Frontline Pharmacist

F rontline Pharmacist Advanced clinical pharmacy services in a nonacademic community hospital

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he role of a pharmacist as a member of the inpatient health care team has continued to evolve as the profession advances. Recent changes in recommended inpatient pharmacy practice models require increasing clinical involvement and interaction with patients and other health care practitioners.1,2 However, the role of the pharmacist varies considerably from institution to institution, and reported patient outcomes demonstrate varying degrees of benefit.3 Additionally, inpatient pharmacies that provide any type of clinical service face numerous obstacles, including insufficient time, inadequate staffing, and a lack of funding or reimbursement.4 Additional challenges exist for nonacademic institutions. While the roles of pharmacists in traditional academic institutions are fairly well defined, many nonacademic institutions do not provide a structured setting for pharmacist interaction with the health care team. This complicates pharmacists’ efforts to make interventions and form a collaborative relationship with providers. A partnership between clinical pharmacists and inpatient health care professionals in a nonacademic institution is vital in order to ensure optimal medication use, and practitioners in nonacademic facilities appear to be amenable to such a partnership.4-6 Unfortunately, there is a paucity of literature describing activities of clinical pharmacists in nonacademic settings.

In 2008, the American Society of Health-System Pharmacists and the Society for Hospital Medicine released a joint statement on hospitalist–pharmacist collaboration.7 The statement identified a number of opportunities for collabora-

tion between hospitalists and pharmacists to expand the role of the pharmacist well beyond safe medication dispensing. This article describes the creation of an advanced clinical pharmacy service in a nonacademic community hospital. Background. Edward Hospital is a 309-bed tertiary care medical center in the western suburbs of Chicago. Despite multiple Joint Commission diseasespecific certifications and national recognition in a variety of specialties, the institution offers no formal medical

teaching programs. A large proportion of patients are admitted via the Edward Hospitalist Group, the only group of internal medicine physicians employed by the hospital. The group consists of 11 hospitalists (9 hospitalists were employed at the initiation of this service) and two physician assistants with rotating 24hour coverage; they admit 20–30 patients daily, with an average daily census of approximately 100 patients. Although the hospitalists coordinate their patients’ medical care, when necessary they consult specialist physicians, who are allowed to order medications directly without involvement by the hospitalists. Due to heavy workloads and complex schedules, the hospitalist group does not conduct formal rounds or provide structured interaction time with other members of the health care team. Fortunately, the hospitalist group and the pharmacy department have a collaborative relationship, and the physicians are interested in clinical services provided by pharmacists. Therefore, the advanced clinical pharmacy service described in this article targets patients of the Edward Hospitalist Group. Current clinical pharmacy services. The Edward Hospital pharmacy is open 24 hours a day and provides clinical pharmacy services on physician request and per medical staff–approved proto-

The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).

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cols, including pharmacokinetic dosing, i.v.-to-oral conversion, renal dosing, indication-based dosing for antibiotics and enoxaparin, basic antibiotic review, anticoagulant review, and warfarin dosing. Clinical staff pharmacists on all shifts are trained to perform these services through a formal orientation program conducted by the clinical manager and senior clinical staff pharmacists within the first 90 days of employment. After completion of training, both centralized and decentralized pharmacists balance provision of clinical services with distribution responsibilities throughout each shift as part of a patient-centered integrated practice model.8 In order to expand the clinical services offered, the hospital contracted with Midwestern University Chicago College of Pharmacy for the services of a cofunded, nontenure-track, internal medicine–trained clinical pharmacy specialist (a college faculty member), who is responsible for developing and maintaining an advanced clinical pharmacy service to serve as a rotation site for pharmacy students and residents. The faculty member provides services at the hospital four days per week, with one day per week devoted to campus responsibilities. Clinical specialist responsibilities. The faculty pharmacist is responsible for providing additional advanced clinical pharmacy services for Edward Hospitalist Group patients. Due to a lack of structured pharmacist–physician interaction (pharmacists are not involved in rounding), the majority of the service involves daily retrospective chart review targeting all newly admitted patients (approximately 25 patients daily). Each patient chart is reviewed only once. Per physician request, the faculty pharmacist prioritizes patients receiving 10 or more medications while admitted, patients receiving 10 or more medications prior to admission, and patients transferred from the intensive care unit to the general medical floor. Per pharmacy department request, the pharmacist also prioritizes patients receiving antibiotics and high-alert medications, as designated by the Institute for Safe Medication Practices (including

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but not limited to antithrombotic agents, opioids, insulin, antiarrhythmic agents, and chemotherapy agents).9 Other new admissions, as well as follow-up issues arising from prior reviews, are addressed as time allows. The faculty pharmacist focuses on several primary intervention targets: • Admission medication reconciliation issues, • Acute disease state management issues, including ensuring appropriate therapy, reducing the risk of adverse events, compliance with national guidelines and patient safety goals, and compliance with hospital initiatives and policies, • Chronic disease state management, including compliance with evidencebased guidelines, compliance with core measures, necessary changes to discharge medication regimens based on acute conditions, and medication duplication or omission, • Discharge medication reconciliation issues, and • Current clinical pharmacy services such as pharmacokinetic dosing.

