ASHP InterSections ASHP InterSections

April 9, 2010

Preventing DVT Helps Patients and Bottom Lines

PHARMACISTS LYNDA THOMAS, Pharm.D., CACP, and Michael Palladino, Pharm.D., are part of a new wave of clinical specialists who oversee patients’ anticoagulation therapy post surgery.

Michael Palladino, Pharm.D., inpatient anticoagulation coordinator of the Jefferson Center for Vascular Diseases, speaks with a patient about the importance of DVT prevention.

They help ensure that orthopedic surgery patients don’t develop deep vein thrombosis (DVT), a potentially dangerous and often preventable condition common among orthopedic surgery patients. The best defense against DVT, anticoagulant therapy also comes with inherent risks. Leaders at Thomas Jefferson University (TJU) Hospital in Philadelphia see pharmacists as best equipped to keep patients safe post surgery.

“Warfarin is one of the top 10 drugs for medical errors,” noted Thomson, inpatient anticoagulation coordinator of the Jefferson

Center for Vascular Diseases, Thomas Jefferson University (TJU) Hospital in Philadelphia. TJU Hospital performs some 3,000 joint surgeries each year.

A New Wave

The pharmacists at TJU help to ensure that a new wave of clinical specialists who oversee patients’ anticoagulation therapy post surgery and help to ensure patients discharged on warfarin and other blood thinners transition safely home. Preventing adverse events and readmissions are key parts of their jobs.

“It’s an excellent chance for pharmacists to demonstrate the value and the return on investment from implementing these clinical services,” said Cynthia Reilly, B.S. Pharm., director of ASHP’s Practice Development Division.

Pharmacists Key to Prevention

Palladino, who is coordinator of the center’s orthopedic anticoagulation program, and Thomson focus on patient and family education around high-risk medications such  as warfarin and other bloodthinners. Their efforts helped TJU meet recent Joint Commission requirements around patient education for anticoagulant therapy.

In working with patients directly, “we’re first asking questions of the patient to get important information,” Palladino said. He added that pharmacists are best positioned to spot possible risks for each patient and to determine the drug and dose to prescribe to avoid bleeding complications or other risks.

TJU Hospital has instituted a computerized physician-order entry system, with automatic order sets prompting prescribers to assess each surgical patient for bleeding complications before offering appropriate prophylaxis anticoagulant options based on the patient’s risk.

“It’s an educational tool, as well as an order set,” Palladino said.

The pharmacists then work with patients to help them understand their medicines, the importance of follow-up monitoring, adherence, and drug-food interactions, and the potential for adverse drug reactions and drug interactions. Time is also spent calling health plans to advocate for patient needs, such as coverage for certain drugs or equipment.

Pharmacists also oversee proper care transitions for patients, scheduling labs and arranging for home health services. For the latter, pharmacists call each patient twice a week for six weeks post discharge to answer questions and ensure that each patient’s recovery goes smoothly.

“We’re transitioning patients back to the primary care physician,” said Thomson, adding that surgeons appreciate the help.

How to Arrange a Congressional Site Visit

I DECIDED TO SCHEDULE A SITE VISIT after participating in ASHP’s Legislative Day in September. There I met with Representative Jerry Moran and his legislative aide for health care, and we discussed ASHP’s key advocacy issues, including health care reform, provider status, medication therapy management, loan forgiveness, and residency funding. I told the congressman that I’d like to show him how health-system pharmacists in his district are a critical element in health care.

Linda Radke, Pharm.D. (left) and Representative Jerry Moran (R-Kansas) (right)

I followed up with the health care aide, who gave me the contact information for Representative Moran’s scheduler in our home district. I spoke with her in September, at which point she warned me that his schedule can get tight. Then, in December, she called with three days notice for the visit! The congressman could only stay for 30 minutes, so it was important to keep the visit concise but meaningful.

Being well prepared helped. I had already met with my hospital’s administration about how to plan the visit and the marketing department regarding logistics and publicity. ASHP really helped me prepare, too. I received great information about key legislative issues that I could share, and I sent Representative Moran an e-mail highlighting those. He actually read it in advance, which helped us make the most of his visit.

