Impact of a Unit-Based Clinical Pharmacist on Communication of Medication Information in an Orthopedic Hospital

Abstract

Background

Medication management, a complex yet essential part of patient care, requires that clinicians and patients understand indication, dosage, frequency, and adverse effects in order to maximize benefits and minimize errors, as well as to transition patients from hospital to home. Clinical pharmacists improve care transitions and safety by interacting with patients, prescribers, and nurses on medication management and self-care. However, little is known on the use of clinical pharmacists on interdisciplinary teams at the unit level within orthopedics.

Questions/Purposes

This study sought to measure the impact of unit-based clinical pharmacists on patient perceptions of communication specific to medication during hospitalization at an orthopedic specialty hospital and on the frequency of medication errors.

Methods

A retrospective, quasi-experimental, two-group evaluative design with nonequivalent controls was used. Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data on six inpatient units was analyzed 6 months before and 6 months after assignment of clinical pharmacists to half these units. Data specific to questions that measure quality of communication as well as medication understanding were analyzed. Additionally, data on medication error frequency were collected and compared between units with and without clinical pharmacists.

Results

A total of 2022 surveys were analyzed. The percentage of patients who reported receipt of medication information and medication understanding increased significantly after the implementation of unit-based clinical pharmacists. Comparison of intervention and non-intervention groups showed no statistically significant difference in the frequency of medication errors.

Conclusion

Results suggest that a clinical pharmacist assigned to an inpatient unit in orthopedics significantly influences patient perceptions of communication about and understanding of their medications.

Electronic supplementary material

The online version of this article (10.1007/s11420-019-09739-2) contains supplementary material, which is available to authorized users.

Introduction

Medication management is a complex yet essential part of clinical treatment, especially in patients who self-manage chronic conditions. A 2012 study found that when they were discharged a significant percentage of patients over 64 years of age who had been hospitalized for heart failure, acute coronary syndrome, or pneumonia misunderstood medication instructions and medication changes unrelated to their primary diagnosis [16]. A 2000 study found that the relative risk of post-operative complications increased almost three-fold in surgical patients admitted with a history of medication use unrelated to surgery compared with patients without such a history [4]. The clinical pharmacist has been shown to prevent harm, improve patient outcomes, and avert healthcare cost in orthopedics settings [11, 14, 15]. In orthopedics, the role of pharmacists is expanding beyond the traditional activities associated with medication dispensing.

Using expert knowledge and clinical experience, clinical pharmacists serve to inform interdisciplinary practice. They perform medication reconciliation and, most important, interact with patients to communicate information on medications, answer related questions, and prepare patients for the transition home [3]. The impact of the clinical pharmacist on patient perceptions of communication about medications has been measured using Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. These scores measure patient perceptions and satisfaction with care provided including medication information received while hospitalized.

Several studies have measured clinical pharmacist impact using HCAHPS; however, none of these studies was conducted in an orthopedics setting. In one study, significant improvement was seen in HCAHPS scores after the introduction of a program that included enhanced pharmacist participation [10]. In a separate study, researchers found an independent association between satisfaction and readmission rates for patients with myocardial infarction, heart failure, or pneumonia, noting a correlation (r = 0.740) between explanation of medication by clinical staff and overall satisfaction [1]. In a more recent study (n = 661), investigators noted increased HCAHPS scores specific to staff communication and medication understanding after an initiative aimed at improving care transitions that included the use of a pharmacist [2].

Patients are most vulnerable to medication errors during care transitions. In a randomized trial (n = 178), adverse drug events were significantly lower (p = 0.01) 30 days after discharge for patients counseled by a pharmacist, compared to patients who did not receive this intervention [12]. In a second similar trial (n = 851), adverse drug events were significantly (IRR = 0.80; CI 0.61–1.04) reduced in the pharmacist-counseled group [5]. Researchers also reported a reduced risk of error through pharmacist-provided patient education [15].

We decided to study the impact at an orthopedic hospital of a clinical pharmacist added to interdisciplinary teams at the unit level on patient satisfaction specific to medication instruction. A secondary aim was to examine the effect of the clinical pharmacist on frequency of medication errors.

Methods

A retrospective, quasi-experimental, two-group evaluative design with nonequivalent controls was used to determine the effect of a clinical pharmacist on orthopedic care at the unit level. In July 2016, clinical pharmacists were assigned to three surgical units, and another three units were selected as controls. Pharmacists’ activities included (1) participation at rounds, (2) medication reconciliation, (3) patient education, and (4) consultation and data collection from pre- and post-intervention time periods.

