Samaneh T. Wilkinson

Effects of a hospitalwide pharmacy practice model change on readmission and return to emergency department rates

PURPOSE The impact of an innovative medication reconciliation and discharge education program on 30-day readmissions and emergency department (ED) visits was evaluated. METHODS An observational pre-post analysis was conducted at an academic medical center to compare rates of hospital readmissions and return to ED visits during three-month periods before and after implementation of a restructured pharmacy practice model including (1) medication reconciliation at transitions of care for every patient and discharge education for a high-risk subgroup, (2) new or expanded services in the preanesthesia testing clinic and ED, (3) a medication reconciliation technician team, and (4) pharmacist-to-patient ratios of 1:30 on acute care floors and 1:18 on critical care units. The primary outcome was the composite of rates of readmissions and return to ED visits within 30 days of discharge. RESULTS A total of 3,316 patients were included in the study. Pharmacy teams completed medication reconciliation in 95.8% of cases at admission and 69.7% of cases at discharge. Discharge education was provided to 73.5% of high-risk patients (defined as those receiving anticoagulation therapy or treatment for acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia). No significant difference was observed between the preimplementation and postimplementation groups with regard to the primary outcome. In the high-risk subgroup, there was a significant reduction in the 30-day rate of hospital readmissions, which declined from 17.8% to 12.3% (p=0.042); cost projections indicated that this reduction in readmissions could yield annual direct cost savings of more than

Can the Targeted Use of a Discharge Pharmacist Significantly Decrease 30-Day Readmissions?:

780,000. CONCLUSION Implementation of a team-based pharmacy practice model resulted in a significant decrease in the rate of 30-day readmissions for high-risk patients.

Preceptor development: providing effective feedback.

Background The prevalence and cost of hospital readmissions have gained attention. The ability to identify patients at high risk for hospital readmission has implications for quality and costs of care. Medication errors have been shown to increase the risk for readmission. Objective To study the impact of a pharmacist-based predischarge medication reconciliation and counseling program on 30-day readmission rates and determine whether polypharmacy and problem medications are important screening criteria. Methods A prospective, nonrandomized cohort study performed at a single medical-surgical unit with telemetry capability at a single academic medical center. The participants were 729 patients, aged 18 years and older, who were discharged between July 1 and October 29, 2010. The intervention was pharmacist medication reconciliation and counseling based on a screening tool. The primary outcome was 30-day readmission rate. Secondary outcomes were the presence of polypharmacy and problem medications and their relationship with observed 30-day readmission rate, including calculation of a problem med/polypharmacy score. Results The pharmacy review group (n = 537) had a lower 30-day readmission rate than the group receiving usual care (n = 192) (16.8% vs 26.0%; odds ratio [OR] 0.572; 95% CI, 0.387-0.852; P = .006). Polypharmacy, defined as either 5 or more or 10 or more scheduled medications, alone and in combination with at least one problem medication had higher 30-day readmission rates. A score of no factors present exhibited good negative predictive value. Conclusions Medication reconciliation and counseling by a pharmacist reduced the 30-day readmission rate. Polypharmacy and problem medications appear to have value individually and together. A pharmacist, guided by a screening tool in predischarge medication reconciliation, is one option to effectively reduce 30-day readmissions.

Implementation of standardized dosing units for i.v. medications

Feedback plays a significant role in precepting and is indispensable in residency training. As described by the Accreditation Council for Graduate Medical Education, the goal of any postgraduate residency program is to prepare individual trainees to function as qualified practitioners. Although feedback and evaluations have traditionally been synonymous, our goal is to differentiate the two and describe the role of each within resident performance. The goal of this article is to provide preceptors with the tools to provide timely, effective, and quality feedback to residents on a regular basis. Although the focus of this article is on residency training, these concepts can be utilized in student rotations as well.

Integrating Precepting Into Your Daily Practice

PURPOSE The implementation of standardized dosing units for six i.v. medications at an academic medical center is described. SUMMARY During the implementation of an electronic health record system at an academic medical center, it was noticed that providers could order some i.v. medications in multiple dosing units, including epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. Possible options to standardize i.v. medications along with their pros and cons were presented for discussion to key providers in all of the intensive care units. Once the providers agreed on a solution, the information was presented to the pharmacy and therapeutics committee for final approval. A nursing education plan was created and administered before the standardization of dosing units was implemented. A nursing survey was conducted before and after implementation of dosing-unit standardization to determine the effectiveness of nursing education on compliance with the standardization of the dosing units for the listed medications. The survey was designed to evaluate, when given a choice, what dosing units nurses would use to administer epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. The decision was made by the key providers to use weight-based dosing-micrograms per kilograms per minute-to allow for consistency of use of these medications for pediatric and adult patients. Nursing education was completed to ensure that nurses were aware of how to safely administer these medications using the new dosing units. CONCLUSION Dosing-unit standardization for dose-adjustable i.v. infusions can provide improved consistency and decrease the potential for dosing errors when administering epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine.

