What would you like to see a pharmacist help with?

[Dred Pirate]

So long story short.
I am a pharmacist who has been at my current hospital for 15+ years. I am moving from a primarily ED/ICU position (I know our hospitalist team very well from an admissions standpoint, and have great relationships with our existing team, so definitely will ask them) to a splitting my time between ED and IM. I will be precepting our IM pharmacy residents.

My question is - in what areas do you as a physician, see a pharmacist adding value to your care and helping in whatever random initiative that gets sent down from above?

1. Medication reconciliation? (my personal vendeta from working in the ED as I see a ridiculous number of errors in this area)
2. We do rounding with the team, so what things do you think are areas of focus? abx recommendations? something else?

Thanks

DP

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[Lord Osis]

ID fellow here. I was a med resident until recently.

1. Yes, med rec! I used to be flabbergasted to see non-medicine peeps (and even medicine PA/NPs) complete half-gluteus med rec and toss the patient to teams. Would not specifically mention examples, but I have seen very dangerous med recs, and at least one of these incidents the incorrect med rec carried through until the end of hospitalization.

2. Empiric antibiotic selection and dosing. Please help the world stop blindly dosing vancomycin and pip/taz - we see too many VREs and XDR GNR. What happens sometimes in this kind of scenario is that the team who receives the patient gets too scared to scale back antibiotic coverage (e.g. no culture positivity) and end up kidney damage, potentially prolonging hospitalization and outcome. Better not start this snowball roll to begin with.

3. COVID therapeutics guidance. To start remdesivir? To give monoclonals or paxlovid? What monoclonals is the chef's choice this week?

 

[Kaustikos]

ID here as well.
Antibiotic approval, helping with COVID treatment modalities..
Helping with PA for certain treatments:
Hep C, DalbaV
Giving updates from the world of pharmacy (you guys have journals just like us)

Also, having close communication and ultimately the best is working together on guidelines or procedures.

 

[Kaustikos]

ID fellow here. I was a med resident until recently.


2. Empiric antibiotic selection and dosing. Please help the world stop blindly dosing vancomycin and pip/taz - we see too many VREs and XDR GNR. What happens sometimes in this kind of scenario is that the team who receives the patient gets too scared to scale back antibiotic coverage (e.g. no culture positivity) and end up kidney damage, potentially prolonging hospitalization and outcome. Better not start this snowball roll to begin with.

I've had Attendings freak out when I use the word de-escalate antibiotics. They seem to think it means I don't think it's an infection when it means it's narrowing antibiotics based on the source. Also, getting people to start transitioning to oral antibiotics from IV even for certain bacteremia.

Time's are changin' people.

Also, to add; antibiotic stewardship meetings with pharmacy are also HUGELY beneficial because it reduces unnecessary consults.

 

[DrMetal]

My question is - in what areas do you as a physician, see a pharmacist adding value to your care

Can you make the patients comply with their PO meds at home? That'd be great.

I've had Attendings freak out when I use the word de-escalate antibiotics.

Yeah. Every ID loves to preach about antibiotic stewardship until it's their name on the chart.

 

[Kaustikos]

Yeah. Every ID loves to preach about antibiotic stewardship until it's their name on the chart.

Not entirely sure your point but we do provide guidelines and references that show we're not just talking nonsense so even though we don't put our name on the chart, they have the source protecting them if god forbid there's litigation. Or, if you want, I'll just drop an unstructured note saying that.

 

[NotAProgDirector]

Admission Med Rec. Contact family / pharmacies if needed to complete.
Vanco dosing managed by pharmacy
Warfarin dosing managed by pharmacy
TPN formulation managed by pharmacy
Insulin management
Prior auths for discharge meds

 

[gutonc]

Admission Med Rec. Contact family / pharmacies if needed to complete.
Vanco dosing managed by pharmacy
Warfarin dosing managed by pharmacy
TPN formulation managed by pharmacy
Insulin management
Prior auths for discharge meds

That last one so much...or a meds to beds program that gets them up to a 30 days supply of whatever new med they need, on discharge.

