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Mayo Clinic Hospital Pharmacy Services Rotation Summary Rotation Title: Medical Cardiology PGY2 (Pharmacotherapy) Rotation Length: 4 weeks Primary Preceptors Names: Narith Ou, PharmD, BCPS Phone: ext 5-9458 (N. Ou); 5-5477 (CCU RPh) Pager: 127-09868 (N. Ou); 127-89723 (CCU RPh) General Description: Mayo's Cardiovascular Division is the largest Division in the Department of Medicine. Comprised of 110 consultants who are committed to provide the best possible care to patients with various forms of cardiac and/or vascular disorders. The Cardiovascular Division cares for approximately 46,000 patients annually. The field of cardiovascular medicine is truly dynamic and advances in diagnostic techniques, imaging modalities, therapeutics, and interventions are continuously being introduced. For this reason, most of our consultant staff are sub-subspecialists in different disciplines of cardiovascular diseases. The practice is supported by many laboratories, sub-subspecialty clinics, and preventive health programs. Saint Marys Hospital has over 180 beds dedicated to patients with cardiovascular diseases including 16 coronary care unit beds serviced by 6 general cardiology services, 2 critical care services, and specialty interventional services such as electrophysiology, device, and cardiac cath lab. Participants in this rotation can expect to be exposed to a wide variety of cardiovascular disease states and therapies. Disease States: Acute Coronary Syndromes Acute Myocardial Infarction Advanced Cardiac Life Support Atrial Arrhythmias Chronic stable angina Hyperlipidemia Heart Failure Hypertension Peripheral arterial disease Venous embolism and thrombosis Ventricular arrhythmias Pulmonary hypertension Goals Selected: R1.1: Exhibit the ongoing development of essential personal skills of a pharmacotherapy practice leader. OBJ R1.1.1: Practice self-managed continuing professional development with the goal of improving the quality of one’s own performance through self-assessment and change. R1.3: Exercise practice leadership. Demonstrate a commitment to advocacy for the optimal care of patients through the assertive and persuasive presentation of patient care issues to members of the health care team, the patient, and/or the patient’s representative(s). R2.1: Develop collaborative professional relationships with members of the health care team. OBJ R2.1.1: Implement a strategy that effectively develops cooperative, collaborative, and communicative working relationships with members of the inpatient interdisciplinary health care team. R2.2: For a caseload of patients, prioritize the delivery of pharmaceutical care. OBJ R2.2.1: Appropriately prioritize the care of patients if given limited time and multiple patient care responsibilities R2.4: Collect and analyze patient information. OBJ R2.4.1: Collect and organize all patient-specific information needed by the pharmacotherapy specialist to anticipate, prevent, detect, and/or resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations as part of the interdisciplinary team. OBJ R2.4.2: Determine the presence of or potential for all clinically significant problems in the patient’s current medication therapy. R2.6: Design evidence-based therapeutic regimens. OBJ R2.6.1: Specify therapeutic goals for a patient incorporating the principles of evidence-based medicine that integrate patient-specific data, disease and medication-specific information, ethics, and quality-of-life considerations. OBJ R2.6.2: Design a patient-centered regimen that meets the evidence-based therapeutic goals established for the patient; integrates patient-specific information, disease and drug information, ethical issues and quality-of-life issues; and considers pharmacogenomic and pharmacoeconomic principles. R2.7: Design evidence-based monitoring plans. OBJ R2.7.1: Design a patient-centered, evidenced-based monitoring plan for a therapeutic regimen that effectively evaluates achievement of the specified therapeutic goals. R2.8: Recommend regimens and monitoring plans. OBJ R2.8.1: Recommend a patient-centered, evidence-based therapeutic regimen and corresponding monitoring plan to other members of the interdisciplinary team in a way that is systematic, logical, accurate, timely, and secures consensus from the team. OBJ R2.8.2: Discuss the proposed patient-centered, evidence-based therapeutic regimen and corresponding monitoring plan with the patient and/or caregiver in a way that is systematic, logical, accurate, timely, sensitive, and secures consensus from the patient and/or caregiver. R2.10: Implement regimens and monitoring plans OBJ 2.10.4: Use effective patient education techniques to provide counseling to patients and caregivers, including information on the disease state, medication therapy, adverse effects, compliance, appropriate use, handling, storage, medication administration, and any other therapeutic interventions R2.11: Evaluate patient progress and redesign regimens and monitoring plans. OBJ R2.11.1: Accurately assess the patient’s progress toward the therapeutic goal(s). OBJ R2.11.2: Redesign the