Prior to the start of my 4th year rotations, also called Advanced Pharmacy Placement Experience (APPEs) at the University of Toronto (UofT), my schedule as a pharmacy student was extremely variable and inconsistent. On some days, I would have 6 hours of classes in a row, and on other days, I would have the entire day off. Each moment between classes was spent organizing notes and studying for the next exams, and I would also work at a pharmacy on the days that I had off.
However, when APPEs started on May 3rd, I was in for a big shock – little did I know how drastically my lifestyle would change. My first rotations started 3 days after my last final exam of third year and my lottery-assigned location was at Winchester District Memorial Hospital in Winchester, Ontario -- over 400 km away from my permanent place of residence. That, alone, was enough to make my head spin. In addition to the move, the hours of the pharmacy department within the hospital were 8:15 AM to 4:15 PM, Monday to Friday, so my body had to adjust from a university-induced night owl to an early bird. It was an abrupt adjustment – with the help of a few cups of coffee – as rounds started at 9 AM.
My clinical rotation day would resemble something like the following:
8:05 - 8:15 AM – Arrive at the hospital and perform COVID screening and a temperature check.
8:15 - 9:00 AM – Arrive at the in-patient pharmacy and check in with the preceptor. Begin familiarizing myself with patient profiles and examining the state of the patient.
9:00 - 9:45 AM – Sign into Zoom for socially distanced rounds, usually with about 10 people in attendance. Rounds are led by nurses, with input from physicians, occupational therapists (OTs), physiotherapists (PTs), and occasionally pharmacists. Updates on the patients are given, COVID-19 or MRSA swabs are evaluated, and next steps are discussed. At this time, the pharmacist may bring up items of concern such as inappropriate drug, dosing, and duration based on microbiology reports and other lab values, as well as therapeutic drug monitoring for medications like vancomycin and digoxin.
9:45 - 10:00 AM – Rounds end.
10:00 AM - 12:00 PM – If any clinical issues are spotted by the pharmacist but was not discussed in rounds, this will be brought up directly to the attending physician. Verbal orders are taken after discussion and decisions are made. The pharmacist then writes the order in the Physician’s Orders section of the patient’s chart. If an order is not required but a suggestion is to be made, a pharmacy note is made in the chart. These issues can sometimes take the entire morning or day to address, but other days, it can be very quick and can be resolved in a few minutes.
12:00 - 12:30 PM – Lunch break. Patients also have lunch at this time.
12:30 - 2:00 PM – Return back to the pharmacy to check the physician’s medication orders. Orders are faxed down to the pharmacy from multiple departments (as this is a small hospital), including obstetrics, medicine/surgery, ECU, and complex continuing care. These orders are either filled by the pharmacy technicians or are available from the automated dispensing cabinet (ADC) on the floor and are taken out from the "ward stock" when needed. The pharmacist is responsible for checking both the physical medications filled as well as the ward stock entered on the patient’s profile, and must reconcile any differences or therapeutic issues with the doctor.
2:00 - 3:15 PM – Another task for the clinical pharmacist is to check the admit and discharge care plans, which determine which medications the patient will be receiving upon admission and discharge. A Medication Reconciliation sheet is used to compare what was ordered with what the patient was taking at home, and differences between the lists are to be discussed and resolved with the physician.