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On-call Clinical Pharmacy Services at the University of Maryland Medical Center: Improving Patient Care by Expanding Access Edward Knapp, PhD, P4 Pharmacy student at the University of Maryland School of Pharmacy and Carla Williams, PharmD, BCPS, Interim Assistant Director of Pharmacy Operations, University of Maryland Medical Center
Recent studies confirm that the involvement of clinical pharmacists in patient care during hospitalization improves outcomes in both ICU and general medical patient populations.1,2 From identifying potential drug interactions to optimizing antibiotic regimens for patients, access to clinical pharmacist expertise enables medical teams to make better informed decisions about therapeutics.3 Having a clinical pharmacist on antimicrobial stewardship teams is associated with reduced incidence of C. difficile infections and lower rates of inappropriate antibiotic use. In an era where medical institution services and reimbursement are increasingly measured against standards of excellence in practice and outcome, there is a clear role for clinical pharmacists on the medical team to improve outcomes and maximize patient value. Unfortunately, there are too few clinical pharmacists to routinely cover every service at the University of Maryland Medical Center (UMMC). The challenge of making clinical pharmacist expertise more widely available to all medical personnel and healthcare providers at UMMC has led to the introduction of three new clinical pharmacy services within the past 3 years: The pharmacokinetics (PK) consult service, the anti-coagulation (AC) consult service, and the PILL pager (BEEP 7455) on-call clinical pharmacy service, all of which are staffed by clinical specialists and residents. Together, these services resulted in 24,987 clinical interventions from July 2012 through June 2013. The most common consult placed during this time period was for vancomycin dosing, representing 72.89% of all consults.4 This is noteworthy, as clinical pharmacist-guided dosing of vancomycin and aminoglycosides is associated with significantly lower patient mortality, rates of adverse reactions, and shorter hospital stays.1 Anti-coagulation with warfarin was the second-most common consult placed, representing 13.55% of all consults.4 As with antibiotic stewardship, clinical pharmacist-guided management of inpatient anticoagulation is associated with significant reductions in patient mortality, the need for blood transfusion, and hospitalization length of stay.1 Mehrnaz Pajoumand, PharmD, BCPS, Clinical Pharmacy Specialist who covers these pharmacy services, says the PK and AC consult services at UMMC function similarly to other types of clinical consults, with some additions. Prescribers can order the service as they would any other consult. A clinical pharmacist or pharmacy resident then provides an initial assessment and recommendations, and documents in the electronic medical record. Each day the pharmacist follows up with the team, adjusting dosing and placing orders for laboratory monitoring as needed as well as providing patient education, discharge counseling, and documenting interventions. Both services also address alternative therapeutic options and administration routes when clinically warranted. PK consults can be placed on adult patients for vancomycin, aminoglycoside antibiotics, digoxin, lithium, theophylline, and anti-convulsant medications. The AC service covers inpatient management of any anti-coagulant, as well as transitions in therapy between agents.
The electronic documentation of the assessment and plan allows the prescriber and nurse taking care of the patient to determine when levels should be drawn as well as the rationale in case there is concern regarding appropriateness. The therapeutic goals for the patient are also specified so that anyone caring for the patient is aware. The notes can be found on the form browser under the heading of Pharmacokinetic Consult Service, Pharmacy to Dose or Antithrombosis Progress Note for PK and AC consults, respectively. While the AC and PK services are ordered consults, the PILL pager (x7455) is a free on-call service that can be accessed by anyone at UMMC who has a question related to pharmacotherapy. Dr. Pajoumand reports that call volume for the PILL pager is heaviest during the holidays, but the pager is staffed year-round 24 hours a day, 7 days a week. From July 2012 to June 2013, PILL pager calls represented 11.5% of all clinical pharmacy service requests.4 Brian Grover, PharmD, BCPS, Clinical Pharmacy Specialist, notes that while tracking precise usage of the PILL pager is difficult, due partly to the lack of a documentation mechanism for forwarded calls, the PILL pager has been generally well-received by a diverse cross-section of clinical staff and medical services, and is showing increasing popularity and usage over time. In conclusion, the PK and AC clinical consult services and the PILL pager represent innovative programs that extend access to clinical pharmacy services to all UMMC clinicians and their patients. Due to the high volume of consults over the past year, it is expected that the use of these services will only continue to grow. References 1 Preslaski CR, Lat I, Maclaren R, et al.Pharmacist contributions as members of the multidisciplinary ICU team.Chest 2013;144:1687-95. 2 Tan EC, Stewart K, Elliott RA, et al.Pharmacist services provided in general practice clinics: A systematic review and meta-analysis.Res Social Adm Pharm2013. (epub ahead of print) pii: S1551-7411(13)00179-4. 3 Cappelletty D, Jacobs D. Evaluating the impact of a pharmacist’s absence from an antimicrobial stewardship team. Am J Health-Syst Pharm2013;70:1065-9. 4 Williams C. Clinical pharmacy consult services FY12 – FY13. Personal communication;October 28, 2013.
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