Finding an Opportunity to Advance Pharmacy Practice During a Pandemic

The COVID-19 pandemic caused by SARS-CoV-2 spread rapidly throughout the world, with more than 33 million reported cases leading to over 2.2 million hospital admissions. Similar to many countries around the world, the health care system in the United States was stretched to its limit.¹

Like many health care providers, pharmacists have been on the frontlines throughout the pandemic providing much needed support to a strained health care system.²

The COVID-19 pandemic has led to significant health care innovation, ranging from the use of investigational therapies—such as the antiviral remdesivir³ and the interleukin-6 inhibitor tocilizumab—⁴ to the development of new antibody cocktails. Many of these novel therapies required robust monitoring to ensure safety and efficacy.

This presented a unique opportunity for pharmacists to advance pharmacy practice by serving as the integral drug monitoring experts of the health care team. Pharmacists have long been seen as the most accessible health care professional; however, the work of what we do in the inpatient setting is not always visible.

Documentation is a great way for pharmacists to demonstrate their impact in optimization of patient care.

As part of advancing patient-centered care, the American Society of Health-System Pharmacists (ASHP) Practice Advancement Initiative 2030 recommends pharmacist documentation to be available to all members of the health care team.⁶ Via documentation, pharmacists can demonstrate their decision-making in a way that is visible to the entire care team, assume accountability for drug therapy, and illustrate the value of having a drug expert actively involved in patient care.

To maximize the benefits of the pharmacist’s expertise, a robust training program needs to be established. The ASHP states that pharmacist documentation is a skill that requires ongoing training and evaluation.⁷

ASHP guidelines recommend developing a formal facility policy and offering appropriate training that includes training pharmacists on what and when to document. A study in the Canadian Journal of Hospital Pharmacy concluded that pharmacists were competent in documenting in a clear, concise, and understandable way, but may require additional training in the specific elements of the note, such as documenting drug related problems, pharmacokinetics, and patient education.⁸

Although pharmacists recognize the importance and benefits of documentation, there are also barriers. Pullinger, et al conducted a survey of pharmacists on their view of documentation in the medical record and concluded that common themes and fears were barriers to a successful program. These included fears of acceptance by other providers, criticism, and making the wrong recommendation in documentation leading to litigation.

The study investigators concluded that fears may be mitigated by additional training of pharmacy staff.⁹ To continue advancing practice, it is imperative for pharmacy leaders to develop best practices to help pharmacists overcome these challenges.

First, pharmacy leaders could leverage clinical pharmacy specialists to develop an education program aimed to increase knowledge and comfort level in communicating via the electronic health record. Interdisciplinary practitioners who are experienced in documentation could be leveraged in the development of documentation templates.

Second, a standardized, objective, and quantifiable competency assessment could be developed to assess the knowledge and skills that are taught. The assessment may also be used as a powerful tool to identify further opportunities for improvement.

Finally, it is equally imperative to develop a methodology to systematically quantify documentation as clinical interventions. This is crucial in demonstrating the clinical and financial impacts pharmacists have for the institution.

At Mount Sinai Beth Israel, as our hospital’s services became COVID-centered, there was an urgent need for therapeutic drug monitoring of remdesivir. In fact, the need was facilitated and championed by our physicians and leadership.

We identified this as a golden opportunity for our pharmacists to collaborate and assume a larger role in optimization of patient outcomes. As the drug specialist, pharmacists would be the best service line to provide a therapeutic drug monitoring consultative service.

Our vision included a program where pharmacists were responsible for monitoring relevant safety and efficacy parameters, evaluating available drug literature, and recommending patient specific care plans. Our management and clinical pharmacy specialist team held a strategy session to develop the framework for service.

We first focused on the development of a training program, in the form of live teaching and recorded training sessions, for the pharmacy staff. Recording the training sessions provided added flexibility as our clinical pharmacy specialist team was not available 24/7.

The training program included the use of bloom’s taxonomy to develop learning outcomes that guided us in the specific skills and knowledge that the pharmacists needed. Some of the examples included:

• Knowledge: identifying lab parameters that required monitoring.
• Comprehension: summarize patient lab parameters for analysis.
• Analysis: compare and differentiate relevant monitoring parameters and compare them to guidance provided by literature.
• Synthesis: develop a care plan based on the findings, and evaluation- recommend the plan in the form of formal documentation.

After delivering the training program to pharmacists, they were then given a competency assessment. The assessment evaluated their ability to build on the skills learned during the training and identified areas for further improvement.

We then initiated a pilot for a subset of patients with the goal of identifying and resolving inefficiencies in the workflow. After the pilot, the program was formally introduced and our workflow leveraged all pharmacists on our staff. This allowed them to document throughout each shift and provided a platform for pharmacists to directly participate in the optimization of patient care outcomes around the clock.

As the profession continues to adapt to the changing landscape of health care, it is imperative we identify opportunities where pharmacists may play key roles in optimizing patient care outcomes.

In a world that has been and continues to be challenged by the pandemic, we are confident that by leveraging the diverse skills of the profession, our future will be bright and our patients will be positioned to receive the best experience in health care.

References

1. CDC COVID Data Tracker. Centers for Disease Control and Prevention. Accessed June 2, 2021 https://covid.cdc.gov/covid-data- tracker/#datatracker-home.
2. Song Z, Hu Y, Zheng S, Yang L, Zhao R. Hospital Pharmacists Pharmaceutical Care for hospitalized patients with COVID-19: Recommendations and guidance from clinical experience. Res. Social Adm. Pharm. 2021; 17:2027-31
3. Beigel JH, et al. Remdesivir for the treatment of Covid-19 – Final Report. N Engl J Med. 2020; 383:1813-1826. DOI: 10.1056/NEJMoa2007764
4. RECOVERY Collaborative Group. Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet. 2021;397(10285):1637-1645.
5. Bhimraj A, Morgan RL, Shumaker AH, Lavergne V, Baden L, Cheng VC, Edwards KM, Gandhi R, Gallagher J, Muller WJ, O'Horo JC, Shoham S, Murad MH, Mustafa RA, Sultan S, Falck-Ytter Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. Infectious Diseases Society of America 2021; Version 4.3.0. Available at https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/. Accessed June 8, 2021
6. American Society of Hospital Pharmacists. ASHP practice advancement initiative 2030: New recommendations for advancing pharmacy practice in health systems.Am J Health Syst Pharm. 2020;77:113-122.
7. American Society of Hospital Pharmacists. ASHP guidelines on documenting pharmaceutical care in patient medical records. Am J Health Syst Pharm. 2003 Apr 1;60(7):705-7. doi: 10.1093/ajhp/60.7.705.)
8. Baranski B, Bolt k, Albers L, Siddiqui R, Bell A, Semchuk W. Development of a documentation rubric and assessment of pharmacists’ competency for documentation in the patient health record. Can J Hosp Pharm. 2017; 70(6):423-9
9. Pullinger W, Franklin BD. Pharmacists’ documentation in patients’ hospital health records: issues and educational implications. Int J Pharm Pract. 2010; 18:108-115. Doi: 10.1211/ijpp/18.02.0006