Pharmacy
Pressure Points: What’s Stressing Your PharmacyMed safety is most visible. Staff shortages mean higher wages, if you can find anybody to hire. And then there’s the drug crunch.
Seven months after three premature infants died in an Indianapolis neonatal intensive care unit from accidental overdoses of heparin, the tragedy still brings a collective shiver to the nation’s hospitals. “The event caused most hospitals that have a neonatal intensive care unit … to see whether something like that could happen in their hospitals, and to put systems in place to prevent it,” says Kasey Thompson, director of patient safety at the American Society of Health-System Pharmacists.
Even so, pharmacy directors, their staffs and their CEOs know that no hospital is fully immune from mistakes.
“One of our big things is trying to build safety into our system,” says Lynn Fitzpatrick, pharmacy director for Agnesian Healthcare in Fond du Lac, Wis.
Nationally, preventable adverse medication events harm at least 1.5 million patients in the United States each year, according to the Institute of Medicine’s 2006 report, “Preventing Medication Errors.” The IOM cited findings that such errors increased the cost of a hospital stay an average of $8,750, not including lost income or potential litigation. The national price tag is tough to calculate, but it’s counted in the billions.
While it’s certainly the most visible issue, patient safety isn’t the only pressure point on hospital pharmacies. From a staffing shortage to the need for more direct involvement in patient care, the pharmacy’s impact on hospital operations is changing. H&HN looks at a few of the big trends facing the field today.
Reconciling Medication Reconciliation
Both a cornerstone and a lightning rod of the Joint Commission’s National Patient Safety Goals, medication reconciliation standards took effect in 2004 and have been surveyed since last year. Yet more than a quarter of all hospitals remain out of compliance, according to Richard Croteau, M.D., executive director for patient safety initiatives at the Joint Commission International Center for Patient Safety.
“For a lot of hospitals, it’s been a real lesson in how to design their workflow,” Croteau says. “They haven’t handled it well at all.”
The commission requires providers to keep a complete record of each patient’s medications from admission through discharge to help prevent incorrect dosing, drug interactions and allergic reactions. Though often cumbersome, most hospitals do the tracking with existing staff.
“We rarely go into specifics for how to do it because the best way, the most efficient way, to do it varies from hospital to hospital,” Croteau says. “The best implementations I’ve seen do involve pharmacies as part of the team. The pharmacists know more about the drugs than anybody else.”
Michelle Modrijan, a senior consultant with Healthia Consulting and a former hospital pharmacist, wishes the commission would require more pharmacy oversight. She likens reconciliation at some hospitals to the party game “Telephone,” in which the first player whispers a story to a second, who passes it to a third, and so on. “At the end of that, something gets garbled up,” she says.
Budget, Staff Squeeze
Douglas Scheckelhoff, ASHP’s director of pharmacy practice sections, says pharmacists have the right knowledge to take the lead on reconciliation, but cautioned, “If there’s not additional resources, it’s very difficult to undertake.”
Budget pressures prevent the pharmacy at 881-bed Huntsville (Ala.) Hospital from taking over reconciliation, says Michael McDaniel, director of pharmacy services. Doing so would pile another 500,000 medication reviews onto the workload and require four more full-time pharmacists, hiking the payroll by roughly $500,000.
“Nobody is paying us to do this,” he adds, referring to the fact that there’s no reimbursement stream for medication reconciliation.
Still, the Joint Commission, in a study published in January 2006, “Reconciling Medications at Admission: Safe Practice Recommendations and Implementation Strategies,” found that it’s best to let other departments take the lead on reconciliation.
“Much of the reconciling relies on changing nursing and physician workflow patterns, activities that pharmacy generally lacks the power to affect,” the report notes.
Croteau says poor data reporting doesn’t allow a true measure of success, but a hospital that adopted reconciliation standards cut medication errors by 70 percent, including 15 percent fewer ADEs, according to the study.
Russ Tessman’s firm is recruiting a pharmacist for a tiny hospital in Iowa, 100 miles from the nearest larger city. The hospital boosted its salary offer more than $105,000—and it’s still a tough sell.
“The whole shortage of pharmacists is going to have an impact on health care, just like the shortage of doctors,” says Tessman, a division manager at Vermillion Group, which keeps 10 pharmacy recruiters busy. “We’re seeing that especially in the areas that we call ‘geographically handicapped.’ It’s much harder now for us to find candidates than it was three or four years ago. Even when we place a pharmacist somewhere, we hold our breath waiting for a counteroffer to come, because we know it’s coming.”
Tessman says retail clients typically offer the fattest wages and bonuses.
“Hospitals can’t afford not to compete with retail,” says McDaniel of Huntsville Hospital, which recently raised base salaries to $104,000, offered $30,000 retention bonuses and improved recruiting tactics to fill nine vacancies on a staff of 55 pharmacists.
The average base pay for hospital pharmacists is $45.43 per hour, or about $95,000 a year for a full-time position, according to Mercer Human Resource Consulting’s 2006 Pharmacy Compensation Survey–Fall Edition. Their salaries rose 9.2 percent in the past two years but lagged behind average retail salaries, which crested at $100,000 last fall. (Mercer’s spring survey results were unavailable at press time.)
The vacancy rate in hospital pharmacies remains about 5 percent to 7 percent. Schools are graduating more pharmacists, but ballooning demand for medications keeps them in short supply. Competition is stiffest for new pharmacists because veterans tend to remain in one career track.
