Expansion of Pharmacy Services During COVID-19: Pharmacists and Pharmacy Extenders Filling the Gaps Through Telehealth Services

Purpose: The Coronavirus 2019 (COVID-19) pandemic created a significant disruption in healthcare. In our health-system located in New York City, the provision of care in the ambulatory care setting moved to a remote model virtually overnight. We describe interventions made during the pandemic to transform ambulatory care pharmacy through expansion of telehealth services. Summary: In March of 2020, the closure of primary care clinics and provider appointment cancellations due to inpatient redeployment created a void. Collaboration with other health care providers and development of standardized telehealth workflows served as a conduit for creating new roles and opportunities for pharmacy team members. Three main interventions where the pharmacy team filled gaps include; (1) Expansion of pharmacist telemedicine visits for high-risk patients to improve access to primary care visits, (2) Partnership with nursing to create a centralized refill call center workflow, (3) Integration of pharmacy extenders into the prior authorization process to prevent medication access issues. Existing collaborative practice agreements for chronic disease management were utilized. A virtual pharmacist model for patient care contributed to an increase in telehealth visits from 51 in 2019 to 2997 total visits in 2020. In addition, the health-system refill call center expanded its services through collaboration with our pharmacy team. Pharmacists and pharmacy interns partnered with nurse practitioners to improve the call center workflow and address the significant increase in refill requests during the outbreak. Furthermore, a prior authorization process was created across multiple ambulatory care clinics to expedite medication access and prevent delays in therapy. Conclusion: Our ambulatory care pharmacy team leveraged technology, innovative workflows, and collaborative teamwork to catalyze a shift in pharmacists' and pharmacy extenders' roles in healthcare delivery to expeditiously meet patients' needs during a pandemic.

Randomized controlled evaluation of an insulin pen storage policy

PURPOSE

Results of a quality-improvement project to enhance safeguards against "wrong-pen-to-patient" insulin pen errors by permitting secure bedside storage of insulin pens are reported.

METHODS

A cluster-randomized controlled evaluation was conducted at an academic medical center to assess adherence with institutional policy on insulin pen storage before and after implementation of a revised policy allowing pen storage in locking boxes in patient rooms. In phase 1 of the study, baseline data on policy adherence were captured for 8 patient care units (4 designated as intervention units and 4 designated as control units). In phase 2, policy adherence was assessed through direct observation during weekly audits after lock boxes were installed on intervention units and education on proper insulin pen storage was provided to nurses in all 8 units.

RESULTS

Phase 1 rates of adherence to insulin pen storage policy were 59% in the intervention units and 49% in the control units (p = 0.56). During phase 2, there was no significant change from baseline in control unit adherence (67%, p = 0.26), but adherence in intervention units improved significantly, to 89% (p = 0.005). Common types of observed nonadherence included pens being unsecured in patient rooms or nurses' pockets or left in patient-specific medication drawers after patient discharge.

CONCLUSION

An institutional policy change permitting secure storage of insulin pens close to the point of care, paired with nurse education, increased adherence more than education alone.

Engaging hospital patients in the medication reconciliation process using tablet computers

Objective

Unintentional medication discrepancies contribute to preventable adverse drug events in patients. Patient engagement in medication safety beyond verbal participation in medication reconciliation is limited. We conducted a pilot study to determine whether patients' use of an electronic home medication review tool could improve medication safety during hospitalization.

Materials and Methods

Patients were randomized to use a tool before or after hospital admission medication reconciliation to review and modify their home medication list. We assessed the quantity, potential severity, and potential harm of patients' and clinicians' medication changes. We also surveyed clinicians to assess the tool's usefulness.

Results

Of 76 patients approached, 65 (86%) participated. Forty-eight (74%) made changes to their home medication list [before: 29 (81%), after: 19 (66%), p = .170]. Before group participants identified 57 changes that clinicians subsequently missed on admission medication reconciliation. Thirty-nine (74%) had a significant or greater potential severity, and 19 (36%) had a greater than 50-50 chance of harm. After group patients identified 68 additional changes to their reconciled medication lists. Fifty-one (75%) had a significant or greater potential severity, and 33 (49%) had a greater than 50-50 chance of harm. Clinicians reported believing that the tool would save time, and patients would supply useful information.

Discussion

The results demonstrate a high willingness of patients to engage in medication reconciliation, and show that patients were able to identify important medication discrepancies and often changes that clinicians missed.

Conclusion

Engaging patients in admission medication reconciliation using an electronic home medication review tool may improve medication safety during hospitalization.

Impact of Hospitalist-Led Interdisciplinary Antimicrobial Stewardship Interventions at an Academic Medical Center

BACKGROUND

Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes.

METHODS

A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5).

RESULTS

Total antibiotic use decreased by 16.8% (p < 0.001), 6.8% (p = 0.08), and 33.0% (p < 0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p < 0.001), 7.8% (p = 0.09), and 32.4% (p < 0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p < 0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p < 0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team.

