1. Engaging the C-suite to Advance Pharmacy Practice Providing quality patient care through progressive pharmacy practice Evaluation of Unit-based Pharmacy

2. Introduction Many deaths attributed to adverse events Medication errors accounted for 7,391 deaths in 1993, up from 2,876 in 1983 –1/131 outpatient deaths –1/854 inpatient deaths

3. Why have unit-based pharmacists? Approximately 28% of adverse drug events (ADEs) are preventable (Bates et al.) Institute of Medicine and Institute for Safe Medication Practices recommendations Clinical pharmacists improve patient safety and increase cost savings

4. Unit-based (UB) Pharmacists Two pharmacists deployed to patient care areas in August 2003 –Rotate biweekly between the pharmacy and critical care units (ICU, PCU, CICU) Direct contact with patients and other healthcare professionals

5. Topics of Discussion… Patient Safety Financial Considerations Nursing/Pharmacy Relations Physician/Pharmacy Relations Pharmacist Job Satisfaction

6. Patient Safety: Medication Errors Total medication errors for ICU, PCU, CICU, and pharmacy 3 months prior and 3 months following were calculated Data normalized to med errors/1000 patient days Substantial reduction observed in all areas examined

7. ICU: Medication Errors/1000 patient days May, June, July Total=29.3 Aug, Sept, Oct Total=6.9 76.5% Reduction!!!

8. PCU: Medication Errors/1000 patient days May, June, July Total=45.5 Aug, Sept, Oct Total=33 27.5% Reduction!!!

9. CICU:Medication Errors/1000 patient days May, June, July Total=40.3 Aug, Sept, Oct Total=4.4 89% Reduction!!!

10. Pharmacy: Med Errors/1000 patient days May, June, July Total=5.76 Aug, Sept, Oct Total=2.49 56.8% Reduction!!!

11. Medication Errors Per Patient Days ICUPCU CICUPharmacy May3/34118/4673/15741/6127 June23/2914/42511/15633/5759 July1/28938/4264/13429/5989 TOTAL 27/921 or 29.3/1000 60/1318 or 45.5/1000 18/447 or 40.3/1000 103/17875 or 5.76/1000 August1/31512/4292/155 11/6126 September2/29319/3900/13718/5472 October3/26510/4220/16515/6062 TOTAL 6/873 or 6.9/1000 41/1241 or 33/1000 2/457 or 4.4/1000 44/17660 or 2.49/1000

12. Medication Error Rates/ 1000 Patient Days

13. Clinical Interventions UB vs staff pharmacists 53.7% higher while in patient care areas 389 total CI’s made while UB 180 total CI’s made while staff

14. MAR Discrepancies: ICU, PCU, CICU July-52 MARs reviewed in ICU, PCU, & CICU with 60 total discrepancies Sept-27 MARs reviewed with 21 total discrepancies Dec-29 MARs reviewed with 12 total discrepancies

15. MAR Discrepancies: 7th and 8th Sept-37 MARs reviewed with 24 total discrepancies Dec-46 MARs reviewed with 17 total discrepancies Thought to decrease due to decreased workload to pharmacy.

16. MAR Discrepancies/MARs reviewed for ICU, PCU, and CICU

17. Financial Benefit: CI ADE prevention Costs of ADEs between $2,000-$5,857 (Leape et al, Bates et al) ADEs associated with a mean increased length of stay of 4.6 days (Bates et al) Value chosen for ADE costs $3,000 UB pharmacists had 10 ADE prevention CI’s ~$30,000 in savings in 3 months, and potential $120,000 over one year

18. Financial Benefit:  ADEs due to  Med Errors Approximately 1% of med errors result in ADEs (Bates et al) Roughly 0.224ADEs/1000pd prevented in ICU, 0.125 in PCU, 0.359 in CICU, and 0.0327 in pharmacy $586 saved on ICU, $465 on PCU, $492 on CICU, and $1732 in pharmacy Total of $3275 saved in first 3 months, ~$13,103 over an entire year

19. Financial Benefit: All Cost Saving CIs Clinical activities tracking software often used to assign cost savings to specific clinical interventions (CI) Do not have appropriate system of documenting CIs Used $30.35 for each CI associated with cost savings. –Examples: CODE response, drug allergy related, formulary switches, IV to PO switches, lab ordered, renal dosing, etc.

