Patient Care

Hospitalists’ Afghan Tour Atypical of Medical Missions in Active Combat Zones


 

As my wife is a hospitalist, I was taken aback to find pictures of Ghazni on the front cover of her trade publication for February 2010. Your article was interesting from the vantage point that I actually lived it. I would add the following clarifications:

Maj. (Ramey) Wilson was the battalion surgeon in Ghazni from 2007 to April of 2008. I succeeded him as the sole American physician in the province for 2008 until Ghazni was turned over to the Polish battle group in November of that year. During that time, combat with enemy forces and IED (improvised explosive device) attacks became significantly more common than in the preceding years.

As a neurologist and clinical neurophysiologist, my expertise prior to coming to Afghanistan in trauma care and first aid was quite limited. Our physician assistant was deployed to another base in the province. As indicated in your article, the practice environment was exceedingly crude, without radiologic, lab, or nursing support. While Dr. Wilson had made tremendous strides with the provincial hospital system, the local Afghan health officials encouraged their physicians to send patients to our base when they felt uncomfortable, rather than proceeding through the Afghan system. This overburdened the aid station when the Afghan facility had superior equipment and resources.

Certainly, both the local population and NATO forces in Ghazni were very fortunate to have a physician of Maj. Wilson’s caliber, as he was a one-man state department and Level I trauma center all wrapped into a single package. When the mission became more combat-focused, the humanitarian portion became both more difficult and more dangerous, and tensions increased between the provincial government and our battalion. Further, only briefly alluded to in your article was the additional effect of prolonged family separation, which adds significant and severe psychological stressors during deployment and on return to the U.S.

In short, I suspect that Maj. Wilson’s “challenges met, success exemplified” is atypical of battalion surgeons in the Middle East combat theatre, and definitely was at odds with my own experience in the same area just months later.

John Ney, MD

Former Maj., U.S. Army;

former Battalion Surgeon,

1-506th Infantry, 4th Brigade, 101st Airborne; senior fellow,

clinical research, University of Washington Department of Neurology, Seattle

Consider HM-Pharmacist Collaborations to Solve Manpower Issues, Improve LOS, and Reduce Medication Costs

The 2008 American Society of Hospital Pharmacists and the Society of Hospital Medicine (ASHP-SHM) Statement on Hospitalist-Pharmacist Collaboration encouraged the development of partnerships in order to optimize outcomes in hospitalized patients.1 This alliance comes naturally, as hospitalists and clinical pharmacists share a common goal: improve patient care through implementation of evidence-based medicine. Despite strong encouragement, little literature exists to describe successful collaborations.

In 2008, Mercy Hospital of Iowa City and the University of Iowa College of Pharmacy jointly hired a clinical pharmacist to be devoted to the hospitalist group at Mercy Hospital. This new hire also became a member of a multidisciplinary team. The pharmacists’ duties were established through implementation of facets of the 2008 ASHP-SHM statement.1 Each of the following duties is incorporated into daily practice:

  • Attend daily hospitalist morning rounds and interdisciplinary rounds;
  • Review patient records on daily basis; confer information or recommendations to physicians as needed throughout the day;
  • Reconcile medication at admission and across the continuum of the hospital stay, including discharge;
  • Provide patient education and counseling as needed;
  • Serve as a drug information resource as needed to physicians, nurses, and other members of the interdisciplinary team;
  • Review medication regimens and prescribing practices to ensure adherence to evidence-based medicine and core measures;
  • Provide recommendations on pharmacokinetic drug monitoring, as well as renal dose adjustment or other dose adjustments; and
  • Assist in the creation and implementation of medication-use policies and protocols, and participate in active, continued surveillance of medication protocols.

It might not be feasible to hire clinical pharmacists to be solely assigned to hospitalist teams, although success has been found at Mercy through the development of a shared clinical position with the College of Pharmacy. Although described as a 50-50 position, a majority of the teaching duties occur on-site at Mercy, working with fourth-year pharmacy students on clinical rotations. It has become a win-win situation: The hospitalist team benefits from a dedicated clinical pharmacist, and the students benefit from a clinical setting with vast opportunities to review general internal-medicine cases.

In contrast to developing a new position, reallocation of resources often is the route by which collaborations evolve. In a 2005 article by Cohen et al at Brookhaven Memorial Hospital in Patchogue, N.Y., patients treated by voluntary attending physicians were compared with patients treated by hospitalists who collaborated with residents from the institution’s accredited pharmacy residency program. Analyses revealed the hospitalist/pharmacist group achieved a 23% shorter length of stay, 21% lower cost of medication, and 1.5 fewer medications per patient.2 The hospitalist/pharmacist group also had a reduced length of IV antibiotic therapy and gastrointestinal medications by 1.7 and 0.9 days, respectively.2

Although anecdotal, an added benefit to having a clinical pharmacist assigned to the HM team at Mercy is continuity and familiarity with the physicians and patients. The clinical pharmacist inherently has a vested interest in the success of the hospitalists as well as the pharmacy department, which provides ongoing momentum for joint projects.

The recent development of the HM model of inpatient care has coincided with a rapid evolution in the role of hospital-based clinical pharmacists. Pharmacologic interventions are utilized for virtually all hospitalized patients, and they are inherently complex and potentially hazardous. Pharmacist involvement with the multidisciplinary hospitalist team provides a mechanism to address and minimize these complexities.

Innovative approaches to reallocate or create collaborative models are needed as the two disciplines, hospitalists and clinical pharmacists, continue to transform inpatient care.

Phyllis Hemerson, PharmD, BCPS

clinical pharmacy specialist

Mercy Hospital, Iowa City

assistant professor, University of Iowa College of Pharmacy

Martin Izakovic, MD, PhD, CPE, FHM, FACP, FACPE

vice president of medical staff affairs and chief medical officer

hospitalist program medical director, Mercy Hospital

References

  1. Cobaugh DJ, Amin A, Bookwalter T, et al. ASHP-SHM Joint Statement on Hospitalist-Pharmacist Collaboration. Am J Health Syst Pharm. 2008;65(3):260-263.
  2. Cohen K, Syed S. Hospitalists, pharmacists partner to cut errors. Healthcare Benchmarks Qual Improv. 2005;12(2):18-19.

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