Jeffrey F. Barletta

Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit

PURPOSE The effect of bar-code-assisted medication administration (BCMA) on the rate of medication errors in adult patients in a medical intensive care unit (ICU) was studied. METHODS Medication errors were identified in a community teaching hospital medical ICU using a direct observation technique whereby nurses were observed administering medications. Observations occurred for four consecutive 24-hour periods one month before and four months after the implementation of BCMA. Errors in the following categories were recorded: wrong drug, wrong administration time, wrong route, wrong dose, omission, administration of a drug with no order, and documentation error. Two evaluators reviewed all errors for accuracy. Medication error rates were calculated and compared by determining the number of medication errors identified per number of medications administered (observed) preimplementation and postimplementation of BCMA. Statistical analyses were conducted to determine significance. RESULTS A total of 1465 medication administrations were observed (775 preimplementation and 690 postimplementation) for 92 patients (45 preimplementation and 47 postimplementation). The medication error rate was reduced by 56% after the implementation of BCMA (19.7% versus 8.7% , p < 0.001). This benefit was related to a reduction associated with errors of wrong administration time. Wrong administration time errors decreased from 18.8% during preimplementation to 7.5% postimplementation (p < 0.001). There were no significant differences in other error types. CONCLUSION The implementation of BCMA significantly reduced the number of wrong administration time errors in an adult medical ICU.

A Review of Recombinant Factor VII for Refractory Bleeding in Nonhemophilic Trauma Patients

BACKGROUND Recombinant factor VII (rFVII) is an attractive agent to control refractory, coagulopathic bleeding in patients following major surgery. The purpose of this review is to evaluate the published experiences of rFVII in adult, nonhemophilic, surgical and trauma patients. METHODS A computerized literature search was conducted to identify articles pertaining to rFVII use for refractory bleeding in adult, nonhemophilic, surgical patients. The selected articles were reviewed and the applicable data was analyzed. RESULTS A total of 117 patients were found in 8 case series and 24 case reports. Overall, rFVII was effective in restoring hemostasis in 99/117 (85%) patients with 76/99 (77%) surviving to hospital discharge. In trauma patients, hemostasis was achieved in 20/26 (77%) patients and 17/20 (85%) survived. There were 5 (4%) thromboembolic events observed in the 117 cases and much disparity was noted with the initial dose. Severe acidosis affected the activity of rFVII. CONCLUSION Recombinant factor VII is an effective therapeutic agent for achieving hemostasis in nonhemophilic surgical patients. Published clinical experiences, however, are limited to small case series and case reports.

Proton Pump Inhibitors and the Risk for Hospital-Acquired Clostridium difficile Infection.

OBJECTIVE To examine the relationship between proton pump inhibitor (PPI) usage and nosocomial Clostridium difficile infection (CDI) and determine the duration of therapy at which CDI risk increases. PATIENTS AND METHODS This retrospective case-control study included consecutive adult patients in whom nosocomial CDI developed after hospitalization for 3 or more days at one of 2 affiliated hospitals between June 1, 2010, and October 31, 2011. These patients were matched to patients hospitalized within 6 months who did not have CDI development in a 1:2 ratio using age, sex, and antibiotic usage. Potential risk factors for CDI, including PPI use and duration, were evaluated. Multivariate analysis was performed to control for confounding variables and identify risk factors. RESULTS A total of 201 patients were evaluated, 67 with CDI and 134 matched controls. Patients in whom CDI developed were more likely to have received a PPI (76% vs 39%; P<.001) and had a longer duration of PPI therapy (median [range], 5 [0-20] days vs 0 [0-11] days; P<.001) than those who did not have CDI development. After controlling for prior hospital admission, intensive care unit admission, admission from a skilled nursing facility, immunosuppression, number of antibiotics received, PPI duration, and time to event via multivariate analysis, PPI duration was found to be a risk factor for CDI (odds ratio, 1.14; 95% CI, 1.02-1.27; P=.018). The probability for CDI was higher when PPI use exceeded 2 days in patients without a prior hospital admission and 1 day in patients with a prior admission. CONCLUSION The duration of PPI therapy is significantly associated with CDI. Clinicians should strongly consider restricting PPI use given the short exposure time associated with this increased risk.