Each unit had approximately 40 post-operative beds. The average daily census of patients recovering from arthroplasty and spine procedures on these six units was 134 patients from July 2015 to June 2016 and 141 patients from July 2016 to June 2017.

The HCAHPS survey enables consumers to report their perspectives on the quality of care delivered by hospitals. Developed by the Agency for Healthcare Research and Quality (AHRQ) in collaboration with the Centers for Medicare and Medicaid Services (CMS), and rigorously analyzed by the American Institutes for Research, Harvard Medical School, and the RAND corporation, the survey is widely used by hospitals nationwide [7]. The survey contains 27 questions for patients to score perceptions on care received and rate provider performance on eight key dimensions. Scaled responses are organized in 4-point Likert format ranging from “never” to “always” or “strongly disagree” to “strongly agree.”

Of interest in this study were responses to survey items listed under the category “communication about medication instructions.” These questions focus on instructions provided on all new medications, explanation of side effects, and understanding of medication purpose at discharge. These questions were selected because they pertain to medication management and were likely to be sensitive to clinical pharmacist presence. The questions analyzed were the following: (1) “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?” (2) “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?” (3) “When I left the hospital, I clearly understood the purpose for taking each of my medications.” HCAHPS responses were dichotomized into “always” and “not always” categories.

The study site used RLDatix, a risk management event reporting system endorsed by the American Hospital Association (Cambridge, MA, USA). All staff had access to the reporting system. Reports use the National Coordinating Council on Medication Error Reporting and Prevention index categorization based on patient outcome severity [8].

Aggregate data for each unit were analyzed including patient age, gender, number of patients admitted during the study time periods, length of stay, and type of surgical procedure were collected (Table 1).

Table 1.

Patient demographics

	July 2015–January 2016 (Pre-intervention)			July 2016–January 2017 (Post-intervention)
	Intervention units	Nonintervention units	p value	Intervention units	Nonintervention units	p value
Patient age, years (mean ± SD)	64.4 ± 13.0	60.3 ± 19.5	< 0.001	63.6 ± 12.8	59.9 ± 18.9	< 0.001
Length of stay, days (mean ± SD)	3.5 ± 3.7	4.1 ± 6.4	< 0.001	3.4 ± 3.2	3.3 ± 5.7	0.446
Gender
Male n (%)	2910 (47)	1705 (47)	0.988	2733 (46)	1446 ( 47)	0.475
Female n (%)	3338 (53)	1957 (53)		3225 (54)	1653 (53)
No. patients	6248	3662		5958	3099
Surgical procedure
Knee n (%)	2075 (33)	1287 (35)	0.050	2083 (35)	1089 (35)	0.866
Hip n (%)	2230 (36)	1098 (30)	< 0.001	2107 (35)	953 (31)	< 0.001
Foot and ankle n (%)	212 (3)	126 (3)	0.900	184 (3)	89 (3)	0.568
Spine n (%)	1247 (20)	553 (15)	< 0.001	1163(20)	458 (15)	< 0.001
Shoulder n (%)	185 (3)	189 (5)	< 0.001	185 (3)	173 (6)	< 0.001
Elbow n (%)	15 (0)	22 (1)	0.004	17 (0)	19 (1)	0.019
Other n (% )	284 (5)	387(11)	< 0.001	219 (4)	318 (10)	< 0.001

HCAHPS data were analyzed from two time periods: pre-intervention (between July 1, 2015, and January 31, 2016) and post-intervention (between July 1, 2016, and January 31, 2017) from six units (three with unit-based pharmacists and three without). These time periods were chosen to capture pre- and post-intervention data, as well as control for any potential seasonal variation. Descriptive statistics and distribution of variables were examined. Group comparison was done with Student t tests for continuous variables (such as age) and χ² tests for categorical variables (such as gender). χ² tests were used to compare pre- and post-intervention responses within the intervention and non-intervention groups. Differences between the two groups were also compared at each time point. Analyses were conducted using SPSS version 17.0 for Windows. The hospital institutional review board approved all study procedures.

Results

In the intervention units, patient satisfaction scores were higher during the post-intervention period than in the pre-intervention period on all three HCAHPS measures (p < 0.05) (Tables 2 and 3). There were no differences in these measures over time in the non-intervention units. There were also no differences in HCAHPS scores between the intervention and non-intervention groups in the pre- and post-intervention time periods.

