Today is going to be another one of those long posts. :)
Intensive Care Unit
Today I started in the intensive care unit (ICU) with nurse Brian. It was a slow day in the ICU (thank goodness!) so there were only two patients, one of them being Brian’s. This gentleman had been in the ICU since Friday, after an ATV accident where he developed serious head injuries including: subarachnoid hemorrhage (bleeding between the brain and tissues that cover the brain) and a hematoma. This is the first time I have had any experience with this type of patient care. I had done rounds at Florida Hospital, however all the patients were stable.
First, I wanted to mention something I thought was very sweet. The patient’s family brought pictures of him, and left a board listing many things about the patient. These include the names of his family members, his hobbies, favorite athletic teams, etc. I thought that this was something they did for every patient in the ICU, but I learned the family constructed it. I thought it was very sweet and helps add a personal touch to the care that he receives.
Brian showed me the med pass process using Barcode-Medication Administration (BCMA). This is where patient medications are crosschecked and verified by using the barcode on the patient’s wrist, as well as the one on the medication. We started with his 9:00 meds. He had many different medications including lorazepam (PRN for agitation, which we did administer), Lovenox, docusate, PEG, sennosides and some other high risk medications. The patient had a nasogastric tube, continuous suction, a continuous normal saline (NS) drip and a urinary catheter. The patient was unable to take medications by mouth, so we crushed all of his tablets, and mixed it with his powders and liquid medications. It was diluted with water and administered to him through his nasogastric tube.
At 10:00a, an antibiotic was administered through his IV. The IV was actually infiltrated and therefore removed (Infiltrationoccurs when IV fluid leaks into surrounding tissue) A PICC line was requested, which would last longer than the peripheral line that he had. We also monitored his blood glucose levels and administered 4 units of Novolog. Following that, Brian and I talked about the different antibiotics used intravenously, as well as protocol for disposing of controlled/non-controlled IVs. It was overall a great experience.
Student/Resident Discussion Hour
Following the ICU, I attended a “student/resident” discussion hour. Abby, a 4th year UNC student who is doing her ambulatory care rotation at the VA, led a discussion on the “Management of Oral Anticoagulation During Invasive Procedures.” She presented a patient case, and talked about how to assess the patient’s risk of thromboembolism with cessation of warfarin in patients with Atrial Fibrillation as well as the risk of bleeding. I learned about the CHADS2 scoring used to determine risk of thromboembolism as well as the HAS-BLED score used to assess the risk of bleeding. We talked about how to bridge warfarin therapy before and after a surgical procedure using Lovenox (Enoxaparin). In the next two weeks, each of us are expected to prepare and lead a discussion on a topic of our choice. Although of course that makes me nervous, I am looking forward to this learning opportunity. The residents (aka Pharmacists!), Alli, Gina and Stephanie were super sweet and explained everything they thought we wouldn’t understand and asked us questions to challenge ourselves as well.
Pharmaceutical Cache Program
Probably one of the coolest parts of my day today was going to, and learning about the Pharmaceutical Cache Program. I don’t want to disclose information, so I will say what is listed on the web:
“The VA Pharmaceutical Cache is designed to treat Veterans, staff, and other victims that may present to local VA Medical Centers (VAMC) in a local mass casualty event, primarily one resulting from the deployment of a Weapon of Mass Destruction (WMD). The caches are intended to provide pharmaceuticals and some equipment for short-term care until other resources could be made available in the immediate area and to support and augment a VA facility’s involvement in the local community disaster plan.”
Let me just say it is amazing! It is incredible what they have prepared for any type of emergency; these include anthrax, hurricanes, tornadoes, or any other event.
Infection Prevention & Control Committee
Next, I attended the Infection Prevention & Control Committee meeting. As indicated by the name, this committee works to prevent the transmission of communicable diseases in the medical center. Something cool that I learned was the hospital’s use of the “GoJo Smartlink” system to prevent Healthcare acquired infections (HAIs). Hand hygiene compliance is less than 50% nationally in hospitals. This system has advanced Purell dispensers and communication devices, measurement tools, and clinician support. The system will count the number of a person washes their hands or uses the Purell dispenser. For those who don’t know, every hospital has some type of hand sanitizer system outside almost every door and in every hallway. In a lot of hospitals, it is required for a clinician to use it upon entering and exiting a patient’s room—no matter what. But of course not everyone does it. I actually helped with a study of this at Florida Hospital when I volunteered in undergrad.. It will count it against every time a person walks in or out of that room, which equals an “opportunity” to use it. This will create a “compliance rate” for administrators to use. They also discussed other important new implementations for the hospital including a program to reduce “CAUTIs” (catheter associated UTIs).
VA Charlotte Health Care Center
The VA Charlotte Health Care Center (HCC) is going to be an extension of the Salisbury VA Medical center. It is projected to open in late 2016, and will help provide easier access to care for veterans in the area. Alyssa and I attended a meeting with Glenn today where he finalized the floor plans with the contractor and another pharmacist administrator. It was interesting to witness this planning process and see the blueprints for the new center. After looking at that, and the virtual tour, I can already tell it is going to be beautiful! Not only will it provide better access to care for veterans but it will also open up so many job opportunities for pharmacy technicians, physicians, pharmacists and nurses.
Although I will be spending the day with the oncology pharmacists tomorrow, I got a little sneak preview of it at the end of the day today. I attended a short meeting between Glen, another pharmacist, and two oncologists regarding treatment for a patient. He was diagnosed with colorectal cancer and has already surpassed the average survival rate. He has failed/not tolerated all of the cancer therapies given to him thus far including FOLFOX, Avastin, cetuximab, and irinotecan (caused excessive diarrhea). He is otherwise healthy and lives a normal, asymptomatic life. The pharmacists and physicians approved the trial of a new therapy for him: Regorafenib. It is in stage 3 clinical trials. These consultations are typically done on an individual patient basis after evaluating all circumstances and the prognosis of the disease. I hope that this new therapy will improve the prognosis of this patient.