Documented Pharmacist Interventions Research Articles

1028: PHARMACOLOGIC INTERVENTIONS ON A SURGICAL INTENSIVE CARE UNIT BY A CLINICAL PHARMACIST

Introduction: Documenting pharmacological interventions in electronic medical record on daily basis can be very time consuming. However, such documentation is extremely important for both quality improvement and cost saving. Methods: A surgical ICU (SICU) clinical pharmacist rounded with the ICU team on the daily basis and documented her pharmacological interventions using Epic ® iVents from January 2021 to June 2022. The SICU had 23 beds, shared by CTICU and Surgical/Trauma ICU. The SICU team included an attending physician (usually a critical care trained trauma surgeon); clinical pharmacist; pharmacy resident; surgical residents; surgical physician assistants; nurses; respiratory therapists; dietitians; and medical school students. Results: The pharmacist documented a total of 3711 ivents in the 18 months. The types of ivents included dosing recommendation (n=1033); initiation of new therapy (n=623); discontinuation of therapy (n= 543); admission medication reconciliation (n=172); recommend lab/test (n=161); therapeutic drug monitoring/kinetics (n=158); iv to po medication switch (n=127); develop medication weaning plans (n=104); duration of therapy (n=81); renew expired medication (n=76); order clarification (n=68); route or formulation change (n=62); restart medication (n=53); antimicrobial de-escalation (n=47); hold medication (n=44); adverse drug event (n=37); high cost drug medication review (n=32); antimicrobial escalation (n=30); restart home medication (n=26); medication rate change (n=22); vancomycin AUC calculation (n=22); clinical drug information (n=17); non-formulation to formulation medication (n=17); VTE prophylaxis initiation (n=17); height and weight verification (n=10); stress ulcer prophylaxis initiation (n=17); drug interaction (n=10); administration time change (n=17); antimicrobial drug-bug mismatch (n=16); restricted medication approval (n=27); and others. Conclusions: The surgical ICU clinical pharmacist was able to document an average of 206 medication interventions in Epic ® per month (ranges: 138 to 296). The highest number of ivents documented occurred in July when new medical house staff started the training. Documenting pharmacist interventions is critical for quality improvement; patient care outcome; and justification for more pharmacist personnel.

42. A Pharmacist-Led Intervention to Decrease Anaerobic Coverage for Hospitalized Patients with Community-Acquired Pneumonia

BackgroundCommunity-acquired pneumonia (CAP) is frequently mis-categorized as aspiration pneumonia, prompting the addition of anaerobic coverage to the antibiotic regimen. In our institution, this usually takes the form of adding metronidazole to ceftriaxone. The 2019 American Thoracic Society and Infectious Diseases Society of America CAP guidelines recommend anaerobic coverage only for hospitalized patients with a suspected lung abscess or empyema. The objective of this study was to determine if a pharmacist-led workflow could increase adherence to the 2019 CAP guideline recommendations by limiting anaerobic coverage to those rare occasions.MethodsThe hospital antimicrobial stewardship committee approved a pharmacist workflow and guidance document which outlines criteria to evaluate appropriateness of anaerobic coverage for hospitalized patients with CAP and no other indications for antibiotics. If anaerobic coverage is not indicated, the pharmacist submits a standardized message to the treating provider via the electronic medical record, recommending discontinuation of metronidazole. This workflow was implemented on October 3, 2019. Metronidazole days of therapy (DOT) per 1000 patient days in quarters 1 through 4 of 2019 and quarter 1 of 2020 were collected as well as percent acceptance of documented pharmacist interventions from October 3, 2019 until March 31, 2020.ResultsBetween October 3, 2019 and March 31, 2020, a total of 221 interventions were made by pharmacists to discontinue metronidazole in hospitalized CAP patients where anaerobic coverage was not indicated. Out of those 221 interventions, 164 (74%) were accepted by providers and only 57 (26%) were rejected.The DOT per 1000 patient days of metronidazole was assessed for the three quarters prior to our intervention and the two quarters after the intervention. Compared to the three quarters prior, metronidazole DOT per 1000 patient days decreased by 26.6% for the two quarters following implementation of the pharmacist-led intervention (Figure 1).Figure 1: Metronidazole DOT per 1000 patient days from January 1, 2019 through March 31, 2020. Vertical line indicates when pharmacist workflow was implemented. ConclusionA pharmacist antimicrobial stewardship intervention at our institution increased adherence to CAP guidelines and decreased unnecessary antibiotic exposure in hospitalized CAP patients when anaerobic coverage was not indicated.Disclosures All Authors: No reported disclosures

Economic Evaluation of a Pharmacist-Led 5-Day Therapeutic Hold of IV Levothyroxine at an Academic Medical Center.

