Expansion of inpatient clinical pharmacy services through reallocation of pharmacists.

PURPOSE: The redesign of an inpatient pharmacy practice model through reallocation of pharmacy resources in order to expand clinical services is described. METHODS: A pharmacy practice model change was implemented at a nonprofit academic medical center to meet the increasing demand for direct patient care services. In order to accomplish this change, the following steps were completed: reevaluation of daily tasks and responsibilities, reallocation of remaining tasks to the most appropriate pharmacy staff member, determination of the ideal number of positions needed to complete each task, and reorganization of the model into a collection of teams. Data were collected in both the preimplementation and postimplementation periods to assess the impact of the model change on operational workflow and clinical service expansion. RESULTS: The mean ± S.D. times to order verification were 17 ± 52 minutes during the preimplementation period and 21 ± 70 minutes in the postimplementation period (p < 0.001). During the 3 months before and after implementation of the model change, the mean number of medication reconciliations performed increased from 114 to 144. After implementation of the model change, total interventions increased 194%. Notably, there was a 736% increase in the number of interventions focused on facilitating safe discharge. CONCLUSION: A pharmacy practice model change was successfully implemented by reallocating existing pharmacist and technician roles and increasing incorporation of pharmacy residents and students. This change led to an expansion of direct patient care coordination services without negatively affecting the operational responsibilities of the pharmacy or the need to hire additional staff.

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.

Survey of transplant-related pharmacy services at large comprehensive transplant centers in the United States.

CONTEXT: United Network for Organ Sharing (UNOS) 2011 bylaws and Centers for Medicare and Medicaid Services (CMS) regulations require a transplant pharmacist to be an active participant in the care of transplant patients. Transplant centers must be members in good standing with UNOS in order to perform transplants and must be certified by CMS to participate with Medicare. OBJECTIVE: To identify characteristics of transplant-related pharmacy services at comprehensive transplant centers. DESIGN: Survey regarding number of full-time equivalent (FTE) transplant pharmacists relative to number of annual transplants, transplant pharmacy model, roles in inpatient and clinic environments, training and specialization, funding sources, and expansion plans.Participants-Surveys were received from 14 (74%) of 19 identified centers that performed 200 to 400 kidney, liver, pancreas, simultaneous kidney/pancreas, heart, and lung transplants in 2010, representing 55 transplant pharmacists. RESULTS: A mean of 325 transplants were performed in 2010 at the surveyed centers. The mean number of pharmacist FTEs was 4.25, which yielded a transplant-to-pharmacist ratio of 76.5. Nine centers (64%) practiced in a pharmacy specialist-only model, 12 (86%) practiced in a service-based fashion, and 10 (71%) saw patients in clinic. Fifty-four pharmacists (98%) had obtained a PharmD degree, 45 (82%) had completed 1 postgraduate year, and 28 (51%) had completed 2 postgraduate years of training. Nine centers (64%) funded FTEs solely through the pharmacy department. Ten centers (71%) plan to expand transplant pharmacist staff by a mean of 1.4 FTEs. CONCLUSIONS: Large comprehensive transplant centers use multiple transplant pharmacists to perform patient care in the inpatient and outpatient environments. Most centers plan to expand FTEs. Further characterization of transplant pharmacists appears warranted.

Development and implementation of a pharmacist-managed inpatient anticoagulation monitoring program.

PURPOSE. A stepwise approach to development and implementation of a program to standardize and increase pharmacists' involvement in anticoagulation therapy at a large academic medical center is described. SUMMARY. In response to the Joint Commission's national goal of improved patient safety in anticoagulation therapy, a work group of pharmacy administrators, educators, clinical specialists, and decentralized pharmacists at the hospital developed the structure for a comprehensive inpatient anticoagulation program (IAP); the work group also developed a list of required competencies, educational materials, assessment methods, and mechanisms for eliciting feedback from IAP pharmacists and other patient care staff. After completion of training that included structured case-review sessions, a one-on-one shadowing experience, and competency assessment, IAP pharmacists began reviewing clinical and laboratory data on patients receiving warfarin and low-molecular-weight heparins and providing recommendations to physicians, nurse practitioners, and other health care team members. Feedback from other clinicians was generally positive, with a majority of those surveyed indicating that increased pharmacist involvement in anticoagulation monitoring and dosage adjustment resulted in improved patient care; about 80% indicated that they concurred with pharmacists' recommendations at least 75% of the time. Results of a survey of IAP pharmacists indicated increased satisfaction with their daily duties but also a need for improved pharmacist-to-pharmacist communication. CONCLUSION. Case-based advanced training and implementation of an IAP in a tertiary care hospital increased pharmacists' involvement in the management of inpatients receiving anticoagulants.

Impact of an inpatient anticoagulation management service on clinical outcomes.

BACKGROUND: Antithrombotic medications require careful management to avoid thrombotic or hemorrhagic complications. The benefits of specialized anticoagulation management services (AMS) in the outpatient setting are well established; less evidence of benefit in the hospital setting is available. OBJECTIVE: To evaluate the clinical benefits of an inpatient AMS to cardiac surgery patients requiring warfarin anticoagulation therapy. METHODS: After obtaining institutional review board approval, we conducted a retrospective, single-center, cohort study of consecutive cardiac surgery patients treated before (January 2003-May 2005) and after (June-December 2005) establishment of an inpatient AMS. Demographic and clinical characteristics as well as laboratory and clinical data were retrieved from institutional electronic databases and compared between the 2 patient cohorts. Comparisons between study groups were conducted using a chi(2) or Fisher's Exact test for categorical variables and a Student's t-test for continuous variables. Analysis of rare event data was conducted using Poisson regression analysis. RESULTS: Of 1919 patients admitted during the study interval, 826 received warfarin (674 pre-AMS, 152 post-AMS). The number of patients with postsurgical panic international normalized ratio (INR) values declined after initiation of the AMS (pre-AMS 90/674 [13.4%] vs post-AMS 11/152 [7.2%]; p = 0.036). There was a trend toward fewer clinically significant postoperative bleeding events (pre-AMS 21/674 [3.1%] vs post-AMS 2/152 [1.3%]; p = 0.22) and fewer repeat surgeries for late postoperative bleeding (pre-AMS 8/674 [1.2%] vs post-AMS 0/152 [0%]; p = 0.08). AMS intervention was associated with a 17% decrease in the average postsurgical length of stay (13.9 days vs 11.6 days; p = 0.015). CONCLUSIONS: A multidisciplinary AMS can improve anticoagulation management, leading to fewer panic INR values and a reduced length of hospital stay.