PGY1 Pharmacy ResidencyCardiology/Cardiac Intensive Care (CICU) Rotation

General DescriptionThe cardiology acute care unit(ACU)/intensive care unit (ICU) is a four week learning experience at University Hospital. The purpose of the cardiology ACU/ICU rotation is to familiarize the resident with the functions of a clinical pharmacist on a cardiology service and to enhance the resident’s knowledge of therapeutics and the skills necessary to provide optimal pharmaceutical care. The cardiology team consists of cardiology attendings, cardiology fellows, medical residents, nursing staff, and a clinical pharmacist who care for the acutely ill on the combined ACU/ICU at University Hospital. Additionally, many consult and admitting teams provide consultative care to patients in the cardiology ACU/ICU.

The pharmacy resident on the cardiology team is responsible for ensuring safe and effective medication use for all patients in the cardiology ACU/ICU. The resident shall be an active member of a multidisciplinary team and follow patients from the time of admission to the cardiology ACU/ICU to time of discharge or transfer to another medical team. The resident will meet daily with the preceptor to discuss findings and recommendations for optimizing care. Other routine responsibilities include reconciling medications for all patients, therapeutic drug monitoring, discharge counseling as needed, and providing drug information and in-services to the medical and nursing staff. Additionally, the resident shares joint responsibility with the clinical pharmacist for precepting pharmacy students and residents assigned to the rotation.

Decentralized clinical pharmacy services are provided on weekdays during daytime hours by the cardiology clinical pharmacist. Weekend, evening, and graveyard pharmacy services are provided by the central pharmacy.

Contact InformationPrimary preceptor: Bethany Kalich, PharmD, BCPS, Assistant Professor, University of the Incarnate Word Feik School of Pharmacy Office: University Hospital Sky Tower, CICU 9th floor, Rm 9-168Cell: (210) 844-4330Office: (210) 883-1177Email: kalich@uthscsa.edu

Communication• Residents are expected to maintain ongoing communication with the preceptor throughout the day• Office or cell phone number: all appropriate for urgent questions pertaining to patient care• Cell phone number: appropriate for all urgent and non-urgent issues

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• E-mail: residents should read e-mails at the beginning and end of each day. E-mail is appropriate for routine, non-urgent communication with the preceptor

Daily Schedule of Activities and Preceptor Interaction• Until 0800 - Prepare for multidisciplinary rounds

• 0800-0830 - Review patients with preceptor

• 0830-1200 - Attend cardiology ACU/ICU patient care rounds

• 1300-1600 - Follow up on issues/questions from rounds, update preceptor on patients, topic discussion with preceptor

• Tuesdays 1200-1300, Weekly PGY2 Critical Care Topic Discussion

• Fridays 1300-1500, Pharmacotherapy Seminar, UTHSCSA McDermott Building

• Fridays 1500-1600, Pharmacotherapy Conference, UTHSCSA McDermott Building

Expected Progression of Resident• Day 1 orientation:

o Preceptor to review learning activities, expectations, schedule, and required readings with residento Preceptor to orient resident to unit, including introductions to the team and tour of patient care areas o Preceptor to assign patients to resident

• Week 1:o Resident to work up six patients and present to preceptor dailyo Preceptor to attend and participate in team rounds with resident, modeling then coaching the resident in his/her role on the health

care team• Week 2:

o Resident to work up all patients on cardiology team and prioritize most critically ill for presentation to preceptor dailyo Resident to begin rounding independently with cardiology team and update preceptor post-rounds

• Weeks 3-4: o Resident will continue to work up all patients and round independently with the team, gaining experience and confidence with

cardiology patientso Resident to attend and participate in rounds as the primary pharmacist, with the preceptor observing periodically to facilitate the

transition to independence

Evaluation Strategy• Formative

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o Formative verbal feedback will be provided throughout the rotation by the preceptoro A formative evaluation (snapshot) on objective 2.6.2 will be completed in Resitrak by the end of the third week of the rotation by

the preceptor and resident, and is based on the performance of one specific activity, not an overall evaluation of performanceo Additional snapshots may be utilized if issues are identified

• Summativeo A summative evaluation by the preceptor and summative self-evaluation, learning experience evaluation, and preceptor evaluation

by the resident will be completed at the end of the rotationo Resitrak will be used for documentation of scheduled evaluations

▪ The resident and preceptor will independently complete the assigned evaluations in Resitrak, then meet to discuss them

Goals and Objectives

Goals and Objectives to be Taught and Formally EvaluatedGoals and Objectives Activities to Facilitate Achievement of Goals

Outcome R2 Provide evidence-based, patient-centered medication therapy management with interdisciplinary teams.Goal R2.2 Place practice priority on the delivery of patient-centered care to patients.

