The Mirror to Hospital Pharmacy

Transcription

1 Fifty years of advancement in American hospital pharmacy Douglas J. Scheckelhoff ar Layar The Mirror to Hospital Pharmacy not only served an important role in assessing the state of pharmacy practice in hospitals 5 years ago but more importantly offered recommendations that contained great vision and direction for practice. 1 The Mirror served as a final report of the Audit of Pharmaceutical Services in Hospitals and was the forerunner to the many national surveys regularly conducted by ASHP over the past 5 years The importance of the Mirror s recommendations and the profound impact they had on driving how pharmacy is practiced in hospitals cannot be overstated. Drivers of change There have been many drivers of change in the evolution of pharmacy practice in hospitals. Professional leadership, often demonstrated through organizations such as ASHP, has been essential to seeing the advances made over the past 5 years. This leadership has been expressed through progressive education and information sharing, such as at the ASHP Midyear Clinical Meeting and, in the Society s early days, at ASHP Am J Health-Syst Pharm. 214; 71: Institutes offered around the country. Specialty conferences, such as the ASHP National Pharmacy Preceptor Conference and the ASHP Conference for Leaders, also have served as a mechanism to share a vision for pharmacy and learn about advances in practice. Professional policy positions, including practice standards such as statements, guidelines, and technical assistance bulletins, have also been important in voicing goals for practice and setting a high bar. Publishing a consistently high-quality journal, the American Journal of Hospital Pharmacy that was later renamed the American Journal of Health-System Pharmacy, has also served an important role in providing a forum where scholarly work can be presented, editorials can express a point of view, and advances can be shared. Changes in pharmacy education, especially the shift to an entry-level doctor of pharmacy degree, have also made a profound impact on how pharmacists practice and what they are prepared and trained to do. The expansion of postgraduate residency training has also played a significant role in both training individuals to better care for patients and elevating the level of practice at the sites where they train. And without a doubt, major advances in therapeutics and the complexity of drugs and biologicals have also created a need for the advanced level of care provided by pharmacists. The profession has been served by a number of visionary initiatives aimed at directing practice and further defining professional goals. Landmark initiatives such as the ASHP Hilton Head Conference in 1985, the Pharmacy in the 21st Century conference in 1989, the Implementing Pharmaceutical Care conference in 1993, the ASHP 215 Health-System Initiative launched in 23, and the ASHP Pharmacy Practice Model Initiative, initiated in 21, have each sought to bring professional consensus around goals for practice, the future roles of pharmacists, and the training needed to achieve those goals Other forces, such as conditions of participation established for facilities authorized to treat Medicare patients and accreditation standards from the Joint Commission, have also influenced how many patient care ser- Douglas J. Scheckelhoff, M.S., FASHP, is Vice President, Office of Practice Advancement, American Society of Health-System Pharmacists, Bethesda, MD (dscheckelhoff@ashp.org). The significant contributions of Craig A. Pedersen and Philip J. Schneider in conducting the ASHP national survey of pharmacy practice in hospital settings, the source of much of the data contained herein, are acknowledged. Presented at the ASHP Midyear Clinical Meeting, Orlando, FL, December 1, 213. The author has declared no potential conflicts of interest. Copyright 214, American Society of Health-System Pharmacists, Inc. All rights reserved /14/ DOI /ajhp14239 Am J Health-Syst Pharm Vol 71 Nov 15,