The faculty pharmacist is also available to respond to requests for patient-specific consultative services from the hospitalist physicians, including discharge counseling, resolving medication-related problems, and providing resources as necessary (e.g., drug information, professional literature, antibiograms). Before the implementation of an electronic medical record (EMR) in April 2013, nonurgent pharmacotherapyrelated recommendations were communicated through written notes in the patient’s paper record; since the transition to an EMR, such recommendations are conveyed in physician-specific electronic messages and medication notes. Urgent messages are communicated via text pages and telephone calls, and faceto-face contact is the preferred method of communication. Prior to EMR implementation, pharmacist-recommended interventions were documented via a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA); this information is now entered into the interven-

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tion documentation system within the EMR. Additional clinical specialist responsibilities. Per physician request, the faculty pharmacist provides pharmacy representation at the quarterly hospitalist meeting to provide information on pharmacy-related topics of interest to the physicians. The pharmacist discusses new medications approved by the Food and Drug Administration, hospital initiatives involving medication-related items, drug shortages, literature updates, medication safety issues, and additional items as requested. On behalf of the pharmacy department, the faculty pharmacist participates in several high-visibility medical staff committees, including the pharmacy and therapeutics and antimicrobial stewardship committees. As a clinical pharmacy specialist, the faculty pharmacist serves as a resource to Edward Hospital clinical staff pharmacists, providing assistance with antibiotic recommendations, renal dosing, drug information, and complex patient-specific issues. The faculty pharmacist also provides pharmacist education on disease states for which the hospital has or is seeking Joint Commission certification (the hospital is currently certified for advanced inpatient diabetes management and has plans to target chronic obstructive pulmonary disease), as required by the standards. Finally, the faculty pharmacist participates in the development of the antimicrobial stewardship program through design and completion of multiple medication-use evaluations, as well as the identification and implementation of targeted prescribing interventions. Assistance with interventions is provided as requested. The faculty pharmacist incorporates pharmacy students working to complete introductory and advanced pharmacy practice experience requirements (as well as nursing students enrolled in a master’s degree program) into the pharmacy service, coordinating their involvement in the chart review process and intervention communication and providing assistance Continued on page 992

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with medication-use evaluations and with clinical staff pharmacist support. Pharmacy residents may participate in the service as an elective rotation. Evaluation of the service. During the period January–May 2013, the faculty pharmacist made approximately 700 interventions. The information tracked for each intervention included patient demographics, the physician’s name, the complexity of the intervention (i.e., simple, moderately complex, or complex), the method of intervention (i.e., written, telephone, or oral), and the outcome. An intervention was considered simple if it primarily involved medication reconciliation, medication dosing, i.v.-to-oral conversion, or drug interactions; moderately complex if it involved medication duplication or omission or compliance with the Joint Commission’s National Patient Safety Goals (NPSGs) and core measures; and complex if it focused on compliance with evidence-based guidelines or local data, such as antibiotic recommendations tailored to local susceptibility patterns. Of the 700 interventions during the five-month evaluation period, approximately 45% were classified as complex, 30% as moderately complex, and 25% as simple. Outcomes for each intervention were categorized as follows: accepted, rejected, informational, or not applicable (e.g., the physician did not see the note or message about the recommended intervention before patient discharge or the patient’s status changed, rendering the recommendation irrelevant). The acceptance rates for recommendations before and after institution of the EMR were 73% and 71%, respectively. At the time of writing, data were not yet available to allow stratification of acceptance rates by type of intervention. Anecdotal physician feedback indicated that the most common reasons for recommendation rejection were specialist preference (e.g., a recommendation to change a cardiac medication was rejected because a cardiologist was following the patient), patient status change, and a lack

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of comfort with altering a medication regimen for chronic disease management. Overall, however, the program garnered very positive feedback from the hospitalist group. That feedback was communicated directly to the faculty pharmacist and also conveyed to the chief medical officer of the health system, the pharmacy administration, and other members of the health care team. Program challenges. During the development and implementation of the clinical pharmacy service, a number of challenges arose; these challenges must be addressed to ensure the successful continuation of this service. First, the structure of the hospitalist service dictates that each patient’s record is reviewed only once and that most medication interventions be made retrospectively, which inherently limits the pharmacist’s ability to influence prescribing at the point of care. As a result, in performing interventions the faculty pharmacist refers to pertinent professional literature (where applicable) or cites guidelines so that the prescribers can adapt the information to a patient’s changing clinical status or use it in subsequent patient care situations. A second challenge is that the involvement of specialist physicians in the medication-use process, while obviously necessary, can make it difficult to obtain approval of interventions. In some cases, a hospitalist may be reluctant to change medications managed by a specialist medical service even if their use is not in compliance with evidence, core measures, or NPSGs. The faculty pharmacist works with the specialists directly in some cases to make interventions; while this is usually effective, it requires extra time and effort on the part of the faculty pharmacist to ensure that all physicians involved in the care of the patient are informed of medication changes. A third challenge is that many hospitalists are uncomfortable changing medication regimens that are part of an outpatient regimen even in the event of noncompliance with evidence-based guidelines. This is especially common in cases involving a short length of stay or a

