Future of Clinical Pharmacy

[Cpcunn3]

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I know the outlook for pharmacy has been addressed numerous times on here. However, most neglect to address the future of clinical/hospital pharm. Personally, I am only interested in the field if I can work in a hospital. I am worried about the future considering less than half of current pharmacists work in clinical, the present and future oversaturation (I want to be able to find a job in a big city, not middle of nowhere), and the reports I've seen about certain hospitals utilizing robots to do most of the job.
From what I've read on the topic, most say do not worry Bc the baby boomers will provide enough jobs. I don't find that very reassuring since they will die off way before I retire. What about the long term? Also I have also seen people express hope in the branching out of pharm services as technology takes over the traditional role. Again, I don't see how that could sustain a large number of pharms.

 

[rxlea]

Define clinical

 

[Cpcunn3]

Define clinical

I mean in a hospital setting

 

[rxlea]

I mean in a hospital setting

Within a hospital, there are different pharmacist roles as well (specialist, clinical staff, staffing, etc.)

 

[Cpcunn3]

Within a hospital, there are different pharmacist roles as well (specialist, clinical staff, staffing, etc.)

I guess I used the wrong terminology. I mean hospital instead of retail.

 

[bacillus1]

I am a clinical pharmacist (currently hybrid, transitioning to a purely clinical position). I had to relocate across the country to find a position I liked. Started looking for a new job back east a year later and took me about a year to find one. So yeah...there aren't too many jobs, even for residency trained people.

 

[gwarm01]

Clinical pharmacy will not provide enough jobs to combat saturation unless there are some serious changes in pharmacist scope of practice and reimbursement. Current clinical pharmacists are often a value add position, and are nowhere near as common as ARNPs or PAs. Honestly, I think it's kind of a joke that clinical pharmacy is as revered as it currently is in academia, considering the reality of the field and the actual impact on patient care compared to staffing positions that are easily more important to the operation of the hospital. The biggest blowhards I know are the pharmacists who are obsessed with being purely "clinical" and think they are better than someone working in a centralized pharmacy.

Anyway, that rant aside, it's hard to say what the future holds. Get a good job and hold on tight, because things can change fast.

 

[Gombrich12]

I can't speak on the future of clinical pharmacy, but I can say that I would not anticipate the scope of practice for pharmacists to expand much. There are going to be more than enough nurse practitioners and physician's assistants in the future to meet any unmet needs. There were 8,000 NP graduates in 2008, in 2014 there were 18,000. As for PAs there were 5000 graduates in 2008 and 7500 in 2014. They are flooding primary care with midlevels who already make less or slightly more than pharmacists, there will be no need for pharmacist to manage diabetes/blood pressure/cholesterol when there are NPs out of work across the country.

source:
http://healthaffairs.org/blog/2015/...nt-and-pharmacist-pipelines-continued-growth/

 

[Rukn]

Clinical pharmacy will never supersede retail or community

The actual practice of pharmacy is in retail/community

 

[steveysmith54]

If you are interested in clinical, it's best to go to medical school. As a hospital pharmacist, the extent of my clinical duties involves dosing and monitoring drugs. This is work that most doctors don't really want to do. I am happy to do it cause it gives me a job.

 

[bacillus1]

If you are interested in clinical, it's best to go to medical school. As a hospital pharmacist, the extent of my clinical duties involves dosing and monitoring drugs. This is work that most doctors don't really want to do. I am happy to do it cause it gives me a job.

Eh, some people don't want to do the physical parts of it...like doing rectal exams, LPs, etc... I'm happy to do clinical things without actually touching the patient.

 

[steveysmith54]

Eh, some people don't want to do the physical parts of it...like doing rectal exams, LPs, etc... I'm happy to do clinical things without actually touching the patient.

"touching" is old school doctoring. Now majority of the touching involves: screen, mouse, and computer, even for an MD. Unless you are primary care and doing annual physicals, I don't think you will doing too many rectal exams.

 

[Lnsean]

How do you do clinical work if you cannot prescribe or change therapy? I don't get it. You'll be spending most of your days making silly IV to PO therapy recommendations to the team to save money. You can't bill for this stuff, so your "clinical" position doesn't really pay for itself...it's probably financially supported by the dispensing team.

