Healthcare often suffers from the silo effect—the lack of sharing vital information across disciplines—which impedes patient care coordination. Operating with a silo mentality not only reduces efficiency and the quality of care but also can have serious patient safety implications (1).
Efforts to enhance patient safety nationwide are underway as healthcare transitions from a fragmented model to an integrated system that fosters a multidisciplinary approach. Connecting healthcare silos through teamwork, collaboration, and communication has contributed to improved patient safety across various disciplines (2). However, literature reports of collaborative efforts between laboratory and pharmacy remain relatively scarce. The paucity of reports on such collaborations is surprising considering that both disciplines are integral to the care of all patients, and that cultivating such partnerships can significantly impact the value of lab tests and drug therapies.
This article highlights examples of laboratory–pharmacy partnerships at University Hospitals Case Medical Center (UHCMC) and the Cleveland Clinic Health System that are providing safer and more coordinated patient care.
Collaborative Therapeutic Drug Monitoring
Monitoring levels of high-risk drugs in the bloodstream can minimize the risks of adverse events due to toxicity and maximize effectiveness by facilitating a constant therapeutic concentration. The timing of specimen collection is crucial because an incorrect draw time relative to the last dose may lead to inaccurate interpretation of test results. Timely result reporting is also important to facilitate prompt dose adjustments when necessary. The success of therapeutic drug monitoring (TDM), therefore, relies heavily on input from both the laboratory and pharmacy and benefits greatly when these two professions collaborate to streamline processes and provide more effective patient care.
At UHCMC, we initiated a laboratory–pharmacy collaboration to optimize TDM of immunosuppressant medications in transplant patients. We found that many patients were having blood drawn at inconsistent times in relation to their previous dose due to variations in the dosing times and in phlebotomy workflow. These variations led to many instances when the blood drug levels did not reflect true trough levels. In addition, results were not always reported in time to make an adjustment prior to the next dose.
The laboratory–pharmacy team tackled this problem by defining consistent draw times (5:30–6 a.m.) and dosing times (6:30 a.m. and 6:30 p.m.) for transplant patients. This improved the frequency with which patients have true trough levels drawn. Under our new process, phlebotomists go to the transplant floors first for morning blood draws and a nurse further expedites collection by flagging the charts of patients who need therapeutic drug levels determined.
Defining the morning run times for immunosuppressant levels in the lab enables results to be available by early afternoon and increases the frequency of drug doses being changed pre- versus post-evening dose. The improvements made by this collaboration also resulted in fewer redraws to assess drug levels, which conserves resources and prevents additional patient discomfort.
Antimicrobial Stewardship
Multiple organizations, including the Centers for Disease Control and Prevention and the World Health Organization, have recently voiced concerns regarding the increasing incidence of multi-drug resistant organisms. Health systems are now focusing efforts in antimicrobial stewardship, which seeks to achieve optimal clinical outcomes related to antimicrobial use, including minimizing toxicity and other adverse events, reducing infection-related healthcare costs, and limiting selection for antimicrobial resistant strains (3). Increased laboratorian–pharmacist collaboration can achieve these goals by accelerating the notification of actionable microbiology results and subsequent adjustment of antimicrobial therapy.
The microbiology laboratory and infectious diseases pharmacists at Cleveland Clinic are collaborating on a stewardship intervention involving rapid diagnostic tests for blood cultures. Pharmacists are notified immediately of positive results and they review patient histories promptly. The pharmacist then notifies the primary medical team of the positive result and any recommended changes in antimicrobial therapy. Verbal communication of positive laboratory results to the pharmacist allows patients to receive targeted antimicrobial treatment sooner. Direct interaction and feedback between the pharmacist and ordering prescriber helps reduce inappropriate use of antimicrobials.
Pharmacogenomics
Pharmacogenomics is an emerging area in medicine that takes into consideration the contribution of genetic variability on drug response. Certain medications administered at recommended doses may yield sub-therapeutic drug levels or cause toxicity due to variations in patients’ genetics. Because pharmacogenomic testing is based on genetic characteristics, the results will not change and can be used to guide medication therapy throughout a patient’s life. Laboratory–pharmacy collaborations are useful in this area to facilitate appropriate test utilization, selection, and interpretation so patients receive suitable drug therapy.
At Cleveland Clinic, our laboratory and pharmacy departments are collaborating on test utilization efforts to ensure that we interrogate appropriate genetic variants for select pharmacogenomic test orders, and that we place the results in the electronic medical record (EMR) for easy accessibility. When the laboratory receives these test results, we enter them into discrete fields in the EMR that are displayed differently than other laboratory results. This makes pharmacogenomic results easily accessible over an extended period of time and ensures they are not buried behind other test results. Additionally, our EMR has clinical decision support functionalities that notify physicians of relevant pharmacogenomic test results when particular medications are prescribed.
Collaborative Approach to
Quality Management
Hospital pharmacies perform sterile compounding of parenteral medications and nutritional products. However, both automated compounding devices and manual preparation techniques carry risks for errors that can lead to patient harm. Laboratorians and pharmacists working together can minimize medication-related errors and improve patient safety by ensuring that medication solutions are mixed accurately.
The UHCMC laboratory and pharmacy have collaborated to implement an additional quality check for the total parenteral nutrition (TPN) batches formulated daily for our pediatric and adult patients. We prepare daily two batches of each formulation and send samples from each batch to the laboratory for testing to ensure that the components are within acceptable limits. The lab calls the results to a pharmacist who signs off on the acceptability of each batch before it is released for patient use. This check ensures that we detect any large variations in either the TPN content or our preparation practice.
Laboratory and pharmacy have successfully collaborated on multiple projects to improve patient care at our institutions. Working toward a shared goal helped each department gain a better understanding of what they contribute to a process and enabled all parties to provide input on how to improve it. Although initiating projects between departments may be challenging, the potential benefits of collaboration are well worth the efforts.
Starting with small interdisciplinary projects to improve patient safety issues helps break down organizational barriers and leads to small victories, creating momentum for larger-scale efforts in the future. By moving away from the silo mentality, our institutions have been able to utilize the expertise of both laboratorians and pharmacists to have a greater impact on patient care.
Tips for Effective Multi-Disciplinary Collaboration
Start from the top
A culture of collaboration begins by establishing a leadership team. Select individuals from your department to serve as leaders who will oversee collaborative efforts and drive progress.
Get on the same page
Working toward a shared goal is a key component of successful collaboration. Establish clear goals and expectations that are aligned so everyone understands the objective.
Know your role
For effective partnerships, define the roles and responsibilities of each team member and each department to promote accountability and efficiency.
Map the process
Mapping the process together—taking current departmental workflows and needs into consideration—is the best way to avoid inefficient and non-sustainable processes. Encourage input from front-line team members to contribute to long-term solutions.
References
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
- Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol In 2014;5:S295–303.
- Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–77.
CLN's Patient Safety Focus is sponsored by ARUP Laboratories.