OBJ R2.2.1(Organization) Choose and manage daily activities so that they reflect a priority on the delivery of appropriate patient-centered care to each patient.

Arrange schedule to assure that all patients are worked up appropriately before rounds

Organize and prioritize daily activities to assure that all patient-care issues are taken care of in a timely manner

Goal R2.6 Design evidence-based therapeutic regimens.

OBJ R2.6.1

(Synthesis) 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

Utilize evidence-based consensus guidelines to specify and design therapeutic goals for each patient

Recognize patient-specific factors that may influence therapeutic goals such as cultural, ethical, mental, financial, and age-related barriers

OBJ R2.6.2

(Synthesis) Design a patient-centered regimen that meets the evidence-based therapeutic goals established for a patient; integrates patient-specific information, disease and drug information, ethical issues and quality-of-life issues; and considers pharmacoeconomic principles

Design a therapeutic plan that incorporates consensus guidelines, primary literature, and patient and drug specific factors for each patient and present to preceptor daily before rounds

Goal R2.7 Design evidence-based monitoring plans.

OBJ R2.7.1(Synthesis) Design a patient-centered, evidenced-based monitoring plan for a therapeutic regimen that effectively evaluates achievement of the patient-specific goals.

Develop a medication monitoring plan for each patient on the MICU services based on individual patient data, age, race, gender, organ function, and disease state

Design specific monitoring plans for patients receiving drugs that require therapeutic drug monitoring

Monitor all parenteral nutrition orders daily

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Goal R2.8 Recommend or communicate regimens and monitoring plans.

OBJ R2.8.1

(Application) Recommend or communicate a patient-centered, evidence-based therapeutic regimen and corresponding monitoring plan to other members of the interdisciplinary team and patients in a way that is systematic, logical, accurate, timely, and secures consensus from the team and patient

Communicate recommendations for therapeutic regimens and monitoring plans to team members during daily rounds and as required

Schedule follow-ups for anticipated laboratory monitoring of therapeutic changes

Goal R2.10 Evaluate patients’ progress and redesign regimens and monitoring plans.

OBJ R2.10.1 (Evaluation) Accurately assess the patient’s progress toward the therapeutic goal(s).

Evaluate the patient’s progress toward specified goals using labs, drug levels, clinical response, and trends.

OBJ R2.10.2(Synthesis) Redesign a patient-centered, evidence-based therapeutic plan as necessary based on evaluation of monitoring data and therapeutic outcomes.

Formulate appropriate therapeutic plan changes based on patient’s individual response

Goals and Objectives to be Taught (Not Formally Evaluated)Goal R2.1 As appropriate, establish collaborative professional relationships with members of the health care team.

OBJ R2.1.1

(Synthesis) Implement a strategy that effectively establishes cooperative, collaborative, and communicative working relationships with members of interdisciplinary health care teams.

Introduce resident to all team members on first day of rotation Participate in daily MICU patient rounds and assist with

pharmacy-specific patient care issues Attend and participate in team conferences as scheduled Organize day to allow for patient care activities with team as

priority with an emphasis on delivery of care to highest acuity patients first

Goal R2.4 Collect and analyze patient information.

OBJ R2.4.1

(Analysis) Collect and organize all patient-specific information needed by the pharmacist to prevent, detect, and resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations as part of the interdisciplinary team

Accurately gather, organize, and analyze patient-specific information on patients prior to pre-rounds with preceptor

Analyze the validity of information presented from different sources to develop a sound plan

OBJ R2.4.2 (Analysis) Determine the presence of any of the following medication therapy problems in a patient's current medication therapy:1. Medication used with no medical indication2. Patient has medical conditions for which there is no

medication prescribed3. Medication prescribed inappropriately for a particular

medical condition4. Immunization regimen is incomplete5. Current medication therapy regimen contains something

inappropriate (dose, dosage form, duration, schedule, route of administration, method of administration)

Analyze patient-specific profiles, medication administration records, and pertinent clinical data/documentation records on a daily basis

Actively question and correct orders in real time to determine the appropriateness of drug orders (i.e. indication, dose, route, frequency, rate of administration, drug interactions, compliance, cost, etc.)

