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MODULE 22: THE HOSPITAL ECOSYSTEM
Section 2.1: The Medical-Surgical (“Med-Surg”) Floor
This is your new home base. Discover how your deep knowledge of chronic disease management is the perfect foundation for excelling on the hospital’s busiest and most fundamental clinical unit.
SECTION 2.1
The Medical-Surgical (“Med-Surg”) Floor: The General Population
The versatile backbone of inpatient care.
2.1.1 The “Why”: The Versatile Backbone of Inpatient Care
If the hospital is a city, the Medical-Surgical (Med-Surg) unit is its sprawling, bustling downtown. It is the default destination for a vast and diverse array of patients. It’s where individuals recover from common surgeries like appendectomies and hip replacements, where they receive IV antibiotics for serious infections like pneumonia and cellulitis, and where they are stabilized during acute flare-ups of the chronic diseases you manage every single day: heart failure, COPD, diabetes, and hypertension. The Med-Surg floor is the operational center of gravity for the entire hospital.
This should be incredibly encouraging to you. The clinical scenarios you will encounter on a Med-Surg floor are not esoteric or exotic; they are the very same disease states you have mastered in the community setting. The difference is a matter of acuity and urgency. You are seeing the same patient with heart failure, but instead of managing their stable diuretic dose, you are now managing their acute fluid overload with IV furosemide. You are seeing the same patient with diabetes, but instead of counseling on A1c goals, you are managing a sliding scale insulin regimen for acute hyperglycemia. Your foundational knowledge is not just relevant—it is the bedrock upon which your hospital practice will be built. You are not starting over; you are leveling up.
Retail Pharmacist Analogy: From Chronic Disease Manager to Acute Crisis Stabilizer
Think of your current role as a trusted primary care provider of pharmacy. You are a Chronic Disease Manager. You build long-term relationships, monitor trends over months and years, and focus on adherence, preventative care, and maintaining stability. You are an expert in the marathon.
The Med-Surg pharmacist role is that of an Acute Crisis Stabilizer. You see the same patients, but at a moment when their chronic marathon has hit a wall. Their stable condition has become unstable, and they need immediate, targeted intervention. You are an expert in the sprint. Your focus is on rapid assessment, intensive short-term therapy (often IV), and constant monitoring to regain control. Your goal is to manage the acute crisis with such proficiency that the patient can be safely discharged back to the care of their trusted long-term pharmacy manager—you, in your community role.
Translating Your Expertise: Retail vs. Med-Surg Perspectives
This table illustrates how your existing knowledge directly maps to the Med-Surg environment. You already know the “what” and the “why” of the drugs; now you will master the “how” in an acute setting.
| Disease State | Your Core Role in Retail Pharmacy | The Acute Problem on the Med-Surg Floor | Your New, Leveled-Up Role in Hospital |
|---|---|---|---|
| Heart Failure (HF) | Counseling on diuretic adherence, monitoring for electrolyte changes from spironolactone, ensuring ACEi/ARB therapy is optimized for long-term mortality benefit. | Acute Decompensated Heart Failure (ADHF): The patient is “wet,” with fluid overload causing severe shortness of breath. | Recommending and monitoring aggressive IV diuretic therapy (e.g., furosemide IV drips), calculating “net fluid loss,” and ensuring safe transition back to a stable oral regimen. |
| Diabetes Mellitus (Type 2) | Counseling on A1c goals, explaining the mechanism of metformin and GLP-1 agonists, teaching proper insulin pen technique for long-acting insulin. | Stress Hyperglycemia: An infection or surgery has caused the patient’s blood glucose to skyrocket to 300-400 mg/dL. | Managing subcutaneous sliding scale insulin (SSI), recommending basal/bolus regimens, and being the expert on transitioning a patient off an insulin drip back to their home regimen. |
| COPD | Ensuring patients have their rescue and maintenance inhalers, counseling on proper inhaler technique, and recommending annual vaccinations. | Acute Exacerbation of COPD (AECOPD): The patient has a viral or bacterial trigger causing severe inflammation, bronchospasm, and respiratory distress. | Ensuring timely administration of scheduled IV/PO corticosteroids (e.g., methylprednisolone) and scheduled nebulized bronchodilators. Screening for antibiotic appropriateness. |
| Atrial Fibrillation (AFib) | Dispensing DOACs or warfarin, counseling on bleeding risk, managing INR results, and checking for drug interactions (e.g., with amiodarone). | AFib with Rapid Ventricular Response (RVR): The patient’s heart rate is sustained >100-120 bpm, causing palpitations and hemodynamic instability. | Recommending IV rate control agents (metoprolol, diltiazem) to bring the heart rate under control. Ensuring anticoagulation is appropriately started or resumed to prevent stroke. |
2.1.2 The Pharmacist’s Role: Master of Core Interventions
On the Med-Surg floor, you are not a passive order verifier. You are an active clinical interventionist. Your day is a continuous cycle of screening patients, identifying opportunities, and communicating recommendations to the medical team. While the variety of patients is vast, your most frequent and highest-impact contributions will revolve around three core competencies: IV-to-PO conversions, pain management transitions, and anticoagulation management. Mastering these three skills will make you an indispensable member of the Med-Surg team.
