ASHP InterSections ASHP InterSections

January 21, 2010

A Year to Remember

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Lynnae M. Mahaney, M.B.A., FASHP

AS WE GREET THE NEW YEAR, I have to admit that, in some ways, I am glad that 2009 is behind us. It was a year of unprecedented economic challenges. We watched as Congress struggled with the critical issue of health care reform. And many of us who work in emergency departments (EDs) dealt with the ongoing challenge of an H1N1 pandemic. This first issue of 2010 reflects some of these challenges and sheds light on what may be coming around the corner. It also shows how far we have come as a profession and the many ways in which we contribute to quality patient care.

Our cover story, on page 8, is about how health care reform may affect hospital pharmacists, and it is eye-opening and full of hope. ASHP has advocated for many years that pharmacists need to be recognized as health care providers. Although the bill that passed the House in November doesn’t explicitly allow for that designation, it does open the door for pharmacists to demonstrate their medication management expertise as part of innovative care models such as “medical homes.” As the saying goes, although we are just at the “beginning of the beginning,” this is very good news.

As you will see on page 12, pharmacists around the country are approaching the pandemic of H1N1 in new and novel ways, finding opportunities for patient counseling, education, and emergency preparedness. For example, after a change in a New York state law allowed pharmacists to administer influenza and pneumococcal vaccines, the pharmacy department at Montefiore Medical Center in the Bronx stepped up to the plate, initiating a series of immunization training programs. Conducted by faculty members from Touro College of Pharmacy in Harlem, the programs have certified more than 60 pharmacists since the fall.

Quality health care is a team affair, and at the Carolinas Medical Center-NorthEast, in Concord, North Carolina, a team of pharmacists is changing how infectious disease cases are handled in the ED. Take a look on page 17 to see how pharmacists are reducing hospital re-admissions caused by infection.

As you can see here, this issue of ASHP InterSections is full of stories about pharmacists who are making a difference. We hope you enjoy it! Drop me a line at prez@ashp.org or contact me on the new ASHP Connect Blog, and let me know what you think.

Lynnae M. Mahaney, M.B.A., FASHP

A New Day For Pharmacy Practice

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Henri R. Manasse, Jr., Ph.D., Sc.D.

Henri R. Manasse, Jr., Ph.D., Sc.D.

THIS ISSUE’S COVER STORY highlights the ways in which health care reform may impact pharmacists in their day-to-day work. It is truly an exciting time to practice pharmacy. But we must remember that the future of our profession is still unwritten. We still haven’t reconciled our traditional notions of what pharmacists do with the new patient-care-oriented training and capabilities that today’s pharmacy school graduates bring to the table.

I believe that pharmacy will be relegated to an ancillary service in the future if we fail to utilize this talent more actively and more effectively. We need a practice revolution of sorts. We need to have a spirited discussion about what our profession should look like in the future.

There is no better time than now, a time when drug therapy is riskier and more complex than ever, a time when pharmacists are proving the value of having a medication expert involved in therapy decisions, and a time when our hospitals are coming under increased pressure to adopt best practices and quality guidelines.

As it has done so often in its history, ASHP is stepping up, taking on the issue of practice model reform. Together with the ASHP Foundation, we have launched a Pharmacy Practice Model Initiative to begin examining these important questions.

This multi-year initiative has a number of components, including an invitational consensus summit, a robust social marketing campaign, and demonstration projects. The initiative will focus on five areas to shape the future of our profession:

• Fostering the creation of new pharmacy practice models that ensure that all hospital and health-system patients receive safe, effective, efficient, accountable, and evidence-based care

• Highlighting patient-care-related services that should be consistently provided by departments of pharmacy in hospitals and health systems

• Identifying which technologies support this new practice model

• Ensuring that pharmacy resources are deployed as efficiently as possible

• Identifying specific actions that we can all take to bring about practice change

We want the Pharmacy Practice Model Initiative to be an ongoing conversation that happens among all members, and we are encouraging pharmacists to participate through a number of avenues. We have a robust website (www.ashp.org/ppmi) with lots of resources for you to delve into. And there will be wide-ranging discussions on ASHP Connect, our online community. Change will only happen if every pharmacist gets involved. Join us. This is your revolution!

