NOTE Pharmacy students
ar
NOTE
Layar
Effect of pharmacy students as primary pharmacy members on inpatient interdisciplinary mental health teams
M
Monica Mathys, Elizabeth Neyland-Turner, Keenan Hamouie, and Emily Kim
edication reconciliation from hospital admission to discharge is a fundamental step for continuity of patient care. Comprehensive medication reconciliation is necessary to ensure safety and to prevent adverse events. The Joint Commission mandated medication reconciliation as a National Patient Safety Goal because “medication discrepancies can affect patient outcomes.”1 Data suggest that having a pharmacist involved in the medication reconciliation process leads to better outcomes. In 2010, Gleason et al.2 reported that after having pharmacists perform thorough medication reconciliations, 69% of inpatient prescriptions needed to be corrected with order changes. Among the prescriptions that were corrected, 64% were considered clinically relevant, where intervention by the pharmacist prevented possible increased hospital length of stay or harm to the patient. In addition to pharmacists, pharmacy students are competent in performing medication reconciliation.3-5 In one study,
Purpose. The effect of pharmacy students as primary pharmacy members on inpatient interdisciplinary mental health teams was investigated. Methods. This retrospective study used Veterans Affairs data from veterans who were admitted to an inpatient mental health unit from January 1, 2010, through December 31, 2012. Eligible veterans had to have been hospitalized for at least five days and treated with at least five scheduled medications during the hospitalization. Information collected by the investigators included patient age, psychiatric diagnoses, accuracy of medication reconciliation on admission and at discharge, and readmission rates within six months and one year. Additional information collected included monitoring parameters for lithium, divalproex, first-generation antipsychotics, and second-generation antipsychotics. The primary outcome was the percentage of accurate medication reconciliations for treatment teams with a fourth-year pharmacy student and without a pharmacy student. Clinical monitoring and readmission rates were also compared.
67% of 326 charts had medication or dosage omissions that were clarified
Monica Mathys, Pharm.D., CGP, BCPP, is Associate Professor of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center (TTUHSC), Dallas. E lizabeth N eyland -Turner, M.S., Pharm.D., is Staff Pharmacist, CVS Pharmacy, Grand Prairie, TX; when this study was performed she was a Pharm.D. student, School of Pharmacy, TTUHSC, Dallas. Keenan Hamouie, Pharm.D., is Staff Pharmacist, H-E-B Pharmacy, Houston, TX; when this study was performed he was a Pharm.D. student, School of Pharmacy, TTUHSC, Dallas. Emily Kim, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Palmetto General Hos-
Results. A total of 526 patients were eligible for study inclusion. Medication reconciliation was performed on admission for all patients followed by a team involving a pharmacy student (experimental group), but only 51% of patients in the control group had documented medication reconciliations in the medical chart. Of the medication reconciliations completed, 82% were performed correctly in the experimental group, compared with 61% when a pharmacy student was not involved (p = 0.006). There were no significant differences between groups in psychotropic monitoring and readmission rates. Conclusion. The presence of fourth-year pharmacy students on inpatient mental health interdisciplinary teams was associated with more frequent interventions, patient counseling, and medication reconciliation, compared with rates for teams without a pharmacy student. Medication reconciliation was performed more consistently and accurately when the teams had a pharmacy student than when they did not. Am J Health-Syst Pharm. 2015; 72:663-7
by pharmacy students on internal medicine clerkships.4 Another study
pital, Hialeah, FL; when this study was performed she was a Pharm.D. student, School of Pharmacy, TTUHSC, Dallas. Address correspondence to Dr. Mathys (monica.mathys@ttuhsc. edu). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0402-0663. DOI 10.2146/ajhp140411
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NOTE Pharmacy students
showed that 922 medication discrepancies involving 330 patients were found by pharmacy students on the general medicine or surgery floors.5 In addition to medication reconciliation, pharmacy students have demonstrated that they are capable of providing high-quality discharge counseling, therapeutic recommendations, and cost avoidance.3,6-8 To date, only one study has evaluated the cost-saving potential of pharmacy students’ clinical interventions in a psychiatric hospital.8 We studied the effect of medication reconciliation by pharmacy students in an inpatient mental health facility. Background This study was conducted in a 40bed Veterans Affairs (VA) inpatient mental health unit with an average daily census of 30–36 patients. Admitted veterans are assigned to one of five interdisciplinary treatment teams. Each team comprises an attending psychiatrist, a psychiatry resident, and a registered nurse, with social workers, psychologists, and hospitalists available when necessary. Only one clinical pharmacist works in the mental health unit. This pharmacist is a full-time faculty member with a local school of pharmacy but also a 0.5-full-time-equivalent contract employee with VA. The clinical pharmacist precepts 16–18 fourthyear pharmacy students throughout the year. During psychiatric rotations, pharmacy students are assigned to an interdisciplinary team such that most treatment teams have a pharmacy member. Pharmacy students provide comprehensive medication reviews for each patient admitted to their treatment team. In addition, they perform medication reconciliation on admission and at discharge and provide discharge counseling. This current clinical– teaching practice was started in 2009. Since that time, the number of pharmacy clinical interventions has increased from 20 to over 200 per 664