Building a Lasting Relationship

My ultimate goal is to build an ongoing relationship with the congressman, so I looked for other ways to keep in touch. First, I signed up for his This Week in Congress electronic newsletter. When one of the newsletters included his reasons for voting against the health care bill, I e-mailed him and reminded him about the issues we had discussed during our Legislative Day visit.

%%SIDEBAR%%Because he had only 30 minutes, we had to make Representative Moran’s site visit as high impact as possible. As part of the pharmacy tour, we watched one of our technicians prepare her IV run, which allowed us to talk about technician training programs being developed in Kansas. A student from the University of Kansas was on rotation and talked about her plans to pursue a PGY1 and PGY2 administrative residency and master’s program. This presented a great opportunity to talk about my hospital’s plans to develop a residency program, as well as residency funding issues. We also went to a patient floor and met with a clinical pharmacist who described a typical day and his unique role in patient care.

Reaching Out to Media

My marketing department had helped reach out to the local media, but the congressman’s office had done so, as well. I was thrilled to see a notice in my local paper the day before the congressman visited us. The newspaper sent a reporter who met with the congressman at the end of the visit, which resulted in a short article with a picture. Our state affiliate featured an article in its newsletter, and my hospital is planning to include an article in our quarterly newsletter. I couldn’t resist putting pictures from the visit on my Facebook page!

Cultivating a Deep Bench for Pharmacy

Michael Kelly, associate dean of the University of Iowa’s College of Pharmacy, works with a high school student.

MICHAEL KELLY, PHARM.D., is a recruiter for the University of Iowa. Instead of wooing young athletes for Hawkeyes sports teams, Kelly recruits potential clinical pharmacy talent.

In his attempts to pack a deep bench of talent among the student body at University of Iowa’s College of Pharmacy, where he is associate dean, Kelly has become an ambassador for health-system pharmacy in general.

“We are trying to move our recruiting down to middle school and early high school years,” Kelly said, adding that exposing young students to what pharmacists do helps to counter misperceptions about the profession and open the minds of young people to the rewards and challenges of a career in the field.

Attracting the Next Generation

“When you ask a little kid what they want to be, they usually don’t say, ‘I want to be a hospital pharmacist,’ ” noted Marni Lun, Pharm.D., M.B.A., director of ASHP’s Pharmacy Student Forum. Efforts such as those at the University of Iowa to educate students about careers in health-system pharmacy “help to ensure that we won’t miss out on valuable talent,” said Lun.

The College of Pharmacy works in partnership with other health sciences programs and with the university’s admissions office to host students, according to Kelly. Hundreds of middle and high school students from around Iowa and as far away as Chicago have participated in the program over the past several years.

In particular, the college is seeking to engage those students who don’t typically think of a career in pharmacy. “We’re focusing on underrepresented minorities,” Kelly says, including African American, Hispanic, and Native American students.

A “Hands On” Approach

RaShauna Applewhite, Spring 2010 Pharm.D. candidate at the University of Iowa

One young student impressed by a visit to University of Iowa’s College of Pharmacy was RaShauna Applewhite. As a freshman at Waterloo East High School in Waterloo, Iowa, several years ago, Applewhite visited the campus as part of a weeklong camp. The notion of a career in pharmacy intrigued her; this May, she expects to earn her Pharm.D. at University of Iowa.

“During one of the days, we visited the College of Pharmacy, and during that visit we made hand lotion,” Applewhite recalls. “Compounding the lotion was so fascinating, and I felt like pharmacy was a career that intrigued me.”

Hands-on activities seem to especially appeal to the students, according to Kelly. “When we get the glassware and chemicals out, they become engaged,” Kelly said, adding that he and his staff also teach students about how pharmacists work collaboratively with physicians and nurses on medical teams to care for patients.

%%SIDEBAR%%Kelly also takes the opportunity to debunk misperceptions about pharmacy, including the predominant view that pharmacists work only in retail settings dispensing medications.

