From the New Practitioner Network

Holly E. Causey, PharmD, BCACP, CPP, CDE

Clinical Pharmacist in Ambulatory Care Duke Outpatient Clinic, Duke University Hospital, Durham, NC

Holly Causey is a graduate of the University of North Carolina Eshelman School of Pharmacy. She completed her PGY1 Community Pharmacy residency with Campbell University College of Pharmacy & Health Sciences (Buies Creek, NC) and Kerr Drug (FuquayVarina, NC). She then completed a PGY2 Ambulatory Care Specialty Residency at Duke University Hospital in Durham, NC. Following completion of her PGY2 residency, she took a position at the Duke Outpatient Clinic. She has had the privilege of implementing a Transitions of Care service and a group hypertension visit in her clinic as well as managing patients for pain, anticoagulation, diabetes, hypertension, and general medication management. Most recently, she has implemented a protocol for the treatment of Hepatitis C Virus within her patient population. She is a clinical pharmacist practitioner (CPP), board certified ambulatory care pharmacist (BCACP), and certified diabetes educator (CDE). She is also an adjunct assistant professor at the UNC Eshelman School of Pharmacy where she teaches in the ambulatory care elective as well as precepts 4th year students on rotation. She also serves as program coordinator for the Duke University Hospital 2nd year ambulatory care pharmacy residency program. She is currently serving as chair of the North Carolina Association of Pharmacists (NCAP) Residency Committee. She has also served as chair of the NCAP New Practitioner Network Executive Committee and has served on the executive committee since 2010. Dr. Causey is also a member of the American Society of Health System Pharmacists (ASHP) Section of Ambulatory Care Practitioners’ (SACP), currently serving on the Advisory Group on Compensation and Practice Sustainability. She has previously served on Medication Therapy Management in the Community Section Advisory Group and the Pain Management and Palliative Care Section Advisory Group and was an ASHP New Practitioner Forum Executive Committee member in 2012-2013. She has been a member of the American Pharmacist Association (APhA) since a student in pharmacy school and has served on the New Practitioner Network Transitions Advisory Editorial Board and diabetes special interest group. Dr. Causey first became involved with NCAP as a student and has remained a very active member. “NCAP allows me to stay connected. I’m able to keep up with the initiatives and legislative updates as well as socially connect with other pharmacist practitioners. On a more personal level, many of the preceptors I had as a student and resident are highly involved with NCAP. Thus, this is a way of giving back to the profession.” Her piece of advice to new practitioners: “Smooth seas do not make for skillful sailors.” My advice is simply this: respect the obstacles and adversity that come your way for they will make you a more resilient person and pharmacist practitioner.

Member Spotlight!

Call for Nominations: The New Practitioner Network (NPN) welcomes nominations of NPN members to be highlighted in a New Member Spotlight. A nomination may be made by any NCAP member. Nominations for the Journal quarterly issues are due as follows — Winter: December 1; Spring: March 1; Summer: June 1, and Fall: September 1. Please send the NPN Spotlight Nomination Form to Olivia Bentley, NPN Chair, olivia@rxclinicpharmacy.com

NOMINATION FORM

Full Name of Nominee: __________________________________________________________________

Employer: ____________________________________________________________________________

College/School of Pharmacy: _____________________________________________________________

Graduation Year: ________________ Degrees/Certifications: __________________________________

Residency Program(s) if applicable: ________________________________________________________

I understand that the nominee must:

· Be an NCAP Member, and · Have received an entry degree in pharmacy less than 5 years ago · Licensed to practice pharmacy in NC · Actively practices community, institutional, ambulatory care, managed care and /or consulting pharmacy

My name: ____________________________________________________________________________

Email: ________________________________________________ Phone: ________________________

Comments In Support of Nominee

Attach additional pages as needed. Provide specific information related to the spotlight criteria that will be of great help to the NPN Executive Committee. Suggestions: discuss the candidate’s current work environment, significant projects, innovations, accomplishments, current involvement in national, state or regional organizations, and community service.

