Morning Rounds with a Clinical Pharmacist

The next patient is a teenager with acute encephalopathy, a neurological condition. She is one of the PICU’s more acutely ill patients. She is intubated and on multiple medications—including anti-seizure medication, anti-coagulants, insulin, corticosteroids, an antibiotic and pain medication. She is also undergoing plasmapheresis, a process that filters the blood and removes harmful antibodies, similar to dialysis. This is going to be a long stop on the morning’s rounds.

As the team begins to discuss the patient’s care, Katy keeps an eye on the order verification queue in EPIC for medication orders coming in from other clinicians. Because some of the PICU patients are so acutely ill, she needs to verify orders minute by minute so the medications can be dispensed in a timely fashion.

Katy and the attending physician, Robert Parker, DO, discuss the compatibility of the medications the patient is receiving through her IV. Some medications can be combined into one IV line; others must be kept separate. This patient’s pain medication and insulin both need to run individually. Timing the administration of different medications can be a delicate needle for Katy and the care team to thread.

Katy responds to a message via Voalte (a HIPAA-compliant texting app) from Central Pharmacy about the albumin this patient will need later. Then the team’s discussion turns to managing the multiple medications the patient is receiving. She’s been on a high dose of steroids, which causes hypertension, and the morphine she’s on for sedation causes constipation. The hypertension and constipation both need to be treated. In addition, the corticosteroids can increase infection risk, leading to a discussion between Katy and Dr. Parker about the appropriate timing of the antibiotics.

A pharmacy technician rolls by with a supply cart. Katy grabs the 10 bottles of albumin that the dialysis nurse will need later for the plasmapheresis and puts them in the patient’s room. There’s another discussion of the Tylenol the patient has been receiving. It’s decided that the dosing can go from a timed schedule to an as-needed basis.

As the team begins to move down the hall to the next round, a medication order for this patient comes into the EPIC system on Katy’s computer. She lingers behind to review it. Because the drug—vancomycin, an antibiotic—is nephrotoxic (meaning it carries the risk of injury to the kidneys), she has to run a quick calculation on the patient’s kidney function before verifying the order. Once verified, the medication is made in the Central Pharmacy’s sterile IV room, to be dispensed.

The next patient is a teenaged boy with an intracranial bleed. Though the cause of the bleed is still unknown, the patient is awake and alert. Dr. Parker asks the residents to calculate how much hypertonic saline the patient needs to be given. Hypertonic saline is a crystalloid intravenous fluid used to reduce intracranial pressure. Dosage depends on a patient’s age, weight and clinical condition. Katy also uses this teaching moment to discuss the use of hypertonic saline versus mannitol, a diuretic medication that can also be used to reduce swelling.

The team moves on to another patient, a 6-day-old baby. At 37 weeks post-menstrual age, he is still not considered full-term. He was admitted to one of the hospital’s medical-surgical floors, and transferred to the PICU yesterday when his body temperature began to drop. Katy notes that it’s not unusual for a premature baby to have trouble regulating their temperature, but hypothermia can also be a sign of infection. Baby C is receiving fluids and sucrose, which acts as an analgesic in small children. With neonates (babies under 3 months of age), extra attention must be paid to their weight to make sure dosing is appropriate. Nutrition dosage must also be exact, because the babies are at a critical time for growth.

Rounds are done, but Katy will stay on the PICU floor. First, she’ll conduct a thorough review of all 10 patients in the unit. Several are post-op cardiac patients. Afterward, she’ll spend the rest of the day doing consults with providers and answering questions, as needed. Getting to know patients and families, many of whom have lengthy stays in the PICU, is one of her favorite things about her job.

With their meticulous attention to detail, Connecticut Children’s clinical pharmacists and pharmacy technicians are on the front lines of patient safety 24/7. They advise physicians and nurses on medication dosing and timing, go on daily rounds to monitor patients in real time, compound medications, help prepare patients and families for discharge, and double-check every order for every medication—from Tylenol to chemotherapy.