Henri R. Manasse, Jr., Ph.D., Sc.D.

Team of Pharmacists Focuses on Antimicrobial Therapy

THE RISING PREVALENCE across the country of infectious diseases in patients who visit emergency departments (EDs) remains one of the biggest challenges being faced by health care personnel today.

The pharmacy team at Carolinas Medical Center-NorthEast won a 2009 ASHP Best Practices Award for its work overseeing patients’ antibiotic regimens.

In this busy environment, pharmacists often must play the role of interventionist to help guide physicians toward appropriate antibiotic selection and dosage to address resistant infections and tailor therapy to local resistance patterns. A team of pharmacists at Carolinas Medical Center-NorthEast, in Concord, N.C., is helping to shift this paradigm. Timothy C. Randolph, Pharm.D.; Andrea Parker, Pharm.D.; Liz Meyer, Pharm.D.; and Renee Zeina, Pharm.D., have moved beyond a consultation role into one of helping to oversee patients’ antibiotic regimens.

“Our team is doing a lot to open the eyes of physicians to show what pharmacists can bring to the ER,” said Randolph, who helped kick off the program in partnership with Mary Anne Nolan, R.N., M.S.N., and Andrew Matthews, M.D.

Dramatic Reductions in Hospital Readmissions

Since June 2008, the team has managed the ED culture review process. When cultures are drawn, the pharmacist on duty helps select empiric antimicrobial therapy. Once culture and sensitivity data is finalized, the ED pharmacist de-escalates the medication regimen.

The results of this shift in responsibilities have been stunning: Not only have the ED pharmacists dramatically cut the number of unplanned readmissions, but they have also saved the ED physicians approximately 50 hours of work each month.

The team’s work is so impressive that it garnered a 2009 ASHP Best Practices Award in Health-System Pharmacy, an award that honors outstanding practitioners who have successfully implemented systems to improve patient care.

The pharmacy team’s submission described the results of a retrospective study conducted to measure the impact that this pharmacist-managed culture review process has had on patient outcomes.

The study of more than 4,600 patient charts measured two primary outcomes—the number of antimicrobial regimens modified and unplanned readmission rates— following culture review. The team then compared data from 12 months of physician-managed culture review against data from 12 months of pharmacist-managed culture review.

A “Win-Win Situation”

The results showed that the pharmacist-managed program resulted in a 3 percent increase in modifications made to patients’ antimicrobial regimens and a 12 percent reduction in the number of unplanned readmissions to the ED occurring within 96 hours of patients’ initial discharge.

“If we can prove that we can prevent a significant number of readmissions, patients will benefit, and the hospital will save money,” Randolph said. “It’s a win-win situation.”

Implementing Clinical Pharmacy Services

Steve Pickett, B.S. Pharm., BCPS

What lead to the pilot project at Providence in 2004?

In 1994, Roger Woolf, pharmacy director at Virginia Mason Medical Center in Spokane, Washington, and Larry Bettesworth, pharmacy director at Providence Sacred Heart Medical Center in Spokane, were inspired by what they heard about a patient-care-centric pharmacy model at the San Antonio Pharmaceutical Care Conference. I helped Woolf through the conversion from 1994 to 1999 and then helped Bettesworth complete the process from 1999 to 2004.

How were you able to get administration buy-in?

The pharmacy directors were passionate about their desire to implement a patient-centered care model and did their best to educate and convince their administrators of its value. The administrator over pharmacy at Providence Sacred Heart Medical Center, Elaine Couture, supported the development of the large program for several years but asked that the value be measured in 2004, which lead to the use of a documentation program.

What was most surprising about the project?