2 Table 1. Hospital Pharmacy Staffing in 1957 Versus Total No. Total No. Pharmacists b Nonpharmacists b % Hospitals With 1 Full-time Pharmacist Hospitals by Bed Size Total No. Total No. Pharmacists a % Hospitals With 1 Full-time Pharmacist Total No. Hospitals by Bed Size No. Beds Nonpharmacists a Total No. <5 2, , c 4, 3, , c 4,48 3, , ,41 1 9,473 9, ,72 1, ,418 8, , ,214 2,657 Total 5, ,513 2,517 4, c 64,225 56,746 a The Mirror reported full-time and part-time pharmacists and nonpharmacists as individuals (total head count). These figures have been converted to full-time equivalents (FTEs). b The ASHP national survey counts full-time and part-time pharmacists and nonpharmacists as FTEs. c Estimate based on 213 ASHP national survey responses. vices are offered, including pharmacy services. Goals for hospital pharmacy Many accomplishments in pharmacy are taken for granted, especially by younger practitioners who have never known anything but patientcentered, advanced levels of practice. But looking back at the state of practice 5 years ago, and examining how it has progressed over the years, bring focus to how important these goals really were. The Mirror to Hospital Pharmacy established six broad goals for hospital pharmacy that would be the focus for the next several decades. There were also many specific recommendations included in the report. 1 The specific goals were as follows: 1. Teach hospital pharmacists by word and precept the philosophy and ethics of hospital pharmacy as one of the healing arts and their personal, individual accountability to assume responsibility for professional practice. 2. Strengthen and expand the scientific and professional aspects of the practice of hospital pharmacy, including the consulting role of the hospital pharmacist, his teaching role, and his activities in the field of investigation and research. 3. Strengthen and perfect the administrative or management skills and tools essential to the hospital pharmacist in his role as a department head. 4. Attract a greater number of welltrained pharmacists to hospital practice, including those with specialized education and training in hospital pharmacy. 5. Promote payment of realistic salaries to hospital pharmacists in both staff and managerial positions in order to attract and retain the services of career personnel. 6. Utilize the resources of hospital pharmacy to assist in the development and improvement of the profession as a whole Am J Health-Syst Pharm Vol 71 Nov 15, 214

3 The ASHP national survey has been used as a tool by which progress on these specific goals is measured, along with other contemporary aspects of practice. In the pages that follow, the progress made on many of these goals is described where objective data exist. This reflection allows for readers to see the changes in practice over time some occurring relatively quickly, others painfully slowly and where we stand today. Pharmacy staffing The numbers of acute care medical surgical hospitals reported in the Mirror and in the most recent ASHP national survey are shown in Table 1. The total number of acute care hospitals and the breakdown by bed size have changed somewhat over this time period, with a shift from smaller hospitals to larger hospitals and to fewer hospitals overall. Most hospitals, however, continue to have fewer than 2 beds. There clearly has been a significant shift in the number of hospitals with one or more pharmacist full-timeequivalents (FTEs) on staff. When the Audit was conducted in 1957, a small number of hospitals with fewer than 1 beds had a pharmacist on staff, with pharmacy services being offered through some combination of part-time staff, a local community pharmacist, and extensive ward stock accessed by nurses. Not having at least one full-time pharmacist greatly reduced oversight for the overall use of medications, security, formulary management, drug information, and safe preparation. This is in contrast to the current situation in which nearly all hospitals have at least one full-time pharmacist. The need for hospitals to recognize the value of employing at least one full-time pharmacist was a specific recommendation made in the Mirror. The relative number of pharmacy staff was also much different in 1957 and at other time points where total staff was measured through the ASHP national survey (Table 1). There were just 4,5 pharmacist FTEs practicing in hospitals at that time, compared with over 64, FTEs now. a The number of nonpharmacist supportive personnel totaled 2,5, compared with over 56,, primarily pharmacy technicians, employed in today s hospitals. Calculation of pharmacists-to-bed ratios in 1957 showed just.71 pharmacist FTE per 1 beds versus 17.8 pharmacists per 1 beds in 213. a The Mirror recommended a regular census of the number of pharmacists working in hospitals, at least once every five years, to help plan for workforce needs in hospital practice. The Mirror identified the need for nonprofessional staff in hospital pharmacy settings, though the authors did not specifically refer to them as pharmacy technicians. The utilization of pharmacy technicians and other support personnel in pharmacies has grown considerably since the Mirror was published, and the number of positions has grown at a similar pace to pharmacist positions. Table 2. Roles and Activities of Pharmacy Technicians in Activity Technicians have historically been assigned many preparation activities that do not require the professional judgment of a pharmacist. Over the years, hospitals have looked increasingly to pharmacy technicians to perform a number of nontraditional activities. This has especially been true in recent years, and a number of hospitals are using pharmacy technicians for innovative roles, such as assisting with medication reconciliation, facilitating transitions of care, and working remotely with video supervision (Table 2). Pharmacy services In addition to staffing, a large portion of the Audit was dedicated to measuring the scope of pharmaceutical services in all hospitals and included numerous recommendations on how to expand services and improve the safety of medication use. Virtually all hospitals provided some form of drug stock delivery to the nursing units, an inpatient prescription service, and a prescription compounding service. Most pro- Restocking floor stock and/or automated dispensing cabinets 1 Replenishing unit-dose carts (if used) 95 Purchasing activities 94 Packaging activities 93 Compounding sterile preparations 87 Quality-assurance activities/unit inspections 76 Billing activities 76 Compounding chemotherapy preparations 69 Controlled substance system management 55 Information technology system management 38 Technician supervising other technicians 3 Tech check tech 16 Order entry (for pharmacist verification) 15 Medication reconciliation (obtaining list) 14 Medication assistance program management 12 Preparation of clinical monitoring information 9 Screening of medical records for medication-related problems 8 Facilitating transitions of care 8 Dispensing monitored by remote video supervision 2 Am J Health-Syst Pharm Vol 71 Nov 15,

