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

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 **

Outpatient/Retail Pharmacist

Inpatient/Clinical Pharmacist

Inpatient Pharmacy at Kaiser

Staff pharmacist

Intensive care unit (ICU) pharmacist

Pediatrics/neonatal ICU pharmacist

Infectious diseases pharmacist

Operating room pharmacist

IV room pharmacist

Responsibilities

Verify doctor’s medication orders and monitor medication therapy of hospitalized patientsReview medication profiles for dosage accuracy, drug-interactions, and side effectsMonitor the distribution, dispensing, and compounding of medications

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

Responsibilities

Evaluate patient’s kidney function and adjust medication dosage accordinglySupervise pharmacy technicians and internsEducate and counsel patients being discharged on new Coumadin therapy and arrange for follow-up visits Respond to code blue and stroke codes

A Typical Day at Work…

7:00am – 3:30pmGet report from graveyard pharmacist and pick up pagerPrint “work list” for the day– Pharmacy protocols

Prioritize critical patients– Blood thinners, antibiotics, total parenteral

nutrition (TPN)

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

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 pharmacy protocol.

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

Pharmacokinetic formulas

Cockcroft and Gault equation: CrCl = [(140 - age) x IBW] / (Scr x 72)

Volume of distribution (Vd) = Weight x 0.75 L/Kg

T 1/2= 0.693 / Kel

Calculate Maintenance dose (MD):_____mg. MD = [(kel) x (Vd) x (ti) x (Cpeak desired) x (1 - e-kT)] / (1 - e-kti)

Calculate Loading dose (LD):_____mg. LD = 25mg/Kg

Vancomycin: Kel = (0.00083 x CrCl) + 0.0044

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

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

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

Throughout the day…

Respond to code blue– Cardiac / respiratory

arrest– Provide emergency

medications

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!

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