Implementation and Evaluation of a Prior Authorization Workflow for New-Start Inpatient Medications in Preparation for Discharge.

Purpose: Medications that require prior authorization can complicate the discharge planning process. This study implemented and evaluated a process for identifying and completing prior authorizations during the inpatient setting prior to patient discharge. Methods: A patient identification tool was developed within the electronic health record to alert the patient care resource manager of inpatient orders for targeted medications that frequently require prior authorization with the potential to delay discharge. A workflow process using the identification tool and flowsheet documentation was developed to prompt the initiation of a prior authorization, if necessary. Following hospital-wide implementation, descriptive data for a 2-month period was collected. Results: The tool detected 1353 medications for 1096 patient encounters over the 2-month period. The most frequent medications identified included apixaban (28.1%), enoxaparin (14.4%), sacubitril/valsartan (6.4%), and darbepoetin (6.4%). For the medications identified, there were 93 medications documented in the flowsheet data for 91 unique patient encounters. Of the 93 medications documented, 30% did not require prior authorization, 29% had prior authorization started, 10% were for patients discharged to a facility, 3% were for home medications, 3% were medications discontinued at discharge, 1% had prior authorization denied, and 24% had missing data. The most frequent medications documented in the flowsheet included apixaban (12%), enoxaparin (10%), and rifaximin (20%). Of the 28 prior authorizations processed, 2 led to a referral to the Medication Assistance Program. Conclusion: The implementation of an identification tool and documentation process can help improve PA workflow and discharge care coordination.

Defining, capturing, and validating pharmacists' patient profile reviews in the electronic medical record.

PURPOSE: To describe the implementation and validation of a novel patient profile review tool in the electronic medical record (EMR) at an academic medical center. SUMMARY: Pharmacy leaders at The Ohio State University Wexner Medical Center aspired to develop a data-driven approach to clinical pharmacy services. The initial phase of this vision highlighted a need to define the clinical activities of a pharmacist and leverage use of the EMR to seamlessly capture data. A comprehensive list of clinical activities was developed and analyzed to determine which activities were currently uncaptured. Patient profile review was prioritized and determined to be variable among staff and undefined. A profile review tool was developed and implemented across the medical center while requiring minimal additional documentation through the EMR. Phase II determined what user audit trail data in the EMR were automatically recorded based on performing various levels of pharmacist-recorded profile review and validated the consistency in utilization of this tool. The information gathered as a result of this study identified interactions within the patient chart that matched profile reviews that were not captured during manual documentation. The department of pharmacy will utilize the data generated from this tool to better make decisions and build a comprehensive clinical productivity model. CONCLUSION: The implementation of a pharmacist patient profile review tool built within the EMR successfully defined, stratified, validated time spent on, and captured a clinical activity.

Evidence Based Scarce Resource Allocation During the COVID-19 Pandemic: A Case Study of Bamlanivimab Administration in the Emergency Department.

Background: Patients presenting for emergency department (ED) evaluation may be appropriate for treatment with monoclonal antibodies for mild to moderate COVID-19. While many sites have implemented infusion centers for these agents, EDs will continue to evaluate these patients where appropriate identification and efficient infusion of eligible patients is critical. Objectives: Patients receiving bamlanivimab in the EDs of an academic medical center are described. The primary objective was to describe operational metrics and secondary objectives reported clinical outcomes. Methods: Patients receiving bamlanivimab and discharged from the ED were included from November 16, 2020 to January 16, 2021 in the retrospective, observational cohort. Primary outcome was adherence to institutional criteria. Secondary outcomes included ED visit metrics, clinical characteristics, and return visits within 30 days. Risk factors for return visits were assessed with regression. Results: One hundred nineteen patients were included. Most (71%) were diagnosed with COVID-19 during the ED visit and median symptom duration was 3(IQR 2-5) days. Median number of risk factors for progression to severe disease was 2 (IQR 1-2). Thirty percent had a documented abnormal chest x-ray. Institutional criteria adherence was 99.2%. Median time from ED room to bamlanivimab was 4 (IQR 3.1-5.2) hours. Thirty patients had return visit within 30 days; 19 were COVID-19 related. Two multivariable regression models were analyzed for COVID-19 related return visit. Characteristics on ED presentation were considered in Model I: male gender (OR 3.01[0.97-9.31]), age (per 10 years) (OR 1.49[1.05-2.12]), African-American race (OR 3.46[1.09-11.06]), and symptom duration (per day) (OR 1.34[1.05-1.73]). Model II included labs and imaging acquired in ED. In Model II, age (per 10 years) (OR 1.52[1.07-2.16]) and abnormal CXR (OR 5.74[1.95-16.9]) were associated with COVID-19 related return visits. Conclusions: Administration of bamlanivimab to ED patients can be done efficiently, with the potential to reduce COVID-19 related return visits. Age and abnormal imaging were independent predictors of COVID-19 return visits.

