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The Development and Implementation of an Admitting Pharmacist in the Community Hospital Setting

Estela Trimino, Pharm.D., Janelle Berg, Pharm.D., BCPS, Fernando J. Zaldivar, B.S. Pharm., Claudia DiStrito, R.N., B.S.N., M.S.H.

 

Mercy Hospital, Miami, Florida

The primary focus of this endeavor was to establish and measure the impact of providing pharmacy services upon admission to the hospital.  Specific goals included: obtaining accurate medication histories, communicating information to the next provider, managing the formulary, selecting timely and appropriate antibiotic therapy, assisting with performance improvement and/or Joint Commission on Accreditation of Healthcare Organizations® (JCAHO®) Core Measures, and preventing adverse drug events (ADEs).

In recent years Emergency Department (ED) healthcare providers have noted a shift towards treating both acute and chronic conditions, in part due to the increased utilization of the ED as a site for primary care visits.  This has resulted in increased demands on system resources and increased holding time for admitted patients.  Through various time study analyses, patient care outcomes, and satisfaction scores it became evident that there was a need to develop a patient-pharmacist-physician relationship early in the admission process.  The pharmacy practice resident was asked to create and cost-justify an admitting pharmacist position which was approved in July, 2002.  Shortly thereafter, the admitting pharmacist was incorporated into the ED workflow.  Patient interviews were conducted to ascertain accurate medication histories and to provide herbal medication teaching and smoking cessation counseling as needed.  In addition, the admitting pharmacist compiled home medication lists, reviewed treatment regimens, evaluated admitting orders, and reconciled discrepancies with physicians if warranted.  The pharmacist also processed initial orders to improve nursing and patient satisfaction and, most importantly, became the “medication specialist” in the ED.  Over time, the role evolved to include participation in the performance improvement program of the hospital.  Working with a multidisciplinary team, the admitting pharmacist developed and implemented an acute coronary syndrome protocol that is initiated at time of triage for chest pain patients.  Additionally, a pneumonia decision tree was developed to assist the ED physicians in choosing appropriate antibiotics. 

A total of 6,639 patients have been interviewed and 7,815 interventions performed with a 92% acceptance rate since implementation.  Use of the acute coronary syndrome protocol increased beta-blocker use from 85% to 95% and aspirin use from 92% to 100% in patients with acute myocardial infarction over a 6 month period.   Although it is not easy to quantify the cost of an adverse drug event, it has been estimated that each ADE can potentially cost the healthcare system $2,162.  Extrapolating that figure to the admitting pharmacist’s prevented ADEs, the total cost avoidance to our healthcare system could be as much as $15 million dollars over the 4 year period since implementation of the program.  Medication history accuracy, communication across the continuum of care, formulary management, and timely and appropriate antibiotic selection have all improved.  In addition, quality outcomes related to the ED services have been impacted significantly. 

This unique and innovative role of an admitting pharmacist in the ED has become an indispensable component of the admission process in this institution.  If positions similar to this were implemented in other hospitals, pharmacists could become the leaders in providing full compliance with JCAHO® continuum of care and ASHP 2015 initiatives to improve patient care while preventing adverse drug events. 

References

Senst BL, Achusim LE, Genest RG et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health-Syst Pharm. 2001; 15:1126-32.

View a pdf of the poster from the Midyear Meeting (291KB).