Team-Based Medicine: Incorporating a Clinical Pharmacist into Pain and Opioid Practice Management.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) reports that death from opioids has increased by more than five times since 1999. In response, federal and state organizations have released guidelines recommending best practice standards to combat the opioid epidemic. OBJECTIVE: To evaluate the impact of a clinical pharmacist in a team-based care model on the adherence to best practice standards and access to care for management of patients prescribed chronic opioid therapy (COT). DESIGN: Retrospective chart review study. SETTING: An outpatient physical medicine and rehabilitation clinic in a tertiary hospital. PATIENTS: Three hundred eighty-three patients presenting to the clinic between January 2012 and August 2016 with chronic, noncancer pain. METHODS: Comparison of adherence to best practice standards-including changes in morphine equivalent dose (MED), compliance with urine drug screenings, documentation of medication agreements, initiation of nonopioid medications, and the impact of comorbidities-was analyzed before and after a clinical pharmacist was added to the team. Data were gathered from the electronic medical record and the Prescription Monitoring Program. A control group of patients who did not see the pharmacist and were managed only by the physician section head was also compared to the group of patients managed by a clinical pharmacist. OUTCOME MEASUREMENTS: The primary outcome measurement evaluates the change in MED values over time. Secondary outcome measurements are to review compliance with annual urine drug screening, documentation of the medication agreement, initiation of nonopioid medications by the pharmacist, and assessment of the access to care for patients with chronic opioid therapy needs. RESULTS: A clinically significant reduction in MED with an average decrease of 207 mg was seen after five or more visits with the pharmacist. The pharmacist initiated nonopioid medications at 209 unique patient visits (19.5%). The pharmacist completed 1197 visits during the study time frame, increasing physician access by at least two additional visits per patient per year. Completion of urine drug screens and medication agreement reviews improved over time (P < .001). There was an increase in MED for patients who did not complete this monitoring, whereas the MED remained stable in patients who did complete the monitoring. CONCLUSIONS: The addition of a clinical pharmacist to an interdisciplinary team managing COT patients resulted in a MED reduction after five or more visits with the pharmacist, improved adherence to best practice standards, optimization of opioid and nonopioid medication therapy, and increased patient access. Developing a role for advanced practitioners, such as clinical pharmacist providers, working with patients on COT can result in significant improvements in patient access to care, adherence to best practice standards, and patient safety. LEVEL OF EVIDENCE: III.

Process improvement for a complex dual medical procedure.

Pancreatic extracorporeal shock wave lithotripsy followed by endoscopic retrograde cholangiopancreatography is accepted worldwide as a treatment for a large, symptomatic, obstructing pancreatic stones. However, timely completion of the combined process requires coordination of equipment and personnel from two different complex procedures. We used Lean management tools in a week-long event to redesign the process around the patient. Using idea-generated Plan Do Study Act cycles to refine the process, from scheduling to postprocedure recovery, equipment and personnel were aligned to allow these two procedures to occur in immediate succession. The redesigned process resulted in all patients receiving both procedures without delay. This eliminated over 8 hours of wait time. Standard work and a newly created complex scheduler improved flow. We reduced the number of anaesthetics for patients without prolonging the procedure length.