Published in the April 2017 issue of Today’s Hospitalist
HOSPITALISTS TALK A LOT about multidisciplinary team-based care, but one small hospital in Arkansas is actually walking that walk. If you want to find clinical pharmacist Todd Weaver, PharmD, look in the hospitalists’ office, not the pharmacy.
“We all fuss about how much of health care is fragmented or silo-based, yet we keep people in separate departments,” explains Jody Smotherman, PharmD, associate administrator of graduate medical education at White River Medical Center.
It was Dr. Smotherman who first placed a full-time pharmacist within the hospitalist group in the Batesville, Ark., hospital two years ago when he was the hospital medicine program director. “With Todd present, a lot of the small things that are very frustrating to physicians and that may slow down care can be picked up and fixed right away.”
While pharmacist-hospitalist collaboration isn’t unusual, embedding a pharmacist who essentially becomes another member of the hospitalist group is a notable step further. That’s particularly true for a small hospital with only two clinical pharmacists on staff.
“I am right here, so I hear all the complaints.”
Miguel Villagra, MD, the current hospitalist medical director at the 220-bed hospital, calls the move a game-changer. “While we are sitting in the office and doing our notes, we can just ask him: ‘Should I worry about this drug-to-drug interaction? Should I decrease this dose?’ ”
Dr. Villagra explains. “He helps us put indications for antibiotics in the EMR, he knows what’s in the formulary and he knows costs. It’s better than trying to reach whoever is on call in the pharmacy department, and he will check immediately.”
Dr. Villagra adds that he often doesn’t even need to ask Dr. Weaver to go talk to a patient. “He already knows to do so because he goes on rounds and to group meetings.”
A close connection
When hospitalists have a personal connection with the pharmacist they see every day, Dr. Villagra points out, they can ask for the answers or clarifications that may seem too small to bother an expert with.
Or they can even express minor complaints. Take, for instance, what happened when Dr. Weaver grasped how testy some hospitalists became when ordering venous thromboembolism prophylaxis for their patients.
“In our CPOE system, we would list four drug options for the physicians to select at the end of their progress note, and one of those was ‘Other,’ ” says Dr. Weaver. “If you pick ‘Other,’ you then have to type in what you are using.” Many of the newer hospitalists are using heparin, which was not one of four options, so they would have to click “Other” and type in “heparin” on each patient every day.
“It didn’t make any sense,” he adds. So he used his IT skills to fix the problem and get rid of the extra typing by expanding menu options. “I try to make their lives easier. Because I’m always around the conversation, I can help them get things done.”
Dr. Weaver can write order sets. He also writes up hospitalist-initiated applications to the hospital’s P&T committee, including a recent one to update the serum potassium protocol. He helps with medication reconciliation questions, including searching a statewide narcotics surveillance system to track any opioid prescriptions that patients have filled. “The physicians have access to this program, but I can save them time by looking up patients on their behalf.”
Another win, Dr. Weaver says, has been his work updating the order set for COPD admissions. Now, the pricey short-acting bronchodilator levalbuterol HCl is no longer the pre-checked, top-of-the-list option. Changing the preselected choice in the order set to the less expensive ipratropium bromide and albuterol sulfate resulted in a 34% reduction of the use of levalbuterol HCl—and nearly $5,000 in savings over three months. The entire effort started, he notes, because he was in the room where doctors talk.
“A hospitalist would always complain, ‘Why do we use so much levalbuterol HCl?’ ” says Dr. Weaver. “I am right here, so I hear all the complaints.”
Integrating clinical pharmacists in patient care teams is a growing phenomenon. But such decentralized pharmacy systems, although common in academic and children’s hospitals, are still rare in smaller facilities. According to Drs. Villagra and Smotherman, White River has shown that the model can be replicated in small hospitals.
Because he is part of the pharmacy’s budget, Dr. Weaver occasionally has to work shifts in the hospital’s pharmacy. That happened recently during a spate of family leaves, but it’s more the exception than the rule. And, as Dr. Weaver points out, he can still take call for the pharmacy from his desk in the hospitalists’ office, including verifying orders and reviewing charts. “I’m a little square of pharmacy in the hospitalist office.”
He recently received, for instance, a call from the pharmacy about an order put in for a medication strength the hospital does not stock.
“I was able to talk to the physician and make the change myself,” Dr. Weaver says. If he hadn’t been in the office, the issue would have become just one more of the countless interruptions hospitalists have to field. He estimates he handles about 20 queries a day from the hospitalists and nurses on everything from meningitis dosing to how to correctly interpret susceptibility tables sent up from the microbiology lab.
According to Dr. Smotherman, other small hospitals thinking of embedding a pharmacist in their hospitalist groups should heed some of the lessons White River has learned.
The most important has been to make sure the pharmacist’s personality and skills complement those of the hospitalists. “Todd is such a concise, data-driven, fact-based guy, that he was a perfect fit. There are no turf wars and no barriers.” In addition, says Dr. Smotherman, Dr. Weaver is “astute enough to pick up on things he hears. He does a lot of finer-level tune-ups because he knows what the hospitalists like and don’t like.”
The model has been such a success that Drs. Smotherman and Villagra eventually plan to expand it and integrate more nonphysicians in the hospitalist team, including physical therapy, dietary and case management.
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.