Neurologic Critical Care Continuum - Bronson Health · The 4 week neurologic critical care continuum elective rotation provides the opportunity for residents to develop and strengthen

Neurologic Critical Care Continuum

Preceptors:

Natalie C. Washburn, PharmD, BCCCP

Medical/Neuro Intensive Care Clinical Pharmacist

Office: 467C

Hours: 0700 - 1530

Cisco: 269.341.6920

Email: [email protected]

Rebecca S. Maynard, PharmD

Neurovascular Unit Clinical Pharmacist

Office: 324

Hours: 0830 – 1700

Cisco: 269.341.7210

Email: [email protected] 

Description:

Bronson Methodist Hospital (BMH) is a 434-bed major teaching/referral center and healthcare resource for southwest Michigan. The neurologic critical care unit (NCCU) on the third floor has a 12 bed capacity. The majority of patients admitted to the NCCU are cared for by the neurology critical care rounding team, with a critical care consult as needed. The interdisciplinary team is composed of an attending physician, an advanced practice provider (APP), a social worker, a case manager, a dietician, nurses, and a clinical pharmacist. The average patient load on the NCCU service is between 6 and 12 patients, with admissions occurring 24 hours a day. Additionally, the NCCU serves as a perioperative area for the neurointerventional lab patients.

The neurovascular unit (NVU) is on the third floor and has a 40 bed capacity. The majority of patients admitted acutely to NVU are non-critical stroke patients cared for by the hospitalist service, with a neurology consult as needed. NVU is also the admission unit for post-spinal surgery patients that are cared for by orthopedic surgeons or neurosurgeons and APPs. The interdisciplinary care team on NVU consists of hospitalists, a social worker, case managers, a dietician, nurses, the Stroke Nurse Navigator and Neurosciences Nurse Navigator, and a

Faculty: Maynard, Becky; Washburn, Natalie

Description:

PGY1 - Pharmacy (43400)

Site:

Bronson Methodist Hospital

Status: Active

Not Required

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clinical pharmacist. The average patient load is between 35 and 40 patients. Within NVU is the Neurologic Monitoring Unit (NMU) which has a 4 bed capacity and typically cares for patients needing continuous video EEG monitoring. Patients in the NMU are cared for by a neurologist and APP.

The role of the pharmacist on these units is to provide exceptional care to each patient through daily chart review, reviewing medication orders, and making recommendations to the medical team for the best of the patient.　 The role also includes reviewing labs, answering phone calls related to the patient, and appropriate documentation in the electronic health record system. As applicable, the pharmacist also educates patients on new medications such as warfarin, rivaroxaban, and apixaban.

The 4 week neurologic critical care continuum elective rotation provides the opportunity for residents to develop and strengthen the skills necessary to provide pharmaceutical care to the adult neuro population. During the rotation, the resident will be responsible for attending and participating in daily multidisciplinary rounds for the NCCU and NVU services. The resident will be responsible for identifying and resolving medication therapy issues for patients and will work toward assuming care of assigned patients on the service throughout the learning experience. They will also be responsible for providing and documenting therapeutic drug monitoring services for patients on their team. The resident, in conjunction with the preceptor, has the ultimate responsibility for the patients. The primary goal of this rotation is for the resident to enhance their medication and disease state knowledge within the neurologic population and successfully apply this knowledge in order to positively impact patient care. This goal will be reinforced daily through patient workup, patient care rounds, and problem-solving within a multidisciplinary team. The resident should become increasingly proficient in problem identification, prioritization, transition of care handoffs, and communication of recommendations throughout this rotation. The resident will also respond to any inpatient stroke call downs and, if there is not a pharmacy resident in the Emergency Department, any stroke call downs in the Emergency Department.

Disease States:

Common disease states and topics in which the resident is expected to gain proficiency through literature review, topic discussion, and/or direct patient care experience may include, but are not limited to:

Required

·       Ischemic Stroke

·       Subarachnoid hemorrhage

·       Status epilepticus

Elective

·       Central diabetes insipidus

·       Cerebral salt wasting

·       Critical illness polyneuropathy

·       EEG or bispectral monitoring for level of sedation

·       Encephalopathy in coma

·       Guillain-Barre

·       Intracerebral hemorrhage

·       Intracranial pressure management

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·       Meningitis and encephalitis

·       Myasthenia gravis

·       Spinal cord injury

·       Targeted temperature management/induced hypothermia

·       Traumatic brain injury

·       Ventriculostomies

Preceptor Interaction:

The resident and preceptor will meet at a minimum for patient rounds each day. The preceptor may or may not be present during team rounds as the resident progresses through the rotation. It is expected that the resident will contact the preceptor with questions as needed. 

Typical Daily Schedule (NCCU/NVU):

0700-0800 Independently work-up patients

0800-0900 Round with NCCU interdisciplinary team

0900-1030 NCCU follow-up and NVU patient workup

1030-1130 NVU rounds

1130-1330 Patient follow-up/lunch/projects/independent time

1330-1700 Meet with preceptor(s) for topic discussions, patient review, journal club, etc.