4 vided drug information as a service, primarily having a pharmacist available to answer questions from prescribers, nurses, and patients. About two thirds offered an outpatient prescription service, much higher than the current state, where less than one third of hospitals have an outpatient pharmacy. An important recommendation in the Mirror centered on the need for demonstration projects designed to improve the safety and efficiency of dispensing, improve labeling, reduce errors, and reduce waste and specifically mentioned the need for unit-dose dispensing and pharmacy preparation of injectable dosage forms. The problems identified with the ward stock system used at the time, along with these recommendations, led to a number of studies and demonstration projects in the years immediately after the publishing of the Mirror. There continued to be a focus on implementing unit-dose drug distribution programs and pharmacy-coordinated intravenous admixture programs for 3 years, and measuring progress with implementation was the focus of many ASHP national surveys in the 197s, 198s, and 199s (Figure 1). Implementation of these drug distribution services has been widespread, and they are now core to nearly all inpatient pharmacy services. The lack of availability of staff, commercially available unit-dose packages, and the lack of systems for efficient distribution were all barriers to early adoption of unitdose systems. As more manufacturers started providing oral dosage forms in unit-dose packaging and pharma- cies started to become computerized, many of the barriers started to fall. The adoption of pharmacycoordinated centralized i.v. admixture programs was slower, partly because these services not only required staff and space but also special equipment (e.g., laminar airflow hoods) and knowledge and skills regarding aseptic technique and sterile compounding. These subjects were largely not taught in pharmacy schools at that time, so numerous training materials were developed and educational institutes were conducted to help develop the knowledge and improve the skills associated with sterile compounding. Although these services are now commonplace, there continues to be a need for education, training, and skills development in sterile compounding. Figure 1. Adoption of unit-dose drug distribution and i.v. admixture programs. 1-1,25 Data were collected only on the adoption of each individual program in Data were collected only on the adoption of the i.v. admixture program in I.V. admixture program Unit-dose distribution program Both Am J Health-Syst Pharm Vol 71 Nov 15, 214

