Dr. Valery Chu, a clinical pharmacist in the SBH Center for Comprehensive Care (CCC), freely admits that when she started working five years ago in the CCC – a center that works with seniors as well as younger patients suffering from diabetes, asthma and other respiratory conditions – its providers “didn’t know what to do with me.” Adds Dr. Chu, “They had some idea of my background, but many of the physicians, nurse practitioners and PAs had never collaborated before with a pharmacist.”
Harris Leitstein, a nurse practitioner who treats diabetic patients in the CCC, agrees. “I must admit early on my attitude was ‘What do we need a pharmacist here for?’” says Leitstein. “But, I have really been won over.”
The model of having a clinical pharmacist collaborate with providers in an ambulatory care setting is rare. Perhaps the biggest reason for this is financial. Pharmacists in an outpatient setting can’t bill independently and so are viewed by many hospitals as a luxury. Yet, as both a Certified Diabetes Educator and Certified Asthma Educator, as well as a smoking cessation instructor, Dr. Chu wears multiple hats. It’s this versatility that has allowed her to play so many roles – troubleshooter, educator, mediator, detective and confessor (as patients tend to “let their guard down” with her, telling her things they might not tell their physician about their health and compliance – or lack thereof.
“Some diabetics, for example, have concerns about injecting. They will tell the doctor, ‘Sure, I’ll do it,’” says Dr. Chu. “Then they’ll come to me and say they never started. I’ll talk this through with them and if necessary find another option. Sometimes the doctor will prescribe medication they take twice a day or suggest they check their sugar at different times. The patient will confess to me that since they can never remember the second dose, or maybe only take it when a home attendant is present, they only get half of what’s been prescribed. So, with this information, we can strategize on next steps, which may mean switching to a once-a-day formulation.”
Much of her day is spent helping patients with medication access. Patients once discharged may find they can’t get the medication they have been prescribed,” she says. “Our population is such that they don’t delve into the reasons why. When they come back to me for follow-up a month later, I’ll say ‘Did you start the new medication?’ and they’ll say ‘No, my pharmacy told me my insurance won’t cover it,’ and it ends there. They will never pick up the phone and say, ‘Hey, I couldn’t get the medicine.’ ”
Meanwhile, Harris Leitstein, who once questioned Dr. Chu’s role in the CCC, today calls her value “priceless.”
“She has a really good feel for the diabetic patient and the medications they take and how to make adjustments,” he says. “This often means jumping through hoops because each insurance is different. I’ll very often say to her, ‘OK, Valery, I want this patient on a GLP-1. I don’t know what her insurance will pay for, but this is what I’m thinking. Can you find out which one the insurance pays for and teach her how to use it?
“This saves me a ton of time because looking up insurances takes forever and then teaching also takes a good amount of time. She’s also really great with medication in knowing what you have to watch out for in terms of conflicts and doing medication reconciliation by going through all of the patient’s meds. I can ask her, ‘Hey, is drug x safe for somebody with limited kidney function?’ and she can tell me right off. When you inject her into the mix, it just makes us so much more efficient and it’s so much better for the patient.”
According to Dr. Anthonia Ajao, associate director of pharmacy clinical services at SBH, transitions of care remains a critical issue at SBH. “Patients cry or get very emotional when they leave the hospital because they can’t afford to get their medication,” she says. “Relieving this fear removes a big burden. Valery is like a bridge for these patients between once they leave our institution and when they come to the clinic. It’s important to find out what has transpired with the patient as soon as possible and to address any medication access issues. She’s involved with this on a daily basis.”
Dr. Chu is only one of several clinical pharmacists embedded throughout the hospital. In the centralized pharmacy model practiced at SBH, staff pharmacists in the main pharmacy team with clinical pharmacists who work on the floors, in the emergency department and ICU as part of the medical team. Here, they round with physicians and work closely with them and other care providers in order to improve patient outcomes.
“We have strived to bring a well-rounded clinical pharmacy team to SBH, one comprised of clinical managers, clinical practice coordinators, and pharmacy residents in a number of key clinical departments: transitions of care/internal medicine, pediatrics, infectious diseases, critical care, emergency medicine and ambulatory care,” says Dr. Ruth Cassidy, senior vice-president, clinical support services and chief pharmacy officer at SBH. “As a health system, we are now fortunate to have a fantastic and incredibly talented group of clinical pharmacists who assist physicians, as well as all other disciplines of the medical team in clinical pharmacy and pharmacotherapeutics. This has brought clinical pharmacy to a completely new level at SBH, one that has proven repeatedly on both a clinical as well as a financial level to be a key component not only for the institution but also for the better health of our patients.”
Transitions of Care and Patient Rounding
Most mornings will find clinical coordinator Dr. Amanda Rampersaud, clinical pharmacy residents like Dr. Ziyun Huang, and Milton Sandoval, an advanced pharmacy tech, at white board huddles with attendings, nurses and medical residents in advance of patient rounding.
“We handle all kinds of medication access issues on a daily basis,” says Dr. Rampersaud. We run the ‘meds to beds’ program where we try to get patients their medications before they are discharged so at least they are leaving with their first month’s supply on hand. Many times the issue arises where patients don’t have insurance. So we tell them about different programs here that will allow them a discount if they fill at a pharmacy we are contracted with. There are lots of moving parts to that process and Milton and I do this daily.”
Like Dr. Chu, they also spend time troubleshooting and educating patients admitted to the hospital with such conditions as asthma, diabetes, heart failure and uncontrolled hypertension. Sandoval also translates for Spanish speaking inpatients.