Missed Days:

The preceptor should be notified in advance (preferably prior to the rotation, but at a minimum on the first day of rotation) of any scheduled absences. In the event of an unexpected absence, the preceptor should be contacted as soon as possible via Cisco phone or email.

Expected Progression:

Throughout the rotation, the resident is expected to progress

 in the following way:

 Day 1:

Meet with preceptors for orientation to the units/patient rooms, review of learning experience description, schedules, and expectations.

Week 1:

The resident will be responsible for working up all NCCU patients prior to rounds and presenting to the preceptor. During daily patient discussions, the resident may be looking for validation of the therapeutic plan for both core/common and less common disease states. The preceptor will participate in rounds (modeling the

Expectation of Learners:

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pharmacist's role in the healthcare team).

Week 2:

The resident will be responsible for working up all NCCU patients and NVU patients who transferred from NCCU. The preceptor may attend/participate in team rounds (coaching the resident to take on more responsibility as a pharmacist on the team).

Weeks 3-4:

The resident will be responsible for working up all NCCU patients and assigned NVU patients prior to rounds and presenting to the preceptor. The resident should have a concrete therapeutic plan for core/common disease states. The preceptor may attend/observe during team rounds. If the preceptor is not present for rounds, the resident will be responsible for providing a summary report regarding rounding activities and use of recommendations made by the resident. Preceptor will be available for questions and will follow patients independently to monitor resident skill development in all aspects of the learning experience (facilitating the resident as the pharmacist on the team).

  The length of time the preceptor spends in each phase of learning will depend on both the resident's

 progression in the current rotation and when the rotation occurs in the residency year.

Non-patient Care Requirements:

Advanced Practice Provider Talk

·       During the final week of the rotation the resident will present a 30 minute talk to the NCCU/MICU advanced practice providers. The talk should be accompanied with a summary handout/pocket guide (no more than one page that can easily be kept in a lab coat pocket) and questions to gauge the learners' knowledge. Topic can be chosen by the resident, but would ideally include input from the advanced practice providers. Topics must be approved by the preceptor.

Journal Club

·       If applicable, the resident will have the opportunity to participate in the Indianapolis Critical Care Journal Club (CCJC). Articles for discussion will be provided to the resident in advance and the resident will prepare one question per article for the presenter. If their schedule allows, resident will participate in the CCJC conference call with the preceptor.

·       Additionally, the resident will be responsible for presenting a key article to preceptor(s). Journal article will be selected by the preceptor.

Nursing Newsletter

·       During the month the resident will be responsible for writing a ½ to 1 page newsletter article on a pharmacy related topic. The article will be published in the weekly NCCU/MICU nursing newsletter. The resident may choose the topic, with approval from the preceptor.

Miscellaneous Projects

·       These may be delegated to the resident based on their interests and/or needs from the NCCU and/or NVU.

Evaluation Strategy:

Three weekly goals are to be set by the resident and emailed to the preceptors by Monday morning each week. Two of the three goals should be rotation related, and the third goal may be related to general residency requirements/activities. Time permitting we will review the goals each Friday and complete a formative assessment. If time does not allow for in-person review, the resident shall self-reflect on the goals and email the reflection to the preceptors by Sunday night. The preceptors will then comment on the resident's progress and

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complete a formative feedback in PharmAcademic.

PharmAcademic will be used for documentation of all formal evaluations. A formal midpoint evaluation will be conducted midway through the rotation, and snapshot formative evaluations will be conducted as needed.

Summative evaluations will take place at the end of the rotation using the ASHP Summative Evaluation, the ASHP Preceptor Evaluations, and the ASHP Learning Experience Evaluation. The resident and preceptors will independently complete all evaluations and bring them to a face-to-face meeting. After both have discussed the evaluations, they will add any additional comments and sign them in PharmAcademic. Additional feedback concerning the resident's performance may be obtained from the healthcare team, including the attending physician, fellow, residents, and nurses.

ActivitiesGoal R1.1 In collaboration with the health care

team, provide safe and effective patient care to a diverse range of patients, including those with multiple co-morbidities, high-risk medication regimens, and multiple medications following a consistent patient care process

OBJ R1.1.1 (Cognitive - Applying) Interact effectively with health care teams to manage patients’ medication therapy

Taught and Evaluated

Bedside care concerns: Integrate with beside staff (nurses, respiratory therapists, dieticians, etc.) to resolve missing doses, address retiming of medications, answer compatibility questions, and resolve any other medication related concerns that may ariseFollow-up patient assessment: Effectively utilize the time of multidisciplinary team members in the afternoon to follow-up on questions, interventions, monitoring, and therapeutic plan changes throughout the dayRounds: Utilize effective recommendation strategies on multidisciplinary rounds and answer medication information questions posed by the medical team in an accurate and timely manner