 

[rokshana]

Admission Med Rec. Contact family / pharmacies if needed to complete.
Vanco dosing managed by pharmacy
Warfarin dosing managed by pharmacy
TPN formulation managed by pharmacy
Insulin management
Prior auths for discharge meds

TPN best done by nutrition and insulin management best by endocrine ( or glucose service)

 

[rokshana]

Finding out costs of d/c medications to Pt …have one hospital that the pharmacist does this and it is a great service to the pt!

 

[Dred Pirate]

Admission Med Rec. Contact family / pharmacies if needed to complete.
Vanco dosing managed by pharmacy
Warfarin dosing managed by pharmacy
TPN formulation managed by pharmacy
Insulin management
Prior auths for discharge meds

thanks all - we already do must of this- never thought of the PA for dc meds (since I have mostly worked on the admission side, not the dc side).

I moonlighted at CVS and I absolutely hated the PA process - I can't image how much of an issue it is when pt's are being discharged from a hospital. There are a few target meds that we ensure are taken care of (entresto, northera, tikosyn- we have a huge heart tower) - This may be a stupid question, but how do you even know what meds require a PA before they are discharged and go to fill their rxs? We have a fairlly robust inhouse service to fill pt's meds before they leave through our outpatient phamacy - so I am guessing those items get caught at that time, but from my memory a PA usually takes a couple of days to get all the work done (but this is through an office doc, not a hospitalist) - I can imagine a delay in discharge if a pt can't get their expensive med.

 

[gutonc]

thanks all - we already do must of this- never thought of the PA for dc meds (since I have mostly worked on the admission side, not the dc side).

I moonlighted at CVS and I absolutely hated the PA process - I can't image how much of an issue it is when pt's are being discharged from a hospital. There are a few target meds that we ensure are taken care of (entresto, northera, tikosyn- we have a huge heart tower) - This may be a stupid question, but how do you even know what meds require a PA before they are discharged and go to fill their rxs? We have a fairlly robust inhouse service to fill pt's meds before they leave through our outpatient phamacy - so I am guessing those items get caught at that time, but from my memory a PA usually takes a couple of days to get all the work done (but this is through an office doc, not a hospitalist) - I can imagine a delay in discharge if a pt can't get their expensive med.

Yeah, it's a total nightmare and stuff gets lost in this system all the time. This is why a short-term supply of d/c meds prior to leaving the hospital would be such a big deal.

Usually what happens for my patients is they get discharged with Rxs for DOACs and long-acting pain meds. They go to the pharmacy, find out the copay is $500 and walk away. Then they show up a few days later in my office for post-hospital f/u and haven't had their DOAC or pain meds since discharge and are a hot mess...then it takes my office another day or 3 to get it sorted.

 

[collegestud2013]

thanks all - we already do must of this- never thought of the PA for dc meds (since I have mostly worked on the admission side, not the dc side).

I moonlighted at CVS and I absolutely hated the PA process - I can't image how much of an issue it is when pt's are being discharged from a hospital. There are a few target meds that we ensure are taken care of (entresto, northera, tikosyn- we have a huge heart tower) - This may be a stupid question, but how do you even know what meds require a PA before they are discharged and go to fill their rxs? We have a fairlly robust inhouse service to fill pt's meds before they leave through our outpatient phamacy - so I am guessing those items get caught at that time, but from my memory a PA usually takes a couple of days to get all the work done (but this is through an office doc, not a hospitalist) - I can imagine a delay in discharge if a pt can't get their expensive med.

You have to look at the formulary for their insurance to see which meds are on it, which ones require PA, and which ones aren't covered at all. It can be initiated on the inpatient side several days before discharge if you known the patient will be discharged with it so it can be done in time.

