Lesson 2: Workflow & Triage

31.2.1 The Command Center: From Data Stream to Actionable Queue

In Lesson 1, you learned about the vast network of data that feeds the surveillance engine. Now, we turn our attention to the human interface where this data becomes actionable: the surveillance alert inbox. This inbox is your command center, your clinical radar screen. At any given moment, it may contain dozens of alerts from across the hospital, each representing a potential risk or opportunity. An amateur sees this inbox as a simple “to-do” list to be worked through from top to bottom. A master sees it as a dynamic, risk-stratified battlefield that requires constant, intelligent triage.

The skills you will learn in this lesson—inbox hygiene, prioritization, rapid chart review, and escalation—are the core competencies that separate an effective surveillance pharmacist from an overwhelmed one. Without a systematic workflow, the constant stream of alerts can quickly lead to decision fatigue and the very real danger of missing a critical finding. With a systematic workflow, you can calmly and confidently process a high volume of information, focus your cognitive energy on the problems that matter most, and translate your findings into timely, life-saving interventions.

31.2.2 Inbox Hygiene & The Prioritization Matrix

Effective triage begins with “inbox hygiene”—a set of principles for managing the queue that ensures every alert is addressed efficiently. The foundational principle is to “touch it once.” This means that for every alert you open, your goal is to make a definitive decision on the first review: either you act on it, you consciously decide to monitor it, or you dismiss it with a clear rationale. Avoid the temptation to “snooze” an alert or leave it unread to “come back to later.” This clutters your workspace and increases the risk of a significant finding getting lost.

To make this “touch it once” philosophy possible, you need a powerful mental model for rapid decision-making. This is the Prioritization Matrix. It forces you to evaluate every alert along two critical axes:

• Clinical Risk: If this alert represents a true problem, how severe is the potential for patient harm? Is it a life-threatening emergency, a significant clinical decline, or a minor deviation from the ideal?
• Actionability: Is there a clear, immediate, and effective intervention that I, as a pharmacist, can recommend to fix this problem?

By plotting each alert on this matrix, you can instantly categorize it into one of four quadrants, each with a pre-defined set of actions. This is how you decide what to do right now, what to investigate further, and what you can safely dismiss.

Masterclass Table: The Four Quadrants of Alert Triage

Quadrant & Priority	Definition	Pharmacist’s Mindset & Action Plan	Concrete Clinical Examples
Q1: High Risk + High Actionability (Top Priority)	These alerts represent a clear and present danger to the patient, and there is a straightforward, evidence-based intervention you can recommend immediately.	Mindset: “Act Now.” This is a five-alarm fire. This alert becomes your immediate focus. Action: Perform a quick, targeted chart review to confirm the data, formulate your recommendation, and escalate immediately via a direct phone call or page.	Supratherapeutic vancomycin trough (>30 mcg/mL). Critically high PTT (>150 seconds) on a heparin drip. New positive blood culture for a resistant organism. Severe AKI (e.g., SCr doubles) in a patient on multiple nephrotoxins. Order for linezolid in a patient actively receiving an SSRI.
Q2: High Risk + Low Actionability (Second Priority)	These alerts point to a potentially serious problem, but the cause is unclear, or the solution is complex and may not be a simple medication change.	Mindset: “Investigate & Correlate.” This is a mystery that requires detective work. Action: This requires a more in-depth chart review. You may need to look at trends over days, read specialist consult notes, and correlate multiple data points. Your intervention might be a detailed note posing a question to the team rather than a simple recommendation.	A 40% drop in platelets over 2 days in a patient on heparin (Could be HIT, but needs full workup). Unexplained, persistent fever in a patient on multiple antibiotics. Subtle but persistent rise in LFTs. A patient on >5 CNS depressants with a high sedation score (Requires a complex, multi-drug taper strategy, not a single change).
Q3: Low Risk + High Actionability (Batch & Process)	These are “good housekeeping” alerts. They represent opportunities to optimize care, reduce costs, or improve compliance with hospital protocols, but a delay of a few hours is not dangerous.	Mindset: “Quick Wins.” These are opportunities to demonstrate value efficiently. Action: These are perfect candidates to “batch.” You can work through all your IV-to-PO conversions or duration reminders at one time. Communication can be via a non-urgent secure chat or EHR message.	IV-to-PO conversion opportunity in a stable patient. Antibiotic duration reminder (e.g., “Day 5 of CAP therapy, consider stopping?”). Therapeutic interchange from a non-formulary to a formulary agent. Patient on a PPI without a clear, documented indication.
Q4: Low Risk + Low Actionability (Dismiss with Rationale)	These alerts are often informational, false positives, or represent a clinical situation where no action is warranted at this time.	Mindset: “Acknowledge & Dismiss.” The goal is to process these quickly to clear your queue, but not without due diligence. Action: Perform a very brief chart review to confirm it’s a false positive or clinically insignificant. Dismiss the alert, and crucially, select the correct dismissal reason (e.g., “Clinically Insignificant,” “Intended by Provider”). This feedback helps refine the rules.	A minor electrolyte abnormality that has already self-corrected on the next lab draw. A “therapeutic duplication” alert for a heparin drip and warfarin during an intended bridge. A low hemoglobin alert for a patient in the oncology unit with chronic, stable anemia. A high glucose alert for a patient who just received a dose of D50W for hypoglycemia.