OBJ R1.1.4 (Cognitive - Analyzing) Analyze and assess information on which to base safe and effective medication therapy

Taught and Evaluated

Follow-up patient assessment: Re-evaluation of the patient’s therapeutic regimen should be specific with a focus on monitoring related to medication therapy, further assessment of questions posed on rounds, and patient therapeutic plan changesOrder verification: Actively question orders in real time to determine appropriateness of orders (indication, dose, route, frequency, rate of administration, drug interactions, compliance, cost, etc.)Overall patient assessment/data analysis: Work-up all assigned patients on a daily basis, so that he/she is ready to review patients with the preceptor and/or independently during patient care rounds

OBJ R1.1.5 (Cognitive - Creating) Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans)

Taught and Evaluated

Literature and reference review: Utilize primary literature, guidelines, package inserts, and other institution specific resources to base recommendationsTherapeutic drug monitoring: Provide therapeutic drug monitoring services per institution-specific protocols for patientsTherapeutic regimen: Design or redesign therapy and/or monitoring plans for each assigned patient on a daily basis

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Goal R1.2 Ensure continuity of care during patient transitions between care settings

OBJ R1.2.1 (Cognitive - Applying) Manage transitions of care effectively

Taught and Evaluated

Handoff communication: Provide essential handoff communication to the receiving decentralized pharmacist when patients are transferred to other unitsMedication Reconciliation: Complete admission medication reconciliation for all assigned patients daily. Complete discharge medication reconciliation as appropriate.Transitions of care: Manage pharmaceutical transitions of care through taking care of patients who transition from the inpatient setting to home, rehabilitation facilities, long term care facilities, or other locations

Goal R3.1 Demonstrate leadership skills

OBJ R3.1.2 (Cognitive - Applying) Apply a process of on-going self-evaluation and personal performance improvement

Taught and Evaluated

Feedback and self-improvement: Utilize self-assessment techniques and personal change tools to improve the quality of one’s own performance related to self- and preceptor-provided feedbackFinal evaluation: Provide self-evaluation related to each rotation objective through completion of the PharmAcadmic summative self-assessment form by the end of the rotation or preceptor specified dateMidpoint evaluation: Identify two objectives the resident is routinely completing well and two objectives the resident would like to continue to improve upon throughout the remainder of the rotationWeekly goals: Develop three weekly SMART goals and submit to the preceptor prior to Monday morning each week. Two goals will be related to the rotation, and one to residency. The resident will self-reflect on these goals at the end of each week

Goal R3.2 Demonstrate management skills

OBJ R3.2.4 (Cognitive - Applying) Manages one’s own practice effectively

Taught and Evaluated

Patient care: Correctly prioritize patient care activities within the structure of the day such that the most acute concerns are handled earliest in the day without losing sight of the less acute concernsProjects: Complete rotation associated projects to the best of the resident’s ability and in a timeline that meets all assigned deadlines

Goal R4.1 Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and groups)

OBJ R4.1.1 (Cognitive - Applying) Design effective educational activities

Taught and Evaluated

Journal club: Develop an educational review of a journal article that has changed practice in this fieldMidlevel provider education: Prepare an evidence-based inservice on an APP chosen topicNursing newsletter: Construct an educational newsletter article regarding a topic from the month for nursing staff

OBJ R4.1.2 (Cognitive - Applying) Use effective presentation and teaching skills to deliver education

Taught and Evaluated

Journal club: Lead a journal club discussion including background information, article summary, critique of the article, and applicability to practiceMidlevel provider education: Conduct inservice targeted at APP-level audiencePatient counseling: Effectively deliver education regarding pharmaceutical therapy to patients, family members, and caregivers prior to discharge

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OBJ R4.1.3 (Cognitive - Applying) Use effective written communication to disseminate knowledge

Taught and Evaluated

Chart documentation: Utilize institution specific documentation (iVents, flowsheets, sticky notes, progress notes, etc.) to convey information to other healthcare staffJournal club: Within a 1 page handout, compile background information, article summary, article critique, and application to practice for other healthcare providersMidlevel provider education: Concisely summarize the vital content of a 30 minute presentation into a half page pocket guide for APPsNursing newsletter: Write an educational, grammatically correct ½ to 1 page article for nursing staff

Evaluations:

Evaluator Evaluated Timing

Summative Evaluation All Preceptors Each Resident Taking this Learning Experience

Ending and Quarterly if Needed

ASHP Preceptor Evaluation Residents All Preceptors of this Learning Experience

Ending and Quarterly if Needed

ASHP Learning Experience Evaluation

Residents Learning Experience Ending and Quarterly if Needed

Summative Evaluation Residents Each Resident Taking this Learning Experience

Ending and Quarterly if Needed

Natalie's Custom Midpoint Residents Learning Experience 50.00%

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