Influence of Intravenous Opioid Dose on Postoperative Ileus

Background: Intravenous opioids represent a major component in the pathophysiology of postoperative ileus (POI). However, the most appropriate measure and threshold to quantify the association between opioid dose (eg, average daily, cumulative, maximum daily) and POI remains unknown. Objective: To evaluate the relationship between opioid dose, POI, and length of stay (LOS) and identify the opioid measure that was most strongly associated with POI, Methods: Consecutive patients admitted to a community teaching hospital who underwent elective colorectal surgery by any technique with an enhanced-recovery protocol postoperatively were retrospectively identified. Patients were excluded if they received epidural analgesia, developed a major intraabdominal complication or medical complication, or had a prolonged workup prior to surgery. Intravenous opioid doses were quantified and converted to hydromorphone equivalents. Classification and regression tree (CART) analysis was used to determine the dosing threshold for the opioid measure most associated with POI and define high versus low use of opioids. Risk factors for POI and prolonged LOS were determined through multivariate analysis. Results: The incidence of POI in 279 patients was 8.6%. CART analysis identified a maximum daily intravenous hydromorphone dose of 2 mg or more as the opioid measure most associated with POI. Multivariate analysis revealed maximum daily hydromorphone dose of 2 mg or more (p = 0.034), open surgical technique (p = 0.045), and days of intravenous narcotic therapy (p = 0.003) as significant risk factors for POI. Variables associated with increased LOS were POI (p < 0.001), maximum daily hydromorphone dose of 2 mg or more (p < 0.001), and age (p = 0.005); laparoscopy (p < 0.001) was associated with a decreased LOS. Conclusions: Intravenous opioid therapy is significantly associated with POI and prolonged LOS, particularly when the maximum hydromorphone dose per day exceeds 2 mg. Clinicians should consider alternative, nonopioid-based pain management options when this occurs.

Clinical and Economic Burden of Opioid Use for Postsurgical Pain: Focus on Ventilatory Impairment and Ileus

Opioid‐related adverse drug events (ORADEs) can have a significant impact on patient recovery after surgery. This review investigates the impact of two ORADEs, respiratory depression and postoperative ileus (POI), on clinical and economic outcomes. Opioid‐induced ventilatory impairment is a potentially serious ORADE that can result in apnea and even death. The incidence of ventilatory impairment is approximately 1%, even among patients receiving opioids using patient‐controlled analgesia. Costs are increased in patients treated with opioids who are at high risk of ventilatory impairment due to the need for more intensive monitoring from nursing staff and the use of alarmed monitoring equipment. Opioids, together with other factors, contribute to the development of POI through a direct effect on gut motility. Postoperative ileus has been shown to significantly increase hospital length of stay and cost of care. A key determinant of ileus development, as well as length of stay and costs, is postsurgical opioid dose. Data from a retrospective analysis show that a daily hydromorphone dose of 2 mg/day markedly increases the risk of POI. In addition, although the incidence of POI is reduced in patients who undergo laparoscopic surgery or hand‐assisted laparoscopic surgery compared with open surgery, the reduction of POI can potentially be negated by excessive opioid use. Therefore, multimodal, opioid‐sparing strategies should be explored and used to reduce severe ORADEs and improve outcomes in the surgical setting.

Proton pump inhibitors increase the risk for hospital-acquired Clostridium difficile infection in critically ill patients

IntroductionProton pump inhibitors (PPI) have been linked to Clostridium difficile infection (CDI) but there are few data specific to ICU patients. We evaluated duration of PPI exposure as a potential risk factor for hospital-acquired CDI in the ICU.MethodsThis retrospective, case-control study was conducted using the Multiparameter Intelligent Monitoring in Intensive Care II database, a large publically available database of more than 35,000 ICU patients. Adult patients with CDI were identified using the ICD-9 code for Clostridium difficile listed as a secondary diagnosis. To be included, patients had to be present in an ICU for ≥48 hours prior to Clostridium difficile acquisition. These patients were then matched to patients without CDI using the ICD-9 primary diagnosis, age (+/−5 years) and SOFA score (+/−1). Successfully matched patients were reviewed for PPI exposure and other potential confounding variables for CDI. PPI exposure was characterized as short (<2 days) or long (≥2 days). Multivariate modeling was performed to identify independent risk factors for CDI.ResultsThere were 408 patients evaluated and 81% received a PPI. The percentage of patients who had a long exposure to PPIs was 83% in the CDI group compared to 73% with controls (P = 0.012). Upon inclusion of the following variables into a multivariate analysis (long PPI exposure, histamine-2-receptor antagonist administration, antibiotic administration, immunosuppression and study duration), long PPI exposure (odds ratio (OR) (95% confidence interval (CI) = 2.03 (1.23 to 3.36), P = 0.006) and antibiotic use (OR (95% CI) = 2.52 (1.23 to 5.18), P = 0.012) were identified as independent predictors of CDI.ConclusionsProton pump inhibitors are independent risk factors for the development of CDI in ICU patients. This risk is particularly exposed after two or more days of therapy.

Cerebral perfusion pressure and intracranial pressure are not surrogates for brain tissue oxygenation in traumatic brain injury.

