Rick Couldry

Nationwide Antibiogram Analysis Using NCCLS M39-A Guidelines

ABSTRACT Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported <100% vancomycin susceptibility for Staphylococcus aureus, 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus, 20% that reported <100% imipenem susceptibility for Escherichia coli, and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.

Effects of a hospitalwide pharmacy practice model change on readmission and return to emergency department rates

PURPOSE The impact of an innovative medication reconciliation and discharge education program on 30-day readmissions and emergency department (ED) visits was evaluated. METHODS An observational pre-post analysis was conducted at an academic medical center to compare rates of hospital readmissions and return to ED visits during three-month periods before and after implementation of a restructured pharmacy practice model including (1) medication reconciliation at transitions of care for every patient and discharge education for a high-risk subgroup, (2) new or expanded services in the preanesthesia testing clinic and ED, (3) a medication reconciliation technician team, and (4) pharmacist-to-patient ratios of 1:30 on acute care floors and 1:18 on critical care units. The primary outcome was the composite of rates of readmissions and return to ED visits within 30 days of discharge. RESULTS A total of 3,316 patients were included in the study. Pharmacy teams completed medication reconciliation in 95.8% of cases at admission and 69.7% of cases at discharge. Discharge education was provided to 73.5% of high-risk patients (defined as those receiving anticoagulation therapy or treatment for acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia). No significant difference was observed between the preimplementation and postimplementation groups with regard to the primary outcome. In the high-risk subgroup, there was a significant reduction in the 30-day rate of hospital readmissions, which declined from 17.8% to 12.3% (p=0.042); cost projections indicated that this reduction in readmissions could yield annual direct cost savings of more than

Preceptor development: providing effective feedback.

780,000. CONCLUSION Implementation of a team-based pharmacy practice model resulted in a significant decrease in the rate of 30-day readmissions for high-risk patients.

Implementation of standardized dosing units for i.v. medications

Feedback plays a significant role in precepting and is indispensable in residency training. As described by the Accreditation Council for Graduate Medical Education, the goal of any postgraduate residency program is to prepare individual trainees to function as qualified practitioners. Although feedback and evaluations have traditionally been synonymous, our goal is to differentiate the two and describe the role of each within resident performance. The goal of this article is to provide preceptors with the tools to provide timely, effective, and quality feedback to residents on a regular basis. Although the focus of this article is on residency training, these concepts can be utilized in student rotations as well.

The Use of Individualized Pharmacist Performance Reports to Reduce Pharmacist-Related Medication Order Entry Errors Following Electronic Medical Record Implementation

PURPOSE The implementation of standardized dosing units for six i.v. medications at an academic medical center is described. SUMMARY During the implementation of an electronic health record system at an academic medical center, it was noticed that providers could order some i.v. medications in multiple dosing units, including epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. Possible options to standardize i.v. medications along with their pros and cons were presented for discussion to key providers in all of the intensive care units. Once the providers agreed on a solution, the information was presented to the pharmacy and therapeutics committee for final approval. A nursing education plan was created and administered before the standardization of dosing units was implemented. A nursing survey was conducted before and after implementation of dosing-unit standardization to determine the effectiveness of nursing education on compliance with the standardization of the dosing units for the listed medications. The survey was designed to evaluate, when given a choice, what dosing units nurses would use to administer epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. The decision was made by the key providers to use weight-based dosing-micrograms per kilograms per minute-to allow for consistency of use of these medications for pediatric and adult patients. Nursing education was completed to ensure that nurses were aware of how to safely administer these medications using the new dosing units. CONCLUSION Dosing-unit standardization for dose-adjustable i.v. infusions can provide improved consistency and decrease the potential for dosing errors when administering epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine.

Leveraging drug-utilization and external benchmarking data to drive change in prescribing behaviors.

Purpose To measure the impact of an individual pharmacist performance report (IPPR) program on pharmacist-related medication order entry errors (MOEEs) at an academic medical center. Methods The number and type of pharmacist-related MOEEs were collected at 2 different times: immediately following implementation of an electronic medical record (baseline) and following completion of the IPPR program. Three different collection methods were utilized to identify and categorize pharmacist-related MOEEs: 1) Patient Safety Net (PSN) incident reporting system, 2) manual event reporting, and 3) a nursing to pharmacy electronic messaging system. The IPPR program consisted of mandatory educational sessions for pharmacist staff. The program content focused on strategies to reduce pharmacist-related MOEEs identified in the baseline data collection period as well as an individualized report generated for each pharmacist having caused an MOEE that showed their performance compared to the departments performance. Results The percentage of event reports containing a pharmacist-related MOEE decreased from baseline to post IPPR program (13.7% and 6.3%, respectively; P < .001). In addition, the total number of pharmacist-related MOEEs was halved after the IPPR program (321 vs 148; P < .001). Significant reductions were noted in the following MOEE categories: duplicate orders, missed orders, wrong frequency, wrong dose, and other. Nonsignificant reductions were noted in errors related to no order and wrong drug. Conclusion Based on the observations and results of this study, it is proposed that individualized performance feedback can be a successful method to improve MOEE performance by pharmacists.