Implementation of pharmacist targeted discharge prescription review in an emergency department.

BACKGROUND/PURPOSE: Little data has been published regarding emergency medicine pharmacist (EMP) review of discharge prescriptions. An internal retrospective review of a limited sample size of emergency department (ED) discharge prescriptions demonstrated a 13.6% potential intervention rate by EMPs. With this information, it was postulated that EMPs could provide a valuable service via a process of targeted review of ED discharge prescriptions that would yield intervention rates higher than the internal audit. The aim of this project was therefore to develop a real-time notification system within the electronic health record (EHR) for targeted discharge prescription review, to establish an associated EMP workflow, and to evaluate the intervention rate achieved through targeted discharge prescription review. METHODS: This was a single-center, retrospective review of the implementation of a new pharmacist-driven clinical service over a 12 week period from February 19th, 2018 to May 14th, 2018. Criteria for prescription review were determined after an internal audit by the EMPs and included an assessment of established high-alert medications. Discharge prescriptions that met the inclusion criteria were filtered into a real-time work queue in the EHR for EMP review. When necessary, EMPs discussed recommendations with prescribers, or adjusted prescriptions according to institutional pharmacist privileges. Interventions were reviewed and categorized to assess rate of intervention and the types of medication-related problems (MRPs) identified. RESULTS: EMPs reviewed 378 discharge prescriptions and a total of 158 prescriptions were identified as having at least one MRP. Of these, 70 prescriptions were intervened upon thereby resulting in an 18.5% intervention rate. The most common interventions included a change in the dose/frequency, duration/refills of the medication, and patient education. The highest number of interventions were made for anticoagulant and antiinfective agents. CONCLUSION: Utilization of a real-time notification system for prospective ED discharge prescription review is feasible. Using targeted criteria for review, pharmacists intervened on 18.5% of prescriptions reviewed. Prospective discharge prescription review by EMPs using a real-time notification system within the electronic health record identified opportunities for the pharmacist to ensure safe and optimal prescribing.

Privileging pharmacists improves time to patient notification in the microbiological test review process for patients discharged from the emergency department.

PURPOSE: Results of a study evaluating the impact of privileging pharmacists to manage microbiologic test results for patients discharged from the emergency department (ED) are reported. METHODS: This was a single-center, retrospective pre-post study that was conducted at an urban academic medical center. Patients discharged from the ED with a subsequent positive microbiologic test result before and after privileging of an ED specialty practice pharmacist (ED-SPP) to manage the results independently were screened for inclusion. Time to patient notification of a required change in antimicrobial therapy was compared between groups. Numbers of erroneous interventions before and after pharmacist privileging were compared to assess the safety of implementation. RESULTS: One hundred seventy-eight positive microbiologic test results (n = 92 pre- and n = 86 postimplementation) were included. The median time to patient notification in the pre-implementation group was 23.6 hours (range, 12.4-93 hours) and in the postimplementation group was 14.9 hours (range, 2.5-27.9 hours; P = 0.0023). As determined by the board-certified infectious disease physician, 1.1% of reviewed microbiologic test results (1 of 92) was erroneous prior to implementation of pharmacist privileging compared with 2.3% (2 of 86) after implementation (P = 0.6105). CONCLUSION: Privileging ED-SPPs to assess microbiologic test results improved the time to patient notification with no statistical difference in the number of erroneous interventions between groups. These findings demonstrate the benefit of clinical privileging and provide support for expansion of this role to other ED-SPPs.

Elevating pharmacists' scope of practice through a health-system clinical privileging process.

PURPOSE: The privileging of pharmacists for clinical activities and the impact that privileging has on enhancing the scope of pharmacy practice in health systems are reviewed. SUMMARY: Health-system pharmacists or pharmacy leaders must gain a thorough understanding of the credentialing and privileging process as they broaden their scope of practice. Clinical privileging affords an expanded scope of practice that is recognized at the institutional level and formally elevates the pharmacist to that of a nonphysician provider. The installation of privileging processes is expected to take many months to complete for individual institutions and should begin now in anticipation of provider status. Model institutions, including Truman Medical Centers, Johns Hopkins Hospital, and The Ohio State University Wexner Medical Center, are highlighted in this article and provide their individual approach to clinical privileging that can be applied to other institutions. The development and evaluation of these programs have given valuable insight into how this individual approach translates to health systems across the country and how the pharmacy profession can continue to unite to convey the value of pharmacists in improving patient care. CONCLUSION: In preparation for the potential approval of pharmacist provider status across the United States, it is essential that pharmacists are privileged by the medical staff at their respective institution. Clinical privileges must be strategically developed with a focus on cost and quality aims and meeting the needs of patients. Implementation and maintenance of high-performing pharmacy privileging programs require both successful leadership and management skills and an understanding of the interprofessional nature of healthcare.