Published in the May 2006 issue of Today’s Hospitalist
Ten years ago, while completing a lung transplant fellowship at Atlanta’s Emory University School of Medicine, Louis Lovett, MD, learned to appreciate the value of working side by side with a pharmacist.
In transplant medicine, after all, properly managing complex antirejection medication regimens can have just as much impact on patient outcomes as physicians’ skills. And nobody knew more about these medications than the pharmacist who worked with many of the Emory transplant teams.
“This pharmacist knew everything there was to know about immune therapy medications,” recalls Dr. Lovett, who is now a hospitalist and chair of medicine at Atlanta Medical Center. “She oversaw the regimens, helped monitor patients and consulted with the physicians about drug interactions and side effects on a daily basis. After working with her, I really began to appreciate the specialized knowledge that pharmacists bring to the table.”
Perhaps because of his early experience with pharmacists, Dr. Lovett continues to find the expertise of pharmacists invaluable when it comes to working as a hospitalist. That applies even to patients with “basic” problems like diabetes.
“When I was a medical student,” Dr. Lovett explains, “we had a handful of medications for managing common conditions such as diabetes. Now we have classes of drugs just for this one condition.”
Besides, he adds, it’s nearly impossible for any one physician to keep track of the plethora of medications, side effects and drug interactions for every patient.
“That’s why pharmacists are so vital,” Dr. Lovett explains. “They play a huge role in ensuring that we use medications correctly.”
Making the rounds
Largely because of the medication management issues cited by Dr. Lovett, a growing number of hospitalists are discovering the value of teaming up with pharmacists. These partnerships are not only helping manage individual patients, but making system-wide changes to reduce medication errors, cut costs and improve patient care.
In many ways, pharmacists are a good match for hospitalists because they share two key character traits: a constant presence in the hospital and a zeal for quality improvement. As a result, hospitalists are often the first clinicians to appreciate the value that pharmacists bring to the patient care team.
That was the experience at Atlanta Medical Center, where pharmacy residents began rounding with hospitalists five years ago. The pairing was so successful that two years later, staff pharmacists started making rounds with hospitalists.
Today, both pharmacists and clinical pharmacy residents round with the three internal medicine teams, which include a hospitalist, a resident and an intern. Dr. Lovett says the sessions are invaluable for both the physicians and the pharmacists.
“The pharmacists learn how we make differential diagnoses,” he explains, “why we order certain tests and how we follow a patient on a daily basis. In turn, they provide information on everything we need to consider when we order a medication.”
Physicians aren’t the only ones who benefit from the experience. Pharmacists at the hospital say that working more closely with attending physicians has been helpful to them as well.
“Before we started rounding together, we struggled to educate physicians about what pharmacists actually do and how much training we have,” says Teresa Pounds, PharmD, clinical pharmacy manager and program director for the pharmacy residency program. “That’s still the case in many hospitals. Pharmacists are usually behind the scenes.”
By bringing pharmacists front and center on the rounding teams, Dr. Pounds says, “we’ve definitely improved our relationship. We can make recommendations at the point of care, our hospitalists appreciate the opportunity to collaborate with us, and they’re more receptive to our recommendations.”
Improving the bottom line
While there is little in the way of data on the number of pharmacists working side by side with physicians, the hospitalists at Brookhaven Memorial Hospital Medical Center in East Patchogue, N.Y., have an idea of how the partnerships affect the bottom line. Pharmacy residents at the hospital round with Brookhaven’s six hospitalists.
Data from an unpublished study that was released in 2003 showed that patients treated by hospitalist/ pharmacist teams had a 23 percent shorter length of stay, a 21 percent lower cost of medications and 1.5 fewer medications per patient than patients treated by private attending physicians. In addition, the average drug cost per case was 29 percent lower, and patients needed IV antibiotics for 1.5 fewer days.
Saeed Syed, MD, a hospitalist with Cogent Healthcare Inc. who led the study, concedes that it’s difficult to separate the impact of the hospitalist model and the impact of the hospitalist/pharmacist teams, noting that his hospitalist service would have achieved at least some of those gains even without the help of pharmacists. Nonetheless, he believes pharmacists play a vital role at a patient’s bedside, and that his study points to that value.
“So many things come up in those discussions,” Dr. Syed says, “whether dosages are correct, whether the patient might benefit from another medication, possible drug interactions. We’re able to immediately follow up on any recommendations. It translates into patients leaving the hospital earlier and a lower cost of care.”
The hospital was so impressed by the study’s results, in fact, that after the research was released, it put a staff pharmacist on every floor to be more accessible to all the physicians. While Dr. Syed says that proximity helps improve the relationship between physicians and pharmacists, he would like to see staff pharmacists rounding with private physicians, not just hospitalists.
He acknowledges that idea would raise eyebrows among hospital administrators not only about costs, but workforce issues. “Right now,” Dr. Syed says, “this isn’t possible. There just aren’t enough pharmacists to go around.”
The staffing situation might not improve anytime soon at Brookhaven, or at any other hospital. A recent survey by the Pharmacy Manpower Project Inc., a nonprofit coalition of pharmaceutical, professional and trade organizations, says that many pharmacists are approaching retirement age (more than 40 percent of all male pharmacists are over 55) and pharmacists of all ages are choosing to work shorter hours.