 

[bacillus1]

How do you do clinical work if you cannot prescribe or change therapy? I don't get it. You'll be spending most of your days making silly IV to PO therapy recommendations to the team to save money. You can't bill for this stuff, so your "clinical" position doesn't really pay for itself...it's probably financially supported by the dispensing team.

I can change the doses for warfarin, LMWHs, vancomycin and aminoglycosides on my own. Also, we also did a study that showed that having a pharmacist on each medicine team performing medication reconciliation at discharge significantly reduced prescribing errors (as opposed to just having one outpatient pharmacist doing it for everyone).

 

[Lnsean]

I can change the doses for warfarin, LMWHs, vancomycin and aminoglycosides on my own. Also, we also did a study that showed that having a pharmacist on each medicine team performing medication reconciliation at discharge significantly reduced prescribing errors (as opposed to just having one outpatient pharmacist doing it for everyone).

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

ALso, can you bill for your services? How are you bringing in money to support your role? Do you need to go around all day and make minute recommendations to justify your role? I've rotated with "clinical" pharmacists before and I'm definitely not impressed. Just my 2 cents.

 

[bacillus1]

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

ALso, can you bill for your services? How are you bringing in money to support your role? Do you need to go around all day and make minute recommendations to justify your role? I've rotated with "clinical" pharmacists before and I'm definitely not impressed. Just my 2 cents.

I don't bill, and I don't care if you doubt me or not. As you guessed it, I work at the VA, but many private hospitals have pharmacy to manage protocols and collaborative practice agreements for vanc and anticoagulants. However, as I said before, we are a hybrid model, so I verify my team's orders as well. Our physicians like that we are a part of the medical team, and are sad whenever we double-cover and can't round with them.

I'm tired of people on this board belittling each other's positions. Let people do what they want to do with their lives.

 

[Lnsean]

I don't bill, and I don't care if you doubt me or not. As you guessed it, I work at the VA, but many private hospitals have pharmacy to manage protocols and collaborative practice agreements for vanc and anticoagulants. However, as I said before, we are a hybrid model, so I verify my team's orders as well. Our physicians like that we are a part of the medical team, and are sad whenever we double-cover and can't round with them.

I'm tired of people on this board belittling each other's positions. Let people do what they want to do with their lives.

Of course you do care...that's why you're here. Otherwise you would have ignored my post. I wouldn't call it belittling...there's always stuff being flinged by "clinical" pharmacists all the time to the other fields of pharmacy. I am just curious as to how they justify their positions and it seems they're always defensive when you get down to the facts. Saying that your MD is sad when you're not around is not helpful to prospective students looking for advice, which was OP's original point here. I'm merely reiterating many of the others' sentiment here.

 

[owlegrad]

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

You're wrong. Very common practice around here in hospitals to let the pharmacy do this.

 

[Lnsean]

You're wrong. Very common practice around here in hospitals to let the pharmacy do this.

Really? without consulting the MD? ...if you have to consult the MD before or after the adjustment then it's not independent. I have yet to see that....but if you are adamant about it then I'll concede this point.

 

[owlegrad]

Really? without consulting the MD? ...if you have to consult the MD before or after the adjustment then it's not independent. I have yet to see that....but if you are adamant about it then I'll concede this point.

Yes, it's really quite common. The doctor orders warfarin and the pharmacy handles dosing. Same with vanco dosing. The doctor orders the therapy, pharmacy doses. There are also amb care clinics where pharmacists do the same thing.

 

[OmiPharmD]

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

ALso, can you bill for your services? How are you bringing in money to support your role? Do you need to go around all day and make minute recommendations to justify your role? I've rotated with "clinical" pharmacists before and I'm definitely not impressed. Just my 2 cents.

I do warfarin, heparin, Vancomycin, and aminoglycoside dosing without physician input. It's automatic. Same for IV to po. They have to throw a fairly large fit and escalate to make us stop.

I am not in a VA. Just a university affiliated teaching hospital. We don't bill for our services separately.