Table 2.

Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results: pre- and post-intervention

	Pre-intervention (July 2015–January 2016)	Post-intervention (July 2016–January 2017)	p value
Pharmacist on unit (3 units)
Always tell you what new medicine was for	80%	85%	0.018
Staff always describe medicine side effect	46%	52%	0.038
Always understood purpose of taking meds	69%	76%	0.003
No pharmacist on unit (3 units)
Always tell you what new medicine was for	84%	82%	0.631
Staff always describe medicine side effect	50%	51%	0.738
Always understood purpose of taking meds	72%	77%	0.099

Table 3.

Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results: intervention and nonintervention

	Intervention	Nonintervention	p value
Pre-intervention (July 2015–January 2016)
Always tell you what new medicine was for	80%	84%	0.217
Staff always describe medicine side effect	46%	50%	0.311
Always understood purpose of taking meds	69%	72%	0.323
Post-intervention (July 2016–January 2017)
Always tell you what new medicine was for	85%	82%	0.215
Staff always describe medicine side effect	52%	51%	0.769
Always understood purpose of taking meds	76%	77%	0.672

A total of 8910 surveys were sent to patients in the two time periods. Patients were significantly (p < 0.001) older in the intervention units. Patient volume was greater and average length of stay was longer on the non-intervention units during the pre-intervention time period. There was also a greater number of spine and hip surgeries on the intervention units and more shoulder surgeries on the non-intervention units (p < 0.001). Furthermore, the types and number of interventions the pharmacists performed were captured using Epic Hyperspace^® (Verona, WI, USA) (Table 4).

Table 4.

Clinical pharmacist interventions

Type of intervention	No. interventions
Adverse drug event	1
Allergy	9
Code participation	2
Dose form change/clarification	26
Dose change/clarification	151
Drug change/clarification	93
Drug interaction clarification	77
Frequency change/clarification	244
Chart review	2568
Discharge counseling	34
Medication reconciliation	68
Missing/incorrect profile information	1
Order clarification	176
Other	24
Patient education	1798
Pharmacy consult	1272
Route change/clarification	43
Therapeutic duplication	293
Therapeutic substitution	5
Therapeutic monitoring	32
Order omission	503
Total	7420

The secondary aim of this study was to contrast the incidence of medication errors on units with a clinical pharmacist and those without. Based on our hospital-wide medical error reporting system, there was no significant difference (p = 0.943) in reporting of adverse events despite a slight increase after the implementation of a pharmacist over the 6-month period (Table 5) In all, there were 7420 clinical actions on the pharmacist-staffed units, most notably patient education (1798) and consultation (1272), clarification and changing and frequency (244), order omission (503), therapeutic duplication (293), and drug monitoring.

Table 5.

Reported medication errors by month, pre- and post-intervention

Pre-intervention (July 2015–January 2016)		Post-intervention (July 2016–January 2017)
July	11	July	20
August	19	August	24
September	15	September	12
October	18	October	22
November	12	November	20
December	21	December	15
January	20	January	14
Total	116	Total	127
Error rate	1.17	Error rate	1.4

Discussion

The primary aim of this study was to evaluate the impact on communication about medication of assigning a clinical pharmacist to the care team, at the unit level, in an orthopedic hospital. As we noted, the work of clinical pharmacists has improved HCAHPS scores within other hospital specialty settings. Our study focused exclusively on the orthopedic setting, where patients go through several care transitions in a single admission. Our study showed patient perceptions of medication-related education improved for both intervention and non-intervention groups.

Limitations of this study include the lack of randomization and the minimally controlled confounding variables inherent to this study method. Also, although both intervention and control groups were orthopedic patients, the groups differed in age and surgical complexity. Within-unit group comparisons also differed with respect to before and after measurement timeframes. Research findings from an orthopedic setting may not be generalizable to other settings.

Our results are consistent with those of previous studies in which investigators noted improved inpatient scores specific to medication questions after the addition of a clinical pharmacist to the interdisciplinary team. However, only our study showed significant improvement in all three medication-education questions. Our bundled approach consisted of an assigned pharmacist who (a) participated in rounds, (b) conducted medication reconciliation, (c) delivered patient education, and (d) provided pharmacy consultation. Post-discharge calls from the pharmacist were not included. Only one other study to our knowledge added phone calls after discharge, and improvements in HCAHPS scores were not significant [7]. The multiple and varied activities across studies made it difficult to contrast research findings or determine which parts of each bundle were most influential. Moreover, previous studies identified “counselling” as an initiative, yet details specific to content and recipients were not clear.

