During the approval process, physicians inquired whether all pharmacists were equally capable of making the clinical judgments involved with the protocols as described and, thusly, whether protocol management should be limited to clinical pharmacists who have less traditional dispensing roles and more experience and time at the bedside. During those discussions we contended that the nature of these protocols were fundamental and applicable to all practicing pharmacists and, if limited, would result in missed opportunities as the clinical pharmacists are focused in specialized areas during weekdays only at UMCPP. For example, a single, centralized night-shift pharmacist could make routine dose or formulation adjustments without the need to awaken a physician as the UMCPP electronic medical record makes available all progress notes, laboratory results, and diagnostics crucial to clinical decision making. All pharmacists, regardless of job title, meet the same requirements for licensure. Post-doctoral residency or fellowship training and advanced certifications in specialty areas of practice exist among both groups as well. The study results support the validity of this argument. The majority of interventions were successfully performed by staff pharmacists with involvement from all shifts, including a third that occurred overnight. This is important because, like at most hospitals, the UMCPP staffing ratio decreases throughout the course of the day presenting changing workflow challenges throughout different shifts.
Several limitations of this study should be noted. Due to its retrospective nature, it is likely that not all interventions were captured. Some decentralized pharmacists reported not emailing interventions as they had verbally communicated the adjustments prior to having the opportunity to send the email. Four interventions could not be assessed as the email notification did not contain all the required patient identifiers or intervention information to permit for appropriate evaluation. The hospital also moved to a newly built facility in the fourth month of protocol implementation, which required significant changes in drug distribution methods, and this could have contributed to the small sample size of interventions. The move temporarily shifted departmental resources to support operational needs.
Another important factor is the voluntary nature of the policy; while it was within the pharmacist’s professional judgment to apply the protocols, pharmacists were encouraged to contact prescribers if there was any ambiguity. Therefore, while one might have expected more resident physicians to be involved with orders that were adjusted, the UMCPP practice philosophy supports contacting training physicians about changes so that they may learn from the discussion to support developing stronger prescribing habits. Future development should therefore support more universal protocol application to all eligible patients to optimize the benefits described here. Lastly, data measuring the clinical outcomes and time savings or increased productivity secondary to the elimination of physician phone calls was not directly measured. We thus sought to first demonstrate to the physician base that pharmacists could successfully apply a variety of protocols that were broader than those formally studied with equal accuracy. With that effectiveness established, future studies should explore if broader protocol application produces a greater optimization of outcomes.
After the study was completed, a survey was conducted of the pharmacists to assess perceptions and guide further policy development. We received a 63.6% response rate (14 of 22 possible respondents) with a strong majority of the respondents expressing a favorable perception of the protocols. A few respondents indicated some protocols were infrequently utilized and there was limited familiarity with others. We anticipate this is largely based on various shift and unit assignments that would make some protocols more applicable than others to the populations serviced. One of the survey questions polled the respondents on the necessity of the email notification to the prescriber given that this practice is of a higher level of notification than other established hospital protocols which only requires a notation of the change within the medication order. Seventy-one percent ( n = 10) of respondents favored removing the email notification, citing primarily that it would be consistent with physician comments regarding the existing notifications. Pharmacists also identified further areas of protocol development including electrocardiogram ordering for QTc monitoring, implementation of a standardized vancomycin dosing protocol, discontinuation of duplicate orders, product substitution for nonformulary items and addition of a protocol for pharmacists to order over-the-counter or nonprescription products as they would in a community setting. This input will shape the revision of the policy and its protocols.