HOSPITAL OR HEALTH-SYSTEM PHARMACY
Dale E. English II, PharmD, FASHP, and John E. Murphy, PharmD, FCCP, FASHP
CASE
F.C. is a pharmacy student beginning a health-system pharmacy APPE rotation in a hospital setting. While going through the student orientation process during the first morning of the rotation, her preceptor is interrupted by one of the other pharmacists asking for assistance. When checking the compounded sterile products that morning, the pharmacist discovered a vancomycin 2-gram intravenous piggyback (IVPB) prepared for a patient. The orders state that the dose is to be infused over a 1-hour period. The pharmacist wants to get confirmation on the appropriateness of the dose and infusion duration for the patient for whom it was prescribed. F.C. is asked to assist the pharmacist in obtaining the information necessary to make this determination.
WHY IT’S ESSENTIAL
As the landscape of healthcare and the profession of pharmacy continue to change, it is important to consider both the challenges and opportunities that the changes create. Pharmacy students and practicing pharmacists must remain competent and confident in their skills as clinical practitioners to participate fully in the many patient care opportunities that are currently available, as well as those that develop over time.
Health-system pharmacy practice in hospitals and other settings is often a required core rotation that provides a foundation on which the education of new pharmacists is grounded and is also a key component on which some other APPE rotations are based. Thus, the skills you should be exposed to and master are vital not only for positive patient outcomes in hospitals but also for overall healthcare quality in a variety of settings. You should make the most of the health-system pharmacy APPE rotation to better understand the entire patient care process, from prevention of disease, to hospital admission, discharge, and follow-up. This process should be viewed as a continuous cycle that, if done correctly, minimizes hospital admissions and readmissions while maximizing patient outcomes.
Full understanding of the concepts relating to sterile technique, pharmaceutical calculations, pharmaceutical compounding, and pharmacokinetic monitoring are critical to enhancing the safety of patients and are fundamental to ensuring the appropriate distribution of the correct medications in the exact dosage and dosage form. Medication-use evaluations are also a component of patient safety that focus on retrospective review of treatment patterns to determine if the patterns are appropriate or if interventions should be made to improve overall treatment.
A wide variety of activities exist in this type of rotation. You will most certainly be exposed to the dispensing and compounding of medications, along with a number of other clinical and patient safety experiences. The setting for the rotation may be a central pharmacy or, increasingly, decentralized pharmacies throughout the institution. In addition to fulfilling the role of pharmacy technician and pharmacist, there may also be opportunities to experience services provided by other health professionals, such as respiratory therapy, nursing, laboratory, and surgery, among other ancillary departments. Lastly, some rotations give students early exposure to clinical experiences on patient floors. A review of Chapter 8 should help prepare you when this option is presented.
A variety of studies have documented the importance of the types of pharmacists’ services that are commonly the focus of hospital and health-system rotations.1,2 The core services routinely provided in institutional settings are also documented in surveys conducted by the American Society of Health-System Pharmacists (ASHP).3-5 For example, pharmacokinetic monitoring and renal dosing services are provided in more than 90% of surveyed institutions, with more than 75% of these allowing pharmacists to order initial drug concentrations and adjust doses. Further, staff pharmacists, rather than specialists, generally provide these services. The ASHP national surveys also indicate that pharmacists increasingly participate in therapeutic interchange, standardization of infusion concentrations, and optimization of the technology, such as bar coding, automated dispensing, and computerized prescriber order entry.
“The practice of individualized medicine is the forefront of optimal patient care. Designing medication regimens to fit the specific needs of each individual patient goes beyond just the selection of the medication. It includes determining the timing, dosing, and frequency of each drug, of which pharmacokinetics often plays an extensive role. For pharmacy students, learning and understanding pharmacokinetics is critical for future pharmacy practice.”—Student
ARRIVING PREPARED
- As with all rotations, contact the preceptor several days before the rotation begins to ask about required readings, specific coursework to review, and logistical information (e.g., parking, expected hours, where and when to meet on the first day).
- Review the rotation syllabus.
