H-IPPE: Clinical Generalist

Clinical generalists work on the floor within the medical team

During our experience, each student had at least one evening shift and mine was on the Clinical Generalist day.  As opposed to a distribution pharmacist in the inpatient pharmacy, the clinical generalist works on the floor with a specific service.  The major responsibility of the clinical generalist is to verify the medication orders put into the computer by the doctors.  Most was accomplished sitting at a desk in the crowded work area.  Using EPIC, she kept up with the new orders on her floor, but they also watched hospital wide to quickly verify high-priority orders.

Because I was on the evening shift, there really wasn't much to see other than order verification.  She went incredibly fast clicking away as they came in.  Several warnings would pop up on orders that she would override.  She explained that our clinical judgement allows us to get past some warnings when the benefits outweigh the risks.  Some medications are hazardous with serious potential complications, but if it cures an infection quickly, it would be worth it.  A few times, the clinical generalist calculated Creatinine Clearance (CrCl) to determine a patient's kidney function which would result in an adjustment of the dosage.  Had I seen a day shift, my experience would have included rounding with the medical team as the generalist makes dosage suggestions.

Usually, a clinical generalist completed one year of residency training.  I enjoyed the experience and would not mind falling into that type of position.  While I may not know all the clinical information yet, you do seem to work towards the peak of your certification making judgement calls and having a potentially active role in patient care on the floor.  Nurses would stop by and ask questions or we would search out doctors to make suggestions. Most importantly, the clinical generalist on the floor helps catch medication errors and optimize patient care.

H-IPPE: Central Outpatient Pharmacy

My rotation day with the Central Outpatient Pharmacy marked my first occasion behind a pharmacy counter.  Having never worked in a pharmacy before, I appreciated seeing this opportunity. Outpatient pharmacy is a hybrid, a mixture of retail and hospital pharmacy. In many respects, the COP acts as any retail, community pharmacy, but there remain numerous differences. They require payment, cash or insurance, and they generally have a quick turn around time. But the COP can only fill prescriptions from prescriber affiliated with the hospital and will not accept transfer prescriptions from an outside pharmacy. Most customers are patients being discharged from the hospital on their way out. 

Many of the pharmacists previously worked at CVS or other retailers before coming to the COP.  That was part of the manager's plan to decrease the wait times for the patients.  Apparently a year ago, patients waited for an hour, while now they are in and out in 20 minutes.  The pharmacist that I spoke to was really happy with his choice to leave retail and come to the COP.  There may have been a major pay cut, but greater quality of life - including less weekends and an actual lunch hour.  It is a lot easier to help the patients because they are attached to the hospital network and can view the entire hospital record for a patient and determine the indication.  Knowing the indication can help with verifying a medication's dosage, especially for pediatrics.  For all pediatric prescriptions, they must recalculate the dosage strength.  This requires the child's weight in kilograms and the indication - both readily available in the COP, not at a local retailer.  

As a public hospital devoted to all North Carolina residents, the COP has a pharmacy assistance program for those that cannot pay.  Some have $4 copays or even zero.  Many patients come from 2-4 hours away to receive their heavily discounted drugs, which is why the hospital is pioneering a mail order program.  Before a patient qualifies for the assistance program, the COP will fill any order for 14 days.  When they come back with the forms and are accepted they will fill the remainder of the order.

Even though I may not know what I want to do in the end of the PharmD program, this was one that I definitely felt comfortable with.  I hear the stories about working in retail and the difficulty of getting into a clinical position, but this sits firmly in the middle.  You help patients on their transition from the hospital to home and you get to use more of your clinical knowledge to help.  I would have no problem working in an outpatient pharmacy after this experience.

HIPPE: Carolina Care at Home

Of my three days with the Med Transition Specialists, I spent one day with another subset of the group called Carolina Care at Home (CC@H).  While med histories dealt with people through the admission into the hospital, this group works with the discharge of patients.  Essentially, CC@H extends the Central Outpatient pharmacy into a bedside delivery service before patients leave the hospital.  There are benefits for both parties.  The patient doesn't have to stop at a local pharmacy on the way home to pick up prescriptions, and the hospital generates revenue from the sales.

