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Trovato A, Tyler LS, Nickman NA, Findlay R. Interventions to reduce waste and improve billing compliance with medications in single-dose vials. Am J Health Syst Pharm 2023; 80:222-226. [PMID: 36322482 DOI: 10.1093/ajhp/zxac330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The purpose of this process improvement project was to implement features in the electronic health record to help reduce inappropriate drug waste and Medicare billing noncompliance for injectable drugs in single-dose vials in outpatient settings. METHODS The pharmacy department mapped processes from order entry to dose administration and claims processing. They used the process map to identify gaps that could lead to inappropriate drug waste. The organization then chose 3 drugs they believed to be at high risk of excess waste and possible billing noncompliance after cross-referencing drug cost, volume of use, and previous Medicare audits in outpatient settings. They tested a grouper and dose rounding on these drugs and compared 3 months of claims before and after implementation to assess the impact on waste and billing compliance. RESULTS This study evaluated 826 claims before implementation and 1,075 claims after implementation. A total of 455 of 826 (55.1%) preimplementation claims included drug waste compared to 224 of 1,075 (20.8%) postimplementation claims. Twenty-three claims before implementation included an amount of waste exceeding the smallest vial size, putting the institution at risk of billing noncompliance. No claims had excess waste in the postimplementation period. The approximate cost of total drug waste before implementation was $1,397,437, with approximately $23,730 from inappropriate carfilzomib claims. The approximate cost of waste after implementation was $569,041. This equated to a reduction in drug waste of approximately $828,396 for bevacizumab-bvzr, carfilzomib, and ipilimumab. CONCLUSION Using a grouper and implementing dose rounding, the institution reduced drug waste, saved money, and reduced the incidence of claims noncompliant with Medicare Part B billing requirements.
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Affiliation(s)
| | - Linda S Tyler
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Nancy A Nickman
- University of Utah Health, Salt Lake City, UT, and University of Utah College of Pharmacy, Salt Lake City, UT, USA
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Abstract
BACKGROUND Automated dispensing cabinets (ADCs) are an integral component of distribution models in pharmacy departments across the country. There are significant challenges to optimizing ADC inventory management while minimizing use of labor and capital resources. The role of enhanced inventory control functionality is not fully defined. OBJECTIVE The aim of this project is to improve ADC inventory management by leveraging dynamic inventory standards and a low inventory alert platform. METHODS Two interventional groups and 1 historical control were included in the study. Each intervention group consisted of 6 ADCs that tested enhanced inventory management functionality. Interventions included dynamic inventory standards and a low inventory alert messaging system. Following separate implementation of each platform, dynamic inventory and low inventory alert systems were applied concurrently to all 12 ADCs. Outcome measures included number and duration of daily stockouts, ADC inventory turns, and number of phone calls related to stockouts received by pharmacy staff. RESULTS Low inventory alerts reduced both the number and duration of stockouts. Dynamic inventory standards reduced the number of daily stockouts without changing the inventory turns and duration of stockouts. No change was observed in number of calls related to stockouts made to pharmacy staff. CONCLUSIONS Low inventory alerts and dynamic inventory standards are feasible mechanisms to help optimize ADC inventory management while minimizing labor and capital resources.