The Importance of MTM in My Practice

Brianna Luft

When I was a student pharmacist, I had the opportunity to particiåpate in a pharmacist-run MTM clinic, as an insurance company established a contract with my preceptor. Every week, I called patients and conducted Targeted Medication Reviews (TMRs) and Conducted Medication Reviews (CMRs). It was an incredible experience as I got to see first-hand how much pharmacists can influence patient care. When I graduated, I was so excited to continue these encounters that I loved so much as a student pharmacist in my new position. I am a community pharmacist, so I get to see and interact with my patients all the time. This is a perfect environment for clinical interactions with patients! However, one of the challenges I immediately faced was how to incorporate MTM into my workflow. You may be facing this same challenge as well. I use two MTM platforms, Outcomes and Mirixa, so at times it can feel a little overwhelming with so many tasks to complete. The biggest issue I found was how to accomplish both what I want to do and what I need to do. But, in my short time as a pharmacist, I’ve started to make it work. It has a taken a few months of trial and error, but here are some of the tips I found that help me:

Make MTM a priority.

Every morning I log into Outcomes and Mirixa, and I see what opportunities await me. I print these out and keep them next to me all day so that I’m thinking about them.

Try to catch patients in the store.

Sometimes you don’t have time to reach out to the patient via phone call, but you can ask them questions when they’re picking up their medications. I’ve also found that sometimes they are more willing to participate in person!

Preparation is key.

For my very first MTM call, I didn’t have everything I needed ready to go, and the call took longer that I had hoped and didn’t go very smoothly. One thing I like to do is fill in the patient’s mediation list from their profile, so that all I have to do is confirm medications, rather than populate them during the encounter.

Have a good grasp on what MTM is and be able to explain in.

When I call a patient, I ask if they would like to participate in a “free medication review” and I make sure to emphasize that it can be completed over the phone in about 10 – 15 minutes. When I ask in this way, they understand what I am trying to accomplish with the call, and they are aware of what I expect of them.

I don’t get to provide these clinical services every day, but I feel much more enriched and connected to my patients on the days where I do get to complete them. Despite initial challenges with balancing it all, I am happy that I have found a way to help my patients stay educated about their medication regimens and help them in any way I can!

Brianna Luft, PharmD, is a staff pharmacist at Rite Aid in High Point, NC.

Selecting a Residency Project That is Congruent with Your Career Interests

Tony Rudisill, PharmD, MBA, Dick Cason, MS, RPh, Regina L. Ramirez, PharmD, BCPS

A Brief Summary Optimization of Automated Dispensing Cabinets to Improve Utilization and Improve Efficiency of Dispensing Workflow at an Academic Medical Center

Tony Rudisill, PharmD, MBA Dick Cason, MS, RPh Regina L. Ramirez, PharmD, BCPS

As part of the requirements for an ASHP-accredited pharmacy practice residency, residents must select a longitudinal project. This experience is both exciting and frightening as the resident will be spending large amounts of time working on this task. As a pharmacy practice resident with an interest in pharmacy leadership, I was able to select a project that afforded me the opportunity to work with managers from multiple departments. My project was identified as a way to improve the medication-use process at the University of Texas Medical Branch in Galveston, Texas.

Introduction

Pharmacy in health systems aims to make the medication-use process more efficient by decreasing the time between a medication order and the administration of that medication. To help facilitate this goal, many hospitals have incorporated automated dispensing cabinets (ADCs) into their workflow. Automated dispensing cabinets serve as a valuable resource to pharmacy departments. In addition to storing and dispensing medications, the computerized software provides reports to assist in controlling and tracking medication distribution. Literature suggests storing medications in ADCs located in patient care areas reduces the risk of medication errors, minimizes medication delays, and improves patient care. It is important for patients to receive their medications in a timely manner because medication delays have been linked to both negative health outcomes and potential delays in transfers and patient discharges.1 Automated dispensing cabinets allow emergent medications, as well as frequently used medications, to be securely stored closer to patients, making them more accessible to nurses when it is time for administration. Approximately 90% of the hospitals in the United States use ADCs, and nearly 70% of all hospitals use ADCs as the primary means for medication dispensing.1,2 The process of preparing and delivering individual orders can cause delays in the medication-use process and medication administration. Delays in medication administration are concerning and lead to patient dissatisfaction and increased numbers of medication re-dispenses from the nursing staff. Better utilization of the ADCs correlate with reduced time between pharmacist order verification and patient medication administration.1,3

