OPERATIONAL FTE JUSTIFICATION
Institution A
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TABLE OF CONTENTS
I.
Executive Summary
Page 3
II.
Introduction
Page 3-4
III.
Summary of Request
Page 5
IV.
Data Analysis
Page 5-9
V.
Operational Impact
Page 9
VI.
Financial Analysis
Page 10
VII.
Timeline
Page 10
VIII.
References
Page 10-11
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I. EXECUTIVE SUMMARY
Clinical pharmacists have consistently been utilized in inpatient settings to improve patient
outcomes while decreasing costs of treatment. Pediatrics has been identified as a high risk
group due to highly individualized regimens based on age and weight-based dosing. Numerous
studies have demonstrated significant therapeutic and financial benefit from the addition of a
clinical pharmacist to the healthcare team.
Currently at Institution B, the pediatric and adult cardiac intensive care units, located at
Institution A and Institution C share a clinical specialist. Due to the increase in patient volume
and physical separation across campus of the two units, the current pharmacist cannot provide
adequate coverage to both teams and will transition to the adult cardiac unit full time. In order
to continue to offer pharmacy coverage to the pediatric cardiac intensive care unit, an
additional clinical pharmacist is required. A full time replacement is requested, which will allow
continuation of the current services with additional opportunity to expand pharmacy services
offered in the Institution A.
Cost savings data in pediatric intensive care units have supported the employment of a clinical
specialist. Cost of errors avoided, optimization of therapy, decrease in annual drug costs, and
addition of new covered services result in substantial cost avoidance.
Not having an additional pharmacist will result in reduced or lack of coverage in a high acuity
area. Based on a published meta-analysis of a pharmacoeconomic benefit:cost ratio, this
position will save Institution A an estimated $633,600.i Additionally, the expansion of
pharmacy coverage will not be possible.
This proposal is highly supported by the Institution A Administrative and Clinical Service Line
Leaders.
II. INTRODUCTION
Since the Joint Commission Sentinel Event Alert addressing pediatric medication errors was
published, research has focused on improving the quality of care in this specialized population.
The American Academy of Pediatrics (AAP) issued a policy statement on prevention of inpatient
medication errors in 2003.ii AAP cited pediatric medication error rates as high as 1 in every 6.4
orders, which were significantly higher than adult rates. Children are more susceptible to
serious consequences from medication errors as a result of immature organ systems with less
capability to buffer errors. In addition, unique challenges are also present in the pediatric
population, including weight-based dosing, age-specific dose ranges, off-label medication use
without accepted doses, and lack of standardized dilution practices.
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In 1992, a report published by the US Poison Control Center found that cardiovascular drugs,
when compared to many other drugs, led to higher fatality events in children.iii Among the
multiple cardiac drugs represented, antiarrhythmics, antihypertensives, cardiac glycosides, and
nitroprusside were implicated in pediatric fatalities. Furthermore, according to a US
Pharmacopeia MEDMARX database query for cardiovascular medication error reports in
pediatric inpatients from 2003-2004, the drugs implicated in harmful drug errors include
calcium channel blockers, phosphodiesterase inhibitors, antiarrhythmics, and digoxin.iv
Incorrect drug dose was cited as the most commonly observed error in the study. Additionally,
the Institute for Safe Medication Practices 2008 List of High Alert Medications includes
numerous drugs commonly utilized in PCU including the aforementioned medications in
addition to concentrated electrolytes, opioids, and sedating agents.
As a result of the high rate and serious consequences of medication errors, pharmacists’
involvement in pharmacotherapy is consistently being researched. Numerous studies have
shown that involving a clinical pharmacist in therapeutic decisions significantly decreases error
rates. A study evaluating thromboembolism and infarction-related events found that adult ICUs
without a designated clinical pharmacist had a 37% higher mortality rate, 14.8% longer length
of stay, and approximately $1,700 higher Medicare and drug charges per patient.v Utilization of
a clinical pharmacist in the pediatric intensive care unit has also resulted in a decreased cost of
care, decrease in medication errors, and optimization of therapy.vi
A large prospective study in two large academic hospitals found that adverse drug events (ADE)
in pediatric units were similar to those in adult units.vii However, potential ADEs were three
times higher in pediatric patients. Potential ADEs were most commonly physicians ordering an
incorrect dose, ordering medications despite documented allergies, failing to include drug
routes, and pharmacy dispensing errors. Of the potential ADE’s 79% were errors that occurred
during the dosing process. After the conclusion of the study, a physician review panel
determined that 94% of the potential ADEs could have been prevented by a pharmacist.
