Friday, August 31, 2012

Joint Commission International

In the United States, many hospitals and health organizations are accredited by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).  Depending on the state, accreditation may be required for licensure and other government reimbursement programs such as Medicaid in California.  NTUH is accredited by the Joint Commission International (JCI), a not-for-profit affiliate of the JCAHO established about 15 years ago.  Similar to U.S. hospitals., NTUH undergoes inspections by JCI every three years for accreditation.  The overall objective of these inspections is to assess their level of performance compared to healthcare organizations around the world and to ensure they are on par with a certain standard established internationally.  Additionally, these inspections push the hospital to find ways to continually improve their quality of care, medical ethics, patient safety, evidence-based medicine, and many other aspects.

During my time at NTUH, the hospital staff was in the process of preparing for the next upcoming inspection.  My UDD preceptor was on the hospital committee in charge of this preparation for JCI.  She said that NTUH is one of the only hospitals in Taiwan that is currently accredited by JCI.  Although it is not required for licensure as it is in California, NTUH wants to stay on the same level as the leading healthcare organizations in the world.  When I went to the floors with my pharmacist, she noted many operational details that could still be improved upon before the inspection ie leaving charts out in view of the public, hospital staff not sanitizing hands before and after entering patient rooms.  All of these inspections and accreditation processes, though grueling from a day to day standpoint, are the best way for health care organizations to continually improve their quality of care and increase their standards.  In the end, it all goes towards serving one population: the patient.

Wednesday, August 29, 2012

EMR Terminology

Chinese Pinyin English
處方 chǔ fāng prescription
急診 jí zhěn emergency
病人 bìng rén patient
過敏紀錄 guò mǐng jì lù allergies
身高 shēn gāo height
體重 tǐ zhòng weight
血壓 xiě yā blood pressure
住院醫師 zhù yuàn yī shī resident physician
主治醫師  zhǔ zhī yī shī attending physician
主訴 zhǔ sù chief complaint
病史 bìng shǐ history of present illness
身體檢查 shēn tǐ jiǎn chá physical exam
影像報告 yǐng xiàng bào gào imaging report
病理報告 bìng lǐng bào gào pathology report
抗生素 kàng shēng sù antibiotics
抗生素感受性報告 kàng shēng sù gǎn shòu bào gào antibiogram
洗腎 xǐ shèn dialysis
門診 mén zhěn outpatient
診斷 zhěn duàn diagnosis
檢驗報告 jiǎn yàn bào gào labs

Tuesday, August 28, 2012

Patient Presentation--Acute Pyelonephritis



At the end of my first week, my preceptor had me present a patient to her and the pharmacist assigned to the Family Medicine service.  The case a chose was among the patients I had been following throughout the week.  

ID: 55 year old female

CC: Fever x 6 days

HPI: 
Date
Note
Before 8/5
Patient visited outpatient clinic for lower abdominal pain and dysuria. She was given an oral antibiotic for a suspected UTI
8/5
Patient developed a subjective fever.
8/7
She went to the ER, WBC 18650 with left shift (Seg 91.2%), UA:  pyuria (WBC >100), sent home on cephalexin
8/9
She returned to the ER, WBC 11070 with left shift (Seg 89.7), UA: pyuria (WBC 20-35).  Renal ECHO revealed parenchymal renal disease.  Admitted for further evaluation and management.

PMH:
  
Hyperlipidemia

Medication List (8/15):
Acetaminophen 500 mg 1 Tablet PO q6h PRN
Cefuroxime Sodium 1500 mg IV q8h                  
NaCl 500 mL IF QD
Acyclovir Cream 5% 
Magnesium Oxide 250 mg 2 Tablets PO TID
Bisacodyl 10 mg 2 pills qod PRN
sennoside A+B calcium 12.5 mg 2 Tablets PO PRN

Allergies: NKDA

Physical Exam:
Unremarkable

VS:  BP: 126/76    T: 36.6     P: 68   RR: 19       Ht : 156cm   Wt : 67kg       BMI:27.5kg/m2

Labs:     WBC 8.18   RBC 4.92        Hgb 10.2         Hct 31.6      Plts 378           BUN 15.6     
SCr 0.7        AST 47            ALT 52            Na 137        K 5.0                LDL 115           
Tg 146         HDL 26           T. Chol 174     

Problem List:
1.     UTI
2.     Hyperlipidemia

1.  Acute pyelonephritis
S/O
Subjective
Dysuria and frequent urination for several days
Objective
1.      Febrile since 8/5
2.      Left CVA tenderness
3.      Leukocytosis (WBC 11070)+left shift (Seg: 89.7%)
4.      UA:  pyuria WBC 20-35, proteinuria (200), WBC esterase, bacteria (3+)
5.      Urine culture:  Enterococcus species, colony count 1000/ml
A
1.      Likely pathogens for pyelonephritis:  Escherichia coli (75 to 95 %), with occasional other species of Enterobacteriaceae, such as Proteus mirabilis and Klebsiella pneumoniae, and Staphylococcus saprophyticus.
2.     Women with pyelonephritis requiring hospitalization should be initially treated with IV antimicrobial therapy: 
·         Fluoroquinolone
·          aminoglycoside ±ampicillin
·         extended-spectrum cephalosporin or extended-spectrum penicillin ± aminoglycoside
·         carbapenem
Regimen should be based on local resistance data and susceptibility results.
-Cefuroxime 1500 mg IV q8h (8/11—)
3.      Antibiotics should be administered for at least 10 to 14 days.
4.      Standard definition of positive urine culture is ≥105CFU/ml together with pyuria.
5.      Though guidelines recommend the usage of extended-spectrum cephalosporins, given that the colony count is low and patient is clinically improving ie UA, the antimicrobial therapy is adequate.
P
Goal
·         Clear infection
·         Relieve dysuria, frequency of urination
·          Restore WBC to normal
·          Restore UA to normal

Monitoring
·       Urine analysis
·       Signs and symptoms of infection:  leukocytosis, fever
·       Side effects of medications
·       Renal function


2.  Hyperlipidemia
S/O
Subjective
Nil
Objective
8/11/2011:  LDL-C:  135
8/13/2012:
·        TG: 146
·        T-CHO:  174
·        LDL-C:  115
·        HDL-C:  26

A
·          Previously on Mevalotin 40 mg PO qHS
·          10-Year Risk by Total Framingham Point Score:  2%
·          ATP III LDL goal is <130 mg/dL
·          Initiation of treatment now is not necessary
P
Monitoring
·        Lipid panel

Goal
LDL-C<130 mg/dL

Case Discussion
At first, I felt the approach to the treatment of UTI's in Taiwan, and infections in general, was very similar to that of the U.S. However, as I looked at more patients and spoke with my preceptor, I found that the treatment strategies are actually different.  In the case of pyelonephritis, this patient would be classified as a complicated UTI and would require a broad spectrum cephalosporin ie at least a 3rd generation to treat the likely pathogens.  However, I've seen many cases similar to this where they have treated with 1st and 2nd generation cephalosporins.  My preceptor noted that the physicians are, for the most part, aware of the IDSA guidelines and recommendations, however they utilize it literally as a guideline and do not follow it as closely as the U.S. does.  In addition, I noticed many cases where antibiotic changes are made without any rhyme or reason, except that the patient spiked a fever.  The scenario is usually a patient spiking a fever while on an antibiotic regimen.  The antibiotic is switched to another class without regard for whether there was any additional microorganism coverage.  I feel that in the area of infectious diseases, pharmacists have many opportunities to make interventions.