Impact of Pharmacist-Managed Warfarin on Patient Outcomes in an Academic Medical Center

PURPOSE Improved outcomes and cost savings achieved at a large hospital through a drug utilization benchmarking and reporting initiative are described. SUMMARY Using the University HealthSystem Consortium (UHC) Clinical Resource Manager (CRM) database, the University of Kansas Hospital identified nine target areas (based on Medicare Severity Diagnosis-Related Group) in which the hospitals drug-utilization practices were deemed suboptimal relative to those of other UHC member facilities with similar caseloads. The pharmacy department developed a CRM template for generating customized reports comparing the hospitals performance on various drug-utilization metrics with that of top-performing peers (i.e., institutions achieving the best patient care outcomes in terms of mortality and length of stay) in the nine target areas. A pre-post comparison of drug-utilization data collected before and after implementation of the reporting initiative indicated improved outcomes in all nine initially selected target areas, with estimated cumulative annualized cost savings of about

Beyond Medication Reconciliation

900,000. The CRM-generated reports are now distributed semiannually to attending physicians and other hospital leaders via electronic and hard-copy means, focusing on variances from UHC top-performer and overall UHC averages in the use of higher-cost drugs. The reporting initiative has generally fostered enhanced physician-pharmacist collaboration in the investigation of identified drug-utilization variances and implementation of practice changes. CONCLUSION By evaluating service-specific trends of internal drug utilization against external benchmarks and emulating prescribing practices at top-performing institutions, an academic medical center has achieved improved patient care outcomes and cost savings.

I.V. admixture contamination rates: Traditional practice site versus a class 1000 cleanroom

Table 1 Patient Demographics | Variable (mean) | Pharmacist-Managed (n=54) | Physician-Managed (n=108) | p value | |:---------------:| ------------------------- | ------------------------- | ------- | | Gender (M/F) | 35 / 19 | 62 / 46 | 0.37 | | Age

Telepharmacy and bar-code technology in an i.v. chemotherapy admixture area

As a health professional, it is always interesting to navigate the health care system from the perspective of a patient. Though I have now worked in a hospital setting for close to 30 years, my personal experience is limited. A decade ago, I accompanied my mother, a gastric cancer patient, through a 4-year journey through various aspects of the health care system. At the time, I reflected on the need for medication counseling upon hospital discharge. Medication reconciliation was only a few years away, and to day, most hospitals perform some form of medication reconciliation for patients at the end of a hospital stay. More recently, I have accompanied my father through a similar journey, involving several hospitalizations in different facilities, frequent visits to physicians, and the need for increasing health care. These are some of my observations revisiting the health care system through the eyes of a patient. I am grateful for the excellent care that my father has received. Improvements in technology and medication practices have propelled patient safety to a new level compared with a decade ago. But in the end, I am reminded that technology is augmentation to a human system. At the core, our policies and practices promote rational and optimal patient care and direct the use of technology to those ends. I am still in awe of the numerous compassionate and selfless individuals who work in our health care system. As was the case almost 10 years ago, most hospitalizations still result in significant medication changes for the patient. In the case of progressive illnesses, therapy usually involves the addition of medications or dosage changes in current therapy. Today, in contrast to a decade ago, medication reconciliation upon discharge is a standard of care. It is apparent that education and counseling of inpatients is a valuable and essential tool in preventing medication errors in the transition home. Unfortunately, the changes in medication therapy that accompany a hospital stay are often overwhelming for elderly patients or caregivers unfamiliar with the health system. Even a medication reconciliation sheet and brief counseling session may not be enough to aid patients through safe medication practices once they return home. After a recent discharge experience with my father, a 20-minute consultation ensued with the community pharmacist to reconcile his ambulatory patient profile with the discharge medication profile, re quiring reconnection with some physicians for new prescriptions. Not every patient has the advantage of a personal advocate and I wonder how many rehospitalizations are related to post discharge compliance and confusion with medications. One response to this dilemma is the BOOST Project (Better Outcomes for Older Adults Through Safe Transitions) sponsored by the Society of Hospital Medicine with the aim at improving the discharge pro cess to reduce 30-day readmission rates for general medicine pa tients. Additional goals are to im prove pa tient satisfaction, en sure the identification of high risk pa tients, and improve patient education. Pharma cists are in volved be yond typical medication reconciliation practices to ensure that in-depth medication education occurs. We should be mindful that medi cations and patient safety does not stop at the hospital lobby door. Hospital Pharmacy invites you to evaluate your discharge planning practices and share your experiences with us. Are there methods for improving patient transition from hospital to home? As pharmacists, are we participating fully in education and communications with others in the ambulatory sector that would improve patient outcomes?