McDaniel argues that each additional pharmacist he hires saves double his or her salary by lowering drug costs and preventing errors. But he says it is a “constant battle” to convince administrators of savings for expenses that never arise because of the extra vigilance.
New Roles, More Retirements
The shortage is exacerbated as pharmacists move into new roles such as informatics. Pharmacists, like nurses and physicians, are being asked to help adopt new computer technologies, which takes them away from clinical work.
And then there is a pending retirement boom. “There are an alarming number of pharmacy directors who will retire in the near future, with a limited pipeline of well-trained future leaders ready to take their place,” Scheckelhoff says. To help fill the void, ASHP earlier this year launched the Center for Health-System Pharmacy Leadership.
When it comes to recruitment—and even more so to retention—money isn’t everything. “If [employers] have created a workplace that is desirable, they generally don’t have a problem hiring and keeping pharmacists,” Scheckelhoff says.
More Pharmacists Leave the Basement
Most hospital pharmacists still work in central pharmacies—sometimes stuck in the basement—but smaller hospitals like Agnesian Healthcare’s St. Agnes are turning the tide toward decentralization, a more common model at larger institutions.
“I think it’s a direction we need to go,” says Fitzpatrick, who hired more pharmacists to make the switch last year. “When you remove the pharmacists from the pharmacy and put them on the floor, they can collaborate with the nurses and all the caregivers. In any one given day, I need five pharmacists out on the floors and only two in the pharmacy.”
Agnesian’s pharmacy also converted to 24-hour operation, enabling pharmacists at St. Agnes to dispense medications through a Pyxis machine at Waupun Community Hospital, its smaller sister hospital 23 miles away.
Having pharmacists working on patient floors not only improves care, it also makes most pharmacists happier, Fitzpatrick says.
McDaniel helped decentralize a hospital pharmacy in Oklahoma before inheriting a decentralized department in Huntsville. Despite higher personnel costs, he believes the model saves hospitals money in the long run.
An April study from CHD Meridian Healthcare found when pharmacists work alongside doctors, the physicians prescribed fewer higher-cost antibiotics that have more side effects and greater risk of building bacterial resistance.
“It is a return to more collaborative care—where doctors, pharmacists and patients all take part in managing health and wellness and where costs are controlled by identifying the best course of treatment the first time around,” says Raymond Fabius, M.D., CEO and chief medical officer at CHD Meridian.
Counterfeit Drugs Fill Void
Drug supply problems drive Fitzpatrick “crazy,” add dollars to McDaniel’s budget and give Purdue Pharma’s Aaron Graham the cold sweats. Graham was an undercover investigator for the Drug Enforcement Administration, Food and Drug Administration and Pfizer Inc. before becoming Purdue Pharma’s vice president and chief security officer.
Organized crime, corrupt governments and even terrorist organizations such as Al Qaeda and Hezbollah counterfeit prescription drugs because the profits far outweigh risks, Graham says. One study estimates that worldwide sales of counterfeit drugs will reach $75 billion by 2010. A graver concern, Graham believes, is the risk that someone could attack U.S. citizens through the drug supply.
Graham says Purdue Pharma was the first of several companies now employing radio frequency identification technology to guard their products from factory to pharmacy. Purdue Pharma has avoided knockoffs of its bestseller, OxyContin, that have shadowed other popular drugs, including Pfizer’s Lipitor.
“Until we have a truly closed system … the potential exists for some clever guy to introduce counterfeit drugs into the hospitals,” Graham says.
Some states require paper trails to prove drug pedigrees. Law or not, experts agree hospitals should contract with wholesalers who can prove they buy directly from manufacturers, not opportunists who emerge during drug shortages. Not all medication resellers work in this so-called “gray market,” but McDaniel compares shadier drug sellers with cockroaches. “You don’t know you even have them until you walk into the kitchen at midnight and flip on the light,” he says.
Counterfeit drugs are frightening, but established drugs such as insulin, opiods and anticoagulants still are implicated in more ADEs, say Thompson of ASHP. Periodic drug shortages, which ASHP tracks, also endanger patients and increase pharmacy workloads.
The pipeline of new drugs has slowed to a trickle, but increasingly complex care regimens keep medication use gushing. Pharmacy orders rose 17 percent per discharge in three years, increasing workloads for doctors, nurses and pharmacists, McDaniel says.
“The busier people get, the more hectic things get, then the more mistakes people make,” he says. “And the more mistakes people make, the more costs go up.”
Technology’s Bigger Byte
Computerized provider order entry. Bar coding. Electronic records. Smart IV infusion. Remote medication order review and dispensing. Robots. These days, it seems talk around hospital pharmacies is as much about IT as Rx.
At its best, technology promises to improve patient safety, cut costs and free pharmacists from “busy work.” But seldom does new technology arrive without baggage, and it’s never cheap.
“The downside of investing in technology is that it takes a lot of pharmacy resources,” Fitzpatrick says. It can take her small department the equivalent of two full-time pharmacists a year to roll out a system. McDaniel says a current information technology deployment is consuming five FTEs through October, overlapping the training period for new hires.
It is generally false, and perhaps dangerous, for hospital administrators to believe technology will decrease the need for pharmacists, ASHP’s Scheckelhoff says. “It’s quite the opposite in most cases.”
Adds his colleague, Thompson: “Hiring more pharmacists might be one of the first ‘technology upgrades’ they want to make.”—Eric Apalategui is a writer in Beaverton, Ore.
This article 1st appeared in the May 2007 issue of HHN Magazine.
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