I'm not suggesting there is a huge future for clinical pharmacy. These are the pieces the attending docs and residents don't want. At the end of the day they all want their own pharmacist but no service wants to pay for a dedicated pharmacist. We provide these basic services listed above for all of our patients.

 

[gwarm01]

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

ALso, can you bill for your services? How are you bringing in money to support your role? Do you need to go around all day and make minute recommendations to justify your role? I've rotated with "clinical" pharmacists before and I'm definitely not impressed. Just my 2 cents.

Well, I'm a big cynic with regard to pharmacy, but I can vouch for this. At my hospital the pharmacy gets an automatic consult for all vanco and aminoglycosides. We can change dosing, intervals, and order levels without consulting the doctor. It's just our hospital policy though, because I've worked in places where you have to track down a resident and beg them to let you draw a trough. Really annoying.

The above poster makes a good point. Every team wants their own pharmacist, but no one wants to pay for it. Some of our services are stretched so thin because we are expected to staff the pharmacy, attend rounds, daily meetings, review protocols and do research for the doctors. I know a pharmacist who routinely stays hours after she clocks out just to fulfill these needs. Personally, I would never do that for free but she feels obligated.

 

[romaniangirl]

I'm just a lowly pharmacy student, but I shadowed a family friend who is a pharmacist at our local community hospital, and she also does aminoglycosides/vanco, LMWH, warfarin, and IV to PO changes with out contacting the MD. The rph pulls a list of all patients on their unit on TPN/Vanco/warfarin etc. and then they order labs, adjust doses, IV to PO, d/c and such without calling the MD or anything. This is at a community hospital with no affiliated universities. Also, my friend is a newer grad with no residency. I guess rph autonomy really depends on the institution and location.

 

[PumpkinSmasher]

I work as ambulatory pharmacist in a family practice office. Have independent prescribing for htn, dm, chf, gout, anticoag and copd, through collaborative drug agreements. Of course if I feel uncomfortable or have question I discuss with the pcp, just as they do with me when they have questions or want a consult.

My position is funded by pharmacy and medical depts. Dispensing pharmacy supports my position and I work collaboratively with them. We have different roles but all working to take care of the patients. Close knit medical home clinic model.

I work out of my office or see pts in exam room. It is a great job, love the work but not for everyone. There are not many of these roles, it is a luxury for the clinic to have me, not a necessity. So if funding goes to hell, I could be out the door. The docs and nps would throw a fit but they would get by without me like they did before I was here. They consistently rate clinical pharmacy as a reason for physician retention at the clinic which is motivation for medical mgmt. It is expensive to lose and retrain physicians.

 

[wagrxm2000]

Lnsean clearly hasnt worked in a hospital. However, while it may seem a pharmacist is using their "clinical" knowledge, they are following a protocol so its just plugging in numbers, the nurse could do it. Why pay a pharmacist?

 

[PumpkinSmasher]

Lnsean clearly hasnt worked in a hospital. However, while it may seem a pharmacist is using their "clinical" knowledge, they are following a protocol so its just plugging in numbers, the nurse could do it. Why pay a pharmacist?

I agree if that is all they are doing, then hand it off to nursing. Clinical pharmacy should be focused on cognitive services and pharmacotherapy decision making.

 

[gwarm01]

Lnsean clearly hasnt worked in a hospital. However, while it may seem a pharmacist is using their "clinical" knowledge, they are following a protocol so its just plugging in numbers, the nurse could do it. Why pay a pharmacist?

I wouldn't go that far. Doing kinetics properly requires some nuance beyond plugging in numbers.

 

[konkan]

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

ALso, can you bill for your services? How are you bringing in money to support your role? Do you need to go around all day and make minute recommendations to justify your role? I've rotated with "clinical" pharmacists before and I'm definitely not impressed. Just my 2 cents.