OBJECTIVE Utilization of brain tissue oxygenation (pBtO(2)) is an important but controversial variable in the treatment of traumatic brain injury (TBI). We evaluated the correlation between pBtO(2)/CPP and pBtO(2)/ICP and determined the parameter most closely related to survival. METHODS Consecutive, adult patients with severe TBI and pBtO(2) monitors were retrospectively identified. Time-indexed measurements of pBtO(2), CPP and ICP were collected and correlation coefficients were determined. Patients were then stratified according to survival and pBtO(2), CPP and ICP values were compared between groups. RESULTS There were 4169 time-indexed data points (i.e., pBtO(2) with respective CPP and ICP values) in 15 patients. The cohort consisted of a mean age of 37±17 years, ISS of 27±7 and GCS of 4.5±1.5. Survival was 53% (8/15). In a normal regression models, neither the ICP (p=0.58) nor the CPP (p=0.71) predict pBtO(2) significantly. There was a significant difference in pBtO(2) in survivors (31.5±3.1 vs. 25.2±4.8, p=0.010) but not in CPP or ICP. Survivors had a lower proportion of time with pBtO(2)<25 mmHg [20% (3.4-44.6) vs. 40% (16.2-89), p=0.049]. In contrast, survivors had a greater proportion of time with CPP<70 and no difference in the proportion of time with and ICP>20. CONCLUSIONS CPP and ICP should not be used as surrogates for pBtO(2) since cerebral oxygenation varies independently of cerebral hemodynamics and pressures. Brain tissue oxygen monitoring in patients with TBI provides unique information regarding cerebral oxygenation the utility of which remains to be fully described. SIGNIFICANCE CPP and ICP are not surrogates for pBtO(2). Brain tissue oxygenation monitoring provides unique information for the treatment of traumatically injured patients.

Reducing the Burden of Postoperative ileus: Evaluating and Implementing an Evidence-based Strategy

BackgroundPostoperative ileus remains a significant clinical and economic burden to the health care system. Over the last decade, several advances in both medical and surgical therapies have been made to reduce the incidence and severity of postoperative ileus. Despite these advances, though, the incidence of ileus remains high. This narrative review focuses on interventions aimed to prevent and treat postoperative ileus while presenting a step-by-step process for implementation of an evidenced-based strategy.MethodsA literature search was performed using Medline/PubMed, and articles related to postoperative ileus were identified. The bibliographies of all retrieved articles were reviewed to obtain additional articles of relevance.ResultsThere are many factors that can influence gastrointestinal recovery that can be categorized as management-, drug-, or surgery-related. While several strategies exist to improve gastrointestinal recovery, few have been shown to reduce length of hospital stay. These strategies are described here, along with a structured approach organized by preoperative, intraoperative, and postoperative considerations.ConclusionsPostoperative ileus is associated with a significant clinical and economic burden to the health care system. Strategies such as the development of a multidisciplinary team and the creation of a multimodal protocol are encouraged with continuous quality assurance to assess outcomes at the local level.

Characteristics of the ideal postgraduate year 1 pharmacy practice residency candidate: a survey of residency program directors.

Objective: Assess pharmacy postgraduate year 1 (PGY1) residency application statistics and identify the qualities most desired in the ideal pharmacy residency candidate. Methods: A list of PGY1 residency program directors across the United States (n = 750) was acquired, and a validated electronic survey was created. The survey contained 25 questions pertaining to program demographics, application statistics, and candidate characteristics. Results: A total of 252 programs completed the survey. The average number of positions per program was 3.4 ± 2.6. The average ratio of applicants to available positions was 15:1. The highest scored quality was familiarity with an applicant’s college of pharmacy (7.7 ± 2.5). Holding a leadership position within the college/university scored 6.5 ± 2, while poster presentations and publications were rated lower (4.1 ± 2.5 and 3.1 ± 2.3, respectively). When asked to rank modifiable characteristics, strong letters of recommendation, letters of intent, and prior experience with the applicant were ranked the highest. Conclusions: Strong letters of recommendation and intent along with prior experience with an applicant are highly valued. Although leadership positions and scholarship are not ranked as highly, they may distinguish applicants if the preceding criteria are met. Applicants should strive to build relationships with preceptors and obtain work experience or experiential rotations at potential residency locations.

Introduction of Alvimopan into an Enhanced Recovery Protocol for Colectomy Offers Benefit in Open But Not Laparoscopic Colectomy

INTRODUCTION Alvimopan coupled with an enhanced recovery protocol (ERP) has been shown to reduce length of stay (LOS) after open colectomy, but its role after laparoscopy remains unknown. This study evaluated alvimopan with an established ERP for laparoscopic (LAP), hand-assisted laparoscopic (HAL), and open colectomy. MATERIALS AND METHODS Consecutive patients who underwent elective colectomy by any technique were retrospectively identified. Patients were excluded if they developed a major intra-abdominal complication, medical complication, or had a complex preoperative evaluation. Patients were stratified into 4 groups based on the surgical approach (open/HAL vs. LAP) and the use of alvimopan. All patients were managed by using an ERP. The incidence of postoperative ileus (POI) and LOS were compared between alvimopan and control groups for each surgical approach. RESULTS There were 282 patients. Demographics were similar across the 4 groups. The mean number of alvimopan doses administered was 6.7±2.6. For patients in the open/HAL group (n=149), the incidence of primary ileus was 9.5% (7/74) and 16% (12/75) for alvimopan and control patients, respectively (P=.231). A significant decrease in LOS was noted with alvimopan (5.6±2.5 vs. 6.8±3.3 days, P=.009). For patients after LAP (n=133), there was no significance difference in POI with or without alvimopan (3.9% [3/76] vs. 3.5% [2/57], P=1.00). There was no difference in LOS (3.9±1 vs. 3.7±1.4 days, P=.305). CONCLUSION The addition of alvimopan to an established ERP will lead to improvement in clinical outcomes in patients after open/HAL colectomy. The benefit of alvimopan after LAP remains negligible.