Stacy Campbell-Bright, PharmD, BCPS, BCCCP
Clinical Specialist, Medicine ICU; Associate Professor for Clinical Education, UNC Eshelman School of Pharmacy
Residency Associated Title and Involvement
Critical Care-Preceptor; Pharmacotherapy-Preceptor, Cardiology-Preceptor, ID- Preceptor, Pharmacy Practice-Preceptor, HSPA-Preceptor
Undergraduate: BS Pharmacy Auburn University
School of Pharmacy: PharmD University of Kentucky
MICU - Introductory; MICU Advanced; MICU Independent
The Medicine Intensive Care Unit (MICU) Introductory Experience rotation is an inpatient acute care experience designed to develop a Critical Care resident's skills in participation in a multidisciplinary critical care environment. Residents will be exposed to a variety of disease states and supportive care issues commonly encountered in critical care, as well as rare cases and patient care issues that are unique to a specialty center. The rotation is designed to be fast-paced and challenging for learners of all ability and experience levels. Learning will be accomplished with a mixture of self-directed exploration, active participation in the care environment, patient-based discussions, and scheduled topic discussions. Residents will refine advanced pharmacotherapeutic skills in the identification and resolution of drug therapy problems in the critically ill medicine population. Beyond the expansion of a knowledge base in critical care medicine, emphasis for the rotation will be placed on the further development of critical thinking skills, time management abilities, and communication skills that will be essential to patient care practice in any setting. The goal of the PGY 1 resident is to be a contributing member of the multidisciplinary team in a proactive manner with the goal of the PGY2 resident being capable of functioning as an independent team member.
The MICU is a 30-bed ICU that serves as the primary care area for critically ill patients with non-surgical issues at UNC. The service is divided into two rounding teams, each led by a Pulmonary / Critical Care attending and fellow and staffed by medical residents. Housestaff provides 24-hour coverage. The structure is multidisciplinary, with active participation by all members of the medical team. This includes nurses, respiratory therapists, dietitians, and case managers, in addition to physicians and pharmacists. PGY2 Critical Care residents will be assigned to a preceptor with one of the rounding teams and will be expected to be responsible for all of the patients on that team. With experience and demonstrated competency residents will be afforded a high level of autonomy during their rotation especially during repeated MICU rotation experiences for PGY 2 residents. An active presence in the ICU is encouraged for all learners, and order verification will be an expectation during this rotation for PGY2 residents.
Description of Rotation Activities:
- Patient Care Pre-rounds: residents are expected to collect and analyze appropriate patient information, and to be prepared to identify potential medication-related issues and make recommendations. A sufficient amount of time should be allotted each morning to pre-rounds preparation to ensure completeness and familiarity with the information gathered. Potential recommendations may be discussed with the preceptor before rounds.
- MICU Core Lecture Series (attendance Highly Recommended): residents are encouraged to attend a morning session intended for house staff education. Topics covered are informative but do not always pertain to pharmacy practice (ex. ventilator management, ARDS, acid/base). These sessions are 30 minutes in duration and generally occur immediately before rounds begin.
- Patient Care Rounds: residents are expected to attend patient care rounds, to be appropriately attentive and professional, and to make recommendations as appropriate for the patients that they are covering. Active participation during rounds will be encouraged throughout the month. The level of autonomy on rounds will be high. Generally, a preceptor will observe rounds for at least the first half of the rotation or on post call days. Residents will be expected to help facilitate the patient care plan determined on rounds. This will include order verification for PGY2's, and will also include making sure that medications are available to be administered, and implementing parts of the care plan or monitoring plan as necessary (entering verbal orders, ordering drug levels, calling central pharmacy, etc.).
- Patient Discussion after rounds or in the afternoon: residents will discuss patients and their medical problems in depth with the preceptor. This will serve as a time to identify problems, discuss the differential diagnosis, develop a plan for pharmacotherapy and monitoring, follow up on interventions, and provide targeted education on specific disease states and supportive care issues that are pertinent to the patients currently on service. These discussions will serve as a key educational component of the rotation and should be expected to take place daily.
- Post-Rounds Follow-Up: residents will be expected to follow up on all recommendations and outstanding issues after rounds. Residents are expected to resolve these issues reliably and in a timely manner. It is also expected that residents will follow up on recommendations during rounds (was the recommendation accepted and why / why not? What was the outcome of the therapeutic intervention? Are further adjustments to the plan necessary given the patient's current condition? Etc.) This is a critical part of patient monitoring in the ICU setting and will be a point of emphasis on this rotation.
- Topic Discussion: 1-2 times a week in addition to POD, residents will participate in structured topic discussions with the preceptor. Topics will be chosen at the beginning of the month, but may change if necessary or as requested. Residents will be provided with some background reading, but are encouraged to add additional depth with a literature search. Residents will be required to lead at least one of these topic discussions during the month. Potential topics are listed elsewhere in this document. Number of topic discussions will depend on patient care needs and time available.
- Transitions of Care: residents are required to assist with transitions of care activities, potentially including medication reconciliation, discharge counseling, and communication with accepting teams. A warm hand-off will occur whenever a patient is transferred to a different level of care (step-down status or floor status) this will entail a direct communication with the pharmacist on the accepting team, highlighting reason for admission, active ongoing issues, the current pharmacotherapy plan, and issues that need follow-up. This communication should happen in a timely manner, no later than after rounds on the following day.