Applewhite pointed to a black female pharmacist at the college, Lois Garland-Patterson, as someone who opened her eyes to the possibilities of a career in health-system pharmacy.

“She inspired me to pursue this career through her intelligence and passion for the profession,” Applewhite said. “Before meeting Lois, I had never met or talked to a pharmacist before, especially not an African American one. Throughout the rest of my high school career, I kept in touch with Lois. I knew when I prepared to graduate from high school that I definitely wanted to go to the University of Iowa.”

Applewhite first pursued a B.S. in microbiology at Iowa and then applied to the College of Pharmacy. At the time, “pharmacy was truly transitioning into a unique field,” she said, noting the profession’s increased patient-care focus.

“I’ve always known that I am a people person, and I like face-to-face interaction with patients daily,” she said. “I knew that with microbiology, I would probably be faced with isolation in a lab on a daily basis. I ultimately realized that pharmacy encompasses infectious disease as well as other disease states that I find  interesting.”

The University of Iowa’s outreach is important because “we don’t want to lose any good students,” said Kelly. Also, with younger students, Kelly is able to plant the seed they need to take four years of math and science in high school to have a realistic shot of getting into pharmacy school.

“We show them that there is a path, but you have to think about it earlier than later,” said Kelly.

“I am forever grateful to the people and opportunities in my life that encouraged me to go to pharmacy school and showed me that there are so many definitions to being a pharmacist,” Applewhite said.

New Pharmacy Services: One Medical Center’s Story

NEW YORK UNIVERSITY (NYU) Langone Medical Center is investing in pharmacists in a big way. Since hiring Thomas O’Brien, Pharm.D., as senior director of pharmacy in July 2008, the 812-bed institution has increased the number of staff pharmacists significantly, bringing the total number to about 60. The medical center has also added pharmacists to medical rounding teams in internal medicine, infectious diseases, critical care, psychiatry, the emergency department (ED), pediatrics/NICU TPN, geriatrics, and hematology/oncology.

Pharmacists at New York University Langone Medical Center have been added to a number of rounding teams.

Hired out of retirement to build a world-class pharmacy for the center and start a pharmacy residency program at NYU, O’Brien (formerly director of pharmacy services for Strong Health at the University of Rochester Medical Center, Rochester, N.Y., and Bassett Medical Center, Cooperstown, N.Y.) was given wide latitude by hospital administrators to enhance pharmacy services.

The primary reason behind the institution’s major commitment to pharmacy is self-evident, according to O’Brien.“Pharmacists assure rational drug therapy,” he said, pointing to the vast number of new drugs on the market as well as the cost-effectiveness of including pharmacists on rounding teams to help avert medication errors, maintain formulary compliance, and help decrease length of stay.

“Pharmacists are viewed as an invaluable resource, and a number of subspecialties have made requests to expand the program,” said Irene Kreuscher, vice president of professional services, NYU Hospitals Center, of having pharmacists round with medical teams. “To me, such recognition by other disciplines is an indisputable measure of success.”

Rising Importance of Pharmacists

In recent years, the issue of medication management has gained visibility as a key component in keeping patients safe. The Joint Commission (TJC) emphasized its importance in 2004 as a way to reduce preventable medication errors.

Thomas O’Brien, Pharm.D.

For years, ASHP has advocated for the involvement and leadership of pharmacists in the medication-use process, advocacy that is
clearly making an impact at TJC, according to O’Brien.

“During our TJC survey in December 2009, one of the surveyors asked, ‘Why aren’t there pharmacists on every medical team?’ That question could only have been prompted by ASHP’s advocacy on behalf of institutional pharmacists,” O’Brien said.

At Langone, medical staff are heeding that advice. “Physicians at the attending, fellow, resident, and intern levels have provided positive feedback,” said Robert Press, M.D., Ph.D., chief medical officer. “They truly value having a clinical pharmacist collaborate with them in patient care.”

Pharmacists at the center are also documenting how they are helping to improve care, according to John Papadopoulos, Pharm.D., FCCM, BCNSP, director of pharmacotherapy, and Movses Hovsepian, M.S., assistant director of clinical pharmacy services, division of pharmacotherapy and clinical pharmacy services.