I was most surprised by how easy it was to gain the resources we needed once we made a solid business case. We also learned how to overcome inertia and manage the change process by involving staff in design and implementation. A change will not work unless staff members feel ownership of the process. We learned that lesson again and again.

When did you expand the pilot to other hospitals?

We knew we were ready when we gained approval for a corporate director of pharmacy clinical services. Data showed that some hospitals could pull through a market share contract or implement a protocol while others could not, and we believed it was related to the level of pharmacy clinical practice. However, it was not until we had a person who was free to travel and work with each hospital to help spread and adopt leading practices that things really took off.

How has patient care been improved?

The best indication we have at this time is the increase in the number of clinical interventions documented. Each intervention is associated with a value that gives it a relative weight of impact on the patient outcome. We track the number of interventions per case and have seen a consistent trend upward. We also are searching for more direct measures, such as reduction of adverse drug events, medication-related legal claims, and length of stay or other clinical outcomes.

If pharmacists are interested in pursuing this project in their own hospitals, what are the top three things they should do?

%%SIDEBAR%%The top thing I recommend is to start the process by developing a shared vision and need for this change with the staff. You can usually bypass resistance by having the pharmacy director, along with an administrator, meet with staff members, state the absolute necessity for the change, and then task them with developing the plan. Secondly, some may not want or be able to practice in a patient-centered model and may choose to leave. Be prepared to allow them that choice. Finally, you must have clinical leadership resources to succeed. If there is no clinical coordinator or manager, then a program is very unlikely to develop and grow.

What has this project meant to you personally and professionally?

When you convert to a patient-centered model, it’s exciting to see the reactions of pharmacists when they realize the impact this change will have on the care of their patients. In almost every case, pharmacists are convinced that patients are receiving safe, effective medication therapy. But when pharmacists are finally freed from distribution and can round or perform profile reviews, they begin to see all the opportunities that are available to improve medication therapy. Once I experienced that epiphany, my practice changed forever. I have now worked with 28 different hospitals to plan and implement a pharmacy clinical practice model and feel like I am just getting started.

NQF Recognizes Pharmacists as Leaders

Picture 17IN ITS NEW SET OF SAFE PRACTICES, the National Quality Forum is championing the need for pharmacists’ leadership in medication management, an exciting development for pharmacists across the country.

Safe Practice 18, titled “Pharmacist Leadership Structures and Systems,” is one of 34 guidelines for organizations that have proved effective in reducing adverse health care events. The practice is explicit in its support for pharmacy leadership, stating: “Pharmacy leaders should have an active role on the administrative leadership team that reflects their authority and accountability for medication management systems performance across the organization.”

Recognizing Pharmacists’ Patient-Care Role

Safe Practice 18 is an important new recognition of the health-system pharmacist’s role in reducing medical errors through medication management, according to Hayley Burgess, Pharm.D., BCPP, director of performance improvement measures, standards, and practices at the Texas Medical Institute of Technology in Austin.

“Pharmacists are good at implementing change, and someone has to go in and identify the gaps where people are getting hurt. This is what we are all well-trained to do,” said Burgess, who helped write the new practice standard.

NQF-LogoSafe Practice 18 is also a call to action for pharmacists to step up and take on larger leadership roles in areas like information technology within their own organizations, Burgess noted. “Pharmacists have the potential to be great leaders, but we haven’t always given ourselves enough credit for that in the past.”

The new practice, according to Burgess, gives pharmacists a road map for a safe medication program, based on the framework of strong leadership, a culture of safety, teamwork, and identifying and mitigating potential harm to patients.

Safe Practice 18 augments the four practices issued by the NQF in 2006, which covered standardized medication labeling and packing, high-alert medications, unit dose medications, and the pharmacist’s role in coordinating both of these kinds of medications.