Masterclass: IV-to-PO Conversions
The pharmacist-driven conversion of intravenous (IV) to oral (PO) medication is one of the single most impactful interventions in hospital pharmacy. It is a win-win-win: it reduces the risk of line-related infections for the patient, it lowers drug acquisition and administration costs for the hospital, and it increases patient mobility and comfort, expediting their discharge. You, as the medication expert, are uniquely positioned to lead this initiative.
Criteria for a Safe Switch: The “Big Four”
Before recommending a switch, you must mentally check these boxes. Can the patient…?
- Tolerate PO intake? The patient must be able to eat and drink without significant nausea or vomiting. The GI tract must be functional.
- Absorb medication? Is there any reason to suspect malabsorption (e.g., short gut syndrome, ileus, severe pancreatitis)?
- Show clinical improvement? The patient should be trending in the right direction. For an infection, this means fevers are resolving and white blood cell count is decreasing.
- Have a suitable oral alternative? Is there an oral formulation of the same drug, or a different drug with a similar spectrum of activity, that has excellent bioavailability?
The High-Bioavailability All-Stars: Your Go-To Conversion Chart
These drugs are your bread and butter. Their oral absorption is so reliable (>90%) that the PO dose is often identical to the IV dose. This is low-hanging fruit for pharmacist intervention.
| Drug Class | Medication | Oral Bioavailability | Common IV-to-PO Conversion | Key Clinical Pearl |
|---|---|---|---|---|
| Fluoroquinolones | Levofloxacin | ~99% | 750mg IV daily → 750mg PO daily | Watch for QTc prolongation and interactions (calcium, iron). A classic pharmacist-driven conversion. |
| Moxifloxacin | ~90% | 400mg IV daily → 400mg PO daily | Excellent anaerobic coverage, but poor for UTIs. No renal dose adjustment needed. | |
| Tetracyclines | Doxycycline | ~95% | 100mg IV Q12H → 100mg PO Q12H | Binds to cations. Separate from antacids, calcium, iron by at least 2 hours. |
| Macrolides | Azithromycin | ~40% (IV to PO is 500→500) | 500mg IV daily → 500mg PO daily | Despite lower bioavailability, the standard institutional switch is 1:1 due to long half-life and tissue penetration. |
| Misc. Antibiotics | Metronidazole | ~99% | 500mg IV Q8H → 500mg PO Q8H | The quintessential 1:1 switch. Counsel on avoiding alcohol due to disulfiram-like reaction. |
| Linezolid | ~100% | 600mg IV Q12H → 600mg PO Q12H | A powerful but expensive drug. Switching to PO saves significant cost. Monitor for serotonin syndrome. | |
| TMP/SMX | ~95% | Dose is based on TMP component and is 1:1. | Ensure patient has adequate hydration to prevent crystalluria. | |
| Antifungals | Fluconazole | >90% | 400mg IV daily → 400mg PO daily | Excellent for Candida albicans. A very common and easy switch. |
| Voriconazole | ~96% | Dosing is complex. PO dose is often 200mg Q12H. | Requires therapeutic drug monitoring. Many drug interactions (CYP3A4 inhibitor). |
The “Do Not Convert” List: Drugs with Poor Oral Bioavailability
Recommending a switch for these drugs would be a clinical error. Knowing what NOT to do is as important as knowing what to do.
- Vancomycin: Oral vancomycin has ~0% systemic absorption. It is only used to treat C. difficile infection locally in the gut.
- Aminoglycosides (Gentamicin, Tobramycin): No significant oral absorption.
- Most Beta-Lactams (Pip/Tazo, Ceftriaxone, Cefepime, Meropenem): While some oral cephalosporins and penicillins exist, they are not direct equivalents for these broad-spectrum IV-only agents. A switch requires de-escalating therapy based on culture results, not a 1:1 conversion.
