Inpatient Learning Experience Descriptions

Cardiology Rotation Type: Required 4 week inpatient learning experience

Site Description: Heart Services at Mission Hospital are primarily provided on one of five units:  Coronary Care Intensive Care Unit (CICU)  Cardiovascular Recovery Unit (CVRU)  Cardiovascular Progressive Care (CVPC)  Medical Cardiology Step Down Unit (MCSD)  Heart Failure Unit

The CICU is a critical care unit for patients with life threatening cardiac problems that require constant medical and nursing care. The CVRU is a unit devoted to unstable patients who have undergone percutaneous coronary interventions (PCI), including angioplasty and stent placement, and is also an immediate post-cardiac surgery unit whose patients have undergone CABG, valve replacement, carotid endarterectomy, or other cardiothoracic surgery. The CVPC unit is a step-down unit primarily devoted to post-surgical patients. MCSD is a unit for more stable medical cardiac patients and is used as a step down unit from CICU and CVRU. The newest cardiology addition is the Heart Failure unit which focuses on patients who have congestive heart failure in an effort to decrease readmissions in this patient population.

During the cardiology rotation, the resident will spend time in each area, but the main focus will be on non-surgical patients. The rotation will primarily concentrate on caring for patients with myocardial infarction, cardiogenic shock, cardiomyopathies, congestive heart failure, arrhythmias, hypertensive crises, and various other cardiac disorders.

Infectious Disease Rotation Type: Required 4 week inpatient learning experience

Site Description: The pharmacy resident training shall provide a learning experience that encompasses multidisciplinary and independent pharmacy patient care. Training will be varied and of sufficient depth to prepare a resident to focus on infectious disease and antibiotic stewardship. The resident will participate in antibiotic management of patients in the Mission Hospitals system with emphasis on patients located on the Memorial and St. Joseph's campuses. The resident will be part of the Mission Hospitals Antibiotic Stewardship Team and will work closely with the ID preceptor and an Infectious Disease physician during the learning experience.

Pediatric Rotation Type: Optional 4 week inpatient learning experience

Site Description: The main objective of this rotation is to understand the application of drug therapy in pre-term neonates, full term neonates, infants, and older children. This will be achieved in part by understanding the physiological and disease-state differences that distinguish these patients from adults. The rotation will provide the resident with opportunities to interact with and be familiar with the roles of other health care professionals involved with the care of neonates and children. The resident will also gain insight into the unique challenges of medication administration to infants and children, and the dangers/contraindications associated with certain medications. Internal Medicine Rotation I Type: Serves as an option for a required 4 week inpatient medicine learning experience

Site Description: The Internal Medicine Teaching service cares for adult medical patients who are admitted to the hospital by the Asheville Hospitalist Group. The patients are located in the adult patient units on the Memorial campus of Mission Hospital. The Internal Medicine team consists of an attending physician (hospitalist), a second or third year Family Practice (FP) resident who oversees the work of the interns, 2-3 first year FP residents, a pharmacist, 1-2 pharmacy resident(s) and 1-2 fourth year PharmD student(s) and occasionally a medical student or PA student. The pharmacy resident is responsible for working with the medical residents and Attending to identify, prevent, and resolve medication therapy issues for patients on the service. Team-work, good communication and interpersonal skills are important in this setting. The resident must devise efficient strategies for accomplishing the required activities in a limited time frame. The resident will also be expected to act as a co-preceptor to 1-2 pharmacy students and will assist the preceptor with answering questions about patient care issues and topic discussions.