Definitely very helpful for hospitalists if Pharmacy does the admission med recs (as staffing allows). Most hospitals probably won't staff enough pharmacists to have them do all the med recs; some will hire pharmacy techs instead for primarily just doing med recs which I suppose financially makes more sense for the hospital. At my current hospital it's currently primarily a RN responsibility to do the admission med recs (with pharmacists helping with some of them when time or staffing allows) and there seems to be a lot more resistance to have RNs do the med recs (and the accuracy of the med recs done by RNs can be borderline in many cases, especially for the more complex patients).

 

[Kaustikos]

Finding out costs of d/c medications to Pt …have one hospital that the pharmacist does this and it is a great service to the pt!

I'm guessing things are different for other EMR. But CIS/Powerchart tells me the cost for medications with patients insurance prior to submitting the order to their pharmacy. But I did work with Meditech which practically didn't do anything.

thanks all - we already do must of this- never thought of the PA for dc meds (since I have mostly worked on the admission side, not the dc side).

I moonlighted at CVS and I absolutely hated the PA process - I can't image how much of an issue it is when pt's are being discharged from a hospital. There are a few target meds that we ensure are taken care of (entresto, northera, tikosyn- we have a huge heart tower) - This may be a stupid question, but how do you even know what meds require a PA before they are discharged and go to fill their rxs? We have a fairly robust inhouse service to fill pt's meds before they leave through our outpatient pharmacy - so I am guessing those items get caught at that time, but from my memory a PA usually takes a couple of days to get all the work done (but this is through an office doc, not a hospitalist) - I can imagine a delay in discharge if a pt can't get their expensive med.

In Clinic; the nurses know and will tell me. Ie; certain HIV meds and HepC meds.
In the hospital, it's usually the pharmacy or I know from prior experience (Dalbavancin).

 

[rokshana]

I'm guessing things are different for other EMR. But CIS/Powerchart tells me the cost for medications with patients insurance prior to submitting the order to their pharmacy. But I did work with Meditech which practically didn't do anything.



In Clinic; the nurses know and will tell me. Ie; certain HIV meds and HepC meds.
In the hospital, it's usually the pharmacy or I know from prior experience (Dalbavancin).

Not everyone has insurance

 

[Kaustikos]

Not everyone has insurance

I misread that. Sorry. With saying that, I'll also add if there are any discounts/etc or programs available.

 

[Dred Pirate]

thanks all for your input.
Do any of you have good IM podcasts that you listen to that? I have a list of ED/ICU ones that I usually do while working out, and figured I could expand my repertoire.

 

[Skeeks]

So long story short.
I am a pharmacist who has been at my current hospital for 15+ years. I am moving from a primarily ED/ICU position (I know our hospitalist team very well from an admissions standpoint, and have great relationships with our existing team, so definitely will ask them) to a splitting my time between ED and IM. I will be precepting our IM pharmacy residents.

My question is - in what areas do you as a physician, see a pharmacist adding value to your care and helping in whatever random initiative that gets sent down from above?

1. Medication reconciliation? (my personal vendeta from working in the ED as I see a ridiculous number of errors in this area)
2. We do rounding with the team, so what things do you think are areas of focus? abx recommendations? something else?

Thanks

DP

I have had the pleasure to have some awesome PharmDs associated with my training.

Med recs are an awesome place to start. Its also helpful for discharge as well as admissions. When someone is going home knowing how to ensure they get things like diabetic supplies for a pt who presented with DKA for the first time comes to mind. Many other examples and it seems you are already aware of how to go about doing this in a way that is helpful.
Antibiotics can certainly be helpful. Being aware and knowing the local microbiome could really help. Dosing is always appreciated in CKD pts etc.
Also, speaking of CKD, renal dosing of pretty much any medication is extremely beneficial and appreciated.

I hope your new colleagues are welcoming and appreciative of your help. They are lucky.

 

[Dred Pirate]

I have had the pleasure to have some awesome PharmDs associated with my training.

