Adult Medicine Rotation

William N. Wishard Memorial Hospital

Wishard Health Services

Bruce C. Carlstedt, PhD, Preceptor, Purdue University

Kerri DeNucci, PharmD, Preceptor, Wishard Health Services Clinical Specialist

Monica Miller, PharmD, Preceptor, Purdue University

Brian R. Overholser, PharmD, Preceptor, Purdue University

Kevin M. Sowinski, PharmD, Preceptor, Purdue University

James E. Tisdale, PharmD, Preceptor, Purdue University

Introduction

The adult medicine rotation consists of a four-week rotation with a team from the medicine service at Wishard Memorial Hospital. The rotation is designed to develop the student's knowledge and skills in general adult medicine, especially as they relate to the application of therapeutic principles. Problem identification, problem solving, healthcare team interaction, use of computers for patient care, communication skills, patient interactions, documentation of consultations, application of pharmacokinetics, and provision of drug information are emphasized through daily encounters with patients, the medical team, and pharmacists responsible for the pharmaceutical care of the patient.

 Goals

The primary goal of the Adult Medicine Rotation is to improve drug and disease state knowledge. A secondary goal is to learn how the drug and disease state knowledge is applied to patient care by actively participating in the pharmaceutical care decision-making process in coordination with the Pharmacy Services Department. An overriding goal is to achieve positive patient outcomes which relate to pharmacotherapy and medications used to treat and prevent disease.

 Objectives

Given the chart, medication administration record (MAR) (or a two to three page patient summary) and POCKET LONG ROUNDS for an adult patient, the student shall be able to:

1.  Identify potential and real drug and disease-related problems;

2.  Assess the clinical significance of drug-related problems by prioritizing the problem list;

3.  Select appropriate goals for resolution of the identified problems including etiology, severity, pharmacotherapy, prevention of the complications of problem progression, prevention of complications of treatment and prevention of problem reoccurrence;

4.  Develop a plan and appropriate monitoring parameters to meet each of the stated goals; and

5.  Identify appropriate interventions for each of the stated problems.

 Activities and responsibilities

To achieve the Goal and Objectives of the rotation, the following activities and responsibilities describe the student's role in the rotation:

          Rounds

The student must attend daily rounds with the assigned team from the adult medicine service. The student must also attend rounds or be present to update profiles, answer questions, etc. at least one day of every weekend (the purpose of this is to maintain the current status of the patient and to demonstrate commitment to the patients and team). Grand rounds and noon conferences should be attended unless the subject matter is not of sufficient interest as determined jointly by the instructor and student. The student is strongly encouraged to take "night call" with the team.

          Maintain a current list of medications

A medication profile (derived from the chart, progress notes, MAR and POCKET ROUNDS) is expected to be maintained for EACH patient on the service. This profile must be updated daily so that ready reference can be made to the drug list and appropriate therapeutic and laboratory monitoring parameters. The GOPHER pocket long rounds report does NOT replace this profile. This profile is useful for rounds when an exact list of patients' current medications is desired and for discussions of the patients with instructors. Appropriate demographic information must also be obtained. The student will be given an ID and password for the computer systems used in patient care. Caution must be exercised by the student not to become dependent on the computer system as a sole source of information but as a tool to improve patient care.

          Documentation

The student will document his/her input/output for the rotation through the following mechanisms:

Interventions/Consultations

The student will document interventions and consultations using the Clini-Doc documentation program.

Patient's file

The student will also document each patient he/she has "followed" by handing in each patient's completed monitoring form by placing it in the appropriate team’s bin in the Instructor’s office.

          Pharmaceutical Care Plans

A "Pharmaceutical Care Plan" for at least three patients may be required (it is strongly recommended to complete the care plans on a timely basis and not wait until the last week).

