The Impact of a Pharmacist's Participation on Hospitalists' Rounds

Background: Expanding the role of pharmacists in the hospital setting has the potential to positively impact the quality of patient care and provide cost savings. Previous studies have shown that integrating pharmacists into rounding teams can enhance patient care through interventions at the point of assessment and prescribing. This study examines these potential benefits at a community hospital that does not have formal hospitalist rounds and in which the pharmacists must make recommendations via written communication. Objective: The primary objective was to identify the number of interventions and to determine how to optimally utilize a pharmacist for a group of 19 hospitalists. Secondary objectives included estimating pharmacist time invested and cost savings. Methods: Initially, methods in this study included reviewing patient medication profiles and informally rounding with the hospitalists. Interventions were performed at the time of rounding. After 2 weeks of rounding, methods were altered to improve the efficiency of the pharmacist’s time. Patient profiles were reviewed and interventions were performed by written communication. Results: A total of 386 patients were reviewed, with 117 interventions discovered. Fifty-eight verbal interventions were made during rounds with a 93% acceptance rate. Fifty-nine written interventions were made in the second part of the study with a 76% acceptance rate. The pharmacist spent an average of 10 minutes reviewing each patient profile, which resulted in a savings of $16 per hour of time invested. An actual cost savings of $3,900 was produced by 64 of the interventions, and the potential cost savings of the remaining 53 interventions exceeded $100,000. Conclusion: Opportunities for pharmacist interventions exist within a hospitalists’ team and the potential benefits to patient care, along with the actual and potential cost savings, should justify creating collaborations between pharmacists and hospitalists. Key Words—collaboration, community hospital, hospitalist, hospitalist team, intervention, pharmacist, rounding Hosp Pharm—2010;45(2):129–134 INTRODUCTION Currently, there are over 50,000 pharmacists practicing in hospitals across the country, and since the 1980s a growing number of them are providing clinical services. These services include rounding with multidisciplinary teams, reconciling medications, providing nutrition support services, assessing antibiotics, and evaluating all patient medication therapy. The role of the clinical pharmacist has also expanded into specialties, such as oncology, pediatrics, transplant, cardiology, and the internal medicine or hospitalist practice. Numerousresearchstudieshaveshownthatclinical pharmacy services can improve patient care, which can translate into considerable cost savings. Schumock et al stated that for every dollar invested in clinical pharmacy services, a hospital can save up to four dollars. An article published by Kucukarslan et al showed *Clinical Pharmacist, Pharmacy Department, Piedmont Hospital, Atlanta, Georgia. Pharmacy Department, Piedmont Hospital, Atlanta, Georgia. Corresponding author: Reena Patel, PharmD, BCPS Piedmont Hospital, 1968 Peachtree Road NW, Atlanta, GA 30309; e-mail: [email protected]. Hospital Pharmacy 129 a significantly reduced rate of preventable adverse drug events (;70%) when a pharmacist participated on rounding teams. The hospitalist practice is also expanding. In 2005, approximately 16,000 hospitalists were practicing in the United States. This number was estimated to be over 20,000 in 2008, an increase of 25% in 3 years. In February 2008, the American Society for HealthSystem Pharmacists (ASHP) and the Society for Hospital Medicine (SHM) released a joint statement to support a collaboration and specifically to ‘‘promote an understanding of the ways in which hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals.’’ In light of these changes over the past several years, this study was conducted to explore the benefits of a collaboration between hospitalists and pharmacists at a community hospital. METHODS The study was conducted at Piedmont Hospital, Atlanta, Georgia, a facility with more than 500 beds. At the time of the study, the hospital employed eight clinical pharmacists, two post-graduate year 1 residents, and more than 40 staff pharmacists. The hospital also employed 19 hospitalists, including four positions added within the last year. Each hospitalist was responsible for the care of 15 to 25 patients each day in addition to admitting patients in the emergency department. Patients were included in this study if they were under the care of a hospitalist. The duration of the study was approximately 4 weeks. The primary objective was to evaluate the number of interventions that one pharmacist could make by working in collaboration with several hospitalists and to determine the most efficient method of working with the hospitalists. The secondary objectives were to estimate the amount of time the pharmacist invested as a part of the hospitalist team and to estimate the financial benefits of the interventions. The financial benefits included both actual savings calculated using this institution’s drug costs and potential savings using reported costs from the literature. Initially the methods in this study included reviewing patient medication profiles, followed by informally rounding with the hospitalists. At the time of this study, there were