ASHP InterSections ASHP InterSections

April 9, 2014

PCIP Helps Pharmacists Make Big Impact in ED

Filed under: Clinical,Current Issue,Feature Stories,Innovation,Managers,Quality,Uncategorized — Kathy Biesecker @ 3:58 pm

ASHP’s Patient Care Impact Program aims to create more ED pharmacist positions in hospitals across the country.

THE SPEED AND COMPLEXITY OF CARE for patients in emergency departments (EDs) is a well-known contributor to medication errors and adverse drug events (ADEs). Studies show that twice as many medication errors occur in EDs than in the inpatient setting.[1]

And of the approximately 110 million patients who receive ED care each year in the U.S., 35 percent experience ADEs. Seventy percent of those are thought to be preventable. [2]

In 2007, the Agency for Healthcare Research and Quality corroborated ASHP’s view that hospital emergency rooms around the country could benefit greatly from pharmacists’ medication knowledge and oversight. It provided funding for the ASHP Patient Care Impact Program (PCIP), a small but crucial six-month traineeship to help practitioners implement an emergency pharmacist role within their own institutions.

“Pharmacists in the ED have been shown to reduce preventable adverse drug events, improve medication reconciliation, and help reduce drug costs,” said Barbara Nussbaum, B.S.  Pharm., MEd, Ph.D., ASHP’s director of adult learning and education programs. “It’s a total win-win for the hospitals who implement a pharmacist position in the ED.”

A Challenging Environment

Up to 10 trainees are picked for the program each year. Nationally recognized expert emergency practitioner Daniel P. Hays, Pharm.D., BCPS, FASHP, specialist in poison information, Arizona Poison & Drug Information Center, Tucson, serves as the program mentor, advising PCIP participants on the clinical projects they have chosen.

The pharmacists then engage in brainstorming sessions and monthly teleconferences for status updates, group mentoring,  and problem solving, all while earning 25 hours of CE credit.

Daniel Hays, Pharm.D., BCPS, FASHP

Daniel Hays, Pharm.D., BCPS, FASHP

“My role is to act as a sounding board for trainees and to provide guidance in moving ED services forward within their institutions,” said Hays. “Implementing this kind of program is not easy, and I help the participants deal with unique challenges they face in the emergency-care environment.”

The high stakes and elevated tensions of an ED can be challenging for a pharmacist who is used to working in a centralized pharmacy, according to Hays. In a place where orders are processed stat, it’s not always clear how and where medication experts fit in.

“Unfortunately, a pharmacist who is not trained in the unique environment of the ED will not last long,” he said. “There may be personality conflicts, and it’s a uniquely chaotic environment. The ED pharmacist needs to be able to function within and to integrate with the team while helping with all aspects of patient care.”

Trainees feel they have gleaned myriad benefits from the program. Rachana Patel, Pharm.D., pharmacy clinical manager, St. John Medical Center, Westlake, Ohio, and her PGY1 resident Steve Margevicius, have used what they learned to help embed a full-time pharmacist in St. John’s emergency department (ED).

Rachana Patel, Pharm.D.

Rachana Patel, Pharm.D.

“We are excited to have hired a pharmacist with several years of critical care experience, and I’ll be using my PCIP experience to help him bridge the pharmacy’s clinical activities throughout a patient’s entire stay in the hospital,” Patel said, adding that she was also able to add three full-time medication reconciliation technicians to the ED.

Tiffany Mitchem, Pharm.D., an emergency room (ER) pharmacist with Mobile Infirmary Health, Mobile, Ala., used the program to get the emergency care skills she needed in lieu of an intensive residency. Mitchem recently led an initiative to expand ER pharmacist’s services in her hospital to seven days a week.

“At Infirmary Health, unless pharmacists are physically in the ER, there is no pharmacist supervision of medication orders there. So, it’s really critical to get these services into the emergency care environment,” Mitchem said, adding that the PCIP program made her much more confident in her clinical abilities.

Saving Lives

Given the fact that 70 pharmacists have completed the program to date, it’s not a stretch to say that the PCIP saves lives.

Cody Maldonado, Pharm.D.

Cody Maldonado, Pharm.D.

During his PCIP traineeship, Cody Maldonado, Pharm.D., clinical emergency department pharmacist, Saint Vincent Healthcare, Billings, Mt., undertook a project to decrease mortality and improve outcomes in patients with septic shock.