The Value of Pharmacists

With Safe Practice 18, NQF is acknowledging the value of pharmacist involvement not only on the frontline delivery of safe patient care but also on the organizational level. That’s because pharmacist involvement at all levels has been shown to significantly improve patient outcomes, prevent harm, and reduce costs, said Mary Andrawis, Pharm.D., M.P.H., ASHP’s director of clinical guidelines and quality improvement.

“This recognition means that pharmacists should be expected to take on enhanced roles and responsibilities within their organizations,” she said, adding that there are three areas critical to enhancing the leadership potential of pharmacists:

1. Provider status: Pharmacists need to be recognized as health care providers for the purpose of liability and billing. ASHP has been aggressively advocating in Congress for the enactment of provider status for pharmacists.

2. Organizational decision making: Pharmacy leaders should be involved with integral system decisions.

3. Direct communication: The organization’s leadership team should have pharmacists engage directly with its board of directors.

Defining Leadership

Burgess believes that defining the skills to become a great leader is a critical, but difficult, step. “Our teams will follow leaders who have core values and behaviors that drive patient safety and organizational performance improvement,” she said.

The new NQF Safe Practice 18 calls for pharmacists to have an active leadership role.

Another critical step, according to Wayne Bohenek, Pharm.D., M.S., FASHP, vice president of care transformation at Catholic Healthcare Partners in Cincinnati, is to begin assessing individual facilities to reveal opportunities for improvement.

“Pharmacy is the only discipline called out by the NQF, which is a great honor,” he said. “But it’s only a first step. We need to find ways to take these concepts and operationalize them.”

As an example, Bohenek points to the NQF’s call for pharmacy leaders to communicate regularly and directly with hospital board members. To understand any barriers to that process, he suggests that pharmacists develop assessment tools similar to those of ASHP’s 2015 Initiative.

“For example, how many pharmacy directors have made a presentation to their facility’s board of directors?” he said, adding that the data could reveal the priority the board places on medication management and pharmacists’ patient-care role.

Lessons Learned

Hospital pharmacists who have already stepped into leadership roles can offer additional insights into how to partner with executives in meeting patient-care goals.

Take, for example, Darin Smith, Pharm.D., BCPS, who has served in his roles as director of pharmacy and director of performance improvement at Norman Regional Health System in Norman, Oklahoma, for more than two years.

Smith updates the health-system’s board monthly on health and safety issues facing the system’s three hospitals. He said his transition was made easier by the trust that the medical staff already had in the pharmacy department.

“They recognized the good work we had already done on quality initiatives,” he said. “When I look at all the work that needs to be done on safety, a good portion is medication-related. If pharmacists don’t step up and jump into these roles, other people will. And they don’t understand the intricacies of the systems like we do. Pharmacy leadership truly is the wave of the future.”

Pharmacy in the Time of H1N1

Pharmacy students at the University of Houston College of Pharmacy administered more than 2,500 flu vaccines this fall.

HOSPITAL AND HEALTH-SYSTEM PHARMACISTS around the country are struggling to keep up with demands being put on emergency rooms by increasing numbers of patients who are walking in with H1N1 flu symptoms.

“This virus has been a huge burden to our emergency room, and there have been a number of areas where our pharmacists have been asked to step up,” said Heather Draper Eppert, Pharm.D., BCPS, clinical specialist in emergency medicine and an assistant professor at the University of Tennessee College of Pharmacy, Knoxville. “Our ICUs are full, both with the usual high-acuity conditions but also with younger patients on the verge of respiratory failure.”

The H1N1 influenza outbreak officially reached pandemic proportions in November 2009, moving into high gear with the advent of the school year. According to the Centers for Disease Control and Prevention (CDC), by mid-November, nearly 22 million people in the U.S. had fallen ill with the virus. Close to 99,000 people had been hospital- ized, with almost 6,000 deaths reported.

Adding to the burden caused by the outbreak has been the media hype regarding the safety of the vaccines to help prevent its spread. The combination of these factors has driven even healthy patients to come to the ER to be checked, further stretching the limits of the nation’s medical infrastructure.

