In 1998, Richard Sakai, Pharm.D., FASHP, FCSHP, became the director of pharmacy service at the 358-bed Children’s Hospital Central California (CHCC) in Madera. For Dr. Sakai, it was a homecoming of sorts. Nearly 20 years earlier, he had left the same hospital to continue his career at several other health systems across California. On his return, Dr. Sakai observed a pretty solid pharmacy program, albeit one that was a bit too centralized in its approach to patient care.
Dr. Sakai had picked up a few ideas in his travels. One thing he noticed was how a decentralized pharmacy could increase patient safety and allow pharmacists to apply and hone their clinical skills. In California, where most health-system pharmacists have a Pharm.D. degree and don’t want to spend much time in a central pharmacy, that flexibility was important.
Integrating Pharmacists into Care Units
Although he brought his vision to bear on CHCC, Dr. Sakai steered away from the prototypical decentralized pharmacy model (typified by satellite pharmacies located near patient care units). Instead, he persuaded the nursing and medical staff to provide pharmacists with space on the units themselves.“Over the years, I found that pharmacists tended to stay in the satellites because orders and questions continually came in. They just wait for ‘customers’ in their little office,” said Dr. Sakai. “Our pharmacists, though, have become integrated directly into the units, and they join team rounds. They can break away, if necessary, to process and validate orders, but they avoid getting bogged down in dispensing activities. To handle those functions, we have robust technology in our central pharmacy.”
Even pharmacists stationed in the central pharmacy provide clinical services—in fact, they are responsible for at least as many interventions as their colleagues out on the units because the central pharmacy operates around the clock. Decentralized pharmacists are on duty 10.5 hours a day. Because of the pharmacy staff’s frequent participation in clinical functions, added Dr. Sakai, they are considered essential components of the health care team. “The end result is that we enjoy a team approach to both dispensing and clinical services,” he said.
Shift in Attitude
That observation squares with the experience of Dave Hebert, Pharm.D., pediatric critical care pharmacist. Dr. Hebert has worked at CHCC for three decades, and he cannot recall a time when the medical staff was so openly reliant on his pharmacologic expertise. He attributes the shift in attitude to decentralization.
“The physicians walk by and want to enter an order into the computer. They also want my advice a lot of the time, and I am right there as a lead pharmacist to help them,” said Dr. Hebert. For instance, a physician might ask him what dose of Lasix he recommends for a child with low urine output. “They are pulling me in on the analytical side, and they usually follow my advice,” Dr. Hebert said.
Pharmacy technicians have also seen their roles expand. “In our facility, qualified technicians are crucial to provide high-tech distributive services and to support a complex pediatric unit-of-use philosophy for commercially available or extemporaneously compounded drugs,” said Dr. Sakai. “Our technicians have a career ladder, and each level requires greater skills and responsibilities.”
For Chris Dervin, CPht, a robot technician who has been at Children’s for more than nine years, work became decidedly more interesting as its scope expanded. “Everything has evolved; there are added safety measures because of technology, such as bar coding and scanning,” she said. “There is also a greater need to pay close attention to fine details and accuracy, which has made my position more challenging and rewarding.”
A Reliance on Technology
Fundamental to the practice model’s calculus is technology. The pharmacy holds an impressive array: robotic dispensing, a TPN compounder, automated dispensing cabinets, computerized prescriber order entry, bedside scanning, a repackaging machine, and automated record keeping. A robotic IV admixture machine is on Dr. Sakai’s wish list.“We use technology whenever feasible to minimize the time pharmacists spend on tasks like compounding, packaging, dispensing and record keeping,” he said. “That’s had a huge impact on efficiency and increased patient safety. When I see medication errors, they are human errors. The robot doesn’t make mistakes.”
The hospital’s administration has received the decentralized model enthusiastically because, according to Dr. Sakai, they embraced a culture of safety. Support from key physicians and medical staff committees were equally important to the program’s adoption and expansion.
The program’s financial impact certainly helped to foster support as well. For example, during the second quarter of 2011, there were 14,496 pharmacist interventions, 99 percent of which were accepted by prescribers. The resulting cost avoidance totaled nearly $350,000.
Dr. Hebert also credits Dr. Sakai for the success of the practice model.
“It took a director who had the vision to see the pharmacist as much more than someone cloistered in the basement,” he said. “Dr. Sakai finds people who have a passion for their work and he encourages them. When you do that, people feel empowered to do the best that they