Objective: Providers often admit patients with active outpatient prescriptions for levothyroxine. During an inpatient admission, providers may instruct critically ill patients to take nothing by mouth, or nil per os (NPO). Thus, they may prescribe the intravenous (IV) formulation of levothyroxine during this period. However, levothyroxine possesses a prolonged half-life of up to 7 days; therefore, immediate transition to IV levothyroxine may not be clinically necessary in the acute NPO setting. Intravenous levothyroxine is significantly more expensive than equivalent oral doses and may prove to be a financial burden for an institution. By understanding the pharmacokinetic properties of levothyroxine, we implemented a cost-saving initiative involving a 5-day therapeutic hold of IV levothyroxine. Methods: This was a retrospective evaluation in 2 intensive care units (ICU): a 20-bed surgical/trauma ICU and an 18-bed mixed medical/surgical ICU. Patient data, utilization data, and documented pharmacist interventions were collected for 6 months prior to implementation of the 5-day IV levothyroxine therapeutic hold and for 6 months post-implementation. All patients prescribed IV levothyroxine during these timeframes were included. Results: During the 6-month pre-implementation phase, 674 doses (691 vials) of IV levothyroxine for 77 unique patients were dispensed from the 2 ICUs. During the 6-month post-implementation phase, 168 doses (188 vials) of IV levothyroxine were dispensed for 44 unique patients. Of the 44 patients (48 orders) who still received IV levothyroxine, 22.9% of orders were deemed clinically necessary by the pharmacist and were not recommended to be held under the protocol, 64.6% were due to the verifying pharmacist being unaware of the protocol, 8.3% of orders were due to protocol non-compliance, and 4.2% were verified after the 5-day hold was complete as the patient remained NPO. This pharmacy-led initiative resulted in a 75% decrease in usage post-implementation and an estimated annualized savings of $80,000. Conclusion: A pharmacy-led initiative comprised of a 5-day therapeutic hold of IV levothyroxine was feasible and led to a 75% reduction in usage and cost over a 6-month period in 2 ICU's. Future steps include additional staff education for improved protocol adherence and expanding the protocol institution-wide for an even greater cost-savings potential.

Controlling postoperative use of i.v. acetaminophen at an academic medical center.

Results of an interprofessional formulary initiative to decrease postoperative prescribing of i.v. acetaminophen are reported. After a medical center added i.v. acetaminophen to its formulary, increased prescribing of the i.v. formulation and a 3-fold price increase resulted in monthly spending of more than $40,000, prompting an organizationwide effort to curtail that cost while maintaining effective pain management. The surgery, anesthesia, and pharmacy departments applied the Institute for Healthcare Improvement's Model for Improvement to implement (1) pharmacist-led enforcement of prescribing restrictions, (2) retrospective evaluation of i.v. acetaminophen's impact on rates of opioid-related adverse effects, (3) restriction of prescribing of the drug to 1 postoperative dose on select patient care services, and (4) guideline-driven pain management according to an enhanced recovery after surgery (ERAS) protocol. Monitored metrics included the monthly i.v. acetaminophen prescribing rate, the proportion of i.v. acetaminophen orders requiring pharmacist intervention to enforce prescribing restrictions, and prescribing rates for select adjunctive analgesics. Within a year of project implementation, the mean monthly i.v. acetaminophen prescribing rate decreased by 83% from baseline to about 6 doses per 100 patient-days, with a decline in the monthly drug cost to about $4,000. Documented pharmacist interventions increased 2.7-fold, and use of oral acetaminophen, ketorolac, and gabapentin in ERAS areas increased by 18% overall. An interprofessional initiative at a large medical center reduced postoperative use of i.v. acetaminophen by more than 80% and yielded over $400,000 in annual cost savings.

Pharmacist involvement on a rapid response team.

The effect of a pharmacist on a rapid response team (RRT) was investigated. This study evaluated 234 patients before and 157 patients after pharmacist involvement on an RRT. The primary outcome was time to medication administration, with a goal turnaround time of less than 30 minutes. Secondary outcomes included most frequently used medications, readmissions to the intensive care unit (ICU) within 48 hours, number of rapid responses that resulted in ICU admission, length of hospital stay, and survival to hospital discharge. Additionally, pharmacist interventions were tracked in the postinterventional group. The preinterventional group screened 326 rapid response events, of which 234 were included for analysis; during the postinterventional phase, 256 rapid response events were evaluated, of which 157 were included. The primary outcome, median time to medication administration from central pharmacy, was lower in the postinterventional group compared with the preinterventional group (32.0 minutes versus 64.5 minutes, p = 0.004). ICU admission rates following rapid response were not significantly different between the two groups. Additionally, there were no significant differences between rates of medical emergency and survival to hospital discharge. The most common medications administered were metoprolol and naloxone. Pharmacists provided documentation for 90 of 157 (57%) patient cases. In the 90 cases with documentation, 18 (20% of patients) had documented pharmacist interventions, including dosing assistance for 8 cases (44% of interventions). The addition of a pharmacist to an RRT reduced time to medication administration, helped improve medication accessibility, and helped optimize medication selection and dosing.