month. The students have helped meet one of the National Patient Safety Goals by providing medication reviews and reconciliation for more than 90% of patients admitted to the inpatient mental health unit from 2009 through 2012. In addition, the students have assisted with providing discharge counseling for 65–70% of these patients.9 Although the coverage of pharmacy services increased dramatically when pharmacy students were assigned to individual interdisciplinary mental health teams, we wanted to explore the clinical impact of the current practice. This study was designed to compare outcomes of the interdisciplinary teams when a pharmacy student was included versus when the teams did not have access to a pharmacy member. The primary outcome was the percentage of accurate medication reconciliations for treatment teams with a fourth-year pharmacy student and without a pharmacy student. Secondary outcomes included the (1) appropriate monitoring of lithium and valproic acid therapy, (2) use of the Abnormal Involuntary Movement Scale (AIMS) for monitoring patients treated with antipsychotics, (3) metabolic monitoring for patients treated with secondgeneration antipsychotics, (4) mental health readmissions within six months of the last discharge date due to medication nonadherence, and (5) mental health readmissions within one year of the last discharge date due to medication nonadherence. Methods This retrospective study used VA data from veterans who were admitted to an inpatient mental health unit from January 1, 2010, through December 31, 2012. The study was approved by the institutional review boards of the VA health system and the university involved. Eligible veterans had to have been hospitalized in the mental health unit for at least five days and treated with at least five
Am J Health-Syst Pharm—Vol 72 Apr 15, 2015
scheduled medications during the hospitalization. During the rotation, pharmacy students were required to enter an admission medication reconciliation note and a medication review note into a patient’s medical record within 24 hours of when they became aware that their team was following that patient. Because most admissions occur during the afternoon and evening hours, patients were not officially assigned to treatment teams until the next weekday morning during rounds. The students had 24 hours from this point to complete their notes. Usually, notes appeared in the chart within two days of a patient’s admission. However, for patients admitted on a Friday or Saturday, the treatment team was not assigned until the following Monday. For these patients, the students’ notes were expected to appear on the following Tuesday, which could have been four days after admission for patients admitted on a Friday. Having a hospital stay of at least five days as an inclusion criterion allowed students to have adequate time to complete their medication reviews. The authors also wanted to include patients who would benefit most from having medication reviews and medication reconciliations performed, such as those taking multiple medications. Requiring study patients to be taking five or more medications ensured that patients with morecomplex regimens were included. Patients were excluded if they were admitted primarily for alcohol or drug detoxification or if they refused inpatient medications at least 75% of the time during their hospital stay. We believed that these exclusion criteria were necessary to accurately determine readmission rates. Patients with psychotic or mood disorders were the intended target population in addition to those who were willing to be compliant with their medications at discharge. Patients followed by the geriatric interdisciplinary
NOTE Pharmacy students
team were excluded from the study because this team includes a clinical pharmacist year-round. Whether a patient had been assigned to a team with a pharmacy student was determined by the date of admission. The clinical pharmacist has students on rotation during the months of January through May but not during the whole month of June. Therefore, patients admitted from January through May were presumed to have had a pharmacy student on their treatment team, while those admitted during the other study months were presumed not to have had a pharmacy student on the team. Pharmacy student involvement was confirmed if a student’s medication review or reconciliation notes could be found in the patient’s chart. As expected, student notes were found for admissions in January–May, but there were no student notes found for the month of June. Information collected by the investigators included patient age, psychiatric diagnoses, accuracy of medication reconciliation on admission and at discharge, and readmission rates within six months and one year. Additional information collected included monitoring parameters for lithium, divalproex, first-generation antipsychotics, and second-generation antipsychotics. The medication reconciliation process was considered accurate if the following could be determined by reviewing the chart: (1) a medication reconciliation note was placed in the chart within 48 hours of admission for Monday–Thursday admissions, within 72 hours for Saturday admissions, and within 96 hours for Friday admissions and on the day of discharge and (2) within the note, the lists of scheduled inpatient and outpatient medications matched (including dose and schedule); if the lists did not match, the reasons for medication changes had to be documented. Reconciliation notes written by the students were considered cor-