patient’s regimen and monitoring plan as necessary, based on evaluation of monitoring data and therapeutic outcomes. R2.12: Communicate pertinent patient information to facilitate continuity of care. OBJ R2.12.2: Formulate a strategy for continuity of pharmaceutical care across all applicable treatment settings. R2.13 Document direct patient-care activities appropriately. OBJ R2.13.1: Appropriately select direct patient-care activities for documentation. OBJ R2.13.2: Write timely and authoritative consults and notes according to the organization’s policies and procedures. R3.1 Employ advanced literature analysis skills in preparing drug information. OBJ R3.1.1: Create an efficient and effective advanced search strategy to prepare a drug information response. OBJ R3.1.9: When presented with limited evidence-based biomedical literature, synthesize a reasonable response for the specific drug information need. R4.1 Provide effective education and training to health care professionals and health care professionals in training. OBJ R4.1.1: Use effective educational techniques in the design of an educational/training activity. OBJ R4.1.6: Use public speaking skills to speak effectively in a small group. E2.1: Identify opportunities for improvement of the safety of aspects of the organization’s medication-use system. OBJ E2.1.1: Contribute to the organization’s evaluation of and response to a medication-related event. Activities: Goals: Participate in patient daily rounds from 8:30 a.m. to ~ noon daily, Monday through R1.1 Friday. Rounds are independent (preceptor is not with resident on rounds). Attend service teaching session (usually daily, either before or after rounds depending on the consultant). For all patients, review electronic medical record (using MICS Last Word, Synthesis, MICS anesthesia viewer, P-Care) to review chart notes and laboratories prior to rounding. Pertinent information includes chief complaint, history of present illness, past medical history, laboratory information, home medications, medications ordered in the hospital, pertinent other history and tests, medicationrelated issues, monitoring plan for medications, and endpoints for therapy. Review all patient medication histories and document in P-Care that medication history complete, admission medication reconciliation complete, and (if a patient transfers) transfer medication reconciliation complete. This means that home medications are either ordered, or it is documented in the dismissal summary what is changed/held & why. Answer drug information requests from physicians and allied health professionals, using literature searches when appropriate and pulling information from guidelines. Review patient medication profiles to identify and prevent medication-related problems. Document findings discussed with service (interventions) in P-Care. Evaluate/monitor drug therapy and recommend changes when necessary, based on organ dysfunction, indication, renal replacement therapy, or other changes in clinical status. Document recommendations (interventions) in P-Care, complete warfarin protocols in P-Care and order doses in MICS Last Word, complete “rules” and monitors in P-Care. With regards to antimicrobial kinetic monitoring, a note is created in Synthesis also; this is part of the permanent medical record. Report and document adverse drug reactions using medication error reporting form on pharmacy services website. Counsel patients about their medications as appropriate (required for dofetilide) and upon request of nurses and prescribers. Meet with the rotation preceptor daily to discuss patients and to review drug therapy & disease state topics (approximately 2 hours/day) Complete all readings assigned by the preceptor (for each topic & as interesting R1.1, R2.2 R2.12 R2.1, R3.1 R2.4 R1.3, R1.6, R1.7, R1.8, R2.1, R2.5, R2.11, R2.13 E2.1 R2.10 R2.6, R2.7, R2.8, R2.10 R1.1 patient cases come up). Present at least one 30–minute case study or topic review to pharmacy residents, students and staff. R4.1 Preceptor Interaction: Daily: 8:30 a.m. to ~ noon - Participate in patient daily rounds, Monday through Friday (preceptor or designee available for questions that arise) Afternoon - Patient discussions with preceptor or designee (approximately 1 hour/day) Afternoon - Topic discussions with preceptor or designee (approximately 16-20 hours for the 4 weeks) Case presentation, topic review, project, or other approved by preceptor Evaluation Strategy ResiTrak will be used for documentation of formal evaluations. For evaluations, resident and preceptor will complete the evaluations separately. Prior to signing the evaluation, the preceptor and the resident will compare and discuss the evaluations. This discussion will provide feedback for both the resident and preceptor on their performance. What type of evaluation Snapshot(s) Mid-point Evaluation Summative Summative Self-evaluation Preceptor, Learning Experience Evaluation Who Preceptor, Resident Preceptor, Resident Preceptor, Resident Resident Resident When As necessary Middle of learning experience End of learning experience End of learning experience End of learning experience