On June 30, 2004, the Conference Center at The Brooklyn Hospital Center was full of mostly energetic, and perhaps slightly apprehensive, new residents. Amongst this group were a few select pharmacists. It was unveiled that these pharmacists were the inaugural class of Pharmacy Practice Residents. These pharmacists are participating in an organized, directed, postgraduate training in a defined area of pharmacy practice. Training focuses on sharpening the judgment necessary for competence in the provision of direct patient care. The program lasts for one year and may be followed by specialty residencies, fellowships, or entrez into a multitude of career opportunities. While residency training is optional for pharmacists, the current nationwide standard for hospital pharmacy practice involves residency training.
At the end of the first year of this program, the American Society of Health-System Pharmacists (ASHP) will survey the program for accreditation. These accreditation standards require that pharmacy practice residents become competent in patient care. Residents must gain exposure to and participate in an effective and safe medication-use process. Such exposure is deemed a service commitment by ASHP. To be effective, service commitments should be met in an integrated and systematic manner. Residents must be responsible for caring for a wide variety of patients and developing drug information skills.
Service commitments are often met in the form of rotations or blocks devoted to a practice area or patient population. Some residency programs may meet this requirement through longitudinal patient care experiences. At The Brooklyn Hospital Center, the Pharmacy Practice Residents have a mixed experience of traditional rotations and longitudinal experiences. Each resident spends two months working with the Internal Medicine service, one month each of the adult critical care areas, one month in the Emergency Department, one month with the Infectious Disease service, one month working on safe medication practices and policies. Additional months are devoted to electives in Cardiology, Nutrition, Drug Information, or other areas of individual interest. Each resident also devotes one afternoon per week to a longitudinal ambulatory care experience. Currently, they are involved in an Anticoagulation Clinic, Asthma Center , HIV Adherence Clinic. A Cardiovascular Risk Reduction Clinic (smoking cessation and dyslipidemia management) is also underway. Each of these clinics function under what is known as "collaborative drug therapy management" and involves having a patient's disease state managed by a pharmacist under a physician's supervision through the use of a established protocols.
Pharmacy Practice Residency programs are not new. Such programs have been in existence for over twenty-five years. Currently there are almost 400 programs nationwide. Nineteen programs exist in New York State ; ten in the New York City area. Most programs recruit anywhere from one to six or more residents. With five residents, the Brooklyn Hospital program is the second largest in New York State . Most of the larger programs include "specialty residents"; currently this is not the case here.
The overall goal of the residency program is to help promote the concept of pharmaceutical care within the hospital. Pharmaceutical Care is a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient's other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective. The goal of Pharmaceutical Care is to optimize the patient's health-related quality of life, and achieve positive clinical outcomes, within realistic economic expenditures.
The motto of this dynamic Pharmacy Practice Residency Program is "The Remedy is Experience" . To gain this experience, each resident works under the supervision of Drs. DiGregorio, Berrios-Colon, and Nogid, in conjunction with the Hospital's attending and house-staff physicians. Under the affiliation agreement with Long Island University , the residents also work with pharmacy students in the hospital and also have teaching responsibilities on campus.
One of the advantages of deploying five residents has been the ability of the Department of Pharmacy's Division of Pharmacotherapy Services to extend its clinical services around the clock through a Pharmacotherapy Resident-On-Call program. The residency on-call program was designed to offer a supportive environment in which the resident is held accountable for pursuing optimal outcomes of drug therapy. The program provides opportunities for the resident to engage in independent decision-making, care for a wide variety of patients, and manage acute illness. Extensive support and performance assessment are provided by preceptors.
Both patients and residents stand to benefit from the on-call program. Services are available overnight, on weekends, and on holidays. The responsibilities of the on-call resident encompass those of a pharmacist caring for individual patients. During late evenings, nights, weekends, and holidays, the primary pharmacist or the clinical pharmacokinetics service may not be available to assess and respond to supratherapeutic serum drug concentrations. The on-call resident is then assigned to provide such services. While all pharmacists provide drug information, detailed consultation is sometimes necessary. Such consultation is provided by the resident and includes recommending drug therapy, assessing adverse drug events, recommending specific drug administration techniques (e.g., electrolyte infusion), screening for drug interactions, recommending treatment for drug toxicity or poisonings, and identifying solid oral dosage forms. The resident is exposed to emergency patient management primarily through direct participation in adult and pediatric resuscitation efforts.
