Andrew Williams, PharmD, BCPP
Supervising Clinical Pharmacist, Behavioral Health
Riverside University Health System
Riverside, CA
Dr. Andy Williams is a graduate of the USC School of Pharmacy. He completed his PGY-1 with Psychiatric emphasis at Keck Hospital of USC and PGY-2 in Psychiatric Pharmacy at USC School of Pharmacy/LAC+USC Medical Center. He currently practices at Riverside University Health System (RUHS) in Riverside, CA as the Supervising Clinical Pharmacist of Behavioral Health Pharmacies. In that role, he serves as the PIC and supervisor of the County of Riverside’s inpatient, discharge, and ambulatory mental health pharmacy operations and clinical services. He has implemented clinical pharmacy services in both the inpatient and outpatient settings, serves as the RUHS PGY-2 Psychiatric Pharmacy Residency Program Director, and is actively involved in the American Association of Psychiatric Pharmacists (AAPP).
“If it wasn’t documented, did it ever happen?” We have all heard this phrase at some point in our training. While documentation may enhance clinical communication and satisfy regulatory and legislative mandates, the importance of documentation extends beyond just clinical progress notes or time spent with a patient. As we continue to demonstrate and justify the importance of having a psychiatric pharmacist as part of the medical team, the amount and type of interventions we have made should be readily available – primed to be used as objective talking points for any potential “elevator pitch” for which you may be faced. Tracking what we do can be eye-opening for supervisors, other disciplines, and sometimes – ourselves. That said, I’d like to share some insights I’ve picked up along the way thus far in my career.
Who should be documenting and tracking interventions?
Everyone! The whole psychiatric pharmacy team should be involved in documenting interventions. You will want to coordinate amongst each other, and make sure that all individuals tracking interventions are on the same page. This will increase the total number of interventions being tracked and provide a more accurate depiction of the psychiatric pharmacy team’s contribution to patient care. If you are the sole psychiatric pharmacist at your facility – no problem! You can always track your own interventions and eventually enlist the assistance of others, such as pharmacy trainees, pharmacy technicians, staff pharmacists, or ancillary staff. At our institution, we require that pharmacy trainees track all interventions that are made while on rotation and use that exercise as a teaching opportunity. Students and residents should be keeping a running tally of meaningful interventions as well, because they will definitely come in handy during residency or job interviews!
What interventions should we be documenting?
Everything! This answer hangs on how we define “intervention.” What is an intervention? Is it every time you touch the patient chart? Every time you interact one-on-one with a patient or with the treatment team? Every time you need to correct a medication order or prescription? All the above? Before getting started with tracking interventions, you will want to have a clear plan of what you want to be tracking. If the thought of tracking every keystroke sounds overwhelming and unfeasible – it probably is. So, start smaller and focus on some key initiatives. One detail to remember is that in addition to the type of intervention being made, the response to intervention is just as important. Be sure to track how effective your interventions are because the level of reception or impact will help guide future intervention efforts.
Where and how can I track my interventions?
Everywhere! Okay… maybe not everywhere. But never underestimate a good old-fashioned computer spreadsheet. My team knows me well and has already come to expect that after we come up with a new clinical service idea, the immediate next step is to “make a tracking spreadsheet.” We store our shared data spreadsheets on a network drive that we can all easily access from any computer within the health system. We like to utilize spreadsheets particularly for interventions that may evolve into some type of research project or justify a new, specific clinical service. At our institution, this level of intervention tracking is typically only accessed by 4-5 pharmacists.
We also track interventions directly in our electronic health record (EHR), Epic. This type of intervention tracking is heavily utilized in our inpatient setting, particularly when verifying medication orders, conducting medication reviews, making recommendations, etc. Furthermore, our EHR intervention tracker has a feature that allows the intervention documentation to be converted into a progress note that will be placed in the patient’s chart. Therefore, we are able to utilize this feature to improve efficiency when documenting any of our pharmacy clinical interventions. These EHR interventions are viewable by anyone in the pharmacy department, including those outside the psychiatric pharmacy team. They are used as a communication between different shifts (overnight shift, weekend shift, etc.) and can be easily tracked by reports that are generated from the EHR system. Pharmacy administration is able to easily access this level of data tracking, and can use this information to justify the addition of staff to a clinical area, in employee performance evaluations, or for other administrative tasks, such as tracking adherence to regulatory and legislative requirements.