Yet the story has one bright spot: The challenges of H1N1 have also provided openings for hospital pharmacists to demonstrate their skills and knowledge, according to Draper Eppert, including patient education, vaccination administration, and emergency preparation.

Pharmacists as Advocates

One of the more alarming aspects of the H1N1 outbreak is the misunderstanding about the safety of the vaccines that can help prevent its spread. An October 2009 ASHP poll of hospital pharmacy directors found that most hospital workers are not vaccinated. According to the study, only 37 percent of the responding hospitals reported staff vaccination rates that topped 70 percent.

Mary Andrawis, Pharm.D., M.P.H., director of ASHP clinical guidelines and quality improvement, believes pharmacists should become flu vaccine advocates.

The problem, it appears, is that even hospital staffs have been misinformed about the safety of the vaccine despite recommendations from the CDC that all health care and emergency services personnel be vaccinated.

“If we aren’t successful at convincing hospital workers to get vaccinated, how can we convince patients?” said Mary Andrawis, Pharm.D., M.P.H., director of ASHP clinical guidelines and quality improvement. “This is an area where pharmacists need to become advocates for everyone to get vaccinated for the seasonal flu as well as H1N1.”

Pharmacists as Vaccinators

An area where pharmacists’ skills have proved invaluable during the outbreak is in their role in dispensing and administering vaccines and antivirals like Tamiflu®. Draper Eppert noted that one of the challenges her team of pharmacists face is making tough decisions regarding the potential rationing of drugs like Tamiflu during an inventory shortfall.

“We even have healthy patients who want a prescription just in case they get sick,” she said. “We have to make tough decisions about whether someone else needs it more.”

With the campaign for immunization under way, pharmacists from around the country have stepped up to administer vaccines. “ASHP has actively been encouraging hospitals and health systems to consider using pharmacists to administer vaccines in order to increase vaccination rates,” said ASHP president Lynnae Mahaney, M.B.A., FASHP.

Even pharmacy students have gotten involved. In Texas, students at the University of Houston College of Pharmacy who completed an immunization course administered more than 2,500 vaccines in a partnership with the Harris County health department.

“The students and faculty preceptors have been excited to get involved and to use their skills for something as important as preventing the further spread of a pandemic influenza virus,” said Kevin  Garey, Pharm.D., M.S., initiator of the program and chair of the department of clinical sciences and administration at the university.

Pharmacists and Emergency Preparedness

%%SIDEBAR%%Emergency preparedness has become a priority for hospitals and health systems in the wake of September 11, and pharmacists continue to play a critical role in such planning. The outbreak of H1N1 and other potential pandemics require planning in terms of vaccine and antiviral stocking and the skills necessary to monitor mass dispensations of those medications. Pharmacists have begun to play an even greater role in assisting public health departments in their planning efforts, according to Andy Stergachis, Ph.D., professor of epidemiology and global health and adjunct professor of pharmacy at the University of Washington School of Public Health, Seattle.

“Public health departments can’t do this alone for two reasons,” said Stergachis, who is also the pharmacy adviser to the public health department of Seattle and King County. “First, health departments have been losing personnel due to the recession. Second, health departments have never had the capability to conduct mass dispensations. This means that public-private partnerships offering pharmacists’ expertise in medicines and distribution are critical to meet community needs.”

Since 1979, the state of Washington has recognized pharmacists’ capabilities to prescribe and administer medications. That year, it created a collaborative drug therapy agreement providing pharmacists with prescriptive authority.

This has allowed pharmacists to play a major role in administering vaccines and to establish relationships with public health departments.

“Pharmacists were brought into the planning process early on and have been able to rapidly assume responsibility for providing oral antivirals and vaccine during the pandemic,” said Tim Fuller, M.S., FASHP, pharmacist consultant to the Washington State Department of Health Board of Pharmacy, which helps manage the state’s stockpile of vaccines and antivirals.

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