          Pharmacy Services

Communications with pharmacists at Wishard

 There have been an increasing number of dosing recommendations, changes, etc. that are making it to the medical teams without having been communicated to the de-central pharmacists.  Obviously this is extremely frustrating to the de-central staff as they are working with those patients, RNs, MDs on a daily basis and have established relationships with many of the people involved.  In addition, please keep in mind that the WHS de-central pharmacists are ultimately responsible for the medication therapy for the patients in their areas.  When they are not aware of a recommendation from our students (especially when it is not consistent with what they would have recommended) then we as a department and as a profession appear to be unorganized, inconsistent, and to the ordering provider, a bother since several people are speaking to them about the same issue.  It is also viewed as a waste of time from our pharmacists perspective after they have spent x number of minutes working on an issue that may have been taken care of already.  I ask that if your students are making any recommendations PLEASE have them discuss their recommendation with the de-central staff.  This is especially important if they involve drugs that are part of our TDM, or dosing recommendations that may be considered “non-standard”.  This is also our opportunity to teach the de-central staff what we are thinking, and the student’s opportunity to learn from our staff who may have been practicing in that area for 15 years and probably have a different perspective on things than we do. Thank you for your attention to this issue.

Christopher M. Scott, PharmD, BCPS, Director of Pharmacy Services

Each student will interact with Wishard Health Services Department of Pharmacy Services by active participation in:

     Drug dosing in patients with impaired renal system

A pocket card for adjusting the dose and/ir regiment for selected drugs has been prepared by Wishard and Clarian. You will be provided a copy of this card. Calculate a creatinine clearance or glomerular filtration rate for each of your patients. Examine the patient’s profile and determine if any drugs represent a real or potential hazard t the patient. The student will contact the pharmacist or team responsible for the patient and determine the appropriate course of action which may include the student contacting the prescriber. The interventions will be documented in the Clini-Doc system.

          Adverse drug reaction reporting

The student will document AT LEAST TWO adverse drug reactions per month which have occurred in his/her patients using the Wishard Health Services Adverse Drug Reaction Report Form. DO NOT USE THE SMALL GREEN FORM. The completed report will be cosigned by the student’s preceptor or a pharmacist and forwarded to Tisha Doty in the Wishard Pharmacy Services offices on the second floor of the Dunlap Building.

         Formulary and non-formulary items

Instructions on how to access Wishard's on-line drug formulary will be given to each student. The student will participate in an orientation to distributive/clinical services (provided by the Department of Pharmacy Services) and how the student and distributive/ clinical services relate to patient care and healthcare team interaction. Trouble-shooting of special medication-related problems may cover a wide array of topics from acquisition of non-formulary items to development of alternative dosage forms. This may include ensuring that drugs with potential problems may be monitored more closely. Close coordination with distributive services is often required for many of these types of situations.

         Calculate dosage regimens

In general, patients who are receiving drugs (aminoglycosides and vancomycin) monitored by the decentralized pharmacist will not require pharmacokinetic monitoring and calculation of the dosage regimen by the student. The student must read and comply with the Wishard Department of Pharmacy Services Therapeutic Drug Monitoring Student Guidelines. However, in certain situations, especially for digoxin, antiarrhythmics and theophylline, the calculation of drug dosage regimens based on pharmacokinetic principles may be useful. The student is expected to work very closely with the decentralized pharmacist and the drug dosing service.

          IV to PO Conversions

Students will be provided with a copy of the Department of Pharmacy Services IV to PO conversion policy and will attempt to convert appropriate patients medications from IV to PO dosage forms. Recommendations will be documented through the clinical intervention reporting program.

Targeted drug monitoring

Students will maintain updated documentation on targeted drugs identified by the Department of Pharmacy Services.

Medication reconciliation

Students will be provided a password and training to use the RxExpress system to identify the patient’s current outpatient drug regimen and refill history

Oral presentations

The student will be required to present one to two oral presentations during the four-week rotation. These may be Drug Class reviews or Patient Cases and will be presented at such a time and place as to facilitate participation from the Department of Pharmacy Services’ pharmacists and technicians.

