How would you push for this?

[Sparda29]

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I want to be able to order labs and tests as a pharmacist. In NYS, we are able to do that but not under hospital policy. I've brought this up to the clinical pharmacist and director a few times but nothing so far. I'm guessing they don't have the time for this right now and I'd probably have to come up with some plan/presentation onto why we should be able.

Has anyone done this at their hospital? How would I go about it?

My main thing would be that physicians/PAs/NPs wouldn't have to be called each time we need to order a simple CBC/SMA7/INR/, therapeutic drug level, etc. 10-20 times a day I have to track down these people to get these labs ordered.

The computer system technically allows me to do it with no restriction, but if someone looks into it and sees that I ordered it without physician approval there can be a complaint about scope of practice, etc.

Hell, one time I ordered labs on behalf of a physician who wasn't in the hospital and I got written up because apparently only the provider or nurse is allowed to enter it.

 

[mustang sally]

I feel like you get the most support with ideas if your director is on board (at least that's the case in my hospital). Did your director ever say anything about it when you mentioned it to him/her? If the DOP is opposed to the idea, I would find out why and take it from there.

Another (more tedious) option might be to do it by passing protocols through P&T. For instance, do you have pharmacy to dose protocols in your hospital for things for vanc and aminoglycosides? If so, it seems like the protocol should allow for pharmacy to order the relevant labs. If not, you could try to write some protocols and get them passed.

 

[Protongenic]

I want to be able to order labs and tests as a pharmacist. In NYS, we are able to do that but not under hospital policy. I've brought this up to the clinical pharmacist and director a few times but nothing so far. I'm guessing they don't have the time for this right now and I'd probably have to come up with some plan/presentation onto why we should be able.

Since I'm unfamiliar with NYS laws, did you mean that NYS pharmacists are not allowed to have a hospital protocol that allows them to order INRs and labs, or that you currently don't have a protocol at your institutions that allows pharmacists to order labs?

In the hospitals that I've practiced in, pharmacist lab-ordering is usually covered under service-specific protocols (e.g. pharmacist managed anticoagulants, antibiotics, etc). In most cases, there would be a specific section embedded into the protocol somewhere that spells out the lab requirements in addition to how to initiate therapy, monitoring, documentations, pertinent guidelines, etc. For example you may see something like the following in a warfarin protocol:

"Baseline PT/INR, CBC if not done within previous 24 hours; pharmacist to order baseline labs above if not already ordered by physicians."

After the protocol is written, depending on the structure of your organization, it may need to be reviewed by the department clinical managers/informatics group, the appropriate P&T Sub-Committees, discussions with physician champions, and/or P&T.

I would take a look at a few examples of protocols that other institutions have implemented; observe the structure and wording before drafting one for your own facility. It would also be super helpful to have the support of your clinical managers/DOP before you start.

Here's an example from University of Kentucky - see page 111 under "Ordering" http://www.hosp.uky.edu/pharmacy/formulary/criteria/Clinical_PKS_Manual-July_2010.pdf

I'd also be happy to share protocols that I have if you think they'll help; just PM me and let me know.

Good luck! 🙂

 

[StellargalS]

Develop an evidence based protocol with a value proposition for all concerned and recruit a physician champion. Then go to pharmacy people.

 

[sakigt]

If youve got a TDM policy, ordering drug levels should be on it, period. If you want to monitor renal function youll have to order just a SCreat, if a Chem 7 isnt already done. If the K comes back high youd be responsible for acting on that level (as the ordering doc per protocol, etc etc).

If youve got a Warfarin monitoring policy, see above. Have it written in. If youve got patients on Warfarin w/o monitoring parameters (like I do actually), we dont verify the order until we see PT/INR results. If you dont ahve that we have to track down an order for one.

 

[zelman]

I might start by keeping track of how much time you spend trying to get labs ordered, and compare your salary for that time to the cost of the labs which providers do not want to order. If more money is spent on your time than would have been spent on unnecessary labs, it seems like a no brainer.

And/Or, when you prompt providers to order labs ask them if they were planning on ordering the lab before you called and keep track of results. If they were going to order it, you would've saved their time if you had lab authority. If they were not going to order the lab and a clinically relevant result comes up, you've got case studies to present and liven up your thus far statistics based argument.

 

[xiphoid2010]

Have labs relevant to drugs dosed by pharmacy in those protocol/policies is the easiest way to justify and get approved through P&T. Also minimize cost and liability to everyone.