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Affiliation(s)
- Russell Findlay
- University of Wisconsin Hospital and Clinics, Department of Pharmacy , Madison, Wisconsin
| | - Aaron Webb
- University of Wisconsin Hospital and Clinics, Department of Pharmacy , Madison, Wisconsin
| | - Jim Lund
- University of Wisconsin Hospital and Clinics, Department of Pharmacy , Madison, Wisconsin
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Rush J, Findlay R. Pharmacy transitions of care services in Wisconsin. J Am Pharm Assoc (2003) 2015; 55:468. [PMID: 26359955 DOI: 10.1331/japha.2015.15032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Vaught A, Findlay R, Davis R, Lanz J, Moore F, Marker P, Tommolino K, Lemon S, Voils S, Ozrazgat-Baslanti T, Bihorac A, Leclaire A, Efron P. Gram stain can be used to safely discontinue vancomycin therapy for early pneumonia in the trauma intensive care unit. Am Surg 2014; 80:1277-1279. [PMID: 25513932 PMCID: PMC4307788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Arthur Vaught
- Department of Anesthesia, University of Florida College of Medicine, Gainesville, Florida, USA
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Vaught A, Findlay R, Davis R, Lanz J, Moore F, Marker P, Tommolino K, Lemon S, Voils S, Ozrazgat-Baslanti T, Bihorac A, Leclaire A, Efron P. Gram Stain Can be Used to Safely Discontinue Vancomycin Therapy for Early Pneumonia in the Trauma Intensive Care Unit. Am Surg 2014. [DOI: 10.1177/000313481408001235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Arthur Vaught
- Department of Anesthesia University of Florida College of Medicine Gainesville, Florida
| | - Russell Findlay
- Department of Pharmacology University of Florida College of Medicine Gainesville, Florida
| | - Ruth Davis
- Department of Surgery University of Florida College of Medicine Gainesville, Florida
| | - Jennifer Lanz
- Department of Surgery University of Florida College of Medicine Gainesville, Florida
| | - Frederick Moore
- Department of Surgery University of Florida College of Medicine Gainesville, Florida
| | - Peggy Marker
- Department of Nursing University of Florida College of Medicine Gainesville, Florida
| | - Karly Tommolino
- Department of Pharmacology University of Florida College of Medicine Gainesville, Florida
| | - Stephen Lemon
- Department of Pharmacology University of Florida College of Medicine Gainesville, Florida
| | - Stacy Voils
- Department of Pharmacology University of Florida College of Medicine Gainesville, Florida
| | | | - Azra Bihorac
- Department of Anesthesia University of Florida College of Medicine Gainesville, Florida
| | - Aimee Leclaire
- Department of Pharmacology University of Florida College of Medicine Gainesville, Florida
| | - Philip Efron
- Department of Surgery University of Florida College of Medicine Gainesville, Florida
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Abstract
OBJECTIVE To report on hyperammonemia noted in a series of patients receiving asparaginase products at our institution. SUMMARY OF CASES We present four patients who experienced symptomatic hyperammonemia after receiving either pegaspargase (three patients) or Erwinia asparaginase (one patient). Presenting symptoms included lethargy, difficulty awakening, confusion, dizziness, numbness and tingling, hallucinations, and paranoia. All patients were treated with lactulose, which led to a decrease in ammonia level and resolution of symptoms. DISCUSSION Hyperammonemia secondary to asparaginase products has been reported in the literature. The signs and symptoms of increased ammonia should be included in consent documents and discussed with patients and their families. Monitoring of ammonia or asparagine levels may help individualize therapy with asparaginase products in the future. CONCLUSION Hyperammonemia can occur during treatment of acute lymphoblastic leukemia with asparaginase products. Lactulose appears to be a useful treatment strategy. Further study is warranted to determine whether dose modifications are required for pegaspargase in some patients. Whether these dose modifications would be in the dose itself or frequency of administration remains to be determined.
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Affiliation(s)
- Vicki Nussbaum
- Department of Pharmacy, American Family Children's Hospital, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Nicole Lubcke
- Department of Pharmacy, American Family Children's Hospital, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Russell Findlay
- Department of Pharmacy, American Family Children's Hospital, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
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Findlay R, Efron P, Bozeman C, Vaught A, O’Brien K, Marker P, Moore F, LeClaire A. 419. Crit Care Med 2012. [DOI: 10.1097/01.ccm.0000424637.84262.d8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Over a three month period there was an outbreak of infection, due to a multi-drug resistant Acinetobacter baumannii in the intensive care burns unit with spread of infection to other patients, both within the unit and elsewhere in the hospital. Microbiological sampling of the environment and of the healthcare workers' (HCWs) hands were carried out. Strain relatedness of the isolates was confirmed by pulsed field gel electrophoresis. Fifteen patients were involved in the outbreak, whose infections were all hospital-acquired. The burns room environment was contaminated with the A. baumannii, as was the door handle of the door leading from the ante-chamber between both rooms. This allowed the hands of HCWs to be contaminated by A. baumannii despite appropriate handwashing procedures prior to leaving the rooms. Two staff members were colonized with A. baumannii. One HCW who was directly involved in patient care was found to be "heavily" colonized, the other, with less patient contact, was only "lightly" colonized. Review of handwashing practices revealed that chlorhexidine/alcohol hand wash solution was not used by the HCW whose hands were heavily colonized.A combination of a review of handwashing practice, education about the spread of bacteria via hands and contaminated environment, and the revision of infection control procedures in the unit contributed to a prompt termination of the outbreak.
