Scoring big: Aligning inpatient clinical pharmacy services through implementation of an electronic scoring system

PURPOSE

Data are limited on utilizing a comprehensive scoring system in the electronic health record to help prioritize, align, and standardize clinical pharmacy services across multiple hospitals and practice models within a health system. The purpose of this article is to describe the development and implementation of an electronic scoring system to help inpatient pharmacists prioritize patient care activities and standardize clinical services across a diverse health system.

SUMMARY

Inpatient pharmacists from all specialty areas across the health system partnered with health information technology pharmacists to develop a scoring system directly integrated into the electronic health record that would help triage patient care, identify opportunities for pharmacist intervention, and prioritize clinical pharmacy services. Individual variables were built based on documented patient parameters such as use of high-risk medications, pharmacy consults, laboratory values, disease states, and patient acuity. Total overall scores were assigned to patients based on the sum of the scores for the individual variables, which update automatically in real time. The total scores were designed to help inpatient pharmacists prioritize patients with higher scores, thus reducing the need for manual chart review to identify high-risk patients.

CONCLUSION

An electronic scoring system with a tiered point system developed for inpatient pharmacists creates a method to prioritize and align clinical pharmacy services across a health system with diverse pharmacy practice models.

Assessing the pharmacy workforce's preparedness for a workplace violence event

PURPOSE

The purpose of this article is to describe the planning, implementation, and findings of a "person with a weapon" exercise for an inpatient pharmacy department.

SUMMARY

There has been an increased focus on workplace violence in healthcare within the last few years. The health-system pharmacy workforce should take an active role in planning for workplace violence events by completing a risk assessment analysis and performing tabletop and functional exercises. This study provides an example of how health-system pharmacists collaborated with an emergency management team, security, and communications to carry out a person with a weapon exercise in an inpatient hospital pharmacy. Areas for improvement were identified for pharmacy, communications, and security during education sessions and the tabletop and functional exercises, demonstrating the importance of a multidisciplinary approach when planning for a person with a weapon event. As a result of this exercise, there was increased awareness of the "run, hide, fight" tactic, an increase in workplace violence education and staff awareness, and an enhancement of security measures, including technology improvements.

CONCLUSION

This workplace violence exercise provides an example of how the pharmacy workforce can engage in emergency preparedness planning and risk mitigation for a workplace violence event. Other health systems can use the action plan, findings, and improvements to raise awareness and train about workplace violence events and support the safety of the pharmacy workforce.

Impact of a Standardized, Pharmacist-Initiated "Test-Claim" Workflow for Anticipating Barriers to Accessing Discharge Antimicrobials

Background: Inability to access and afford discharge oral antimicrobials may delay discharges or result in therapeutic failure. "Test-claims" have the potential to identify such barriers. Objective: This study evaluated discharge antimicrobial access and patient outcomes after implementation of a standardized, inpatient pharmacist-initiated antimicrobial discharge medication cost inquiry (aDMCI) process. Methods: This was an Institutional Review Board (IRB)-approved, pilot retrospective cohort study that included adults admitted for ≥72 hours from November 1, 2018, to February 28, 2019, and discharged on oral antimicrobials. Patients with a cost inquiry (aDMCI group) were compared with those without (standard-of-care, SOC, group). Primary endpoint was discharge delay. Secondary endpoints included percentage of patients discharged on suboptimal antimicrobials and medication errors from aDMCI. Results: 84 patients were included: 43 in SOC and 41 in aDMCI. Seventy-five antimicrobial cost inquiries were evaluated among 41 patients. There were no discharge delays or medication errors associated with the standardized "test-claim" (aDMCI) workflow. Patients in the SOC group had a greater Charlson Comorbidity Index (4 [2-6] vs 2 [1-4], P =0.004), were more likely to be immunosuppressed (24, 56% vs 12, 29%; P =0.014), and had longer hospitalization (8 [5-15] vs 6 [5-9] days, P =0.026). Primary access barriers were prior-authorization (8, 11%) and associated with linezolid and moxifloxacin cost inquiries. Most aDMCIs results were available in <24 hours (66, 88%). Conclusions: The aDMCI process is safe and offers an actionable transition of care tool that can identify barriers to accessing discharge medications while insulating patients from surprise out-of-pocket cost.

Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

IMPORTANCE

Although prescribers face numerous patient-centered challenges during transitions of care (TOC) at hospital discharge, prolonged duration of antimicrobial therapy for common infections remains problematic, and resources are needed for antimicrobial stewardship throughout this period.

OBJECTIVE

To evaluate a pharmacist-driven intervention designed to improve selection and duration of oral antimicrobial therapy prescribed at hospital discharge for common infections.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a nonrandomized stepped-wedge design with 3 study phases from September 1, 2018, to August 31, 2019. Seventeen distinct medicine, surgery, and specialty units from a health system in Southeast Michigan participated, including 1 academic tertiary hospital and 4 community hospitals. Hospitalized adults who had urinary, respiratory, skin and/or soft tissue, and intra-abdominal infections and were prescribed antimicrobials at discharge were included in the analysis. Data were analyzed from February 18, 2020, to February 28, 2022.

INTERVENTIONS

Clinical pharmacists engaged in a new standard of care for antimicrobial stewardship practices during TOC by identifying patients to be discharged with a prescription for oral antimicrobials and collaborating with primary teams to prescribe optimal therapy. Academic and community hospitals used both antimicrobial stewardship and clinical pharmacists in a multidisciplinary rounding model to discuss, document, and facilitate order entry of the antimicrobial prescription at discharge.

MAIN OUTCOMES AND MEASURES

The primary end point was frequency of optimized antimicrobial prescription at discharge. Health system guidelines developed from national guidelines and best practices for short-course therapies were used to evaluate optimal therapy.

RESULTS

A total of 800 patients prescribed oral antimicrobials at hospital discharge were included in the analysis (441 women [55.1%]; mean [SD] age, 66.8 [17.3] years): 400 in the preintervention period and 400 in the postintervention period. The most common diagnoses were pneumonia (264 [33.0%]), upper respiratory tract infection and/or acute exacerbation of chronic obstructive pulmonary disease (214 [26.8%]), and urinary tract infection (203 [25.4%]). Patients in the postintervention group were more likely to have an optimal antimicrobial prescription (time-adjusted generalized estimating equation odds ratio, 5.63 [95% CI, 3.69-8.60]). The absolute increase in optimal prescribing in the postintervention group was consistent in both academic (37.4% [95% CI, 27.5%-46.7%]) and community (43.2% [95% CI, 32.4%-52.8%]) TOC models. There were no differences in clinical resolution or mortality. Fewer severe antimicrobial-related adverse effects (time-adjusted generalized estimating equation odds ratio, 0.40 [95% CI, 0.18-0.88]) were identified in the postintervention (13 [3.2%]) compared with the preintervention (36 [9.0%]) groups.

CONCLUSIONS AND RELEVANCE

The findings of this quality improvement study suggest that targeted antimicrobial stewardship interventions during TOC were associated with increased optimal, guideline-concordant antimicrobial prescriptions at discharge.

An electronic tool for health systems to assess and communicate discharge medication access

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

The purpose of this study was to describe how the discharge medication cost inquiry (DMCI) consult order and workflow were created and used to communicate transition of care needs and medication access barriers before discharge.

SUMMARY

Health-system pharmacists collaborated with the information technology department to develop the DMCI consult order and workflow. This institutional review board-approved retrospective case study evaluated use of the DMCI consult order throughout the health system. Outcomes that could not be retrieved electronically were collected for every third patient encounter using manual chart review. The DMCI consult order was used at each hospital in the health system. Physicians placed the most DMCI consult orders; however, pharmacists at the large academic tertiary hospital utilized the DMCI consult order the most. The DMCI consult order was sent most frequently for anticoagulants. Although most medications were covered by insurance, the tool and workflow identified barriers to medication access. Almost 90% of the patients with a DMCI consult order had at least one prescription generated on discharge.

CONCLUSION

The DMCI consult order is a novel electronic tool to aid in communicating discharge medication needs. When incorporated into care transition planning, the DMCI consult order and workflow provide a model to ensure patients have access to medications. It can also be used to document and evaluate the role of pharmacy in transitions of care in the health system.

Improving pediatric pharmacy services in a primarily adult emergency department

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

The American Society of Health-System Pharmacists (ASHP) and Pediatric Pharmacy Advocacy Group (PPAG) guidelines for providing pediatric pharmacy services in hospitals and health systems can be used to improve medication safety wherever pediatric patients receive care, including in the emergency department (ED). The purpose of this initiative was to improve compliance with these guidelines in a primarily adult ED.

Methods

This quality improvement initiative was conducted in a level 1 trauma center ED between October 2019 and March 2020. The ASHP-PPAG guidelines were used to create practice elements applicable to the ED. An initial compliance assessment defined elements as noncompliant, partially compliant, fully compliant, or not applicable. Investigators identified interventions to improve compliance for noncompliant or partially compliant elements and then reassessed compliance following implementation. Data were expressed using descriptive statistics. This initiative was exempt from institutional review board approval.

Results

Ninety-three ED practice elements were identified within the 9 standards of the ASHP-PPAG guidelines. At the initial compliance assessment, the majority (59.8%) of practice elements were fully compliant; however, various service gaps were identified in 8 of the standards, and 16 interventions were implemented to improve compliance. At the final compliance assessment, there was a 19.5% increase in full compliance. Barriers to achieving full compliance included technology restrictions, time constraints, financial limitations, and influences external to pharmacy.

Conclusion

This quality improvement initiative demonstrated that the ASHP-PPAG guidelines can be used to improve ED pediatric pharmacy services in a primarily adult institution. The initiative may serve as an example for other hospitals to improve compliance with the guidelines.

Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications

PURPOSE

The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications.

SUMMARY

Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge.

CONCLUSION

Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.

Hospital-Based Clinical Pharmacy Services to Improve Ambulatory Management of Chronic Obstructive Pulmonary Disease

Background: No systematic evaluations of a comprehensive clinical pharmacy process measures currently exist to determine an optimal ambulatory care collaboration model for chronic obstructive pulmonary disease (COPD) patients. Objective: Describe the impact of a pharmacist-provided clinical COPD bundle on the management of COPD in a hospital-based ambulatory care clinic. Methods: This retrospective cohort analysis evaluated patients with COPD managed in an outpatient pulmonary clinic. The primary objective of this study was to assess the completion of 4 metrics known to improve the management of COPD: (1) medication therapy management, (2) quality measures including smoking cessation and vaccines, (3) patient adherence, and (4) patient education. The secondary objective was to evaluate the impact of the clinical COPD bundle on clinical and economic outcomes at 30 and 90 days post–initial visit. Results: A total of 138 patients were included in the study; 70 patients served as controls and 68 patients received the COPD bundle from the clinical pharmacist. No patients from the control group had all 4 metrics completed as documented, compared to 66 of the COPD bundle group ( P < .0001). Additionally, a statistically significant difference was found in all 4 metrics when evaluated individually. Clinical pharmacy services reduced the number of phone call consults at 90 days ( P = .04) but did not have a statistically significant impact on any additional pre-identified clinical outcomes. Conclusion: A pharmacist-driven clinical COPD bundle was associated with significant increases in the completion and documentation of 4 metrics known to improve the outpatient management of COPD.

Impact of a Multidisciplinary Culture Follow-up Program of Antimicrobial Therapy in the Emergency Department

Introduction

Antimicrobial prescribing in the emergency department is predominantly empiric, with final microbiology results either unavailable or reported after most patients are discharged home. Systematic follow-up processes are needed to ensure appropriate antimicrobial therapy at this transition of care. The objective of this study was to assess the impact of a culture follow-up (CFU) program on the frequency of emergency department (ED) revisits within 72 h and hospital admissions within 30 days compared to the historical standard of care (SOC). Additionally, infection characteristics and antimicrobial therapy were compared.

Methods

A single group, pre-test post-test quasi-experimental study was conducted comparing a retrospective SOC group to a prospective CFU group. CFU was implemented using computerized decision-support software and a multidisciplinary team of pharmacists and emergency physician staff.

Results

Over the four-month intervention period the CFU group evaluated 197 cultures and modified antimicrobial therapy in 25.5%. The rate of combined ED revisits within 72 h and hospital admissions within 30 days was 16.9% in the SOC group and 10.2% in the CFU group (p = 0.079). When evaluating the uninsured population alone, revisits to the ED within 72 h were reduced from 15.3% in the SOC group to 2.4% in the CFU group (p = 0.044).

