Critical Care Rotation - Bronson Healthcare

Critical Care Rotation

Critical Care

PGY1 - Pharmacy (43400)

Preceptors: Blostica, Thomas; Curtis, James; Washburn, Natalie; Brousseau, Stacy

Description:

Medical Intensive Care Unit (MICU)

Preceptor: Natalie Washburn, PharmD, Office: 467C

Hours: 8:00-4:30

Phone: (269)341-6920

Email: washburn@bronsonhg.org

 

Trauma Intensive Care Unit (TCU):

Preceptors: Tyler Monroe, PharmD

Mark Brown, RPh Office: 1st Floor Hours: 07:00-5:00

Phone: (269)341-8466

Email: monroet@bronsonhg.org

Emergency Department (ED):

Preceptors: Thomas Blostica, PharmD (primary), Stacy Brousseau, PharmD, BCPS Jesse Hogue, PharmD, Joshua Peterson, PharmD, Corinne English, PharmD

 Office: ED

Hours: Variable Phone: (269)341-7407

Email: blostict@bronsonhg.org

 

General Description:

Intensive Care is a required four week learning experience at Bronson Methodist Hospital. This rotation may be completed in the MICU, TCU, or ED. Each area may be completed as an elective, also, once the required component is completed. There are 14 ICU beds in the MICU, which is located on the fourth floor and cares primarily for medical and cardiac intensive care patients. While in the MICU residents may also have opportunity to spend time in the eight-bed Neuro Critical Care Unit (NCCU) depending on interest and patient load. The TCU has 20 beds and is located on the first floor. The TCU patient population consists of trauma, surgical and burn intensive care patients. The ED has roughly 50 beds and is also located on the first floor.

In the ICU and TCU the resident will be assigned to the critical care rounding team for the selected month. The team is a multi-disciplinary team composed of attending physicians (Intensivists), medical residents/students, pharmacists, respiratory therapists, dieticians, social workers, case managers, and nurses. The resident is responsible for identifying and resolving medication therapy issues for patients and will work toward assuming care of assigned patients on the service throughout the learning experience. When students are on service the pharmacy resident is the point person in conjunction with the preceptor to assign tasks and patient load. The resident will be responsible for assigning patients, drug information requests, topic reviews, lead patient discussions and journal clubs. They will also be responsible for providing and documenting therapeutic drug monitoring services for patients on their team. The resident in conjunction with the preceptor has the ultimate responsibility for the patients.

In the ED, the resident will work directly with the ED Pharmacist. This rotation will provide the resident with the opportunity to work closely with the health care team in the ED and to experience and learn from the diverse patient care issues that arise in this challenging environment. The resident will have the opportunity to participate in a variety of the following activities: interaction with all members of the health care team in the ED, medication reconciliation, provision of drug information including appropriate drug selection and dosing, patient and clinician education, provision of care in "code" situations, and identification and resolution of problems with medication regimens. The resident will be expected to develop problem solving skills as well as verbal and/or written communication skills during the rotation. The resident may also have opportunities to work with the preceptor on development of protocols for use in the ED.

All interventions will be documented in a timely manner by the resident, decentralized pharmacist, and/or preceptor

Disease States:

Common disease states in which the resident will be expected to gain proficiency through literature review, topic discussion, and/or direct patient care experience may include, but are not limited to:

○    Acid/Base (Required in MICU and TCU)

○    Acute alcohol withdrawal

○    Chronic Obstructive Pulmonary Disease

○    Cirrhosis and associated complications

○    Congestive heart failure

○    Diabetic Ketoacidosis

○    Drug overdose/toxicology

○    Pancreatitis

○    Management of select infectious diseases (intraabdominal infections, surgical wound infections, pneumonia (both community acquired and hospital associated), urinary tract infections, line sepsis, cellulitis)

○    Sepsis (Required)

○    Pressors & Inotropes (Required in MICU)

○    Renal failure (acute/chronic)

○    Rapid Sequence Intubation/Sedation/Neuromuscular blocking agents (Required)

○    Acute coronary syndrome

○    Stroke

○    Trauma/orthopedic injuries

○    Pain management

○    Nutrition management

○    Hemodynamics and physiologic monitoring

○    Principles of mechanical ventilation

○    Stress ulcer prophylaxis

○    Prophylaxis and management of DVT/PE

○    Basic ECG analysis and arrhythmia management (ACLS guidelines)

○    Fluid and electrolyte management

Missed Days:

The preceptor should be notified in advance (preferably prior to the rotation, but at a minimum on the first day of rotation) of any scheduled absences.  In the event of an unexpected absence, the preceptor should be contacted as soon as possible via Cisco phone or email.

Preceptor Interaction in MICU and TCU

Daily: 0700 - 0900 Work-up patients (on own)

0900 - 1100 Round with team

1100 - 1400 Patient follow-up/lunch/projects (on own)

1400 Meet with preceptor for topic discussions, patient reviews, journal club, etc

Day 1 Meet with preceptor for orientation to the Unit and to review Intensive Care learning activities, schedules, and expectations.

Week 1 Resident to work up assigned patients and present to preceptor. Preceptor will participate in rounds (modeling the pharmacist's role in the healthcare team).

Week 2 Resident to work up assigned patients and present to preceptor and students. Preceptor may attend/participate in team rounds (coaching the resident to take on more responsibility as a pharmacist on the team).

Week 3-4 Resident to work up assigned patients and present to preceptor and students. Preceptor may attend and observe the resident's participation in team rounds, and/or may expect a summary report from the resident regarding rounding activities and use of recommendations made by the resident. Preceptor will be available for questions and will follow patients independently to monitor resident skill development in all aspects of the learning experience (facilitating the resident as the pharmacist on the team).