Emergency Medicine Rotation Type: Elective 4 week inpatient learning experience

Site Description: The emergency medicine clerkship is based in the emergency department (ED) on the Memorial campus. The ED is a 60-bed department composed of 7 areas: A-1 side (beds 1-15), A-2 side (beds 23-30), B-3 side (beds 31-40), B-4 side (beds 41-50), C side (beds 16-22), and Care Plus (8 beds). The ED pharmacists also cover the B3 South Clinical Decision Observation Unit (CDOU). A-1 is the primary section of the ED. This is the area where the most critical patients will likely be placed on arrival to the ED. The other sections usually contain less severe patients. Care Plus is an 8-bed area designed to treat minor complaints prior to being discharged home. The ED pharmacist is involved in a variety of daily activities including but not limited to: verifying physician ordered medications; completing antimicrobial follow-up evaluations on discharged patients; responding to CODEs (STEMI, Stroke, Trauma, and Blue); responding to Trauma Alerts; facilitating medication delivery from the central pharmacy; preparing STAT IV infusions in emergency situations; answering medication questions regarding dosing, side effects, toxicology, pharmacology, administration, IV compatibilities, pharmacokinetics, and cost-effectiveness; making therapeutic recommendations; obtaining home medication histories; and acting as a liaison between the ED and the pharmacy. To be successful in this setting, a pharmacist must be able to multi-task, prioritize, gather drug information quickly, and have excellent interpersonal and communication skills.

Drug Information Rotation Type: Optional 2-4 week inpatient learning experience

Site Description: The western North Carolina Regional Drug Information Center was established by Mission Hospitals and the Mountain Area Health Education Center (MAHEC). Its mission is to provide health care professionals with accurate, up-to-date, objective drug information in a timely manner to ensure the safe, appropriate, and cost-effective use of drugs. The experience involves the provision of drug information from an established, regional Drug Information Center (DIC). There is a longitudinal DI experience involving completion of the following: a drug class monograph for Formulary Review, Journal Club meetings and participation in the Adverse Drug Reaction Reporting program and assisting with drug shortage issues. The resident is responsible for working with the Drug Information pharmacist and effectively researching and answering various drug information requests. They may share the rotation with a PharmD student and assist with precepting.

MAHEC/Mission Family Medicine Inpatient Rotation Type: Serves as an option for a Required 4 week inpatient Medicine learning experience

Site Description: The goal of the Family Medicine clerkship is to provide the resident with experience in the family medicine in the inpatient setting. The resident should gain knowledge and experience in the treatment of acute illness in the setting of a family medicine service. This rotation focuses on complete care of all patients, from infants to end of life. Residents should gain understanding not only of inpatient matters, but the continuum of care including outpatient, inpatient, and the transitions of care between the two settings.

Neurotrauma Critical Care Rotation Type: One of the choices for a required 4 week ICU learning experience, and can serve as an additional elective if desired

Site Description: The Neurotrauma ICU (NTICU) is composed of two critical care units with a total of 14 beds. These patients have experienced life threatening traumas and/or neurologic injury that require constant medical and nursing care, and the majority of patients require ventilatory support. Typical traumas include motor vehicle accidents (MVA), motorcycle accidents, traumatic brain injuries (TBI), blunt traumas and gunshot wounds. Common complications that occur during the ICU stay include nosocomial infections, renal insufficiency/failure, septic shock and alcohol withdrawal and acid/base and electrolyte abnormalities. A highly aggressive approach is taken to care for the patient utilizing a wide variety of hospital resources.

The trauma team consists of four attending trauma surgeons/intensivists, a pharmacist(s), the trauma care nurse coordinator, patient care nurses, a metabolic support clinician and a respiratory therapist. Daily team rounds (including the trauma physician on call for the week) occur to discuss the management plan for each patient.

The pharmacist(s) is expected to keep abreast of each patient's course, plays an integral role on the health care team and is often asked to comment on and/or make decisions on specific medication choices, side effects, pharmacologic action, cost effectiveness, pharmacokinetics and dosing of medications in this setting.. The primary preceptor is a Clinical Pharmacy Practitioner (CPP) and is allowed to initiate, modify and discontinue all medications for these ICU patients. Resident and student learners are allowed to practice with the CPP under this model. Medical/Surgical Intensive Care Rotation Type: Serves as an option for a Required 4 week inpatient Critical Care rotation

Site Description: The Medical/Surgical Intensive Care (MSICU) is a fourteen-bed unit located on the Mission Hospital campus or the Coli Intensive Care unit is a fourteen-bed Medical-Surgical ICU located on the St. Joseph Hospital campus. Criteria for admission to either unit include critically ill post-surgical and medical patients. Surgical cases include the hemodynamically unstable patient requiring higher levels of monitoring, ventilatory support, or extensive nursing care. Medical admissions are often secondary to infections and/or exacerbations of pulmonary disease requiring mechanical ventilation. Other reasons for admission may include acute renal impairment, gastrointestinal bleeding, severe sepsis and drug overdose. Many MSICU and Coli ICU patients have management issues related to multiple organ dysfunctions.

