Two days into writing orders - I realize what my true purpose is...

[aboveliquidice]

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Doing the work no one else wants...

I have been given the "book" - It is a constantly evolving binder that holds a physical record of the clinical interventions pharmacy makes for dosing. This includes Vanco, Levaquin, Hep, and Enox. Curiously, my hospital does not allow pharmacy to dose warfarin.

After following the book for two days - its clear that none of the staff pharmacists enjoy this task - If I even mention the word "clinical" - the more-than-jaded staff get into a tissy... especially since the only clinical pharmacist gave up his position for a 7 on 7 off graveyard shift. I am having a pretty freakin good time though 😀

So this has been my first week on rotations... What did you kids do during your first week???

 

[PumpkinSmasher]

Doing the work no one else wants...

I have been given the "book" - It is a constantly evolving binder that holds a physical record of the clinical interventions pharmacy makes for dosing. This includes Vanco, Levaquin, Hep, and Enox. Curiously, my hospital does not allow pharmacy to dose warfarin.

After following the book for two days - its clear that none of the staff pharmacists enjoy this task - If I even mention the word "clinical" - the more-than-jaded staff get into a tissy... especially since the only clinical pharmacist gave up his position for a 7 on 7 off graveyard shift. I am having a pretty freakin good time though 😀

So this has been my first week on rotations... What did you kids do during your first week???

So what exactly do you do with the book? I am just a youngin without much hospital experience.

 

[grizzlesgrizzlies]

rotations= free labor and/or learning experience...

gotta pay your dues before you practice...

 

[bigpharmD]

WHere are you at some middle of nowhere hospital?

I dont think it what no one "wants" to do...they just arent confident in doing and want some else to follow etc....think of it this way

Is the guy with a staph infection that ID is consulted on for an IM team what they dont want to deal with...yes...but they would prob do it wrong anyways....is the guy with a fib post surgery that cardiology is consulted something the surgeons dont want to deal with...no...but the surgeons wouldnt be good at it anyways

I always say this to students who say all we do as pharmacists is consult...well so does everyone else

 

[StaviZFingerZ]

Ahhhhh the "Clinical Binder!"



Get used to it. I think it's a good idea..it's quick, dirty, and easy.

Warfarin dosing... here's the deal. Pharmacists can do it...but how many warfarin patients do you have? And what is the length of stay at the hospital? Many patients don't even reach the steady state while in hospital.

I'd only recommend pharmacy dose Warfarin if you have the staffing to do it... and who can afford 24/7 clinical service that'll dose warfarin???? Busy work man...let someone else do it.

 

[WVUPharm2007]

I'd only recommend pharmacy dose Warfarin if you have the staffing to do it... and who can afford 24/7 clinical service that'll dose warfarin???? Busy work man...let someone else do it.

I've actually noticed this myself. It seems like the vast majority of "clinical" work our staffers do is ******ed. IV->PO (lame), our JCAHO-mandated anticoag monitoring is ...well we are essentially babysitters (lame), vanc/dig/glycoside adjustments are lame (easy, formulaic...lame)...I've found that doing order entry is actually more interesting and challenging because there is more variety and more of an opportunity to make on-the-fly interventions. I actually have pretty much stopped doing our hoity-toity clinical shift because that's pretty much all it is. They took all of the most annoying tasks...put the word "clinical" over top of it and people all of a sudden enjoyed doing it. I thought it was interesting at first because it was all new to me...but once I got used to it, boy did it get old fast...

 

[bigpharmD]

I've actually noticed this myself. It seems like the vast majority of "clinical" work our staffers do is ******ed. IV->PO (lame), our JCAHO-mandated anticoag monitoring is ...well we are essentially babysitters (lame), vanc/dig/glycoside adjustments are lame (easy, formulaic...lame)...I've found that doing order entry is actually more interesting and challenging because there is more variety and more of an opportunity to make on-the-fly interventions. I actually have pretty much stopped doing our hoity-toity clinical shift because that's pretty much all it is. They took all of the most annoying tasks...put the word "clinical" over top of it and people all of a sudden enjoyed doing it. I thought it was interesting at first because it was all new to me...but once I got used to it, boy did it get old fast...

Try rounding with ID for a week....its called our JOB...JOBs are mostly boring

 

[StaviZFingerZ]

I've actually noticed this myself. It seems like the vast majority of "clinical" work our staffers do is ******ed. IV->PO (lame), our JCAHO-mandated anticoag monitoring is ...well we are essentially babysitters (lame), vanc/dig/glycoside adjustments are lame (easy, formulaic...lame)...I've found that doing order entry is actually more interesting and challenging because there is more variety and more of an opportunity to make on-the-fly interventions. I actually have pretty much stopped doing our hoity-toity clinical shift because that's pretty much all it is. They took all of the most annoying tasks...put the word "clinical" over top of it and people all of a sudden enjoyed doing it. I thought it was interesting at first because it was all new to me...but once I got used to it, boy did it get old fast...