I'm really surprised to read your answer. I work in a mid. size teaching hospital in Midwest. We have decentralized pharmacy model in am, and centralized pm and night shift. I can honestly say that clinically our pharmacy is not that advanced, but all pharmacists (not just specialists) dose vanco, aminoglycosides, all noags, warfarin, lovenox, fondaparinux, heparin, argatroban. I might have missed some. Actually we get consulted automatically for every single one of them. Also we can order not just levels for abx, but cbc, mp, factor xa and so forth. I know that in all mid. to major hospitals in my area pharmacists can do all that, and more advanced ones can do more. At our local va hospital pharmacists run their own clinics and do much more. Were do you live where rphs cant do those things?
as far as do we bill for those services, no we dont bill, and i have no idea how is it handled from the financial point of view.

 

[wagrxm2000]

I wouldn't go that far. Doing kinetics properly requires some nuance beyond plugging in numbers.

It's been awhile since I've done kinetics but I could have sworn the protocol we followed had the exact formula we were required to use where you plug in the info for desired peak and trough with age weight etc then the program gives the results.

 

[El Trombopag]

It's been awhile since I've done kinetics but I could have sworn the protocol we followed had the exact formula we were required to use where you plug in the info for desired peak and trough with age weight etc then the program gives the results.

Protocols and formulas are a good start (and a good way to standardize), but time-to-steady state, interpretation of random levels, obesity+crappy renal function, concurrent nephrotoxic meds, I/O status, drug interactions, line management all are relevant and can result in departure from protocol. All of our collaborative agreements include the key 'clinical judgement' phrase.

I don't have much to compare it too (this is the only pharmacy job I've had), but I think the physicians really appreciate offloading as much of this stuff as possible, as long as they feel they can trust 'the process'. Nurses are great at handling many things, but I've come to the conclusion that the less math they have to do, the better.

 

[wagrxm2000]

Don't you work at Walgreen's? Maybe you haven't seen it because you have to call to change from tablet to capsule ....... :-(

Lol im honestly just trolling. I just love it when I see hospital pharmacists call themselves clinical pharmacists as if I don't use my knowledge everyday. We're all clinical pharmacists.

Oh and no I don't call to switch between tablets and capsules.

 

[bacillus1]

It's been awhile since I've done kinetics but I could have sworn the protocol we followed had the exact formula we were required to use where you plug in the info for desired peak and trough with age weight etc then the program gives the results.

...Until you get a dose by level patient with unstable renal function.

 

[TheBlaah]

Lol im honestly just trolling. I just love it when I see hospital pharmacists call themselves clinical pharmacists as if I don't use my knowledge everyday. We're all clinical pharmacists.

Oh and no I don't call to switch between tablets and capsules.

Dude. He was talking to LnSean. He even quotes him in the post.

 

[wagrxm2000]

Dude. He was talking to LnSean. He even quotes him in the post.

Lol I guess he was. I saw my company and had to respond.

 

[Lnsean]

Guys,

I do work for Walgreens. The protocol thing I wasn't sure about and I did concede the point to Owlgrad when he pointed it out. I did state in my original post that I wasn't sure and for people to correct me if I'm wrong. However, that's just one of the many points that I have brought up regarding clinical pharmacy. I'm reiterating what others have already said with regards to the fact that these positions are limited in scope, practice, and reimbursement.

Staying true to OP's original objective, I am curious as to how a "clinical" pharmacist can justify his/her position other than holding it in good faith that they are adding value to the team. Saying that the MD is sad when you're not around isn't anything concrete that prospective students can rely on. If the current foundation for clinical pharmacist is based on this then its future is shaky at best. Just my 2 cents.

 

[bacillus1]

Guys,

I do work for Walgreens. The protocol thing I wasn't sure about and I did concede the point to Owlgrad when he pointed it out. I did state in my original post that I wasn't sure and for people to correct me if I'm wrong. However, that's just one of the many points that I have brought up regarding clinical pharmacy. I'm reiterating what others have already said with regards to the fact that these positions are limited in scope, practice, and reimbursement.

Staying true to OP's original objective, I am curious as to how a "clinical" pharmacist can justify his/her position other than holding it in good faith that they are adding value to the team. Saying that the MD is sad when you're not around isn't anything concrete that prospective students can rely on. If the current foundation for clinical pharmacist is based on this then its future is shaky at best. Just my 2 cents.