We started early in the morning by checking the eligibility of the patients about to be discharged from the hospital.  Because there are only four members of this group, they focus on patients with insurance instead of self-pay.  After identifying potential customers, we went through the floors to offer them the service.  After watching the person I was shadowing a few times, I felt comfortable enough to give it a go.  I walked into a patient's room a little nervous, but prepared.  The 26-year-old patient was alone in his room watching TV when we entered.  I asked if he would be interested in bedside delivery, but I didn't get much feedback from him.  I kind of freaked out that I was bad at this and every patient would respond to me in the same way.  After leaving, a nurse let us know that he had the mental capacity of a 5-year-old and probably didn't understand what we were saying.  When we spoke to his guardian later that morning, I noticed that the patient was watching Sesame Street on the TV.  Fortunately, not all of the patient encounters turned out that way.  In fact, pretty much everyone I spoke to was eager to have the meds delivered before leaving the hospital - except one patient that received free medications on the military base.  Of any day on the HIPPE rotation, I spoke to the most patients with the CC@H.

After a patient agreed to CC@H, we would fax their prescriptions down to the Central Outpatient Pharmacy and let them know something was coming.  The popular service could easily overwhelm the staff down there in their little corner of the COP, so it would not be surprising for a 2 hour turn around.  When we went through the floors of her service area, we headed down to the COP to pick up the orders and take them back up to the rooms.  After we left, a pharmacist in the COP would call the patient's room, counsel them on the medications, and collect their payment over credit card.  If the patient paid in cash, we brought up the meds, took their money to the pharmacy, and brought their change back up to the room.  There was a lot of walking done on this day.  Actually, because I have a FitBit I can tell exactly how much walking was done - 14,000 steps for over 5 miles.  For this job, comfortable shoes are a must.

Overall, the Carolina Care at Home initiative is a great program.  The pharmacy can reach out to a hospital full of confined customers.  Patients can receive what they need before leaving and head straight home.  I don't know if other hospitals have a similar program, but if I end up in one that doesn't I will attempt to start it.  Transitions of care is a hot topic in the health care field.  This can earn money from the hospital and help prevent patients from readmission.  Win-Win.

H-IPPE: Transitions of Care

Spurred by the Affordable Care Act, hospitals have turned their focus to reducing hospital readmission rates.  Medicare will no longer reimburse hospitals if a patient is readmitted to the hospital within a month of their discharge.  To prevent these readmissions, hospitals take great interest in the transitions of care - admission, transfers, and discharges - for at-risk patients.  High-risk patients are determined by

This patient is high-risk for readmission and
needs medication review and reconciliation.

age, comorbidities, multiple medications, and economic status.  Once a patient is identified, the Med Transition Specialists come into play to collect a complete and accurate Medication History.  On this team, we spent three days during our rotation.  Though all the IPPE's had different experiences, I enjoyed my time interacting with patients and feeling like I had an impact on their admission to the hospital.

Medication histories are generally taken by the nurses when a patient has been admitted.  A lot of the time, the nurse can just copy and paste from their medical records.  But time and again, this has shown to lead to inaccuracies and missed medications.  Nurses have huge responsibilites in caring for the patient, the pharmacy department is best suited to taking care of a patient's medications.  So at UNC and other hospitals, a team of pharmacy technicians review the collected histories which a pharmacist checks off for medication errors or duplications of therapy.

Unfortunately, the Med history team at UNC only consists of four technicians for the entire hospital.  The means that they must focus on the high or moderate risk patients when collecting patient histories.  The process was relatively simple.

1. Print off the Medications Prior to Admissions from EPIC (computer system)
2. Call the pharmacy if listed in their records to get their last refills (dates and quantities)
3. Interview the patient to confirm which medications their are taking (and how)
4. Make notes in EPIC regarding med use in records.

A person could probably get through 10 a day depending on the patients.  Some interviews take longer when a patient talkative or lonely.  Sometimes, their wrong pharmacy is listed or the person uses multiple pharmacies  Some drug lists are longer - 15 or more medications.  Over my days, we found a patient taking two medicines for the same condition, not taking enough (to make the expensive medicine last longer), taking too much (if some is good), or not taking their medicines at all (unpleasant side effects).

