Request for Emergency Department Pharmacist Program
Institution A
<Date>
Executive Summary
Pharmacy Service, in conjunction with Medical Service is requesting 4.6 Pharmacist FTEE to allow intensive pharmacy services in the Emergency Department 24 hours a day, 7 days a week. The additional full time pharmacists will simultaneously allow for improved patient safety via prospective review of ED and radiology as well as bring the Institution A into compliance with JCAHO and other regulatory codes and regulations. We do not believe the Institution A will be able to meet the Joint Commission standards without the implementation of this program. Additional benefits from this proposal include:
· Improving inventory/formulary regulation resulting in more effective budget management, improved streamlining of the ED workflow, as well as assuring an increase in patient safety within our system.
· Increased effectiveness of medication reconciliation via decreasing medication discrepancies through prospective pharmacist review in the ED where the majority of non-elective hospital admissions occur.
· Assisting in meeting Institution A established criteria goals.
· Provide a medication usage information source.
· Relieving ED staff of the additional burden of tasks preferentially handled by pharmacy staff.
· Expanding code blue coverage in the hospital.
· Minimizing the potential for costly litigation by decreasing overall medication errors in the ED.
· Increasing patient satisfaction and decreasing overall wait times while providing the highest quality of care for our veterans.
Through a review of published cost analysis literature analyzing the overall financial benefit of pharmacists in the ED it is estimated that the addition of these pharmacy positions will cost at the most approximately $100,000, however we believe that this proposal will come close to completely offsetting the additional cost incurred with the possibility of the Institution A realizing an overall cost savings. In addition, with the substantial increase in workload absorbed over the past several years without a compensatory increase in staffing, undertaking such a sizeable workload without additional FTEE would not be feasible.
ESTIMATED COSTS4.6 FTEE @ $104,000/FTEE annually / $478,400
Benefits (estimated at 30%) / $143,520
ESTIMATED SAVINGS
Savings range (see section II) / $586,500-863,800
Probable financial impact on Facility / (-$35,420) – 241,880
I. Background
Pharmacy Service, with cooperation, support and input from the Emergency Department (ED), is requesting 4.6 Pharmacist FTEE to institute a comprehensive ED pharmacist program. Below you will find a thorough analysis and justification detailing the reasons for these positions at the Institution A and the anticipated outcomes of the program. The 4.6 Pharmacists would allow intensive pharmacy services in the Emergency Department 24 hours a day, 7 days a week. This document will demonstrate that we believe we can do this at little net cost to the Institution A while significantly improving patient safety and compliance with Joint Commission and other regulatory requirements. It is not possible for Pharmacy Service to accomplish any of these tasks in any meaningful way without additional FTEE due to the continued increase in Pharmacy workload in all its sections and the resultant relative shortage of current staffing levels. We do not believe the Institution A will be able to meet the Joint Commission standards without the implementation of this program. We are asking that the RMC take action quickly on this request so that we can gain all the advantages of the program for optimizing patient care in the ED. The approval of this proposal is also timely for hiring of qualified pharmacists as a number of potential candidates will be ending their advanced clinical residencies at the end of June.
II. Cost Avoidance/Cost Savings Initiatives
The following studies evaluated the impact of pharmacy involvement in the ED. Although none of the studies were designed to assign direct mortality data from pharmacy involvement in the ED, they were able to quantify the number of interventions pharmacists made, evaluate which areas the pharmacists had the greatest impact as well as calculate projected total cost savings.
In 2002 Lee et al. evaluated 600 pharmacist recommendations at a 344 bed Institution A serving over 220,000 patient visits per year providing care to approximately 25,000 veteran patients. Using Institution A costs, pharmacist recommendations and their clinical and economic outcomes were evaluated. The mean cost avoidance per inpatient recommendation was calculated to be $1,057. The table below indicates the types of interventions and recommendations documented and the associated average cost avoidance (1).
Type of Recommendation / Average Cost avoided per recommendationProbable financial impact on Facility / (-$35,420) – $241,880
Drug interaction / $1,647
Prevent or manage drug allergy / $1,375
Adjust dose or frequency / $1,188
Untreated diagnosis / $1,106
Prevent or manage adverse drug event / $1,098
Drug not indicated / $724
Duplication of therapy / $165
A study by Lada et al. looked at pharmacist interventions in a 340- bed, university-affiliated, urban level-I trauma center for adult patients. In 2001, over 84,000 adult patients were seen in the hospital’s 100-bed ED. The ED reported 2,150 interventions in a 4 month period with a mean ± SD of 17.5 ± 1.43 within a 24 hour period. This extrapolates to a total of approximately 6,400 interventions per year. The most common interventions involved provision of drug information, dosage adjustment recommendations, responses to nursing questions, formulary interchanges, and suggestions for the initiation of drug therapy. A breakdown of the pharmacist interventions is shown below.
Category / No. Interventions (n = 2150)Drug information / 362
Dosage adjustment / 353
Nursing questions / 316
Formulary interchanges / 181
Suggest initiation of Rx / 180
Order clarification / 164
Change to alternative Rx / 157
Compatibility issues / 143
Patient information / 77
Change route of administration / 66
Discontinue drug therapy / 58
Toxicology / 43
Allergy notification / 40
Drug therapy duplication / 8
Drug interaction / 2
Cost avoidance during the 4 month study period was determined to be $1,029,776. Extrapolated to one year the total yearly cost avoidance totals $3,089,328. (2) It should be noted that the data presented by Lee and Lada were based on Institution A costs and thus provide the most accurate depiction of the impact pharmacy services may have on the Institution A ED.
Year / # of interventions / # of saving interventions / Cost savings ($) / Cost savings in 2007 dollars ($)1989 / 9,700 / 1,334 / 31,041.20 / 50,942.36
1990 / 15,770 / 1,464 / 54,007.09 / 84,088.67
1991 / 15,637 / 1,541 / 93,561.22 / 139,791.59
Ling et al. looked at pharmacist interventions in an ED at a large, urban, teaching institution that treats over 100,000 patients annually. A satellite pharmacy was open for 8 hours daily to support medication distribution, and a clinical pharmacist specialist was available for consultation and code response for an additional 8 hours on weekdays. The study documented 401interventions; the total cost avoidance estimated for these interventions was $192,923. This extrapolates to an annual cost avoidance of $463,015. The acceptance rate of pharmacist interventions by other health care professionals was 89%. The top five interventions captured were 1) switching from a non-formulary to a formulary preferred agent, 2) correcting a subtherapeutic dose or frequency, 3) correcting a supratherapeutic dose or frequency, 4) providing professional services, and 5) documenting allergies. The events most frequently avoided were suboptimal disease management, adverse drug reactions, and drug cost avoidance.(3) Levy conducted a separate study which reported cost savings calculated by pharmacist interventions in an emergency department from 1989-1991. Pharmacists were instructed to document all clinical interventions. The data was then compiled for each year and the results are shown below.
While analyzing total cost savings, the study calculated only material costs resulting from medication interchanges and adjunctive equipment. Additional cost benefit resulting from time saving interventions, decreased hospital stay and avoidance of adverse events and interactions was not taken into consideration with this study. This would likely result in a significant underestimation of total cost benefit from having a pharmacist employed in the emergency department. The author cited several examples where pharmacist presence in the emergency department had a positive impact on delivery of patient care in the emergency department via distributional, clinical, and educational services performed. The study concluded that pharmacist presence in the emergency department improved medication ordering, administration, and charting in addition to minimizing medication errors while saving almost $180,000 in medication costs over the three year period (4). In current dollars this represents a $275,000 savings in medication costs independent of the potential improvements that could be made to the present inventory management system.
Bates et al. assessed the resource utilization associated with an ADE (adverse drug event). Among the 4,108 admissions to medical and surgical units analyzed, 190 ADEs were documented, 60 of which were preventable. The ADEs were associated with a mean additional length of stay of 2.2 days and an average increase in cost of $2,595 per event. For preventable ADEs the associated increased length of stay was 4.6 days with an increase in cost of $4,685 (5).
Senst and colleagues performed a study in which one of the goals was to analyze data from multiple hospital admissions and project costs of ADEs occurring after admission and resulting in admission. Data was collected from a healthcare system comprised of a 383-bed tertiary care facility; a 60-bed Mental Health Center, an 84-bed Children's Psychiatric unit, and a 30-bed facility for children with disabilities. The estimated ADE rate during hospitalization was 4.2 events per 100 admissions, with a cost of $2,162 per ADE. In addition, 3.2% of admissions were caused by ADEs, with an associated cost of $6,685 per event (6). Based on the study, 15% of hospital ADEs and 76% of ADEs causing admission were judged preventable.
A retrospective study by Beers et al. sampled 424 randomly selected adults seeking care at a university-affiliated 24 bed hospital ED that sees over 37,000 patients per year. Among patients who received medications at the ED, they found a 10% rate of exposure to what were considered clinically relevant potential ADEs. Upon reviewing patient charts, there was little indication that physicians were aware of the potential for adverse drug reactions (7).
