Medication Education Process Prior to Student Involvement
The EPITOME program was designed to provide all patients with information about their medications throughout their hospitalization.7,8
Nurses were trained to provide medication information each time they administered a medication from the day of admission through the day of discharge. For patient care units with a unit-based pharmacist, that pharmacist provided medication education to patients identified as candidates for pharmacist-delivered education. For those units without a unit-based pharmacist, a staff pharmacist was assigned each day to provide education to all patients who met the consult criteria.
Each morning, pharmacists assigned to EPITOME downloaded the list of eligible patients to tablet computers. The patients on the list included those not currently in an intensive care unit (ICU) who had not already received pharmacist education during the current admission, had been in the hospital for greater than 1 day, and for whom greater than 10 scheduled oral medications had been prescribed as identified by the hospital's clinical data repository (Medical Archival Systems [MARS], Pittsburgh, Pennsylvania). The pharmacists then triaged the patients who would be seen that day. Priority was given to patients who eventually would be discharged to home and managing their own medications. Patients who would be discharged to a long-term care facility did not receive the service. Education was delayed for patients who were acutely delirious or who would be undergoing a major procedure or surgery, and those for whom discharge plan was not yet known. Caregivers, if they were available, were the focus of the education in the cases of patients with dementia who would be going home.
During education sessions, the Health Behavior Change Model9-11
was used by the pharmacists to assess the patient's baseline knowledge, attitudes, and readiness for new information before verbal medication education was provided. Although the style for each education session was left to the discretion of the pharmacist and tailored to the unique needs of each patient, pharmacists routinely educated patients on the indication, dosage, side effects, and other medication-specific information for all medications that would likely be continued following discharge. Medication education was not necessarily provided on the day of discharge since patients who are educated about medications on the day of discharge did not recall medication information better than those educated a few days prior to discharge.12
During the work-up and education session with the patient, the pharmacists also conducted medication reviews. Within the permanent medical record, the pharmacist wrote a note in the progress note section that described the education session, provided an assessment of the patient's medication knowledge and compliance, and if needed, included recommendations to improve the patient's medication regimen.
Inpatient Medication Education Advanced Pharmacy Practice Experience
Within months of implementing EPITOME, it became evident that time constraints made it difficult for the unit-based staff pharmacists to conduct a thorough chart review in order to successfully provide a meaningful education experience for the patients. Since the hiring of additional pharmacists was not possible, other options for maintaining the EPITOME program were contemplated, including offering an experience to pharmacy students. As a result, the hospital's pharmacy operations managers and the pharmacy faculty coordinator for the EPITOME program met with the director of experiential learning at the University of Pittsburgh School of Pharmacy to propose an Inpatient Medication Education APPE.
At the time when the Inpatient Medication Education APPE was first offered in May 2007, the APPE program at the University of Pittsburgh School of Pharmacy was administered in twelve 4-week blocks. During the last (P4) year of the PharmD curriculum, each student completed 7 of these 4-week APPE blocks. Students selected 1 each of 4 types of APPEs: community, ambulatory care, institutional, and acute care/internal medicine. Students also selected an additional ambulatory care or acute care/internal medicine APPE. Two APPEs were selected from a variety of elective options across a wide array of practice settings, services, and experiences. Following the completion of each APPE, all students completed a standard evaluation supplied by the school. The evaluation included 9, 6, and 8 survey questions for the students to answer using a Likert scale to evaluate the preceptor, practice site, and their self-learning, respectively, during the APPE. It also included a section for written comments. These evaluations were de-identified and shared with the preceptor periodically.
As a result of the collaboration between the school and hospital, an Inpatient Medication Education APPE was created and offered to 1 student for each of the twelve 4-week rotation blocks, effectively increasing the personnel devoted to the EPITOME service by 1 for 48 weeks per year. The hospital's EPITOME-trained pharmacists trained and supervised the students.
The goal of the first week of the Inpatient Medication Education APPE was to orient the student to the hospital and to EPITOME procedures. On the first day, the student was provided with an overview of the program and a brief course on the principles and application of the Health Behavior Change Model. The student was taught how to access the patient lists from the electronic server and become familiar with both electronic and written medical records to determine whether the patient met the criteria for pharmacist education. The student spent much of the second and third days observing and helping the preceptor perform chart reviews to prepare for and conduct patient education. By the fourth day, the majority of students were competent to independently assess patients' needs for education and identify drug-related problems. By the sixth day, the majority of students were confident enough to lead the patient education session.
Upon arrival at the site each day, the student independently downloaded the patient list, triaged the patients to be seen that day, and began assessing patients. This process is included in Appendix 1
. Throughout the day and at convenient times for the unit-based clinical pharmacist, the student presented patients to the pharmacist and highlighted specific points to be discussed. The pharmacist accompanied the student into each patient's room for the education session and allowed the student to conduct the interview and education session, only interrupting to clarify or add anything that the student may have missed. For each patient, the student prepared a handwritten progress note that documented the education, assessed the patient's understanding of his or her medication regimen, and noted any recommendations for improving the patient's medication regimen. After the pharmacist reviewed and cosigned the note, the student placed it in the patient's chart. The pharmacist provided informal verbal feedback to the student following each patient encounter in an effort to help the student improve his or her patient assessment and counseling skills.
During weeks 2 through 4, students typically triaged 6 to 10 patients per day and counseled 2 to 5 patients per day. In addition, the students were required to prepare 2 formal presentations. Typically, 1 of the presentations was an overview and literature review of a newly approved medication or an overview of recently publicized news related to a particular side effect or new indication for a medication. The second presentation was a case presentation that included a disease-state overview as well as an overview of therapeutic alternatives for the treatment of the disease state. Students also met with 1 of the pharmacists each week to review a topic that was either assigned by the pharmacist or selected by the student in advance.
To assess the impact of the role of students within the EPITOME program, the numbers of patients assessed, educated, and provided medication therapy management during the 3-month time period prior to student involvement was compared to the first 3 months of the APPE.