Study confirms importance of hands-on patient care
Pharmacists on rounding teams reduce preventable ADEs by 78%
A study published in 1999 showed that having a pharmacist on a physician rounding team in an intensive care unit (ICU) reduced the incidence of adverse drug events (ADEs) by two-thirds. Now a new study finds similar results for pharmacists rounding with physicians in general medicine units.
The new study was conducted at Henry Ford Hospital in Detroit from Sept. 2, 2000, through Nov. 31, 2000. Patients admitted to and discharged from the general practice unit and the internal medicine service were included in the study.
The primary outcome measure was preventable ADEs, which were defined as undesired reactions to medication, which may have been prevented by appropriate drug selection or management. Patient records were randomly selected and evaluated by a blinded process involving independent senior pharmacist specialists and a senior staff physician. Interventions made by the pharmacists in the treatment group also were documented.
The rate of preventable ADEs was reduced by 78% by pharmacists rounding with the physician teams, from 26.5 to 5.7 per 1,000 hospital days. The pharmacists made 150 documented intervention recommendations during the rounding process; the physician team accepted 147 of them. The most common interventions were dosing-related changes and recommendations to add a drug to therapy. The findings from the study were published in the Sept. 22 issue of the journal Archives of Internal Medicine.
The results show the importance of pharmacist intervention in patient care, says Mark Mlynarek, RPh, BCPS, clinical pharmacist specialist in the surgical ICU at Henry Ford Hospital, and one of the researchers on the study. "Every day we make an impact and think, If I weren’t here, what would happen?’"
Some interventions might prevent serious ADEs, while some ADEs might have gone unnoticed without the pharmacist input. "Sometimes, we change dosages, and it might not make that much of a difference," Mlynarek says. "Other times you say, Wow — we need to be here all the time.’"
That’s an impetus for doing this study, he adds. "To prove that pharmacists are needed."
One patient unit was control group
The researchers used both of Henry Ford’s patient care units, primarily an internal medicine service, in the study. One unit was used as the intervention group and the other as the control group. Patients had an equal chance of being admitted to either group; the decision was based upon the availability of beds and physician service. To be included in the study, the patients had to remain in the same patient care unit. The demographics and number of comorbidities in both groups were compared to determine if they were similar.
Researchers assigned two clinical pharmacists to provide patient care services at the bedside of the intervention group. These pharmacists rounded with physician teams, documented pharmacotherapy history, and provided discharge counseling. The pharmacist-patient ratio was about 1-to-15.
The control group, on the other hand, received "standard" care. This entailed having one pharmacist, for about 30 patients, providing retrospective analysis of evaluating medication profiles. The pharmacist identified medication-related problems through the review of medication orders every morning. The pharmacist also reviewed a list of the medications that the patients were actually receiving. "Drugs that we feel need to be monitored closely are put on that list," Mlynarek says.
The pharmacists in the intervention group had the opportunity to review all the medications for the patients they were seeing. The pharmacist in the control group, however, had to pick and choose which medications to review because of time constraints.
The information required for evaluating the appropriateness of drug therapy is limited for many pharmacists practicing in an institutional setting, the researchers say. In these settings, the pharmacist is placed at a distance from the medication-selection step of the patient care process. "Intervening with recommendations to adjust doses, to add or delete drugs to therapy, to monitor laboratory values, or to identify potential problems at discharge are more difficult to identify and to respond to in a timely manner because of the pharmacist’s distance from the decision-making process," they say.
Working for the patient
Through hands-on patient care, the pharmacists are able to do three things, Mlynarek says. "The main thing we do is make sure the patient gets the right dose and the right drug for the right disease state. We also try to recommend the most cost-effective therapy."
The interventions made by pharmacists in this study included dosage or frequency adjustments (35%), the addition of drugs to therapy (21%), the identification of potential problems with continuing therapy after discharge (8%), deletion of drugs from therapy (7%), and recommendation of laboratory monitoring (6%).
The researchers also noted the problem of affordability of medications, as one in 10 patients in the study were cash customers. They felt pharmacists recommending affordable medication for these patients might reduce the likelihood of noncompliance due to economic reasons.
The physicians at Henry Ford acted on almost all of the pharmacists’ recommendations, which shows that pharmacists are well respected in the institution, Mlynarek says. This trust has a long history, though. Pharmacists at Henry Ford have been rounding with physicians for more than 20 years, although not on all patient floors. When he first began working at his job about 22 years ago, physicians and pharmacists were learning to work with each other, and physicians were more reluctant to follow the pharmacists’ advice.
Pharmacists who stay far from the patient floors and have limited interaction with physicians may have more difficulty gaining their trust, he says. For example, physicians may double-check pharmacist recommendations themselves before acting upon them.
That is why research showing the benefits of hands-on patient care for pharmacists is so important. "I think it is going to be great for the pharmacy industry," Mlynarek says. "It shows that pharmacists need to be there whenever medications are prescribed."
A study published in 1999 showed that having a pharmacist on a physician rounding team in an intensive care unit (ICU) reduced the incidence of adverse drug events (ADEs) by two-thirds.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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