Scope of Practice in Wisconsin Expands to Drug Product Administration
A recently enacted law in Wisconsin will allow pharmacists to administer injectable medications—including products other than vaccines and in situations other than teaching patients how to inject themselves.
"We would be another available resource for patients," UW Health's Joe Cesarz said he told two legislative committees when they held hearings on the legislation.
In the Community
UW Health, whose pharmacists at 14 dispensing pharmacies in Madison can administer vaccines, has not fully determined how the new law will affect patient care, said Cesarz, manager of ambulatory care pharmacy services.
But one of the goals, he affirmed, will be to improve medication adherence among patients who are prescribed a weekly or monthly injection and have "needle phobia" or inadequate manual dexterity.
By being able to administer medications, Cesarz said, community-based pharmacists can help those patients, who otherwise would have to find a willing friend or family member or schedule an appointment at their prescriber's office.
Cesarz also floated the possibility that patients who now come to the UW Health infusion center on the health system's main campus for subcutaneous or intramuscular injections could instead have them administered by a local community-based pharmacist.
In the Hospital
Cathyyen Dang, at the flagship hospital of Froedtert & the Medical College of Wisconsin health network, said she and the other emergency medicine clinical pharmacists are excited about the potential expansion of their scope of practice.
Dang said there are certain emergent situations when a nurse is needed but may not be immediately available to administer timing-sensitive medication injections.
For example, she said, the arrival of multiple trauma patients at Froedtert Hospital, a level 1 trauma center in Milwaukee, can hamper the availability of emergency department (ED) nurses to administer the medications for rapid-sequence intubation.
"Usually pharmacists will . . . draw up the medication and have it readily available for the nurses to give," Dang said.
But in a crisis situation, she noted, "it would make sense for the pharmacist to administer this medication immediately so we can intubate the patient."
All of Froedtert Hospital's emergency medicine pharmacists have completed training in advanced cardiac life support, she said. They respond to all code-blue alerts in the ED and in all cases involving trauma, acute ischemic stroke, or ST-segment elevation myocardial infarction.
One of the pharmacists' responsibilities is to prepare the bolus and infusion doses of alteplase for patients with stroke, Dang said.
If a patient needs those doses and no ED nurse is available, she said, the pharmacist who prepared the doses may be allowed to administer them under the new law.
In the Hospital-Based Clinic
For Erin Newkirk, on the other hand, the new law will not change her practice at Froedtert Hospital's four-year-old, pharmacist-run anemia service, a hospital-based clinic that she helped develop.
Newkirk said she and the other pharmacists who provide the service to patients with chronic kidney disease or a kidney transplant administer epoetin alfa by subcutaneous injection through a collaborative practice agreement with a nephrologist.
The pharmacists review the patients' laboratory test results, refer some patients to the infusion clinic for iron therapy, and administer the erythropoiesis-stimulating agent when appropriate (which is in most cases), she said. Pharmacy technicians who work in the nearby pharmacist-run anticoagulation clinic draw blood from the anemia service's patients for processing with a hemoglobin point-of-care testing device.
Newkirk's skill at administering epoetin alfa, she said, stems from her experience as a certified diabetes educator trained in insulin injection. She also completed an immunization certification course.
A second collaborative practice agreement with the nephrologist allows the anemia service's pharmacists to administer vaccines, Newkirk said.
Hepatitis B vaccine administration, in particular, excited the nephrologists, she said. That's because the pharmacists can help ensure that patients with chronic kidney disease have protection against hepatitis B before they need dialysis or a kidney transplant.
At the Capitol
Anna Legreid Dopp, vice president of public affairs at the Pharmacy Society of Wisconsin (PSW), said the legislation started with the organization's members.
They wanted to serve their patients better, she said.
"We heard from our members in community settings, in ambulatory care settings, in emergency services, and acute care settings where they felt that the way that our pharmacy practice act was written . . . restricted [them] in their ability to administer injectable medication," Dopp said.
A Wisconsin pharmacy practice regulation states that a pharmacist may administer drug products and devices other than vaccines "in the course of teaching a patient self-administration techniques."
As for vaccines, a pair of statutes allows their administration by pharmacists "pursuant to vaccination protocols."
The state requires pharmacists who want to administer drug products, devices, or vaccines to first complete 12 hours of education approved by the Accreditation Council for Pharmacy Education or the Wisconsin board of pharmacy.
"So we brought the idea forward through one of our legislative days," Dopp said. "And then one of the legislators that our members spoke with liked the idea and offered to work with PSW on behalf of our members to draft legislation."
The legislative process, Dopp acknowledged, "is never easy."
"However, when you come with sound policy that has data that back up that it will improve patient care," she said, "that is a pretty easy ask to bring to legislative offices."
With the hoped-for legislation being fairly straightforward, Dopp said, PSW worked with the statewide medical, hospital, and nursing associations to address their concerns.
The goal, she explained, was to adjust the legislation so that upon its introduction the other associations would express support or, at worst, stay neutral.
Representatives Jeremy Thiesfeldt, of Fond du Lac, and John Nygren, of Marinette, introduced the legislation on February 4.
Senators Leah Vukmir, of Brookfield, and Alberta Darling, of River Hills in Milwaukee County, introduced companion legislation on February 9.
The Wisconsin assembly and state senate committees with jurisdiction over the legislation scheduled their hearings for February 10 and 11, respectively.
Cesarz and Dopp spoke in favor of the legislation at both hearings. So did Philip J. Trapskin, secretary of the board of pharmacy and manager of UW Health's Drug Policy Program and the pharmacy department's patient care services; and Stacy Graham, a pharmacy manager at Genoa Healthcare, which serves behavioral health consumers. Erin Elliott, then director of government relations for UW Health, spoke to the senate committee.
No one appeared in opposition to the legislation, according to state records.
As luck would have it, PSW Legislative Day was February 11.
"We happened to have 300 pharmacists in town and ready to march across to the capitol to reach out to the rest of the [legislative] offices," Dopp said.
By March 29, the legislation was ready for the governor's signature.
Governor Scott Walker signed the legislation into law the next day.
The Wisconsin Pharmacy Examining Board has stated that it anticipates holding a public hearing on the related pharmacy practice rule this fall.
Dopp, who was interviewed in July, started employment with ASHP on August 8 as the director of clinical guidelines and quality improvement.
[This news story appears in the Sept. 15, 2016, issue of AJHP.]