All studies cited specific assignment of a pharmacist to a unit or service; however, it is not clear if pharmacists were stationed on the unit and accessible during all shifts, as was the case in our study. This access to a pharmacist may have served as a direct and consistent resource for patients, nurses, and medical staff, thereby improving medication knowledge and communication. It is also worth mentioning that HCAHPS questions do not evaluate the actions of a particular type of provider. Other professionals on the healthcare team also perform medication activities. The amount of initiative (such as patient education) delivered by each specific professional was not isolated. Though the staffing models were similar across all units studied, individual characteristics of clinicians including pharmacists were not measured.

Overall, the non-intervention group had scores that were unchanged or showed small improvement. The absence of significance between the intervention and non-intervention groups with respect to improvement is likely related to differences in pre-scores. The intervention units had considerably lower scores than the non-intervention units before the intervention. This low performance was the impetus for pharmacist assignment as an improvement strategy. The non-treatment group may have had better scores at the outset due to a younger and less complicated surgical population. Post-implementation scores for the intervention group increased to a level similar to that of the non-intervention group; consequently, group difference was small and not significant.

We found no difference in staff-reported medication errors in the intervention group after the addition of a clinical pharmacist. The clinical pharmacist performed 7420 care-related actions during our post-intervention period. Results from previous studies are mixed. In a systematic review of 36 studies published between 1985 through 2005, researchers identified two studies that focused on the effect of a pharmacist participating in medical rounds on intensive care units [3]. The first study (n = 275) noted a significant decrease in adverse events (p < 0.0001) in the ICU, and the second study (n = 266) reported significantly fewer adverse events (p = 0.03) in a medical progressive care unit [6, 13].

In more recent studies, investigators evaluated the effect of multiple interventions across different inpatient settings. Comparison of our study’s impact on adverse drug events with that of previous studies is strained, as errors across studies varied by definition and source of reporting. Interventions consisted largely of medication reconciliation, education, and post-discharge follow-up activities. In a quasi-experimental study (n = 278) that compared the effect of a pharmacy-led intervention in a large urban facility, researchers noted 4.8% fewer adverse drug events reported by patients; however, this difference was not significant [9]. Likewise, in a randomized trial (n = 851) conducted in a cardiac setting, researchers found a reduced number of adverse drug events in the intervention group, although it was not statistically significant [6]. Schnipper and colleagues in 2006 found a significant decrease in preventable events, although there were no group differences with respect to actual events [12].

The increase in errors as we defined them during the course of this intervention is likely attributable to enhanced access to a pharmacist. In the elective surgery setting, patients typically have numerous temporary medications over the course of multiple transitions. We attribute our findings of slightly increased numbers of medication errors on units with a clinical pharmacist to higher reporting as a result of the clinical pharmacist helping the medical team to identify errors.

Future research is needed to understand what specific actions taken by the pharmacist most affect patient outcomes. Additionally, information about the pharmacist such as education level, years of experience, and certifications may inform future staffing practices if found to influence patient satisfaction and outcomes. Medication errors measured using a standard definition, as well as clarity on both recipient and reporter, would afford more accurate measurement and comparison of improvements designed to minimize errors. Measurement of patient errors, which are most relevant, would require careful follow-up of patients after discharge.

In conclusion, clinical pharmacists are working across health care institutions to help patients manage their medications and to prevent medication errors. We found that the addition of a clinical pharmacist to an inpatient orthopedic unit significantly increased patients’ perception of communication and their understanding of their medications. This result is likely related to an enhanced unit-based community and culture, where pharmacists work side by side with those providing care.

Compliance with Ethical Standards

Conflict of Interest

Kelly Guerin, PharmD, BCPS, Patricia Quinlan, PhD, MPA, RN, CPHQ, Robert Wessolock, PharmD, MS, RPh, Stephanie Goldberg, MSN, RN, NEA-BC, and Patricia W. Stone, PhD, RN, FAAN, declare that they have no conflicts of interest. Joseph T. Nguyen, MPH, reports a grant to his institution from the Clinical Translational Science Center (CTSC), National Center for Advancing Translational Sciences (NCATS), grant #UL1-RR024996, outside the submitted work. The content is solely the responsibility of the authors and does not necessarily represent the official views of NCATS.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all patients for being included in this study.

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