“We found that the key to improving outcomes was faster detection and administration of antibiotics and fluids,” Maldonado said. “So, we implemented a ‘sepsis swarm’ that would alert the physician, pharmacist, charge nurse, and bedside nurse to the life-threatening situation. By having a pharmacist deliver the antibiotic directly to the patient’s bedside, we decreased average time from sepsis recognition to administration of antibiotics from over three hours to less than one hour.

“This multi-disciplinary alert has greatly improved awareness about sepsis, and I believe that it is part of the reason why our sepsis mortality has decreased by over 50 percent.”

Sharing Knowledge

The six-month traineeship concludes with a poster presentation given by each participant at ASHP’s Midyear Clinical Meeting. The information that trainees share with the thousands of pharmacists who attend ASHP’s Midyear serves to sensitize many more practitioners to the special aspects of emergency care.

PCIP participants present the findings of their ED projects at ASHP's Midyear Clinical Meeting.

PCIP participants present the findings of their ED projects at ASHP’s Midyear Clinical Meeting.

Nussbaum noted the success of a specific 2013 poster on antibiotic stewardship in the ED.

“Understanding the resistance patterns of patients who are coming in from outpatient settings is a hot issue because of the upswing in more dangerous bacterial strains,” she noted, adding that trainees are developing processes to use the most-effective medications in the ED setting.

Other participants appreciate the opportunity the PCIP provides them to present on a profession-wide “stage.”

“The PCIP advanced several career goals of mine, including my desire to publish more within my specialty and to present the results of our project at Midyear,” said Nicole Abolins, Pharm.D., emergency medicine clinical pharmacist with Novant Health Forsyth Medical Center, Winston Salem, N.C.

Abolins presented a poster at the 2013 Midyear on “Expanding emergency department pharmacy services by decentralizing existing pharmacy staff resources.”

The Payoff

Despite the challenges of practicing in an emergency environment, the payoffs can be big, according to Hays. Working directly with critically ill patients requires special skills but can be a real gift.

“When a pharmacist works in the ER, not only is he or she providing safe medication use, but he or she is a key part of the care team’s front line,” Hays said. “I tell my mentees, ‘Don’t be afraid to get a warm blanket for someone.’ And I’ve never heard an ER pharmacist say, ‘That’s not my job.’ ”

 –By Evan Mulvihill



[1] Santell JP, Hicks RW, Cousins DD. Medication errors in emergency department settings—5 year review. Presented at American Society of Health-System Pharmacists Summer Meeting; June 2004; Las Vegas, NV. Abstract.

[2] Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Eng J Med. 1991;324(6):370-376.

April 4, 2014

The Importance of Staying Current on New Guidelines

Filed under: Clinical,Current Issue,Residents,Students,Uncategorized,What Worked for Me — Kathy Biesecker @ 3:04 pm

Bryan P. White, Pharm.D.

AS A NEW PRACTITIONER at a 250-bed hospital, working the weekends can be intimidating. Fewer pharmacy staff work on weekends, and clinical and administrative support is only available via paging. The punctuality of a call back can vary widely.

On the weekends, you also receive many verbal orders and admissions from on-call physicians, a concern because increased error rates with verbal orders have been well documented.1 As an evening pharmacist, I often work two and half hours alone. Pharmacists must always be vigilant to ensure the best patient care, but the need to have heightened safeguards is even more important when you practice under low-staffing conditions.

Questioning a Verbal Order

Working in this environment builds your confidence, but the first year is difficult. Interventions can happen at any time. Late one Saturday night, I received a verbal order for “low-dose dopamine titrate to systolic blood pressure greater than 90 mm Hg” for a patient in the ICU.

Two blood cultures were also ordered by the same physician. I called the nurse to ascertain what was going on with the patient. The patient was hypotensive with mean arterial pressures less than 65 mm Hg and possible sepsis. Because new “Surviving Sepsis” guidelines2 indicate that norepinephrine was the vasopressor of choice, I wanted to ensure that the ordering physician had a specific reason for placing the patient on this particular regimen.

Interventions can be a great opportunity to educate fellow health care professionals about what pharmacists know and why we do what we do.