no formal multidisciplinary hospitalist rounds. As a result, ‘‘rounding’’ consisted of the pharmacist and physician. Interventions were performed at the time of rounding. After 2 weeks of rounding, the methods were modified. It was determined that rounding with the hospitalist may not be an efficient use of the pharmacist’s time as there was little role for the pharmacist during the physician’s physical assessment of the patient. In an attempt to improve efficiency, methods were altered; the pharmacist reviewed patient profiles and performed interventions primarily by written communication, with follow-up being performed within 24 hours. Also, interventions were made independently as outlined by Piedmont’s pharmacy and therapeutics guidelines. Responsibilities of the pharmacist included reviewing patient profiles, detecting and preventing adverse drug events, adjusting doses for disease state or compromised renal function, monitoring drug interactions, performing discharge medication counseling, converting intravenous to oral dosage forms, recognizing untreated indications, and assisting with medication reconciliation. Data Collection Information that was collected included patient demographics, attending physician, admitting diagnoses, other medication therapies, whether interventions were solicited by the physician, the type of intervention, and whether recommendations were accepted. The specific amount of time spent in performing medication profile reviews, rounding with the physician, and conducting follow-up was also documented at the end of each day. Cost Savings Analysis All interventions were divided into those that lead to direct savings and those that lead to indirect savings. The direct cost savings included drug costs and accounted for a clinical pharmacist’s salary. The direct costs saved were calculated using the differences in acquisition prices for drugs at this community hospital at the time of this study, for example, the costs saved when switching from intravenous (IV) esomeprozole to the oral (PO) dosage form. The indirect savings for interventions, such as medication reconciliation, were conservatively estimated based on recently reported figures in the literature. RESULTS Primary Objective During the 4-week study period, 386 patients were reviewed and 117 interventions were identified. Approximately one intervention was made for every three patients who were reviewed. When participating in rounds with the hospitalists, the pharmacist was able to review 135 patients and make 58 interventions. The hospitalists accepted 93% (54 out of 58) of the interventions when the pharmacist was present during rounds. Impact of a Pharmacist's Participation on Rounds 130 Volume 45, February 2010 When the pharmacist did not round with the hospitalists, 251 patients were reviewed with 59 interventions identified. The acceptance rate dropped to 76% (45 out of 59) during this phase of the study. As shown in Figure 1, 53 interventions were those that prevented a possible adverse drug event. Figure 2 shows a further breakdown of these interventions. Seventeen of the 53 interventions were duplications in drug therapies. Others included renal dosing adjustments, dosing adjustments based on disease state, or discontinuation of unnecessary drug therapies. Additional interventions included drug monitoring, IV to PO conversions, medication reconciliation, drug information, and discharge counseling. Intravenous toPO conversionsconsisted of27 interventions, primarily with levofloxacin (Levaquin) and esomeprazole magnesium (Nexium). The majority of these types of interventions were made after consulting with the hospitalists. A few of the conversions of Nexium IV to oral dosage forms were made independently by the pharmacist as outlined in the guidelines provided by the Pharmacy and Therapeutics Committee at Piedmont Hospital. Secondary Objectives During rounding in the first 2 weeks, 15 to 20 patients were reviewed each day. When the pharmacist did not round in the second 2 weeks, an average of 25 to 30 patients were reviewed each day. This time included reviewing medication profiles, rounding with the hospitalists (first 2 weeks only), and performing follow-up on interventions. Of the 117 interventions that were identified, 64 of the interventions were used to determine the actual costs saved during this study. These interventions can be found in Table 1 and included IV to PO conversions, formulary interchanges, renal dosing adjustments, and discontinuation of duplicate and unnecessary drug therapies. The 27 IV to PO conversions led to a cost savings of $1,701. A formulary interchange of losartan for olmesartan saved $54. The discontinuation of 16 duplicate drug therapies saved $960 and discontinuation of unnecessary drug therapies led to a savings of $627. This resulted in an overall actual cost savings of $1,341 when the pharmacist rounded with physician and $2,559 when the pharmacist did not round. The average savings per intervention with rounding was $56 and $64 without rounding. The total actual cost savings divided by the amount of time invested during the entire duration of the study resulted in an overall cost savings of $61 per hour of pharmacist time. Assuming an average pharmacist salary of $45 per hour, this institution potentially saved $16 an hour for every hour that the pharmacist worked. The remaining 47 interventions were used to calculate potential cost savings using cost information from previous studies. As shown in Table 2, the