Med recs are an awesome place to start. Its also helpful for discharge as well as admissions. When someone is going home knowing how to ensure they get things like diabetic supplies for a pt who presented with DKA for the first time comes to mind. Many other examples and it seems you are already aware of how to go about doing this in a way that is helpful.
Antibiotics can certainly be helpful. Being aware and knowing the local microbiome could really help. Dosing is always appreciated in CKD pts etc.
Also, speaking of CKD, renal dosing of pretty much any medication is extremely beneficial and appreciated.

I hope your new colleagues are welcoming and appreciative of your help. They are lucky.

thanks man
ya luckily we have most of the renal dosing set up to automatically be done - so I don't have to annoy you for somebody in AKI - I can just do it. I have worked mainly ED for 15 years, but I float to the medicine floors, and and responsible for processing the admissions, so I know most of the hospitalists well - some have been there for the 15+ years as I have - so that makes the transition much easier.

 

[Redpancreas]

So long story short.
I am a pharmacist who has been at my current hospital for 15+ years. I am moving from a primarily ED/ICU position (I know our hospitalist team very well from an admissions standpoint, and have great relationships with our existing team, so definitely will ask them) to a splitting my time between ED and IM. I will be precepting our IM pharmacy residents.

My question is - in what areas do you as a physician, see a pharmacist adding value to your care and helping in whatever random initiative that gets sent down from above?

1. Medication reconciliation? (my personal vendeta from working in the ED as I see a ridiculous number of errors in this area)
2. We do rounding with the team, so what things do you think are areas of focus? abx recommendations? something else?

Thanks

DP

Just speak up and do your job, residents egos be damned. If you think the patient isn't on DVT prophylaxis and needs to be (or it dropped off), wait until the resident is done and add that bit. Ideally tell the resident before rounds and try to share your thoughts and perspectives but sometimes there isn't time.

One thing I will say is try to avoid getting into dogmatic discussions on controversial topics where your institution's ordering habits go against the evidence. You're going to make more enemies than friends that way.

 

[Kaustikos]

One thing I will say is try to avoid getting into dogmatic discussions on controversial topics where your institution's ordering habits go against the evidence. You're going to make more enemies than friends that way.

Uh...not really. You can choose to be open minded or not but if Pharmacy is telling you recent research/evidence saying why X is better than Y, they're usually right.
Case in point - Surgery always ALWAYS thinks that Meropenem is the go to drug for nec pancreatitis because of "higher levels in the tissue" when every research article says this is semantics as the Cefepime levels are sufficient enough to treat. Why waste Meropenem at this point? Because of old school dogma? No thanks. You get Cefepime and Flagyl.

Another example - people are so focused on treating VAP for 14 days when all research/evidence nowadays show that 7 days is non-inferior as that and actually leads to reduced hospital stay.

or that the prior belief that AMPC organisms are Spice organisms is no longer true.
All things that we and pharmacy know about and talk about.
So, it's not controversial if its true. But you choose to keep relying on old/retired data or get with the times.

 

[Redpancreas]

Uh...not really. You can choose to be open minded or not but if Pharmacy is telling you recent research/evidence saying why X is better than Y, they're usually right.
Case in point - Surgery always ALWAYS thinks that Meropenem is the go to drug for nec pancreatitis because of "higher levels in the tissue" when every research article says this is semantics as the Cefepime levels are sufficient enough to treat. Why waste Meropenem at this point? Because of old school dogma? No thanks. You get Cefepime and Flagyl.

Another example - people are so focused on treating VAP for 14 days when all research/evidence nowadays show that 7 days is non-inferior as that and actually leads to reduced hospital stay.

or that the prior belief that AMPC organisms are Spice organisms is no longer true.
All things that we and pharmacy know about and talk about.
So, it's not controversial if its true. But you choose to keep relying on old/retired data or get with the times.

That’s not what I was saying and or meant. Personally I tend to change my mind 90% of a time a good pharmacist/resident asks me something and I’ve unlearnt a lot of older dogma that way and I totally agree they’re budding with new information. I’ll even go as far to say I’ve learnt more about medicine from pharmacists this year than attending physicians.