“We try to flag those patients who are at a high risk for readmission,” says Dr. Rampersaud. “For a patient being discharged on high risk medications, this might mean explaining proper techniques to help increase adherence.”
Transitions of care can influence readmission rates, which make this an institutional-wide concern for both reasons of quality patient care and reimbursement. “When patients are not transitioned appropriately with the correct medication, they are more likely to come back,” says Dr. Manisha Kulshreshtha, Vice President and Associate Medical Director. “Amanda works with the physicians and the nurses to ensure that medications are appropriately dispensed to the patient, she teaches our patients how to use them, and makes sure they are sent home with the correct medications. Should there be issues with regard to dispensing medications, the clinical pharmacist knows exactly who to call and is very helpful in getting things accomplished. This is not only for discharge planning, but also in helping residents understand the depth and breadth of side effects, dosing, and preventing errors.”
This makes a huge difference with SBH’s high-risk patients, which includes a significant number of indigent and homeless patients. It may mean having medications picked up and delivered to patient’s beds, explaining medication discounts and enrolling patients in our 340B program, where 80 percent of medication costs are covered. The clinical pharmacists also play a key role in reconciling patients’ new medications with those they took before they were hospitalized.
This impacts patients regardless of age. “We are a pediatric unit in an adult hospital,” says Dr. Kathleen Asas, division director, pediatric inpatients. “So, the intricacies of pediatric dosing of medications are extremely important for kids, where there is a higher risk of medication errors because all medications are weight-based. What has been very important to us, is to be able to work closely with the pharmacy team in making sure our pediatric patients are protected from medication errors by taking into account the nuances of their age and how they metabolize medications.”
Similarly, a clinical pharmacist, Dr. Robert O’Connell, and a clinical pharmacy resident, Dr. Myroslava Sharabun, are embedded in the ED with Dr. Andrew Smith, who oversees the SBH ED clinical pharmacy residency program as an assistant professor of pharmacy practice at Touro College of Pharmacy. Here, they work closely with our emergency department physicians, residents, and nurses to oversee the safe and effective use of medications.
“A lot of our work is focused on acute resuscitation,” says Dr. Smith. “A patient, say, comes in with septic shock or in respiratory arrest, and we’re part of the team that treats them. We assist in the preparation and labeling of medications which is then handed off to the nurse for administering. Once a patient is intubated, and the residents are getting their labs and putting in orders, we’re thinking about the next step. Does this patient need antibiotics because she came in with pneumonia? What antibiotics will she need? What dose? A loading dose vs. a non-loading dose? Will she need sedation? This takes a lot of the bandwidth off the physicians, allowing them to focus more on diagnostic medicine.”
According to Dr. Daniel Murphy, chair, emergency medicine at SBH, the clinical pharmacists in the ED give the department “bang for their buck.”
“An emergency department by definition is unscheduled, occasionally hectic, and interruption driven, and having someone around to help with the often complex calculations and orders of very crucial medications is amazingly important,” says Dr. Murphy. “When it comes to the more critically ill, having them around is immeasurably beneficial. When it comes to the not-so-critically ill, having them around to watch our P’s and Q’s and to guide us on error avoidance is just as crucial. On a scale of 1 to 10, having a Pharm D in an inner city emergency department is an 11.”
Intensive Care Unit and Antimicrobial Stewardship
Similarly, there can be little doubt of the benefits of having a clinical pharmacist in the ICU. “This has been shown to significantly improve patient outcomes year after year,” says Dr. Raghu Loganathan, director, division of ICU/pulmonary medicine at SBH. “You have high acuity patients with very small room for errors, and a number of events that occur in a critical care setting are related to medications. Having a critical care pharmacist significantly increases the level of care and provides very important staff support and guidance to the physician and nursing staff. We certainly feel the difference when they’re not here.”
One important factor is medication utilization. Having a critical care clinical pharmacist has been shown to decrease medication usage and costs. A steady decrease in terms of the total days of therapy for all ICU medications has been shown over the past year, as well as individually for IV GI prophylaxis medications such as pantoprazole and analgesic medications such as fentanyl; albumin use; sedation medications like lorazepam, midazolam, propofol and precedex; and broad spectrum antibiotics such as vancomycin, cefepime and zosyn.
“The whole goal here is to discontinue unnecessary therapy and narrow therapy from acuity IV to PO stabilized when appropriate (i.e. medication taken orally) so patients can be transferred out of the ICU,” says Dr. Frank Piacenti, the clinical pharmacy practice manager who works in the ICU and with patients treated by the infectious disease team. “An IV to PO medication conversion also decreases the risk of a systemic infection or an IV line/device related infection. In addition, the quicker you get patients from IV to PO, the quicker you will shorten their ICU length of stay and possibly hospital length of stay.”
This all fits in well with the Joint Commission’s new criteria on antimicrobial stewardship. An antimicrobial stewardship program is a multi-disciplinary approach between pharmacy, medicine, infectious diseases, surgery, ED, infection control, and nursing in order to manage antibiotics appropriately. “We have policies, guidelines, and practices in place to manage broad spectrum antibiotics, which is part of what I do in the ICU and with infectious diseases,” says Dr. Piacenti. “Our goal is to minimize antibiotic use, recommend the most appropriate dose and antibiotic based on disease state, review culture results and antibiotic sensitivity, also to decrease unnecessary therapy, switch IV to PO, and minimize multi-drug resistant organisms in the institution.” As part of our antimicrobial stewardship program, we collect data on antibiotic usage, cost, pharmacy interventions, and collect data on positive antimicrobial cultures in order to trend antibiotic susceptibilities and to prepare and distribute our most current antibiogram biannually.