Do larger hospitals have an edge? Maybe

I’ve worked in several hospitals over the course of my career, ranging in size from 25 acute care beds to nearly 600 (584 beds to be exact). While 600 beds isn’t a large hospital, it certainly isn’t small. Regardless of the size of the hospital I’ve worked in, the operations inside the walls of the pharmacy are strikingly similar, including from the way pharmacists process orders to the way technicians handle distribution. There are differences to be sure, but the basics are the same. Differences to note include clinical services and use of automation and technology.

Smaller facilities typically have fewer pharmacists resulting in a more centralized approach to pharmacy services, while larger facilities typically have more pharmacists to shuffle around into a broad range of pharmacy services. Larger facilities typically have a more developed, more robust clinical services often including clinical specialists in fields such as cardiology, infectious disease, critical care medicine, pediatrics, and so on. Unfortunately, smaller facilities typically don’t have the luxury of a clinical specialist because they don’t have pharmacists to spare.

Beyond clinical services, I find smaller facilities tend to lack the amount of automation and technology that I see in larger facilities. It’s not for lack of desire, but rather a lack of funds. Budgets appear to be proportional to hospital size (i.e. the larger the hospital, the bigger the budget), which results in smaller facilities utilizing less technology and automation. This doesn’t mean that small hospitals aren’t progressive in their approach; it simply means that you won’t find many million dollar robots filling carts for 20 patients.

The American Society of Health-System Pharmacists recently published its national survey of pharmacy practice in hospital settings (1). The data was collected in 2010 and evaluates practices and technologies related to prescribing and transcribing. While that may sound like a relatively narrow focus, the data presented is actually quite extensive.

Hospitals in the survey were broken down into seven categories based on bed size: < 50, 50-99, 100-199, 200-299, 300-399,400-599, and > 600.

Several items in the survey caught my attention and help distinguish larger facilities from smaller ones. These items include:

1. Approximately 20-30% of hospitals with 0-599 beds responded to the survey, while greater than 40% (41.4%) of the facilities with more than 600 staffed beds responded. Interesting.
2. Facilities with more than 600 staffed beds had the largest percentage of “restricted prescribing of certain categories of medications to certain specialties or only with consultation.” The percentage of hospitals using such a policy trends upward as the size of the facility increases (i.e. the smallest had the lowest percentage while the largest had the largest percentage). I wonder if that’s more a product of the evolution of the practice model or the simple fact that larger healthcare systems have more specialty practitioners.
3. The use of pharmacists to help with medication compliance and medical history is woefully low with only 31% of responding facilities indicating that pharmacists were involved. In my opinion, a pharmacist should be involved with medication compliance 100% of the time.
4. Drug information:
   1. Nearly 89% of pharmacy directors reported that electronic drug information sources were available on the hospital network, but “the availability of electronic drug information varies by hospital size (p < 0.05); for example, 100% of hospitals with 400 or more staffed beds have drug information available on the hospital network, compared with only 78% of hospitals with fewer than 50 staffed beds.”
   2. Only 25.5% of respondents provided electronic information on individual hand-held devices. This doesn’t mean that more clinicians weren’t using mobile drug information; it simply means that the facilities weren’t providing it. I think this will change over time as drug information providers will develop more robust licensing agreements with facilities to provide drug information across multiple electronic platforms.
   3. Only 19% of facilities utilized embedded electronic drug information in CPOE systems. Not surprising when you consider the large number of facilities across the country that have yet to implement a formal CPOE system.
5. “Regardless of the pharmacy department’s hours of service, 10.1% of hospitals have pharmacists process patient care orders from home through a telework-type arrangement.” This is a great use of telemedicine, and I hope to see the trend of using this technology continue to rise.
6. 34.5% of hospitals have BCMA and hospitals with 200-299 staffed beds are most likely to have BCMA systems. This is the one item in the survey that went against the trend of larger facilities being at the top. With that said, I was a little surprised at the low percentage of facilities with BCMA.
7. Only 19% of hospitals have CPOE systems with CDS, and larger hospitals are more likely to have CPOE systems in place. Expect this number to rise significantly in 2011-2012 secondary to ARRA and the HITECH Act.
8. 65% of hospitals are using smart infusion pumps, but again, it’s more common in larger facilities with over 90% of facilities who have more than 600 staffed beds using smart pump technology.
9. Just over 40% of hospitals surveyed used some form of an antibiotic stewardship program. More than 80% of hospitals with more than 600 staffed beds reporting its use.
10. Surprisingly, smaller hospitals administer significantly more doses both per 100 occupied beds and per patient day. I’m not sure how to take this, but suspect that there are fewer policies in place in smaller facilities to help curb unnecessary prescribing; pure speculation on my part.
11. Inpatient pharmacists outnumber pharmacy technicians per 100 occupied beds; 15.4 pharmacist FTEs per 100 occupied beds vs. 13.2 pharmacy technician FTEs per 100 occupied beds. Interesting.

Overall it appears that larger hospitals do have a slight edge over smaller hospitals. They’re more likely to have CPOE systems in place, utilize smart infusion pumps, have online drug information resources, and appear to be more likely to make use of advance clinical services like antibiotic stewardship programs. Does this mean that larger facilities provide better patient care? That’s a difficult question to answer.

Ultimately, I believe there are two ways to look at the data presented by ASHP. First, if you want to be on the cutting-edge of technology and pharmacy practice, then you should look to larger hospitals for gainful employment as a pharmacist. However, an alternate viewpoint might be that smaller hospitals provide more opportunity. For example, if you want to build a pharmacy practice model of your very own, you might want to consider looking into smaller facilities where services and technologies have yet to be fully implemented. The choice is yours.

(1)    Am J Health-Syst Pharm. 2011:68:669-88