Published in the March 2014 issue of Today’s Hospitalist
LIKE MANY OTHER HOSPITALISTS, Martin Johns, MD, used to think a lot about finding a low-cost solution to improving medication reconciliation at his hospital.
He and the rest of the medical safety team at Gifford Medical Center, a critical access hospital in Randolph, Vt., knew they had medication errors, which led to patient complaints. Dr. Johns attributed that to “guesswork and patchwork” problems with their med rec, which was typically handled by ED nurses.
The hospital didn’t have the resources to add what many consider the gold standard: 24/7 pharmacy technicians. But instead of settling for the status quo, Dr. Johns and his team started looking at existing staff to see who was not only capable of doing med rec, but who had the time to take that task on.
A year ago, the hospital found an answer.
“We decided we would utilize a resource that all critical access hospitals are required to have, and who have occasional downtime: respiratory therapists,” says Dr. Johns, medical director of the hospital medicine division at the 25-bed hospital.
When not involved in a code or managing a ventilator or patient treatments, respiratory therapists would fill their time by helping with hearing screens in the nursery or handling ECGs for busy nurses. “This was an instance where better time management could fit med rec in,” Dr. Johns says.
Given the respiratory therapists’ expertise at taking histories and developing patient relationships, he was confident that they would do a great job with the often tough task of teasing out patients’ drug information at admission.
Perhaps not surprisingly, the hospital’s five respiratory therapists weren’t as enthusiastic. Med rec, they contended, wasn’t a good fit for their training and licensure.
Convinced otherwise, Dr. Johns ramped up their education and assured the therapists that they weren’t about to become medication experts. Instead, he says, they were about to become a critical part of the inpatient team.
Like other critical access hospitals, Gifford was doing its best with limited resources when it came to medication reconciliation. The ED nurses doing the job didn’t have the time to do more than write down what patients told them and enter that information in the computer.
“They were essentially transposing the patient list,” Dr. Johns says, “and you know that can be very inaccurate.”
One problem in figuring out how to staff med rec was the inconsistent need. Some days, the hospital might have eight admissions; other days, there could be none.
“You can’t have someone sitting there in the emergency room full-time waiting for admissions,” he says. The hospitalist service is made up of both physicians and midlevels, and there are huge swings in acuity and volume.
And those physicians and midlevels were too busy for the job. Plus, Dr. Johns points out, they aren’t the best candidates because they tend to fill in the blanks if patients are unsure. “A patient might say, ‘I’m on this medication,’ and the PA, NP or physician hospitalist would assume it’s Prozac because of his or her knowledge base,” he explains. Or clinicians might fix a dose that seems out of line when, in fact, that is the dose the patient is taking.
Respiratory therapists, on the other hand, held more potential. At Gifford, they are in the hospital from 7 a.m. to 10 p.m., take call, and have not only fact-finding skills but the ability to put patients at ease.
RTs in the ED
Key to moving respiratory therapists into med rec was assuring them that they didn’t have to work without a net.
The therapists met with the pharmacist to learn how to do a good medication history, finished an online med-rec course and got up to speed with the EMR before hitting the frontlines. They were trained to compare lists from the pharmacy with that of the primary care physicians and the patients, ask questions, and merge those data together to create a comprehensive list.
If certain information is unknown, they’re advised to say just what they know. For example, Dr. Johns says, “It’s a little blue pill not in the last office note. Said for depression. Not sure what it is.” Respiratory therapists also don’t worry about flagging drug-drug interactions.
After the therapist enters the information in the computer system, the pharmacist reviews it and typically OKs the medications listed. The pharmacist will then correct discrepancies or alert the hospitalist to drug interaction issues or other problems. The hospitalist NP, PA or MD then completes admitting orders using the med list in the computer via the CPOE system.
The respiratory therapist can talk directly to the hospitalist with any immediate concerns. One therapist, for example, asked Dr. Johns if a patient in for a GI bleed was at risk because he was taking three over-the-counter medications that could interact with his other meds and cause bleeding.
“Ultimately,” says Dr. Johns, “they’re not prescribing or recommending. They’re just presenting the list.”
How it works
To fit the task into the therapists’ schedule, registration gathers paperwork and pages the respiratory therapist to let him or her know a patient is being admitted from the ED. If it’s a critical situation, the floor ward clerk will alert the therapist that med rec is needed right away.
Otherwise, the therapist asks how much time he or she has to get there. There’s no rigid time structure, but response time is usually within an hour, according to Dr. Johns. “The RT might know there’s someone in the ER but can finish up a breathing treatment or deal with a situation in the stress lab first, then do the admission.”
If the admission occurs overnight and the patient is stable, the emergency physician writes holding orders. First thing in the morning, the respiratory therapist does the med rec while the hospitalist sees the patient.
While the scheduling works most of the time, there are instances “especially during the flu and respiratory syncytial virus seasons “when the therapists are overwhelmed with their respiratory-related work. In those cases, the pharmacist will step in if the med rec is needed right away. If the pharmacist isn’t available, the hospitalist will do it, Dr. Johns says.
As for compensation, he notes that the therapists don’t see anything extra in terms of money or benefits. However, he monitors the time they spend on med rec because that time is charged to the hospital medicine division budget.
Having an impact
The process has led to better upfront information, says Dr. Johns, and the hospitalists are certainly happier.
Moreover, the once-reluctant therapists have found a satisfying niche. “They’ve always been on the periphery, helping when needed, but this puts them in the middle of admissions,” he says. As a result, they get a higher profile with patients and families, and they are now a more integral part of the inpatient staff.
Once the therapists realized the positive impact they could make, they embraced their new role. “They really feel like a part of the hospitalist team,” Dr. Johns says. “They’re proud of what they’re doing, and I am thrilled with their work.”
He’s now crunching the numbers to evaluate the program’s impact on medication error rates. He’s also planning to refine the program so other hospitals can reap the benefits.
“It can be reproducible nationally,” says Dr. Johns, “because every critical access hospital absolutely needs both RTs and a sound medication reconciliation process.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.