Clinical and economic evaluation of pharmacists' contribution to patient care on a multi-disciplinary liver transplant team.

We aimed to describe and to evaluate the clinical and economic implications of pharmacists' interventions as members of the liver transplant team for hospitalized liver recipients. Retrospective descriptive and cost-benefit analysis of documented pharmacist interventions for hospitalized patients from January 2010 to June 2012 was conducted. The type of drug-related problems (DRPs) was categorized. The clinical significance of pharmacist interventions was rated using five scales by two professionals. The cost avoidance was estimated based on the probability that an adverse drug event (ADE) would have occurred without intervention using previously reported additional costs for ADE treatment. A total of 1,880 interventions were documented for 420 liver transplant recipients. The most common DRP was "need additional drug therapy" (42.6%), followed by "dosage problems" (23.5%). The most common drug class addressed by intervention was antimicrobials (51.4%). Most interventions were rated as more than clinically "significant". Analysis showed that pharmacist activities related to potential ADE prevention had a clear cost-benefit with a net cost-benefit € 94,009 and a cost-benefit ratio of 3.8. This study demonstrated the positive impact of clinical pharmacists on the care of hospitalized liver transplant patients in terms of both clinical and economic outcomes.

Assessment of Clinical Pharmacy Interventions in the Intensive Care Unit

Clinical pharmacy services have been shown to reduce adverse drug events and health care costs. However, few studies have assessed their effect on patient outcomes in the intensive care unit (ICU). To describe characteristics of ICU patients with documented pharmacist interventions and to evaluate the relationships between patients' complexity level and pharmacists' interventions and between pharmacists' interventions and mortality rate. Inpatient records of admissions between January 1, 2004, and March 31, 2007, were analyzed to identify the presence of clinical pharmacy notes (CPNs). The characteristics of patients with and without CPNs were compared using descriptive statistics. For primary analysis of the association between patient complexity level and presence of CPNs, logistic regression modelling was performed to adjust for potential confounding. Logistic regression was also used to explore the possible association between CPNs and mortality. Finally, mortality analysis was carried out for patients with and without CPNs, with matching by complexity level. The main study cohort comprised 1561 patients: 333 (21.3%) with CPNs and 1228 (78.7%) with no CPNs. A greater proportion of those with a CPN had the highest complexity level: 295 (88.6%) of those with CPNs versus 660 (53.7%) of those with no CPNs. After adjustment for age and sex, the odds ratio for having a CPN among patients with complexity level 4 (relative to patients with lower complexity levels) was 8.20 (95% confidence interval 5.44-12.38). Mortality rates were not significantly different between the 2 groups: 26.7% (89/333) among patients with CPNs and 27.9% (343/1228) among those without CPNs (p = 0.66). After adjustment for age, sex, complexity level, and length of stay in the ICU, the presence of a CPN was not significantly associated with mortality. Mortality rates in the matched cohort (n = 1078) were also similar between patients with and without CPNs (89/333 [26.7%] and 226/745 [30.3%], respectively; p = 0.23), and the presence of a CPN was not significantly associated with mortality after adjustments for potential confounding factors. Documenting clinical pharmacy activities is essential for assessing pharmacists' impact on patient outcomes. These data suggest that ICU pharmacists prioritize clinical activities to care for the sickest patients.

Documenting clinical pharmacist intervention before and after the introduction of a web-based tool