Investigate potential adverse drug reactions Assure adherence to the Adult Immunization Schedule Check all medications to ensure adherence to protocols Construct and prioritize a problem list for each patient

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6. There is therapeutic duplication7. Medication to which the patient is allergic has been

prescribed8. There are adverse drug or device-related events or potential

for such events9. There are clinically significant drug-drug, drug-disease,

drug-nutrient, or drug-laboratory test interactions or potential for such interactions

10. Medical therapy has been interfered with by social, recreational, nonprescription, or nontraditional drug use by the patient or others

11 Patient not receiving full benefit of prescribed medication therapy

12. There are problems arising from the financial impact of medication therapy on the patient

13. Patient lacks understanding of medication therapy14. Patient not adhering to medication regimen

OBJ R2.4.3 (Analysis) Using an organized collection of patient-specific information, summarize patients’ health care needs.

Differentiate patient problems in order of acuity while also evaluating how problems are interrelated and impact the overall therapy

Goal R2.11 Communicate ongoing patient information.

OBJ R2.11.1

(Application) When given a patient who is transitioning from one health care setting to another, communicate pertinent pharmacotherapeutic information to the receiving health care professionals.

Communicate pharmacotherapeutic information to receiving providers when a patient is transferred (e.g., outpatient clinic, LTAC, rehab hospital, etc.)

OBJ R2.11.2(Application) Ensure that accurate and timely medication-specific information regarding a specific patient reaches those who need it at the appropriate time.

Determine urgency of patient-specific medication information, and prioritize and communicate accordingly (e.g., lab or micro results, drug information questions, etc.)

Apply effective and timely verbal communication skills when contacting patient or care provider to notify them of important monitoring results or modifications to therapeutic plan

Goal R2.12 Document direct patient care activities appropriately.

OBJ R2.12.1 (Analysis) Appropriately select direct patient-care activities for documentation.

Record interventions appropriately in the pharmacy computer intervention program

Investigate and report adverse drug event if patient experienced a reaction

Analyze patient-specific information to document recommendations for treatment and monitoring plans in EMR

OBJ R2.12.2 (Application) Use effective communication practices when documenting a direct patient-care activity.

Utilize appropriate and sufficient information for recording clinical interventions and ADRs

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OBJ R2.12.3 (Comprehension) Explain the characteristics of exemplary documentation systems that may be used in the organization’s environment.

Distinguish different systems for documentation and be able to identify appropriate venue for documentation

Learning Topics During the rotation, the resident is expected to develop a working knowledge of the following topics through literature review, topic discussions, didactic lectures, and/or direct patient care experience:

1. Acute Coronary Syndromes2. Ischemic Heart Disease3. Chronic Heart Failure4. Acute Decompensated Heart Failure5. Atrial Fibrillation6. Ventricular Arrhythmias7. Hypertensive Urgency/Emergency8. Cardiogenic Shock9. Invasive hemodynamic monitoring10. Mechanical circulatory support11. Valvular disease12. Hypertrophic cardiomyopathy

Required Reading

Acute Coronary Syndrome1. Libby P. Mechanisms of Acute Coronary Syndromes and Their Implications for Therapy. New England Journal of Medicine.

2013;368(21):2004–2013.2. Yusuf S, Bijsterveld NR, Moons AHM. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-

segment elevation: the Clopidogrel in Unstable Angina to Prevent recurrent Events Trial Investigators. The New England journal of medicine. 2001;345(7):494–502.(CURE)

3. Mehta SR, Tanguay J-F, Eikelboom JW, et al. Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet. 2010;376(9748):1233–1243.

4. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. New England Journal of Medicine. 2009;361(11):1045–1057. (PLATO)

5. Pfeffer M, Braunwalk E, Moye LA, Basta L, Brown Jr E, Cuddy TF. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: SAVE. New England Journal of Medicine. 1992;327(10):669–77.

6. Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366(9497):1622–1632. (COMMIT)

7. Cannon C, Braunwald E, McCabe C, et al. Intensive versus Moderate Lipid Lowering with Statins after Acute Coronary Syndromes. New. 2004;350(15):1495-1504.(PROVE-IT)

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Ischemic Heart Disease1. Wilson JF. Stable Ischemic Heart Disease. Annals of Internal Medicine. 2014;160(1):ITC1–1. 2. Banon D, Filion KB, Budlovsky T, Franck C, Eisenberg MJ. The Usefulness of Ranolazine for the Treatment of Refractory Chronic Stable

Angina Pectoris as Determined from a Systematic Review of Randomized Controlled Trials. The American Journal of Cardiology. 2014;113(6):1075-1082.

