Enforcing a policy for restricting antimicrobial drug use

An institution's experience in enforcing a policy for restricting the use of antimicrobial agents is described. A policy to restrict the use of eight intravenous antimicrobial agents had been in place for two years at a large county teaching hospital but had never been enforced. In 1994 an organized effort to enforce the policy was begun. Memorandums were sent to all medical staff, residents, pharmacists, and nurses informing them that the policy would be diligently enforced. Before a restricted antimicrobial could be dispensed, the approval of a physician specializing in infectious diseases was required. Under the direction of the pharmacy and therapeutics committee and an antimicrobial subcommittee, a specially hired team of pharmacists started to encourage more effective and economical prescribing of antimicrobials. During a nine-month period after enforcement began, use of the restricted antimicrobials declined, and use of nonrestricted antimicrobials increased. After two months, acquisition costs for the restricted drugs had been reduced by more than $82,000; however, a similar increase in acquisition costs for nonrestricted antimicrobials occurred. As a result, one nonrestricted agent was reclassified as restricted, and inservice sessions were held to teach prescribes about the appropriate use of another agent. In general, physicians were very compliant with the antimicrobial-restriction policy; the greatest resistance was encountered from surgical residents. Some-pharmacists needed warnings beyond the initial memorandum. Enforcement of an antimicrobial-restriction policy led to decreased use of the restricted drugs and substantial cost avoidance. As new patterns of antimicrobial use emerged, the restriction policy was modified as necessary.

Pharmacy-managed protocol for warfarin use in orthopedic surgery patients

A pharmacy-managed protocol for warfarin use in orthopedic surgery patients was studied. In 1990 a protocol designed to accommodate either protocol- or physician-determined dosing of warfarin for orthopedic antithrombotic prophylaxis (OAP) was implemented at a community hospital. A "protocol" group consisting of patients treated entirely under the protocol-determined dosing option was prospectively identified over a two-year period. A "physician" group consisting of patients treated by physicians in the 10 months immediately preceding implementation of the protocol was also identified. The ability of the protocol to achieve laboratory-test and clinical goals was assessed by comparing the two groups. The proportion of patients who received OAP increased from 89% for the physician group to 98% for the protocol group. Mean prothrombin times (PTs) were significantly higher in the protocol group only on postoperative day 2; 66% of all PTs beyond post-operative day 1 in the protocol group were within the targeted range, which reflected an International Normalized Ratio of 1.6-3.2. The frequencies of clinically apparent postoperative thrombotic events and bleeding episodes were low in each group and comparable to literature values. Analysis of protocol-group patients with PTs of > 20 seconds indicated that lower weight, female sex, and blood loss during surgery were associated with an elevated PT. The protocol was revised to provide for a lower initial warfarin dose in elderly women. A pharmacy-managed protocol for dosing warfarin achieved therapeutic goals and promoted nearly universal use of OAP in patients undergoing high-risk orthopedic surgery.

Continuous quality improvement as an ideal in hospital practice

Continuous quality improvement (CQI) is an important part of successfully managing change in health care. This article describes a CQI plan and process created to develop a comprehensive plan for a rapidly evolving organization. Four key components of the planning process are described: initial initiatives, customer service orientation, teamwork approach, and physician involvement. A case study is also included to illustrate how one CQI plan and process was implemented and evaluated.

Practical guides. II: Hospital pharmacy quality control services

This article briefly reviews the evolution, scope and operation of hospital quality control (QC) services. Recent initiatives and developments are considered alongside the traditional 'core' QC/quality assurance (QA) work. Important new areas of work which could benefit from QC involvement are also discussed.

Evaluating the value, accuracy, and operational feasibility of DUE criteria

The purpose of this investigation was to evaluate the value, accuracy, and operational feasibility of indicators/criteria in a drug use evaluation (DUE) examining IV histamine2-receptor antagonists (H2-RA). Pharmacists in 40 hospitals collected DUE data concurrent with hospital stays on a total of 1,200 patients. After completing the DUE, pharmacist data collectors were asked to evaluate each DUE criterion. Most reported that criteria relating to indications for use, therapeutic drug monitoring, and adverse drug reactions/drug interactions should be included in a DUE, but some criteria were not easy to collect or were inaccurate. The data suggest the need to carefully select DUE criteria that can be used for continuous improvements that meet JCAHO accreditation requirements.

