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Smith SE, Nei AM. Defining the "ideal state": A primer on critical care pharmacy practice models. Am J Health Syst Pharm 2024:zxae135. [PMID: 38741290 DOI: 10.1093/ajhp/zxae135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Indexed: 05/16/2024] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Critical care pharmacists (CCPs) have been clearly established as value-added members of the interprofessional team, and their contributions positively impact patient outcomes in the intensive care unit (ICU). Despite this, not every critically ill patient in the US receives care from a CCP and the model through which CCPs practice is variable, which has important implications. The purpose of this primer is to review current CCP models and discuss elements of the optimal CCP practice model. SUMMARY Current CCP practice models are defined, including the drug processing and dispensing model, clinical pharmacy specialist model, integrated pharmacy generalist model, and hybrid model, as well as unit-based vs service-based models. The optimal CCP practice model considers the Triple Domain of CCP workload, which includes direct patient care, indirect patient care, and professional service. Elements of the ideal CCP practice model including 24/7/365 CCP services, unit- vs service-based models, prescriptive authority, operational support, and CCP-to-patient ratio are discussed. Other vital elements include protected offline time, use of appropriate workload metrics, development of career ladders, opportunities for professional development, and providing wellness resources. The ideal CCP practice model must also be considered through the lens of the patient and medical team, the CCP, the institution, and professional organizations. Strategies for optimizing current CCP practice models are provided, and application of optimal CCP practice model elements is explored through 5 case studies. CONCLUSION The optimal CCP practice model includes multiple elements and incorporates the viewpoints of patients, providers, CCPs, institutions, and professional organizations; this model will increase access of all ICU patients to CCPs, enhance the scope of CCP cognitive services, and ensure the economic sustainability of CCP practice while establishing CCP involvement in activities outside of patient care and in professional service.
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Affiliation(s)
- Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital-Rochester, Rochester, MN, USA
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Gormley L, Mullins C, Sylvia LM. Implementation of a Synergistic, Complementary Pharmacy Practice Model for an Advanced Heart Failure/Heart Transplant Program. J Pharm Pract 2024; 37:17-26. [PMID: 35603500 DOI: 10.1177/08971900221104257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Study Objective: A pharmacy practice model for an Advanced Heart Failure (HF)/Transplant program was designed to address gaps in medication access, medication education and transitions of care (ToC). Activities specific to these initiatives performed by a four-member pharmacy team (3 pharmacists, 1 specialty technician) are described. Methods: Data were prospectively collected in 2020 for 284 admissions involving a high-risk cohort of advanced HF/transplant patients and a similar cohort seen in an ambulatory HF clinic. Interventions including medication reconciliation, e-prescribing, patient consultation and telephone call backs were performed daily to ensure medication access on discharge and as outpatients, comprehensive medication education on a continuum, and improved ToC. Metrics specific to these interventions and revenue reflecting outpatient prescription volume were quantified. Results: Standardized discharge medication education was provided to 97% of the cohort (n = 275). Of the 51 patients newly transplanted or receiving a left ventricular assist device, 100% had medication access on discharge and received follow-up telephone consultation within 48 hours. ToC was performed on admission (97%), pre-operatively (n = 51; 100%), post-operatively (n = 51; 100%) and on discharge (97%). Outpatient prescription volume increased 42% with net revenue increasing 157%. Conclusion: A pharmacy practice model involving an integrated 4-member team improved medication access and education and allowed for ToC at multiple points in the care process thereby improving medication safety. Collaboration between pharmacists and technicians working in inpatient, outpatient and specialty pharmacy settings is encouraged to provide complementary care to high-risk patients.
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Affiliation(s)
- Luke Gormley
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Caitlin Mullins
- Department of Pharmacy, Tufts Medical Center, Boston, MA, USA
| | - Lynne M Sylvia
- Department of Pharmacy, Tufts Medical Center, Boston, MA, USA
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Kelley TN, Canfield S, Diamantides E, Ryther AMK, Pedersen CA, Pierce G. ASHP Survey of Health-System Specialty Pharmacy Practice: Practice Models, Operations, and Workforce - 2022. Am J Health Syst Pharm 2023; 80:1796-1821. [PMID: 37742303 DOI: 10.1093/ajhp/zxad235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Indexed: 09/26/2023] Open
Abstract
PURPOSE The results of the 2022 American Society of Health-System Pharmacists (ASHP) Survey of Health-System Specialty Pharmacy (HSSP) Practice: Practice Models, Operations, and Workforce are presented. METHODS A total of 273 leaders in HSSPs were contacted by email to complete a survey hosted using Qualtrics. The survey sample was compiled from ASHP member lists, the presence of a specialty pharmacy indicated in previous ASHP surveys, and outreach to ASHP member organizational leaders. RESULTS The survey response rate was 35.9%. Most HSSPs dispense 30,000 or fewer specialty prescriptions annually. Most respondents have an annual revenue of $100 million or less, are part of a 340B-covered entity, operate one location, have 1 to 2 specialty pharmacy accreditations, dispense both nonspecialty and specialty medications, and employ an average of 15.5 pharmacists and 17.6 technicians. The majority (66.7%) dispense 50% or less of prescriptions written by internal providers due to payor and manufacturer network restrictions. Over one-third employ nonpharmacist and nontechnician professionals. Specialty pharmacists are involved in treatment decisions and therapy selection before prescription generation (69.8%), and 47.7% of respondents report pharmacists operating under collaborative practice agreements. Most (82.6%) offer experiential or formal education in specialty pharmacy. The top point of pride remains patient satisfaction and level of service. Top challenges include access to payor networks, the ability to hire and retain qualified staff, and shrinking reimbursement from payors. CONCLUSION The HSSP is a continually maturing integrated advanced practice model focused on providing patient-centric care to all patients and employees of the health system regardless of network status. HSSPs are raising the standards for quality in specialty pharmacy care.