Preceptor Interaction in the ED

Daily: Due to the nature of the workflow in the emergency department (ED), a daily routine is not always possible. Also, times of meeting will vary as resident will be expected to come in on some night shifts. Activities that will occur on a daily basis include: reviewing ED patient charts to identify possible opportunities for pharmacotherapeutic intervention, reviewing appropriate disease state management, participating in the medication reconciliation process, periodic topic discussions, increasing familiarity with sources of drug-related information, reviewing admission orders, and attending any ED related meetings.

Day 1 Meet with preceptor for orientation to the ED and to review Intensive Care learning activities, schedules, and expectations.

Week 1: Resident to become familiar with ED workflow and computer system. Preceptor will guide and acclimate resident to the ED processes and staff. Resident to review patient charts and discuss with preceptor. Resident will prepare topic discussions and discuss with preceptor. Preceptor will conduct impromptu disease state discussions with the resident as topics arise.

Weeks 2-4: Resident's role of functioning as the ED pharmacist will increase depending on preceptor and resident's level of comfort with workflow and knowledge. Resident will continue to prepare assigned topic discussions for presentation. Preceptor will conduct impromptu disease state discussions with the resident as topics arise.

[The length of time the preceptor spends in each of the phases of learning will depend BOTH on the resident's progressions in the current rotation and where the rotation occurs in the residency program]

Evaluation Strategy

The resident will receive on-going, regular formative verbal feedback throughout the rotation. At the completion of the rotation the resident and preceptor will independently complete the Summative Evaluation, then will meet and compare the evaluations prior to cosigning. The resident will also complete the Learning Experience Evaluation and a Preceptor Evaluation for each preceptor.

Expectation of Residents:

See General Description for patient care expectations during this rotation. Non-patient Care Requirements:

  • Medical Resident Talk - (If time allows in the ED, otherwise the resident will complete an informational drug of the month write-up to be shared with the medical team). This will be an informal talk to the medical residents/students on rotation. Plan to talk about 10 minutes or so and typically it will lead to a mini- discussion or some questions at the end. Prepare a handout to give to everyone that provides a summary/cheat sheet of your topic. The handout should be no more than 1 page front/back as many of them will keep in their lab coats. Topics are your choice but can have medical resident input on topic ideas they would like to hear about. Topics must be approved by preceptor.
  • Informal journal club - This will be presented to preceptor and pharmacy students (if on rotation). Journal article selected must be critical care related and from the previous 12 months.
  • Other projects may be delegated to the resident based on resident interest and/or need from the medical team.

Taught and Evaluated Objectives

Activities

Goal R1.1

In collaboration with the health care team, provide safe and effective patient care to a diverse range of patients, including those with multiple co-morbidities, high-risk medication regimens, and multiple medications following a consistent patient care process

 

OBJ R1.1.1

(Applying) Interact effectively with health care teams to manage patients' medication therapy

Actively participate in daily multi-disciplinary rounds. Expectations will be that patients are fully worked up prior to rounds with recommendations discussed with preceptor, as needed.

Communicate with nurses/physicians as needed for follow up on recommendations made during rounds.

OBJ R1.1.2

(Applying) Interact effectively with patients, family members, and caregivers

Educated patient/family/caregiver on new anticoagulants or other high risk medication at discharge.

Obtain medication reconciliation information from patient/family/caregiver when not completed on admission

OBJ R1.1.3

(Analyzing) Collect information on which to base safe and effective medication therapy

Develop a proper patient monitoring sheet to ensure organized and efficient data collection so the resident is fully prepared prior to rounds.

OBJ R1.1.4

(Analyzing) Analyze and assess information on which to base safe and effective medication therapy

Develop a method to collect and assess pertinent data from the EMR to assist in developing patients care plan.

OBJ R1.1.5

(Creating) Design or redesign safe and effective patient- centered therapeutic regimens and monitoring plans (care plans)

Utilize evidence based guidelines and primary literature to formulate the best treatment plan based on evidence-based practice and patient specific factors

OBJ R1.1.6

(Applying) Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions

Daily follow up post-rounding to ensure accepted recommendations were completed and assess outcome of recommendations.

OBJ R1.1.7

(Applying) Document direct patient care activities appropriately in the medical record or where appropriate

Any recommendation made to the team (accepted or not) will be documented as an EPIC I-vent and, if appropriate, as a progress note.

Pharmacokinetics, warfarins, and heparin will be probably documented in assessment flowsheet and progress notes will be written based on policy.

OBJ R1.1.8

(Applying) Demonstrate responsibility to patients

Daily follow up post-rounding to ensure accepted recommendations were completed and assess outcome of recommendations.

Goal R1.2

Ensure continuity of care during patient transitions between care settings

 

OBJ R1.2.1

(Applying) Manage transitions of care effectively

Effectively communicate pertinent patient information to floor pharmacist where transferring in-person, I-vent, and/or progress note.

Goal E5.1

Participate in the management of medical emergencies

 

OBJ E5.1.1

(Applying) Exercise skill as a team member in the management of medical emergencies according to the organization's policies and procedures

Actively participate in any inpatient code blue and/or stroke call down that occurs during rotation.

Assist in drug preparation/obtainment during intubated or any other medical emergence that occurs on the unit.

Evaluations:

Evaluation

Evaluator

Evaluated

Timing

Summative Evaluation

All Preceptors

Each Resident Taking this Learning Experience

Ending and Quarterly if Needed

ASHP Learning Experience Evaluation

Residents

Learning Experience

Ending and Quarterly if Needed

ASHP Preceptor Evaluation

Residents

All Preceptors of this Learning Experience

Ending and Quarterly if Needed

Summative Evaluation

Residents

Each Resident Taking this Learning Experience

Ending and Quarterly if Needed

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