Pharmaceutical care role model in psychiatry--pharmacist prescribing

Pharmacist's expanded roles in a mental health clinic are described. A needs assessment identified problems which could be solved by expanding the pharmacist's scope of practice. Pharmacy, psychiatry, and medical center administration approved the pharmacist's psychiatric prescribing privileges and the authority to order appropriate laboratory tests, which provides the mechanism of solving the problems identified. Psychiatry's acceptance of pharmacists in this new role is demonstrated by the continued expansion of this program. By the end of a 4-year period, pharmacists were seeing 46% of all psychiatric medication visits. A description of the privileges, roles, and process is provided.

Initiating a drug blood level monitoring program through CQI

A blood level monitoring program was developed at St. James Hospital and Health Centers--a 472-bed community hospital located in Chicago Heights, IL. The primary goal of the program was to improve patient care by ensuring that drug levels were within their target range for the condition being treated. Additional benefits obtained from the program included meeting Joint Commission on Accreditation of Healthcare Organization's standards for medication monitoring and generating additional revenue for the institution from pharmacokinetic consults. Highlights of the service and its implementation are presented in this article.

Evaluation of a patient education program for solid organ transplant patients

Medication counselling of transplant patients plays a major role in the outcome of the transplant. The medication counselling program at Vancouver Hospital and Health Sciences Centre for Solid Organ Transplant (SOT) patients consists of verbal counselling by a pharmacist, provision of medication teaching sheets, and patient participation in the self-medication program. The objectives of this study were to evaluate the effectiveness of the medication counselling program for SOT patients and to develop a series of tests to serve as a teaching tool. Solid organ transplant patients who were English speaking and tolerated oral medications were enrolled in the study. A prospective evaluation of the medication counselling program was done through a series of identical tests. Percent scores were calculated for each test, and pre-test scores (scores prior to counselling) were compared to post-test scores (scores after counselling). Twenty-eight SOT patients participated in the study. Patients scored an average of 25% on the pre-test prior to the counselling session and 66% on the post-test at the time of discharge. When scores on specific questions were compared, patients did well on drug identification, dosage and indications, but poorly on questions regarding side effects. Patient counselling improves medication knowledge in SOT patients as indicated by an increase in test scores. The combination of repeated counselling sessions and the participation in the self-medication program reinforces medication knowledge and maximizes retention of knowledge.

A team approach to adverse drug reaction surveillance: success at a tertiary care hospital

A retrospective adverse drug reaction (ADR) reporting system has been in place at Cedars-Sinai Medical Center for 7 years. Initially, the system identified 300 to 400 ADRs per year. After adding a checklist, that number increased to 750 to 850 per year, an ADR rate of about 2% of total patient admissions. To increase the ADR reporting rate, we initiated a concurrent surveillance program in conjunction with the retrospective system. In the first year of the program, the combined systems identified 1,174 ADRs. In addition, the ADR rate per 100 patient days increased to between 0.5 and 0.7, and the ADR per admission rate increased to 4%. As a result of the more effective ADR surveillance program, the P & T Committee has additional data from which to develop guidelines and educational programs to increase ADR awareness and prevention, and thus, to improve patient outcomes.

Development of a comprehensive clinical pharmacy workload documentation system

The purpose of this project was to develop a workload documentation system which captures the clinical activities of the pharmacist, as well as the pharmacist's impact on the patient's drug therapy outcomes and costs. The documentation system consists of three sections: clinical activities, clinical effectiveness indicators, and cost-effectiveness indicators. In addition to those established by the National Hospital Productivity Improvement Program-Pharmacy Workload Measurement System, other indicators are incorporated to more accurately reflect the pharmacists' daily clinical activities. Clinical effectiveness indicators of patient outcomes include the number and type of drug-related problems identified and resolved and the number of therapeutic interventions made and accepted. Cost-effectiveness is measured by pharmacists' interventions on 14 focused areas of drug therapy. Compliance with daily documentation is facilitated by use of pocket-sized cards for data collection and retrieval. This documentation system has been implemented since December 1990. Quarterly reports submitted to the Director identify changes and trends in workload. Information is used for staff justification, impact assessment of clinical service provided, identification of needs for staff development and planning future clinical directions. In order to enhance the efficiency of documentation and data analysis, future plans include computerization and evaluation of the frequency of data collection.