rect if (1) they found discrepancies while performing the medication reconciliation process, (2) they documented these discrepancies, and (3) the discrepancies were resolved by the treatment team. To assess for appropriate psychotropic monitoring, the authors reviewed the charts for the recommended laboratory test values commonly noted in drug information references. Serum concentrations of lithium and valproic acid must have been checked during hospitalization to be considered as “appropriate monitoring.” In addition, patients must have had recommended baseline laboratory tests performed during hospitalization if they had not been done within six months before the hospitalization. These included a basic metabolic profile, thyroidstimulating hormone concentration, urinalysis (for patients taking lithium), or a complete blood count and liver function tests (for patients taking valproic acid). An AIMS assessment needed to be documented during the hospitalization for any patient taking antipsychotics who did not have such an assessment noted in the chart within six months of the hospitalization. Baseline metabolic monitoring, including body mass index, fasting glucose concentration, lipid panel, and blood pressure, was required for patients who were initiated on a new second-generation antipsychotic. Data for all eligible patients were entered into a spreadsheet and numbered. Software for the generation of random numbers was used to select the study patients from among eligible patients. Because all outcomes data were nominal, primary and secondary endpoints were analyzed using chi-square analysis or Fisher’s exact test when appropriate. The a priori level of significance was 0.05. Results Of the 1747 inpatient admissions identified from January 2010
through December 2012, a total of 526 patients were eligible for study inclusion. The most common reason for exclusion was a length of stay of less than five days. One hundred patient admissions were randomly selected for each group (experimental and control). Baseline characteristics are shown in Table 1. The mean age of patients was 52 years. The most common reason for inpatient admission was suicidal ideation. Major depressive disorder and psychotic disorder were the most common psychiatric diagnoses observed. Medication reconciliation was performed on admission for all patients followed by a team involving a pharmacy student (experimental group), but only 51% of patients in the control group had documented medication reconciliations in the medical chart (Table 2). Of the medication reconciliations completed, 82% were performed correctly in the experimental group, compared with 61% when a pharmacy student was not involved (p = 0.006). At discharge, 86% of medication reconciliations were performed correctly by the team with pharmacy student involvement compared with 68% in the control group (p = 0.005). Appropriate psychotropic medication monitoring was observed in 85% of patients in the experimental group and 84% in the control group (Table 3). All-cause readmission rates did not differ significantly between groups (100 patients per group) at six months (36 and 33 patients in the experimental and control groups, respectively) or at one year (47 and 43 patients in the experimental and control groups, respectively). Similarly, the rate of readmission attributable to medication noncompliance did not differ significantly between groups (100 patients per group) at six months (12 and 9 patients in the experimental and control groups, respectively) or at one year (17 and 13 patients in the experimental and control groups, respectively).
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Discussion During the mental health rotation, pharmacy students were required to perform medication reconciliation on admission and at discharge and provide thorough medication reviews and document these in the patients’ charts. The pre-
ceptor kept close watch of the admissions and discharges and knew which patients the students were following. The preceptor also ensured that all notes were completed, so there was little chance that these notes were not done as required. Students were taught that their medication review
Table 1.
Baseline Characteristics of Study Groups Patients Assigned to Teams With Pharmacy Student (n = 100)
Variable
Patients Assigned to Teams Without Pharmacy Student (n = 100)
p
Mean ± S.D. age, yr 52.2 ± 10.0 52.9 ± 11.0 0.622 No. men 93 94 >0.999 Diagnosis, no. patientsa Anxiety 1 1 >0.999 Bipolar disorder 21 20 >0.999 Depression 52 40 0.118 Posttraumatic stress disorder 13 11 0.828 Psychotic disorder 23 31 0.265 Reason for admission, no. patients Depression 2 6 0.279 Homicidal ideation 5 13 0.081 Mania 5 5 >0.999 Psychosis 28 31 0.757 Suicidal ideation 60 45 0.047 a
Patients may have had more than one psychiatric diagnosis.
notes should (1) address all of a patient’s diseases, (2) ensure that each medication has an indication and that a disease is not being undertreated, (3) assess the current treatments, and (4) address the recommended medication monitoring. Pharmacy recommendations were communicated in the note and orally during rounds. The students continued to follow their assigned patients daily. On the day of discharge, the students completed discharge medication reconciliation notes and provided counseling to their patients, emphasizing the new medications and the changes that occurred during the hospitalization. The medication reconciliation process involves comparing active inpatient and outpatient medications using VA’s Computerized Patient Record System and interviewing the patients to inquire about non-VAprescribed medications. If discrepancies were found during the medication reconciliation process, the students were instructed to notify the pharmacy preceptor or the attending psychiatrist so that corrections could be made as soon as possible. Our study found that medication reconciliation was more likely to be documented in the chart on admission
Table 2.