You know... NPSG 3E didn't mandate "pharmacy" monitor and dose anticoags. And if your DOP bent over and accepted it...then let's talk about "lack of backbone." You're in a "community hospital" setting where you're not equipped to handle monitoring of all anticoags...you simply don't have the manpower.

IV to PO...yeah yeah... overplayed..it really saves very little money to go from Protonix IV $3.50 to PO $0.20 (cuz you're DSH)...so you saved $3.30.. so if you did about 20 of these a day..(which I doubt)..you saved the hospital a whopping $66.!!!! yay!!! Ok...maybe you can decrease the LOS... but I doubt it.

Convert Zyvox IV to PO...now that saves some money... but convert Zosyn 4.5G Q6h to Cefepime... now that saves about $70..

Again, don't let people full you...order processing "IS" clinical..because that's where you intervene and make interventions. And this should be done right there on the floor in the nursing unit.

 

[njac]

I agree with WVU. I actually like rounding, but I really felt the most effective in the MICU. Mostly I looked for DVT and GI prophy and then abx, and made sure everything was renally dosed.

What I've enjoyed the most, is just staffing on the floors. You're available to the nurses and the physicians, in person, and you do orders. Of course there's that clinical stuff - abx report, anticoag and kinetics. I really think it is a nice mix of "order entry monkey" and "clinical"

 

[StaviZFingerZ]

I agree with WVU. I actually like rounding, but I really felt the most effective in the MICU. Mostly I looked for DVT and GI prophy and then abx, and made sure everything was renally dosed.

What I've enjoyed the most, is just staffing on the floors. You're available to the nurses and the physicians, in person, and you do orders. Of course there's that clinical stuff - abx report, anticoag and kinetics. I really think it is a nice mix of "order entry monkey" and "clinical"

Isn't that what I'm saying? How come you can't give me any credit!!

 

[njac]

Isn't that what I'm saying? How come you can't give me any credit!!

After I posted I read your post! I was like, wait, I just said that.

Someone was telling me that they felt the decentralized model was "outdated" - what do you think about that?

we do decentralized from 0700-1730, with at least 2 RPhs inpatient, and then from 1300-0700 there are at least 2 pharmacists at all times (3 or 4 until 2330, 2 on graveyard) in the main pharmacy. I think it works pretty well. We've recently added a bunch of staff and it seems like the more people there are, the less work each one does. Too much delegation and "that's not my job."

 

[StaviZFingerZ]

After I posted I read your post! I was like, wait, I just said that.

Someone was telling me that they felt the decentralized model was "outdated" - what do you think about that?

we do decentralized from 0700-1730, with at least 2 RPhs inpatient, and then from 1300-0700 there are at least 2 pharmacists at all times (3 or 4 until 2330, 2 on graveyard) in the main pharmacy. I think it works pretty well. We've recently added a bunch of staff and it seems like the more people there are, the less work each one does. Too much delegation and "that's not my job."

That someone is "oudated."

Let me tell you the story of decentralization. In the 80's there were 2 schools of thought; clip board clinical pharmacist and almost fully stocked satelite pharmacy.

The clip board pharamcist was en vogue because they were "clinical" and roamed the hallways in their neatly pressed white coat and gave advice on what to prescribe and what the drug interactions were. Well, admin quickly realized that was not cost effective and canned this sort of program.. This was a west coast phenomenon. Unfortunately, east of the rockies were little late to the game and thought that was how clinical pharmacy was practiced and tried it..and failed later.

The stocked decentralized satelite pharmacy was a good idea until Pyxis came out.... that's early 90's. Goodbye satelite pharmacy. So.. for a brief period in the 90's and the early 2000's.. pharmacists were back in the central pharmacy. But now with a better order scanning system and profile dispense automated system, it makes more sense to have pharmacists on the floor working with physicians and nurses..processing order..

It's the way to go... outdated someones says? That person is wrong.

 

[njac]

well, you know where that person is practicing.

you still haven't provided any dirt.

 

[StaviZFingerZ]

well, you know where that person is practicing.

you still haven't provided any dirt.

I'm spending an entire week with him. I'll get something.

 

[bigpharmD]

That someone is "oudated."

Let me tell you the story of decentralization. In the 80's there were 2 schools of thought; clip board clinical pharmacist and almost fully stocked satelite pharmacy.

The clip board pharamcist was en vogue because they were "clinical" and roamed the hallways in their neatly pressed white coat and gave advice on what to prescribe and what the drug interactions were. Well, admin quickly realized that was not cost effective and canned this sort of program.. This was a west coast phenomenon. Unfortunately, east of the rockies were little late to the game and thought that was how clinical pharmacy was practiced and tried it..and failed later.

