Expansion of a Pharmacist’s Role in a Pediatric Ambulatory Clinic Setting at a Large Academic Medical Center
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Background: Texas Children’s Hospital (TCH) is a 658-bed pediatric hospital consisting of 45 ambulatory care clinics that receive 21,990 patient visits per month. The TCH infusion center administers roughly 900 high-risk medications per month for patients seen in endocrinology, allergy & immunology, GI & hepatology, and pulmonary clinics. Patients are scheduled for an appointment to the infusion center and their medication infusion plans are entered in advance by prescribers. Upon the day of patient appointment, orders from infusion plans are “released” by nursing staff for pharmacy verification and preparation. I would add more of a description that reveals that there is no real monitoring or pro-active review rather than the steps in patient appointments. Also add a hint of what is to come- the need for review prior to administration. Objectives: The primary objectives of this study are: 1) Develop specific monitoring parameters for high-risk medications commonly used in the infusion center 2) Create and implement a tool to evaluate appropriateness of orders (laboratory monitoring, dose, duration of therapy, post-infusion monitoring) 3) Identify financial risk and benefit for the organization through increased pharmacy presence in a high-risk, high-cost ambulatory setting servicing special populations. Methods: This is a single institution, retrospective analysis of pediatric patients 2 to 18 years of age treated at Texas Children’s Hospital Outpatient Infusion Center between September 15, 2013 and February 7, 2014. Patients were included if they received one of the following 5 identified high-risk medications in the infusion center: methylprednisolone, infliximab, immune globulin, methotrexate, omalizumab. Exclusions included patients > 18years of age and those not receiving any of the specific monitoring parameters for the selected drugs were developed. Additionally, 4-day pre-screenings of patients scheduled for appointments from January 6, 2014 through February 7, 2014 were performed by a clinic pharmacist. Therapy plans entered by physicians for patients in the EHR were utilized by the clinic-based pharmacist to prospectively review medications and make appropriate interventions. Data collection included the following parameters for high risk medications: • medication-specific monitoring labs • pre-medications • dosage • duration of therapy • post-infusion monitoring. Potential adverse drug events were collected from retrospective and prospective chart review. Data were collected on paper forms and results were transcribed into an electronic database. Estimated cost avoidance (ECA) of identified potential adverse events was quantified using methods from existing literature Results: Standard monitoring parameters for the following five drugs were developed: methylprednisolone, infliximab, immune globulin, methotrexate, omalizumab. Therapy plans entered by physicians for patients in the EHR were utilized by the clinic-based pharmacist to prospectively review medications and make appropriate interventions. Twenty-six interventions out of 206 total orders were made during a 1-month period. A retrospective review of 569 orders over a 3-month period revealed 55 inappropriate orders. Number of adverse drug events (ADE) found during the 1-month prospective review broken down by ADE category: labs – 12, dosage – 2, duration – 3, adverse drug reaction – 3, documentation – 6. A 1-month estimated cost avoidance of $3,164 was realized, extrapolated to $37,968 per year. Conclusions: Implementation of a pharmacist performing prospective reviews of patients scheduled for appointment in the infusion center using developed monitoring parameters contributed to estimated cost avoidance for the health system. Medical and pharmacy staffs were receptive of pharmacist’s prospective review and were actively engaged in reviewing changes based on interventions Tools utilized to perform this function will be further developed for future use through expansion of standardized monitoring parameters for other commonly infused medications and more seamless communication to providers about interventions.