Pharmacists deliver MTM through decentralized services

Zipperlen uses education, collaboration to make a difference for patients, families

Carl Zipperlen, BSPharm, began working as a clinical pharmacist at South Nassau Communities Hospital in Oceanside, NY, in 1994. Back then, the pharmacy department was primarily distributive, and pharmacists answered medication questions on an as-needed basis. Several years ago, Zipperlen spearheaded efforts to make pharmacy a more clinically oriented department.

Today, through a remarkable metamorphosis based on medication therapy management (MTM), the pharmacist’s role at South Nassau has greatly expanded. The hospital boasts a team of unit-based pharmacists who spend their time rounding on hospital floors with multidisciplinary groups. “The sky’s the limit as far as having pharmacists up on the units,” said Zipperlen. “We get to practice pharmacy as we’ve always dreamed about. This is what we went to pharmacy school for.” Zipperlen also launched several programs where pharmacists are deeply entrenched in educating patients and their families about asthma, diabetes, and other disease states. “We looked for any opportunity to make our way in to do patient education,” he added.

A typical day for Zipperlen includes unit rounding, providing drug information, performing patient profile reviews, communicating with the various health care disciplines, working closely with pharmacy staff, and interacting with patients. “Unit-based rounding has allowed us as pharmacists to have an open field to go in and speak with patients about any number of things,” said Zipperlen. “We go into a patient’s room and we’re able to clear up any concerns about taking a particular medication, formulary issues, or medication changes.”

Carl Zipperlen, BSPharm, discusses a patient with Lynn Bert, RN, Nurse Manager Pediatrics.

Rounding with the team

South Nassau, a 435-bed acute care facility on Long Island, has provided care to patients for more than 80 years. The pharmacy staff includes 13 full-time pharmacy technicians, 18 full-time pharmacists, and 4 part-time pharmacists, one of whom works in the evenings in the emergency department (ED).

Possibly the biggest transformation in pharmacy practice at South Nassau began in 2007. Under the leadership of Edward R. DeLucie, BSPharm, MBA, Administrative Director of Pharmacy and Respiratory Care at South Nassau, pharmacists began rounding on different units beginning with the ED, followed by the critical care units and a medical–surgical unit. Last year, DeLucie set up a trial of a pharmacist in the hospital’s labor and delivery unit. “We think of ourselves as a quarterback when we’re up on a particular unit,” said Zipperlen. “We have the physicians right there, the patients are right there, and the nurses are right there, so from a communications standpoint, you can’t beat being on the unit.”

DeLucie originally thought to dedicate a particular pharmacist to an assigned unit. “We started with the notion of having a specific pharmacist for ED, and when that person was off, we would have another staff pharmacist cover. We did same thing for critical care,” explained DeLucie. “Then we started cross training and having pharmacists cover each other’s areas. It was more satisfying for pharmacists not to be pigeonholed to a particular unit. Now we have seven full-time day pharmacists who cover various units.”

Interdisciplinary interactions are enabled by decentralized services set up by the South Nassau team, led by Edward R. Delucie, BSPharm. Here, Zipperlen and critical care pharmacist Keri Danaher, BSPharm, talk with Tricia Santaniello, RN, on the floors of South Nassau.

Unit-based activities

As multidisciplinary team members, pharmacists can make recommendations as medication orders are being written to make sure that patients are getting the right doses, resolve any drug interactions, and ensure that the medication reconciliation process is being handled properly. “The physicians love it because as pharmacists, we identify things that we’re able to fine tune and focus on. A prescriber or a physician has a million and one things going on and doesn’t always look at [a situation] from the particular angle of a pharmacist,” said Zipperlen. The nurses are also supportive of having pharmacists on the units. “The nurses love it because right then and there we can talk to them about compatibility issues, [adverse] effect issues, and administration issues,” he added.

Christian Brickner, PharmD, CDE, is a unit-based pharmacist at South Nassau. “It’s all a matter of building relationships by getting into the mix of things, and [the benefit] of being on a unit is that you are taking care of a problem at the cause, not 3 hours later,” he said.

Brickner recently met with a patient who was recovering from joint replacement surgery. One look in her eyes told Brickner that the patient was in severe pain. Being up on the unit allowed Brickner to make immediate changes to the patient’s medication to get the pain under control. Once the pain was tolerable, Brickner was able to counsel the patient about her medications and the recovery process.