Medication Reconciliation (MC) Accuracy Fraction (%) Patients Variable
Teams With Pharmacy Student
Admission MC notes documented Notes done correctly Notes not done correctlya Medication missing from inpatient list Wrong dosage started in hospital Discharge MC notes documented Notes done correctly Notes not done correctlya Medication missing from outpatient list Wrong outpatient dosage started Wrong outpatient drug started Outpatient drug continued when no longer indicated
100/100 (100) 82/100 (82) 18/100 (18) 12/18 (67) 7/18 (39) 86/100 (86) 74/86 (86) 12/86 (14) 8/12 (67) 9/12 (75) 1/12 (8) 3/12 (25)
MC could have been done incorrectly in multiple ways. NC = not calculated.
a
666
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Teams Without Pharmacy Student
p
51/100 (51) 0.0001 31/100 (31) 0.006 20/51 (39) NC 17/20 (85) 3/20 (15) 93/100 (93) 0.165 63/93 (68) 0.005 30/93 (32) NC 14/30 (47) 8/30 (27) 1/30 (1) 12/30 (40)
NOTE Pharmacy students
and to be performed correctly during both admission and discharge when the mental health teams had a pharmacy student as part of the team. For patients who were followed by a team that included a pharmacy student, 100% of medication reconciliations were performed on admission by the pharmacy student. However, at hospital discharge, only 86% of these same patients had medication reconciliation documented by a pharmacy student. The most likely reason for this is that the student had left the rotation before the patient was discharged. For the remaining 14%, all but one patient had a medication reconciliation note documented in their record, but the reconciliation was performed by another team member. Our study did not find a significant difference between the experimental and control groups regarding appropriate psychotropic monitoring. However, it should be noted that pharmacy students did provide other recommendations besides drug monitoring such as drug selection and dosage adjustments. In addition, the students alerted the teams to potential drug–drug interactions, drug– disease interactions, therapy duplications, and medications without an indication. These interventions were not captured in this study. Physician acceptance rates of students’ recommendations were also not measured. Similar to what was observed in the study by Szkiladz et al.,6 we did not find that pharmacy student involvement helped decrease hospital readmission rates. Because readmissions and medication nonadherence are common among mental health patients, we wanted to help decrease these phenomena through the pharmacy students’ rotation in the inpatient mental health unit. One change that has already been implemented is that pharmacy students provide each patient a discharge counseling sheet that is easy to understand and assists with medication organization.
Table 3.
Rates of Appropriate Psychotropic Monitoring Fraction (%) Pts With Appropriate Monitoringa Teams With Pharmacy Student
Monitoring Variable
Lithium treatment Lithium concentration 9/9 (100) Basic metabolic profile 9/9 (100) Thyroid stimulating hormone concentration 8/9 (89) Urinalysis 7/9 (78) Valproic acid treatment Valproic acid concentration 21/23 (91) Liver function tests 21/23 (91) Complete blood count 21/23 (91) Use of Abnormal Involuntary Movement Scale 34/64 (53) Second-generation antipsychotics treatment Weight or body mass index 47/57 (82) Blood glucose concentration 57/57 (100) Lipid profile 49/57 (86) Blood pressure 55/57 (96) All applicable monitoring 338/397 (85)
Teams Without Pharmacy Student 11/11 (100) 11/11 (100) 10/11 (91) 7/11 (64) 25/30 (83) 26/30 (87) 27/30 (90) 42/68 (62) 44/52 (85) 52/52 (100) 42/52 (81) 49/52 (94) 346/410 (84)
No differences between study groups were significant.
a
In addition, the pharmacy preceptor and students will begin providing follow-up telephone calls to patients for whom new psychotropic medications are initiated. These calls will be made a week or two after discharge to inquire about adverse effects and medication adherence. Conclusion The presence of fourth-year pharmacy students on inpatient mental health interdisciplinary teams was associated with more frequent interventions, patient counseling, and medication reconciliation, compared with rates for teams without a pharmacy student. Medication reconciliation was performed more consistently and accurately when the teams had a pharmacy student than when they did not. References 1. Joint Commission. National Patient Safety Goals. www.jointcommission.org/ standards_infor mation/nps g s.aspx (accessed 2014 Feb 18).
2. Gleason KM, McDaniel MR, Feinglass J et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010; 25:441-7. 3. Mersfelder TL, Bouthillier MJ. Value of the student pharmacist to experiential practice sites: a review of the literature. Ann Pharmacother. 2012; 46:541-8. 4. Mersfelder TL, Bickel RJ. Inpatient medication history verification by pharmacy students. Am J Health-Syst Pharm. 2008; 65:2273-5. 5. Lubowski TJ, Cronin LM, Pavelka RW et al. Effectiveness of a medication reconciliation project conducted by PharmD students. Am J Pharm Educ. 2007; 71:94. 6. Szkiladz A, Carey K, Ackerbauer K et al. Impact of pharmacy student and residentled discharge counseling on heart failure patients. J Pharm Pract. 2013; 26:574-9. 7. Pham DQ. Evaluating the impact of clinical interventions by PharmD students on internal medicine clerkships: the results of a 3 year study. Ann Pharmacother. 2006; 40:1541-5. 8. Campbell AR, Nelson LA, Elliott E et al. Analysis of cost avoidance from pharmacy students’ clinical interventions at a psychiatric hospital. Am J Pharm Educ. 2011; 75:8. 9. Mathys M, Bakshi R, Gray K et al. Utilizing 4th year pharmacy students as the primary pharmacy members within mental health interdisciplinary teams. J Pharm Pract. 2011; 24:247.
