the medication is ordered. My job was to check that each product matched the product that was requested by each floor.
Remainder of the morning – Sentri 7 renal dose adjustments and therapeutic duplications. St. Joe’s has a computer system called Sentri 7 that pulls in patient information from their charting program and helps pharmacists know where to focus their attention. For example, Sentri 7 helps pharmacists focus on anticoagulation, antimicrobial stewardship, renal dose adjustments, and many more clinical tasks. The P4 students are responsible for the renal dose adjustments and the therapeutic duplications. In the renal dose adjustment section, for each patient I would see which of their medications are renally dose-adjusted, calculate their creatinine clearance (an estimate of their renal function), then make sure the patient’s medications are dosed appropriately. If they were, I would document that in the system. If not, I would contact a pharmacist or physician treating that patient and ask them if they could adjust the dose to be appropriate for the patient’s kidney function. Most of the medications that needed dose adjustments were antibiotics. For the therapeutic duplications, I would see what medications Sentri 7 thought were duplicates, look in the patient’s chart to see if they were actually receiving both medications, determine if the patient had a need for both medications, then contact the physician if I thought one of the medications should be discontinued.
Early afternoon – patient’s own meds. Most of the time the hospital provides all of the medications a patient takes in the hospital, but sometimes, a patient wants to take a medication they bring in from home. Many of these medications are inhalers, birth control packs, or unique/expensive medications that the hospital doesn’t have on its formulary. In this case, the physician would write an order for a “patient’s own med” and I would go to the patient’s room, verify that it was the correct medication, then label the medication with a barcode so the nurse could scan it when the patient took the medication.
Late afternoon – ALS boxes and bags. Ambulances carry boxes and bags full of medications to administer to patients on their way to the hospital. When the patient arrives at the hospital, the used box or bag gets dropped off at the hospital to be replenished, and the ambulance takes a fully stocked box or bag that the pharmacy staff members already refilled. As a P3, I refilled the bags and boxes in the manner that a technician does. Now, as a P4, I checked the bags and boxes and added the controlled substances in the manner that a pharmacist does.
Other projects I worked on during gaps in my daily routine included a journal club presentation and an audit. The audit assessed discrepancies in patients’ medication lists from their primary care physician and their hospital discharge papers, before and after St. Joe’s hired four med historians to perform medication histories when patients are admitted to the hospital. We found that the med historians decreased the number of discrepancies between the patients’ medication lists with the addition of the med historians, although the discrepancies were not eliminated completely.
Other special activities I completed throughout this rotation included rounding with two residents, reviewing patient profiles, performing anticoagulation assessments and antimicrobial stewardship reviews, discussing IVà PO (oral) medication conversions, verifying orders that are part of order sets, and answering drug information questions.
My most rewarding experience this rotation came when one resident had a patient with HIV on his service. Since I recently completed an HIV rotation, the resident asked if I would mind looking at the patient’s HIV therapy to make sure it was appropriate. When I looked at the patient’s profile, I noticed the patient’s HIV medications did not compose a logical regimen. It appeared that the physician had ordered a medication called “Intelence” instead of a medication called “Isentress.” While these medications sound very similar, they are from two different classes of antiretrovirals. I paged the physician to ask if he meant to order the other medication, and he said he did and he would update the order. I was very proud that my knowledge of medications led to a significant improvement in patient care!
Overall, I am much more interested in being a clinical pharmacy specialist than working in the institutional setting doing drug distribution and verifying orders, but I understand why this rotation is important. The pharmacy needs to get the right drug to the right patient at the right time before pharmacists can be involved in more clinical work.

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