Keri Danaher, BSPharm, is a pharmacist who rounds with the multidisciplinary teams at South Nassau’s critical care units. “We have the opportunity to offer suggestions to improve patients’ therapy,” she said. “It’s a good way to learn the whole picture of the patient. We see everyone’s input from different angles and it can make a difference in outcomes.”

Face-to-face interactions help Christian Brickner, PharmD, CDE, provide the best possible MTM services to patients with diabetes.

Patient, family education

In addition to integrating pharmacists into hospital units, Zipperlen was instrumental in expanding South Nassau’s patient and family medication education efforts. To increase the number of patients vaccinated and dispel vaccine misconceptions, Zipperlen began including vaccine counseling and education as part of his rounds in 2004. In 2007, he launched a successful pediatric asthma education program. “It can be overwhelming for parents to bring a young child to the hospital for breathing difficulties and keep track of new medications,” said Zipperlen, who takes great pride in speaking to children with reactive airway disease and to their parents.

Zipperlen starts by reviewing the patient’s chart. He then talks to the child and the parents about asthma, common triggers, and ways to avoid these triggers. He also provides education about control medications versus rescue medications, explains how to administer medications, and highlights possible adverse effects. “Quite often we are able to identify either a common household trigger or an issue with a medication that is not being administered correctly,” said Zipperlen. “We as pharmacists are able to spend time with these families, and I consider it quite rewarding to see them leave [feeling] a little more relieved.”

In 2010, Zipperlen launched a robust diabetes education program. “We [realized] that many patients with diabetes were not receiving the optimal treatment, not only on the outside, but also inside the hospital,” he said. Zipperlen and his team identified opportunities for improvement in areas such as the use of oral agents for patients in the hospital, the timing of blood glucose monitoring to better coincide with patient meals, and enhancing staff knowledge of current recommendations for treatment options for patients with hypoglycemia.

Zipperlen and Brickner became part of a multidisciplinary committee that included an endocrinologist and a dietitian, as well as nursing, performance improvement, and laboratory staff. The committee created a standardized order form called Adult Subcutaneous Insulin Order Form for Patients Who Are Eating. The order form allows health care providers to write a brief description of the weight-based insulin requirements for patients with type 1 and type 2 diabetes, and it has boxes that can be checked for a prandial short-acting analogue and a basal insulin.

A predefined correction dose and custom dosing algorithms were also created. Blood glucose monitoring may be recommended when necessary, and a process was developed to ensure that patients receive prandial insulin in accordance with meal trays. “We also decided that pen administration of insulin would be more beneficial to the patient, as opposed to drawing up from a vial. This led to us getting our short-acting analogue in a pen,” said Zipperlen, who admitted that this has been a most challenging project to date at South Nassau. “Between reluctance from prescribers and patients alike, we as pharmacists have our work cut out for us,” he added.

Zipperlen and his colleague, Brickner, also provide diabetes education. “If we can change our insulin regimens to be proactive instead of reactive, avoid oral agents while in the hospital, and give patients an education that will help them for years to come, I think that we will see a positive trend for in-house glucose values, as well as [fewer] readmits for diabetic complications,” explained Zipperlen.

Patient education is a key component of MTM care at South Nassau. Danaher talks with a patient about her medications.

The results

According to DeLucie, Zipperlen’s efforts have created more opportunities for pharmacists to provide patient education than ever before. “For us, patient education has never just been about discharge counseling. It’s any nook or cranny that we can get ourselves into, from the time the patient gets here until the time the patient leaves,” he said. In 2010, only 19 patient and family education occurrences were documented by pharmacists, but the numbers have been rising steadily with the launch of new education programs. In 2011, 498 education occurrences were documented; 289 occurrences were already documented as of April 2012. “We also recently added an additional component to patient and family education with the inclusion [of pharmacists] as the primary discharge medication educators for patients undergoing total joint and total hip surgeries,” said DeLucie.

Although the numbers are encouraging, the pharmacists at South Nassau Communities Hospital measure their success by helping as many patients as they can. “The best part about my job is going into a patient’s room and leaving feeling like an actual difference was made because of something I did as a pharmacist. I also really enjoy when a physician is thankful when we convey information to them that they didn’t readily know,” he said. “I enjoy that too, but not quite as much as helping a patient out.”

For DeLucie, it is rewarding to hear about the pharmacy team’s successes. “It is satisfying to see that we’re becoming accepted and very much sought after,” DeLucie said.