Craig A. Pedersen, R.Ph., Ph.D., FAPhA Associate Professor

1. Comparing Pharmacy Practice in VA Hospitals to General Medical-Surgical Hospitals: Results from the 2004-2006 ASHP National Hospital Pharmacy Surveys Craig A. Pedersen, R.Ph., Ph.D., FAPhA Associate Professor The Ohio State University College of Pharmacy 614.292.3011 Pedersen.18@osu.edu

2. Acknowledgements • William Jones, M.S., R.Ph. (Southwest CMOP) • ASHP • Philip J. Schneider, M.S., FASHP (OSU) • Douglas J. Scheckelhoff, M.S., FASHP (ASHP) • Elizabeth H. Chang (OSU) • Virginia S. Torrise, Pharm.D. (Dept of VA) • Merck & Co, Inc. for funding of the survey

3. History of the ASHP National Survey • ASHP has a long and distinguished history of support for examining hospital pharmacy practice • First examination by Don Francke and Clifton Latiolais, “Mirror to Hospital Pharmacy” published in 1964 • Study took 8 years to complete (1956-1963) • Objective: “to determine what constitutes good pharmacy services for patients in hospitals and to study methods of improving the quality and expanding the scope of these services in the interest of better patient care”

4. Mirror to Hospital Pharmacy

5. History of the ASHP National Survey • That vision has remained throughout the years • ASHP continued to biannually surveyed hospital practice from mid-1970s through 1996 • Beginning in 1998 survey redesigned to capture the role pharmacists play in managing and improving the six steps of the medication-use process: • Year 1: Prescribing and Transcribing • Year 2: Dispensing and Administration • Year 3: Monitoring and Patient Education

6. The “Swiss Cheese” Model: Weaknesses in the Medication Use System Reason, J. BMJ. 2000;320:768-770.

7. What does the VA Inpatient Medication Use System Look Like? • VA hospitals are widely thought the lead the way in pharmacy practice • Technology (BCMA, CPOE, eMAR) • Pharmacists’ roles and responsibilities in ambulatory care (Knapp 2005) • Last examination was from 1993 (Crawford) • No broad-based comparison data exist Knapp KK, Okamoto MP, Black BL. ASHP survey of ambulatory care pharmacy practice in health systems – 2004. Am J Hosp Pharm. 2005;62: 274-84. Crawford SY, Santell JP. ASHP national survey of pharmaceutical services in federal hospitals – 1993. Am J Hosp Pharm. 1994;51:2377-93.

8. Objective • To compare the pharmacy practice between Veterans Affairs hospitals, and general and children’s medical-surgical hospitals. • 6 steps in the medication-use process • Technology • 2004-2006 surveys

9. Usable Surveys (Response Rates)

10. Caveats • Results are from pharmacy director responses to survey questions • Respondents may be different from non-respondents (response rates were low for VA hospitals) • Your feedback on the results is critical • Don’t shoot the messenger!

11. Prescribing and Transcribing 2004 ASHP National Survey

12. Formulary System Management Tools

13. Clinical Practice Guidelines and MUE

14. Pharmacist Consultation

15. Providing Drug Information to Prescribers

16. Use of CPOE with Clinical Decision Support (2006) 2007: ~10% (Gen-Med-Surg)

17. Transcribing • Without CPOE / eMAR (Gen-med-surg hospitals) • Standard physician order forms • Any illegible order is clarified before transcription / entry onto MARs • Reconcile MARs and pharmacy patient profiles daily • Special transcribing procedures are used for high-risk medications • If computerized prescriber order entry (CPOE) not available, physicians must print / type all medication orders • Countersign verbal orders • Read back all verbal orders (including spelling the drug name, dose, dosage form, and name of patient) • VA = 81.6% , GenMedSurg=81.9%, 400+=94.2%

18. Dispensing and Administration 2005 ASHP National Survey

19. Use of Dispensing Technologies (2005)

20. Primary Method of First Dose Medication Distribution

21. Primary Method of Maintenance Dose Medication Distribution

22. Philosophy and Direction of Drug Distribution System

23. Primary Method Used to Check Doses Dispensed by Pharmacy

24. Ways to Build Safety Into Drug Preparation and Dispensing • Using true “unit dose” (93% orals*, 65% injectables) • No manipulations at the bedside • No “note strength” labels • Two pharmacist check before dispensing high-risk drug therapies, e.g. chemo (67%)* • TPN • Large volume base compounder (37%) • Additive compounder (19%)

25. Formal quality improvement process for medication preparation and dispensing

26. Pharmacists Review of Orders in the Traditional “Black Holes” of the Hospital Better than others, but opportunity exists here