Currently, at Institution B, the pediatric cardiac intensive care unit shares a clinical pharmacist
with the adult cardiac intensive care unit, located in Institution C. Due to the expanded services
in adult cardiothoracic services, development of a lung transplant program, and physical
separation across campus between adult and pediatric services, the current clinical pharmacist
cannot adequately cover both teams to the extent needed and will be transitioned to location A
only. As a result, the addition of 1 FTE for the Institution A Pharmacy Services is requested for
FY 2010. The addition of 1 FTE will continue to allow clinical pharmacist coverage in the
Pediatric Cardiothoracic and Cardiology Services. In addition to continuing the aforementioned
services, coverage would be expanded to include the 2 Cath Labs as well as Same Day
Observation. Additionally, increased clinical pharmacy presence has been requested in the
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Children’s Emergency Department. Shifting of coverage responsibilities will create an
opportunity to initiate coverage in the Children’s ED.
III. SUMMARY OF REQUEST
We respectfully request the addition of 1 FTE for the Institution A Pharmacy Services for
FY2011. Recruitment and interviewing will begin as soon as possible to take advantage of the
graduating residency class.
IV. DATA ANALYSIS
Current Clinical Specialist Inpatient/Outpatient Service Coverage (4FTE)
Specialist
He
m/
Onc
Gen
Peds 1
Gen
Peds 2
Gen
Peds 3
PICU
CV 1
Peds
surg
NICU/
SCN
PCU 1
Adult
CT/HT
4cath
1
4cath
2
A
12
mo
2 mo
B
2 mo
C
3 mo
6 mo
-
8 mo
8 mo
4 mo
3 mo
9 mo
D*
12 mo
Faculty A
6 mo
Faculty B
4 mo
4 mo
Faculty C
3 mo
3 mo
12 mo
12 mo
TOTAL
Months of
Coverage
-
12
mo
12 mo
8 mo
4mo
-
4 mo
3 mo
12 mo
12 mo
12 mo
-
12 mo
12 mo
12 mo
12 mo
none
*position to be replaced with 1 FTE pediatric clinical specialist; position being requested
- lack of coverage from this group
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Proposed Clinical Specialist Inpatient/Outpatient Service Coverage (4FTE)
EXPANDED SERVICES
Specialist
Hem/Onc
A
12 mo
Gen
Peds
1
B
2 mo
C
3 mo
Gen
Peds
2
Gen
Peds
3
2 mo
6 mo
PICU
8 mo
Peds
surg
NICU/
SCN
4 mo
4 mo
Faculty C
3 mo
3 mo
12
mo
12 mo
12 mo
4cath1
4cath2
SDO
12mo
12mo
12mo
12 mo
12mo
9 mo
6 mo
Faculty B
ED
12
mo
12 mo
Faculty A
PCU
4 mo
3 mo
D*
TOTAL
months of
coverage
CV1
12 mo
8 mo
4mo
3 mo
12 mo
12 mo
12 mo
12 mo
12 mo
12 mo
12
mo
12 mo
* position being requested
The charts above highlight the plans for the expanded coverage of services for this new
position.
