In this podcast, Dr. William Hammond and Patricia Valdez discuss the AJHP Descriptive Report, “Impact of a pharmacy technician on an interprofessional antithrombotic stewardship program at an academic medical center,” with host and AJHP Editor in Chief Dr. Daniel Cobaugh.
The information presented during the podcast reflects solely the opinions of the presenter. The information and materials are not, and are not intended as, a comprehensive source of drug information on this topic. The contents of the podcast have not been reviewed by ASHP, and should neither be interpreted as the official policies of ASHP, nor an endorsement of any product(s), nor should they be considered as a substitute for the professional judgment of the pharmacist or physician.
Welcome to AJHP Voices, a series of discussions with AJHP authors and interviews focused on contemporary practice issues. AJHP is the official journal of ASHP, and its mission is to advance science, pharmacy practice, and health outcomes. Hi, this is Daniel Coba, the editor-in-chief of HHP. Thanks for joining us for this episode of HHP Voices. Here's a drive to standardize and monitor anticoagulation management through establishment of health system-based anti-thrombotic stewardship programs. Here today to discuss their integration of a pharmacy technician into an interprofessional anti-thrombotic stewardship program at West Virginia University Health System, for Dr. William Hammons, pharmacy manager, WVU medicine, and Patricia Valdez, clinical pharmacy technician, WVU medicine. Bill Patti, welcome. Good to be here. Thank you. Well, let me start off with you. There's been really a national push towards anti-thrombotic stewardship programs, really as a follow-on to originally anti-microbial stewardship programs. And the anticoagulation forum has actually established core program elements. Can you talk about those? I'm glad you mentioned anti-microbial stewardship because that's something we as a program looked at a lot when establishing our program. So we looked at the anticoagulation forum really for almost all of our resources because that is their bread and butter. So the AC forum or anticoagulation forum, they have this, I like to call it a playbook or they're for elements for establishing an anti-thrombotic stewardship program. Even if an institution doesn't have a formal stewardship program for anti-thrombotics, even just as a self-assessment for how are we doing, are we not thinking of everything? That is a perfect playbook to look at. So it talks through both starting up a brand new anti-thrombotic stewardship program, but also things to consider when you're maintaining a program or maintaining anti-thrombotic stewardship at your institution. So that's something that we looked at both when developing the business plan and then also starting up the program once all the staff were hired for the program. Three kind of domains that I pulled out of the playbook or the core elements when thinking about today's conversation were implementation of systematic care. So they talk a lot about a standardized approach at your institution to anti-thrombotic management. We use that a lot to achieve some of the core measures that we'll talk about later. They also have a really big focus on transitions of care, which I feel is probably Patty's biggest role in the program, and that I'm excited to hear her talk a little bit more about. But also education, not only for patients, but for staff and clinicians when thinking of anti-paragulation management. So those are really big domains that I feel like are pushed in the core elements. But the AC4M has lots of resources, they even have a nice checklist that they drew from the core elements to really easily go through and say, "Do we have these elements? Do we have these pieces to our program?" And if not, it kind of pushes you to think about having a comprehensive anti-thrombotic stewardship program. And well, what drove at the WVU Health System, what drove the need to establish an anti-thrombotic stewardship program? Two main drivers were as a result of our hospital's performance on some external benchmarking. So two specifically were our hospital-acquired venous thromboembolism rate, as well as our rate of hospital-acquired INRs greater than five. So those, of course, both related to anti-thrombotic use, both hospital-acquired and both from a business plan perspective, can be tied to some sort of financial return on investment. So those were what really drove the exploration of an anti-thrombotic stewardship program. We also looked at some of our education rates, so not directly related to these external benchmarkings. But we did have some push for better patient education upon discharge, so we really looked at that for inclusion in this program, which is why a nurse was included. But also, transitions of care was a huge focus, especially at our institution, because we are a very rural state. The patients are super commonly going three, four plus hours away once they're discharged, and we may not have contact with them after that. So that immediately post-discharge transitions of care, I think, was a huge component and does tie into some of our measures, as well. So those were the main pushes, as well as how we fit into a lot of our Joint Commission National Patient Safety Goals. We did some self-evaluation of that when