Masterclass: Pain Management Transitions
Patients on Med-Surg floors are frequently in pain, either from their medical condition or a surgical procedure. A common scenario involves transitioning a patient from IV opioids, often a patient-controlled analgesia (PCA) pump, to an effective oral regimen that will control their pain and allow for discharge. This requires a mastery of equianalgesic dosing—a core competency of the hospital pharmacist.
Equianalgesic Opioid Dosing Table: Your Conversion Bible
This table provides the approximate dose of each opioid that is considered equivalent to 10 mg of IV morphine. Memorizing the morphine-hydromorphone-oxycodone ratios is essential.
| Opioid | Approx. Equianalgesic IV/IM Dose | Approx. Equianalgesic Oral Dose | Key Pharmacist Pearl |
|---|---|---|---|
| Morphine | 10 mg | 30 mg | The gold standard for comparison. Use with caution in renal impairment due to active metabolite accumulation. |
| Hydromorphone (Dilaudid) | 1.5 mg | 7.5 mg | A potent and common choice. A good option in renal impairment. The IV:PO ratio is 1:5. |
| Oxycodone | N/A | 20 mg | No standard IV formulation. Excellent oral agent. Often found in combination with acetaminophen (Percocet). |
| Fentanyl | 0.1 mg (100 mcg) | N/A (Transdermal/Buccal) | Extremely potent. Primarily used IV in the hospital for acute, severe pain. Transdermal patches are for chronic pain only. |
| Codeine | 130 mg | 200 mg | Generally avoided due to unpredictable metabolism via CYP2D6 and high incidence of nausea. |
Case Study: Converting a Hydromorphone PCA to an Oral Regimen
Scenario: A 55-year-old male is post-op day #2 from a knee replacement. He is on a hydromorphone PCA and the surgeon wants to switch him to oral pain medication to prepare for discharge. You check the PCA pump history.
- PCA settings: Hydromorphone 0.2 mg every 10 minutes, no basal rate.
- 24-hour summary: Patient administered 48 doses.
Step 1: Calculate the total 24-hour IV opioid use.
$$\text{Total IV Hydromorphone} = \text{Number of Doses} \times \text{Dose per Demand}$$
$$\text{48 doses} \times \text{0.2 mg/dose} = \text{9.6 mg of IV hydromorphone in 24 hours}$$
Step 2: Convert the total IV dose to an equianalgesic ORAL dose.
$$\text{Oral Hydromorphone Equiv.} = \text{Total IV Dose} \times \text{(IV:PO Ratio)}$$
$$\text{9.6 mg IV} \times \text{5 mg PO / 1 mg IV} = \text{48 mg of oral hydromorphone equivalent}$$
Step 3: Convert to the desired oral agent and create a regimen.
The team wants to use oral oxycodone. From our table, 20 mg of oral oxycodone is roughly equivalent to 30 mg of oral morphine. 7.5 mg of oral hydromorphone is equivalent to 30 mg of oral morphine. Therefore, 7.5 mg oral hydromorphone ≈ 20 mg oral oxycodone.
$$\text{Total Oral Oxycodone} = \text{48 mg Oral Hydromorphone} \times \frac{\text{20 mg Oral Oxycodone}}{\text{7.5 mg Oral Hydromorphone}} \approx \text{128 mg of oral oxycodone per 24 hours}$$
You now need to create a sensible regimen. A standard approach is to provide 50-75% of the total 24-hour requirement as a scheduled, long-acting agent and the remainder as a short-acting agent for breakthrough pain.
- Scheduled component: Let’s target ~60% as long-acting. 128 mg * 0.60 = ~77 mg. The closest long-acting oxycodone (OxyContin) formulation would be 40 mg PO Q12H (80 mg/day).
- Breakthrough component: The remaining ~48 mg can be given as needed. A reasonable breakthrough dose is 10-15% of the total daily dose. 128 mg * 0.15 = ~19 mg. A standard dose is oxycodone 10 mg or 15 mg.
Your Final Recommendation to the Physician:
“I’ve reviewed the patient’s PCA use, which was 9.6 mg of IV hydromorphone in the last 24 hours. To convert this to an oral regimen, I recommend the following:
- 1. Discontinue the hydromorphone PCA.
- 2. Start scheduled OxyContin 40 mg PO every 12 hours for baseline pain control.
- 3. For breakthrough pain, order immediate-release oxycodone 10 mg PO every 4 hours as needed.