20. Financial Benefit: CI’s (cont’d.) Cost saving CI’s while UB: 216 x $30.35=$6555.60 Cost saving CI’s while in pharmacy: 136 x $30.35=$4127.60 ~$2428 cost savings in first 3 months, approx. $9712 over entire year

21. Financial Benefit: Cost of UB Pharmacist Additional cost of pharmacist in pt care areas determined by productivity differences UB pharmacist completes ~63.7% of the workload of “staff” pharmacist Therefore, cost to re-deploy is 36.3% of pharmacist salary plus benefits $36.30/h base pay; 36.3%=$7,716 in 3 months and ~$33,437 for an entire year

22. Productivity Comparison of UB vs. Staff Pharmacist

23. Financial Benefit: The Grand Total 1st 3 months: ($30,000+$3275+$2428)-$7716 =$27,987 in cost savings Extrapolated to one year: ($120,000+$13,103+$9712)-$33,437 =$109,378 in cost savings

24. Nursing/Pharmacy Relations Satisfaction survey distributed to nursing staff on ICU,PCU,CICU 20 nurses completed initial survey given prior to implementation of UB pharmacist 21 nurses completed follow-up survey given after implementation

25. Nursing/Pharmacy Relations Accessibility of pharmacists # of nurses responding “very accessible”  ed by 47% Helpfulness of pharmacists # responding “very helpful”  ed by 33% Quality of work # “very good” or “excellent”  ed by 43%

26. Nursing/Pharmacy Relations Consultation of pharmacists # of nurses consulting pharmacists 4-6 times/day  ed by 33% Most valuable service # of “unit based” responses  ed by 36% Drug information, drug distribution, and appropriate drug selection remained most important duties of pharmacists according to nursing staff.

27. Physician/Pharmacy Relations Small survey of physicians Seven surveys distributed, six completed and returned UB pharmacists very well received by responding physicians All stated UB pharmacists improve pt care, provide useful recommendations, and would recommend continuing the program.

28. Job Satisfaction Survey by Sansgiry et. al. Diversity, advancement opportunities, and clinical and pt focused activities key to satisfaction. Dissatisfaction with lack of opportunity and self-actualization in areas of clinical practice.

29. Job Satisfaction Dissatisfaction leads to organizational ineffectiveness. Using pharmacists skills  satisfaction and long-term commitment Providing clinical opportunities for pharmacists   ed productivity, recruitment and retention

30. Why Unit-based Pharmacy Works! Medication errors: –49% during prescribing stage Clinical pharmacists can impact physician prescribing and provide recommendations –11% during transcription More acutely aware of pts condition and can catch transcription errors more frequently –14% during dispensing  ed by  ed distraction in the main pharmacy and  ed workload in the pharmacy

31. Why Unit-based Pharmacy Works (cont’d.) Medication errors (cont’d.) –26% during administration UB pharmacists readily available to answer any nursing questions re: administration –UB pharmacists also have time to monitor patients and review meds to ensure proper monitoring parameters are performed.

32. Literature… Kucukarslan et al showed 78% decline in ADE’s with UB pharmacists McMullin et al: ~$113,000 each year saved with UB pharmacists –Projected $394,000 in savings/year if expanded throughout entire hospital Bond et al: As staffing of clinical pharmacists  ed, drug costs  ed. …Benefis Healthcare’s results are reproducible and valid!!!

33. Improvements for future… Clinical intervention documentation Patient counseling and in-services to nursing staff More involvement in protocol development Expansion throughout hospital!!!!!

34. Conclusion Increasing costs of pharmaceuticals provide dilemma to contain costs Deploying pharmacists to patient care areas effective and efficient in  ing costs Patient care, interdepartmental relations, retention have all improved Expansion throughout the hospital to provide WORLDCLASS service to patients, staff, and administration