identifying how we could fit into this program. Patty, we're going to talk a lot about your role today, but I'm interested to learn a little bit more prior to assuming this position with the anti-thrombotic stewardship program. What was your experience as a pharmacy technician? I have been certified since 2002. I began working at a certified retail pharmacy at a very fast-paced, independent pharmacy. There I worked for several years, and then I transitioned to retail. After retail, I transitioned to the hospital setting in 2016, and in 2021, I began with anti-thrombotic stewardship service. Got it. So will a steering committee oversaw the establishment of the anti-thrombotic stewardship program? Who was included on that steering committee? Pharmacy, I will say, was the main driver in really pushing for the need, and that recognizing though that it is multidisciplinary. So their quality department was huge in helping us get a handle on some of those external benchmarks, but we also really needed those content experts at the table. So nursing played a huge part in this program as well as our medical director kind of works in the cardiology space, really with that connection with surgical and non-surgical teams that have a really high use of anti-coagulant. So helping to understand, hey, this is something that's coming. This is something we are exploring, really getting those content experts to idea share on what the needs are. Once the program was approved, though, I think it was really crucial to get that hands-on time with the team. So Patty can elaborate, but we did a lot of either meeting or shadowing or brainstorming with care management with some of our bedside nurses who were involved in education of patients at the time, or who were involved in helping with prescription access. I think it's important to call out to hear that Patty and then the two pharmacists that were hired and the additional nurses that was hired as a result of this business plan were all internal to the institution. So already had some of those relationships with different patient care teams, but that emphasis might have been a little bit more to if someone were to be hired or onboarded external to the institution. And I'll say Patty's relationships with different folks in pharmacy as well as our pharmacists and nurses that were already a part of the program, their relationships with different teams or key. And then the last thing I'll say from a business plan or approval standpoint, this was a big proposal with multiple new personnel potentially being added to the organization. So having those senior leaders involved who not only are within pharmacy but external to pharmacy such as finance, that's really key in ensuring that this business plan goes successfully, especially if you're considering adding personnel to the institution. So well I think that some folks would find it very interesting that there was a vision from the start to include a pharmacy technician on the steering committee. What drove that? Where did that vision come from? How did you think that we need a pharmacy technician here at the table as well? Well at WVU, we were kind of set up for success in that front. So we already had a clinical pharmacy technician presence on some other teams. So we have medication history at our institution and we have clinical pharmacy technicians in several different pockets of our pharmacy team. So that was already something that had been explored before in terms of advanced pharmacy technician roles. When you think about an ophthalmotic stewardship program though, a lot of the activities that were kind of identified as in need. So transitions of care, prescription access, post discharge, certainly were in scope of a pharmacy technician but also would be activities that the pharmacist may otherwise be doing. So I think having pharmacy technicians in the forefront of your mind with any pharmacy expansion is key. I think Patty's inclusion on the team makes it possible for the pharmacists and the other clinicians on the team to be able to do more. And I think having a pharmacy technician just is really the key to a successful program because they can do so much. And I think just really depends on your organization though and what's already there. I think we were fortunate in that we already had a technician ladder so to speak that Patty could be slotted into pretty easily. So well what's the focus of the anti-thrombotic stewardship program at WVU? So we have just to make it a little simpler kind of two main patient care arms if you will. So we have a focus on via acute care side and then a focus on transitions of care. Our two pharmacists on the team take turns on who's responsible for what? On the acute care side of things, they're really focused on patients who are actively on anti-coagulants and they are identifying interventions for those patients. So they use a scoring system to do that, to trigger dose adjustments or drug interactions, et cetera. They then will communicate those with a primary team to make interventions and kind of recommend changes to patient care. On the transitions of hair side, this is really where Patty comes into play as well but from a pharmacist standpoint, they're following patients who were newly started on anti-coagulants to ensure that they're set up for discharge. So Patty drives a lot of that work