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Affiliation(s)
- Tara N Kelley
- Vanderbilt Specialty Pharmacy Services, Nashville, TN, USA
| | - Scott Canfield
- Clinical Program Development, Johns Hopkins Home Care Group, Baltimore, MD, USA
| | | | | | - Craig A Pedersen
- Virginia Mason Franciscan Health, Seattle, WA, and University of Washington, Seattle, WA, USA
| | - Gabrielle Pierce
- Member Relations, Section of Specialty Pharmacy Practitioners, American Society of Health-System Pharmacists, Bethesda, MD, USA
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Wiggins EH, Kramer J, Burgess LH, Warren C. Implementation of Clinical Pharmacy Surveillance Technology and a Pharmacy Practice Model Re-Design Across a Multi-State Health System. HCA Healthc J Med 2023; 4:111-117. [PMID: 37424983 PMCID: PMC10324869 DOI: 10.36518/2689-0216.1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Background Outcomes-directed pharmacy models are necessary to further comprehensive, patient-centric clinical care. This report describes the implementation of clinical surveillance technology and the development of clinical pharmacy metrics to measure outcomes that support return on investment. The overall goal of clinical surveillance technology implementation in this quality improvement project was to extend the pharmacists' reach and to improve patient safety and clinical outcomes with greater operational efficiencies. Methods In 2013, a clinical pharmacy surveillance tool was piloted and expanded over the next 2 years to 154 hospitals across the health system. Over the next 6 years, the number of hospitals utilizing the technology, the number of drug therapy modifications, the time to pharmacist intervention, clinical pharmacy metric results, and return on investment were tracked. Results From 2015 to 2021, the number of hospitals with clinical surveillance technology implemented grew to 177 hospitals. During this same time, the number of frontline clinical pharmacist drug therapy modifications more than doubled, and the time for pharmacists to respond to alerts decreased from 13.9 to 2.6 hours. Since 2015, the percentage of patients on vancomycin de-escalated by 3 days of therapy has increased by 12% and the percentage of patients with a UTI treated with fluoroquinolone decreased by 25%. Hard and soft dollar savings resulted in an annual return on investment of 1:12.9. Conclusion After implementing the redesigned pharmacy services model, pharmacists were more efficient and patient outcomes improved.
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Affiliation(s)
| | | | - L Hayley Burgess
- Clinical Services Group, HCA Healthcare, Nashville, TN
- VigiLanz Corporation, Minneapolis, MN
| | - Carley Warren
- Clinical Services Group, HCA Healthcare, Nashville, TN
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Abstract
PURPOSE Results of the first ASHP National Survey of Health-System Specialty Pharmacy Practice are presented. METHODS A sample of 230 leaders in health-system specialty pharmacies were contacted by email and invited to participate in a survey hosted using an online survey application. The survey sample was compiled from ASHP member lists, through review of data from other ASHP surveys indicating the presence of specialty pharmacies, and by outreach to ASHP member organizational leaders. RESULTS The response rate was 53.0%. Most health-system specialty pharmacies dispense 30,000 or fewer specialty prescriptions per year, have an annual revenue of $100 million or less, are part of an entity eligible to participate in the 340B Drug Pricing Program, operate 1 specialty pharmacy location, have at least 1 specialty pharmacy accreditation, dispense nonspecialty medications in addition to specialty medications, and employ an average of 13 pharmacists and 15 technicians. More than two-thirds of health-system specialty pharmacies (68.8%) dispense no more than half of the prescriptions written by their providers due to payer network restrictions or limited distribution drugs. The health-system specialty pharmacy practice model includes access to the electronic health record (100% of respondents), pharmacists and technicians dedicated to specific clinics (64.9% and 57.7%, respectively), specialty pharmacist involvement in treatment decisions and drug therapy selection prior to the prescription being written (64.9%), and documenting recommendations and progress notes in patients' electronic health record (93.4%). Most health-system specialty pharmacies (83.3%) offer experiential or formal education in specialty pharmacy. Top challenges that survey respondents expected to face in the next year included restricted access to payer networks and limited distribution drugs, 340B Drug Pricing Program changes, and shrinking reimbursement from payers. CONCLUSION The health-system specialty pharmacy represents an integrated advanced practice model that incorporates specialty medication-use management across the continuum of care.
