Less administrative burden, less burnout on ED boarder service

Pharmacy students helped hospitalists with medication histories.


Background

In 2018, the Massachusetts General Physicians Organization, which employs the physician staff at MGH, recognized that clinician burnout was a problem and funded mini-grants to start to tackle the issue.

“Much of what was being done at the time was thinking about interventions that improve resiliency or other forms of well-being, but one of the ways that we wanted to try to address burnout was to think about ways to reduce the administrative burden on our hospitalist staff,” said David J. Lucier, MD, MBA, MPH, a hospitalist and chair of quality and safety for the department of medicine at MGH.

At that point, attending physician and advanced practice provider hospitalist staff were obtaining medication histories and completing medication reconciliation for admitted patients themselves. But with the average MGH general medicine patient taking 10 or more medications at home, the process of gathering the medication history, which can be completed by someone without a prescribing license, placed considerable time burden on the hospitalists, Dr. Lucier said.

A brainstorming session with the hospitalist unit led to the idea of getting help from the pharmacy. “There have been some national studies on medication reconciliation showing how important it is for excellent patient outcomes, and that pharmacy personnel tend to gather more accurate medication histories than physicians. But it's never been studied, as far as we knew, with regards to provider burnout,” he said.

How it works

The project targeted the hospital's high-volume 24/7 medicine ED boarder service, which cares for ED patients waiting more than two hours for a general medicine bed. Dr. Lucier partnered with John Marshall, PharmD, to pilot a program in which pharmacy students completed the best possible medication history and updated the record for these patients.

“During daytime hours, generally weekdays but sometimes weekends as well, we would have one of the pharmacy students attached to our ED boarder team,” Dr. Lucier said, and clinicians on the team could ask for help obtaining a medication history whenever they wanted.

Results

In 2019, 57 and 77 hospitalists anonymously completed pre- and post-pilot surveys, respectively, which showed statistically significant improvements in their responses to the questions “I feel burned out working on [the ED boarder service]” and “I feel emotionally drained from working on [the ED boarder service],” according to results published online on July 29, 2020, by the Journal of General Internal Medicine. In addition, a threshold analysis demonstrated a large improvement in the proportion of respondents reporting low-frequency burnout and exhaustion, but improvements in high-frequency burnout did not reach significance, likely due to sample size.

Dr. Lucier was not surprised by the improvements, partially because he had been hearing anecdotal feedback along the way. “In annual surveys of the hospital medicine unit, the ED boarder service was one of the least favorite services to work and moonlight on, and after we did this intervention, it became one of the most favorite for people to work on,” he said. “Personally, it's actually my favorite shift because I'm able to work at the top of my license.”

Challenges

Initially, it took a while for the hospitalists to get used to the idea that someone could complete a medication history for them. “A lot of people felt bad even asking the pharmacy student to help them, because they knew how much of a burden the work was,” said Dr. Lucier. To address this problem, the group gave the pharmacy students access to the census list so they could see patients more proactively, without having to be asked.

Overall, the pharmacy students have been more than happy to help, Dr. Lucier said. “They're always very interested and eager and very thoughtful, and I think it is valuable to them for their learning as well.”

Next steps

After obtaining these pilot data, the researchers received another year of grant funding from the Massachusetts General Physicians Organization. “That second year was really to help us come up with a transition plan, because you can't grant fund this intervention forever,” Dr. Lucier said.

The transition entailed newly funded permanent full-time equivalent positions for pharmacy technicians, although there have been hiring challenges. “At the moment, the biggest challenge we have is expanding the program, because it's been very hard to find pharmacy technicians in the Boston area. The students are still doing this work though until we hire permanent technicians,” he said. “But ultimately, we hope to expand this hospital-wide.”