CONCLUSION

Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.

Implementation of an emergency department-based clinical pharmacist transitions-of-care program

PURPOSE

The implementation of an emergency department (ED)-based clinical pharmacist transitions-of-care (TOC) program is described.

SUMMARY

The intervention program consisted of collaboration between ED and ambulatory care pharmacists to provide patient-specific comprehensive medication review and education in the ED setting and to help ensure a coordinated transition to the ambulatory care setting by scheduling an ambulatory pharmacy clinic or home-based visit. Patients who sought care at an adult ED for an exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) were assessed for issues with medication adherence or administration technique, patient-specific concerns regarding medication use, access to medications at discharge, the need for modification of chronic therapy, contraindicated medications, and vaccination status, if applicable. The pharmacist then referred the patient to follow up in an ambulatory care pharmacy clinic or with the home-based medication management (HBMM) program. Of the 18 program participants who were referred to follow-up care, 5 successfully followed up with a pharmacist after ED discharge. The mean time from the ED visit to follow-up for these 5 patients was 16.6 ± 8.6 days. In addition, 5 patients followed up with their primary care provider within 30 days of the initial ED visit; 2 of these patients also followed up with a pharmacist. Within 30 days of the initial ED encounter, 4 patients had ED revisits.

CONCLUSION

A TOC pharmacist-led program targeting patients who arrived at the ED with the chief complaint of asthma exacerbation, COPD, or CHF provided interventions from an ED or ambulatory care pharmacist as well as follow-up opportunities at outpatient clinics or an HBMM program.

Evaluation of a Nurse-Managed Insulin Infusion Protocol

BACKGROUND

The purpose of this study was to evaluate the performance of an insulin infusion protocol targeting a blood glucose (BG) level of 140-180 mg/dL and to characterize protocol adherence.

MATERIALS AND METHODS

This was a retrospective observational cohort study including patients for whom the protocol was ordered from January 2012 to May 2013. Performance metrics were assessed in all patients and in patients with an initial BG level of ≥200 mg/dL. Protocol adherence was assessed in a random subset of 50 patients without hypoglycemia and in all hypoglycemic patients.

RESULTS

In patients with an initial BG level of ≥200 mg/dL, the mean time to goal was 7.1 h. The rate of decline of BG level in the first 6 h was 16.4 mg/dL/h. Mean BG level was 167 mg/dL, with 43.9% of BG values within goal and 80.3% between 80 and 199 mg/dL. The rate of hypoglycemic events was 0.14 per 100 h. The mean protocol violation rate was higher in patients with hypoglycemia compared with those without (39.8 vs. 23.5 per 100 h, P = 0.002), and 60.7% of hypoglycemic events were attributable to protocol violations. The protocol violation rate (42.8 vs. 17.6 per 100 h; P < 0.001) and the odds of hypoglycemia (odds ratio = 5.2; 95% confidence interval, 1.6, 16.5) were higher in the cardiac surgery patients compared with other patients.

CONCLUSIONS

This protocol provides adequate BG control within the clinically acceptable range of 80-199 mg/dL but not within the narrower range of 140-180 mg/dL, with a low incidence of hypoglycemia. Risk factors for hypoglycemia and barriers to protocol adherence in the cardiac surgery population should be elucidated.

Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice

BACKGROUND

Strategies for successful implementation of hospitalwide glucose control efforts were addressed in a conceptual model for the development and implementation of an institutional inpatient glucose management program. CONCEPTUAL MODEL COMPONENTS: The Glucose Steering Committee incrementally developed and implemented hospitalwide glucose policies, coupled with targeted education and clinical decision support to facilitate policy acceptance and uptake by staffwhile incorporating process and outcome measures to objectively assess the effectiveness of quality improvement efforts. The model includes four components: (1) engaging staff and hospital executives in the importance of inpatient glycemic management, (2) educating staff involved in the care of patients with diabetes through structured knowledge dissemination, (3) executing evidence-based inpatient glucose management through development of policies and clinical decision aids, and (4) evaluating intervention effectiveness through assessing process measures, intermediary glucometric outcomes, and clinical and economic outcomes. An educational curriculum for nursing, provider, and pharmacist diabetes education programs and current glucometrics were also developed.

OUTCOMES

Overall the average patient-day-weighted mean blood glucose (PDWMBG) was below the currently recommended maximum of 180 mg/dL in patients with diabetes and hyperglycemia, with a significant decrease in PDWMBG of 7.8 mg/dL in patients with hyperglycemia. The program resulted in an 18.8% reduction in hypoglycemia event rates, which was sustained.

CONCLUSION

Inpatient glucose management remains an important area for patient safety, quality improvement, and clinical research, and the implementation model should guide other hospitals in their glucose management initiatives.