Cost-Savings Projections
Critically ill patients often have multiple organ dysfunctions, which results in altered drug
pharmacokinetics and pharmacodynamics. According to one study, the presence of a
pharmacist in an adult ICU has resulted in $1700 per patient decrease in total charges.v Based
on the results of the study, a clinical pharmacist in PCU would save Institution B approximately
$155,000 annually on drug modifications due to end organ function. Another study of cost
savings in an adult ICU resulted in 322 interventions in a 13-week study period leading to an
extrapolated >$72,000 savings annually.vi Additionally, for patients in a pediatric ICU, age and
weight-based dosing increases the complexity of pharmacotherapy. The most commonly cited
interventions by pharmacists are drug dosing changes. Even in a small ICU, with an average
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census of 4.9 patients, interventions by the pharmacist in drug dosing changes alone have
resulted in a cost savings of $9,135/year.vi Based on the results of this study, a clinical
pharmacist in PCU would save MUSC approximately $15,000 annually. Because the study only
included dosing changes, the total is significantly conservative. Additionally, discontinued
medication calculations only included a 24-hour supply. Labor, materials, cost of errors avoided,
benefits of education, and optimization of drug therapy were not included in the cost savings
analysis. Analysis of the financial impact of a clinical pharmacist intervention in a pediatric
cardiac intensive care unit has been studied.viii Because pediatric patients who have undergone
cardiac surgery have an increased risk of renal insufficiency, cost avoidance was based solely on
renal dosage adjustments. Medications that were monitored through serum levels were
excluded. A yearly cost savings of $50,000 was extrapolated from renal dosing, most of which
was a decrease in drug utilization alone. Because of the large study population, the savings to
Institution B calculated from the study would be approximately >$5,000 annually for renal
adjustments.
Cost data from Institution B is impossible to calculate accurately because we currently have
pharmacist coverage in PCU. However, PCU is a major user of many expensive medications
including Factor VII, albumin, dexmedetomidine, IVIG, and antithymocyte globulin. The annual
utilization of these common medications in PCU for the fiscal year 2008-2009 is shown in the
chart below.
Total Cost for Medication for Fiscal Year 2008-2009
$59,797.13
$60,000.00
$51,385.25
$48,047.71
$50,000.00
$36,465.00
Cost
$40,000.00
$30,000.00
$20,514.12 $20,475.49 $18,803.74
$20,000.00
$10,000.00
$0.00
Albumin
Mannitol
IVIG
Antithymocyte
globulin
Factor VIIa Recomb
Dexmedetomidine
Chlorothiazide
Medication
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In addition to the cost savings seen in PCU, coverage of the Institution A’s ED will result in
further cost avoidance. Pharmacy presence in the ED is an emerging way to apply pharmacist
input to patient care. Currently, there are no standard practices in the ED, yet each ED that has
implemented pharmacy services has found a significant impact for their institution. Studies
have shown potential cost savings of $1.95 million - $3 million annually due to pharmacist
interventions.ix, v
After reviewing all the studies highlighted above and considering each of these pieces that our
clinical specialist will perform, we expect to save over $1 million dollars by continuing to
provide the clinical pharmacy services to the PCICU and implementing the clinical pharmacy
coverage to the Pediatric ED.
Service Agreement
1. 12 month clinical specialist coverage for PCU
a. AM and PM rounds with intensivist team
b. PN optimization
c. Antibiotics utilization
d. Management of:
i. Sedation
ii. Continuous infusion
iii. Anticoagulation
iv. Stress prophylaxis
e. Drug dosing
i. Weight and age based
ii. Renal adjustments
f. Form optimization and review
2. 12 month clinical specialist coverage for CV1
a. Daily rounds with team
b. Arranging medications for discharge patients
c. Antibiotic utilization
d. Catheterization management
e. Management of anticoagulation
3. 12 month clinical specialist coverage for cath1 and cath2
a. Initiate and implement standardization of practice through development of
order forms
4. 12 month clinical specialist coverage for Same Day Observation (SDO)
a. Outpatient clinic consults
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5.
6.
7.
8.
i. Long-term antibiotic monitoring
ii. Transplant management
Pediatric Pharmacy On-Call
a. All specialists and faculty are on-call for 8-9 weeks per year
b. 2-3 weeks specialists and faculty act as primary on-call responder
Committee assignments
a. All specialists and faculty participate with service related committees/work
groups
b. All specialists are assigned one department/hospital wide committee
Staff development/Education
a. Pharmacy and Resident Training
i. Minimum 6 months with student/resident on rotation
ii. Orientation participation
iii. Didactic lectures for PharmD students through the College of Pharmacy
b. Clinical Pharmacist Training
i. Topic reviews
ii. Shadow experiences
Scholarly/Research activities
a. Abstract/manuscript publications
b. Service project advisors
c. Medication Use Evaluation liaisons
V. OPERATIONAL IMPACT
Without an additional specialist, the PICU/CV1 specialist would be asked to cover PCU. As a
result, there will be a decreased pharmacy presence in each of these high acuity areas. PCU is in
the adult hospital while PICU is in the Institution A which results in significant physical
separation. Additionally, patient care rounds occur simultaneously, making it impossible for the
specialist to attend both. These barriers would decrease specialist participation, resulting in
limited opportunity for medication error prevention and cost effectiveness. As a result, two
high acuity areas would be inadequately covered, substantially compromising quality patient
care. Without an additional pharmacist dedicated to PCU, coverage may have to be withdrawn
from PCICU due to lack of resources.