5 Other developments that have had a significant impact on the practice of pharmacy are the computerization of pharmacy records and, more recently, automation and other technology associated with dispensing of medications. Figure 2 shows the adoption rates of pharmacy computers, some standalone and others as part of a hospital mainframe, starting in 1975 (although some early computer applications predated this first survey). While just 7% reported having a pharmacy computer in the mid-197s, this percentage quickly grew and by the mid-198s it was up to 32%. Just 1 years later, over 9% of hospital pharmacies were computerized. These advances greatly improved efficiency, reduced errors associated with manual transcription and copying of orders, supported the efficient use of unit-dose systems (since cart-fill lists could now be generated), and brought many other benefits. While the need for computerization was not a specific recommendation in the Mirror (the possibilities of computerization were unimaginable to most at that time), many of the deficiencies of the drug distribution systems that were corrected by computerization were identified as specific problems in the Mirror. Figure 2 also shows the evolution of dispensing systems after computerization, beginning predominantly with manual unit-dose cart systems, some satellite pharmacies, some robotic systems, and some use of automated dispensing cabinets (ADCs). Over the next 1 years, the shift from a manual unit-dose cart system to greater automation, such as ADCs, became significant. In nearly all cases, the ADCs are interfaced with the pharmacy computer so that doses can generally not be removed unless the order is reviewed and authorized by a pharmacist. The need for after-hours services was identified as an issue in the Mirror, since pharmacies did not provide 24-hour services at that time. As the scope of pharmacy services grew, it became apparent that closing the pharmacy overnight was no longer acceptable, especially in larger hospitals. The growth in 24-hour pharmacy services began in the 19s and 197s, and by 1975, about 6% of hospitals provided pharmacy services 24 hours per day, seven days per week. The pro- Figure 2. Adoption of pharmacy computerization and automated dispensing methods. 1-1,15,18,21, Pharmacy computerization Centralized manual dispensing (e.g., unit dose) Decentralized manual dispensing (e.g., satellite pharmacies) Centralized automated dispensing (e.g., robot) Decentralized automated dispensing (e.g., automated dispensing cabinet) Am J Health-Syst Pharm Vol 71 Nov 15,

6 vision of 24-hour services grew rapidly, increasing to 19% of hospitals by 1985, to over 3% by the mid-199s, and peaking at 39% in 211. Twenty-four-hour access to pharmacists reinforces the value they Table 3. Pharmacy and Therapeutics Committee Activities Reported in Activity bring to patient care for order review, the provision of drug information, and the resolution of medicationrelated problems. Since it is not always practical to have a pharmacist physically onsite (such as in smaller Establishes that the pharmacy department is responsible for determining acceptable sources of drug supply 66 Develops list of emergency drugs to stock on nursing units 54 Approves drugs by nonproprietary (generic) name 5 Determines what drugs should be on the formulary and stocked in the pharmacy 48 Develops procedures for medication ordering by physicians and interns 34 Establishes policies regarding investigational drugs 26 hospitals), alternative solutions have been developed, in many cases using newly available technology. Figure 3 shows the evolution of different methods of continuous access to pharmacist services such as order review. In the 197s, 198s, and 199s, continuous access required that the pharmacist be onsite or, in a few cases, be available by telephone. By the mid-2s, after-hours order review became more readily available from remote locations, either from companies offering the service or from affiliated hospitals. High-speed computer access, the availability of remote video technology, and the limited number of standardized pharmacy information systems have allowed these methods to grow and be effective. So the after-hours service problem identified in the Mirror Figure 3. Adoption of 24-hour pharmacist medication order review methods. 1-3,5,8,18,2,23,24, No review Review by on-call pharmacist Review by affiliated hospital Review by company Review by 24-hour pharmacy service Am J Health-Syst Pharm Vol 71 Nov 15, 214