Project Rationale

The University of Texas Medical Branch (UTMB Health) is an academic medical center located in Galveston, Texas. The average census is about 481 patients, and UTMB Health utilizes a combination of ADCs, manual deliverers, and cartfills for medication distribution. There are a total of 74 Pyxis Medstations® located throughout the medical center. Prior to this optimization project in 2016, despite having ADCs in most patient care areas, only 45% of all medication doses were dispensed from ADCs. Delays in medication delivery are reported by nursing to the Patient Safety Net (PSN) reporting system. These reports are frequently monitored for impact on patient outcomes. In addition to reporting delays through PSN, nurses send messages directly to the pharmacy requesting the patient’s medications. Once the message has been read, a pharmacist will often re-dispense the needed medication, unless he or she is certain the medication has recently been delivered. Better availability of medications in the ADCs should reduce the number of reported delivery delays, inbasket messages, and medication re-dispenses. Therefore, putting more of the appropriate medications in ADCs is believed to increase nurse satis-

faction while decreasing PSNs, unnecessary inbasket messages, and re-dispenses.

Project Methods

The need to optimize ADC utilization was supported by hospital leadership as well as pharmacy managers. Early in my residency year (2016-2017), the opportunity to be part of the optimization project was presented to me. From the start, it was apparent my interventions through this project would have a positive impact throughout the entire hospital. My study focused on ADC use and the overall cabinet utilization in ten selected patient care units located in the new Jennie Sealy Hospital. The units were selected based on multiple criteria including pre-optimization utilization rate, total dispenses to each unit, and nurse manager requests. The patient care units where the interventions took place were all adult populations which included: adult medicine, cardiology, surgical/ trauma intensive care unit, geriatric, oncology, transplant, and general surgery. The project consisted of three periods over six months. Each period was two months in duration and identified as: pre-optimization, intervention, and post-optimization. The pre-optimization period took place in September and October was strictly a data collection period. During the next two-month period, November and December, all interventions for the ADC optimization project occurred. During this period, medication inventory was modified within each ADC in order to provide those medications used most frequently on that patient care unit. The final phase, labeled post-optimization, was another data collection period during January and February. To better assess the impact of the optimization project, no adjustments were made to the ADC inventory during the pre- and post-optimization periods, which were strictly data collection periods. The primary endpoint was to measure ADC utilization within ten selected patient care units, as described above. In addition, secondary endpoints evaluated the number of Patient Safety Net (PSN) reports, inbasket messages, as well as medication re-dispenses. Automated dispensing cabinet utilization rate was defined as the total number of medications dispensed within a patient care unit from an ADC divided by the total number of medications dispensed to that unit from all dispensing locations. The optimization process evaluated the appropriateness of the medications placed in each cabinet. The intended outcome was to support the proposal that adding frequently used medications to ADCs, in conjunction with par (pick-and-replenish) level adjustments, reduces the time to medication administration and unnecessary workload for the pharmacy team. Par level adjustments were made to help reduce the number of reported stockouts by setting 3-day minimum medications supplies, and five- to sevenday maximum supplies if space permitted.

Results

Prior to 2016, it is unknown when the last time an ADC assessment had taken place. Despite an institution-wide pre-optimization ADC utilization rate of 45%, a closer look at the ten selected patient care units revealed a much lower ADC utilization rate. Postoptimization analysis revealed an increase in utilization rates for all of the ADCs selected. Overall, the average utilization rate increased from 31% pre-optimization to 53% post-optimization in the study patient-care units. Other endpoints analyzed included inbasket messages, re-dispenses, and PSNs reported. The analysis of these endpoints revealed that there were no correlations between ADC utilization and any of the secondary endpoints. Inbasket messages increased in some units and decreased in others, leading to a total decrease of 7%. The hypothesis was that if inbasket messages decrease, so would re-dispenses. The opposite was actually observed and total re-dispenses increased 6%. The total number of PSNs reported also increased from six during pre-optimization to sixteen post-optimization.

