Physicians make decisions about medical treatment for their patients, but pharmacists and nurses are essential to carry out a physician's intent and guard against inadvertent harm.
Pharmacists school themselves in properties of drugs, their interactions and side effects. Nurses are at the bedside to double-check orders one last time for something that might not seem right. Both professionals have special skills that are crucial to detecting and heading off medical errors.
Yet you'll often see pharmacists in a back room filling orders and nurses bent over a desk filling out forms or waiting on hold for a test result. Some hospital managers are looking to change that.
"The whole work of the pharmacist has to be re-engineered," says Mary Dowd Struck, senior vice president for patient care at Women and Infants Hospital, Providence, R.I. "We have an excellent staff in pharmacy, but they're stuck behind glass partitions."
Computerized systems that automate parts of the medication ordering and fulfillment processes are taking some of the grunt work out of the daily routines of pharmacists and nurses. The result has been more time for pharmacists to consult with physicians on appropriate medications and more time for nurses to make sure they get orders right and administer them on time.
At Blount Memorial Hospital in Maryville, Tenn., pharmacists are stationed on medical/surgical units, putting them in company with physicians as they order medications, says Jeanne Ezell, director of pharmacy. It allows pharmacists to use their knowledge to monitor doses and ultimately gauge their effect on patients.
"It's part of physicians' traditional role, but it's not their primary role," Ezell says about drug expertise. "It's the pharmacist's main role."
Pharmacists on patient floors at Our Lady of the Lake Regional Medical Center, Baton Rouge, La., enter orders at a computer station near where the caregiving takes place, says Nancy Luttrell, director of nursing informatics and patient-care services.
Physicians dictate or write their prescriptions, which gives pharmacists and physicians a chance to confer about orders and discuss some of the issues that might be raised, she says. The computer system also pops alerts up on-screen for possible allergic reactions or other patient-specific considerations, she adds.
Having a pharmacist in the vicinity is a comfort to caregivers as well, says Terri Sterling, vice president of patient-care services. "The nurses love it. It's so great to just be able to ask a question," she says.
For example, patient floors have automated drug storage machines, and in limited circumstances a nurse is authorized to dispense a drug when needed in an emergency. A pharmacist can backstop the situation, confirming the dose or other particulars, Sterling says.
Nursing duties that are automated by clinical documentation systems and other computerization leave more time for patient care. At University of Illinois at Chicago Medical Center, for example, caregivers using an electronic medical record report spending one hour less per shift on the medication administration process, according to a just-released report on the clinical system's impact. Registered nurses in a charge-nurse role report spending 2.75 fewer hours on such duties.
Medical charting compliance, which is necessary to capture charges and document adherence to policies and procedures, is better under the computerized regimen, says Roseanne McBride, an administrative nurse in a 27-bed telemetry unit at UIC Medical Center.
Instead of recording every medication administered-often trying to recall it all at the end of a shift-nurses audit the scheduled meds in a computerized medication administration record that tracks orders, spacing between doses and medication starts and stops. "By the end of the shift, everything's been charted and done," McBride says.
The unit also has been getting fewer "repeaters," patients who relapse after going home because they're not taking care of themselves the way they should, she says. With more time at the bedside, nurses can educate patients about their conditions more fully and spend additional time preparing them at discharge, McBride says.
For supervisory nurses, whose duties include backtracking patient data to resolve complaints or prepare reports such as chemotherapy histories, the electronic record is "a great tool," says Joanne Grashot, a nurse manager at Our Lady of the Lake. It affords easy access to research a problem, accomplishing in minutes what used to take a day searching for charted information in paper records, she says.
UIC Medical Center's report estimated it had gained $1.2 million worth of nurse time reallocated away from manual documentation tasks. In a nursing shortage, the institution isn't looking to reduce staff but rather to reinvest that savings in patient-care improvement and improved nursing skills, says Joy Keeler, chief information officer.
Within a year of the changeover to an electronic record, nurses on the telemetry unit managed by McBride were trained to take recovering angioplasty patients that formerly were in an intensive-care unit. That cut the expense of caring for those patients approximately in half, to $700 a day compared with $1,200 to $1,400 a day in the ICU, McBride says.
The computerized record provided information on what the patients' medications were and what was done, she says. And the decrease in documentation time freed up staff to attend special classes and increase their skill level.
Pharmacists in automated facilities also are spending more time working on complicated activities employing their full skills instead of counting out pills or entering written orders into the computer.
The freed-up time represented by a move to physician order entry allowed Montefiore Medical Center to support the addition of medical services that required heavy support from the pharmacy, says John Manzo, pharmacy director at the New York teaching facility.
The pharmacists were able to make more of certain types of products, such as the special solutions involved in filtering toxins from blood through hemoperfusion, that would have been difficult to supply when professionals had to handle many more mundane duties, Manzo says.
The time saved by delegating dispensing chores to a pharmacy robot allowed pharmacists at Blount Memorial to spend more time on higher-level duties such as double-checking chemotherapy regimens and mixing nutritional solutions for patients unable to eat or drink, Ezell says.
A sudden increase in hospital occupancy nearly three years ago resulted in a 35% to 40% increase in calls for total parenteral nutrition. The labor-intensive support service involves mixing up to 10 ingredients instead of the usual one solution for intravenous delivery.
Chemotherapy volume also rose during that time, but the existing staff was able to handle the increase, Ezell says. The extra latitude for pharmacists also allowed them to double the length of the average preparation time to include more double-checking.