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ar
NOTE
Layar
Effect of pharmacy students as primary pharmacy members on inpatient interdisciplinary mental health teams
M
Monica Mathys, Elizabeth Neyland-Turner, Keenan Hamouie, and Emily Kim
edication reconciliation from hospital admission to discharge is a fundamental step for continuity of patient care. Comprehensive medication reconciliation is necessary to ensure safety and to prevent adverse events. The Joint Commission mandated medication reconciliation as a National Patient Safety Goal because “medication discrepancies can affect patient outcomes.”1 Data suggest that having a pharmacist involved in the medication reconciliation process leads to better outcomes. In 2010, Gleason et al.2 reported that after having pharmacists perform thorough medication reconciliations, 69% of inpatient prescriptions needed to be corrected with order changes. Among the prescriptions that were corrected, 64% were considered clinically relevant, where intervention by the pharmacist prevented possible increased hospital length of stay or harm to the patient. In addition to pharmacists, pharmacy students are competent in performing medication reconciliation.3-5 In one study,
Purpose. The effect of pharmacy students as primary pharmacy members on inpatient interdisciplinary mental health teams was investigated. Methods. This retrospective study used Veterans Affairs data from veterans who were admitted to an inpatient mental health unit from January 1, 2010, through December 31, 2012. Eligible veterans had to have been hospitalized for at least five days and treated with at least five scheduled medications during the hospitalization. Information collected by the investigators included patient age, psychiatric diagnoses, accuracy of medication reconciliation on admission and at discharge, and readmission rates within six months and one year. Additional information collected included monitoring parameters for lithium, divalproex, first-generation antipsychotics, and second-generation antipsychotics. The primary outcome was the percentage of accurate medication reconciliations for treatment teams with a fourth-year pharmacy student and without a pharmacy student. Clinical monitoring and readmission rates were also compared.
67% of 326 charts had medication or dosage omissions that were clarified
Monica Mathys, Pharm.D., CGP, BCPP, is Associate Professor of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center (TTUHSC), Dallas. E lizabeth N eyland -Turner, M.S., Pharm.D., is Staff Pharmacist, CVS Pharmacy, Grand Prairie, TX; when this study was performed she was a Pharm.D. student, School of Pharmacy, TTUHSC, Dallas. Keenan Hamouie, Pharm.D., is Staff Pharmacist, H-E-B Pharmacy, Houston, TX; when this study was performed he was a Pharm.D. student, School of Pharmacy, TTUHSC, Dallas. Emily Kim, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Palmetto General Hos-
Results. A total of 526 patients were eligible for study inclusion. Medication reconciliation was performed on admission for all patients followed by a team involving a pharmacy student (experimental group), but only 51% of patients in the control group had documented medication reconciliations in the medical chart. Of the medication reconciliations completed, 82% were performed correctly in the experimental group, compared with 61% when a pharmacy student was not involved (p = 0.006). There were no significant differences between groups in psychotropic monitoring and readmission rates. Conclusion. The presence of fourth-year pharmacy students on inpatient mental health interdisciplinary teams was associated with more frequent interventions, patient counseling, and medication reconciliation, compared with rates for teams without a pharmacy student. Medication reconciliation was performed more consistently and accurately when the teams had a pharmacy student than when they did not. Am J Health-Syst Pharm. 2015; 72:663-7
by pharmacy students on internal medicine clerkships.4 Another study
pital, Hialeah, FL; when this study was performed she was a Pharm.D. student, School of Pharmacy, TTUHSC, Dallas. Address correspondence to Dr. Mathys (monica.mathys@ttuhsc. edu). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0402-0663. DOI 10.2146/ajhp140411
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663
NOTE Pharmacy students
showed that 922 medication discrepancies involving 330 patients were found by pharmacy students on the general medicine or surgery floors.5 In addition to medication reconciliation, pharmacy students have demonstrated that they are capable of providing high-quality discharge counseling, therapeutic recommendations, and cost avoidance.3,6-8 To date, only one study has evaluated the cost-saving potential of pharmacy students’ clinical interventions in a psychiatric hospital.8 We studied the effect of medication reconciliation by pharmacy students in an inpatient mental health facility. Background This study was conducted in a 40bed Veterans Affairs (VA) inpatient mental health unit with an average daily census of 30–36 patients. Admitted veterans are assigned to one of five interdisciplinary treatment teams. Each team comprises an attending psychiatrist, a psychiatry resident, and a registered nurse, with social workers, psychologists, and hospitalists available when necessary. Only one clinical pharmacist works in the mental health unit. This pharmacist is a full-time faculty member with a local school of pharmacy but also a 0.5-full-time-equivalent contract employee with VA. The clinical pharmacist precepts 16–18 fourthyear pharmacy students throughout the year. During psychiatric rotations, pharmacy students are assigned to an interdisciplinary team such that most treatment teams have a pharmacy member. Pharmacy students provide comprehensive medication reviews for each patient admitted to their treatment team. In addition, they perform medication reconciliation on admission and at discharge and provide discharge counseling. This current clinical– teaching practice was started in 2009. Since that time, the number of pharmacy clinical interventions has increased from 20 to over 200 per 664
