Pharmacy director offers pointers on decentralizing

Make change in gradual steps

For many hospital pharmacy departments, decentralization is an important goal for the purpose of improving patient care and safety and encouraging greater collaboration between pharmacists, nurses, and physicians.

But what is a workable model for making this change?

"We've wanted to do this for a long time, but we've never had enough pharmacy staff to decentralize," says Toni Covato, RPh, MS, director of pharmacy at Flagler Hospital in St. Augustine, FL.

"Most hospital pharmacies would like to do this, but it's an issue of how and do you have the resources," Covato adds. "So we made as many electronic and technology changes as we could to free up pharmacist time and put a pharmacist on the floor."

For instance, the hospital now has a wireless computer system, and there are computers on wheels. So pharmacists can take these with them to the floor and to look up patients' drug information, she explains.

"We wanted to try to set up the pharmacist so they'd be free of chasing down doses and could look at patient profiles and be in a position to speak with nurses or doctors to resolve problems," Covato says.

The decentralized pharmacy model employed by Flagler Hospital is one that might be practical for many smaller hospitals because it began small with just one pharmacist spending time in the hospital's acute care areas.

"We have been able to free up one pharmacist on most days to spend the morning on the floor," Covato says. "Our long-term goal is to free up three or four pharmacists so we could cover most acute care parts of the house."

The ultimate goal is to have pharmacists handle issues related to Medicare, total parenteral nutrition monitoring (TPN), the Joint Commission's anticoagulation monitoring requirements, and IV to PO therapy switches, Covato explains.

"If we're there with patients we can access their charts to see if patients can swallow and if we can switch them to PO therapy," Covato says. "This way, we're not calling and interrupting nurses – we're there to see for ourselves."

Having a pharmacist on the floor helps improve patient care, and it's beneficial to be able to speak with physicians face-to-face, Covato says.

Including Covato, the hospital has 12 pharmacists who provide 24/7 coverage.

"Normally, during the day I have at least three pharmacists here and a clinical coordinator who is responsible for developing all clinical programs, education, and following patients," she says.

The hospital doesn't yet have the resources for a pharmacist to assist full-time with medication reconciliation, but the hospital's pharmacists will monitor for mistakes on prescription orders, Covato adds.

The key to convincing hospital leadership that decentralizing the pharmacy would be a good move is to gather data on both safety improvement and saving costs, Covato notes.

"Usually, your administrator wants economics information, so you have to track interventions and try to see how having a pharmacist involved saves costs," she explains. "That's very hard to do, except with some big items where you can show savings, such as IV to PO changes."

For example, when Flagler Hospital's critical care area began to use the expensive drug drotecogin (Xigris®) for treating sepsis patients, physicians were using it automatically for all patients with that diagnosis instead of reserving it for high-risk, severe sepsis patients, Covato says.

"So we reviewed the literature, came up with a protocol, and have the pharmacist check off on the protocol," she says.

After tracking the hospital's use of drotecogin, pharmacists found that a small number of physicians were prescribing it more than others. "So we went back to them and said, 'Why are you using it?' and we developed criteria for its use," Covato says.

The pharmacist on the floor would check the patient, look at the patient's lab results, and speak with the physician about the case, she explains.

The reason this process works better with a pharmacist serving in a decentralized capacity is because pharmacists can catch physicians when they are writing orders and talk with them then, Covato says.

If pharmacists try to call physicians from the pharmacy department, they might have difficulty reaching them and convincing them to reconsider their treatment plan.

The decentralized pharmacy approach also involved oversight of all patients with the sepsis diagnosis.

"We looked at each and every sepsis patient to make sure physicians were meeting the criteria," she adds. "If they weren't, then we'd go back to the physician and say, 'These patients don't meet the criteria,' and they'd say, 'yes' or no.'"

By asking physicians questions about the prescribing habit, pharmacists helped them to rethink their process.

This cut down the drotecogin prescriptions from four or five patients per month to one every three or four months, Covato says.

"We're a small hospital, so our use was pretty high," she notes. "This saved us $100,000 a year, and the administrator was happy about that."