Chronic Heart Failure

1. WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128(16):e240-e327.

2. Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovascular Pathology. 2012;21(5):365-371. 3. The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: Results of the Cooperative

North Scandinavian Enalapril Survival Study (CONSENSUS). N Eng J Med. 1987;316(23):1429-35. 4. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure

(MERIT-HF). Lancet. 1999;353(9169):2001-2007.5. Bristow MR, Gilbert EM, Abraham WT, et al. Carvedilol produces dose-related improvements in left ventricular function and survival in

subjects with chronic heart failure. MOCHA Investigators. Circulation. 1996;94(11):2807-2816. 6. Pfeffer MA, Swedberg K, Granger CB, et al. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the

CHARM-Overall programme. Lancet. 2003;362(9386):759-766. 7. Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. New England Journal of

Medicine. 2011;364(1):11–21. 2. (EMPHASIS)

Acute Decompensated Heart Failure

1. Channer K, McLean K, Lawson-Matthew P, Richardson M. Combination diuretic treatment in severe heart failure: a randomised controlled trial. Br heart J. 1994;71:146-150. 

2. Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. New England Journal of Medicine. 2011;364(9):797–805.(DOSE study)

3. Fonarow GC, Abraham WT, Albert NM. Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure. Findings from the OPTIMIZE-HF Program. J Am Coll Cardiol. 2008;52:190-9.

4. Jondeau G, Neuder Y, Eicher J-C, et al. B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with Congestive heart failure hospitalizED for a decompensation episode. European Heart Journal. 2009;30(18):2186-2192.

5. Chen HH, Anstrom KJ, Givertz MM, et al. Low-Dose Dopamine or Low-Dose Nesiritide in Acute Heart Failure With Renal Dysfunction: The ROSE Acute Heart Failure Randomized Trial. JAMA. 2013;310(23):2533–2543.

Atrial Fibrillation

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1. Beck H, See VY. Acute management of atrial fibrillation: from emergency department to cardiac care unit. Cardiology Clinics.2012;30:567-589

2. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825-1833. (AFFIRM)

3. Roy D, Talajic M, Nattel S, et al. Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure. New England Journal of Medicine. 2008;358(25):2667-2677. (AF-CHF)

4. Van Gelder IC, Groenveld HF, Crijns HJ, et al. Lenient versus strict rate control in patients with atrial fibrillation. New England Journal of Medicine. 2010;362(15):1363–1373. (RACE II)

5. ACTIVE Writing Group of the ACTIVE Investigators, Connolly S, Pogue J, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367(9526):1903-1912.

6. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. New England Journal of Medicine. 2009;361(12):1139–1151. (RE-LY)

7. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. New England Journal of Medicine. 2011;365(10):883–891. (ROCKET-AF)

8. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. New England Journal of Medicine. 2011;365(11):981–992. (ARISTOTLE)

Ventricular Arrhythmias1. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and

the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114(10):e385-e484.

Hypertensive Urgency/Emergency

1. Johnson W, Nguyen M-L, Patel R. Hypertension Crisis in the Emergency Department. Cardiology Clinics. 2012;30(4):533-543. doi:10.1016/j.ccl.2012.07.011.

2. Hirschl MM, Binder M, Bur A, et al. Clinical evaluation of different doses of intravenous enalaprilat in patients with hypertensive crises. Arch Intern Med. 1995;155(20):2217-2223.

3. Peacock WF, Chandra A, Char D, et al. Clevidipine in acute heart failure: Results of the A Study of Blood Pressure Control in Acute Heart Failure—A Pilot Study (PRONTO). American Heart Journal. 2014;167(4):529-536.

4. Holzer-Richling N, Holzer M, Herkner H, et al. Randomized placebo controlled trial of furosemide on subjective perception of dyspnoea in patients with pulmonary oedema because of hypertensive crisis: FUROSEMIDE IN PULMONARY OEDEMA BECAUSE OF HYPERTENSIVE CRISIS. European Journal of Clinical Investigation. 2011;41(6):627-634.

5. Anderson CS, Heeley E, Huang Y, et al. Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage. New England Journal of Medicine. 2013;368(25):2355-2365. (INTERACT2)

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Other handouts and articles will be given as topics are assigned by preceptor. Additional materials can be found on the rotation website at www.cicurotation.weebly.com. (Password: UIWFSOPCICU)

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