The stocked decentralized satelite pharmacy was a good idea until Pyxis came out.... that's early 90's. Goodbye satelite pharmacy. So.. for a brief period in the 90's and the early 2000's.. pharmacists were back in the central pharmacy. But now with a better order scanning system and profile dispense automated system, it makes more sense to have pharmacists on the floor working with physicians and nurses..processing order..

It's the way to go... outdated someones says? That person is wrong.

I still think you need some specialty trained pharmds in certain areas....ie heme/onc, cc, id, etc....i work in a mixed model with very few specialists (which is not what I am used to) and we miss the boat on a lot of things...and lack leadership in many areas

I feel like i am most effective when i am with the same people month after month...which i am now as a pgy2...i get stuff changed they come to me..call me ...etc...as a pgy1 or student you are just some random white coat for 4 weeks

but hey im biased...i am doing a specialty...with that being said i dont mind entering some orders...and it would be a lot better if i was verifying

 

[aboveliquidice]

I've actually noticed this myself. It seems like the vast majority of "clinical" work our staffers do is ******ed. IV->PO (lame), our JCAHO-mandated anticoag monitoring is ...well we are essentially babysitters (lame), vanc/dig/glycoside adjustments are lame (easy, formulaic...lame)...I've found that doing order entry is actually more interesting and challenging because there is more variety and more of an opportunity to make on-the-fly interventions. I actually have pretty much stopped doing our hoity-toity clinical shift because that's pretty much all it is. They took all of the most annoying tasks...put the word "clinical" over top of it and people all of a sudden enjoyed doing it. I thought it was interesting at first because it was all new to me...but once I got used to it, boy did it get old fast...

Everything is new - We'll see how I feel come week 6. I actually received a whole conversation concerning DRG for payment with medicaid. I had no idea hospital reimbursement worked this way. I was questioned as to whether or not the number of PTTs I had requested were legit - considering the total amount of money we would be getting for the patient...

For reference - I am at a 150 bed community hospital, 18 of which are ICU beds. The hospital is rather large for the community however, and more goes on here than I had initially thought (moving from a big city to a smallish town).

The only thing missing here is rounding - which does not exist here in "scrubs" fashion. Aside from that - this experience has been pretty awesome thus far.

 

[StaviZFingerZ]

I still think you need some specialty trained pharmds in certain areas....ie heme/onc, cc, id, etc....i work in a mixed model with very few specialists (which is not what I am used to) and we miss the boat on a lot of things...and lack leadership in many areas

I feel like i am most effective when i am with the same people month after month...which i am now as a pgy2...i get stuff changed they come to me..call me ...etc...as a pgy1 or student you are just some random white coat for 4 weeks

but hey im biased...i am doing a specialty...with that being said i dont mind entering some orders...and it would be a lot better if i was verifying

I believe Heme/Onc, ID, ED, and Critical Care trained druggists would come in handy.

 

[StaviZFingerZ]

Everything is new - We'll see how I feel come week 6. I actually received a whole conversation concerning DRG for payment with medicaid. I had no idea hospital reimbursement worked this way. I was questioned as to whether or not the number of PTTs I had requested were legit - considering the total amount of money we would be getting for the patient...

For reference - I am at a 150 bed community hospital, 18 of which are ICU beds. The hospital is rather large for the community however, and more goes on here than I had initially thought (moving from a big city to a smallish town).

The only thing missing here is rounding - which does not exist here in "scrubs" fashion. Aside from that - this experience has been pretty awesome thus far.

Those are the best place to practice... at least in my not so humble opinion.

 

[bigpharmD]

I believe Heme/Onc, ID, ED, and Critical Care trained druggists would come in handy.

and transplant😎

 

[MarchIoda]

I believe Heme/Onc, ID, ED, and Critical Care trained druggists would come in handy.

What about psych? BCPP? Do they come in handy too? Or not so much?

 

[njac]

For reference - I am at a 150 bed community hospital, 18 of which are ICU beds. The hospital is rather large for the community however, and more goes on here than I had initially thought (moving from a big city to a smallish town).

The only thing missing here is rounding - which does not exist here in "scrubs" fashion. Aside from that - this experience has been pretty awesome thus far.

Are they really ICU beds? Or glorified SAC beds? How many patients on a vent?

 

[aboveliquidice]

Are they really ICU beds? Or glorified SAC beds? How many patients on a vent?

All 18 are setup for it - we currently have 10 or 11 patients on breathing - We have a PCU - Progressive Care Unit as well - I haven't figured out what types of patients end up there...

 

[WVUPharm2007]

All 18 are setup for it - we currently have 10 or 11 patients on breathing - We have a PCU - Progressive Care Unit as well - I haven't figured out what types of patients end up there...

That's what I call the halfway house.