Heidemarie Windham MacMaster

A detailed description of the implementation of inpatient insulin orders with a commercial electronic health record system.

Background: In the setting of Meaningful Use laws and professional society guidelines, hospitals are rapidly implementing electronic glycemic management order sets. There are a number of best practices established in the literature for glycemic management protocols and programs. We believe that this is the first published account of the detailed steps to be taken to design, implement, and optimize glycemic management protocols in a commercial computerized provider order entry (CPOE) system. Process: Prior to CPOE implementation, our hospital already had a mature glycemic management program. To transition to CPOE, we underwent the following 4 steps: (1) preparation and requirements gathering, (2) design and build, (3) implementation and dissemination, and (4) optimization. These steps required more than 2 years of coordinated work between physicians, nurses, pharmacists, and programmers. With the move to CPOE, our complex glycemic management order sets were successfully implemented without any significant interruptions in care. With feedback from users, we have continued to refine the order sets, and this remains an ongoing process. Conclusions: Successful implementation of glycemic management protocols in CPOE is dependent on broad stakeholder input and buy-in. When using a commercial CPOE system, there may be limitations of the system, necessitating workarounds. There should be an upfront plan to apply resources for continuous process improvement and optimization after implementation.

Pharmacists' Impact on Glycemic Control Among Surgical Patients at a Large Academic Institution.

Hyperglycemia has been associated with poor outcomes in several large studies. Repeated or prolonged hyperglycemia has been linked to an increased risk of adverse outcomes, including limb amputation, acute myocardial infarction, prolonged length of hospital stay, and increased mortality, in various populations (1–4). Suspension of oral antidiabetic agents in anticipation of procedures for which oral nutritional intake is contraindicated, along with insulin resistance resulting from acute illness, often leaves patients without proper glucose control when admitted to the hospital. The National Quality Forum (NQF), a not-for-profit organization, supports evidence-based consensus standards to achieve better health outcomes. NQF endorses many Centers for Medicare & Medicaid Services (CMS) quality measures, which often affect reimbursement. This attempts to hold institutions accountable for providing quality patient care. Among these measures are standards focusing on patients presenting with heart failure, acute myocardial infarction, and pneumonia. Currently, serum glucose–related CMS measures have been developed but are not yet implemented; these measures include the average percentage of hyperglycemic and hypoglycemic hospital days. More information about these measures can be found on the NQF’s website (http://www.qualityforum.org). With an increasing focus on quality and outcomes measures, the need exists to quickly identify hyperglycemic patients and initiate appropriate interventions. Optimization of insulin therapy requires careful assessment of multiple patient-specific factors, including nutritional intake, prior insulin requirements, and concomitant medications (5). With knowledge of drug therapy, drug preparation, and dispensing, pharmacists are well situated to be involved in many aspects of glycemic management in the inpatient setting (6). Clinical pharmacist participation in rounds and surveillance of prescribing patterns can optimize serum glucose management (5–7). This single-center, prospective, observational cohort study aimed to evaluate the impact of dedicated clinical pharmacy services on serum glucose management among high-risk surgical inpatients. At the University of California, San Francisco (UCSF) …

Pharmacists' role in glycemic management in the inpatient setting: An opinion of the endocrine and metabolism practice and research network of the American College of Clinical Pharmacy

The objective of this opinion paper was to identify and describe the role of pharmacists in ensuring safe and optimal management of patients with glycemic excursions in the inpatient setting. The role of the pharmacist includes involvement in admission medication history and reconciliation, formulary management of glucose‐lowering medications and devices, individual patient medication management, discharge transition of care, and interprofessional collaboration with other health care providers. Recommendations are based on review of published guidelines and literature focusing on the management of patients with hypo‐ and hyperglycemia in the hospital as well as during the time of transition to and from the inpatient setting.

Improving Emergency Insulin Administration

with wound edge necrosis or wound dehiscence without signs of infection were not scored as having a superficial SSI. Nevertheless, we cannot rule out that some of the superficial SSIs actually were cases of local wound problems without infection. However, as the low threshold for diagnosis of a superficial SSI will have affected both groups equally, it should not have influenced our conclusion. Dr Goodwin and colleagues note that of 58 patients in the superficial infection group, only 2 had local wound treatment to address it, and 9 were managed without antibiotics, which would argue against a true SSI. We do not agree on this point, as it is common practice in the Netherlands to be restrictive with starting antibiotic treatment to prevent multiresistant microorganisms. All 9 patients with conservative management successfully recovered. We cannot draw any conclusions about deep SSIs from the underpowered subgroup analyses, as Goodwin and colleagues also state. A potential beneficial effect of antibiotic prophylaxis on the incidence of deep SSI should be the focus of new studies. We agree that a more unambiguous end point should be used in such a study. However, uniformity in diagnosis of superficial SSIs remains difficult, regardless of the use of a standardized definition like the CDC criteria.2 Given the findings of our study, we advise against the use of routine antibiotic prophylaxis in the removal of orthopedic implants, which agrees with the current CDC guideline.3 However, we encourage others to collaborate in investigating the reason for the high SSI rate following implant removal and the role of antibiotic prophylaxis for prevention of deep SSIs.

A Survey of Opioid Medication Stewardship Practices at Academic Medical Centers

Purpose: The results of a survey of academic medical centers assessing the presence and description of opioid stewardship activities. Methods: Academic medical centers within the Vizient University Health System Consortium Pharmacy Network were asked to complete a survey related to opioid stewardship activities. The survey consisted of 30 questions aimed at identifying current opioid stewardship practices among hospitals and health systems. Results: There were 27 respondents to the survey. Only 42.3% of respondents have opioid stewardship activities in place. Opioid stewardship practices are primarily linked to either formal consult services or the role of a clinical pharmacy specialist. Very few institutions have opioid stewardship embedded into the daily practice of clinical pharmacists. Just over half of respondents have pharmacists as part of a pain consult team. Principle roles of pharmacists on consult teams include provider education, patient education, and optimization of therapy outside of a collaborative practice or prescribing role. Over half of the respondents participating in stewardship maintain a pharmacist’s role in monitoring surgery and postoperative opioid prescribing. The majority of respondents have opioid medication policies in place to address range orders, smart pump programming of opioids, limits on meperidine use, and cumulative limits on acetaminophen dosing. Conclusion: There are limited examples of pharmacy services related to opioid stewardship. The authors believe this is a pharmacy practice model that will evolve with the national attention to the opioid epidemic and new Joint Commission Standards.