month. The students have helped meet one of the National Patient Safety Goals by providing medication reviews and reconciliation for more than 90% of patients admitted to the inpatient mental health unit from 2009 through 2012. In addition, the students have assisted with providing discharge counseling for 65–70% of these patients.9 Although the coverage of pharmacy services increased dramatically when pharmacy students were assigned to individual interdisciplinary mental health teams, we wanted to explore the clinical impact of the current practice. This study was designed to compare outcomes of the interdisciplinary teams when a pharmacy student was included versus when the teams did not have access to a pharmacy member. The primary outcome was the percentage of accurate medication reconciliations for treatment teams with a fourth-year pharmacy student and without a pharmacy student. Secondary outcomes included the (1) appropriate monitoring of lithium and valproic acid therapy, (2) use of the Abnormal Involuntary Movement Scale (AIMS) for monitoring patients treated with antipsychotics, (3) metabolic monitoring for patients treated with secondgeneration antipsychotics, (4) mental health readmissions within six months of the last discharge date due to medication nonadherence, and (5) mental health readmissions within one year of the last discharge date due to medication nonadherence. Methods This retrospective study used VA data from veterans who were admitted to an inpatient mental health unit from January 1, 2010, through December 31, 2012. The study was approved by the institutional review boards of the VA health system and the university involved. Eligible veterans had to have been hospitalized in the mental health unit for at least five days and treated with at least five
Am J Health-Syst Pharm—Vol 72 Apr 15, 2015
scheduled medications during the hospitalization. During the rotation, pharmacy students were required to enter an admission medication reconciliation note and a medication review note into a patient’s medical record within 24 hours of when they became aware that their team was following that patient. Because most admissions occur during the afternoon and evening hours, patients were not officially assigned to treatment teams until the next weekday morning during rounds. The students had 24 hours from this point to complete their notes. Usually, notes appeared in the chart within two days of a patient’s admission. However, for patients admitted on a Friday or Saturday, the treatment team was not assigned until the following Monday. For these patients, the students’ notes were expected to appear on the following Tuesday, which could have been four days after admission for patients admitted on a Friday. Having a hospital stay of at least five days as an inclusion criterion allowed students to have adequate time to complete their medication reviews. The authors also wanted to include patients who would benefit most from having medication reviews and medication reconciliations performed, such as those taking multiple medications. Requiring study patients to be taking five or more medications ensured that patients with morecomplex regimens were included. Patients were excluded if they were admitted primarily for alcohol or drug detoxification or if they refused inpatient medications at least 75% of the time during their hospital stay. We believed that these exclusion criteria were necessary to accurately determine readmission rates. Patients with psychotic or mood disorders were the intended target population in addition to those who were willing to be compliant with their medications at discharge. Patients followed by the geriatric interdisciplinary
NOTE Pharmacy students
team were excluded from the study because this team includes a clinical pharmacist year-round. Whether a patient had been assigned to a team with a pharmacy student was determined by the date of admission. The clinical pharmacist has students on rotation during the months of January through May but not during the whole month of June. Therefore, patients admitted from January through May were presumed to have had a pharmacy student on their treatment team, while those admitted during the other study months were presumed not to have had a pharmacy student on the team. Pharmacy student involvement was confirmed if a student’s medication review or reconciliation notes could be found in the patient’s chart. As expected, student notes were found for admissions in January–May, but there were no student notes found for the month of June. Information collected by the investigators included patient age, psychiatric diagnoses, accuracy of medication reconciliation on admission and at discharge, and readmission rates within six months and one year. Additional information collected included monitoring parameters for lithium, divalproex, first-generation antipsychotics, and second-generation antipsychotics. The medication reconciliation process was considered accurate if the following could be determined by reviewing the chart: (1) a medication reconciliation note was placed in the chart within 48 hours of admission for Monday–Thursday admissions, within 72 hours for Saturday admissions, and within 96 hours for Friday admissions and on the day of discharge and (2) within the note, the lists of scheduled inpatient and outpatient medications matched (including dose and schedule); if the lists did not match, the reasons for medication changes had to be documented. Reconciliation notes written by the students were considered cor-