- Arrive professionally dressed, including wearing a white coat.
- Bring a device for performing calculations, including natural log (ln) functions.
- Bring electronic or pocket reference guides.
- Bring some type of electronic or paper notebook for recording information.
- Review pertinent class notes:
Basic and clinical pharmacokinetics
Principles of therapeutic drug monitoring
Therapeutic ranges and common doses for medicines routinely evaluated with drug concentration measurements
Approaches to dose adjustments for patients with diminished renal function
Sterile and nonsterile compounding
Pharmacy calculations
Medication error prevention and quality assurance
Personnel management
Presentation skills
Patient interviewing and counseling skills
Technology in healthcare systems
The impact of the following on medication dosing:
Aging
Reduced renal or hepatic function
Various diseases
Obesity
Drug and food interactions
PHARMACY CALCULATIONS
Your health-system or hospital pharmacy rotation offers the ideal setting to utilize your skills in pharmacokinetics, renal dosing, and other pharmacy-related calculations. By applying what you have learned in the classroom to real-life patients, you can have a significant impact by individualizing medication regimens to minimize adverse events and maximize outcomes.
Applied Pharmacokinetics
Typical activities associated with applying pharmacokinetic principles to the care of individual patients may include the following:
- Daily review of drug concentrations measured in the hospital to determine if they are within the commonly accepted therapeutic ranges
- Reviewing patient charts to determine characteristics that might impact the pharmacokinetics of a drug in question, such as estimated renal and hepatic function, potential drug–drug or drug–food interactions, and patient weight, age, and sex
- Predicting concentrations based on the drug’s population pharmacokinetic values and the patient’s characteristics
- Evaluating the accuracy of measured concentrations, such as determining whether concentrations were drawn at the time scheduled or if the dose was given at the correct time (particularly important when predictions of concentrations are far from those measured)
- Scheduling ordered drug concentrations
- Determining the need for additional monitoring of drug concentrations, other laboratory tests, and patient outcome measures
What are two important pieces of patient-related information that will help determine if the 2-gram dose is appropriate for the patient?
You should be versed in the use of the pharmacokinetic formulas (see Appendix 9-A) that form the basis of calculations used for the various dosing situations, should possess a basic understanding of therapeutic drug monitoring principles, should know the commonly accepted therapeutic range for drugs that may be monitored at the institution (see Appendix 9-B), and should have a good understanding of the outcomes expected for the drugs that are routinely monitored. It is important to have ready access to information on pharmacokinetic population values for the drugs that are monitored (i.e., clearance, volume of distribution, and half-life), as well as information on how patient characteristics and drug–drug or drug–food interactions may impact the population values. The information is available in textbooks, or the pharmacokinetic values can be found in the product information (package insert) or primary literature.6,7
QUICK TIP
Predicting measured drug concentrations based on population values helps students learn how often the predictors are reasonably accurate and gives a sense of their utility or lack of utility when determining a dose and schedule for desired steady-state concentrations of a drug. Unfortunately, errors in the system of drug administration often impact concentrations more than variability of the patient compared to the population. A missed dose or a concentration drawn at the wrong time can create large differences in predicted and actual concentrations, even if the patient fits the population values closely.
QUICK TIP
A variety of individuals will be important to appropriately assess measured drug concentrations and patient outcomes. Get to know individuals in the laboratory that can help troubleshoot unusual concentrations. Phlebotomists are critical to drawing concentrations at the right time. Finally, nurses that administer the medications can let you know if the doses were given off schedule.
When students participate in the pharmacokinetic monitoring of patients, typical activities will vary according to how patients are identified for consultation or for dosing and monitoring recommendations. For example, in a more passive service, where formal consultations do not originate from a prescriber’s request, pharmacists may monitor all drug concentrations measured in the institution and follow up on those that are above or below the drug’s generally accepted therapeutic range. In this approach, a trip to the patient’s floor to review a chart will prepare you to provide suggestions to the pharmacist in charge. These recommendations might include such actions as altering a dose, schedule adjustment, or additional monitoring.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