An increase in clinical specialist presence has been requested in the Institution A’s Emergency
Department. With the current load, the specialists are unable to consistently offer this service.
Without an additional specialist, the pharmacy will continue to be unable to provide pharmacy
clinical services to the ED. In addition, expansion of pharmacy involvement to include the
catheterization labs and Same Day Observation (SDO) will not be possible.
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An article published in Pharmacotherapy and endorsed by ASHP describes the benefit: cost
ratio of pharmacy services provided in the hospital setting. Based upon this meta-analysis we
would expect a favorable cost to benefit ratio of 1:4.8.i These savings include medication cost
reduction, as well as prevented adverse events, and reduced hospital time. The types of
services described in the study are precisely the type of activities that we’ve described this new
pharmacist providing, disease state management, general pharmacotherapeutic monitoring,
pharmacokinetic monitoring, and target drug programs. Based on this established ratio we
expect to continue to save Institution D $633,600 each year in medication cost, reduced ICU
time, reduced medication errors, and adverse events. Below is a description of the return on
investment that we expect by maintaining the clinical pharmacy services in the PCICU and
adding the clinical pharmacy coverage in the Pediatric ED.
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VI. FINANCIAL ANALYSIS
Description
Year 1
Year 5
Drug Cost Avoidance in PCICU
$633,600
$734,500
Cost Avoidance in Pediatric ED
$600,000
$695,500
Salary Cost with Benefits
($151,000)
($175,000)
Net Cost/savings
$1,082,600
$1,255,000
COST TO BENEFIT RATIO
1:4.8
VII. TIMELINE FOR IMPLEMENTATION
February 2010:
Submit request for new positions to administrative group for approval.
March 2010:
Proceed with hiring procedures; review applications and interview
applicants
July/August 2010:
Orientation and training. Note, position to be hired in FY11.
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References:
iMacLauren
R, Bond C. Effects of Pharmacist Participation in Intensive Care Units on Clinical and
Economic Outcomes of Critically Ill Patients with Thromboembolic or Infarction-related Events.
Pharmacotherapy 2009;29:761-768.
iiPerez
A, et al. Economic Evaluation of Clinical Pharmacy Services: 2001 – 2005. Pharmacother
2008;28(11):285e – 323e.
The Joint Commission: Preventing pediatric medication errors: Sentinel Event Alert #39 April
11, 2008. Available online:
www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm
iii
ivLitovitz
T, Manoguerra A. Comparison of Pediatric Poisoning Hazards: An analysis of 3.8 Million
Exposure Incidents. A Report from the American Association of Poison Control Centers.
Pediatrics 1992;89:999-1006.
vLada
P, Delgado G. Documentation of pharmacists’ intervention in an emergency department
and associated cost avoidance. Am J Health-Syst Pharm 2007;64:63-68.
viMoffett
B, Mott A, Nelson D, Gurwitch K. Medication Dosing and Renal Insufficiency in a
Pediatric Cardiac Intensive Care Unit: Impact of Pharmacist Consultation. Pediatr Cardiol 2008;
29:744-748.
viiKrupicka
M, Bratton S, Sonnenthal K, Goldstein B. Impact of a pediatric pharmacist in the
pediatric intensive care unit. Crit Care Med 2002;30:919-921.
viiiAlexander
D, et al. Cardiovascular Medication Errors in Children. Pediatrics 2009;124:324-332.
ixKaushal
R, Bates D, Landrigan C, et al. Medication Errors and Adverse Drug Events in Pediatric
Patients. JAMA 2001;285:2114-2120.
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