31.2.3 The Quick Chart Review Checklist (AIPLOL)

Once you have triaged an alert and decided to investigate it, you need a method for reviewing the patient’s chart that is both lightning-fast and reliably thorough. A full, comprehensive chart review can take 30 minutes; you have about 60-90 seconds. This requires a targeted approach. The AIPLOL checklist is a mnemonic-driven framework designed for exactly this purpose. It forces you to look at the six most critical domains of information in a logical sequence to rapidly build the clinical context you need to make a decision.

Masterclass Table: The AIPLOL Rapid Review Framework

Mnemonic	Domain	Guiding Questions for Your 90-Second Review
A	Allergies	Is there a documented allergy to the medication in question or anything in its class? What is the nature of the reaction (e.g., rash vs. anaphylaxis)? Has the patient safely received this or a similar drug in the past?
I	Indication	Why is the patient in the hospital? (Check the problem list/admission diagnosis). Why is this specific drug being used? Does the indication make sense? Does the clinical context of the alert align with the primary diagnosis? (e.g., an AKI alert in a septic patient is less surprising than in a healthy patient).
P	PK / PD (Pharmacokinetics/ Pharmacodynamics)	How is this drug being absorbed, distributed, metabolized, and eliminated? For level-based alerts (e.g., Vancomycin): What is the full dosing history? Was the level a peak or a trough? Was it drawn at the correct time? For interaction alerts: What is the mechanism of the interaction (e.g., CYP, P-gp)? How significant is it?
O	Organs	Kidneys: What is the creatinine trend over the last 3-4 days? What is today’s calculated CrCl? Liver: What are the LFTs (AST/ALT, Alk Phos, Bilirubin)? Are they stable, rising, or falling? Bone Marrow: What is the trend of the WBC, Hgb, and Platelets?
L	Lines (IV Access)	Is the patient’s IV access peripheral or central? Does the drug in question require a central line (e.g., vasopressors, high-concentration TPN, chemotherapy)? Is there a potential compatibility issue with other drugs being infused through the same line? (This is a frequent cause for bedside calls).
L	Labs & Logs (Trends & Context)	Look beyond the single lab value that triggered the alert. What are the trends of related labs? (e.g., for a hyperkalemia alert, also check Mg, Ca, and renal function). Quickly scan the MAR log. What other relevant drugs has the patient received in the last 24 hours? Scan the last 24 hours of nursing and provider notes for any key context.

31.2.4 Escalation Pathways & “No-Miss” Timers

After you’ve triaged an alert and performed your rapid review, you must communicate your findings. The method and urgency of your communication must match the clinical risk you’ve identified. Escalating a routine IV-to-PO switch with a STAT page is just as inappropriate as sending a secure message about a life-threatening heparin overdose. You must master the use of your hospital’s communication tools and apply them with clinical judgment.

Masterclass Table: Matching the Message to the Method

Communication Method	Best Used For (Priority Tier)	Advantages	Disadvantages & Pitfalls
Direct Phone Call	All Tier 1 (High Risk, High Actionability) alerts. Also used for escalation after a failed page on a Tier 2 alert.	Immediate, synchronous communication. Allows for real-time conversation and clarification. Creates a “closed loop” where you get immediate confirmation that your message was received and a plan is in place.	Interruptive to the provider’s workflow. Should be reserved for truly urgent or emergent issues to maintain its impact.
Pager / Alpha-Numeric Page	Most Tier 2 (High Risk, Low Actionability) alerts. Use for issues that require a timely response but are not immediately life-threatening.	More urgent than a secure chat. Creates an auditable record of the time you sent the message. Allows the provider to finish their current task before responding.	Asynchronous; you don’t know when or if the provider has seen the page. This is why the “No-Miss Timer” is essential when using this method for high-risk issues.
Secure Chat / EHR Message	Most Tier 3 (Low Risk, High Actionability) alerts. Perfect for routine optimizations, recommendations, and FYIs.	Non-interruptive; allows the provider to respond when they have a free moment. Creates a clear, written record of your recommendation directly within the EHR. Excellent for “batching” your quick-win interventions.	Should NEVER be used for urgent or emergent issues. There is no guarantee when the message will be read. Using this for a critical lab value is a major safety failure.

31.2.5 Activity & Assessment

Activity: Triage the Inbox

For each of the following alerts, assign a Triage Quadrant (Q1, Q2, Q3, Q4), the appropriate first-line communication method, and a one-sentence rationale.

Alert Description	Triage Quadrant	Communication Method	Rationale
Patient on IV ciprofloxacin for 3 days is now tolerating a regular diet.
New blood culture result is positive for Gram-Positive Cocci in Clusters. Patient is septic and on Zosyn.
Patient on enoxaparin has a platelet count that dropped from 250k yesterday to 180k today.
Patient has a documented penicillin allergy (reaction: rash) and a new order for Zosyn (piperacillin-tazobactam).
An alert for hyperkalemia (K=5.6) fires, but you see a repeat lab drawn 30 minutes later is normal (K=4.5).