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Hospital Pharmacy

Patient safety and medication management are the hot healthcare topics of the new millennium. However, with all the attention to bar code systems and point-of-care medication administration by nurses, it's easy to temporarily overlook the hub of medication in a hospital system--the pharmacy department.

While the sophistication of medication management technology occurs at the point of care, a world of automated decision support capability also exists for pharmacy managers and pharmacy departments, critical players in every hospital's attempt to reduce medication errors and avoid adverse drug events.

Palmetto Health Richland is at the forefront as a critical player in the endeavor to reduce medication errors. Palmetto Health Richland in Columbia, SC, is a 655-bed regional community teaching medical center with 3,300 employees and 800 medical and dental staff. Our pharmacy department, consisting of 50 pharmacists and 50 pharmacy technicians, is responsible for medications for more than 30,000 inpatients and 400,000 outpatients annually. Teams of pharmacists provide clinical pharmacy services, covering all inpatient beds and our ambulatory clinics.

Three years ago, we transitioned from a manual process for identifying medication-related problems to an automated decision support system, which utilizes push technology that has streamlined our operation and significantly improved our efficiency.

Automated Decision Support

Hospital pharmacy departments are no strangers to the concept of decision support. Long before the spread of healthcare information technology, pharmacy departments have been charged with functioning as the decision support center for medication provision within hospitals and delivery systems. While the advent of clinical documentation, laboratory and radiology information systems has considerably streamlined the collection, manipulation and utilization of patient data by clinicians, pharmacy departments still remain the hub of medication review and evaluation.

Even with automated clinical documentation and laboratory systems, in June 1999 Palmetto Health Richland faced an uphill climb in this area before installing a clinical decision support system for its department of pharmaceutical services. Until then, the pharmacy department reviewed and managed medications manually on a case-by-case basis.

Pharmacists reviewed large volumes of data from three distinct sources to determine any potential medication problems. First, each patient's medication profile in the pharmacy system was individually re viewed. Next, a pharmacist would evaluate each patient's laboratory values from the laboratory system. Finally, a pharmacist would analyze each patient's medical history and progress notes from the paper chart. The composite of these three steps was necessary for a pharmacist to effectively monitor medication disbursement and effectiveness. This process exhausted a considerable amount of the pharmacists' time, and, of course, presented an opportunity for errors.

In the late 1990s, we decided to invest in an automated decision support tool to assist pharmacy staff in identifying medication-related problems, and to assist in routine medication monitoring of the effectiveness of medications and potential adverse effects.

We researched several options before deciding upon Clinical Event Manager, the product that has evolved into the more robust Insight from Misys Healthcare Systems. The product was brought to our attention at a time when we were trying to develop an interface between lab and pharmacy for the organization, in an attempt to provide the same functions we gained with Insight. This is a vendor-neutral product, able to integrate with clinical systems from other suppliers such as Cerner or McKesson.

In addition, Palmetto Health Richland already used Sunquest (now Misys) for its laboratory information system, so we had confidence in the company as a supplier. Functionality and capability were key factors in our decision-making process. Insight offers a 550-rules-based alerting system, supported by push technology and coupled with e-mail and pager options for delivering medication alerts to clinicians. Our goal in adopting the system was to spend very little time maintaining or troubleshooting the system, while being able to automate the functions we previously performed manually.

Here is an example of how it works. An adult trauma patient developed pneumonia while hospitalized. Initially, the patient was treated with an empiric antibiotic regimen while final culture results were being determined. Final culture results came to the pharmacist's pager while she was on rounds with the physician. The original antibiotic regimen did not cover the organism that was cultured. Receiving an alert on her pager, the pharmacist was able to make recommendations and attain a change in antibiotics orders within a few minutes of receiving the alert.

Installation

The system installed at Palmetto Health Richland utilized three HL7 interfaces: an interface with HBOC pharmacy (for medication orders), an interface with Misys Laboratory (for lab results), and an interface with our HBOC ADT system (for patient location information).

There were two steps in the implementation. First, Misys configured the hardware off-site using an upload from our pharmacy system and lab system. After the database was constructed and the rules mapped to our medication and lab codes, the hardware was sent to our facility and installed. The second step involved setting up each user. This included defining each pharmacist's coverage area by patient location, identifying which rules would be used and setting up how each pharmacist would receive alerts. In our case, we chose to send all the alerts to e-mail boxes set up for each team of pharmacists and to send critical alerts to the pharmacists' pagers.