I paged the physician and discussed with him the current guidelines that show dopamine had higher mortality and supraventricular and ventricular arrhythmias when compared to dopamine. Because the guidelines had just come out, he was unaware of the new recommendations and thanked me for calling this to his attention. He went on to give me a new verbal order to change the patient to norepinephrine.

I walked up to the ICU and wrote the verbal orders to discontinue the dopamine drip and start a norepinephrine drip. I also spoke with the patient’s nurse and another nurse on the floor about the current “Surviving Sepsis” guideline recommendations on vasopressors.

An Opportunity to Build Relationships

The extensive time that it takes new knowledge to disseminate is well-documented in the literature. (It typically takes about 17 years before it becomes routine practice). Pharmacists can ensure they are doing what’s best for the patient by staying as up-to-date as possible on new clinical guidelines and recommendations. Being on the sharp edge of new information on medication use—and helping to disseminate that information to other members of the health care team—is critical to providing safe and effective treatment.

These types of interventions are not atypical, but I believe that they can be a great opportunity to educate fellow health care professionals about what pharmacists know and why we do what we do. It’s also important for new practitioners to develop confidence in discussing therapeutic changes with physicians. Interventions such as this one help to increase your rapport with practitioners, boost appreciation for a pharmacist’s role in patient care, and increase one’s own self-confidence in performing the critical duties of a pharmacist.

–By Bryan Pinckney White, Pharm.D., Staff Pharmacist, St. Francis Hospital, Columbus, GA

    1. Fijn R; Van den Bemt, P.M.L.A.; Chow, M.; De Blaey, C.J.; Jong‐Van den Berg, D.; & Brouwers, J.R.B.J. (2002). Hospital prescribing errors: Epidemiological assessment of predictors. British journal of clinical pharmacology, 53(3), 326-331.

 

  1. Dellinger, R.P.; Levy, M.; Rhodes, A.; Annane, D,; Gerlach, H.; Opal, S.M.;  Moreno, R. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine, 39(2), 165-228.

 

 

April 3, 2014

New ASHP eReports Focus on Practice Challenges

Filed under: Ambulatory Care,ASHP News,Clinical,Current Issue,InfoCentral — Kathy Biesecker @ 12:25 pm

ASHP RECENTLY LAUNCHED a new product line in its eBookstore called “ASHP eReports.” Similar to Amazon Kindle Singles, the eBook publications cost $9.95 each and focus on specific practice topics. Check out the current offerings at ebooks.ashp.org:

April 2, 2014

Patient Safety Award Highlights Best of the Best

University of Wisconsin Hospital and Clinics, Madison, won the 2011 award for its innovative anticoagulation stewardship program. Above, Philip Trapskin, Pharm.D., BCPS, confers with Anne Rose, Pharm.D.

NO ONE KNOWS MEDICATION SAFETY like a pharmacist, and the ASHP Research and Education Foundation’s Award for Excellence in Medication-Use Safety has showcased many of the best programs in the country since its launch a decade ago.

“This award is associated with projects that help to expand the role of pharmacists. It’s a model for showcasing pharmacists’ abilities to lead interprofessional teams to yield organization-wide, safety and quality initiatives,” said Stephen J. Allen, R.Ph., M.S., FASHP, the Foundation’s chief executive officer.

Supported by a grant from the Cardinal Health Foundation, the award provides $50,000 each year to a pharmacist-led multidisciplinary team for implementing significant institution-wide system improvements relating to medication use. Two finalists also receive $10,000 each.

Since the first award was given to OhioHealth in Columbus for its adoption of mechanisms to consistently identify adverse drug events and provide a platform for best practices across the system, the number of applications has climbed steadily to more than 30 per year, and the types of programs recognized have expanded from medication reconciliation to include a range of care areas such as post-discharge follow-up, anticoagulation stewardship, post-transplant care, diabetes care, and oncology.

As pharmacy practice and health care have evolved, the award has evolved with the work becoming sophisticated with significant impact and touching all areas of healthcare,” said Dianne Radigan, vice president of community relations at Cardinal Health.

Assessing Success

To win the award, a program or initiative must be able to provide evidence that it has improved medication-use safety and patient care. There must be quantifiable outcomes, and the applicant must be able to record specific, concrete ways that pharmacists and other members of a multidisciplinary team have worked together to produce the best patient outcomes.