- 4. We must also start a scheduled bowel regimen, such as senna + docusate, to prevent opioid-induced constipation.”
Masterclass: Anticoagulation Management
Medication errors involving anticoagulants are consistently among the most harmful. On a Med-Surg floor, where many patients are at high risk for blood clots (Venous Thromboembolism or VTE) and many others are undergoing procedures, your role as the anticoagulant steward is paramount. Your two main responsibilities are ensuring appropriate VTE prophylaxis and managing the safe interruption and resumption of chronic anticoagulation for procedures.
VTE Prophylaxis: The Default Safety Net
Nearly every patient admitted to a Med-Surg floor has risk factors for VTE (immobility being the most common) and should be on some form of prophylaxis unless there is a strong contraindication (e.g., active bleeding). You are the safety check to ensure this happens.
| Agent | Standard Prophylactic Dose | Required Renal Dose Adjustment | Key Pharmacist Pearl |
|---|---|---|---|
| Heparin (Unfractionated) | 5000 units SUBCUT Q8H or Q12H | None | Short half-life. The go-to agent for patients with severe renal impairment (CrCl < 30) or those who may need to go to surgery urgently. |
| Enoxaparin (Lovenox) | 40 mg SUBCUT daily | If CrCl < 30 mL/min: Change dose to 30 mg SUBCUT daily. | Longer half-life than heparin. Avoid in patients with a history of HIT. This is the most common agent for VTE prophylaxis. |
| Apixaban (Eliquis) | 2.5 mg PO BID | None (Use with caution in ESRD) | An oral option, often used in post-op orthopedic patients. More expensive than injectables. |
| Rivaroxaban (Xarelto) | 10 mg PO daily | Avoid if CrCl < 30 mL/min | Another oral option for orthopedic surgery prophylaxis. |
Periprocedural Anticoagulation: The High-Stakes Balancing Act
This is one of the most complex decisions in hospital pharmacy. You must balance the risk of clotting if you stop the anticoagulant against the risk of bleeding if you don’t. The decision depends on the patient’s underlying clot risk and the procedural bleed risk.
Neuraxial Anesthesia: A Red Alert
The most feared complication is a spinal or epidural hematoma if a patient receives neuraxial anesthesia (e.g., an epidural for pain control) while anticoagulated. This can cause permanent paralysis. There are extremely strict guidelines for timing of LMWH/heparin doses around catheter placement and removal. You are the final checkpoint to prevent this catastrophic error.
| Anticoagulant | Time to Hold Before High-Bleed-Risk Procedure | Restarting Post-Procedure & Bridging |
|---|---|---|
| Warfarin | Hold ~5 days prior. Goal is an INR < 1.5 before the procedure. | Resume 12-24 hours post-procedure once hemostasis is achieved. For high-risk patients (e.g., mechanical heart valve), “bridging” with heparin or enoxaparin is required when the INR is subtherapeutic. |
| Dabigatran (Pradaxa) | Hold 2-3 days (if CrCl ≥ 50). Hold for 4-5 days if CrCl < 50. | Resume 24-72 hours post-procedure, depending on bleed risk. Bridging is generally not needed due to rapid onset. |
| Apixaban (Eliquis) / Rivaroxaban (Xarelto) | Hold at least 48 hours prior. | Resume 24-72 hours post-procedure. Bridging is not needed due to rapid onset. |
SECTION SUMMARY
Key Takeaways for the Med-Surg Floor
Consolidate your understanding of the pharmacist’s pivotal role.
As you transition to the Med-Surg environment, anchor your practice in these core principles. Your success hinges not on knowing every rare disease, but on mastering the most common and high-impact clinical interventions.
- Leverage Your Foundation: Your expertise in chronic disease is your greatest asset. Med-Surg is the acute application of the knowledge you already possess. You are not starting over; you are specializing.
- Master the “Big Three”: Your daily impact will be maximized by mastering the core skills of IV-to-PO conversions, equianalgesic pain management, and anticoagulation stewardship. These are the pillars of Med-Surg pharmacy practice.
- Be a Vocal Safety Advocate: You are the final safety net for high-alert medications. From ensuring correct VTE prophylaxis to preventing catastrophic errors with anticoagulants near procedures, your vigilance protects patients from harm.
- Communicate with Confidence: Formulate your recommendations clearly and concisely. Presenting a well-reasoned plan, like the pain management case study, builds trust and establishes you as an indispensable member of the healthcare team.
