Medication Recommendations: Pharmacist Vs Attending

[Sparda29]

This is a little bit of a vent. So at my hospital there are no medical residents except for the orthopedics dudes. There are the private practice attendings, and a bunch of PAs/NPs who work 8-12 hour shifts. Generally, the PAs/NPs do the admissions for the attendings who come in the next day to review and sign off.

Here is my gripe. Patient is admitted for say.. healthcare associated pneumonia from the nursing home.

89 year old male, 177.8 cm, 80 kg, baseline SCr = 1.14. Renal function is pretty good IMO (CrCL = 49). So the empiric treatment here would be Zosyn + Vancomycin.

Zosyn we have a pharmacist protocol for:
CrCL < 20 = 3.375 gm q12
CrCL > 20 = 3.375 gm q8

Vancomycin, we don't have a pharmacist protocol for. According to my calculations, patient should get at least 750 mg q12 to start with. PA enters order for 1 gm q24, way too low since expected trough would be like 7 when we're aiming for 15-20.

I call up the PA to get her to change the order. Tell her all the evidence/calculations and still, nope I want to talk to the attending first. WTF?

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[primadonna22274]

You're being unfair. That PA has an obligation to her attending to follow the attending's practice habits--now, could they both be educated and change/improve those habits? Let's hope so. But you are forgetting the little detail that the PA does not have an independent license and it is appropriate for her to run her questions by her supervising physician--up the food chain.
And maybe it's time for you to come up with a pharmacy dosing protocol for the vanc--seriously, every hospital I've ever worked in had one.

 

[deleted6669]

YUP, everywhere I work anytime an order is put in for vanco there is an automatic pharmacy consult and they determine the dose. doesn't matter who orders it.

 

[Makati2008]

This is a little bit of a vent. So at my hospital there are no medical residents except for the orthopedics dudes. There are the private practice attendings, and a bunch of PAs/NPs who work 8-12 hour shifts. Generally, the PAs/NPs do the admissions for the attendings who come in the next day to review and sign off.

Here is my gripe. Patient is admitted for say.. healthcare associated pneumonia from the nursing home.

89 year old male, 177.8 cm, 80 kg, baseline SCr = 1.14. Renal function is pretty good IMO (CrCL = 49). So the empiric treatment here would be Zosyn + Vancomycin.

Zosyn we have a pharmacist protocol for:
CrCL < 20 = 3.375 gm q12
CrCL > 20 = 3.375 gm q8

Vancomycin, we don't have a pharmacist protocol for. According to my calculations, patient should get at least 750 mg q12 to start with. PA enters order for 1 gm q24, way too low since expected trough would be like 7 when we're aiming for 15-20.

I call up the PA to get her to change the order. Tell her all the evidence/calculations and still, nope I want to talk to the attending first. WTF?

As other posters have said the PA must listen to her SP.

To be honest her doctor could be one that doesn't want the pharmacist changing things without him or her knowing. I saw in Derm numerous times where the doctor would be irked that
his rx was changed from ointment to soln by the pharmacist because the soln Was all they had(he was a PHD chemist prior to becoming a doc) as well as hearing internist saying the same thing about thyroid drugs being changed over to the generic. I'm not saying these things are right but I can see why the PA was not willing to change the dose when some attending have these feelings

 

[Sparda29]

You're being unfair. That PA has an obligation to her attending to follow the attending's practice habits--now, could they both be educated and change/improve those habits? Let's hope so. But you are forgetting the little detail that the PA does not have an independent license and it is appropriate for her to run her questions by her supervising physician--up the food chain.
And maybe it's time for you to come up with a pharmacy dosing protocol for the vanc--seriously, every hospital I've ever worked in had one.

YUP, everywhere I work anytime an order is put in for vanco there is an automatic pharmacy consult and they determine the dose. doesn't matter who orders it.

This is what I honestly want the hospital to do. Every ****ing time I bring something up about getting a policy change, it takes months before its even brought to the P&T committee for consideration. Same thing for labs, it's pointless for me to have to chase down a PA or MD to get a vanco trough, phenytoin level, chem7, INR, etc ordered.

 

[primadonna22274]

This is what I honestly want the hospital to do. Every ******* time I bring something up about getting a policy change, it takes months before its even brought to the P&T committee for consideration. Same thing for labs, it's pointless for me to have to chase down a PA or MD to get a vanco trough, phenytoin level, chem7, INR, etc ordered.

I wholeheartedly agree! At least maybe this episode gave you enough righteous momentum to write a proposal and effect positive change
Glad you were able to understand (with our help) why the PA was hesitant to accept your recommendation--it can be very tiring to be a perpetually dependent practitioner, and well-thought-out protocols that make sense help alleviate some of these administrative burdens and just make good patient care sense.

 

[Sparda29]

We currently have a program where whenever vancomycin is ordered the pharmacist crunches the numbers and determines the most appropriate dose based on the indication and either verifies it if it's correct or suspends it pending contacting the prescriber. Something I noticed is that a lot of prescribers tend to underdose vancomycin as opposed to being aggressive and aiming for a high trough.