Pilot Project Demonstrates Success of Medication History Collection in ED
When Tyler Van Schyndel, Pharm.D., was choosing his pharmacy residency project in 2011, he wanted one that would leave a lasting mark. He chose well. His pilot study demonstrated that pharmacy technicians could efficiently and accurately collect medication histories in the emergency department (ED) of Froedtert Health,Milwaukee.
Dr. Van Schyndel’s work was so compelling that the hospital eventually adopted the practice as standard procedure in and beyond the ED.
“I saw a greater role for pharmacy technicians as something that could benefit the hospital,” said Dr. Van Schyndel, who conducted the project while a first-year pharmacy resident at Froedtert. “I also knew that ASHP’s Pharmacy Practice Model Initiative (PPMI) was a priority there, and that a big part of it is expanding roles for technicians.” (Dr. Van Schyndel is currently a second-year resident in critical care medicine at the University of Wisconsin Hospital and Clinics Pharmacy Services, Madison.)
Prior to the study, pharmacists conducted most medication histories after patients were admitted. That meant physicians frequently wrote initial medication orders before seeing a patient’s most up-to-date and accurate medication information. Because of this system, pharmacists would have to contact the prescribing physician to sort out discrepancies due to medication list changes that occurred after pharmacists met with patients on the floor to complete the medication reconciliation.
“From the standpoint of accuracy and medication safety, it was very important to obtain those medication histories as soon as patients came through the door,” added Jordan Dow, Pharm.D., M.S., Froedtert’s manager of medication utilization and Dr. Van Schyndel’s residency project preceptor.
Prior to the study, only 10 percent of medication histories were completed before admission orders were written. During the pilot, 98 percent of patient medication lists were updated prior to admission orders being written.
In the pilot study, one experienced technician was trained to conduct medication histories, gathering medication histories in the pre-admission testing clinic while being shadowed by a pharmacist. That was followed by three weeks of medication history taking in the ED, again under a pharmacist’s supervision.
Dr. Van Schyndel measured the technician’s efficiency and accuracy: The technician completed more than 13 histories daily, and pharmacist verification identified an average of 0.3 discrepancies per history. He also estimated that widespread use of technicians to take medication histories—rather than pharmacists or nurses—would save the hospital more than $110,000. It was clear to Dr. Van Schyndel that this was a cost-efficient way to arm physicians with the most accurate drug information about a patient before any drug orders were written.
“It’s safer for patients, requires less work redoing medication reconciliation on the floor, and requires far less time going back and forth with the physician to correct discrepancies,” he said.
Roles Shift to Benefit Patients
Dr. Van Schyndel presented his findings to the pharmacy department to justify re-allocating pharmacy technicians for medication history collection. That shift would become even more important after the hospital completed its planned transition to computerized prescription order entry (CPOE) in August 2012. Once that occurred, the primary role of technicians—transcribing prescribers’ written medication orders into the electronic medical record—would become obsolete. (Froedtert did complete its transition to CPOE on schedule last summer.)
“We needed to figure out how to best use the substantial amount of technician time that was freed up while simultaneously enabling pharmacists to perform higher-level functions, such as more direct patient care,” said Dr. Dow.
The hospital agreed. Pharmacy technicians now collect medication histories at the two major patient admission points: the ED and the pre-admission clinic, which are the gateways for about 75 percent of all admissions. A few histories are still collected on the inpatient side.
Dr. Dow emphasized that pharmacists remain accountable for the technicians’ performance and check their work before signing off on it. Four pharmacy technicians have so far been trained to conduct medication histories. Two more are in training to increase the pool of qualified technicians and avoid issues of insufficient staffing.
“The pilot study demonstrated the value of this technician-led service—both on paper and in practice—to our inpatient pharmacists as well as to our physicians and nursing colleagues in these areas, and it paved the way to roll out the initiative hospital-wide,” said Dr. Dow.
The change also represented a significant culture change for the pharmacy department. Pharmacists were concerned about allowing technicians to interact at such a high level with patients, but the technicians’ performance allayed their fears.
“After the study, the team completely supported the new arrangement,” said Dr. Dow, “and have even asked for more of the same.”