Reports From the Field

Optimizing Inpatient Pharmacotherapy Using a Single Clinical Policy Streamlining Pharmacy Protocols


 

References

From the Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ.

Abstract

  • Objectives: To describe the implementation of broadly scoped clinical pharmacy protocols positioned as a singular policy in a community hospital. These protocols were designed to expand the established benefits demonstrated using narrower, traditional protocols.
  • Methods: A retrospective chart review of protocol interventions in the first year of the policy’s implementation was conducted to evaluate prescriber acceptance of protocol interventions. Interventions were identified from required email notifications. The frequency of use of each protocol was assessed, including evaluation of novel characteristics of specific protocols. Pharmacist utilization patterns were assessed for job classification, shift, and practice setting (ie, centralized or decentralized).
  • Results: In the 1-year assessment period, 145 interventions were reported and 144 were accepted by the prescribing physicians. Interventions involved orders from hospitalists and intensivists most frequently, with the renal dosing and dose formulations protocols being the most commonly utilized. Staff pharmacists used the policy more frequently than clinical pharmacists, primarily during day shift from decentralized locations on the patient care units.
  • Conclusions: The implementation of broadly scoped clinical pharmacy protocols for items our pharmacists routinely contact physicians about (and our physicians deemed were within the practice of pharmacy) instituted a cultural shift that expanded the elements considered to be part of routine pharmacy practice. As a result, pharmacists more seamlessly applied their expertise as pharmacotherapy specialists to optimize pharmacotherapy, which streamlined workflow for both pharmacists and physicians. This expanded the proven benefits of allowing professionals to work to their fullest extent, as established in the literature.

Allowing pharmacists to apply their expertise has been associated with improved outcomes in both pharmacotherapy quality (eg, reduction in mortality and length of stay [1]) and savings in health care dollars. Studies of focused protocols, including intravenous-to-oral (IV-to-PO) switch [2–20], renal dosing [21], stress ulcer prophylaxis [22] and anticoagulation management [1,23,24] demonstrate these benefits in a multitude of practice areas. While such protocols have become commonplace in the acute care setting [25–28], most continue to be singularly focused and impose patient population restrictions that preclude comprehensive patient evaluation. Many are administered as a task within the pharmacist workflow using a patient list generated by the limited protocol criteria, which are often restricted to agent or patient characteristics.

Better outcomes are associated with permitting professionals such as pharmacists to work to the fullest extent of their scope and expertise [29–31]. In specific cases, studies evaluating pharmacists’ impact within a multi-disciplinary health care team have demonstrated improved outcomes in regard to both patient care and cost [29–31]. Recognizing this, accountable care organizations (ACOs) have developed practice models that are based on this benefit. Each team member is expected to robustly apply their training and expertise to achieve the best outcomes [32,33]. As health care moves toward a more integrative approach, it is paramount that pharmacists utilize the full scope of the skills in which they are trained.

This report describes the development, implementation, and outcomes of a singular policy outlining comprehensively scoped protocols allowing acute care hospital pharmacists within Princeton HealthCare System to optimize pharmacotherapy during the course of their usual clinical practice.

Methods

Setting

The University Medical Center of Princeton at Plainsboro (UMCPP), part of the Princeton HealthCare System, is a 230-bed community acute care hospital located in central New Jersey. The hospital facility relocated in May 2012 from its previous location in Princeton to a new state-of-the-art facility in Plainsboro. As an affiliate of the Robert Wood Johnson Medical School and the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey (ie, Rutgers), it is an academic teaching hospital with a mixed model for providing patient care. UMCPP employs both faculty physicians leading academic teams alongside hospitalists and private attendings.

Pharmacy services are provided on facility 24 hours a day, 365 days a year. The department of pharmacy services provides a full scope medication services from a centralized location with 3 full-time day pharmacists and 1 oncology satellite pharmacist. During weekdays, decentralized pharmacists provide medication review, patient education, and medication reconciliation on 2 to 3 inpatient care units. Centralized support decreases to 2 pharmacists in the evening and 1 overnight. Clinical pharmacists, both hospital-based and Rutgers faculty, work in conjunction with the staff pharmacists to ensure appropriate management of patients throughout different levels of care.

Program Overview and Implementation

To enhance protocols allowing pharmacists to more holistically and robustly optimize pharmacotherapy, UMCPP implemented the Clinical Pharmacy Services policy in February 2012. The policy

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