Critical Care Rotation - Bronson Healthcare

Medical Critical Care Rotation

Medical Critical Care

PGY1 - Pharmacy (43400)

Faculty: Natalie Washburn

Site: Bronson Methodist Hospital

Status: Active

Required

Description:

Preceptors: Natalie C. Washburn, PharmD, BCCCP

Medical/Neuro Intensive Care Clinical Pharmacist

Office: 467C

Hours: 07:00-15:30

Phone: (269)341-6920

Email: washburn@bronsonhg.org

Description:

Bronson Methodist Hospital is a 434-bed major teaching/referral center and healthcare resource for southwest Michigan. The medical intensive care unit (ICU) on the fourth floor has a 14 bed capacity. Patients admitted the medical intensive care unit (MICU) at Bronson Methodist Hospital are cared for by the critical care rounding team. The interdisciplinary team is composed of an attending physician, a senior resident, two medical residents, medical students, and a clinical pharmacist. The team also works closely with respiratory therapists, registered dieticians, nurse case managers, social workers, and the bedside critical care nursing staff. The average patient load on the MICU service is between 8 and 14 patients, with admissions to the MICU team occurring 24 hours a day.

The role of the pharmacist on this unit is to provide exceptional care to each patient through daily chart review, reviewing medication orders, and making recommendations to the medical team for the best of the patient. The role also includes reviewing labs, answering phone calls related to the patient, and appropriate documentation in the electronic health record system.

The 4 week medical critical care rotation provides the opportunity for residents to develop and strengthen the skills necessary to provide pharmaceutical care to the adult critical care population. During the MICU rotation, the resident will be responsible for attending and participating in daily multidisciplinary rounds for the MICU service. Additionally, 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. 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. The primary goal of this rotation is for the resident to enhance their medication and disease state knowledge within the critically ill population and successfully apply this knowledge in order to positively impact patient care. This goal will be reinforced daily through patient workup, patient care rounds, and problem-solving within a multidisciplinary team. The resident should become increasingly proficient in problem identification, prioritization, and communication of recommendations throughout this rotation.

Disease States:

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

Required

  • Acid/Base Disturbances
  • DVT Prophylaxis
  • Fluid and Electrolytes
  • Pain, Agitation/Sedation, Delirium, Immobility, and Sleep
  • Sepsis
  • Stress Ulcer Prophylaxis
  • Vasopressors and Inotropes Elective
  • Acute alcohol withdrawal
  • Acute coronary syndrome
  • Basic ECG analysis and arrhythmia management (ACLS Guidelines)
  • Chronic Obstructive Pulmonary Disease
  • Cirrhosis and associated complications
  • Congestive heart failure
  • Diabetic Ketoacidosis
  • Drug overdose/toxicology
  • Hemodynamics and physiologic monitoring
  • Infectious diseases
  • Intra-abdominal infections
  • Surgical wound infections
  • Pneumonia (CAP, HAP, VAP, aspiration)
  • Urinary tract infections/CAUTI
  • Line infections
  • Cellulitis
  • Neuromuscular Blockers
  • Nutrition management
  • Pancreatitis

Preceptor Interaction:

The resident and preceptor will meet at a minimum for patient rounds each day. The preceptor may or may not be present during team rounds as the resident progresses through the rotation. It is expected that the resident would contact the preceptor with questions as needed.

Typical Daily Schedule:

0700-0900 Independently work-up patients

0900-1100 Round with the interdisciplinary team

1100-1400 Patient follow-up/lunch/projects/independent time

1400-1500 Meet with preceptor for topic discussions, patient review, journal club, etc.

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.

Expected Progression:

Throughout the rotation, the resident is expected to progress in the following way:

Day 1: Meet with preceptor for orientation to the unit/patient room, review of learning experience description, schedules, and expectations.

Week 1: The resident will be responsible for working up all assigned patients prior to rounds and presenting to the preceptor. During daily patient discussions, the resident may be looking for validation of the therapeutic plan for both core/common and less common disease states. The preceptor will participate in rounds (modeling the pharmacist's role in the healthcare team).