7 for 1% of hospitals has been addressed in three fourths of hospitals through the availability of an onsite pharmacist or a technology-supported remote service. Mirror, and there were specific recommendations that hospitals should have a formulary, that the formulary should be the responsibility of the pharmacy, and that hospitals should use the American Hospital Formulary Service as a timesaving resource in compiling their formularies. There were also recommendations on using generic (nonproprietary) names Medication utilization and formulary systems The concept of a formulary system, based on a collaborative effort of the pharmacy and medical staff of a hospital, was described in the Minimum Standard for Hospital Pharmacies by the American College of Surgeons in By the time of the Audit in 1957, many hospitals (76%) had some type of a pharmacy and therapeutics committee and about half had a formulary system (48%). Table 3 lists the types of pharmacy and therapeutics committee activities described in the Mirror. The importance of having a formulary was recognized in the Table 4. Formulary Management Techniques Reported in Activity Therapeutic interchange policy 91.9 Minimal duplication of multisource products 91.3 Minimal duplication of therapeutically equivalent products 82.8 Pharmacist interventions designed to help monitor prescriber compliance with medication-use policies 82.3 Regular review of new therapeutic agents 69.4 Evaluation of prescribers regarding medication costs 62.6 Regular review of therapeutic categories 57.4 Regular review of nonformulary drugs 56.3 Comparative-effectiveness research 4.3 Prior approval required for use of nonformulary products 32.5 Regular evaluation of prescriber adherence to medication-use policies 31. Figure 4. Changes in pharmaceutical cost per patient day. 1,7-1,15-26 Dollar values adjusted for inflation using the consumer price index and reflect 213 value, using the Bureau of Labor Statistics calculator ( year2=212) Cost per Patient Day ($) Am J Health-Syst Pharm Vol 71 Nov 15,

8 for listing in the formulary and in drug labeling. There were also recommendations on using the formulary as a means of avoiding duplication of multisource products. The role and sophistication of pharmacy and therapeutics committees have grown considerably since the Mirror was published, and most hospitals now use multiple techniques to manage formulary use (Table 4). The use of therapeutic interchange policies has become commonplace, as have efforts to minimize duplication of multisource products and therapeutically equivalent drugs. Many of these additional techniques are due to the enhanced role that pharmacy plays in ensuring appropriate drug use and are possible because of a strong relationship between pharmacy and medicine. Recommendations in the Mirror point to the need to have regular communication between pharmacy and medicine, especially on issues related to medication use. There were specific recommendations in the Mirror about pharmacy purchasing and contracting, and while group purchasing organizations (GPOs) did not exist as we know them now, many hospitals made efforts to seek competitive bids from pharmaceutical companies for drugs. Forty-one percent of hospitals in the Audit reported bidding out drugs often, suggesting that there was not a formal structure for an annual bid of all drugs but that at least some products were bid out on a selective basis. In the 19s and 197s, hospitals banded together to form GPOs; by 1975, 41% had joined a GPO for the purposes of bidding, negotiating, and contracting for drug purchases. By 1987, this percentage had risen to 91%, rising to 98.8% in The percentage of hospitals that have formed GPOs remains high today, though these data are no longer tracked in the ASHP national survey. Hospitals also simplified their purchasing process by moving to a single prime vendor wholesaler for the acquisition of most of their pharmaceutical needs. By 1987, 95% of hospitals reported using a prime vendor. Not unexpectedly, the cost of pharmaceuticals has risen significantly over time. Data were collected in the Audit on the total pharmaceutical expenditure per year, comparing those hospitals with formularies to those without, as well as the cost per patient admission and the average cost per patient day. The mean expenditure per hospital in 1957 was $53,986 ($447,559 when adjusted for inflation), varying greatly based on hospital size. The average cost per patient admission was $12.36 ($12.47 when adjusted for inflation), and the average cost per patient day was $1.61 ($13.35 when adjusted for in- Figure 5. Growth of basic clinical services and activities. 1,3-9,14,23,25 Data for pharmacist on rounds not collected in 1994, 21, and 212. Patient monitoring data not collected in 21 and 21. Pharmacokinetic consultations data not collected in 1978, 1985, and Responding Clinical Services Pharmacist on rounds Patient monitoring Pharmacokinetics consultations Am J Health-Syst Pharm Vol 71 Nov 15, 214

9 Figure 6. Growth in pharmacist monitoring, authority to order laboratory tests, and authority to adjust therapy. 13,16,19,22,25 Reporting Clinical Services Patient monitoring Authority to order an initial serum medication level Pharmacy Service Authority to adjust a dosage for a routinely monitored medication Figure 7. Growth of ASHP-accredited residency training programs (Teeters J, ASHP Accreditation Services, personal communication, 214 Mar 25). 2 No. Residency Programs Postgraduate year 2 Specialized Clinical Postgraduate year 1 Pharmacy practice Hospital Am J Health-Syst Pharm Vol 71 Nov 15,