27. Medication Administration Record

28. Safe Medication Administration Practices

29. Routine MAR Tasks

30. System Failures and Interceptions 39% 12% 11% 38% System Failures (Where errors occur) 48% 33% 34% 2% Interceptions of Potential ADE’s (How often errors are detected) Prescribing Transcribing Dispensing Administration Source: Leape et al. JAMA. 1995;274:35-43

31. Use of Medication Administration Technologies (2006) 2007: ~20% ~41% (Gen-Med-Surg)

32. Smart Infusion Pumps • IV errors have greatest opportunity for adverse events • Nurses value assistance with calculations • Extensive library (65%*less) • Library composition • Used throughout the hospital (88%) • Drug library automatically on • Avoid rate-set-go

33. Monitoring and Patient Education 2006 ASHP National Survey

34. Who Performs Medication Therapy Monitoring

35. Pharmacists Spend More Time Monitoring and Monitor More Patients in VA’s • Greater proportion of pharmacist time spent in medication therapy monitoring activities • 30% or more of time • 49% VA : 24% Gen-med-surg : 35% 400+ • Greater proportion of patients monitored by pharmacists • 75% or more of patients • 35% VA : 24% Gen-med-surg : 28% 400+ • Mechanisms implemented to improve medication therapy monitoring (top 2) • VA: 61% report increased hiring of clinical staff, and 43% report marketing impact of clinical pharmacy services • Gen-Med-Surg: 46% report expanding technicians responsibilities, and 45% increasing access to patient-data

36. Excellent Electronic Access to Information

37. Pharmacist Authority to Manage Medication Therapy • Monitor Medication Levels (88%) • Order Serum Medication Level (74%) • Adjust Dosages (67%) • Notification when Levels are Outside Therapeutic Range • 63% VA • ~45% Gen-med-surg and 400+ • Pharmacists document in medical record • 95% VA • ~65% Gen-med-surg and 400+

38. Methods used to monitor patients for adverse drug events

39. More Patients Receive Medication Education by Pharmacists • More than 25% of patients at discharge • 71% of VA hospitals • <10% of gen-med-surg and 400+ • More than 25% of patients during inpatient stay • 40% of VA hospitals • <10% of gen-med-surg and 400+

40. Summary • VA has adopted technology at a much higher rate • Technology appears to be a strategic focus of the organization • P&T and formulary process is more active (e.g., CPG’s) because local/regional/national all take on some aspects of drug policy and evaluation • Philosophy of drug distribution is of more centralization, a robot, patient specific medications, and ADC’s in procedure areas and not the whole hospital

41. Summary • VA has more QI activities associated with medication preparation and dispensing activities • There is increased control of medication use • Better use of MAR because of eMAR • More time on medication therapy monitoring and more patients monitored • Monitoring is baked in the cake

42. Summary • ADE monitoring and reporting occurs much more frequently through pharmacist contact with patients and rounding with physicians • Share more ADE reports externally to learn and not make mistake again • Centralized VA control over system has led to rapid advancements and faster adoption than highly fragmented systems

43. Summary • Patient teaching is much more prevalent • More patients are counseled, more documentation, more routine education of patient on high-risk medications • More physician collaboration through pharmacist consultations • Opportunities exist to get even better!

44. Where are the Opportunities for VA Pharmacy? • Biggest gaps: Self assessment • Speed to impact: What can you do by next Tuesday? • Magnitude of impact: What errors are most common? • External factors: TJC, USP, National VA initiatives • Local factors: Politics, need, resources • Change requires: Leadership, infrastructure, competence, and will

45. The “Swiss Cheese” Model: Weaknesses in the Medication Use System Reason, J. BMJ. 2000;320:768-770.

46. 2004-2006 Surveys • Pedersen CA, Schneider PJ, Scheckelhoff DJ. “ASHP National Survey of Pharmacy Practice in Hospital Settings: Prescribing and Ttranscribing—2004.” American Journal of Health-System Pharmacy 2005; 62:378-90. • Pedersen CA, Schneider PJ, Scheckelhoff DJ. "ASHP National Survey of Pharmacy Practice in Hospital Settings: Dispensing and Administration—2005." American Journal of Health-System Pharmacy 2006; 63:327-45. • Pedersen CA, Schneider PJ, Scheckelhoff DJ. "ASHP National Survey of Pharmacy Practice in Hospital Settings: Monitoring and Patient Education—2006." American Journal of Health-System Pharmacy 2007; 64:507-20.

47. Comparing Pharmacy Practice in VA Hospitals to General Medical-Surgical Hospitals: Results from the 2004-2006 ASHP National Hospital Pharmacy Surveys Craig A. Pedersen, R.Ph., Ph.D., FAPhA Associate Professor The Ohio State University College of Pharmacy 614.292.3011 Pedersen.18@osu.edu