The unit's multidisciplinary team consists of a pulmonologist, respiratory therapist, pharmacist, critical care nurse, case manager, a nursing educator and metabolic support personnel. The resident is trained to perform the duties of the pharmacist on the team and to assist with patient-centered medication regimens of the patients.

Metabolic Support Rotation Type: Optional 2- 4 weeks inpatient learning experience

Site Description: The Metabolic Support Service (MSS) is a multi-disciplinary team consisting of health care professionals who assist in the provision of specialized nutrition support to inpatients of Mission Hospital. MSS completes nutritional assessments and follows all patients at Mission on parenteral nutrition and all patients in the intensive care units on enteral nutrition. Members of the team include registered clinical dietitians, a pharmacist, and a physician advisor. During the metabolic support clinical rotation, the resident will spend time in various areas of the hospital system with the primary focus on the intensive care units. The resident is responsible for working with physicians, nurses, pharmacists, dietitians, and case-managers to ensure the appropriate provision of nutrition therapy for patients on the service.

Management Rotation Type: Required 4 week inpatient learning experience

Site Description: The Mission Hospitals Pharmacy Management learning experience has two components, a longitudinal experience and a one month rotation. The one month rotation is designed to provide the resident with actual working experience as a pharmacy leader; including director, operational management, clinical management, and ambulatory care/ disease management responsibilities. The resident is part of the Mission Hospitals Pharmacy Leadership team during the month and is assigned to projects demonstrating inter-departmental interactions, performance improvement, data analysis importance, and technological influences on medication processes. The longitudinal experience is designed to expose the resident to current topics in leadership and management, and to develop their communication and application skills. Current management and leadership articles are distributed to the residents for reviewing. After reviewing the articles, the resident meets with the Pharmacy Director monthly to discuss how concepts in the article apply to pharmacy or to their personal lives.

Psychiatry Rotation Type: Elective 4 week (optional 2 weeks) inpatient learning experience

Site Description: The Copestone Psychiatry Service cares for adult, pediatric, adolescent, and geriatric psychiatric patients. The team consists of nurses, social workers, a pharmacist, a nurse practitioner, and physicians. Adult patients are usually admitted to the stabilization unit (5 North) and progress to the open unit (5 South) as their status improves. The resident is responsible for working with the staff pharmacist, physicians, and nurse practitioners to identify, prevent, and resolve medication therapy issues for patients on the service during daily rounds. The resident will also facilitate group meetings in the open and adolescent units during the second half of the rotation two days/week (topics include things such as management of side effects, compliance, onset of effect, and proper administration).

Oncology Inpatient Service Rotation Type: Elective 2-4 week inpatient learning experience

Site Description: The oncology service involves a variety of disciplines that provide therapies for cancer patients. Chemotherapy, surgery, and radiological procedures are treatments that are provided routinely by the oncology service. In addition, specialized radiological procedures are available for patients, including intra-arterial chemotherapy and chemoembolization. The adult hematology and medical oncology services are based on the tenth floor of St. Joseph's (north campus) hospital. Radiation oncology is based primarily at Mission Hospital (south campus). The obstetric and gynecological oncology team, composed of medical residents and attending physicians, provide their services at the Mission campus. There is also a new Cancer Center that houses the outpatient infusion services. The resident is expected to work with the oncology pharmacist and assume responsibility for the specialized pharmaceutical care needs of the oncology patient, including treatment and prevention of disease, antiemetic therapy and pain management.

Medication Safety Rotation Type: Elective 2 or 4 week rotation for PGY1 Resident

Site Description: The Medication Safety rotation is designed to allow the learner to become well versed in many aspects of medication safety. This includes study of The Joint Commission (TJC) standards and National Patient Safety Goals, participation on multidisciplinary medication use committees, and pharmacy safety improvement projects. The learner will also become familiar with principles surrounding culture of safety, specifically Just Culture and human factors engineering. Learning medication error investigation techniques to pinpoint opportunities for system improvements will be a key topic.