Guidelines on the provision of facilities for the care of adult patients with haematological malignancies (including leukaemia and lymphoma and severe bone marrow failure). British Committee for Standards in Haematology Clinical Haematology Task Force

This report defines four levels of care required for the management of adult patients with haematological malignancies and marrow failure (acute and chronic leukaemias, lymphomas, myelodysplastic and myeloproliferative disorders, myeloma and severe aplastic anaemia). The higher levels of care require increasing specialist expertise, staffing and resources. Staffing includes both the medical, nursing and scientific/laboratory professions and other support staff. Resources include ward provision, bed numbers, equipment, laboratory and radiotherapy facilities, pharmacy, support services and research. Blood transfusion services and their organisation are discussed separately. The guidelines indicate to providers and purchasers the issues to be considered in placing contracts for the care of these patients. A glossary of terms is provided for purchasers.

How a CQI program improved aminoglycoside use in a community hospital

The P & T Committee of our institution, a 285-bed, non-tertiary care regional medical center, undertook a study to evaluate the use of the aminoglycoside amikacin sulfate (Amikin). Results of an initial DUE, a follow-up to an educational effort, and the estimated annual cost savings that could be achieved with appropriate prescribing of aminoglycosides are presented.

Reducing inappropriate prescribing of sublingual nifedipine

OBJECTIVE

To report a program to reduce the practice of prescribing sublingual nifedipine.

MONITORING AND EDUCATIONAL PROGRAM

Pharmacy records were used to identify orders for sublingual nifedipine at Georgetown University Medical Center. Initial review showed 30-40 orders/month, or approximately 11% of all nifedipine orders. A newsletter was published outlining Pharmacy and Therapeutics Committee guidelines for the use of nifedipine when rapid onset of action is desired. Further educational efforts involved correspondence with each attending physician responsible for the sublingual nifedipine orders. A reduction in orders for sublingual nifedipine to approximately 10 orders/month (3.9% of total nifedipine orders) was observed after using this educational approach. The reduction in orders has been maintained by frequent contact with the attending physicians.

CONCLUSIONS

Repeated educational measures have resulted in a reduction in the inappropriate prescribing of sublingual nifedipine.

Impact of vancomycin therapeutic drug monitoring on patient care

OBJECTIVE

To document differences in the outcome of vancomycin therapy in patients managed through a therapeutic drug monitoring (TDM) service and patients managed empirically, without the participation of a TDM service.

DESIGN

Prospective, cohort study.

SETTING

An 1100-bed, tertiary-care, teaching hospital.

PATIENTS

Those who received vancomycin for more than four days, were at least 18 years old, had an estimated creatinine clearance of more than 0.33 mL/s (20 mL/min), were not neutropenic at the start of vancomycin therapy, and were not treated in a critical care unit were enrolled in the study. A total of 116 patients (61 TDM; 55 non-TDM) were monitored prospectively from June 1990 through March 1991.

INTERVENTIONS

Patients in the TDM group had vancomycin drug therapy monitored daily by a pharmacist and vancomycin dosages adjusted following a pharmacokinetic analysis of vancomycin serum concentrations. For patients in the non-TDM group, the pharmacist only completed a data collection form. The patients and physicians were unaware of the monitoring.

MAIN OUTCOME MEASURES

Duration of therapy, total vancomycin dosage, infection site, concomitant antibiotics, body temperature, and white blood cell counts were compared between the two groups. Length of stay data were also compared. Nephrotoxicity was evaluated by comparing serum creatinine concentration and estimated creatinine clearance.

RESULTS

TDM of vancomycin appeared to reduce the incidence of vancomycin-related renal insufficiency (TDM 7 percent; non-TDM 24 percent). Patients managed through the TDM service received an average of 5 g less of vancomycin than did the patients in the non-TDM group. The duration of vancomycin therapy was an average of 2 days less for patients in the TDM group. Mean length of stay was 38.0 days for the TDM group and 44.5 days for the non-TDM group. Other measures of efficacy, infection site, and concomitant antibiotics were the same for both groups.

CONCLUSIONS

TDM of vancomycin was associated with fewer cases of vancomycin-related renal insufficiency. Vancomycin efficacy was not compromised by TDM. Provision of TDM for vancomycin therapy aided in patient management.