Well, we do have studies such as The Asheville Project, which showed that pharmacists can improve outcomes and lower healthcare costs. Some other smaller studies as well. "The MD is sad" can also justify new positions. In my current position, the MDs felt like pharmacists were important to the healthcare team, and therefore they asked administration for a pharmacist to be on their team. As soon as funding became available, pharmacists were hired. I do agree, however, that such positions aren't plentiful, and I had to move across the country for mine. I am not saying that every graduating student will be able to become a clinical pharmacist. I am just saying that such positions are important to healthcare and benefit patients, that is all.

Also, I can't even imagine what would happen if we told our physicians: "from today on, please do not ask us about dosing warfarin, vancomycin, med recs or other clinical recommendations. These are clearly above our ability and should be left alone to the almighty physician". Our physicians expect pharmacists to be valuable members of the healthcare team, and more than just people who dispense medications and nothing else.

Anyway, I'm hybrid, as are all pharmacists at the hospital, so I guess that's how my position can be justified. If I were purely clinical, however, I feel like there would be more things I could have time for, such as med rec on admission (let's face it, physicians and nurses do a terrible job at this) as well as maybe post-discharge follow-up on medication adherence for at-risk patients. I also wouldn't feel constantly rushed, as I am now. I guess we'll see what happens.

 

[pillpharmer14]

I just staff at University teaching hospital and we have automatic consults for warfarin, vanc and any drug that is renally cleared. No residency required. You learn this stuff in pharmacy school and it's not that hard, definitely don't need additional training to achieve therapeutic results. As for the plug and chug comments, that may be true for warfarin and renal dosing, but vanc is a whole other animal. Even at steady state, people don't always response predictably to dose adjustment. As others have pointed out, there's quite an art to it, especially in those 500 pounders with acute on CKD.

And let the nurses do it? That guy obviously doesn't work with many nurses.

All that being said, I'm not sure how the purely clinical positions are justified either. I never see or hear from our purely clinical staff. I have no doubt that they could school every single one of the staffers on pharm knowledge, I'm just not entirely sure what they do all day.

 

[Lnsean]

I just staff at University teaching hospital and we have automatic consults for warfarin, vanc and any drug that is renally cleared. No residency required. You learn this stuff in pharmacy school and it's not that hard, definitely don't need additional training to achieve therapeutic results. As for the plug and chug comments, that may be true for warfarin and renal dosing, but vanc is a whole other animal. Even at steady state, people don't always response predictably to dose adjustment. As others have pointed out, there's quite an art to it, especially in those 500 pounders with acute on CKD.

And let the nurses do it? That guy obviously doesn't work with many nurses.

All that being said, I'm not sure how the purely clinical positions are justified either. I never see or hear from our purely clinical staff. I have no doubt that they could school every single one of the staffers on pharm knowledge, I'm just not entirely sure what they do all day.

It's really not about what's hard or what's easy....it's about liability.

I agree with your other points.

 

[pillpharmer14]

It's really not about what's hard or what's easy....it's about liability.

I agree with your other points.

What about liability? Why refuse to provide services that we are perfectly capable of providing?

 

[Lnsean]

What about liability? Why refuse to provide services that we are perfectly capable of providing?

Whether something is easy or hard or whether you're capable or not has nothing to do with it. You can only do what is outlined in the protocol because of liability issues. That's why protocols exist otherwise people would just do what they're capable of, and that's definitely not the case. Hence, while your claim is correct your reasoning is off. Although, we are going off topic anyway.

 

[rxlea]

Really? without consulting the MD? ...if you have to consult the MD before or after the adjustment then it's not independent. I have yet to see that....but if you are adamant about it then I'll concede this point.

Not sure where you live but where I come from and where I trained, there are many things pharmacist do per protocol as owlegrad points out. I change warfarin, vanco, aminoglycosides, other abx, and other stuff without "consulting an MD". I, of course, communicate to the team what I'm doing and why I'm doing it. Communication is important.

 

[rxlea]

...Until you get a dose by level patient with unstable renal function.

CRRT FTW!

 

[konkan]

It's really not about what's hard or what's easy....it's about liability.