Data published by Leape et al., which addressed the pharmacist’s impact at the time of prescribing, showed that the active participation of a pharmacist during clinical ICU rounds was associated with a 66% reduction in ADEs with respect to baseline (from 10.4 to 3.5 ADEs per 1000 patient-days), with no change in the incidence of ADEs being noted in the control group. These outcomes were achieved with a clinical pharmacist being available in the morning on rounds and by consult thereafter (8).
Our proposal allows for an onsite pharmacist to participate in all ED admissions around the clock, while also serving to actively process and deliver medications, control medication inventories, and assess progress and outcomes of therapy as part of the ED team. The majority of the studies reviewed implemented programs that provided service support for less than 24 hours, suggesting that our 24 hour program should result in further benefits relative to those reported.
Assigning monetary value to the individual patient care contributions made by a healthcare provider is challenging and represents a barrier in accurately determining the true fiscal impact a pharmacist’s contributions may have on a service. Studies addressing the drug-related morbidity costs and drug cost-avoidance are thus important in developing accurate estimations of the dollar value of the ED pharmacist program. A model developed by Ling et al. combined study outcomes from both cost-avoidance and drug-related morbidity studies. Interventions were stratified into 6 levels in an attempt to categorize the impact of each intervention. The table below provides an example of the average cost savings of each type of intervention (3).
Unit type / Cost per eventMedical ICU / $3,369
Surgical ICU / $5,097
General Medical / $2,738
General Surgical / $1,772
Total avg. / $2,595
Outcomes of ED Interventions by Pharmacists:
Adapted from Ling et al
Level / Cost Avoidance / Explanation / Category / Cost ($)1a / Information inquiry (≤5 min) / Verbal info / Drug info / 26.17
1b / Information inquiry (>5 min i.e. oral/written presentation) / Verbal info with presentation and/or articles / Drug info / 54.89
2 / Dosage adjustment, formulary/restricted medication, IV/PO switch, therapeutic duplication / Drug cost avoidance / Drug cost avoidance / 30.35
3a / Additional treatment / Medications, aerosolizations, transfusions, oxygen / Avoidance of additional treatment / 260.46
3b / Additional tests / Chemistry panels, CBCs, drug concentrations etc. / Avoidance of additional treatment / 109.00
3c / Noninvasive procedure, additional tests / CT, angiography, ECG, Doppler, EEG, ECHO, MRI, CXR, PFT etc. + 3b / Avoidance of additional treatment / 320.70
4a / Additional treatment and additional tests / 3a+3b / Avoidance of additional treatment / 370.04
4b / Noninvasive procedure, additional treatment, and additional tests / 3a + 3c / Avoidance of additional treatment / 581.75
4c / Increased length of stay or admission from med. related problem + 4b / Daily room rate + 4b / Avoidance of additional treatment / 3,562.79
4d / Invasive procedure + 4c / Cath, MI perfusion studies, PTCA, surgery, dialysis, pericardiocentesis + 4c / Avoidance of additional treatment / 6,437.13
5a / Transfer to ICU + 4c / ICU bed, art line, Swan-Ganz, intubation, cardiac arrest + 4c / Avoidance of additional treatment / 6,592.03
5b / Transfer to ICU, invasive procedure + 4c / Invasive procedures + 5a / Avoidance of additional treatment / 9,466.36
5c / Long term care admission + previous / Self-explanatory / Avoidance of additional treatment / 11,837.51
6 / Death / Self explanatory / Avoidance of additional treatment / 100,000
Based on the model above and the cost avoidance data presented by Lada et al. (2) it can be estimated that a pharmacist staffed ED that sees 8-9 acutely ill patients daily will realize savings of $6,428 -$9,465 per 24 hour period relative to an ED that does not employ the service of a clinical pharmacist. The presented range of savings was calculated by multiplying the lower and higher average costs of an individual ADE ($400-500) by the average number of ADEs reported daily +/- the standard deviation (17.5+/- 1.43). The value of an individual ADE was extrapolated from the Ling et al. data. A conservative extrapolation of these numbers to our facility suggests that a more moderate recovery of resources would likely offset the $620,000 invested into salaries (including benefits) for 24 hour ED coverage by a pharmacist. For example, if both the number of patients seen daily and the savings per intervention are reduced by 50%, a savings of $586,500-863,800 is still attainable. This implies that it is beneficial from both a resource investment and patient outcome perspective to implement such a program within the Institution A facility.