Good afternoon, my name is Anthony Hawkins, and I'm a clinical associate professor and member of the UGAC3 at the UGA College of Pharmacy, and today we'll be discussing critical access to pharmacists in critical access hospitals. I have no conflicts of interest, but I would like to disclose that I am a pharmacist that practices in a large community hospital within a rural setting, so while I do not practice in a critical access hospital, I am part of a health system that has critical access hospitals and receive transfers from critical access hospitals. Our objectives today will be to discuss the role of the critical access hospital pharmacist as part of the hospital team and describe factors that influence the availability of critical care medications in a critical access hospital. While the pharmacy staff may not be as robust as a larger health system, the responsibilities of the pharmacist and the pharmacy team are still present, and we'll talk about several of those factors that influence some of what these responsibilities may look like. The most recent position paper on ICU pharmacy services describes the pharmacist's responsibility as prospectively evaluating all drug therapy for appropriate indication, dose, interactions, and allergies, and to monitor the patient's therapeutic regimen for effectiveness and adverse events and intervene as needed. And this was considered to be foundational for facilities providing all levels of care, which includes our critical access hospitals. So the pharmacist has foundational responsibilities that are quite cumbersome, and several characteristics about the different types of critical access hospitals can definitely make emergency medicine and ICU pharmacy services look a little bit different. So there is not a one-size-fits-all approach. Pharmacy services can be as basic as core medication dispensing functions, such as order review, product selection and preparation, inventory management, and it can be as advanced as the pharmacist at the bedside assessing the patient's sedation level and hemodynamics to make therapeutic recommendations. So with this large variability in practice, we'll talk next about several factors that can influence where on the spectrum a critical access hospital pharmacy services may lie. There are several factors that influence pharmacy services. Is the critical access hospital a part of a health system, or is it a standalone private entity? This has specific implications for the pharmacy services provided and over what time of day that these services may be provided. For example, if a critical access hospital is part of a health system, if the pharmacy department closes at the critical access hospital at 5 p.m., there may be hospital staff that's part of the sister hospital that can remote in and do telepharmacy to verify orders remotely during that time. Whereas standalone private hospitals, they may not have access to those types of resources. Another consideration is the details of the outside hospitals. So how far away are the hospitals that you would be transferring patients to? For example, you may have to do a lot more fiber analytics for an acute MI if the outside hospital is far enough away to not warrant judicious transfer for PCI capabilities. It's also an important consideration for who provides EMS services. If the county provides those, then the critical access hospital, their pharmacy staff may be responsible for producing EMS drug boxes. It is also true to consider if the EMS provide services are outsourced, then the EMS boxes are probably also outsourced. And so that has implications on what types of responsibilities the pharmacy staff at the critical access hospital may have that may also dictate some of maybe the staffing requirements. Bed allocation is an important consideration. If a critical access hospital has beds that are specifically dedicated to some surgeries or maybe swing beds or more acute care, depending on the bed allocation for that versus just emergency medicine before transfer, that can certainly impact the number of pharmacists and the types of pharmacy services provided. Laws and regulations are important to consider, especially as we think about remote order entry and remote telepharmacy services. Some states require that a pharmacist cannot verify orders remotely or even provide pharmacy technicians supervision remotely unless they are licensed within that specific state. This is not true for all states, and so that may have specific implications for how easy it is for telepharmacy services to be provided. Services provided by the hospital itself can certainly indicate or dictate which pharmacy services are provided. If you are a stroke center or if you do fiber analytics, like I mentioned earlier, there may be more demands for pharmacy services to be more hands-on and at the bedside. Whereas if you don't provide as many services and you're much more of a triage and transfer, then pharmacy services may also be limited. Informatics is something that we may not think about. Something related to paper charts versus electronic medical records certainly has implications on what type of pharmacy services can be provided remotely versus only in person. And other things to consider related to informatics, such as inventory management. If a hospital has a carousel system in their pharmacy to manage inventory, this can definitely impact the type of pharmacy services provided at the bedside as well as in the pharmacy because you have a better handle on what drugs are available. And lastly, it's important to consider the staff that is available. Are the pharmacy staff, do they have postgraduate training? The types of nursing staff or providers staff, are they critical care trained? Depending on the type and location of your critical access hospital, you may be in very rural areas and specifically where I practice, I know it's pretty difficult to recruit and retain very highly trained individuals of all professions. And as I alluded to earlier, there's a lot of responsibilities that the pharmacist will be involved with regardless of the size of the hospital. And so the pharmacist is involved in a lot of behind the scenes work, such as policies and procedures, formulary management, committee involvement, which we all know can take up a lot of time. And then what we'll talk a little bit more about in a few minutes is drug acquisition. Now we can talk about pharmacy services provided or we can talk about other non-pharmacy services that the critical access hospital provides. And what they have in common is drug availability. And so certainly we would love to have a formulary and access to a variety of different medications, especially within each drug class so that we can offer better, more individualized medicine. But in reality, there are some instances and factors, which we'll discuss more in a moment, that can really dictate and limit potentially the drug availability access that you may have at a critical access hospital. I think sometimes we have this idea that a critical access hospital are really the minimalists of health care, where they have just enough of the supplies they need to survive. And I'm not so sure that that's always the case, but there are definitely factors that may contribute to this being true or maybe not so true. So I think access to critical care medications is pretty heavily dependent on the drug budget and the allocation of that budget. There are certainly some quintessential items