Friday, August 24, 2012

Electronic Medical Record

I was surprised at how modern the electronic medical record system at NTUH was.  The computer system is similar to that of UC Davis Medical Center in many ways.  Just from briefly perusing the interface, it reminded me of the Epic system I used in my previous inpatient rotations.  Almost everything is online, including the labs, imaging results, HPI on admission, discharge summary, medication administration record, etc.  Day to day progress notes and nursing notes, however, are still handwritten. In order to follow a patient's hospital course, I had to travel to the nursing stations to look through patient binders, something that I had never done in my previous rotations.  Even though the progress notes were often times difficult to decipher, I realized that handwritten notes are much more concise and to the point.  At UCDMC, the pet peeve of many attending physicians is that progress notes are notoriously lengthy, with too much copying and pasting.  The benefit of making people hand write their notes is that it forces them to focus on the most prevalent points.

The medication administration process is also reminiscent of UCDMC: doctors order prescriptions online, the pharmacy fills it, it gets verified by a pharmacist, and the medications are sent to the wards on carts.  Dispensing, on the other hand, is quite different.  All oral medications are provided in unit-dose packages.  Liquid medications are bottled by an automated machine and parenteral medications are dispensed in their original packaging.  All pharmacy interventions are documented in the computer system.  I was unable to obtain permission to post a screenshot of the home screen, so I will do my best to describe it in words.  I mentioned in a previous post that reading Chinese characters would be a challenge for me.  Most of the links and tabs are in Chinese.  I took this as an opportunity to compile a list of medical terminology, which I will include in my next post.  The interface is split up into three sections.  The top 1/3 is the banner, where the patient information and the most current labs are displayed.  The middle 1/3 consists of tabs which serve as quick links to various reports including labs, cultures, pathology, imaging, discharge planning, MAR, diagnoses, inpatient medications, outpatient medications, etc.  The bottom 1/3 contains a list of the active medications the patient is on, along with both brand and generic name, dose, route, and schedule.  Under the generic name of certain medications, there is an icon, indicating that dose adjustment algorithms are available for that particular drug.  The algorithm can be viewed by simply clicking on the icon.  I found this to be a very helpful function.

My preceptor noted that NTUH is moving in the direction of acquiring a point of care dispensing system, similar to a Pyxis machine, to automate the dispensing process and allow pharmacists to focus more on the clinical aspect of their work.  In addition, there are plans to upgrade the software system to allow direct communication between pharmacy and the health care professionals on the wards.  Currently, even though doctors can place orders electronically, communication from pharmacy to the wards is strictly done by phone.
View from the UDD (10th floor of the new hospital building)

Wednesday, August 22, 2012

Monday Conference

Pharmacy Degree
In U.S., college students choose their undergraduate major and then decide along the way, or possibly even after finishing college, if they want to pursue a graduate degree.  In Taiwan, students who want to pursue a health professional degree ie medicine, dentistry, pharmacy, need to make that decision at the end of high school.  For medicine, instead of having 4 years of undergraduate studies and 4 years of medical school, it is all lumped into a 7-year program.  Pharmacy is a Bachelor's degree, and therefore, graduates can take the licensure exam right after completion of the 4-year program.  The graduates have the option of doing a Master's program for an additional 2 years, where there is a focus on clinical rotations.  At NTU, there is also a 6-year program (starting right after high school) which is the closest equivalent to the Pharm.D. program in the U.S.  It is currently the only one in the country. 

Informal Discussion
On Monday, 8/20, we were invited to attend what was referred to as an "Informal Discussion".  It was reminiscent of our Monday Conferences at UC Davis, where the students from their Master's program meet to go over patient cases.  The conference is faciliated by two faculty members from the school of pharmacy, one of which is a Pharm.D. graduate from Purdue who did 2 years of residency at the University of Michigan.  Every week, two students present patients and the facilitators ask questions or make teaching points out of the case discussions.  This conference started out with the previous week's presenters following up on questions they had to research.  The students for this week proceeded to present their cases.  Although the majority of the presentation was in Mandarin, many of the diagnoses and treatments were discussed using English terminology.  One thing I noticed about one of the patient cases, and in many other cases where patients have infections, is that they commonly switch antibiotics if the patient spikes a fever without having a target of therapy.  Although a switch in therapy may be warranted, in some cases, I've noticed the microorganism coverage of the new antibiotic is no better than the previous treatment.  It's something I will ask my preceptor about and look into more as I go through more patients.