Therapeutics in various pharmacy settings

Primary care

• non-emergency

• general, mid-level practioners

• first point of contact

• outpatient

Secondary care

• specialists

• refferred from PCP

Tertiary care

• hospital

• advanced/complex equipment

• highly specialized medical professionals

Quaternary care

• extremely specialized care

• patient transport to quaternary care facilities

Inpatient settings

• acute care (ED, hospital)

• Long-term care (SNF, LTAC)

• hospice

Outpatient setting

• community (neighborhood pharmacy)

• ambulatory (clinic, urgent care)

• hospice

Outpatient characteristics

• treat over time

• prevent disease progression, long-term management

• chronic conditions

• longer time between follow up

Inpatient characteristics

• treat acute illness and discharge

• short-term treatment

• monitoring/follow up based on acuity

Community conditions managed

• drug interactions

• immunizations

• OTC conditions

• some chronic conditions

Ambulatory conditions managed

chronic conditions

Low acuity hospital conditions

• stablization

• preparation for discharge

• BG management

• anticoagulation

• infection management

High acuity hospital conditions

• acute conditions

• sepsis/infection

• hemodynamic instability

• cardiac arrest

• surgery

• trauma

5 rights of patients in hospital

• number of staff

• skill level

• place

• time

• assignment

ED level of care

• evaluate, manage, treat unexpected injuries/illnesses

• safety net for those who lack access

Observation level of care

• clinical decision/short-stay

• diagnose, treat, and monitor 6-24 hours

Floor/Ward level of care

• stable, lower intensity but cannot be managed outpt

• intermittent monitoring

Step down level of care

• higher level than ward

• lower level than ICU

ICU level of care

• highest level

• enhanced monitoring capabilites

• multiple modailties for physiologic organ support

Hemodynamic instability

• medical emergency

• abnormally low or unstable BP → inadequate perfusion of organs

• S/Sx: confusion/AMS, loss of consciousness, BP drop, SOB, chest pain, restlessness, cold extremities

• Tx: fix underlying problems

IV compatibility resources

• Trissel’s IV compatibility tool

• King GUide

• Micromedex

• ASHP injectable drug info book

Community Documentation

• problem specific

• brief

• focused

• may not have monitoring/follow-up

Ambulatory documentation

• comprehensive or problem specific

• brief or extensive

• monitoring based on protocol

• follow up weeks/months

Low acuity hospital documentation

• problem specific

• brief

• focused

• monitoring based on protocol or physician

• daily follow up

High acuity hospital documentation

• comprehensive or problem specific

• brief or extensive

• focused or comprehensive

• monitoring based on protocol or physician

• hourly/daily follow up