Amassing the data provides an opportunity to assess the success of a program, said Teri B. Cardwell, R.Ph., Pharm.D., M.H.A., senior director of population health at Novant Health in Winston-Salem, N.C.  Novant won the award in 2008 for its outpatient medication reconciliation program for patients older than 65.

“It’s interesting to write it all down and see it in front of you,” Cardwell said. “We thought we were doing well, but when we got someone to run the numbers and look at the program more in depth, we learned just how much we’d done, and where we might want to go next.”

[The award] shows physicians and surgeons what a great resource they have in pharmacists and how pharmacists optimize care and help patients understand their medications.

Winning the award provided a boost to the team at the Medical University of South Carolina in Charleston, honored in 2010 for its initiative to decrease length of stay, preventable re-admissions, and adverse drug events for kidney transplant patients. The award brought the team recognition within their health system and landed them another award, this time from the hospital itself, to extend the initiative to other hospital services.

“Because this is a multidisciplinary process, the Award for Excellence in Medication Use Safety highlights to hospital leaders outside pharmacy how pharmacists can affect outcomes directly,” said Nicole A. Weimert-Pilch, Pharm.D., MSCR, BCPS, clinical specialist in solid organ transplantation and clinical assistant professor.

“It shows physicians and surgeons what a great resource they have in pharmacists and how pharmacists optimize care and help patients understand their medications. The process is worth the application in and of itself. Even if you don’t get nominated or win, it highlights your program to internal leaders.”

James Rudolph, M.D., M.S.

James Rudolph, M.D., M.S.

James Rudolph, M.D., M.S., chief of geriatrics at the Boston VA Healthcare System, can vouch for that. The Boston VA won in 2012 for its Pharmacological Intervention in Late Life (PILL) Service, in which pharmacists conduct medication reviews and follow-up calls with older adults, particularly those with cognitive impairment. Rudolph said that working with the team drove home for him how important pharmacists are to such efforts.

“It’s critical to have a pharmacist involved. PILL never would have taken off without one,” he said, noting that the award has enabled the program to expand its reach and work with other groups of patients.

Rudolph said that physicians can learn more from pharmacists than any other specialty or discipline. “We don’t get enough pharmacology training in med school. It’s a learning process when you start practicing, and it’s eye-opening when you take care of a patient who is on 15 meds and see how a pharmacist can improve care.”

Leading the Profession to New Heights

Anne Rose, Pharm.D., anticoagulation stewardship program coordinator at the University of Wisconsin Hospital and Clinics in Madison, which won in 2011, points to the value of the national recognition that comes with award.

Patient education is often key to programs that win the safety award.

Above, Erin Robinson, Pharm.D., CACP, with University of Wisconsin Hospitals and Clinics, counsels a patient.

“We had a great year after we won, going on the radio media tour and speaking about our programs and anticoagulation needs in general,” she said. “It’s more than the award itself. It’s being able to meet others doing similar things or who want to do what you do, so you can share it with them.”

She said the publicity can only help the profession as a whole. “It goes to show how far we have come and how we are branching out. Hopefully, being able to show how we can provide care, lead medication management programs, and work beyond traditional pharmacy roles will help us attain provider status.”

Advancing the pharmacy profession comes back to the increasing sophistication of pharmacist-led programs, said Daniel D. Degnan, III, Pharm.D., M.S., CPPS, senior project manager at Purdue University’s Center for Medication Safety Advancement in

 “We see programs from all over the country that are on the cutting edge of medication safety. There is a diversity of projects, but also of the types of organizations that apply, from large systems that cover big geographic areas to smaller, more traditional hospitals.”

These programs demonstrate leadership, Degnan added. “When we do site visits, we see people who are passionate about pharmacy and medication safety. These are typically great pharmacists who are active in their professional associations.”

That kind of enthusiasm is crucial to driving change in the profession, said Allen, noting that the award reflects a key goal of ASHP’s Pharmacy Practice Model Initiative.

“We want to help systems across the country expand pharmacist responsibilities and broaden pharmacists’ direct patient care, so they are not in the basement, but working with physicians and nurses,” he noted.

“You can’t change pharmacy practice without leaders, and by recognizing the impact pharmacists have on coordinating quality, process, and project improvement design, this award is a wonderful showcase for the many ways in which pharmacists can lead improvements in patient care.”

By Terri D’Arrigo

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