10 flation). A comparison of the average costs per patient day are shown in Figure 4. Clinical services and training The Mirror identified the need for pharmacists to take a much more active role in clinical professional practice and recognized the need for additional training. Clinical pharmacy practice started to evolve in the 19s and 197s, with many new patient care services being offered by pharmacists, such as the inclusion of pharmacists on patient care rounds, admission drug histories, clinical pharmacokinetics, and pharmacist management of medication dosing. Growth of some of these services has been tracked in the ASHP national survey over the years, starting in 1975 (Figure 5). Pharmacist provision of these services has grown substantially, to the point where active patient monitoring is commonplace and pharmacist participation on patient rounds (especially in larger hospitals) is routine. Specific services, such as therapeutic drug monitoring, have also continued to grow (Figure 6) and have largely evolved from a pharmacy specialist service to one provided routinely by pharmacy generalists to patients in all sizes and types of hospitals. Clinical pharmacy programs have evolved beyond many of these core pharmacy services. Pharmacist training was recognized as a need in the Mirror, and the specific recommendation that pharmacy move to a six-year curriculum granting a Doctor of Pharmacy degree was thought to be appropriate. Some pharmacy schools began offering postgraduate and entrylevel doctoral programs as early as the 195s. As of 2, all pharmacy schools had transitioned to entrylevel Doctor of Pharmacy programs. The recognition by the profession that such a shift in training was needed will undoubtedly continue to have an impact on what pharmacists do and what they are trained to do. In fact, many new graduates actively seek roles where they will be able to utilize their clinical training, further accelerating the shift toward more clinical pharmacy roles. The need for additional training, such as accredited residency training, was described in several recommendations in the Mirror. ASHP began accrediting residencies in 1962, and the growth in both programs and positions has continued (Figure 7). Residency training has played an important role in complementing the professional training of pharmacists and further preparing pharmacists for clinical practice. The accreditation process also has led to advances in practice through the peer review of pharmacy services against the accreditation standard. The value that residencies bring to new graduates, helping them learn how the medication-use system works, build on their knowledge base, and improve their confidence and communication skills, has increased the demand for residency-trained pharmacists. Demand by pharmacy graduates seeking residency positions has also grown significantly, with the number of applicants outpacing the number of positions available for the past 1 years. Conclusion Many factors have helped drive change and advance pharmacy practice in hospitals. The significance of the change, using data reported in the Mirror to Hospital Pharmacy as baseline and measured over time by ASHP national surveys, shows how far practice has come. Major advances have been made in pharmacists improving patient care, safety, and health outcomes. While it is impossible to know where practice would be today without the active planning and visionary efforts of pharmacy leaders, it is safe to say that their leadership has sped change and advanced pharmacists toward a common vision. The recommendations in the Mirror were profound and have served as a beacon for practice for over 5 years. a The Mirror reported pharmacist and nonpharmacist positions as an individual head count. Total positions were converted to full-time equivalents (FTEs) for comparison purposes in this article and in calculations of pharmacist FTEs per 1 hospital beds. References 1. Francke DE, Latiolais CJ, Francke GN et al. Mirror to hospital pharmacy. org/menu/aboutus/history/mirrorto-hospital-pharmacy.aspx (accessed 214 Aug 7). 2. Stolar MH. National survey of selected hospital pharmacy practices. Am J Hosp Pharm. 1976; 33: Stolar MH. National survey of hospital pharmaceutical services Am J Hosp Pharm. 1979; 36: Stolar MH. National survey of hospital pharmaceutical services Am J Hosp Pharm. 1983; 4: Stolar MH. ASHP national survey of hospital pharmaceutical services Am J Hosp Pharm. 1985; 42: Stolar MH. ASHP national survey of hospital pharmaceutical services Am J Hosp Pharm. 1988; 45: Crawford SY. ASHP national survey of hospital-based pharmaceutical services 199. Am J Hosp Pharm. 199; 47: Crawford SY, Myers CM. 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