that we feel like we must have. But then there are also some maybe luxury items that aren't necessary but sure would be nice to have. And so we'll talk in a few minutes about how critical access hospital as part of a health system may have its pros and cons related to this, as well as those related to a private hospital. Not only does your budget determine and influence that access to the variety of medications you have access to, but also the stock, the inventory of some of those medications, especially those that are very potentially cost prohibitive. We live in a time where medication shortages are of utmost importance and probably keeps a lot of pharmacists up at night. So drug procurement is really important as we talk about and consider medication access at critical access hospitals. And again, I think this is one of a really big influencer of this is whether a critical access hospital is part of a larger health system or is maybe privately owned. Part of a larger health system, they have certainly have more purchasing power. And so things that are on shortage from a manufacturer or from a wholesaler, they have priority points. So they are more likely to be able to procure drugs that are on shortage. However, when you're part of a larger health system, you also have the constrictions. You have to buy from certain manufacturers and use certain wholesalers. And so you're a little bit limited from that standpoint. On the opposite end of that, if you are a private hospital, you certainly do not have the purchasing power. So with your small purchase orders, you do not have any priority. So if drugs are on back order from a manufacturer, you are at the very bottom of the list. The difference though is that you are not restricted by a formulary or any specific wholesalers. And in fact, you also don't really have the governance. And if you need, some of these private critical access hospitals can also gain access to medications off the gray market. Now when we talk about medication access at critical access hospitals, it's not only important to talk about the influencers or factors that determine what drugs you have on hand, but also what about the drugs that you don't have on hand in case of an emergency. Here if you're a part of a health system, you probably have access to a courier service where you can just shift drugs from one sister hospital to the next. If you're an independent or privately owned hospital, you may have to borrow a drug from one of your neighboring hospitals, or you may have to buy drugs from one of your neighboring hospitals. And if you can't do that, you may have to transfer a patient. It's also important to determine how terrain and weather may limit these options. For example, if you do rely on a courier service, that courier service will have the same weather restrictions or terrain restrictions that you have for transferring a patient out. I've certainly heard some horror stories about being unable to transfer a patient and they run out of Crofab, for example, or surfactant for a pediatric patient. Likewise, you may have to, I've heard stories of having to hire a state patrol officer to serve as your courier service to transfer drugs from one health system to the next. We've talked about pharmacy services provided, but it's also important to remember and consider how pharmacy services or medications are accessed and provided when there are no on-site pharmacy services that are offered. So I know I mentioned that a lot of hospitals can outsource, do telepharmacy services. They may or may not be able to supervise technician activities on site from a remote location. Again, that's really dependent on state law and regulations. So when the pharmacy is closed, a lot of the access and the care that's provided is really determined by drug access, like what is available on the floor, what's your floor stock and your omnicells or whatever other medication dispensing cabinets that they may use. Pre-mixed medications that may be available, because certainly you have to worry about drug stability. And then in the off chance that medications are needed from the pharmacy that are not stocked on the floor, what's the process that, what does that look like? And so I know some hospitals, they will send two nurses that have specific credentials to access into the pharmacy and they will pull the medications that they need. And there's a lot of internal policies and procedures. So they may have to pull two of whatever drug they need and leave one of them for the pharmacist that comes in the next day or whenever the pharmacist does become available and document what they removed and those types of things. But again, a lot of your regulatory bodies, they're a little bit unclear about pharmacy services and medication prescribing and dispensing, specifically focusing on the dispensing. And rules and regs are not very clear related to this. And I think there's a lot of opportunity for improvement here. And medication access and pharmacy services provided really come to fruition and sometimes dictate the type of care that we provide to patients. For example, in a critical access hospital, you don't have the luxury of always having central line access. Central line access. And so in general, it's probably safer to have standard stock drug concentrations that's safe to be administered peripherally. Smaller over larger bags of drugs to dispense. And this has a lot to do with, again, inventory management. If you're a triage and transfer hospital, we don't want to give a patient a drug infusion that could last for 12 hours and they're only there for four hours because we just burned eight hours worth of drug inventory. So really talking about cost containment and medication waste is extremely important. IV push and short infusion times are preferred over prolonged or continuous infusions for a lot of that same reason, as well as the education and experience and skill set of the staff, whether it's pharmacy or non-pharmacy staff. You may be limited in the resources that you have for monitoring paralytics, for example. And so a continuous infusion paralytic may be very prohibited, but you may be able to get away with maybe push dose boluses of paralytics as an example. In summary, there are several factors that influence pharmacy services, drug availability and access to medications. Relationships between the critical access hospital and the surrounding hospitals are crucial for drug acquisition, whether it's for borrowing or buying from neighboring hospitals. Definitely influences direct patient care because there's got to be decisions made between transferring patients out versus borrowing drugs and bringing those in. And also directly as it relates to transitions of care and transferring those patients to the neighboring hospitals. And one thing I can't emphasize enough is if you work at a larger health system where you receive transfers from your critical access hospitals, it's so important to get to know the details of those surrounding critical access hospitals, the services that they provide, the drugs that they have available, because that can significantly help you with the expectations that you have in receiving those patients, the empathy for the services that they provide and the quality of care that they're providing patients with the resources that they have available to them, as well as just the transferring process.

critical access hospitals

pharmacists

pharmacy staff

drug therapy

patient care