Project Limitations

There were several limitations to the project that should be considered. During the post-optimization data collection period, the hospital had to relocate patients from the old John Sealy Hospital to the Jennie Sealy Hospital where the ten intervention units were located. Relocated units included: the burn unit, the neonatal intensive care unit, the cardiac catheterization lab, and post-partum mothers and babies, to name a few. The relocation was unexpected and may help explain why the secondary outcomes did not correlate with increased ADC utilization. For example, the post-partum mothers and babies unit was relocated to a geriatric unit in January where ADC optimization had already occurred. Due to the timing of the relocation, no changes could be made to the ADC inventory; therefore, medications in the ADC were

more appropriate for the geriatric population. Several other units were affected by patient relocations, but not as significantly as the unit previously mentioned. Another limitation is education regarding the changes that occurred in the ADCs. Unit-specific handouts were created and posted to show medications that were added to each of the ADCs. I personally met with pharmacy and nurse managers to discuss ADC changes. Despite the communication efforts, there were still reports that some employees were not aware of the changes that had occurred.

Project Conclusion

Since the post-optimization period, I have had the opportunity to meet with pharmacy and nurse managers to discuss the changes supported by this project. The intervention has been well received, and pharmacy staff has been able to adjust to workflow shifts. Hospital leadership recently reported to pharmacy managers that nurse satisfaction with the ADCs and pharmacy has improved. This project is being considered successful, and the department did not have to spend money on additional equipment or supplies. Going forward, in an effort to further increase ADC utilization rates, a budget request has been placed to add auxiliary cabinets for additional storage on the patient care units. It is also felt that having a staff member routinely monitor ADC stock will also help dispensing efficiency. The optimization project has helped to align a required residency project with my leadership interest. The project has allowed me to work directly with pharmacy leadership, nurse managers, as well as front-line pharmacists and technicians. The project has allowed me to gain a better understanding of hospital operations and how something as simple as adding a few medications to ADCs can have major impacts on pharmacy workflow. I have also gained a new appreciation for working on a longitudinal project, as this was the first time I was involved in a project of this magnitude. Overall, I have greatly enjoyed the project, and I know that going forward I will be able to apply the experiences gained through this project to other projects that will present in the future. My advice for future residents selecting projects would be to select a project that is within your interest area. You will be dedicating a great deal of time to this project, and it is something that you should enjoy. Do not be afraid to ask many questions initially and be a bit skeptical about whether the project will have significant contributions. Initially, I started with a different project relating to patient care in our emergency department. However, after several brainstorming sessions with the principal investigator and other clinical staff, it was determined that the project was not appropriate. Completing the project as described above actually worked out better because I know that my project will have great contributions to the hospital for years to come.

Tony Rudisill, PharmD, MBA, a 2016 graduate of Wingate University School of Pharmacy, is a Pharmacy Practice Resident at The University of Texas Medical Branch in Galveston, Texas. Dick Cason, MS, RPh, is the Administrative Director of Pharmacy, The University of Texas Medical Branch in Galveston, Texas. Regina L. Ramirez, PharmD, BCPS, is the PGY1 Pharmacy Residency Program Director and Clinical Practice Specialist – Solid Organ Transplant and VAD Programs, The University of Texas Medical Branch in Galveston, Texas.

References:

(1) Pedersen CA, Schneider

PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011. Am

J Health Syst

Pharm 2012;69(9):768–85. doi: 10.2146/ajhp110735.

(2) State of Pharmacy Automation. August 2015.

Pharmacy Purchasing and

Products. Vol 12(8): 72-76

(3) O’Neil DP, Miller, A., et al. A comparison of automated cabinet methods.

Am J Health System Pharm 2016; 73:e400-e405. doi:10.2146/ajhp150423