It may be impractical for an institution to have clinical pharmacists available 24 hours a day, but having an on-call resident monitor selected patients (e.g., those expected to become more ill or others requiring particularly close attention) can extend a pharmacy department's ability to provide intensive care consistently. This model resembles the medical house-staff cross-cover model. Before leaving for the day, the primary pharmacist may inform the on-call resident of anticipated serum drug concentrations, as well as pending results of cultures and other laboratory tests that may require close monitoring. The resident provides the requested service during the on-call shift and, on the following day, informs the primary pharmacist about changes in the patient's condition and any interventions. This contributes to a continuity of high-level care.
Each pharmacy resident participates in the on-call program regardless of the focus of his or her residency. On-call services are provided in single 24-hour shifts beginning at 8:00 AM each day. The on-call resident remains in the institution overnight and carries additional pagers, each devoted to a defined role or on-call activity. All pharmacy residents have 24-hour access to drug information, resources. They are expected to contact a pharmacist (preceptor) should they need advice.
All pharmacy residents are considered house-staff officers and receive many of the same benefits as their medical resident colleagues. Pharmacy residents are provided an assigned on-call room in the house-staff on-call area, a cafeteria stipend for each on-call shift, and appropriate attire (e.g., scrubs). During the initial orientation sessions, residents are introduced to departmental and drug policies and attend sessions on pharmacokinetic monitoring principles and policies for all drugs assessed by the therapeutic drug monitoring laboratory. To increase the resident's comfort with emergencies, there are meetings devoted to cardiopulmonary resuscitation, including simulations requiring the provision of medication from an emergency drug cart. Pediatric emergencies are also reviewed. Residents also complete the examination for adult cardiac life support (ACLS). Upon certification as an ACLS provider, the resident is eligible to begin on-call shifts.
In addition to these patient care activities, each Resident also participates in a variety of projects designed to improve the overall level of care provided by the Department of Pharmacy Services. Examples of these projects include: pharmacoeconomic analyses of new medications that are proposed for use in the hospital, implementation of safety measures to prevent medication errors, development of emergency preparedness plans for the provision of medications during a crisis, development of a system to promote the use of oral medications in place of injectable medications, obtaining thorough medication histories on patients as they are admitted to the hospital, providing medication information to patients upon discharge from the hospital, and a variety of research projects, to name a few. Not only do these activities enhance the care of our patients, but many of these "best practices" have been associated nationwide with an overall cost-savings for health-care institutions. On average, it has been reported that hospitals that provide this level of pharmacy service are able to lower their drug costs by over $3700.00 per occupied bed per year.
The residency program is administered jointly through the Department of Pharmacy's Division of Pharmacotherapy Services and Long Island University 's Arnold and Marie Schwartz College of Pharmacy. The program is under the direction of Robert V. DiGregorio, Pharm.D., Director of Pharmacotherapy who is also a full-time faculty member from the neighboring Arnold & Marie Schwartz College of Pharmacy. Working with Dr. DiGregorio are Evangelina Berrios-Colon , Pharm.D. and Boris Nogid, Pharm.D., Clinical Coordinators for Ambulatory Care Pharmacotherapy and Inpatient Pharmacotherapy, respectively. Both Clinical Coordinators are graduates of Long Island University and graduates of nationally accredited residency programs. This team of pharmacotherapists have implemented such services as: an anticoagulation clinic; asthma center; automatic substitution of certain medications for more cost-effective drug therapy; clinical monitoring of critical care, internal medicine and infectious diseases patients.
This year's residency class includes Drs. Shaffee Bacchus, Mijiro Okobiah, Veronica Oviedo, Padma Sivaraju, and Sara Dedeyan.
Questions or requests for more information on pharmacotherapy services or the Pharmacy Practice Residency Program should be directed to Dr. Robert DiGregorio at (718) 250-8182.