rect if (1) they found discrepancies while performing the medication reconciliation process, (2) they documented these discrepancies, and (3) the discrepancies were resolved by the treatment team. To assess for appropriate psychotropic monitoring, the authors reviewed the charts for the recommended laboratory test values commonly noted in drug information references. Serum concentrations of lithium and valproic acid must have been checked during hospitalization to be considered as “appropriate monitoring.” In addition, patients must have had recommended baseline laboratory tests performed during hospitalization if they had not been done within six months before the hospitalization. These included a basic metabolic profile, thyroidstimulating hormone concentration, urinalysis (for patients taking lithium), or a complete blood count and liver function tests (for patients taking valproic acid). An AIMS assessment needed to be documented during the hospitalization for any patient taking antipsychotics who did not have such an assessment noted in the chart within six months of the hospitalization. Baseline metabolic monitoring, including body mass index, fasting glucose concentration, lipid panel, and blood pressure, was required for patients who were initiated on a new second-generation antipsychotic. Data for all eligible patients were entered into a spreadsheet and numbered. Software for the generation of random numbers was used to select the study patients from among eligible patients. Because all outcomes data were nominal, primary and secondary endpoints were analyzed using chi-square analysis or Fisher’s exact test when appropriate. The a priori level of significance was 0.05. Results Of the 1747 inpatient admissions identified from January 2010
through December 2012, a total of 526 patients were eligible for study inclusion. The most common reason for exclusion was a length of stay of less than five days. One hundred patient admissions were randomly selected for each group (experimental and control). Baseline characteristics are shown in Table 1. The mean age of patients was 52 years. The most common reason for inpatient admission was suicidal ideation. Major depressive disorder and psychotic disorder were the most common psychiatric diagnoses observed. Medication reconciliation was performed on admission for all patients followed by a team involving a pharmacy student (experimental group), but only 51% of patients in the control group had documented medication reconciliations in the medical chart (Table 2). Of the medication reconciliations completed, 82% were performed correctly in the experimental group, compared with 61% when a pharmacy student was not involved (p = 0.006). At discharge, 86% of medication reconciliations were performed correctly by the team with pharmacy student involvement compared with 68% in the control group (p = 0.005). Appropriate psychotropic medication monitoring was observed in 85% of patients in the experimental group and 84% in the control group (Table 3). All-cause readmission rates did not differ significantly between groups (100 patients per group) at six months (36 and 33 patients in the experimental and control groups, respectively) or at one year (47 and 43 patients in the experimental and control groups, respectively). Similarly, the rate of readmission attributable to medication noncompliance did not differ significantly between groups (100 patients per group) at six months (12 and 9 patients in the experimental and control groups, respectively) or at one year (17 and 13 patients in the experimental and control groups, respectively).
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NOTE Pharmacy students
Discussion During the mental health rotation, pharmacy students were required to perform medication reconciliation on admission and at discharge and provide thorough medication reviews and document these in the patients’ charts. The pre-
ceptor kept close watch of the admissions and discharges and knew which patients the students were following. The preceptor also ensured that all notes were completed, so there was little chance that these notes were not done as required. Students were taught that their medication review
Table 1.
Baseline Characteristics of Study Groups Patients Assigned to Teams With Pharmacy Student (n = 100)
Variable
Patients Assigned to Teams Without Pharmacy Student (n = 100)
p
Mean ± S.D. age, yr 52.2 ± 10.0 52.9 ± 11.0 0.622 No. men 93 94 >0.999 Diagnosis, no. patientsa Anxiety 1 1 >0.999 Bipolar disorder 21 20 >0.999 Depression 52 40 0.118 Posttraumatic stress disorder 13 11 0.828 Psychotic disorder 23 31 0.265 Reason for admission, no. patients Depression 2 6 0.279 Homicidal ideation 5 13 0.081 Mania 5 5 >0.999 Psychosis 28 31 0.757 Suicidal ideation 60 45 0.047 a
Patients may have had more than one psychiatric diagnosis.
notes should (1) address all of a patient’s diseases, (2) ensure that each medication has an indication and that a disease is not being undertreated, (3) assess the current treatments, and (4) address the recommended medication monitoring. Pharmacy recommendations were communicated in the note and orally during rounds. The students continued to follow their assigned patients daily. On the day of discharge, the students completed discharge medication reconciliation notes and provided counseling to their patients, emphasizing the new medications and the changes that occurred during the hospitalization. The medication reconciliation process involves comparing active inpatient and outpatient medications using VA’s Computerized Patient Record System and interviewing the patients to inquire about non-VAprescribed medications. If discrepancies were found during the medication reconciliation process, the students were instructed to notify the pharmacy preceptor or the attending psychiatrist so that corrections could be made as soon as possible. Our study found that medication reconciliation was more likely to be documented in the chart on admission
Table 2.