I agree with your other points.

It's not about liability lol - it's about protecting your turf. Medicine has much stronger lobby and they are not allowing to creep on their turf which, as we all know, is income. Having more turf is the same whether you work in healthcare or sell drugs on the streets - it's about income.

 

[Lnsean]

It's not about liability lol - it's about protecting your turf. Medicine has much stronger lobby and they are not allowing to creep on their turf which, as we all know, is income. Having more turf is the same whether you work in healthcare or sell drugs on the streets - it's about income.

I do agree with this as well..although it's not really relevant to OP's original discussion.

 

[troponin2012]

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

In my hospital, the clinical or staff pharmacists can make changes to a patients therapy without consulting the physician UNLESS a level is way off (i.e. usually if a level is supratherapeutic)

 

[Carboxide]

I do warfarin, heparin, Vancomycin, and aminoglycoside dosing without physician input. It's automatic. Same for IV to po. They have to throw a fairly large fit and escalate to make us stop.

I am not in a VA. Just a university affiliated teaching hospital. We don't bill for our services separately.

I'm not suggesting there is a huge future for clinical pharmacy. These are the pieces the attending docs and residents don't want. At the end of the day they all want their own pharmacist but no service wants to pay for a dedicated pharmacist. We provide these basic services listed above for all of our patients.

We do all antibiotic dosing, vanco + ags included. That includes pre-op dosing as well. We manage most anticoag (RNs have a heparin drip protocol for adjusting the dose based on PTT, I think most hospitals have that). We get automatic pharmacy consults for falls and mental status changes to evaluate for possible medication causes, which we write up in a note in the chart. We do IV to PO for almost anything (although I typically just page on abx and let the MD decide based on their judgment). We discontinue orders that are duplicates, like PPI + H2RA. We adjust dosing times for any drug that should be given at a specific time of day (Synthroid, warfarin, Singulair, BID diuretics, etc). We convert some specific drips to pushes (e.g. IV PPI). We do substitutions for non-formulary drugs. We change drug dosings of any kind that are renally dosed, when necessary based on changes in kidney function. We decrease drug dosing or frequency in specific drugs, like Ambien and tramadol.

This is all per protocol, no MD permission required. Some of it is non-negotiable despite physician preference (e.g. women or age > 65 men cannot have more than 5 mg Ambien no matter what). There is a lot more but that is all I can think of off the top of my head - haven't been at work in a few days.

I am a staff pharmacist - I do not work on the floors. This is just what I personally do, our floor people do different stuff. I do not work at an academic hospital or a VA.

 

[tongiecc]

Really? I highly doubt you can change those dosages without consulting the MD first. Maybe...maybe in the VA. I am unaware of any setting where a pharmacist can make therapy changes independently. Please do correct me if I'm wrong.

ALso, can you bill for your services? How are you bringing in money to support your role? Do you need to go around all day and make minute recommendations to justify your role? I've rotated with "clinical" pharmacists before and I'm definitely not impressed. Just my 2 cents.

No trying to stir the pot, but this is true at my institution as well. I rotate through managing all the anti coag and we typically adjust vanc, AMGs, and certain other ABX (levaquin, cefepime, zosyn, etc) w/o calling the MD or consulting. I mean, if you're an MD and you trust you are working with halfway decent pharms, do you really want to be called every time a dose is adjusted? We have approval via policy to adjust specific meds w/o asking MDs, so not sure how it works everywhere else. In the midwest when I worked there, pharmacy had less leeway, but it was a little smaller hospital. Neither were VA or Gov't, but I totally get your skepticism as I'm sure its not everywhere, but there are several places that do this.

 

[tongiecc]

We do all antibiotic dosing, vanco + ags included. That includes pre-op dosing as well. We manage most anticoag (RNs have a heparin drip protocol for adjusting the dose based on PTT, I think most hospitals have that). We get automatic pharmacy consults for falls and mental status changes to evaluate for possible medication causes, which we write up in a note in the chart. We do IV to PO for almost anything (although I typically just page on abx and let the MD decide based on their judgment). We discontinue orders that are duplicates, like PPI + H2RA. We adjust dosing times for any drug that should be given at a specific time of day (Synthroid, warfarin, Singulair, BID diuretics, etc). We convert some specific drips to pushes (e.g. IV PPI). We do substitutions for non-formulary drugs. We change drug dosings of any kind that are renally dosed, when necessary based on changes in kidney function. We decrease drug dosing or frequency in specific drugs, like Ambien and tramadol.