With 100 pharmacy schools in the United States graduating 80 to 100 students a year, hospitals find themselves struggling to compete with industry and retail practice settings, which often offer better starting salaries, to fill vacant positions.
Going beyond rounds
Even when there aren’t enough pharmacists to round with every physician, hospitals are discovering other forms of collaboration to reduce inappropriate medication use and prevent errors.
At Atlanta Medical Center, for example, a committee of hospitalists and pharmacists examines issues of antibiotic overuse. Dr. Lovett took this step last year after noticing during chart reviews that many patients were receiving antibiotics when there was no indication for them. That raises not only concerns about the inappropriate use of medications, but antibiotic resistance.
The committee created guidelines for the use of antibiotics and antifungals, and pharmacists were asked to take a greater role in monitoring the use of antibiotics. “We were able to create an awareness of this issue that wasn’t there before,” says Dr. Lovett.
In less than a year, the initiative has had a significant impact. While antibiotics used to account for 25 percent of the hospital’s total medication costs, that figure has dropped to 15 percent. The committee is now working on designing an antibiotic order form that will require every physician to document the reason for the antibiotic, as well as information about the drug’s dose and duration.
Dr. Lovett concedes that for some physicians, this level of pharmacist interaction may be a little too close for comfort. “Any time you allow a nonphysician to enter into the care of a patient,” he says, “there’s always a fear that you are losing control.” He was able to convince hospitalists of the benefits of collaboration, however, by pointing to results fairly soon after the initiative was implemented. Just three months after the hospital introduced guidelines for antibiotics and antifungals, for example, antifungal use significantly dropped. “Just that result convinced a lot of people,” says Dr. Lovett.
At Northwestern Memorial Hospital in Chicago, pharmacists similarly work with hospitalists on a variety of initiatives.
When the hospital decided to implement a computerized order entry system in August 2004, hospitalists worked with pharmacists to customize it for the entire hospital. According to hospitalist Kevin O’Leary, MD, the system was piloted with the hospitalist service, which has a staff of 22 physicians. They were the first to place medication orders through the system, which were filled by the pharmacists.
Together, they caught a few kinks in the system. They discovered, for example, that when a physician ordered a daily medication, the system would automatically assign it to be administered at a “default” time, like 10:00 a.m. This created the potential for a patient to miss a dose or get an extra dose, depending on the time the order was entered. Because of the collaboration of the hospitalists and the pharmacists, the system was modified before it was rolled out to the rest of the hospital.
A hospitalist and pharmacist are also leading a medication reconciliation project so that physicians and nurses can refer to a master medication list for each patient. “In the future,” Dr. O’Leary says, “the hospitalist will help create the initial list and enter it into the medical record; a pharmacist and staff nurse will then follow up to verify that there are no discrepancies.”
“We purposefully try to pilot these kinds of efforts with hospitalist/pharmacist teams,” he adds. “They’re both extremely motivated groups, and they’re generally very interested in patient safety and quality improvement.”
Northwestern also has a group of pharmacists with expertise in pain medications who have formed an analgesic dosing service. They’re often called to the bedside of patients with chronic or difficult-to-control pain.
“Patients with illnesses such as sickle cell anemia, cancer or chronic pancreatitis are often on complicated pain regimens,” says Dr. O’Leary. “The pharmacists on the analgesic dosing service can help us convert them from oral to IV pain medications, or help us understand the impact of different opioids, all of which have slightly different side effects.”
The dosing service is available to all physicians, but Dr. O’Leary believes that hospitalists might be more apt to take advantage of it. “Hospitalists tend to be more in tune with a multidisciplinary approach to patient care,” he says.
Even in hospitals that have no formal systems for bringing together hospitalists and pharmacists, the two groups are finding ways to work more closely.
The pharmacists at Mission Hospital in Mission Viejo, Calif., used to take a retroactive approach to interventions, calling the physician if they felt a medication wasn’t the most appropriate choice. Now, explains pharmacist Jim Kuzma, PharmD, he and his colleagues are taking a more proactive approach when it comes to more alternative therapies.
When hospitalists don’t agree with the recommendations, conflicts are quickly resolved. “A few physicians resist when we suggest therapeutic substitutions, such as Levaquin instead of Cipro,” he says. “We work around that by allowing some ‘wiggle room’ in our policies, such as allowing the physician to write ‘do not substitute’ on the order.”
Dr. Kuzma also points out that the give and take between hospitalists and pharmacists works largely because of the comfort level between the two groups.
“Some of the hospitalists have been here for 15 years,” he says, “so we’re in tune with each other’s goals. A lot of hospitalists work with us the way they would with a physician’s assistant or nurse practitioner.”
Mission’s hospitalists say they appreciate this flexibility, as well as the easy access to pharmacists, who are readily available in satellite pharmacies or via phone or beeper.
“Pharmacists recommend specific medications or dosages, suggest medications we might not be familiar with and help us catch potential drug interactions,” says Gerald Sugino, MD, one of the 16 hospitalists on staff. “They save us a lot of time, and they allow us to spend more time on patient care.”
Yasmine Iqbal is a freelance writer specializing in health care.