In the end, I found the people interesting and enjoyed working on real patients.  Med Histories are important to provide the doctor with a full background of the patient before coming into the hospital.  Later during the month, I wound up on pediatric rounds for patients if cystic fibrosis.  The medical team had a long debate about what the kid was taking at home and how much we should give them while in the hospital.  Since Med Transitions only have 4 technicians, they can't get everywhere.  Perhaps the automation of the pharmacies will open up technicians to move to roles of taking med histories through out the hospital.  I know that the focus is on high-risk medicare patients, but all patients are at some risk when they transition from one place to another.  And pharmacists are the best suited members of the medical team to oversee those transitions.

H-IPPE: Investigational Drug Service

For my first rotation for the month of May, I visited one of the different departments at the hospital.  The Investigational Drug Service (IDS) controls the distribution of all drugs related to clinical trials taking place throughout the hospital.  Not every hospital runs 200-400 clinical trials at the same time and often lack an IDS department.  The investigational drug service dispenses every drug related to clinical trials with the UNC system, including the hospital, Medicine, Dentistry, Pharmacy, Public Health, etc.  The drugs include some commercial products being tested for other indications, but also drugs from companies with just letter-number designations.  The third floor office takes care of the IV preparations of drugs.  We had Zithromax for C-section s and a few others.  They have to be very careful about storing the medications and keep detailed records about the temperatures of the refrigerator.  While I was there the electrician changed over the circuits for the wing, which shut down the refrigerators for 10-15 minutes.  They eyed the thermometers as the temperature approached 8 degrees C - the point that they would have to fill out special forms for each and every one of the drugs in the refrigerator.

My favorite part of the department is the use of placebos.  In more modern clinical trials, the traditional placebo is used less frequently. If a new drug needs to be tested, it must be compared to the current, accepted standard method of treatment. So the "placebo" group will receive the standard treatment, and the experimental group will receive both the standard treatment and the added treatment to be investigated. In most cases, a protocol exists and the new drug seeks to improve upon it. These standards change with new drugs every year. For instance, if Sovaldi becomes the standard treatment every ongoing clinical trial comparing the old protocol will become invalid. Most modern placebo experiments involve adding a drug to the current treatment. If a disease is treated with A+B, a clinical trial may determine if A+B+C works better. Double-blinding begins at the IDS office. In most trials, they enter the patient into a computer database that randomly assigns them to the new drug or placebo. In some trials, even the pharmacist does not know which group the patient belongs to. Other trials are "open label" and will indicated exactly what the treatment is on the drug label itself and all parties will know exactly what treatment is being administered. This method is implemented in trials that use a standard of care as a base treatment.

To protect the doctors and nurses doing the trials for themselves or for big pharmaceutical companies, the IDS controls the blinding process by randomly assigning the new drug or the placebo to the patient.  Often, only the pharmacists and technicians in IDS know whether they have given the drug or placebo.  When an order comes in, the request is put into a computer system that spits out the result of an algorithm to determine what the patient should receive.  Sometimes, the nurses are accidentally unblinded through the process.  In one instance, the trial was to determine the appropriate strength of drug - 10mg/mL vs 15 mg/mL.  However, the new computer system requires a strength to print the label to dispense the medication.  As soon as 15 mg/mL shows up on the label, everyone knows what group the patient belongs to - thus unblinding trial.  When I left for the month, they were attempting to enter zeros for the concentration.  I never learned of the resolution.   

The IDS could be a really interesting area, at the forefront of future medicine.  There is a ton of paper work with monitors coming every so often from the companies to make sure everything is documented correctly.  But they could be dispensing the trial drugs that are the next wave of pharmacy.  They performed several sofosbuvir trials that have have a lot of HIV and HCV researchers and clinicians excited.  If you appreciate the scientific method with blinds, placebos, and protocols, you would enjoy the IDS.

IPPE Yippies

During the entire month of May, I interned at the University of North Carolina Hospital.  The coveted Chapel Hill placement gave me a ton of opportunities that other PY1s may not have experienced.  The first thing you need to know is that UNC Health Care is huge.  The campus covers the entirety of South Campus and houses the Memorial Hospital, Children's Hospital, Women's Hospital, Neurosciences and Cancer Center.  There are three amazing places to eat and the world's largest Starbucks (24/7 and a 20% discount).