- Documentation of Patient Care Activities: Residents will maintain Pharmacy Plan notes and pharmacy sign-out notes for patients that they are following, which will include a summary of relevant daily events and issues for follow-up, per departmental procedure. Medication issues requiring a pharmacy note in the medical record (vancomycin or aminoglycoside consult, medication counseling, etc.) will be resolved by the resident. Residents will also be responsible for documenting adverse drug events (ADE) or other medication-related issues in the Patient Occurrence Reporting System (PORS) as appropriate.
- Drug Information: residents will respond to drug information requests from the interdisciplinary team, during and after rounds, using appropriate literature resources or knowledge base. For complicated questions, time may be required to complete a thorough literature search and follow-up should be completed after rounds or the following day. Emphasis will be placed on the ability to determine the actual need in the drug information request, and the ability to appropriately evaluate available literature to formulate a response. Residents will be expected to respond in a timely manner, taking into consideration the acuity and complexity of the request.
- Critical Care Pharmacotherapy Inservice: each month, residents are required to deliver one 30-minute in-service to the MICU house staff during a morning session. The topic will be chosen by the resident and can take a variety of forms .Common topics include sedation, vasopressor agents, neuromuscular blockade, toxicology, and antibiotics. A slide set or handout of some kind will be required. The preceptor will review the presentation for content and is responsible for providing feedback.
- Journal Club: residents will lead a journal club discussion on one recent and relevant article in the critical care literature. A handout is not required, but appropriate assessment of background literature and the methods of the study is expected.
- Co-precepting: if the opportunity is available, residents will also be involved in co-precepting of pharmacy students and/or PGY1 residents. This will include participation as a leader in patient discussion and topic discussion. Assistance with formal evaluation of PY4 students and PGY1 residents will be expected.
Hours of Rotation
Monday through Friday, 7AM-5PM
- Hours may vary slightly from day to day depending on rotational and off-rotation responsibilities
- Patient care rounds will occur daily from 8:45AM-Noon
- Time before rounds should be spent pre-rounding and identifying patient care issues to be addressed. Learners should plan to arrive to rotation with adequate time to prepare for patient care rounds and patient discussion.
- Generally preceptors will expect resident to run the list between 7:00-7:45 am to discuss any questions or concerns prior to rounds
- Activities after patient care rounds will vary from day to day but will include: patient discussion with preceptor, follow-up on patient care issues, and planned / unplanned rotation-related learning opportunities (i.e. topic discussion, small group POD lecture)
Required Meetings/Conferences Educational Activities
First Day Meeting
This meeting will be held on the first day of rotation or in week prior to rotation if desired , and will serve as an opportunity to:
- Review the syllabus
- Give an overview of the MICU and the rotation
- Establish preceptor and resident expectations
- Work on a calendar for the rotation
Weekly meeting with preceptor
Residents will meet with their preceptor once week (generally at the end of the week) to provide and receive feedback on the rotation and their performance
Wrap-up Meeting / Final Evaluation
To be held within 5 business days of completion of the rotation, this meeting will provide an opportunity to offer final feedback, both from the resident and preceptor perspective, and to complete the resident's final evaluation
Critical Care Conference (time to be determined)
A monthly multidisciplinary meeting aimed at continuing education of practitioners in critical care. Seminars will be presented by experts in a variety of specialty areas. Critical Care POD (Usually weekly on Tuesdays from 2-3pm)
Targeted at the PGY1 level, these sessions, led by one of the critical care preceptors or PGY2 critical care resident, is attended by PGY1/PGY2 and PY4 learners. Readings will be assigned ahead of time, and we will have an active discussion of common disease states and supportive care issues in critically ill patients. Topics will be selected by survey each month and will be scheduled prior to the start of rotation.
Case Conference (Mondays, 12-1)
Educational sessions taught by residents and students, focusing on core learning objectives of a pharmacy residency program. Attendance at case conference is required for PGY1 residents.
In-service Presentation (see Description of Rotation Activities)
Journal Club (see Description of Rotation Activities)
Topic Discussions (see Description of Rotation Activities)
End Goals of Rotation (by the end of the rotation, what should the learner be able to do?)
- Demonstrate in-depth knowledge of disease states and pharmacology commonly encountered in the Medicine ICU and in the supportive care of critically ill patients, including primary literature
- Formulate a daily patient problem list and present patients in a problem-oriented manner, highlighting each pharmacotherapy problem as well as differential diagnosis, drug therapy, monitoring parameters, and endpoints of therapy
- Develop a daily pharmacotherapy plan for each patient, including medication recommendations and necessary laboratory orders
- Collect and critically assess all clinically relevant data to facilitate monitoring and management of pharmacotherapy plan, as well as necessary interventions
- Perform therapeutic drug monitoring for critically ill patients for the following medications: aminoglycosides, vancomycin, phenytoin, digoxin, tacrolimus, cyclosporine, voriconazole, posaconazole, and others
- Document daily therapeutic plans, interventions, goals, and monitoring appropriately
- Communicate at an appropriate level with other healthcare professionals, including attending, fellows, and residents, interns, nurses, respiratory therapists, dietitians, and other pharmacy colleagues in order to optimize drug therapy
- Round with the medical team and make appropriate recommendations for monitoring and drug therapy with limited clinical oversight
- Effectively collect and analyze appropriate pharmacotherapy literature to respond to drug information requests from the medical team, patient, or family members
- Implement plans and document activities appropriately per departmental policy
- Function independently as the primary pharmacy presence for an ICU team
- When appropriate, participate in the clinical precepting of PY4 pharmacy students and PGY1 residents