To develop a database for documenting pharmacist intervention through a web-based application. The secondary endpoint was to determine if the new, web-based application provides any benefits with regards to documentation compliance by clinical pharmacists and ease of calculating cost savings compared with our previous method of documenting pharmacist interventions. A tertiary care hospital in Saudi Arabia. The documentation of interventions using a web-based documentation application was retrospectively compared with previous methods of documentation of clinical pharmacists' interventions (multi-user PC software). The number and types of interventions recorded by pharmacists, data mining of archived data, efficiency, cost savings, and the accuracy of the data generated. The number of documented clinical interventions increased from 4,926, using the multi-user PC software, to 6,840 for the web-based application. On average, we observed 653 interventions per clinical pharmacist using the web-based application, which showed an increase compared to an average of 493 interventions using the old multi-user PC software. However, using a paired Student's t-test there was no statistical significance difference between the two means (P = 0.201). Using a χ² test, which captured management level and the type of system used, we found a strong effect of management level (P < 2.2 × 10⁻¹⁶) on the number of documented interventions. We also found a moderately significant relationship between educational level and the number of interventions documented (P = 0.045). The mean ± SD time required to document an intervention using the web-based application was 66.55 ± 8.98 s. Using the web-based application, 29.06% of documented interventions resulted in cost-savings, while using the multi-user PC software only 4.75% of interventions did so. The majority of cost savings across both platforms resulted from the discontinuation of unnecessary drugs and a change in dosage regimen. Data collection using the web-based application was consistently more complete when compared to the multi-user PC software. The web-based application is an efficient system for documenting pharmacist interventions. Its flexibility and accessibility, as well as its detailed report functionality is a useful tool that will hopefully encourage other primary and secondary care facilities to adopt similar applications.

Implementing Personal Digital Assistant Documentation of Pharmacist Interventions in a Military Treatment Facility

To describe the use of personal digital assistants (PDAs) in documenting pharmacists' clinical interventions. Evans Army Community Hospital (EACH), a 78-bed military treatment facility, in Colorado Springs. Pharmacists on staff at EACH. All pharmacists at EACH used PDAs with the pilot software to record interventions for 1 month. The program underwent final design changes and then became the sole source for recording pharmacist interventions. The results of this project are being evaluated every 3 months for the first year and yearly thereafter. Visual CE (Syware Inc. Cambridge, Mass.) software was selected to develop fields for the documentation tool. This software is simple and easy to use, and users can retrieve reports of interventions from both inpatient and outpatient sections. The software needed to be designed so that data entry would only take a few minutes and ad hoc reports could be produced easily. Number of pharmacist interventions reported, time spent in clinical interventions, and outcome of clinical intervention. Implementing a PDA-based system for documenting pharmacist interventions across ambulatory, inpatient, and clinical services dramatically increased reporting during the first 6 months after implementation (August 2004-February 2005). After initial fielding, clinical pharmacists in advanced practice settings (such as disease management clinic, anticoagulation clinic) recognized a need to tailor the program to their specific activities, which resulted in a spin-off program unique to their practice roles. A PDA-based system for documenting clinical interventions at a military treatment facility increased reporting of interventions across all pharmacy points of service. Pharmacy leadership used these data to document the impact of pharmacist interventions on safety and quality of pharmaceutical care provided.

Do Community Pharmacists Influence Prescribing?

To evaluate whether community pharmacists have the ability to influence prescribing decisions and to determine the extent to which they do so. International Pharmaceutical Abstracts was searched for articles published between January 1970 and September 2002 and MEDLINE was searched for articles published between January 1966 and September 2002 that contain the terms pharmaceutical care or pharmacist and intervention. Selected studies documented pharmacist interventions that resulted in a change in prescribing that required influencing the prescriber, included a complete description of methods and results, and were conducted in community pharmacies in the United States. Selected studies were examined to determine whether, in what ways, and to what extent community pharmacists influenced prescribing. Community pharmacists in traditional practices regularly, but infrequently, recommend to prescribers that they initiate, discontinue, or change drug therapy. Prescribers usually accept and implement pharmacists' suggestions. Pharmacists are more likely to intervene to correct drug therapy problems when they have been trained to provide pharmaceutical care and have modified their practices to accommodate a more patient-centered style of practice. In the larger reviewed studies, pharmacists intervened to change therapy for the majority of their patients. Community pharmacists routinely intervene to influence prescribing. They do so, for the most part, to correct clinical problems or to provide their patients with more affordable therapy. In the majority of interventions, physicians accept and implement pharmacists' suggestions.

Documenting pharmacist interventions on an intranet.

The process of developing and implementing an intranet Web site for clinical intervention documentation is described. An inpatient pharmacy department initiated an organizationwide effort to improve documentation of interventions by pharmacists at its seven hospitals to achieve real-time capture of meaningful benchmarking data. Standardization of intervention types would allow the health system to contrast and compare medication use, process improvement, and patient care initiatives among its hospitals. After completing a needs assessment and reviewing current methodologies, a computerized tracking tool was developed in-house and integrated with the organization's intranet. Representatives from all hospitals agreed on content and functionality requirements for the Web site. The site was completed and activated in February 2002. Before this Web site was established, the most documented intervention types were Renal Adjustment and Clarify Dose, with a daily average of four and three, respectively. After site activation, daily averages for Renal Adjustment remained unchanged, but Clarify Dose is now documented nine times per day. Drug Information and i.v.-to-p.o. intervention types, which previously averaged less than one intervention per day, are now documented an average of four times daily. Approximately 91% of staff pharmacists are using this site. Future plans for this site include enhanced accessibility to the site with wireless personal digital assistants. The design and implementation of an intranet Web site to document pharmacists' interventions doubled the rate of intervention documentation and standardized the intervention types among hospitals in the health system.