to ensure that patients can afford their medications that they're going to be able to pick it up, that they're delivered to our own site. Gorge pharmacy if the patient prefers that. At that point, the pharmacist also jumps in to help address any clinical needs. It could be a dosing issue, something with a loading dose or starter pack, I think, is a really common intervention and they're really also setting that patient up for the post-discharge education that our nurses will do. Third arm, which everyone is involved in in the team, is the stewardship and oversight of clinical guidelines, protocols, and initiatives surrounding anti-coagulation. So if there is an initiative at our hospital going on that relates to an anti-coagulant, our pharmacists are likely involved in it on the ASP team, they sit on our P&T committee and they also sit on several other safety and quality related committees to really have that broad oversight of anti-thromatic use, which I think is really key in both of our pharmacists play a huge role in that as well. So Patti, what type of training did you go through for this special role as part of the overall anti-thrombotic stewardship program? We are the first hospital institution to have a pharmacy technician in this program, so there was no training modules for me or guidelines. I basically had to start from scratch. I started by reviewing tools and webinars available on the AC Forum website. I also independently read articles focusing on quality improvement for inpatient anti-coagulation practices. I read a lot of articles. Additionally, I trained with our hospital's medication history technicians, our nurse educators, and care managers. We then identified what the needs of our institutions were to come up with where I could start making interventions. So tell us Patti, what's your day look like, walk us through your typical day working with patients who are on anticoagulants and the care teams that are taking care of those patients. I review the patient oral anti-coagulation list to determine which patients are new starts and which are not, the ones that are not removed from my list. I then evaluate them for potential financial barriers as well as ensure proper transcription to a pharmacy. If I identify issues, I engage the primary pharmacist and my team pharmacist for further management and I will assist as I am able to. I also follow up to verify medications were delivered to patients at bedside or picked up at whatever pharmacy they choose. This is to ensure the patient has their drug in hand. Patti, I don't know if you were approached to take this role or if you applied for it, but regardless of the situation, what excited you about this job? What made you think this is something I'd really like to do? I was actually approached to take this job. I was excited about the fact that I would be helping people or patients with their financial needs and being able to get their medications. When you take a step back and look at it and your participation on the steering committee and when you see what you're doing on a daily basis, including ensuring that people have their financial needs met so that they can obtain their medications, it's fair to say that it gives you a sense of seeing the bigger picture and I would imagine a sense of satisfaction in terms of what you're doing every day. Yes, it does. It helps me feel fulfilled in my job in helping patients as much as I am able to. What role did having a pharmacy technician career ladder already in place? What role did that play in terms of the success of this program in integrating Patti in as a pharmacy technician on the team? I think having a career ladder in place for technicians was crucial to having Patti slotted into this program. I think without a formalized career ladder already in place, I'm not sure how possible it would have been to have a technician in this advanced role. I do think that that's super important when considering advanced technician roles does your institution already have a career ladder in place because that's set us up to have advanced technician roles in multiple areas at WVU, ASP being one of them and a really important one, but it's been really crucial for a lot of our technician services. What's the level of clinical supervision that is provided to oversee a pharmacy technician? In this case, Patti's activities as part of the care team taking care of people who run some really high risk medications. A few different ways that we're able to achieve that supervision for Patti's work. She does thankfully share an office with our two ASP pharmacists. In the moment, over-site and bouncing questions off of one another, et cetera, is key. From a documentation standpoint, though, Patti was describing some of her activities. She'll document all that in the medical records and the pharmacist then reviews that. They use that either to publish a progress note or they can use that to determine if there's some sort of clinical intervention that's needed for that patient. A lot of times, Patti set them up for it. I was always really impressed with Patti for saying, "Oh, that dosing is different than what I'm used to seeing. Can the pharmacist take a look at that and intervene?" Drawing that line on, Patti can really pick up on a lot of those clinical discrepancies so to speak, but then knowing the pharmacist will