Karli Swartz, a fourth-year Doctor of Pharmacy student at Shenandoah University’s Bernard J. Dunn School of Pharmacy, had no idea how a five-week rotation at Johns Hopkins Bayview Medical Center in Baltimore would change her life.
She initially headed into the clinical rotation at the Johns Hopkins Bayview Medical Center thinking she would focus on pediatrics. However, that rotation had to be changed to a medication safety rotation with overwhelmingly positive repercussions.
“It was quite serendipitous,” said Isha John, Pharm.D, MBA, assistant director of clinical pharmacy services at Bayview, who remembers sitting down with Swartz and telling the student that it was a “bit of a unique rotation.”
Or as Bernard J. Dunn School of Pharmacy Dean and Professor Alan B. McKay, Ph.D., put it: “It was a typical rotation that turned atypical.”
Swartz participated in a pilot program, in which she reviewed the accuracy of medication lists entered by a nurse or other provider by interviewing newly admitted emergency department patients and/or family members, confirming allergies and verifying medications via a variety of sources, including pharmacies, doctor’s offices and insurance companies.
“It was such an eye-opening experience to see how many patients have no idea what medications they are taking,” said Swartz, a 24-year-old from York, Pennsylvania, whose mother is a consultant pharmacist for an independent pharmacy. “Without an accurate medication list on admission, there is no wonder there are so many adverse drug events in the hospital setting. This can be easily prevented if the time is taken at admission to find out this imperative information,” she said.
The pilot program advanced the idea that a “pharmacist extender,” such as a student pharmacist, could verify patient medication lists, said Dr. John, who noted that she is always impressed by the Shenandoah University student pharmacists who complete rotations at Bayview.
Each year of Shenandoah’s four-year pharmacy program incorporates experiential elements, but the final year is devoted to advanced pharmacy practice experiential rotations, according to Sarah Parnapy Jawaid, Pharm. D., vice chair and associate professor, Department of Pharmacy Practice, at the Dunn School of Pharmacy. During the fourth year, students go through rotations in a variety of areas, including community pharmacy, ambulatory care, administration/management, institutional/health-system pharmacy, inpatient acute care, drug information and medication safety.
In her Bayview medication safety rotation, which ran from Oct. 6 through Nov. 7, 2014, Swartz interviewed 188 patients, and found that 55 percent of them had at least one medication omitted from their history and roughly 45 percent had omitted over-the-counter medications, John said.
Swartz recalled one case in which a patient was admitted to the emergency department for a fall. The physician, who suspected inappropriate medications or duplicate therapies, asked for pharmacy assistance in gathering a medication history. After checking with the patient’s insurance company, it became clear the patient had used four pharmacies in two states. All that checking made a huge difference. “What began as a medication list with 16 medications quickly turned into a medication list of approximately 40 medications with many duplicate therapies,” Swartz said.
“While the decision to discharge the patient was made in the emergency department, this valuable information was compiled into a note in the patient’s chart and forwarded to the patient’s primary care doctor, so that medication reconciliation could be evaluated and completed as an outpatient,” she added.
It worked out so well that this pilot program was conducted with a student who is very driven and focused, said Ashley Martinelli, Pharm.D., who with John developed how the pilot project would work and became a mentor to Swartz during the rotation. Dr. Martinelli is the full-time pharmacist in Bayview’s emergency department, and she signed off on all of Swartz’s work.
Swartz brought an enthusiasm and excitement to her work and she “really wants to make a difference,” Martinelli said.
“The pilot program certainly changed my perception of pharmacy work,” Swartz said. “This was the first time I really felt like my interventions directly affected patient care and outcomes. After we compiled the data, it turned out that I made some sort of intervention on 76.1 percent of patients.” Swartz said that number reflects how inaccurate medication lists are when patients are admitted, simply because nurses and providers do not have the time to confirm each medication for each patient. “On average, it took me about 24 minutes per patient to complete the process from beginning to end. Nurses and providers simply do not have the time to devote to this process. As the medication experts, it really made me see how vital it is to have pharmacy department involvement in the admission process and the impact that pharmacy can have on patient care.”
Bayview’s emergency department is a busy one that often serves an indigent population. Martinelli said it typically sees about 55,000 patients per year.
Martinelli said she believes all hospitals are trying to wrap their heads around how to best compile the best medication histories for patients, particularly when a patient may not know their medication dosages or names, or even how to pronounce the names of the drugs they’re taking.
Overall, health care providers are interested in raising care quality and satisfying patients in more efficient, lower-cost ways, Dr. McKay said. Poor medication use research, in particular, is getting attention, because medication issues are often a cause of early readmission (less than 30 days) to a hospital, which now initiates financial penalties via the Affordable Care Act.
The impact of Swartz’s work, of course, extended well beyond Bayview. “The response from providers was unbelievable!” she said. “They were so grateful that someone was taking the time to provide them information about their patient’s medication. Since each medication was confirmed with reliable sources, the providers stated they felt like they were able to trust this compiled medication list versus the one entered originally.”
The pilot program made a difference in Swartz’s life, too. She spoke before Bayview’s executive council, which included the president and vice president of the hospital, about the pilot program and how it helped change her career path.
In January, Swartz began an administration rotation at Bayview, where she’s helping with a business plan to help justify high-level technician positions to conduct the same kind of work she piloted. “We are currently looking back at the data and figuring out how many of the medications were high alert medications that could have caused a serious adverse drug event,” she said in January.
John said Swartz is also helping with a pharmacy impact plan to show how pharmacists impact patient care through reducing readmissions and improving transitions of care for patients.
After her experiences at Bayview — Swartz also did internal medicine and anticoagulation clinic rotations there — she has “decided that a residency is most certainly the way I want to go after graduation.” She will experience two more rotations before she graduates: one will be back in her hometown at York Hospital, in ambulatory care, and her final rotation will be at Mercy Medical Center in Baltimore. “Although independent pharmacy is great, I feel like in the hospital, pharmacists can have such greater impact on patient care. I am currently in the process of applying to many different [residency] programs, including Bayview.”
John was hopeful Swartz would take the residency route, and said she believes that Swartz will be a wonderful pharmacist.
Contributed by Stephanie Mangino