My internship was called the Introductory Pharmacy Practice Experience (IPPE).  Working with a preceptor, we are expected to learn the ins and outs of being a hospital pharmacist.  Almost every other pharmacy school sends their first year students into the community first, but we do things a bit differently.  You definitely start off feeling out of place on a content level and lost on a physical level.  My goal at the beginning was simple - find out if there was any area of hospital pharmacy that I could not see myself doing.  In the end, I felt comfortable throughout and could not find anything to mark off the list of possible future careers.

I and my 14 fellow IPPEs experienced many different areas of hospital pharmacy during our rotation in May.  I feel that we probably received a broader education than IPPEs that went off to other hospitals, especially the smaller ones.  While spending more than one day in an area would give depth to the experience, I would not trade the breadth.  I will be writing about each of the different areas that we went in much more detail throughout the month.  I have a lot to say about each of them and maybe they help some other people.

One major difference to mention now would be the set up.  Instead of a single pharmacist in charge of us, UNC delegates the IPPE education to two outgoing PGY2-Administration residents.  The Pharmacy Administration Residency is a two year program and they do a lot regarding management and leadership.  As a former coach, I have great respect for those particular aspects of the pharmacy world.  Our 15 students were divided into two groups for a challenge to have a pizza lunch with the Director of Pharmacy at the hospital.  My team, the IPPE Yippies, took on the Conformational Floppies through several tasks.

1. We wrote on Wiki site through the School of Pharmacy about pretty much anything.  Whoever wrote the most received the most points for their team.  I hadn't planned on doing, but a another student pounced on it early.  I soon made my goal to catch her, but she had such a huge lead that I could only achieve second place.  
2. One day we debated the merits of the 340B program that UNC Hospitals use for cheaper medications.  Our team won that by having the pro-340B side with all of the judges being hospital pharmacy residents.  I will write more about 340B later.
3. We wrote SBAR memos to the director to make suggestions about improving the hospital.  SBAR is a common method of communication in the hospital to deliver ideas or information quickly and efficiently.  The Conformational Floppies dominated us in this one.  They wrote 7 suggestions while my team only wrote 3 (and I had 2 of them).  At this point, it did not seem like my team was interested in winning the competition.
4. Finally, we mapped out the flow of medication through the hospital from order, verification, dispensation and administration.  Each team had to make one in a group effort to understand the hospital.  The Conformational Floppies apparently met for several hours on a Sunday to do theirs.  The IPPE Yippies put it off until the last second.  I tried to organize a lunch meeting to work on it, but it was a no go.  We really did not want to win apparently.  On the last day, we knew that we had to turn something in, so someone put it together quickly.  We looked it over on Google Docs and submitted it with no color and very little effort.  Whichever team won the map would win for the month.  

By a vote of 2-1, the IPPE Yippies prepared the most accurate medication map for the hospital.  Theirs was prettier, but ours was better.  You could say that we were shocked at the announcement.  We did not expect to win, nor did we really try.  Oops.  In the end, I suggested that everyone should be invited to the lunch with the Director.  And on the last day, after evaluations, we ate pizza and said our anticlimactic goodbyes for the rest of the summer.  It was weird leaving the hospital that last day.  Our badges had been taken and we had nothing left to do.  Classes wouldn't start for 2 months and all the stress and anxiety of our first pharmacy rotation had come to an end.  I am grateful for the opportunity to experience each of the areas at the UNC Hospital.  I have much more to say about everything that happened for my own reflection and for those interested as well.

New Drug Update - Ibruvica (ibrutinib)

During our Hospital IPPE month, we had to give a presentation on a recently approved drug from the last year.  A lot of important medicines received approval including to oral treatments to Hepatitis C.  I also liked that each of these drugs had been discussed during our lecture classes.  I might not have remembered what they did, but I at least recognized some of the names.

I waited until the end of the sign up period, because I did not really care what I got.  In the end, I selected Imbruvica, the oral treatment for mantle cell lymphoma and chronic lymphocyctic leukemia.  We also had to find some way to actively engage the audience during our presentation.  It's almost like I have a Master's degree in that.  But really, I do.  I chose to impersonate a couple of our professors from the semester.  I had a pickle jar with everyone's name in it, a chemist hat, played pharmacy hangman, and wrote a short poem.  I also chose a punny subtitle for the lecture.  PO is the pharmacy abbreviation for ORAL - tablet, capsule, etc.

Ibrutinib Presentation by Adam Corey