      Drug class reviews

The student will select a class of drugs that has not been presented by another student. A handout will be prepared which describes the class of drugs, a summary of primary literature, costs, and the rationale for the best choice in each class. The presentation should be around 30 minutes in length. Use of a pre-test and post-test is strongly encouraged. Some examples of drug class presentations include:

     Injectable anti-fungal agents

     Statins

     Third-generation parenteral cephalosporins

     The Penems

     The Triptans

     The PPIs

          Patient case

The student will identify a therapeutic dilemma in one of his or her patients and search the primary literature for the solution. The student will present the patient, state the problem, review the literature and make a conclusion or recommendation. A handout will be prepared which describes the patient, a summary of studies, costs of therapy if applicable, and the rationale for the recommendation. Each presentation should be around 30 minutes (depending on the instructor) in length. Use of a pre-test and post-test is strongly encouraged.

     Provide drug-related information

Questions from the medical team about drugs and/or drug therapy may be directed to the Pharm. D. student who will then research the question, contact the decentral pharmacist if appropriate, provide the response to the team or individual requesting the information, and document the question and response on the appropriate form. Short reviews on a drug or drug therapy-related problem may be presented informally to the team, as a more formal presentation at attending rounds, or at other times as deemed necessary.

         Patient education

Patient education would be provided only at the request of the intern/resident and/or attending physician or if identified by the student as a patient needing education and with consent by the team.

          Meetings with Primary Instructor

Regular discussions between the student and instructor will be held to review the student's individualized patient history, problem list, care plan outline, and proposed interventions including pharmacokinetic and nutritional recommendations for each patient. Preferably, these will be one-on-one discussions but may sometimes involve two to four students with an instructor.  Selected topics will form the basis for discussions although individual patients and other topics may be considered. The student will prepare himself/herself to sufficient depth of knowledge to be able to lead the discussion on the topic. A three-ring binder which contains articles or notes of interest may be provided. It is the responsibility of the student or students on the rotation to obtain the book and peruse the readings. These meetings may be held two to three times weekly, at variable daily times depending on the student's team work and attending rounds schedule and the instructor’s schedule. The student's week to week progress will be monitored and reported to the student verbally at the end of each week and in writing at the end of week 4.

          Oral End-of-Block Examination

An oral end-of-block examination may be given during the final week of the rotation to assess the student's ability to integrate data from the patient care setting. The oral examination may be administered in one of two ways:

1.  The morning of the examination, the student's instructor will review data for patients admitted to medicine teams (other than the student's team) and identify a patient for the student to outline a patient care plan. The student will present the patient's history, and list both current medications and medications that the patient was receiving prior to admission.  The student will assess the patient's current treatment regimen and then develop a care plan for the patient.  The care plan outline will include a prioritized problem list, treatment goals, plan/monitoring parameters, and interventions. The first problem MUST be "Drug-Related Problems".  The pharmacy student will design consultations that improve the patient's care.

          2.    The student’s instructor will prepare a case for the student to review and prepare a patient care plan. The student will assess the patient's current treatment regimen and then develop a care plan for the patient.  The care plan outline will include a prioritized problem list, treatment goals, plan/monitoring parameters, and interventions. The pharmacy student will design consultations that improve the patient's care.

The student will present the care plan outline and consultations to his/her instructor.  Although two instructors may be present, the student's primary instructor will assign pass/fail status. The exam may be repeated the following day for an unsatisfactory performance.

          Crash Courses

During the first two weeks of the rotation, “crash courses” which are 1-1.5 hour lectures on topics pertaining to rotations and services offered at Wishard will be presented. The student is expected to attend. The following courses are currently being offered:

          Arrhythmias

          Continuity of Care/ Medication Reconciliation

          Pharmacokinetics

          Journal Club

          Stress Ulcer/ Deep Vein Thrombosis Prophylaxis

          Arrhythmias

           Asthma

           Diabetes Mellitus

           CHF

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Date: November 4, 2008 (The above Goals, Objectives, Activities and Responsibilities are guidelines for the rotation and may be modified at the discretion of the preceptor).