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Affiliation(s)
- S A Roberts
- Middlemore Hospital, South Auckland, New Zealand
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Block SL, Hedrick J, Tyler R, Smith A, Findlay R, Keegan E, Stroman DW. Increasing bacterial resistance in pediatric acute conjunctivitis (1997-1998). Antimicrob Agents Chemother 2000; 44:1650-4. [PMID: 10817723 PMCID: PMC89927 DOI: 10.1128/aac.44.6.1650-1654.2000] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We sought to determine the current level of resistance in Haemophilus influenzae and Streptococcus pneumoniae, the primary pathogens of pediatric conjunctivitis. Between January 1997 and March 1998, we prospectively cultured acute conjunctivitis in 250 ambulatory pediatric patients from rural Kentucky whose average age was 24.3 months. In those 250 cases, 106 H. influenzae (42% of the total) and 75 S. pneumoniae (30% of the total) pathogens were isolated, with no growth or no pathogen resulting in 79 cases (32% of the total). Beta-lactamase was detected in 60 (69%) of 87 tested strains of H. influenzae. Among 65 isolates of S. pneumoniae tested for penicillin susceptibility, 44 (68%) were susceptible, 17 (26%) were resistant, and 4 (6%) were intermediate. Conjunctivitis with acute otitis media was observed in 97 patients (39%), and H. influenzae was recovered in 57% of these 97 cases. As for in vitro activity, ciprofloxacin, ofloxacin, and tetracycline were the most active; and gentamicin, tobramycin, polymyxin B-trimethoprim, and polymyxin B-neomycin were intermediately active. Sulfamethoxazole possessed no activity against either pathogen. Beta-lactamase production was detected in 69% of H. influenzae strains, which still remains the primary causative pathogen of both conjunctivitis and conjunctivitis-otitis syndrome. Penicillin-nonsusceptible S. pneumoniae was observed in 32% of 65 patients with S. pneumoniae conjunctivitis, with most strains being penicillin resistant.
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Affiliation(s)
- S L Block
- Kentucky Pediatric Research, Inc., Bardstown, Kentucky 40004, USA.
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Rings T, Findlay R, Lang S. Ethnicity and methicillin-resistant S. aureus in South Auckland. N Z Med J 1998; 111:151. [PMID: 9612478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kilgour RD, Carranza A, Findlay R. Suppression of the reactive hyperemic response in the forearm due to local hand cooling. Aviat Space Environ Med 1997; 68:46-50. [PMID: 9006882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
METHODS Forearm blood flow (FBF) was measured by electrical impedance plethysmography in order to identify the influence of local cooling of the contralateral hand after 3 min of arterial occlusion. Ten volunteers (six females, four males) were randomly assigned to the following three experimental conditions on separate days: a) 6 min of local hand cooling (5-7 degrees C); b) 3 min of arterial occlusion of the forearm; and c) combined arterial occlusion and local cooling. RESULTS All subjects experienced the typical pressor response during 6 min of hand cooling as evidenced by the significant increase (p < and = 0.05) in heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP). The FBF responses demonstrated an immediate increase (p < and = 0.05) within the first 30 s of hand submersion and then progressively declined over the next 5 min. The forearm vascular resistance (FVR = MAP/FBF) made an initial drop during the first 30 s of cooling and then gradually rose to reach peak levels between 5-6 min of cooling. With respect to the hyperemic response, FBF significantly increased (p < and = 0.05) from baseline (mean +/- SEM; 1.09 +/- 0.18 ml x 100 ml-1.min-1) and achieved peak levels (6.75 +/- 0.64 ml x 100 ml-1.min-1) within the initial 30 s of the post-occlusion period. Thereafter, FBF declined rapidly by 30-60 s (1.67 +/- 0.29 ml x 100 ml-1.min-1) and 60-90 s (1.26 +/- 0.33 ml x 100 ml-1.min-1) of the post-occlusion period. CONCLUSION When the reactive hyperemic response was coupled with hand cooling, FBF increased above baseline values and reached peak levels during the initial 30 s of the post-occlusion period. However, the magnitude of the hyperemic response was significantly lower in the cold condition compared to the hyperemia alone (3.20 +/- 0.42 vs 6.75 +/- 0.64 ml x 100 ml-1.min-1; p < and = 0.05). Clearly, the overall sympathetic response to local cooling had an overriding effect on the factors that promote peripheral vasodilation following brief periods (3 min) of arterial occlusion.