Another area that we utilize to document and track interventions is in our institution’s incident reporting (IR) system. There are several systems available, but our institution utilizes Datix. Datix is an IR software where employees can report events that causes a loss, injury, or near miss to a patient, staff, or others. This toolis particularly helpful at tracking specific, higher impact medication error/medication safety interventions. We have used this route of tracking when we need to proactively call attention to or resolve hazards prior to a more severe or tragic outcome occurring. Of the three examples of tracking, this example involves a multi-disciplinary committee who will be monitoring and tracking the interventions. By monitoring and reporting the number of instances that safety deviations occurred, the multi-disciplinary team is able to initiate immediate corrective action plans to address the risky situation. We’ve used this method in the past to address antipsychotics being administered intravenously, long acting injectable antipsychotics being administered incorrectly, certain psychotropics (i.e. lamotrigine, clozapine) being titrated too rapidly, insulin protocol deviations, etc. Worth noting, this method also takes the most time to enter an intervention, given the amount of detail necessary for the incident report tracking system, but is particularly helpful when we encounter serious safety risks or widespread institutional concerns.
When should I be tracking my interventions?
Every day! As supervisor for the mental health pharmacies, my job is to make my team shine. The best way to do that is to brag about all the wonderful interventions that they are completing on a day to day basis. I compile our psychiatric pharmacy team’s interventions and include them in monthly, quarterly, and annual reports for various committees and meetings.
RUHS Psychiatric Pharmacists operate under a collaborative practice agreement granting them mid-level practitioner status in the outpatient setting. As such, we keep intervention spreadsheets for each psychiatric pharmacy clinic where we log interventions into 1 of 11 types: medication education, medication started, medication stopped, dose adjustment, medication change (ADR), medication change (DDI), medication refill, lab ordered, mental health rating scale administered, provider education, collaborative care for patient. The psychiatric pharmacist logs these interventions after each clinic day. When it comes time for reports, we are then able to quickly present stratified data to medical directors or other key stakeholders as necessary.
On our inpatient units, psychiatric pharmacists log interventions made for patients receiving multiple antipsychotics, clozapine monitoring, medication education group attendance, long acting injectable monitoring/recommendations, high risk medication reconciliations, antibiotic stewardship, metabolic monitoring and diabetic glucose monitoring. The pharmacists log their interventions daily, and I am able to present data to hospital administrators on the advantages of utilizing psychiatric pharmacists. For example, RUHS psychiatric pharmacist interventions have improved the antibiotic management of urinary tract infections, decreased the number of patients discharged on inappropriate dual antipsychotic therapy, and increased utilization of long acting injectable antipsychotics. In each of these instances, we are able to present the exact number of recommendations/interventions made and patient’s medical records that these interventions are associated with.
It’s vital that you incorporate time to document interventions into your workflow. The more time that goes by, the less likely you are to remember everything you did. You want to give yourself credit for your work, but at the same time, remain efficient. I recommend that you document your interventions at least daily.
Why should I track my interventions?
Beyond tracking the interventions, you need to share those results! If you are taking the effort to regularly document interventions, you will want to have a greater purpose for that documentation. Taking a step back and dissecting the amount and types of interventions that you have made will assist you in identifying areas of clinical expansions and fine-tune your current service. The amount and type of interventions will justify your job! The interventions will serve as an objective measure to illustrate all your hard work. They can be presented to your supervisor during one-on-one meetings or during performance evaluation sessions. Furthermore, they can be presented to health system committees, such as Pharmacy & Therapeutics, Psychiatry Department meetings, etc.
Consistency with interventions is key, one can’t expect miracles or rapid change after one intervention. For example, initiation of medication education groups at our institution took place in 2017 as part of an interdisciplinary initiative to decrease patient on patient assaults on our inpatient units. To date, the psychiatric pharmacy team is still commended by other disciplines for their continued commitment to the medication group process and the large number of patients who are reached through this service. This dedication and persistence catches the attention of hospital administrators as well as we were just rewarded with new office furniture as a thank you. Furthermore, the increased presence of psychiatric pharmacists physically present on the unit has gained the attention of our psychiatric emergency department staff who has requested that a psychiatric pharmacist work alongside them in the emergency department.
In an effort to support this continued growth, we are currently working on an administrative project at our institution involving tracked interventions being used to calculate budgeted labor hours for our clinical area. Currently, the amount of labor hours allotted to our mental health pharmacy is calculated with a formula incorporating the number of doses dispensed in the inpatient setting and the daily prescription count from the outpatient setting. To further justify the presence of clinical pharmacists, we plan on incorporating the biweekly number of interventions into this formula as well.
Tracking interventions and clinical psychiatric pharmacy research also go hand-in-hand. As previously mentioned, we commonly track interventions when we initiate a new service project at our institution. Sometimes, however, clinical projects have been brainstormed out of an already existing collection of interventions. You never know when a bright idea is going to strike and having your interventions already at your fingertips will greatly facilitate project formation. We’ve been successful at publishing manuscripts and presenting poster abstracts using our tracked interventions.1-9
Ultimately, tracking your interventions and sharing that data further justifies your hard work and exemplifies the advocacy we have for our patients. We can all learn from our collected data and continue to advance our specialty forward. Don’t be scared to toot your own horn, and that first toot happens with documenting your interventions.