Medication Reconciliation (MC) Accuracy Fraction (%) Patients Variable
Teams With Pharmacy Student
Admission MC notes documented Notes done correctly Notes not done correctlya Medication missing from inpatient list Wrong dosage started in hospital Discharge MC notes documented Notes done correctly Notes not done correctlya Medication missing from outpatient list Wrong outpatient dosage started Wrong outpatient drug started Outpatient drug continued when no longer indicated
100/100 (100) 82/100 (82) 18/100 (18) 12/18 (67) 7/18 (39) 86/100 (86) 74/86 (86) 12/86 (14) 8/12 (67) 9/12 (75) 1/12 (8) 3/12 (25)
MC could have been done incorrectly in multiple ways. NC = not calculated.
a
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Teams Without Pharmacy Student
p
51/100 (51) 0.0001 31/100 (31) 0.006 20/51 (39) NC 17/20 (85) 3/20 (15) 93/100 (93) 0.165 63/93 (68) 0.005 30/93 (32) NC 14/30 (47) 8/30 (27) 1/30 (1) 12/30 (40)
NOTE Pharmacy students
and to be performed correctly during both admission and discharge when the mental health teams had a pharmacy student as part of the team. For patients who were followed by a team that included a pharmacy student, 100% of medication reconciliations were performed on admission by the pharmacy student. However, at hospital discharge, only 86% of these same patients had medication reconciliation documented by a pharmacy student. The most likely reason for this is that the student had left the rotation before the patient was discharged. For the remaining 14%, all but one patient had a medication reconciliation note documented in their record, but the reconciliation was performed by another team member. Our study did not find a significant difference between the experimental and control groups regarding appropriate psychotropic monitoring. However, it should be noted that pharmacy students did provide other recommendations besides drug monitoring such as drug selection and dosage adjustments. In addition, the students alerted the teams to potential drug–drug interactions, drug– disease interactions, therapy duplications, and medications without an indication. These interventions were not captured in this study. Physician acceptance rates of students’ recommendations were also not measured. Similar to what was observed in the study by Szkiladz et al.,6 we did not find that pharmacy student involvement helped decrease hospital readmission rates. Because readmissions and medication nonadherence are common among mental health patients, we wanted to help decrease these phenomena through the pharmacy students’ rotation in the inpatient mental health unit. One change that has already been implemented is that pharmacy students provide each patient a discharge counseling sheet that is easy to understand and assists with medication organization.
Table 3.
Rates of Appropriate Psychotropic Monitoring Fraction (%) Pts With Appropriate Monitoringa Teams With Pharmacy Student
Monitoring Variable
Lithium treatment Lithium concentration 9/9 (100) Basic metabolic profile 9/9 (100) Thyroid stimulating hormone concentration 8/9 (89) Urinalysis 7/9 (78) Valproic acid treatment Valproic acid concentration 21/23 (91) Liver function tests 21/23 (91) Complete blood count 21/23 (91) Use of Abnormal Involuntary Movement Scale 34/64 (53) Second-generation antipsychotics treatment Weight or body mass index 47/57 (82) Blood glucose concentration 57/57 (100) Lipid profile 49/57 (86) Blood pressure 55/57 (96) All applicable monitoring 338/397 (85)
Teams Without Pharmacy Student 11/11 (100) 11/11 (100) 10/11 (91) 7/11 (64) 25/30 (83) 26/30 (87) 27/30 (90) 42/68 (62) 44/52 (85) 52/52 (100) 42/52 (81) 49/52 (94) 346/410 (84)
No differences between study groups were significant.
a
In addition, the pharmacy preceptor and students will begin providing follow-up telephone calls to patients for whom new psychotropic medications are initiated. These calls will be made a week or two after discharge to inquire about adverse effects and medication adherence. Conclusion The presence of fourth-year pharmacy students on inpatient mental health interdisciplinary teams was associated with more frequent interventions, patient counseling, and medication reconciliation, compared with rates for teams without a pharmacy student. Medication reconciliation was performed more consistently and accurately when the teams had a pharmacy student than when they did not. References 1. Joint Commission. National Patient Safety Goals. www.jointcommission.org/ standards_infor mation/nps g s.aspx (accessed 2014 Feb 18).
2. Gleason KM, McDaniel MR, Feinglass J et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010; 25:441-7. 3. Mersfelder TL, Bouthillier MJ. Value of the student pharmacist to experiential practice sites: a review of the literature. Ann Pharmacother. 2012; 46:541-8. 4. Mersfelder TL, Bickel RJ. Inpatient medication history verification by pharmacy students. Am J Health-Syst Pharm. 2008; 65:2273-5. 5. Lubowski TJ, Cronin LM, Pavelka RW et al. Effectiveness of a medication reconciliation project conducted by PharmD students. Am J Pharm Educ. 2007; 71:94. 6. Szkiladz A, Carey K, Ackerbauer K et al. Impact of pharmacy student and residentled discharge counseling on heart failure patients. J Pharm Pract. 2013; 26:574-9. 7. Pham DQ. Evaluating the impact of clinical interventions by PharmD students on internal medicine clerkships: the results of a 3 year study. Ann Pharmacother. 2006; 40:1541-5. 8. Campbell AR, Nelson LA, Elliott E et al. Analysis of cost avoidance from pharmacy students’ clinical interventions at a psychiatric hospital. Am J Pharm Educ. 2011; 75:8. 9. Mathys M, Bakshi R, Gray K et al. Utilizing 4th year pharmacy students as the primary pharmacy members within mental health interdisciplinary teams. J Pharm Pract. 2011; 24:247.
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