Hospital Pharmacy - July/August 2019 - 234

234

Hospital Pharmacy 54(4)

Table 1. TheraDoc® Alerts.
Alert category

Laboratory parameter

Blood glucose
Magnesium
Phosphorus
Potassium
Sodium
Lactate

<70 or >180 mg/dL
<1.7 or >3 mg/dL
<2.6 or >4.6 mg/dL
<2.8 or >6 mmoL/L
<128 or >152 mmoL/L
>2 mmoL/L

In July 2015, a residency-trained critical care pharmacist
joined the current pharmacist to form the tele-ICU Clinical
Pharmacy team and provided the system with its fifth adult
critical care clinical specialist. Tele-ICU pharmacy services
went live in September 2015, with the 2 telepharmacists
alternating VCC coverage weekly, with one working in the
tele-ICU and the other working as a rounding clinical specialist at a 35-bed medical-surgical ICU at the system's second largest facility. Staffing limitations precluded dayshift,
overnight, and weekend telepharmacist coverage. In July
2017, a dayshift pharmacist began to provide coverage for 4
hours a day, 3 days a week. Initially, telepharmacists worked
from the COR location, but with continued expansion, additional nursing space was needed. This allowed the pharmacists to work from bunkers.
During the months preceding go-live, the telepharmacists
familiarized themselves with TheraDoc® with the goal of
using this secondary platform for custom alerts, stimulus for
interventions, and report generation. This was necessary
because of the difficulty of extracting pharmacist intervention data from the EMR. Data retrieval was streamlined with
the TheraDoc® system and assisted with ongoing progress
reports for the tele-ICU physician leadership and both critical care and pharmacy administration. TheraDoc® alerts
were designed for abnormal glucose, electrolyte, and lactate
levels (Table 1).
Custom intervention categories were also designed in
TheraDoc® to allow telepharmacists to tie interventions to
alerts and included 6 overarching categories: glucose management, medication management, Code Sepsis evaluation,
electrolyte management, stress ulcer prophylaxis, and venous
thromboembolism prophylaxis. Individual intervention
activities (eg, increase sliding scale insulin or add basal insulin) were added to each category to provide depth to intervention reporting. A seventh category, blood culture
identification (BCID) calls, was added in 2017. Descriptions
of the activities performed in each category are included in
Table 2.

Second-Shift Workflow
A standard workflow was developed and refined by the
telepharmacists. This model is remote patient monitoring
with asynchronous communication and a responsive mode of

care. Although real-time, synchronous video communication
capabilities are available, the second-shift model does not
incorporate this technology. TheraDoc® alerts are the primary source for prompting patient review on second shift,
with each alert generating a full chart review in addition to
investigation of the alert. At the beginning of each shift,
interventions are manually tallied by the pharmacist. This
provides an initial snapshot of the anticipated workload
throughout the day; however, it is an overestimation as
patients without ICU-status orders and those at the quaternary referral center are not routinely reviewed. EMR reviews
are also conducted for new admissions or when consulted by
a VCC or bedside provider for assistance.
On second shift, interventions are proposed to intensivists
via an electronic triage board. The tele-ICU pharmacist
enters pertinent details and the requested medication or laboratory orders. This request is flagged directly to the tele-ICU
intensivist who reviews and responds to the pharmacist
within the intervention request in real-time. After the intensivist agrees with a recommendation or provides an alternate
course of action, the pharmacist enters these orders as a verbal communication and writes a short progress note detailing
the changes in the EMR. The orders and progress note are
then cosigned by the intensivist, so they appear readily in the
chart for the bedside nurses, physicians, or pharmacists to
view. The medication changes are then communicated to the
bedside nurses by the tele-ICU nurse or the pharmacist
(Figure 1).
In January 2017, second-shift VCC pharmacy collaborated with the Antimicrobial Support Program (ASP) to
receive calls from the microbiology laboratory regarding
positive rapid BCID results. The VCC pharmacist receives
these calls from 4:30 pm to 10:30 pm and is responsible for
initiating or escalating antimicrobial regimens for inpatients
as well as notifying emergency departments, pediatric pharmacists, and primary teams of patients requiring follow-up.
Although the process for obtaining orders was the same for
ICU-status patients, non-ICU-status patients required contacting the primary physician team (or infectious diseases, if
consulted) via page, a secure text messaging platform, or via
telephone. In this model, orders were ultimately entered by
the provider or as a telephone order by the VCC pharmacist
after a phone call had occurred. This further expanded the
scope of the tele-ICU pharmacist.

Dayshift Expansion and Workflow
In early 2017, the second-shift tele-ICU pharmacists were
approached regarding the addition of a critical care pharmacist to the VCC team to determine the feasibility of dayshift
services. This pharmacist also serves as faculty at a nearby
school of pharmacy and wished to establish an innovative
practice site. After this pharmacist shadowed the secondshift tele-ICU pharmacists for several weeks, the pharmacist
transitioned to daytime hours to determine workflow. This

Hospital Pharmacy - July/August 2019

Table of Contents for the Digital Edition of Hospital Pharmacy - July/August 2019