Section 26.2: Full-Scale Case Simulation and CPA Implementation

26.2.1 The “Why”: The Crucible of Practice

You have reviewed the blueprints. Now it is time to build the house. This section is designed to be the ultimate test of your integrated knowledge—a full-scale, dynamic simulation that takes you from the chaos of the Emergency Department to the nuanced management of a longitudinal clinic visit. You will follow a single, complex patient, Mr. Frank Harrison, as he traverses the healthcare system. This is not a series of discrete, academic questions. It is a flowing narrative designed to replicate the pressures, challenges, and triumphs of real-world collaborative practice.

The purpose of this simulation is threefold. First, it will force you to apply your clinical knowledge not in isolated silos, but as an interconnected web. You will see firsthand how a decision about sepsis management in the ICU directly impacts the titration of heart failure medications in your clinic weeks later. Second, it will move you beyond simply making recommendations to taking ownership of the therapeutic plan through the implementation of a Collaborative Practice Agreement. You will be asked to write orders, draft progress notes, and communicate with the team as a privileged provider. Finally, this simulation will serve as a crucible, forging your confidence and competence, ensuring you are not just certified, but truly prepared for the responsibilities and rewards of this advanced practice role.

Part I: The Acute Crisis – ED Arrival and ICU Admission

The simulation begins at the most chaotic and vulnerable point of entry into the hospital: the Emergency Department.

26.2.2 Patient Presentation & Initial Workup

Case Introduction: Mr. Frank Harrison

Emergency Department Triage Note (Time: 08:00)

Initial Labs & Imaging Results (Time: 08:45)

Chest X-Ray: Large right lower lobe infiltrate, consistent with pneumonia. Bilateral vascular congestion and pleural effusions noted.

ED Physician’s Initial Assessment & Orders (Time: 09:00)

26.2.3 Masterclass Response: ED Intervention Strategy

An experienced CCPP would immediately recognize several critical issues that require urgent intervention. The approach must be rapid, logical, and communicated effectively. Here is the breakdown of the thought process and action plan.

Problem #1: Inadequate Empiric Antibiotic Coverage

The Issue: Levofloxacin monotherapy is an inappropriate choice for a septic patient with CAP requiring ICU admission. While it covers typical and atypical pathogens, regional resistance rates for Strep. pneumoniae to fluoroquinolones can be high. More importantly, it does not provide any coverage for Pseudomonas, which is a risk factor in patients with underlying structural lung disease (often comorbid with HF) or from healthcare settings. For a patient this sick, broader coverage is essential.

The Solution: Switch to guideline-recommended, broad-spectrum therapy. The patient has a non-anaphylactic penicillin allergy (rash), so cephalosporins are safe. The ideal regimen is an anti-pseudomonal beta-lactam plus atypical coverage.

• Primary Recommendation: Cefepime + Azithromycin. This covers Strep pneumo, H. flu, atypicals, and Pseudomonas.
• Risk Factor Assessment: Does he need MRSA coverage? He is coming from home, but his multiple comorbidities and recent healthcare exposures could be a risk factor. Given the severity of his illness (septic shock), adding empiric Vancomycin is the safest approach and is consistent with institutional protocols.

Problem #2: Critical Dosing Errors due to AKI

The Issue: The patient has severe AKI on top of his CKD. His creatinine has nearly doubled, and his calculated CrCl is now acutely much lower. $$ \text{CrCl (Cockcroft-Gault)} = \frac{(140 – \text{Age}) \times \text{Weight (kg)}}{(72 \times \text{SCr})} \times 0.85 \text{ (if female)} $$ $$ \text{CrCl} = \frac{(140 – 72) \times 85}{(72 \times 3.1)} = \frac{5780}{223.2} \approx 25.9 \text{ mL/\min} $$ The ordered dose of Levofloxacin 750 mg daily is incorrect for this level of renal function; it should be 750 mg x1, then 750 mg every 48 hours. More importantly, the new recommended regimen (Cefepime + Vancomycin) requires significant dose adjustment.

The Solution:

• Cefepime: The standard dose is 2g Q8H. For a CrCl of 25.9 mL/min, the correct dose is 2g Q24H. To optimize PK/PD in this critically ill patient, you should recommend a prolonged infusion of this dose (e.g., infused over 4 hours).
• Vancomycin: A loading dose is essential in sepsis to rapidly achieve therapeutic concentrations. A load of 25-30 mg/kg (actual body weight) is recommended. For this 85 kg patient, this is approximately 2125-2550 mg. You would recommend a 2250 mg loading dose. A maintenance dose would be calculated later based on levels.

