Onboarding Home Infusion Anti-Infective Patients: A Descriptive Study of Nurse and Pharmacist Time
Danell Haines, PhD — Research Consultant
Michelle C. Simpson, PharmD, BCSCP, MWC — National Home Infusion Association
michelle.simpson@nhia.org
Jennifer Charron, RN, MSN, MBA — National Home Infusion Association
Abstract
Introduction
Home infusion anti-infective therapy is an important component of post-acute care, allowing patients to transition more quickly from facility-based treatment to home-based intravenous therapy. The patient onboarding phase is a critical and resource-intensive period that requires coordinated activities by nurses and pharmacists, including clinical assessment, care planning, medication preparation, patient education, documentation, and communication with prescribers and other care team members. Home infusion providers invest professional time toward patient onboarding before payment begins, and a significant proportion of referred patients may not ultimately receive billable home infusion services. Limited evidence exists quantifying the combined nursing and pharmacist time required to onboard home infusion anti-infective patients. This study evaluated the time and task distribution associated with nurse and pharmacist tasks during patient onboarding activities for home infusion anti-infective therapy.
Methods
The National Home Infusion Foundation conducted descriptive, observational time studies among home and specialty infusion providers. Nurses and pharmacists used standardized data collection tools to retrospectively record time spent on anti-infective patient care tasks. Patient onboarding tasks for nurses were defined as activities completed before the first nurse visit to the patient’s home. Pharmacist onboarding time included patient care activities from referral through the first dispensing of the home infusion medication. Task frequencies, percentages, and mean time by task category were analyzed for anti-infective patients.
Results
Among 28 anti-infective patients in the nurse time study, 14 had patient onboarding tasks completed before the first nurse visit. Nurses completed 68 patient onboarding tasks, averaging 4.86 tasks per patient. The most common patient onboarding task category was care coordination and telephonic communication, accounting for 41.18% of nurse tasks, followed by patient assessment and documentation at 29.41%. Patient education required the greatest mean nurse time per task at 29 minutes. Pharmacist tasks for patient onboarding data included 22 anti-infective patients and 129 tasks, averaging 5.86 tasks per patient. Most pharmacist tasks involved drug preparation and compounding activities, representing 44.19% of pharmacist tasks for onboarding patients, followed by patient assessment and documentation at 27.13%. The most time-intensive pharmacist task category was patient assessment and documentation, averaging 45 minutes per task. Combined patient onboarding time demonstrated substantial multidisciplinary effort, with nurse and pharmacist activities contributing an average of more than 4 hours of professional time before or during therapy initiation.
Conclusion
Onboarding home infusion anti-infective patients requires substantial nurse and pharmacist time before therapy is fully initiated in the home. Nurse activities were concentrated in care coordination, communication, assessment, and patient education, while pharmacist activities centered on drug preparation, compounding, assessment, documentation, and care coordination. These findings highlight the multidisciplinary and front-loaded nature of home infusion patient onboarding and provide data to inform staffing models, workflow planning, and reimbursement discussions for home-based anti-infective therapy.
Keywords: Home infusion, Outpatient Antimicrobial Therapy, OPAT, Nurse, Pharmacy, Pharmacist, Onboarding
Introduction
Drug utilization review (DUR) is a systematic process used to evaluate the prescribing, dispensing, and use of medications to ensure safe and effective therapy. DUR involves a comprehensive review of a patient’s drug therapy and medical history against predetermined criteria for appropriate drug therapy.¹ Pharmacists can engage with DUR systems as part of medication therapy management and clinical decision support system. DUR systems can help pharmacists identify Drug-Drug interactions, drug-patient precautions, and drug-disease contraindications to better inform clinical decision-making. Alerts triggered from DUR systems thus serve as valuable tools for improving patient care, enhancing patient outcomes, and reducing overall health care costs.²
These clinical decision support systems, however, have some drawbacks. For example, there are discrepancies between the evidence provided for various alerts and the clinical significance of the evidence. As the number and frequency of DUR alerts—especially those that are redundant, clinically irrelevant, or erroneous—appear when reviewing patient medications, alert fatigue can occur.³ Alert fatigue can be dangerous, especially when a clinician overrides a number of alerts but misses one that can jeopardize patient care and safety. Thus, it is imperative that DUR alerts are clinically relevant and accurate to minimize alert fatigue and optimize patient care.
