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Inpatient Pharmacy

Inpatient Pharmacy. Vivian Sinkaset, Pharm.D., BCPS Miramar Science Club Guest Speaker April 28, 2010. Outline . Education Terminology Inpatient pharmacist responsibilities All in a day’s work. Education. Pre-requisite courses for pharmacy school

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Inpatient Pharmacy

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  1. Inpatient Pharmacy Vivian Sinkaset, Pharm.D., BCPS Miramar Science Club Guest Speaker April 28, 2010

  2. Outline • Education • Terminology • Inpatient pharmacist responsibilities • All in a day’s work

  3. Education • Pre-requisite courses for pharmacy school • Bachelor’s degree (B.S., B.A.) – recommended, but optional • Doctor of Pharmacy degree (Pharm.D.) • Residency – post-doctorate training optional How long does it take to become an inpatient pharmacist? ** 5 – 9 years **

  4. Outpatient/Retail Pharmacist

  5. Inpatient/Clinical Pharmacist

  6. Inpatient Pharmacy at Kaiser • Staff pharmacist • Intensive care unit (ICU) pharmacist • Pediatrics/neonatal ICU pharmacist • Infectious diseases pharmacist • Operating room pharmacist • IV room pharmacist

  7. Responsibilities • Verify doctor’s medication orders and monitor medication therapy of hospitalized patients • Review medication profiles for dosage accuracy, drug-interactions, and side effects • Monitor the distribution, dispensing, and compounding of medications

  8. Responsibilities • Perform pharmacokinetic evaluations on anitibiotics and anticoagulants • Schedule and order drug levels • Collaborate with dietitians to formulate and provide parenteral nutrition to patients who cannot receive oral feedings

  9. Responsibilities • Evaluate patient’s kidney function and adjust medication dosage accordingly • Supervise pharmacy technicians and interns • Educate and counsel patients being discharged on new Coumadin therapy and arrange for follow-up visits • Respond to code blue and stroke codes

  10. A Typical Day at Work… • 7:00am – 3:30pm • Get report from graveyard pharmacist and pick up pager • Print “work list” for the day • Pharmacy protocols • Prioritize critical patients • Blood thinners, antibiotics, total parenteral nutrition (TPN)

  11. Pharmacy protocols • Antibiotics • Vancomycin, Gentamicin, Amikacin, Tobramycin • Blood thinners • Heparin, Enoxaparin, Fondaparinux and Warfarin (Coumadin®) • Parenteral nutrition • Renal dosage adjustment • Adjust medication doses based on kidney function

  12. Patient Case • 38 y.o. male complain of swelling and redness on left lower leg x 1 week. Seen in clinic 3 days ago, given oral antibiotics, but symptoms worsened. Now has fever of 101.7 °F. Admitted for cellulitis. Doctor wants to start IV antibiotics with Zosyn and vancomycin per pharmacyprotocol.

  13. Fred Flintstone • Obtain patient information -- • Age: 38 y.o. Gender: Male • Height: 5’9” Weight: 180 lbs (= 81.8 kg) • Serum creatinine: 0.9mg/dL • Perform pharmacokinetic calculations

  14. Pharmacokinetic formulas Cockcroft and Gault equation:       CrCl = [(140 - age) x IBW] / (Scr x 72)  Volume of distribution (Vd) = Weight x 0.75 L/Kg Vancomycin: Kel = (0.00083 x CrCl)  + 0.0044 T 1/2= 0.693 / Kel Calculate Loading dose (LD):_____mg.   LD = 25mg/Kg Calculate Maintenance dose (MD):_____mg.   MD = [(kel) x (Vd) x (ti) x (Cpeak desired) x (1 - e-kT)] / (1 - e-kti)

  15. Pharmacist Note • Subjective / Objective: • 38 y/o caucasian male admitted with cellulitis, start vancomycin per pharmacy • Pertinent labs: • SCr: 0.9 mg/dL • WBC 18,000 Temp: 101.7 °F • 4/28/10 Wound cultures: pending • Assessment / Plan: • Give vancomycin loading dose 2000mg IV x1, then start vancomycin 1750mg IV every 12 hours for target concentration of 10-15mcg/ml. • Check level on 4/30/10 before morning dose

  16. Pharmacy protocols • Antibiotics • Vancomycin, Gentamicin, Amikacin, Tobramycin • Blood thinners • Heparin, Enoxaparin, Fondaparinux and Warfarin (Coumadin®) • Parenteral nutrition • Renal dosage adjustment • Adjust medication doses based on kidney function

  17. Throughout the day… • Communicate with nurses and doctors • Medication related issues • Intravenous compatibility, infusion rate • Drug-drug interactions, drug-food interactions • Clarify orders • Recommend antibiotic regimens

  18. Throughout the day… • Respond to code blue • Cardiac / respiratory arrest • Provide emergency medications

  19. Conclusion • Communication skills • Explain treatments to patients as well as co-ordinate treatment with other healthcare professionals • Organization • Workload can be extremely hectic and stressful. Prioritize and multitask without making mistakes • Attention to detail • Dispensing the right medicines and right dosage can be a “life and death” activity. Mistakes really could be fatal!

  20. Questions?

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