Problem #3: Supratherapeutic INR and Acute Bleed Risk

The Issue: The patient has an INR of 3.8. Sepsis itself can cause coagulopathy and thrombocytopenia, increasing bleed risk. He is about to undergo potential procedures in the ICU (e.g., central line placement). Active anticoagulation is dangerous.

The Solution: The warfarin must be held. The INR needs to be corrected. While there is no active, life-threatening bleed, the high INR in this critically ill patient warrants reversal.

• Recommendation: Administer Vitamin K 5 mg IVPB. An oral dose would be too slow and absorption is unreliable. Kcentra (4F-PCC) is not indicated as there is no major hemorrhage.

Problem #4: Unsafe Management of Hyperkalemia and Decompensated HF

The Issue: The patient is hyperkalemic (5.6 mEq/L) in the setting of severe AKI. His home medications include an ARNI (sacubitril/valsartan) and an MRA (spironolactone), both of which cause hyperkalemia. Furthermore, he is in acute decompensated heart failure and is hypotensive. His beta-blocker (metoprolol succinate) and ARNI are contraindicated in this state.

The Solution: While the order to “Hold all home medications” is generally correct, you must ensure this is done with specific intent.

• Confirm Holds: Specifically confirm with the team that the sacubitril/valsartan, spironolactone, and metoprolol are being held due to AKI, hyperkalemia, and hypotension. This ensures these are not accidentally restarted.
• Rate Control Choice: The choice of a diltiazem drip for rate control is reasonable for AFib RVR. However, as a non-dihydropyridine calcium channel blocker, it has negative inotropic effects and can worsen hypotension in a patient with HFrEF and septic shock. An alternative like amiodarone might be safer from a hemodynamic standpoint, though diltiazem is often tried first. Your role is to monitor the blood pressure response closely after the drip is initiated.

Problem #5: Fluid Management in Sepsis vs. Heart Failure

The Issue: This is a classic clinical dilemma. The sepsis protocol demands a large-volume fluid bolus (30 mL/kg = ~2.5 Liters) to restore intravascular volume and perfusion. However, the patient is in a florid heart failure exacerbation with pulmonary edema. A large fluid bolus could worsen his respiratory status significantly.

The Solution: There is no easy answer here, but the immediate threat to life is the distributive shock from sepsis. The hypoperfusion must be treated. The standard of care is to give the fluid, but with extreme caution and preparedness to escalate respiratory support.

• Your Role: You must support the decision to give the fluid bolus as it is guideline-directed for sepsis, but your role is to be the voice of caution and anticipation. You should communicate: “I agree with the fluid bolus for his septic shock. Given his severe CHF, we need to monitor his respiratory status very closely during the infusion and be prepared for a potential increase in oxygen requirements or the need for earlier intubation. We should also be ready to start vasopressors (norepinephrine) immediately if he remains hypotensive after the initial portion of the bolus.” This demonstrates a systems-level understanding of competing pathologies.

Part II: The ICU Course – Stabilization and Complications

Mr. Harrison is admitted to the ICU. Your recommendations are accepted and implemented. Despite the fluid bolus and antibiotics, his blood pressure remains low, and his respiratory status worsens. He is intubated for hypoxic respiratory failure.

ICU Progress Note – Hospital Day 1 (Time: 16:00)

Masterclass Response: ICU Optimization Strategy

The CCPP’s role in the ICU is proactive, not reactive. You must anticipate the next steps in the resuscitation and supportive care cascade.

Recommendation #1: Add Second-Line Vasopressor & Stress-Dose Steroids

The Rationale: The patient meets the definition of refractory shock (requiring >0.25 mcg/kg/min of norepinephrine is a common trigger, and he is approaching that). Guideline-directed care calls for two interventions:

• Add Vasopressin: This will work synergistically with norepinephrine via a different mechanism (V1 agonism) and may be catecholamine-sparing. The dose is fixed and not titrated.
• Add Stress-Dose Steroids: To address potential relative adrenal insufficiency.

The Order Recommendation: “I recommend we start a Vasopressin drip at 0.03 units/minute and administer Hydrocortisone 50 mg IV every 6 hours.”

Recommendation #2: Optimize Sedation to Improve Hemodynamics

The Rationale: Propofol is an excellent sedative but is a potent vasodilator and negative inotrope. In a patient with septic shock and cardiogenic shock from HFrEF, it is actively contributing to his hypotension and high vasopressor needs. A switch to a more hemodynamically neutral agent is warranted.

The Order Recommendation: “The propofol is likely worsening his shock state. I recommend we stop the propofol and switch to Dexmedetomidine. We can start the drip at 0.7 mcg/kg/hr and titrate to a RASS goal of -2 to -3. This should allow us to wean his norepinephrine.”