For the 13 months that ended in January 2010, the center’s division of pharmacotherapy, for example, intervened nearly 8,000 times to optimize drug therapy, improve IV-to-PO step-down, and provide medication reconciliation, among other things.

Remaking the Pharmacy

The first thing O’Brien realized when he got to Langone was that the institution wasn’t making the best use of its pharmacists. The hospital had been paying $1.8 million a year in overtime for pharmacists.

Moreover, pharmacists were not involved in direct patient care, even though evidence supported the need for it. “There were pharmacists here for 25 years who never left the basement,” said O’Brien.

Langone began the process of change by investing more in human and technology resources. A software system that places a monetary value on clinical interventions was installed, as well as barcode technology to safely process unit-dose medicines and perform other duties.

“We utilize an intervention tracking software that collects our clinical pharmacists’ interventions and converts the intervention numbers to hard and soft dollar savings, which are significant,” Press noted, adding that the total savings for a recent 13-month period was more than $800,000.

Hospital pharmacy staff also saw their duties reshuffled.

“We had to get to where the patients were,” O’Brien said, noting that pharmacotherapy specialists were added to medical rounding teams throughout the hospital, including the ED.

Kanika Ballani, Pharm.D., PGY1 pharmacy resident, consults with John Papadopoulos, Pharm.D., FCCM , BCN SP, pharmacy residency program director and director of pharmacotherapy.

“The ED is a very vulnerable place,” said O’Brien, adding that “when a patient enters, they may be unable to give you their name, soit’s even more unlikely that they can relate anallergy to penicillin or other medications.”

Additionally, NYU Langone Medical Center accepted its first class of PGY1 pharmacy residents in 2009 and will be adding exciting technologies in the new Department of Pharmacy, including a pharmacy robot, a robotic “mini-warehouse,” and a USP 797—compliant clean room.

The changes have brought about real change in patient outcomes, according to Press.

“Collectively, we have seen an increase in patient specific interventions that we believe has led to a positive patient impact,” Press said. “We have seen our ‘perfect care’ numbers increase, possibly due to the collaborative patient care provided by our clinical pharmacists.”

The ability of pharmacists to optimize medication therapies, prevent errors, and increase medication cost efficiencies isn’t a surprise to O’Brien. Educating other health care providers, administrators, and the public to those capabilities is the real challenge.

“Pharmacy needs to continue to evolve as an intellectual, clinical discipline,” O’Brien stressed. “Pharmacy’s value to health care is not measured simply by how many prescriptions we can fill in an hour.”

Blazing a New Trail for Pharmacy

TWENTY-FIVE YEARS after the influential Hilton Head conference, ASHP and the ASHP Foundation are once again embarking on a groundbreaking national effort to guide the future of hospital and health-system practice.

The Pharmacy Practice Model Initiative (PPMI), officially launched in 2009, will revisit the hard consensus-building work of Hilton Head and other ASHP-hosted legacy conferences as pharmacists in all practice settings debate what the future of the profession should look like.

“National health care reform, constantly evolving technologies, massive amounts of new drugs entering the market every year, scientific breakthroughs… All of these and more are demanding that we, as pharmacists, really step up and begin to own the medication-use policies and procedures within our institutions,” said ASHP president Lynnae Mahaney, M.B.A., FASHP, chief of pharmacy services at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.

Expectations Versus Actual Opportunities

“We’re in an environment where there is national concern about the future state of health care,” said David Chen, R.Ph., M.B.A., director of ASHP Pharmacy Practice Sections. “Additionally, we’re seeing growing demand for enhanced pharmacy services and increasing pressure to integrate technology advances. We really need a self-critical analysis of the state of pharmacy practice.”

Although the Hilton Head conference and other ones like it successfully laid the groundwork for the all-Pharm.D. degree and many of the professional opportunities that pharmacists now enjoy, there is much more to achieve, according to Doug Scheckelhoff, M.S., ASHP vice president of professional development.