System Use

We have five teams of pharmacists who cover all inpatient beds. The rules were selected to support our basic clinical activities, as follows:

TPN monitoring. The product identifies lab abnormalities in patients receiving parenteral nutrition, and the pharmacist can recommend changes in the TPN formula to correct the abnormality.

Serum drug level monitoring. The system alerts a pharmacist when serum drug levels are done by the lab. The pharmacist verifies that the dosage of medication is correct.

Renal function monitoring. The system monitors lab values that indicate kidney function. If the system detects impaired renal function, it checks the patient's list of medications for any drug that may require a dosage adjustment.

Monitoring for medication toxicity. The product monitors lab values that indicate toxicity for certain drugs--for example, a low platelet count in a patient receiving heparin sodium, which can cause thrombocytopenia.

Misys Insight has helped us assure a consistent level of clinical activities for all patients. We feel confident that the system can identify key medication problems and relevant clinical data.

Efficiency Gains

Our first-year gains--gains that have continued since installation--yielded significant improvements. Mostly notably, automation of many previously manual functions has produced a 38 percent time savings for Palmetto Health Richland pharmacists--the equivalent of nearly two days per week.

We put that 38 percent time savings to fruitful use and generated a subsequent 24 percent increase in our medication therapy interventions. Time that used to be spent manually combing through paper files or drilling down into computerized lab or pharmacy data is now dedicated to assisting and counseling physicians about possible medication adjustments or changes that could be beneficial, educating students and residents in pharmaceutical science, providing more and more frequent drug information to floor nurses, and also counseling patients about their medications.

Each of these interventions represents a medication-related problem that was identified and corrected. Our overall increase in interventions was 3,188 for the same year. This indicates that 55 percent of the 5,775 interventions would not have been identified through the old system.

Financial Savings

In a one-on-one study using literature and Pharmatrend information, we assigned hard dollar amounts to certain alerts. We determined a $91,000 reduction in medication costs for indigent or non-reimbursed care, through renal function monitoring and IV-to-PO conversion alerts within the first year. We also estimated $440,000 per year in total cost avoidance for all interventions, based on industry models that are used to gauge the cost of alerts (exclusive of any potential liability costs).

Specific Results for Year 2000

# of alerts generated by the system:    36,640
# of patients with monitoring alerts:   14,740
# of interventions from these alerts:    5,776

RELATED ARTICLE: What they didn't teach you in medical school.

It's Saturday night in an urban emergency department (ED). Two young men bring in their friend, a young woman, who is unconscious. "She's been messing with Georgia Home Boy," they tell the admitting nurse, and leave. It's a potential life-and-death situation, but what's the medical issue? A sexual assault? A fight?

MICROMEDEX has recently improved POISINDEX, its toxicity database, so a quick check of a hand-held device reveals that "Georgia Home Boy" is a slang term for Gamma Hydroxybutyric Acid, or GHB, an illegal drug that induces a sense of euphoria and intoxication. The drug is sometimes mixed with alcohol to intensify its effects, which can result in respiratory depression and coma. The ED staff can now take proper steps to treat the young woman.

This addition to POISINDEX provides a searchable database of more than 4,000 slang street drug terms to allow doctors to quickly determine what a patient has taken when they don't know the real name of the drug. There are more than 70 identified slang terms for amphetamines, and more than 130 common street names for crack cocaine, all available from a laptop computer or hand-held device.

Many of these slang terms are regional in nature, so even a seasoned emergency physician from one part of the country may not be familiar with phrases used in another area.

To develop and maintain the database, company researchers surveyed practitioners nationwide, researched and verified the survey results, and organized the resulting data into a searchable database. The company sampled from all areas of the country to ensure that as many regional slang variations as possible would be included. Also, clinicians are surveyed regularly to ensure that new street drugs and terms are consistently updated.

By looking up the slang term, clinicians can find not only what has been taken, but also quickly get symptoms, likely uses (e.g., if the drug is usually taken with alcohol, etc.) and best practice treatments.

"In an emergency situation, seconds count. This information would not be as useful for professionals if it were a book kept in a specific room of an ED," says Dr. Rich Klasco, chief medical officer at MICROMEDEX. "By making the information available at the point of care with minimal disruption to workflow, this tool that can make a difference in patients' lives."

David Amsden, Pharm.D., B.C.N.S.P., is a pharmacy manager of Palmetto Health Richland, Richland, SC.

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