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regimen that is not directly related to the acute problem requiring admission. To address this issue, the faculty pharmacist encourages hospitalists to make recommendations to primary care providers by way of the hospital discharge summary or direct communication. In some instances, the faculty pharmacist works with the patient to assess outpatient medication regimens and relay recommendations to outpatient providers. The biggest challenge for the clinical pharmacy service involves a lack of structured pharmacist–physician interaction time (i.e., no formal rounding). Four or five practitioners care for patients simultaneously, creating physical challenges with regard to contacting prescribers to make interventions and difficulties achieving face-to-face contact. Patients are often cared for by multiple hospitalists over the course of their admission; recommendations provided to one hospitalist might not be conveyed to the hospitalist most suited to address the intervention. Without structured interaction time, the faculty pharmacist relies on the hospitalists’ schedule to try to determine where to direct the intervention. The faculty pharmacist attempts to triage recommendations so as to build credibility and not overload the providers. Future directions. With the advent of advanced clinical services, the pharmacy department at Edward Hospital has begun to have a positive impact on the internal medicine patient population through a number of high-level pharmaceutical care interventions. However, additional internal medicine pharmacist resources will be necessary to continue to support these activities. The Edward Hospitalist Group anticipates expansion in the next few years, and one faculty pharmacist will not be sufficient to provide the depth of retrospective patient review or consultative services needed to adequately care for a growing volume of patients. Currently, the faculty pharmacist provides patient care services four days per week; when the faculty pharmacist is not onsite, these services are not provided. The ultimate goal of the program is to gain the ability to provide services five

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days a week, at minimum, even in the absence of the faculty pharmacist; however, continued data collection and economic analyses of the service will be required to justify the necessary resources. The hiring of additional internal medicine– trained pharmacists would increase the pharmacy staff ’s ability to communicate with patients and physicians in person and could allow the service to focus on specific outcomes (e.g., targeted disease states or core measures) if desired. Expansion of the internal medicine– oriented pharmacy service would also augment a pharmacy-driven antimicrobial stewardship program that is currently in the early stages of implementation. Finally, as resources allow, advanced clinical pharmacy services could eventually include conducting clinical research, writing case reports, and participating in clinical trials at Edward Hospital, or facilitating transitions of care to outpatient facilities within or outside the EdwardElmhurst Healthcare network. Although Edward Hospital is not an academic institution, its experience with an internal medicine–focused clinical pharmacy program illustrates that there

are multiple opportunities for pharmacists to provide clinical services that enhance patient care.

9. Institute for Safe Medication Practices. ISMP list of high-alert medications. www. ismp.org/tools/institutionalhighAlert.asp (accessed 2013 Nov 8).

1. Haas CE, Eckel S, Arif S et al., for the American College of Clinical Pharmacy. Acute care clinical pharmacy practice: unit vs. service-based models. Pharmacotherapy. 2012; 32:e35-44. 2. Zellmer WA. The future of health-system pharmacy: opportunities and challenges in practice model change. Ann Pharmacother. 2012; 46:s41-5. 3. Kripalani S, Roumie CL, Dalal AK et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012; 157:1-10. 4. Cruthirds DL, Hughes PJ, Weaver S. Value of pharmacy services to the healthcare system: an interdisciplinary assessment. Int J Pharm Pract. 2013; 21:38-45. 5. Patel MR, Chen AY, Roe MT et al. A comparison of acute coronary syndrome care at academic and nonacademic hospitals. Am J Med. 2007; 120:40-6. 6. Belle L, Labarere J, Fourny M et al. Quality of care for myocardial infarction at academic and nonacademic hospitals. Am J Med. 2012; 125:365-73. 7. Cobaugh DJ, Amin A, Bookwalter T et al. ASHP–SHM joint statement on hospitalist–pharmacist collaboration. Am J Health-Syst Pharm. 2008; 65:260-3. 8. Woods TM, Lucas AJ, Robke JT. Making a case for a patient-centered integrated pharmacy practice model. Am J HealthSyst Pharm. 2011; 68:259-63.

Laura H. Waite, Pharm.D., BCPS, CLS, BC-ADM, Assistant Professor of Clinical Pharmacy Department of Pharmacy Practice and Pharmacy Administration Philadelphia College of Pharmacy University of the Sciences Philadelphia, PA [email protected] Lisa Heuser, Pharm.D., Manager, Clinical Pharmacy Services Phillip C. Williams, B.S.Pharm., Pharm.D., M.B.A., Administrative Director of Pharmacy Services Edward-Elmhurst Healthcare Naperville, IL Susan R. Winkler, Pharm.D., BCPS, FCCP, Professor and Chair, Pharmacy Practice Midwestern University Chicago College of Pharmacy Downers Grove, IL

The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130554

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Advanced clinical pharmacy services in a nonacademic community hospital.

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