Expansion of the Anticoagulation Center through Increased Utilization of Outpatient Pharmacists

Background: Over 2,300 patients were seen in the Harris Health System for anticoagulation management in 2012. Due to high patient volume and limited appointments, many patients cannot be seen in a timely manner. Efforts have been made to increase anticoagulation visits, such as increasing the number of appointments for clinical pharmacy specialists (CLPS). Also, a telephone management service was established for clinical staff pharmacists (CSPs) to provide anticoagulation management. Objective: The primary objective is to assess the total number of visits per month before and after increased pharmacist utilization. Secondary objectives include time to 3rd available appointment, proportion of patients in therapeutic range at 30 days, and 30 day readmission due to anticoagulation adverse effects pre and post intervention. Methods: Prior to the initiation of the study, Institutional Review Board (IRB) approval was obtained, along with a waiver of informed consent. This is a retrospective cohort study using a quasi-experimental design. To be included in this study, patients must have been seen by the clinical pharmacy specialist. The data will be collected from the time period of October 1, 2011 to April 1, 2014 for four clinics within the Harris Health System. In addition, a secondary analysis will evaluate productivity for the CLPS by evaluating the number of completed publications and projects pre and post intervention. We will also evaluate the pharmacy productivity standards per month for the four piloted clinics pre and post intervention for CSPs. Results: Piloted clinics increased anticoagulation visits from 134 patients to 143 patients monthly. However, this result was not statically significant. Time to third available appointment decreased from 12 days to 7 days, which was not statistically significant (p=0.03). This was due to a noted statistical decrease at the Northwest Clinic. No changes in time in therapeutic range and readmissions were noted. No difference was noted in clinics based on productivity, which was defined as work hours over prescription volume. In addition, no difference was noted on amount of projects completed by CLPS. Conclusions: Results show increase access to care during the post intervention period. However, visits did not increase as predicted. Time to appointment and high quality clinical outcomes were maintained. More research should be completed to further evaluate expanding coverage through the use of CSPs.Pharmacy, College o

Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing.

OBJECTIVE: Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS: This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS: Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p \u3c 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p \u3c 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p \u3c 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION: Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS