Improving Utilization of a Nursing-Initiated Supportive Medication Order Panel in the Inpatient Setting

BACKGROUND

Many medications are low-risk but must undergo the same ordering process as high-risk medications in the inpatient setting. Nurses identify the need for supportive medications and notify providers. An order panel and policy were developed to allow nurses to order low-risk, supportive medications.

PURPOSE

The aim of this study was to increase order panel utilization from a 6% to a goal of 15%.

METHODS

This was a quality improvement study at a 1000-bed academic medical center. Five plan-do-study-act (PDSA) cycles were implemented. The primary end point was order panel utilization, and secondary end points were individual nursing unit utilization and the number of orders for each medication on the panel.

RESULTS

After each PDSA cycle, order panel utilization improved to 7.8%, 13.2%, 7.5%, 10.2%, and 10.6%, respectively. The units using the order panel most often were general medicine (n = 95, 28%), medical intensive care (n = 71, 21%), and inpatient oncology (n = 40, 12%). The medication most frequently ordered was lanolin alcohols-mineral oil with petrolatum (Eucerin) cream (n = 220, 28%).

CONCLUSIONS

Order panel utilization improved from a baseline of 6% to an average of 9.9%. Increasing awareness of the order panel and adding medications will contribute to improvement in order panel utilization in the long-term.

Operationalizing influenza vaccination in an urban safety-net emergency department

INTRODUCTION

Influenza vaccination is a recommended tool in preventing influenza-related illnesses, medical visits, and hospitalizations. With many patients remaining unvaccinated each year, the Emergency Department (ED) represents a unique opportunity to provide vaccinations to patient not yet vaccinated. However, busy urban safety-net EDs maybe challenged to safely execute such a vaccination program. The aim of this quality improvement project was to assess influenza vaccination feasibility in the ED and improve influenza vaccination rates in our community.

METHODS

The quality improvement work-group, comprised of ED physicians, nurses, and pharmacists, designed and implemented an influenza vaccination protocol that aligned with the ED workflow. The outcome measure was the total number of patients vaccinated per month and per influenza season. Process measures included the type of influenza vaccine administered and type of care area within ED. Balancing measures were also included.

RESULTS

Following the initiative, a total of 337 patients received influenza vaccinations in the ED between September 1, 2018 and December 31, 2020 compared to none during the previous influenza season. With each influenza season, the number of vaccinated patients increased from 61 to 134 and 142, respectively. The average age of the patients was 48.23 ± 15.29, 52.89 ± 15.91, and 44.92 ± 18.97 years old. Most patients received the vaccination while roomed in the high acuity section of the adult ED. No adverse effects or automated dispensing cabinet stockouts were observed.

CONCLUSION

Our structured program indicates that influenza vaccine administration to eligible patients is feasible in a busy urban safety-net ED. Piloting new and further developing existing ED-based influenza vaccination programs have the potential to significantly benefit public health.

Equity in disease prevention: Vaccines for the older adults - a national workshop, Australia 2014

On the 20th June, 2014 the National Health and Medical Research Council's Centre for Research Excellence in Population Health "Immunisation in under Studied and Special Risk Populations", in collaboration with the Public Health Association of Australia, hosted a workshop "Equity in disease prevention: vaccines for the older adults". The workshop featured international and national speakers on ageing and vaccinology. The workshop was attended by health service providers, stakeholders in immunisation, ageing, primary care, researchers, government and non-government organisations, community representatives, and advocacy groups. The aims of the workshop were to: provide an update on the latest evidence around immunisation for the older adults; address barriers for prevention of infection in the older adults; and identify immunisation needs of these groups and provide recommendations to inform policy. There is a gap in immunisation coverage of funded vaccines between adults and infants. The workshop reviewed provider misconceptions, lack of Randomised Control Trials (RCT) and cost-effectiveness data in the frail elderly, loss of autonomy, value judgements and ageism in health care and the need for an adult vaccination register. Workshop recommendations included recognising the right of elderly people to prevention, the need for promotion in the community and amongst healthcare workers of the high burden of vaccine preventable diseases and the need to achieve high levels of vaccination coverage, in older adults and in health workers involved in their care. Research into new vaccine strategies for older adults which address poor coverage, provider attitudes and immunosenescence is a priority. A well designed national register for tracking vaccinations in older adults is a vital and basic requirement for a successful adult immunisation program. Eliminating financial barriers, by addressing inequities in the mechanisms for funding and subsidising vaccines for the older adults compared to those for children, is important to improve equity of access and vaccination coverage. Vaccination coverage rates should be included in quality indicators of care in residential aged care for older adults. Vaccination is key to healthy ageing, and there is a need to focus on reducing the immunisation gap between adults and children.

The management of pneumonia in internal medicine

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP.

Assessment of candidacy for pneumococcal vaccination in intensive care patients

OBJECTIVES

The 23-valent pneumococcal vaccine has been shown to be effective in reducing mortality and complications from pneumonia. The US Centers for Disease Control (CDC) have published guidelines for vaccination eligibility. The intensive care unit (ICU) may represent a missed opportunity for administration of the pneumococcal vaccine to eligible patients. This study assessed the characteristics of patients in an ICU in relation to their candidacy for pneumococcal vaccination. RESEARCH METHODOLOGY/SETTING: A retrospective chart review was performed of all patients with a single admission to a mixed 25 bed ICU of a tertiary-care community teaching hospital from October 2010 to January 2011. Information procured included demographic information, pneumococcal vaccine eligibility, documentation of prior vaccination status or vaccine administration and patient outcomes.

RESULTS

Two-hundred and sixty three individual medical and surgical admissions to the ICU occurred during the study period. The mean number of indicator risk factors for pneumococcal vaccine was 2.3 (95% CI (2.117-2.513), with the majority of patients being over age 65 (57%) and having chronic heart or lung disease (81%). Despite this only seven patients had immunisation status documented and only 14 patients received pneumococcal vaccination during the index hospital stay.

CONCLUSION

In a large tertiary-care teaching hospital, most patients admitted to the ICU had multiple indications for pneumococcal vaccination. However, only a small percentage were assessed or given vaccination during their hospital stay. ICU protocols that give nurses the ability to assess and administer pneumococcal vaccines may improve immunisation rates.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.