That said, Medicine’s not straight forward though and more than a flow diagram. Maybe this isn’t the case with all pharmacists (and I never said it was), but there are some pharmacists (I was advising OP to not be one like this) who have their one "get up". One was obsessed about Entresto without looking at the patients frailty, follow up potential, and SES. Some are obsessed about adding SGLT2is to every diabetic patient with a heart conditions even if they’re homeless. Another thing is for any legitimate/suspected UGIB, some of our GI attendings like PPI infusion. Don't ask me why. The fellows who trained elsewhere and residents know PPI oral BID is more than sufficient. I always order the PPI BID orally knowing full well GI will change it when consulted because we can't do endoscopies and at our hospital can't order endoscopies without GI involvement. One pharmacist has an issue with that and tries to make us change it back, but I'm not interested in fighting that battle and if he cares so much, he should talk to the emeritus GI faculty or whoever has made it a practice habit at our institution, not me. When I’m practicing and patient's are under my name, I’ll use Oral BID.

 

[Redpancreas]

…or that the prior belief that AMPC organisms are Spice organisms is no longer true.

Say you have serratia with ceftriaxone resistance. You wouldn’t choose cefepime over zosyn or reach for meropenem? I’d like to hear any thoughts/new data regarding the Ampc stuff if you have expertise in this matter.

If SPICE is no longer a thing, I guess it maybe hard for those who learnt about the mechanisms of antibacterial resistance to let go of that logic because potentially it detracts their value as a physician given it’s something they spent time learning about and applying.

 

[Kaustikos]

That’s not what I was saying and or meant. Personally I tend to change my mind 90% of a time a good pharmacist/resident asks me something and I’ve unlearnt a lot of older dogma that way and I totally agree they’re budding with new information. I’ll even go as far to say I’ve learnt more about medicine from pharmacists this year than attendings. That said, Medicine’s not straight forward though and more than a flow diagram. Maybe this isn’t the case with all pharmacists but there are some pharmacists who have their one "get up". One was obsessed about Entresto without looking at the patients frailty, follow up potential, and SES. Some are obsessed about adding SGLT2is to every diabetic patient with a heart condition even if they’re homeless. Another thing is for any legitimate/suspected UGIB, some of our GI attendings like PPI infusion. Don't ask me why. The fellows who trained elsewhere and residents know PPI oral BID is more than sufficient. I always order the PPI BID orally knowing full well GI will change it when consulted to evaluate the bleed. One pharmacist has an issue with that and tries to make us change it back. I’m not interested in having this back and forth. When I’m practicing I’ll use Oral BID.

Well, when you phrase it like that, you make ME sound like an dingus. . I misunderstood. I was actually going to mention that whole PPI thing but I refrained because that's not my forte anymore. I agree with what you're saying in regards to being that way which pharmacists/doctors/students can do which can be annoying/wrong.

Say you have serratia with ceftriaxone resistance. You wouldn’t choose cefepime over zosyn or reach for meropenem? I’d like to hear any thoughts/new data regarding the Ampc stuff if you have expertise in this matter.

If SPICE is no longer a thing, I guess it maybe hard for those who learnt about the mechanisms of antibacterial resistance to let go of that logic because potentially it detracts their value as a physician given it’s something they spent time learning about and applying.

Well, it's not something we expect everyone to know considering it was
a) just released November 2021
b) it's not something even all people in ID are aware of
So, that was honestly a stretch to say.

And it's just three - Enterobacter, Kleb Aerogenes and Citrobacter Freundii.
But, keep in mind, it's just saying these are higher on the totem poll of clinically significant ampc production. So, would you be wrong in using SPICE in an ICU setting? Obviously not.

 

[Kaustikos]

Also, Serratia is not really the one we worry about. Steno.Malt is more worrisome. Or Burk.Cep. Yes, I'm using short versions of their names because even I get tired of saying their names.