When Wilson Chu, PharmD, and his wife Evelyn, who is also a pharmacist, moved to Las Vegas to work at Sunrise Hospital and Medical Center in 1990, he became part of a transformation that brought pharmacists closer to the patient bedside. At the time, pharmacists were accessible to the physicians and the patient care team but were closely tied to conventional distributive tasks such as dispensing, checking carts, and verifying the work of pharmacy technicians. Chu, who is now Director of Pharmacy Services at Sunrise, overhauled the pharmacy department by implementing new technologies and integrating pharmacists throughout the medical center. “The move to adopt automation technologies allowed us to maximize efficiency while improving the accuracy and consistency of the medication distribution process,” Chu told Pharmacy Today. “As pharmacists moved away from the traditional role of dispensing, the opportunity to expand clinical functions became a reality.”
Chu began by modifying the existing pharmacy system to improve workflow. He was responsible for the launch of the hospital’s first pharmacy system integrated with the house-wide computerized health information system and assisted in an initiative to employ unit-based automated dispensing cabinets. He was a member of the visionary management team that directed the installation of a pharmacy robot nicknamed “D. Spenser,” medication carousels, and various other high-tech components. He was the pharmacy lead for the implementation of the bedside bar code medication administration system in 2001.
Over the years, the adoption of automation and technology, along with the development of new collaborative and clinical programs, profoundly changed how pharmacists spent their time. Pharmacists transitioned from a narrow centralized function to a wider clinical role that spanned the entire hospital. “We have a culture of ‘never say no,’ which I believe is the key to our success in everything from adopting new technologies to improving workflow processes,” said Chu.
Implementing new technologies at Sunrise required more than simply installing sophisticated machines. As computer programs and robotics took over routine tasks, pharmacists began to dedicate more attention to clinical issues, patient counseling, and medication management. Chu helped develop training modules so that pharmacists could improve and certify their competency as their functions became more focused on the delivery of evidence-based pharmaceutical care.
Chu believes that preparing the pharmacy staff to transition to their expanded clinical role was critical to the department’s success. “We created ‘homegrown’ certification programs in clinical nutrition and pharmacokinetics, for example, to provide structured training [for pharmacists],” he explained. “[The programs] also helped raise the level of confidence for the staff [who were] certified through the training program.” To elevate competencies of the pharmacy technicians, Chu and his team made Pharmacy Technician Certification Board (PTCB) certification a minimum qualification in 2004. “Amazingly, encouraged and assisted by pharmacists volunteering to conduct review courses, all technicians became certified by the deadline. It was a motivational moment for us all when the last batch of technicians received the notification from PTCB,” he said.
As Las Vegas’s largest acute care facility, Sunrise has a dedicated group of clinical pharmacists and pharmacy technicians who are fully integrated throughout the hospital. “There is a constant demand for the expertise of the clinical pharmacist in almost every aspect of the provision of care to our patients,” said Chu.
Clinical pharmacists typically manage a heavy clinical consult load in addition to other responsibilities; for example, pharmacists participate in medical ICU rounds, make recommendations about drug therapies, and address the needs of critically ill patients. Pharmacists also round with the trauma team, which comprises physicians, nurses, a case manager, a clinical dietitian, a physical therapist, an occupational therapist, and other personnel. Pharmacists discuss new patients, medications, patient progress, and future treatment plans for trauma patients. Pediatric clinical pharmacists are based at the pediatric satellite pharmacy and often assist at the patient’s bedside.
Sunrise has an aggressive inpatient clinical program in which physicians routinely consult pharmacists on the dose of nearly all medications. “Once patients are placed on the consult list, pharmacists follow the patient while [he or she is] on the medications [and] make recommendations and dosing adjustments as needed,” explained Chu.
Pharmacists also collaborate across the hospital’s management infrastructure. Each month, pharmacy clinical specialists prepare and present formulary class reviews to the Pharmacy and Therapeutics (P&T) Committee for approval. In April 2012, for example, Julie Squires, PharmD, a clinical specialist, collaborated with Theresa Ortega, CPhT, a pharmacy inventory control and resource coordinator, to review the 12-month usage and purchases for drugs in the penicillin class for the pediatric and adult patient populations.