Internal Medicine II Type: Serves as a required 4 week adult medicine learning experience

Site Description: The multidisciplinary round rotation provides an opportunity for the resident to participate in rounds on an adult medicine floor. This rotation is autonomous, so the resident will attend rounds and cover the floor without the presence of a pharmacist, although the preceptor (or another adult medicine pharmacist) shall be available via phone call at all times. The patients are adult general medicine patients who are admitted to the Asheville Hospitalist Group service. The rounding team consists of a hospitalist attending, charge nurse, discharge coordinator, and patient-specific nurses, as well as occasionally a physical therapist and a respiratory therapist. Rounds occur as walking rounds on 20-25 patients daily. The pharmacy resident is responsible for pre-rounding on the patients to determine necessary interventions. The resident will attend rounds, which involved being available to make medication recommendations, enter verbal orders from the physician, and answer drug information questions. After rounds, the resident will complete any consults for the patients on the floor. The resident will also be available on the floor to complete order verification and assist the nurses and physicians with drug information questions and assist the core pharmacy with order verification.

Transitions of Care Type: Serves as an option for an elective 4 week adult medicine learning experience

Site Description: The resident participates in transitions of care opportunities, including but not limited to completing medication histories, evaluating patient’s ability to access and adhere to medications, reviewing inpatient medication record, reviewing the discharge medication reconciliation and performing medication discharge counseling. The resident is involved in post-discharge communication with community pharmacists, care managers, family care physicians, and patients to assist with the transition into the community. The resident can expect to gain a wider understanding of the transitions of care stakeholders in our hospital and our community, as well as awareness of local and national data to support these efforts. They will be exposed to a wide variety of both clinical and non-clinical patient care issues that will prepare them to take care of the whole patient, as dictated by the patient-centered medical home concept that has evolved out of the Affordable Care Act. Ambulatory Care Learning Experience Descriptions Medication Assistance Program (MAP) Rotation Type: Serves as a choice for an elective four week (optional 2 weeks) outpatient experience in ambulatory care

Site Description: Mission Health System Medication Assistance Program (MAP) exists to improve clinical, economic, and humanistic outcomes to patients by providing medications, education, collaborative care and disease state management to low-income individuals. The program actively integrates Medication Therapy Management Services (MTMS) into other programs within the hospital and in the community to improve the care of the underserved in Buncombe County. The patients generally live at or below 150% of federal poverty level. They are considered higher risk patients due to their multiple disease states and higher number of medications. MAP has been able to demonstrate a reduction in hospital and inpatient admissions and length of stay for patients enrolled in the program. Residents participating in this transitions- in -care site will receive exposure to many chronic diseases including diabetes, depression, asthma, COPD, HF, HTN, and hyperlipidemia. They will also have the opportunity to witness the increasing challenges faced by low-income individuals in accessing proper health care. Anticoagulation Clinic Type: Serves as a choice for an elective four week (optional 2 weeks) outpatient experience in ambulatory care

Site Description: The Outpatient Anticoagulation Service of Mission Health System exists to provide safe and effective management of anticoagulation therapy for outpatients in western North Carolina through appropriate initiation of therapy, provision of patient education, continuous monitoring, and quality assurance programs. It is a physician referral based clinic that provides warfarin initiation, education and monitoring, enoxaparin and fondaparinux initiation bridge therapy management and education, and therapy management of all of the newer anticoagulation agents. This rotation is open to pharmacy students, PGY1 and PGY1 residents in ambulatory care. Pharmacy residents can assist with precepting students and will be expected to perform at a higher level than a student. For example, pharmacy residents will be expected to directly communicate with physicians regarding patient care, while pharmacy students will serve in more of an observational role. By the end of the month, the resident is expected to require little to no precepting intervention whereas a student may require little to moderate intervention. Pharmacotherapy Rotation Type: Serves as an option for a four week elective outpatient learning experience

