A retrospective review of cases throughout the first year of the policy’s implementation was conducted, including interventions made between 1 February 2012 and 31 January 2013. Cases were identified through the required email notification of the auditing clinical pharmacist. The patient’s electronic medical record for that defined visit was reviewed. To assess pharmacist utilization patterns, data captured included the agent involved in the intervention, date, day of week and shift, whether the pharmacist was centralized or decentralized, and whether that pharmacist was classified as staff or clinical. Decentralized pharmacists were defined as a pharmacist working on the patient care unit with direct access to other practitioners and patients, rather than those performing their functions from within the confines of the pharmacy department.
Prescribers were described both by status (ie, attending or resident/training) and specialty. Physician acceptance was assessed through evaluation of order trends as the electronic medical record allows for all changes to an order to be audited and tracked; a review of progress notes to capture any commentary or rationale regarding interventions or the surrounding circumstances; as well as a review of any associated laboratory or diagnostic reports and nursing notes. If the order was not altered by the physician within 24 hours (ie, the time frame in which orders must be reviewed by the prescriber per institutional standards) of the pharmacist’s protocol change it was deemed accepted by the physician. Changes made within 24 hours for clinical reasons unrelated to the protocol change as verified by documentation in the progress notes were considered as accepted. These included, for example, the discontinuation of empiric antibiotics that had been dose adjusted by the pharmacist for patients in whom infection had been ruled out or a change from the adjusted agent to one of another class (such as might occur during de-escalation of antibiotic therapy). Interventions were excluded if there were insufficient patient and/or intervention details to allow complete assessment.
For protocol evaluation, details concerning the nature of the adjustment were collected. For formulation changes, agents were classified by their bioavailability. Renal dose adjustments were classified by the patient’s estimated creatinine clearance range since interventions were not restricted to ranges or agents. Stress ulcer prophylaxis adjustments were classified as those involving initiation, changes or discontinuation of therapy. For parenteral product adjustments, the initial and final base solution and/or the change in concentration was captured. Pain management order adjustments were classified as those involving the same agent with overlapping indications or those with oral and intravenous orders for the same pain scale range. When laboratory tests were ordered, the type of test was captured.
The study was approved by the institutional review boards of Princeton HealthCare System and Rutgers.
Results
There were 145 interventions occurring between 1 February 2012 and 31 January 2013, with 144 (99.3%) of those being accepted by the prescriber. The 1 intervention that was not accepted involved an IV to oral conversion of levothyroxine. The pharmacist performed the conversion appropriately as the patient was tolerating other oral medications. However, on the day of the change, the patient refused all oral medications despite having the ability to accept them and, as a result, all medications were converted back to parenteral formulations.