Week 2: The resident will be responsible for working up all assigned patients prior to rounds and presenting to the preceptor. The preceptor may attend/participate in team rounds (coaching the resident to take on more responsibility as a pharmacist on the team).

Weeks 3-4: The resident will be responsible for working up all assigned patients prior to rounds and presenting to the preceptor. The resident should have a concrete therapeutic plan for core/common disease states. The preceptor may attend/observe during team rounds. If the preceptor is not present for rounds, the resident will be responsible for providing a summary report 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).

The length of time the preceptor spends in each phase of learning will depend on both the resident's progression in the current rotation and when the rotation occurs in the residency year.

Expectation of Learners:

See General Description for patient care expectations during this rotation.

Non-patient Care Requirements:

  • Medical Resident Talk - During the final half of the rotation the resident will present a 10-15 minute talk to the medical residents/students on rotation. The talk should be accompanied with a summary handout/pocket guide (no more than one page that can easily be kept in a lab coat pocket) and questions to gauge the learners' knowledge. Topic can be chosen by the resident, but would ideally include input from the medical residents. Topics must be approved by the preceptor.
  • Journal Club - If applicable, the resident will have the opportunity to participate in the Indianapolis Critical Care Journal Club (CCJC). Articles for discussion will be provided to the resident in advance and the resident will prepare one question per article for the presenter. If their schedule allows, resident will participate in the CCJC conference call with the preceptor.
  • Nursing Newsletter - During the month the resident will be responsible for writing a ½ to 1 page newsletter article on a pharmacy related topic. The article will be published in the weekly MICU nursing newsletter. The resident may choose the topic, with approval from the preceptor.
  • Miscellaneous Projects - These may be delegated to the resident based on their interests and/or needs from the MICU.

Evaluation Strategy:

Three weekly goals are to be set by the resident and emailed to the preceptor by Monday morning each week. Two of the three goals should be rotation related, and the third goal may be related to general residency requirements/activities. Time permitting we will review the goals each Friday and complete a formative assessment. If time does not allow for in-person review, the resident shall self-reflect on the goals and email the reflection to the preceptor by Sunday night. The preceptor will then comment on the resident's progress and complete a formative feedback in PharmAcademic.

PharmAcademic will be used for documentation of all formal evaluations. A formal midpoint evaluation will be conducted midway through the rotation, and snapshot formative evaluations will be conducted as needed.

Summative evaluations will take place at the end of the rotation using the ASHP Summative Evaluation, the ASHP Preceptor Evaluations, and the ASHP Learning Experience Evaluation. The resident and preceptor will independently complete all evaluations and bring them to a face-to-face meeting. After both have discussed the evaluations, they will add any additional comments and sign them in PharmAcademic. Additional feedback concerning the resident's performance may be obtained from the healthcare team, including the attending physician, fellow, residents, and nurses.

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 comorbidities, high-risk medication regimens, and multiple medications following a consistent patient care process

OBJ R1.1.1

(Cognitive - Applying) Interact effectively with health care teams to manage patients’ medication therapy

Bedside care concerns: Integrate with beside staff (nurses, respiratory therapists, dieticians, etc.) to resolve missing doses, address retiming of medications, answer compatibility questions, and resolve any other medication related concerns that may arise

Follow-up patient assessment: Effectively utilize the time of multidisciplinary team members in the afternoon to follow-up on questions, interventions, monitoring, and therapeutic plan changes throughout the day

Order reconciliation/verification: Work with physicians to resolve issues found when reconciling patients’ medications prescribed on admission with medications taken as an outpatient and to resolve concerns identified when verifying new medication orders

Rounds: Utilize effective recommendation strategies on multidisciplinary rounds and answer medication information questions posed by the medical team in an accurate and timely manner

OBJ R1.1.2

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

Education: Educate patients/family members/caregivers on new anticoagulants and/or other high risk medications prior to discharge

Medication reconciliation: Obtain accurate information from patients/family members/caregivers regarding home medications, last doses, and allergies when medication reconciliation is not completed prior on admission to the ICU