Impact of a pharmacist on drug costs in a coronary care unit.

The impact of clinical pharmacy services on direct drug costs in a coronary care unit (CCU) was studied. An observational, nonrandomized study was conducted on all patients admitted to the CCU to evaluate the impact of clinical pharmacy services on direct drug costs. Clinical pharmacy services were introduced into the CCU in July 1998. Patient characteristics, mean drug costs per admission, mean drug category costs per admission, and total hospital costs per admission were determined for October 1997 to June 1998 (nonintervention period), July 1998 to March 1999 (intervention period 1), and April 1999 to December 1999 (intervention period 2). The Clini-Trend program was used to estimate the total reduction in drug costs associated with documented pharmacist interventions from January to December 1999. Mean patient age, sex, admitting diagnosis-related group, Medicare case-mix index, ventilator days, length of stay, and number of deaths did not differ significantly among the three study periods. Mean +/- S.D. drug costs per admission for the nonintervention period were $374.05 +/- $75.51. With the introduction of clinical pharmacy services, mean +/- S.D. drug costs per admission were $381.94 +/- $66.16 (p > 0.1 for intervention period 1 compared with the nonintervention period) and $233.74 +/- $84.16 (p = 0.002 for intervention period 2 compared with the nonintervention period). From January to December 1999, 4151 pharmacist interventions were documented. The estimated reduction in drug costs associated with the interventions totaled $372,384. A pharmacist's clinical services in the CCU allowed for significant estimated reductions in total drug costs.

Measuring the impact of patient counseling in the outpatient pharmacy setting: development and implementation of the counseling models for the kaiser permanente/USC patient consultation study

The Southern California region Kaiser Permanente Medical Care Program, which serves 2.2 million patients, and the University of Southern California School of Pharmacy have designed and implemented a patient consultation study to determine the cost-effectiveness of three different approaches to providing pharmacist consultation to outpatients. This paper describes the development and implementation of these three models. A total of 107 pharmacies (approximately 600 pharmacists) participated in the study and were assigned to provide one of the models of patient consultation, designated the Kaiser Permanente (KP) model, the state model, and the control model. The KP model (20 pharmacies) provided targeted pharmaceutical care services to high-risk patients based on drug use. The state model (67 pharmacies) provided California-mandated patient consultation to patients with new or changed prescriptions, instructions for use, relevant warnings and precautions, storage requirements, and the importance of compliance. The control model (20 pharmacies) provided consultation when deemed necessary by the pharmacist and provided care similar to that provided before mandatory consultation in California. The KP and state models used the same pharmacist/technician/clerk resources, but the control pharmacies limited personnel resources to those existing before the mandatory consultation law was passed in California. The paper describes the KP model in detail and provides a literature-based rationale for targeting particular high-risk patients for expanded services. The paper also describes the training process, gives an example of a high-risk patient intervention, provides information on documenting pharmacist interventions in all models, and explains the method used for monitoring implementation of the models.

Comparison of two systems for documenting pharmacist interventions in patient care

Manual and computerized systems for documenting interventions by pharmacists at a large university teaching hospital are compared. The manual system allows patient data and pharmacist interventions to be quickly documented on written profiles. Completed forms are entered into a personal computer for analysis. The computerized system is a direct-entry version of the manual intervention log. Five screens allow pharmacists to enter information into a mainframe computer from any terminal. Data can be downloaded from the mainframe into a personal computer. During the first part of the study, nine pharmacists used the manual system for seven days. After a two-week pause, the same pharmacists used the computerized system for seven days. The systems were evaluated by using time-and-motion analysis and a questionnaire. Also, the number of interventions documented and the characteristics of each were compared. The mean +/- S.D. time required to document an intervention was significantly less with the computerized system (81.8 +/- 24.9 seconds) than with the manual system (100.7 +/- 37.3 seconds). Administrative time for analysis and report generation was also less with the computerized system. The pharmacists rated the computerized system more highly in terms of ease of use, accessibility, time efficiency, and acceptability. The number of interventions documented did not differ between the systems. A computerized system for documenting pharmacist interventions compared favorably with a manual system.