This is all per protocol, no MD permission required. Some of it is non-negotiable despite physician preference (e.g. women or age > 65 men cannot have more than 5 mg Ambien no matter what). There is a lot more but that is all I can think of off the top of my head - haven't been at work in a few days.

I am a staff pharmacist - I do not work on the floors. This is just what I personally do, our floor people do different stuff. I do not work at an academic hospital or a VA.

Care if I ask a few things?

1. what time do you guys do warfarin admin times, 1800?
2. Do you change even GI bleed protonix gtts to IV push? Prob not those right? or what situations do you?
3. How do you guys do decreases in zolpidem and tramadol, just adjust to what is acceptable/typical when ordered outside typical dosing?

Thanks for the reply, I appreciate it! Just curious esp on the PPI gtts, other stuff looks pretty identical to what we do.

 

[Carboxide]

Care if I ask a few things?

1. what time do you guys do warfarin admin times, 1800?
2. Do you change even GI bleed protonix gtts to IV push? Prob not those right? or what situations do you?
3. How do you guys do decreases in zolpidem and tramadol, just adjust to what is acceptable/typical when ordered outside typical dosing?

Thanks for the reply, I appreciate it! Just curious esp on the PPI gtts, other stuff looks pretty identical to what we do.

1. With dinner (1700)

2. Absolutely. We don't allow IV PPI for non-GI bleeds. The data VERY strongly support the pushes. Several large meta-analyses as well as individual studies have shown that there is no benefit of drip over IVP in any patient population. We do an 80 mg bolus then 40 mg Q12. There is no reason to do drips unless you like flushing money down the toilet. The only person who can order a drip is the section head of GI. If it is nighttime - too bad, you better call him at home.

3. Ambien: We enforce a max dose of 5 mg for all women, anyone age > 65, and anyone who was not on 10 mg at home. If a woman or senior was on 10 mg HS, they are still maxed at 5. No exceptions here. If someone complains I usually suggest trazodone instead which you can increase quite far if needed (although it rarely is). If it is a man < 65 yo and 10 mg is ordered (or 5-10 mg) we check home med list, if they were not on it we change to 5 as well. Same rule, no exceptions.

Tramadol: Our system automatically inputs a comment of max dose 400 mg/day or 300 mg/day for age > 75, so that we keep as is. For CrCl < 30, we adjust dose to whatever makes sense to not exceed 100 mg every 12 hours. So I will let 50 mg Q6 PRN go by but not 100 mg Q6, I will change that to Q12. If it is scheduled I change the frequency as needed - so if it is 100 mg TID I change to BID and put a note in the comments that max dose is 200 mg/day for CrCl < 30. Same thing for age > 75, if scheduled then I ensure that the frequency will not exceed 300 mg/day and if it does then I change it to comply with max dose. I do not change frequency for PRN doses in age > 75 because there is no restriction on frequency, just total daily dosage (unlike CrCl).

 

[Carboxide]

Not sure where you live but where I come from and where I trained, there are many things pharmacist do per protocol as owlegrad points out. I change warfarin, vanco, aminoglycosides, other abx, and other stuff without "consulting an MD". I, of course, communicate to the team what I'm doing and why I'm doing it. Communication is important.

Honestly the only time I communicate to the team is if they try to change it back and I need to explain why they can't, or if they made a big mistake and they need to know that they could have caused harm. Everything I do is in protocol, I don't need to tell them anything and they don't care, they rely on us to do it. When I am on the floor I might talk about it with the residents as an education point, but usually after the fact whenever we all have time.

I honestly think that 90% of prescribers would be like, "Uh...okay? Thanks...do I need to do something?" if I paged them. I don't interrupt them unless I need to, just like we don't want them or nursing to call us if they don't need to.