Recommendation #3: Aggressively Manage Hyperkalemia

The Rationale: A potassium of 5.8 mEq/L with worsening AKI is a medical emergency that can lead to fatal arrhythmias. He needs immediate treatment.

The Order Recommendation: “For his critical hyperkalemia, I recommend the following STAT orders: 1 gram Calcium Gluconate IV to stabilize the cardiac membrane, 10 units Regular Insulin IV with 25 grams of D50W to shift potassium intracellularly, and 10 mg of Albuterol nebulized.”

Recommendation #4: Plan for VTE and Stress Ulcer Prophylaxis

The Rationale: The patient is critically ill and immobile, placing him at very high risk for a deep vein thrombosis (DVT). He is also intubated, a primary indication for stress ulcer prophylaxis (SUP).

The Order Recommendation: “His platelets are still low at 120 and he has a coagulopathy from sepsis, so I think pharmacologic VTE prophylaxis should be held for now. I recommend we place sequential compression devices (SCDs) bilaterally. For SUP, let’s start Pantoprazole 40 mg IV daily.”

Part III: The Transition – Medical Floor to Discharge

Over the next 5 days, Mr. Harrison improves dramatically. He is extubated, his pressors are weaned off, and he is transferred to the medical floor. His creatinine has improved to 2.2 mg/dL. Urine and blood cultures grew E. coli, sensitive to Cefepime.

Masterclass Response: Transitions of Care Plan

Action #1: Antimicrobial De-escalation (Stewardship)

The Rationale: The patient has a clear pathogen with known sensitivities. Continuing triple-antibiotic therapy is unnecessary, costly, and drives resistance.

The Recommendation: “Based on culture results showing Cefepime-sensitive E. coli, I recommend we discontinue the Vancomycin and Azithromycin. We should complete a total 7-day course of Cefepime for his complicated UTI/urosepsis. His last day of therapy will be [Date].”

Action #2: Cautious Re-initiation of Guideline-Directed Medical Therapy (HFrEF)

The Rationale: The patient survived his acute illness, but now he is at high risk for rehospitalization if his chronic HFrEF is not re-optimized. However, restarting his full home regimen is dangerous given his recent hemodynamic instability and kidney injury.

The Recommendation (a step-wise approach):

1. Beta-Blocker: “His blood pressure and heart rate are now stable. Let’s restart his Metoprolol Succinate, but at a lower dose. I recommend 50 mg daily. We will monitor for bradycardia and hypotension and titrate up as tolerated.”
2. ARNI: “His SCr is still elevated at 2.2. Restarting his sacubitril/valsartan now carries a high risk of worsening his AKI and causing hyperkalemia. I recommend we continue to hold the ARNI for now. We will re-evaluate in the pharmacist-led clinic post-discharge.”
3. MRA & SGLT2i: “For the same reason, his spironolactone must remain held. However, SGLT2 inhibitors like empagliflozin have shown renal-protective benefits. Given his stable K+ and BP, I recommend we restart the Empagliflozin 10 mg daily.”

Action #3: Modernize and Plan for Long-Term Anticoagulation

The Rationale: The patient was on warfarin, which is difficult to manage post-hospitalization due to fluctuating nutrition, antibiotics, and acute illness. This is an ideal opportunity to transition to a safer, more effective DOAC. Apixaban is preferred in patients with renal impairment.

The Recommendation:

• The Switch: “Given the difficulty of managing his INR after this critical illness, I recommend we switch his anticoagulation from warfarin to apixaban for his atrial fibrillation.”
• Dosing: “To dose apixaban, we need to apply the 2 of 3 rule: Age ≥80, Weight ≤60kg, SCr ≥1.5. He meets one criteria (SCr). Therefore, the standard dose is appropriate. I recommend Apixaban 5 mg PO BID. We should plan to start this on his last day of Cefepime therapy.”
• Discharge Planning: “I will complete the prior authorization for the apixaban and provide extensive counseling to the patient and his daughter on the importance of adherence and the differences from warfarin.”

Action #4: Create a Cohesive Discharge Plan

The final step is to synthesize all of this into a clear, safe, and actionable plan for the patient, who will be discharging to a Skilled Nursing Facility (SNF) for rehab.

Part IV: CPA Implementation in the Ambulatory Clinic

Two weeks after discharge, Mr. Harrison presents to your pharmacist-led Cardiovascular Risk Reduction Clinic for his follow-up appointment. You operate under a comprehensive CPA with the cardiology service. This is the official document that grants you the authority to perform the following actions.

Masterclass Response: The Pharmacist-Led Clinic Visit

This is the culmination of your training, where you function as an autonomous provider managing complex chronic disease.

The Patient Interview & Assessment

The Pharmacist’s SOAP Note & CPA Implementation