“Hilton Head was focused on the clinical profession of pharmacy and the types of training needed to get there,” Scheckelhoff said. “It was really pivotal in setting a clear direction. The PPMI will be just as important, but in a different way.”

A joint project of ASHP and the ASHP Foundation, the PPMI will comprise three components: an invitational summit this fall, a campaign to promote change, and demonstration projects funded by Foundation grants. At press time, McKesson Corporation had signed on as a Leadership-Level sponsor of the Initiative, and Omnicell, Inc. and CareFusion had signed on as Gold-Level sponsors.

An Unsettling Trend

The Initiative reflects a powerful movement within ASHP’s membership. The need for a new practice paradigm has surfaced again and again during the past several years in ASHP’s policymaking Councils and membership Sections, as well as during strategic planning for the Society’s Leadership Agenda.

“We’ve been monitoring a trend in which professionals other than pharmacists are taking roles that have traditionally been pharmacists’ roles, both by design and by direct competition,” Chen said, adding that the movement is troubling because pharmacists have the knowledge and skills to conduct direct patient care and medication management.

“We need to put our stake in the ground and become the recognized experts among our medical peers on drug therapy and medication-use processes,” he said. “We also have to start taking into consideration external influences that we don’t directly control but that will ultimately affect our opportunities.” 

The issue is particularly stark when one considers the scientific breakthroughs happening today, according to Karl Gumpper, R.Ph., BCPS, director of ASHP’s Section of Pharmacy Informatics and Technology. The Section recently published a Vision Statement on Technology-Enabled Practice, acknowledging many of the challenges and opportunities that lie ahead for pharmacists.

“Medication management eventually will move toward genetics and genomics,” Gumpper noted. “All of that science will go into dosing and even picking a medication. There is no one more qualified than pharmacists to do that job.”

Finding the Right Balance

Ultimately, the best pharmacy practice models are those that find optimal balance, matching the work to the skills of the individual and using automation and technology wherever possible to improve safety and efficiency, according to Scheckelhoff. “What are technicians capable of doing and what should they be doing?” he asked. “How can we use technology to improve our processes? And how can pharmacists directly impact the care of patients?”

Scheckelhoff noted the disparities that currently exist among pharmacy services at different types of hospitals and health systems across the country. ASHP’s National Survey has repeatedly shown that “innovator hospitals” offer high levels of pharmacy services. In contrast, less progressive hospitals still provide the same kinds of  services that they provided 30 to 40 years ago.

“We need to look for ways to close that gap,” Scheckelhoff said. “Our patients need it, and they deserve it.” ASHP created a website just for the Initiative and is encouraging members to disseminate their thoughts on the best practice models via ASHPConnect discussion boards.

The first major activity will be a multidisciplinary invitational summit this fall that will focus on developing a framework of pharmacy practice that takes into consideration the internal and external factors that will affect patient care in the future.

From there, a synopsis of proceedings will help members do their own critical analysis about what types of pharmacy services they are offering. This process will, in turn, drive the development of new practice models.

“To actually change our practice models, we will need leadership at every level of pharmacy…from the pharmacy director, to the clinician at the bedside, to the technician,” said Daniel J. Cobaugh, Pharm.D., FAACT, DABAT, the Foundation’s senior director for research and operations. “It won’t be easy, and it will take time and commitment, but we all need to be engaged in this exciting process.”

Summit Dates Announced
To kick off the PPMIMI, ASHP will host an invitational consensus conference Nov. 7-9, 2010, in Dallas. The conference will bring together thought leaders throughout hospital and health-system pharmacy to reach consensus on optimal practice models.

For more information on ASHP’s Pharmacy Practice Model Inititiave, go to www.ashp.org/ppmi.

Student Leadership Program Offered

WANT TO GET INVOLVED in the key issues affecting pharmacy and meet pharmacy veterans? Come to the second annual Pharmacy Student Leadership Development Program at the 2010 ASHP Summer Meeting. All student attendees will be paired with a seasoned practitioner through the new Mentoring Emerging Leaders program. Register today at www.ashp.org/sm10.

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