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Affiliation(s)
- JoAnn Stubbings
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Craig A Pedersen
- Virginia Mason Medical Center, Seattle, WA.,University of Washington, Seattle, WA, USA
| | - Karly Low
- American Society of Health-System Pharmacists, Bethesda, MD, USA
| | - David Chen
- American Society of Health-System Pharmacists, Bethesda, MD, USA
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Newsome AS, Anderson D, Gwynn ME, Waller JL. Characterization of changes in medication complexity using a modified scoring tool. Am J Health Syst Pharm 2020; 76:S92-S95. [PMID: 31586396 DOI: 10.1093/ajhp/zxz213] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
PURPOSE The purpose of this study was to characterize dynamic changes in medication regimen complexity over time in critically ill adults and to validate a modified version of the medication regimen complexity-intensive care unit (MRC-ICU) scoring tool. SUMMARY A single-center, retrospective, observational chart review was conducted with a primary aim of assessing changes in medication regimen complexity over time, as measured by both the 39-item MRC-ICU scoring tool and a modified version (the mMRC-ICU) containing just 17 items. Secondary aims included validation of the mMRC-ICU and exploration of relationships between medication regimen complexity and ICU length of stay (LOS), inpatient mortality, and patient acuity. Adults admitted to a medical ICU from November 2016 through June 2017 were included. The medication regimens of a total of 130 patients were scored in order to test, modify, and validate the MRC-ICU and mMRC-ICU tools. The modified tool was validated by evaluating correlation of mMRC-ICU scores with MRC-ICU scores and with patient outcomes including patient acuity, ICU LOS, and inpatient mortality. mMRC-ICU scores were collected at 24 and 48 hours after admission and at ICU discharge to evaluate changes over time. Significant changes in medication regimen complexity over time were observed, with the highest scores observed at 24 hours after admission. CONCLUSION Medication regimen complexity may provide valuable insights into pharmacist activity and resource allocation. Further validation of the MRC-ICU and mMRC-ICU scoring tools in other critically ill populations and at external sites is required.
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Affiliation(s)
- Andrea Sikora Newsome
- College of Pharmacy, University of Georgia, Augusta, GA, and Department of Pharmacy, Augusta University Medical Center, Augusta, GA
| | - Daniel Anderson
- Department of Pharmacy, Emory Healthcare, Atlanta, GA, and College of Pharmacy, University of Georgia, Augusta, GA
| | - Morgan E Gwynn
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - Jennifer L Waller
- Department of Population Health Sciences, Division of Biostatistics and Data Science, Augusta University, Augusta, GA
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Abstract
BACKGROUND The MRC-ICU, a novel regimen complexity scoring tool, provides an objective measure of medication regimen complexity in critically ill patients. The MRC-ICU may have the ability to evaluate the impact of critical care pharmacists on patient outcomes but requires further validation. The objective of this study was to confirm the external validity of the MRC-ICU scoring tool at multiple institutions and intensive care unit (ICU) settings. METHODS This was a multicenter, prospective, observational study. The electronic medical record was reviewed to collect patient demographics and patient outcomes, and the medication administration record was reviewed to collect MRC-ICU scores at 24 hours, 48 hours, and ICU discharge. Validation was performed by assessing convergent and divergent validity of the score. Spearman rank-order correlation was used to determine correlation. RESULTS A total of 230 patients were evaluated across both centers in both medical ICUs and surgical ICUs. Differences between the original center and the new site included that total number of orders (29 vs 126; P < 0.001) and total number of medication orders (17 vs 36; P < 0.001) were higher at the new site, whereas the original site had higher overall MRC-ICU scores (14 vs 11; P = 0.004). The MRC-ICU showed appropriate convergent validity with number of orders and medication orders (all P < 0.001) and appropriate divergent validity with no significant correlation found between age, weight, or gender (all P > 0.05). CONCLUSIONS External validity of the MRC-ICU has been confirmed through evaluation at an external site and in the surgical ICU population. The MRC-ICU scoring tool requires prospective evaluation to provide objective data regarding optimal pharmacist use.
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Affiliation(s)
- Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA
| | - William J Olney
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA
| | - Timothy W Jones
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA
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