 

[Sparda29]

I feel like you get the most support with ideas if your director is on board (at least that's the case in my hospital). Did your director ever say anything about it when you mentioned it to him/her? If the DOP is opposed to the idea, I would find out why and take it from there.

Another (more tedious) option might be to do it by passing protocols through P&T. For instance, do you have pharmacy to dose protocols in your hospital for things for vanc and aminoglycosides? If so, it seems like the protocol should allow for pharmacy to order the relevant labs. If not, you could try to write some protocols and get them passed.

I think the only way is going through P&T and I believe the clinical pharmacist and the DOP are the only ones who go there. Not sure if I'd be allowed to go there, and even if I was, I think it probably happens before my shift starts at 3PM. I don't think my union will like me doing work related stuff off the clock, and my DOP would never pay me overtime to attend a P&T meeting.

Since I'm unfamiliar with NYS laws, did you mean that NYS pharmacists are not allowed to have a hospital protocol that allows them to order INRs and labs, or that you currently don't have a protocol at your institutions that allows pharmacists to order labs?

In the hospitals that I've practiced in, pharmacist lab-ordering is usually covered under service-specific protocols (e.g. pharmacist managed anticoagulants, antibiotics, etc). In most cases, there would be a specific section embedded into the protocol somewhere that spells out the lab requirements in addition to how to initiate therapy, monitoring, documentations, pertinent guidelines, etc. For example you may see something like the following in a warfarin protocol:

"Baseline PT/INR, CBC if not done within previous 24 hours; pharmacist to order baseline labs above if not already ordered by physicians."

After the protocol is written, depending on the structure of your organization, it may need to be reviewed by the department clinical managers/informatics group, the appropriate P&T Sub-Committees, discussions with physician champions, and/or P&T.

I would take a look at a few examples of protocols that other institutions have implemented; observe the structure and wording before drafting one for your own facility. It would also be super helpful to have the support of your clinical managers/DOP before you start.

Here's an example from University of Kentucky - see page 111 under "Ordering" http://www.hosp.uky.edu/pharmacy/formulary/criteria/Clinical_PKS_Manual-July_2010.pdf

I'd also be happy to share protocols that I have if you think they'll help; just PM me and let me know.

Good luck! 🙂

I meant that we don't have a protocol at our hospital that allows pharmacists to order labs.

Why is it so hard to track them down? I usually just send a text page and its done within the hour or they call back asking me to take care of it for them.. we are allowed to order labs at my hospital, I usually don't tho incase they want to get other lab work done at the same time (i.e. I only want a BUN/Cr but the can get a chem 10 out of that same amount of blood, etc). I also sometimes document in the chart with a note regarding dosing/follow up labs. If they don't order it, the nurses will get on them about it for me.

Most of the physicians who work at my hospital are private practice docs.

We have a few PAs throughout the daytime and nighttime, and an on-call "house doctor" who could be an MD, DO, PA, NP. The only residents at our hospital are the orthopedics residents.

The problem is that the private practice docs are very stealthy about making their presence in the hospital known. They come in quietly, see their patients, order what they want to order, and leave to go to another hospital or back to their office, home, etc. If I see a problem order from one of these guys, I quickly call the floor their on and sweet talk my way with the unit secretary to get her to find the doctor for me. If that fails I gotta page them on their pager # or page them overhead (which administration doesn't like). Then call their office, and if that fails call their answering service. Why can't these guys just have a direct cell phone and give that number out to the hospitals where they work?

Now the on-call house doctors don't like to get involved in much. One time the ID doc forgot to order troughs on all her patients, so I called the house doctor to put in the trough orders. Nope, he doesn't wanna get involved and tells me to just let the ID doc deal with it the next day.

 

[bacillus1]

You would likely have to go through your director. Also, to have a scope, you need to have 24 hour coverage under the scope, meaning that there need to be pharmacists during all shifts of the day that are willing to abide by the protocol.

 

[BenJammin]

A pharmacist has no business ordering labs unless there is a pharmacist/provider agreement where a drug dose can be changes/reduced/increased without direct approval. Hospitals do not need another reason to spend more money needlessly.

 

[zelman]

A pharmacist has no business ordering labs unless there is a pharmacist/provider agreement where a drug dose can be changes/reduced/increased without direct approval. Hospitals do not need another reason to spend more money needlessly.

We'd better get rid of pharmacist access to patient allergies then. Since I can't change an order for penicillin for a penicillin-allergic patient, why clutter my screen and waste time reviewing it?

Nobody is saying they want every lab for every patient (as nice as that would be...except for the resulting hypovolemia). There are just occasions when monitoring falls through the cracks, and we are in a position to help.