Disagreeing on rotation

[Foscarnet]

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my regular preceptor is off and i am with another pharmacist who does things way differently, especially dosing

it goes against things i was taught at other sites and at my internship

not rounding up the SCr in older person

differences in interval dosing and infusion rates

stuff like that. those are just a couple of examples.

Do I just nod and smile or what? I dont want to ask my preceptor about it or am i way off base here????

I am getting confused about what to do, how to do it, when to do it, etc.

 

[Chillz87]

I'm currently on my 5th rotation, and I have learned 5 different ways to dose vanco. Whether it be nomagram, globalrph, protocol, per pt, etc. I don't disagree with my preceptors, unless I think it will harm the patient in some way.

I think it is perfectly reasonable to ask your preceptor why they did it a certain way. You can also do the calculation your way, and ask them what they think about that. I thought my preceptor phrased it well when he said to learn from everyone, and when you are practicing on your own to do it how you feel comfortable since it is your license on the line.

Loading dose: I personally never heard of a load as high as 30mg/kg, I've always done 15-25 depending where I am (20 personally).

Rounding SCr: Most preceptors I had rounded to 1, but one did not. Not everyone rounds though, it isn't necessarily wrong.

Interval dosing/infusion rates: tbw, abw, ibw, scr(rounding or not rounding) can change your interval drastically. Hospital/preceptor preference protocol (ex. one of mine never did q36 due to different times nurses admin vanco each day) also influences. Infusion rates are also preference/protocol it seems, unless you have side effects. Cost could factor as well in that.

I brought all those things up because I think it is so crazy how different preceptors practice. I am on my 5th rotation, but 4/5 have been in different hospitals, and 3/5 have been in different cities. Like what I mentioned earlier though, disagreeing is definitely appropriate if you think it will harm the patient, otherwise just asking why they did it a certain way it reasonable (especially if you phrase it in a learning/motivated/smiling/etc kind of way).

my regular preceptor is off and i am with another pharmacist who does things way differently, especially dosing

it goes against things i was taught at other sites and at my internship

like 30mg/kg load of vanco on an elderly pt with CrCl 16 for pneumonia/UTI whos already on levaquin

not rounding up the SCr in older person

differences in interval dosing and infusion rates

stuff like that. those are just a couple of examples.

Do I just nod and smile or what? I dont want to ask my preceptor about it or am i way off base here????

I am getting confused about what to do, how to do it, when to do it, etc.

 

[hereticmnk]

I agree with the above poster. It is more of an art than an exact science. Every clinician has their own way of doing dosing for Vanc. Remember CrCl is not even close to an exact representation of kidney function. Only bring up concerns if you really do think that the dosing will harm the patient or when you want to learn to do things the clinicians way.

 

[Foscarnet]

Thanks for the advice.

Also, this person isnt technically my preceptor and I know my preceptor doesnt do this. this same person dosed gentamicin on a pt with a skin/open wound infection that turned up with MRSA and pseudomonas. I asked about the coverage for the MRSA because nothing else was ordered/added. when my preceptor came back the next day they added vanco (pt was serious enough for it).

Im being accepting of the advice im getting but i dont want to go somewhere else and look like an idiot.

 

[habeansha]

ask them why they do it that way?

 

[smercer]

Thanks for the advice. Yeah I totally get that people do things differently but I feel like the 30mg/kg is kind of off base from EVERYTHING i have ever been told from every pharmacist i have ever received instruction from.

Also, this person isnt technically my preceptor and I know my preceptor doesnt do this. this same person dosed gentamicin on a pt with a skin/open wound infection that turned up with MRSA and pseudomonas. I asked about the coverage for the MRSA because nothing else was ordered/added. when my preceptor came back the next day they added vanco (pt was serious enough for it).

Im being accepting of the advice im getting but i dont want to go somewhere else and look like an idiot.

Even if the dosing made sense to you, you still should have asked why they did it. This is about taking in as much information as possible. Thus every time you see someone do anything that varies from what you have seen you should ask. Clearly you want to be sure to word your questions correctly, as not to offend anyone. I would ask something along the lines as:

I have noticed that Vanco dosing seems to vary from pharmacist to pharmacist. I was just wondering what guided you towards using this dosing regime? Maybe they give you some explanation that explains why they are doing that very well, or maybe they have no idea why they use it.

 

[Ackj]

The various vanco dosing methods are all estimates anyway. Until you get that trough, all you're doing is hoping that your dose is appropriate.

Same goes for CrCl estimates. The rounding Scr to 1, it is widely done, but pretty arbitrary. If the SCr is 0.4 and you round it to 1, that's a lot different than going from 0.9 to 1. I read an article recently where the authors suggested decreasing the final SCr by 15mL/min in patients with albumin below 3. I thought that was a pretty interesting approach.

 

[psychoandy]

You're using limited experience to refute this person's clinical skill. I'm not saying that you're wrong but if some pharmacy student told me I'm dosing vanco wrong just because they've never seen it dosed that particular way...it wouldn't end well. 30mg/kg is a little excessive especially since if their est CrCl is that bad it probably won't clear well, so why give more dose than you have to.

How about using objective info or evidence based guidelines to politely disagree with them or to discuss? I would start with reading IDSA guidelines on treating MRSA as well as CAP/HCAP guidelines.

 

[joetrisman]

You're using limited experience to refute this person's clinical skill.

This. My thought process for rotations is I'm there to learn, this is their court, and they have years of clinical experience to draw from compared to my super limited exposure. Even if someone tells me something I know is wrong, I still know this person's clinical experience can still teach me volumes of things that are right and therefore it is a non-issue.