Site Description: The mission of the Pharmacotherapy Clinic is to improve patient outcomes and facilitate continuity of care by providing medication therapy management (MTM) services that promote safer and more effective medication use in our community. In an effort to fulfill our mission and assist with medication reconciliation, the Pharmacotherapy Clinic began providing MTM services in January 2006 for elective orthopedic and neurosurgery patients. The service is currently expanding to include general surgical patients and some cardiovascular surgical patients, with an eventual goal to see all elective surgical patients. The Joint Commission on Accreditation of Healthcare Organizations added medication reconciliation to its National Patient Safety Goals in 2005, requiring compliance with this standard in 2006. Medication reconciliation requires comparing a patient's current medication orders to all the medications the patient has been taking when a transition in care occurs. Pharmacy residents under the supervision of pharmacists staffing at the clinic, will obtain accurate and complete medication histories from patients during preadmission and make appropriate recommendations regarding medication therapy in order to promote medication safety and facilitate medication reconciliation during admission. Pharmacy residents will be expected to assist with precepting pharmacy students. Oncology - Adult Ambulatory Type: Elective rotation. Offered as a 4-week block, 2-week block, or one ½ day per week longitudinal experience.

Site Description: The adult ambulatory oncology rotation will focus on the drug therapy of patients at the SECU Mission Cancer Center. The resident will be working directly with the preceptor in clinic to manage drug therapy and provide ongoing education to patients (4-6 half-day clinics per week). Resident will attend multidisciplinary treatment planning meetings and infusion center patient care rounds daily. This experience offers the opportunity to be involved in developing and dynamic practices of outpatient oncology pharmacy.

Academia - Mission Hospital/UNC-Asheville Eshelman School of Pharmacy Type: 4-week Education Elective / Strongly encouraged if participating in the Teaching and Learning Curriculum

Site Description: The academia rotation is intended to give the resident an immersion experience in academic practice. The resident applies knowledge learned during the Teaching and Learning Curriculum via practical experiences in precepting, small group facilitation, and didactic lecturing. The resident is responsible for precepting of a learner on a rotation he or she previously completed so that they can focus on the concepts of precepting while still being exposed to a clinical rotation environment.

Personalized Medicine Rotation Type: Serves as a non-patient care elective 2-4 week Personalized Medicine learning experience

Site Description: The Personalized Medicine Program (PMP) at Mission Health was created to prepare the region for the use of genomic medicine in the management of chronic diseases and cancer. The program integrates with medical services across the Mission Health system, adding to the existing expertise and infrastructure, to ensure quality, safety and effective care by using a science-based genomic approach to cancer and non- cancer treatment. Current program services in include facilitating genomic test ordering, helping with interpretation and application of results, providing education and awareness for health care practitioners and the community, and serving as a resource for researching pharmacogenomic questions. Current projects in oncology include ensuring that Mission providers are meeting or exceeding national guidelines for tumor marker testing to guide treatment and conducting quality improvement studies for consistent best practices for tumor markers.

The resident will spend time with the PMP director, clinical pharmacist, and coordinator to learn the opportunities and barriers to using pharmacogenomics in clinical care, evaluate the potential for pharmacogenomics to impact safety and quality of medication management, identify available resources for implementing pharmacogenomics in clinical care, and understand the key components of providing consultation for pharmacogenomics results.

Pharmacy Informatics Rotation

Type: Serves as a choice for an elective four week (optional 2 week) experience

Site Description:

The Pharmacy Informatics team consists of pharmacists, technicians, and application specialists who are responsible for the system-wide design, build, training, implementation, and support of all medication use technology-based processes. The team acts as consultant to Nursing and Clinical Informatics departments providing medication information for the development of integrated medication-related system functionalities. The resident will become familiar with concepts involving computerized provider order entry (CPOE), the electronic medication administration record (eMAR), unit-based cabinet dispensing, pharmacy-based packaging, dispensing, compounding robotics, smart pump applications, and pharmacy system infrastructure supporting bar-coded bedside medication administration and data mining. By the end of the rotation, the resident is expected to understand change management, system change impact, and high-level system infrastructure.