Preceptor Development: Providing Effective Feedback, Part 2

It’s 11:00 a.m. on a Thursday morning. You have just completed rounds and are scrambling to catch up with orders awaiting verification in your queue. Your pager goes off, and the physician on the other end of the line would like you to discuss a phenytoin level and the plan for continued therapy. While you are on the phone, a nurse asks you if insulin and norepinephrine are compatible. A beep from your smartphone alerts you that you are now 5 minutes late for your annual performance review with your boss. You take action on all the critical issues and proceed to your meeting where you are asked to begin taking pharmacy residents on your service. You think to yourself, “How am I ever going to do my job effectively and manage a resident at the same time?” In 2006, the American College of Clinical Pharmacy (ACCP) published a position statement recommending that all pharmacists with direct patient care practice be required to complete formal postgraduate residency training.1 Echoing this sentiment, the American Society of Health-System Pharmacists (ASHP) has proposed a resolution that by the year 2020 all graduating pharmacists will complete an ASHP-accredited pharmacy residency prior to undertaking direct patient care practice.2 At this time, there is not program capacity to fulfill these requirements. In 2012, there were 4,204 applicants for postgraduate year one (PGY1) and postgraduate year two (PGY2) pharmacy residencies. Of those applicants, 1,610 went unmatched with a residency program.3 Mandated residency training coupled with residency position shortages will require the creation of new residency programs as well as the expansion of existing residency programs. To keep up with this demand, preceptors must be able to effectively and efficiently care for patients and educate the future practitioners of our profession. This difficult task can be achieved through incorporation of a few principles into daily practice.

The Complexity and Importance of Residency Precepting: A Series Introduction

An integral part of providing effective feedback to pharmacy residents occurs during the evaluation process. Residency evaluation involves measuring and documenting performance as it relates to standardized residency outcomes, goals, and learning objectives. Evaluations may be formative or summative and include the preceptors evaluation of the residents performance, the residents self-assessments, and the residents evaluation of the preceptor and learning experience. Evaluations are more structured than feedback, and they involve documentation of the verbal feedback that was provided throughout the learning experience. This article will focus on the preceptors role in providing effective resident evaluations based on specific learning activities.

Optimizing the Customized Residency Plan

Preceptor development is an area of significant challenge facing residency leadership and preceptors across the nation. This series will focus on establishing a foundation necessary for successful precepting in todays fast-paced profession. Through discussion and presentation of these materials, preceptors should be able to enhance current precepting skills and identify ways to improve preceptor development programs at their practice sites. The series will review current preceptor development programs and provide options for programs that may be struggling with where to start with preceptor development. Key topics covered will include characteristics of good precepting, generational needs, effective feedback, development of a preceptor program, and finally comparison of resident and student learning needs.

Methods to Promote Preceptor Scholarship through Resident Collaboration

Residents and residency program directors (RPDs) understand that the goal of the residency year is to earn a residency certificate through achievement of established goals and objectives. The customized residency plan provides a map for the resident and RPD to follow throughout the course of the residency year, helping to keep everyone on track to accomplish the established goals and objectives of the program. It also provides information that allows preceptors to take the individual residents plan into consideration when customizing a learning experience. This article will focus on the process for developing a customized residency plan and implementing it over the course of the residency year.

Leveraging drug-utilization and external benchmarking data to drive change in prescribing behaviors.

Preceptor participation in scholarly endeavors is recognized in the American Society of Health-System Pharmacistss (ASHP) residency accreditation standards as a method to demonstrate commitment and contribute to the profession of pharmacy. Although workplace demands and position responsibilities may not allow adequate time for preceptors to pursue scholarly activities, collaboration with pharmacy residents in a structured environment can be mutually beneficial and aid in the professional development of the resident and preceptor. The goal of this article is to provide preceptors with a description of activities suitable for collaboration with residents and with tips to ensure success within the residency year.