be the one to vet that and make sure it's appropriate to bring up to the team. Yeah, that's kind of how the supervision works for Patti's activities. Many of us who practice pharmacy would attest to the fact that we've been saved many times by a good pharmacy technician. Patti, what's your experience been with this program? Do you enjoy your role? Yes, I do, but I especially enjoy the aspect of helping patients overcome financial barriers to obtaining the medication they need. It's very gratifying to be able to assist in finding solutions and ensuring that financial challenges don't stand in their way of their treatment that they need to receive. Overall, the experience has been both professionally and personally enriching, and I look forward to continuing to contribute to our team's success. Will, when you look at the numbers, when you quantitate to the experience with the program, what's it been so far? I would say one thing that surprised me when we started intervention tracking to really get a handle on what each team member was doing was that most of the interventions were actually those discharge transitions of care intervention, both from a financial perspective within a clinical perspective as well, which I think highlights Patti's role in the program because that's her primary focus, but also maybe where most of the needs were in the program and with anti-thromatic use, I think that's helped to guide a lot of other initiatives that we work on related to discharge transitions of care. It's also been really good to see the acceptance rate of our intervention, so we do track that just shy of 80% of our interventions are implemented by the team, which I think it's has to our pharmacists relationships with those team members, so I've been really pleased with that. I think it's helped to guide a lot of what we do, but really impressed with the transitions of care focus on it, especially considering our patient population in West Virginia. With those successes in mind, where does the WVU health system go next with advanced practice opportunities for pharmacy technicians? Something that we have actually been trying to beef up a little bit is, I think, a perfect example of what ASP has done well in that is discharge transitions. We have a pretty robust admission medication history process, but really nothing dedicated or standardized on the discharge piece outside of our onsite discharge pharmacy, so we are exploring how potentially a pharmacy technician could be leveraged for patient access. We have them at the dispensation and delivery piece, but really what Patty's doing is talking with the patients, ensuring they pick up their medications, ensuring they have access to it after they leave the hospital. I think that's really key and really exploring how we can continue leveraging clinical technicians. That's what Patty is. That's what our medication history technicians are. We've considered how they can play a role in clinics, really in that direct patient care role, whether it be met history or met access, but I think there's a lot of different areas that we can use clinical pharmacy techs. Think from a ASP standpoint, so our team is currently really focused on our flagship hospital. We do have a 20 hospital system though that could probably use some support and Patty's miles because often they get asked about that, so I think if we ever expand to the system, we will definitely need more personnel and then I think pharmacy technicians, clinical pharmacy technicians are definitely part of that if we were to ever expand to system support or enterprise support. Patty, what would you add to that? What do you see from a boots-on-the-ground perspective doing this on a day-to-day basis and also having been involved in the planning, where do you see the opportunities for pharmacy technicians to come in and contribute at a higher level? If we were to get any more pharmacy technicians in our program, areas we see technicians practicing would be leading conversations between the inpatient services and outpatient services to correct transcription errors and further improve transitions of care, that way it would cut out the middleman instead of having to go through my team pharmacists to get in communication with the inpatient services, we're trying to see where we can improve or I can just directly do that myself. For a more inpatient role, we foresee them operating at the top of their licenses for helping pharmacists identify inappropriate VTE procolaxes and doactosing. So it really seems to be focused on what's best for the patient? Yes. And with that, that's all the time we have today. I want to thank Dr. Will Hammons and Patty Valdez for joining us today to discuss their article "Impact of a Pharmacy Technician on an Interprofessional Antithrombotic Stewardship Program at an Academic Medical Center," which was recently published on agehp.org. Please join us here each month for discussions on contemporary practice issues and interviews with agehp authors. If you enjoyed this podcast, please share it with your colleagues and via your social media of choice. Thank you for listening to AJHP Voices. For more information about AJHP, the premier source for impactful, relevant, and cutting edge professional and scientific content that drives optimal medication use and health outcomes. Please visit agehp.org. [music]