Conclusion

Implementation of a multidisciplinary CFU program was associated with a reduction in ED revisits within 72 h and hospital admissions within 30 days. One-fourth of patients required post-discharge intervention, representing a large need for antimicrobial stewardship expansion to ED practice models.

Electronic supplementary material

The online version of this article (doi:10.1007/s40121-014-0026-x) contains supplementary material, which is available to authorized users.

Direct imaging of aligned neurofilament networks assembled using in situ dialysis in microchannels

We report a technique to produce aligned neurofilament networks for direct imaging and diffraction studies using in situ dialysis in a microfluidic device. The alignment is achieved by assembling neurofilaments from protein subunits confined within microchannels. Resulting network structure was probed by polarized optical microscopy and atomic force microscopy, which confirmed a high degree of protein alignment inside the microchannels. This technique can be expanded to facilitate structural studies of a wide range of filamentous proteins and their hierarchical assemblies under varying assembly conditions.

Microchannel systems in titanium and silicon for structural and mechanical studies of aligned protein self-assemblies

We report a technique for the alignment of self-assembled protein systems, such as F-actin bundles and microtubules, in a surface-modified titanium or silicon microfluidic device. Assembling filamentous protein systems in a confined geometry produces highly aligned samples for structural and mechanical studies. Biomolecular self-assembly can be investigated in a controlled fashion under different molecular concentration gradients and conditions along a channel length. We have shown that surface-modified devices produced via a high aspect ratio etch process in titanium and silicon can be used to confine and control such macromolecular assemblies and present examples of F-actin bundles and microtubules in this system.

The in vivo delivery of heterologous proteins by microencapsulated recombinant cells

The microencapsulation of recombinant cells is a novel and potentially cost-effective method of heterologous protein delivery. A 'universal' cell line, genetically modified to secrete any desired protein, is immunologically protected from tissue rejection by enclosure in microcapsules. The microcapsule can then be implanted in different recipients to deliver recombinant proteins in vivo.

Acetaminophen: a practical pharmacologic overview

Acetaminophen is an effective analgesic and antipyretic agent with few adverse effects when used in recommended dosages. The drug is metabolized mainly in the liver, and the several end products have no harmful effects. An intermediate compound in a minor metabolic pathway, however, is toxic; it is normally inactivated by glutathione. In the case of an acetaminophen overdose the hepatic stores of glutathione seem to become depleted, leaving the toxic intermediate free to damage liver tissue. Such damage is unlikely to occur unless the plasma concentration of acetaminophen peaks above 150 micrograms/mL--a level far in excess of the 5 to 20 micrograms/mL achieved with therapeutic doses of the drug. Long-term therapeutic use of acetaminophen does not appear to be associated with liver damage, although some case reports suggest the possibility. Acetaminophen poisoning follows an acute overdose and, if untreated, is manifested clinically by an initial phase of nonspecific signs and symptoms, a latent period in which the liver transaminase levels rise and then, 3 to 5 days after the ingestion, signs of more serious hepatic dysfunction. Most patients do not progress beyond the first or second phase. They and those who survive the third phase recover with no residual injury to the liver. Appropriate antidotal therapy markedly reduces the severity of the initial damage.

Stability of methacholine chloride in bronchial provocation test solutions

The stability of methacholine chloride (5 mg/ml) in 0.9% sodium chloride solution was measured. A reliable colorimetric assay (530 nm) based on the formation of a hydroxamic acid-iron complex was used. At appropriate time intervals, samples were removed from solutions stored at 4, 20, 37, 60, or 80 degrees C and assayed. The degradation of methacholine chloride followed apparent first-order kinetics of methacholine chloride followed apparent first-order kinetics at all temperatures, with observed half-lives ranging from 29.3 days at 80 degrees C to 693 days 4 degrees C. Methacholine chloride in 0.9% sodium chloride solution does not degrade as rapidly as previously suggested. According to an Arrhenius plot, storage of such solutions at 30 or 4 degrees C would result in not more than 10% degradation over a period of approximately two or five months, respectively. Thus, it should be possible to prepare stock solutions of this deliquescent drug.