Squires consulted with the pediatric pharmacists at Sunrise Children’s Hospital to make sure that any special pharmacotherapy needs for pediatric and neonatal patients were considered. They also met with the microbiology lab staff and ran their review past infectious disease physicians before presenting the full report to the P&T Committee. Squires and her colleagues, clinical specialists Kim Ly, PharmD, and Kim Conrad, PharmD, also present medication usage reviews and other reports such as formulary additions and formulary interchange proposals to the P&T Committee.
Presentations made by pharmacists have received “positive feedback and approval at the committee level … [which] helps streamline formulary inventory management, physician medication ordering, order processing by the clinical pharmacists, and ultimately improves our ability to deliver cost-effective pharmaceutical care to our patients,” said Chu.
If an important clinical matter comes up, such as a new agent or a formulary change, the pharmacists will often develop a Medication Safety Tips (MST) document, a bulletin published for hospital-wide distribution. The editorial team for MST includes Pharmacy Manager Katie Gillson, PharmD, and Pharmacy Clinical Supervisors Kathryn Craven, PharmD, Luis Curras, BSPharm, and Donald Fey, PharmD.
Another important aspect in the evolution of pharmacy at Sunrise was the launch of a successful clinical intervention program to document the clinical pharmacists’ work. “Recommendations made by clinical pharmacists as a result of intervening on rounds are documented … [and] entered in the clinical intervention [program],” which compares and tracks individual clinical interventions made by pharmacists, Chu said. In the early days, a “clinical intervention of the month” was routinely celebrated to keep up the positive momentum; that tradition continues today. Now, the clinical intervention program is completely standardized in terms of data collection and reporting, which helps Sunrise’s pharmacists meet the increasing demand for their skills and expertise.
The success of the program is demonstrated by the incremental growth in the number of interventions each month since the program was launched. An analysis of the interventions by category and the number of interventions entered by the pharmacists is presented to the P&T Committee on a monthly basis. The clinical intervention and cost-saving data are shared at the individual, departmental, and facility levels. “Physicians and hospital staff are more aware of the work of the clinical pharmacist through the monthly clinical intervention reports,” Chu remarked. “Interestingly, the clinical intervention program, along with other patient safety initiatives, correlate with a reducing trend for adverse drug events reported year over year.”
Chu and his clinical pharmacy team are engaged in several major technology expansion projects in 2012, including going live with computerized provider order entry (CPOE) in the fall. “This project involves a nearly complete redesign of the pharmacy module … and will change how medications are ordered by the physicians and verified by the pharmacists,” explained Chu. CPOE will offer the entire staff at Sunrise the opportunity to standardize the use of medications.
Chu anticipates that problems related to paper chart orders, such as legibility, use of abbreviations, and timing or dating, will be greatly minimized once the CPOE system is up and running. “Clinical pharmacists will receive training to look at computerized orders differently than paper orders to ensure [that] the medication ordered is appropriate for the condition and applicable [to the] pharmacokinetic parameters of the patient,” Chu told Today.
Discussions are under way to establish how pharmacist interventions and verbal and telephone orders will be handled in the new system. Because Sunrise’s clinical pharmacists began using computer order entry well before 2000, “their experience and role in building the new system will be a tremendous asset to the physicians,” said Chu.
Other projects in development this year include a formulary standardization project, a hospital-wide conversion of automated dispensing cabinets to a new vendor, standardizing I.V. concentrations for the pediatric and neonatal departments, and updating smart pump datasets. The Sunrise pharmacy team is also in the final phase of a multistep antimicrobial management program, which will allow the team to monitor antimicrobial cultures to identify and recommend targeted therapies, streamline antibiotic regimens, and determine the appropriate duration of antibiotic treatment. “Normally, just one of these projects would require the full dedication of all of our clinical and management resources,” said Chu. “Once again, the staff is rising to the challenge by prioritizing and volunteering their expertise to take on important roles to ensure that these projects stay on track.”
For more than 20 years, Chu has worked tirelessly to implement new technologies and develop clinical programs so that pharmacists can take on a greater role as key members of the patient care team. “This is achieved by continuing to automate distributive functions and by taking advantage of the education and training of our staff pharmacists and technicians,” he said.
The adoption of automation and patient safety technologies continue to be a significant factor in shaping how pharmacists spend their time at Sunrise. “I encourage exemplary performance [by] involving the staff in the decision making process, by acknowledging their contributions, [and by] measuring and celebrating key successes. I am confident [that] the department will always be able to achieve its goals, given that we have the best pharmacy staff a director can possibly have,” said Chu.