Rounds: Actively participate in daily bedside rounds with the multi-disciplinary care team in a way that expresses empathy to patients/family members/caregivers

OBJ R1.1.3

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

Data collection: Collect necessary information to make safe and effective medication therapy recommendations in preparation for daily rounds and as patients are admitted or transferred to the team throughout the day

Data organization: Develop an organized and efficient method for recording patient information as to facilitate meaningful rounding and preceptor discussions

Electronic health record: Navigate the electronic health record in an efficient and effective manner to facilitate the medication–use process

Medication reconciliation: conduct patient medication histories/reconciliation upon admission and discharge.

OBJ R1.1.4

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

Follow-up patient assessment: Re-evaluation of the patient’s therapeutic regimen should be specific with a focus on monitoring related to medication therapy, further assessment of questions posed on rounds, and patient therapeutic plan changes

Order verification: Actively question orders in real time to determine appropriateness of orders (indication, dose, route, frequency, rate of administration, drug interactions, compliance, cost, etc.)

Overall patient assessment/data analysis: Work-up all assigned patients on a daily basis, so that he/she is ready to review patients with the preceptor and/or independently during patient care rounds.

OBJ R1.1.5

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

Literature and reference review: Utilize primary literature, guidelines, package inserts, and other institution specific resources to base recommendations

Therapeutic drug monitoring: Provide therapeutic drug monitoring services per institution-specific protocols for patients

Therapeutic regimen: Design or redesign therapy and/or monitoring plans for each assigned patient on a daily basis

OBJ R1.1.6

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

Administration/preparation of medications: resident will participate in setting up medications on smart pumps, priming intravenous piggybacks, and/or drawing up intravenous push medications

Electronic health record: resident will navigate the electronic health record in an efficient and effective manner to facilitate the medication-use process Medication procurement: resident will assist with medication procurement including non-formulary approval, home medication use, and drug shortage alternatives as needed

Plan implementation: resident will implement specific aspects of the therapeutic regimen and monitoring parameters as necessary in accordance with the health system’s policies and procedures and/or unit specific protocols

OBJ R1.1.7

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

Flowsheet documentation: Warfarin, heparin, argatroban, vancomycin, aminoglycosides, and total parenteral nutrition will be thoroughly documented in a flowsheet and progress notes will be written based on hospital policy

Ivent documentation: Ivents will be utilized at a minimum to document pertinent information that other pharmacy staff should be aware of and for close monitoring of pertinent medications; if time allows, all accepted and rejected recommendations will be documented

Sticky note documentation: Sticky note documentation will be utilized for handoff to other pharmacists and additional pertinent information related to flowsheet documentation.

OBJ R1.1.8

(Cognitive - Applying) Demonstrate responsibility to patients

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

Education: Patient or family medication education will be performed prior to discharge

Preparation for rounds: Time will be dedicated to ensure each patient is thoroughly worked-up prior to multidisciplinary rounds each day.

Goal R1.2

Ensure continuity of care during patient transitions between care settings

OBJ R1.2.1

(Cognitive - Applying) Manage transitions of care effectively

Handoff communication: Provide essential handoff communication to the receiving decentralized pharmacist when patients are transferred to other units

Medication Reconciliation: Complete admission medication reconciliation for all assigned patients daily. Complete discharge medication reconciliation as appropriate.

Transitions of care: Manage pharmaceutical transitions of care through taking care of patients who transition from the inpatient setting to home, rehabilitation facilities, long term care facilities, or other locations.

Goal E5.1

Participate in the management of medical emergencies

OBJ E5.1.1

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

Communication: Clearly communicate between all bedside staff in a focused and intentional manner

Medication preparation: Assist in medication dosing, preparation, and obtainment during rapid sequence intubation and any other medical emergencies

Participation: Respond to all inpatient code blue, STEMI, and/or stroke call downs that occur during rotation

Evaluations:

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

Natalie's Custom Midpoint

Residents

Learning Experience

50.00%