There are published studies examining pharmacists’ perceptions of DUR alerts, but a limited number of those studies consider how these alerts should be improved upon.⁴⁻⁶ This lack of information is suboptimal, especially since one of the best practices outlined in the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Community/Ambulatory Pharmacy is the periodic evaluation of pharmacy computer systems for “clinically insignificant and false positive alerts,” as well as “action taken to minimize alert fatigue.”⁷ The publication of specific analyses that pharmacies have performed to improve their alert system would be helpful to inform other pharmacies on best practices they may want to consider adopting.
This study aims to address this gap by analyzing DUR alerts overridden in the outpatient pharmacy medication dispensing system within our health system. We selected the system used in our outpatient pharmacies because it is the most robust platform available to us for capturing a large data set. Although infusion medications are dispensed through other systems in our organization, medication profiles for our infusion patients can still be found in our outpatient pharmacy medication dispensing system. By examining pharmacist responses and documentation within this primary system, we aim to provide actionable recommendations to optimize alert frequency, type, and presentation. These recommendations are intended to be applicable to all pharmacy dispensing systems, including those used in infusion practice settings, though we acknowledge that alert logic and workflows can vary across vendors. Ultimately, this will support improved clinical review processes and lay the foundation for future studies comparing DUR alert performance across other systems to enhance medication safety, regardless of specific pharmacy dispensing system.
Pharmacist Responses to DUR Alerts
Of the 4 radial buttons available for pharmacists to click to override the alerts, the most common response was Clinician Reviewed (89.4%). The full breakdown of pharmacist responses and frequency can be found in Table 3.
Pharmacist free-text responses to Drug-Drug alerts were also reviewed, since one of the primary responsibilities of pharmacists is to ensure that concomitant medications are taken safely. The pharmacy dispensing system only requires review and override of High and Very High importance Drug-Drug alerts, which comprise severe and contraindicated Drug-Drug interactions, respectively. A key finding was that of the 6,923 total Drug-Drug alerts overridden in the system, only 78 (1.2%) of these had comments that further explained why reviewing pharmacists overrode the alerts. The full breakdown of Drug-Drug alert response by importance severity can be found in Table 4.
A summary of the major themes gathered from review of the free-text comments provided by pharmacists overriding severe or contraindicated Drug-Drug interactions can be found in Table 5.
Discussion
High Volumes of Overridden DUR Alerts
The results of this study demonstrate that a large number of alerts were overridden in the pharmacy dispensing system and reviewed by outpatient pharmacists. An average of approximately 1,011 DUR alerts were reviewed in the pharmacy dispensing system each day. In addition, 2 DUR alert categories (Duplicate Therapy and Drug-Food) accounted for most alerts (65.2%) versus Drug-Drug alerts comprising only 7.4% of alerts.
These findings raise some important questions: How valuable are all these alerts when clinically reviewing prescriptions? Do they contribute to alert fatigue and potentially obscure more serious alerts (e.g., Drug-Drug alerts)? Targeting these high-volume categories for refinement could significantly reduce alert burden and improve pharmacist focus on clinically relevant issues.
References
- Academy of Managed Care Pharmacy. Drug Utilization Review. Accessed August 14, 2024. https://www.amcp.org/concepts-managed-care-pharmacy/drug-utilization-review
- Carver N, Jamal Z, Dering Anderson AM. Drug Utilization Review. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.
- Reynolds JL, Rupp MT. Improving Clinical Decision Support in Pharmacy: Toward the Perfect DUR Alert. Journal of Managed Care & Specialty Pharmacy. 2017;23(1):38-43. doi: 10.18553/jmcp.2017.23.1.38.
- Alshehri N, Alanazi A. Pharmacists’ Perceptions on Safety Alerts of the Drug Utilization Review (DUR) in Electronic Health Records in a Tertiary Healthcare Hospital. Pharmacy. 2023;11(4). doi: 10.3390/pharmacy1104011.
- Lee S-M, Lee S-O, Kim D-S. Physicians’ and pharmacists’ perceptions on real-time drug utilization review system: a nationwide survey. International Journal for Quality in Health Care. 2017;29(5):634-41. doi: 10.1093/intqhc/mzx085.
- Moon J, Chladek JS, Wilson P, Chui MA. Clinical decision support systems in community pharmacies: a scoping review. Journal of the American Medical Informatics Association. 2024;31(1):231-9. doi: 10.1093/jamia/ocad208.
- Institute for Safe Medication Practices. 2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy. Accessed August 14, 2024. https://www.ismp.org/sites/default/files/attachments/2017-11/2017_ISMP_CommunityAmbulatory_Pharmacy_Self_Assessment.pdf
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