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Affiliation(s)
- R D Kilgour
- Department of Exercise Science, Concordia University, Montreal, Quebec, Canada
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Abstract
Forty adults and 40 children, all right-handed, were presented with either of two series of six nonsense shapes to palpate: Those who were divided into sections by grid lines and thus provided categorical information or those who provided a whole shape and coordinate information that could be processed globally. Subjects were given an Input condition where they formed a mental representation of the shape while palpating the unseen tactual stimulus with either hand, followed by an Evaluation condition in which they attempted to solve the task by generating and using the previously stored image. Evaluation response times showed that the left hemisphere was significantly faster at generating images from categorically stored information. Neither hemisphere had an advantage when generating an image from globally stored information.
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Affiliation(s)
- R Findlay
- Department of Psychology, University of Queensland, Brisbane, Australia
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Sehgal S, Ewing C, Waring P, Findlay R, Bean X, Taeusch HW. Morbidity of low-birthweight infants with intrauterine cocaine exposure. J Natl Med Assoc 1993; 85:20-4. [PMID: 8426379 PMCID: PMC2571728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The effects of intrauterine cocaine exposure on 158 low-birthweight infants (500 g to 2500 g) were compared with 536 low-birthweight infants not known to be exposed to cocaine who were admitted to our neonatal intensive care unit. Univariate analyses indicated that drug-exposed infants had lower birthweights when compared with control infants. Frequency of necrotizing enterocolitis differed between the drug-exposed infants and controls (11% versus 6%). Frequency of severe respiratory distress syndrome, severe intraventricular hemorrhage, and bronchopulmonary dysplasia did not differ between groups of similar birthweight. We conclude that the most evident risks of prenatal cocaine exposure are low birthweight and increased incidence of necrotizing enterocolitis.
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Affiliation(s)
- S Sehgal
- Department of Pediatrics, Drew University College of Medicine, Los Angeles, California
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Fan BR, Bruni R, Taeusch HW, Findlay R, Waring AJ. Antibodies against synthetic amphipathic helical sequences of surfactant protein SP-B detect a conformational change in the native protein. FEBS Lett 1991; 282:220-4. [PMID: 2037039 DOI: 10.1016/0014-5793(91)80481-h] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Synthetic peptides based on the native human sequence of surfactant protein B have been used to generate polyclonal monospecific antibodies against specific segments of the native SP-B protein. Circular dichroism analysis of the synthetic peptides shows they have a dominant helical content in structure promoting environments and tensiometric measurements indicate these peptides lower surface tension at air-water interfaces implying that they contain amphipathic alpha helical motifs. Antibodies directed against the C-terminal segment of SP-B react with the native protein in the oxidized and reduced state. Antibodies directed against the N-terminal sequence of SP-B react with the native protein only in the reduced state suggesting that this domain has a conformation dependent on disulfide bond formation.
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Affiliation(s)
- B R Fan
- Department of Pediatrics, King/Drew Medical Center-UCLA 90059
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Jardini L, Findlay R, Burgi E, Hinderer K, Agarwal A. Auditory changes associated with moderate blood salicylate levels. Rheumatol Rehabil 1978; 17:233-6. [PMID: 366719 DOI: 10.1093/rheumatology/17.4.233] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thirty patients with rheumatoid arthritis were randomly assigned to two groups: aspirin and placebo. Aspirin group subjects received five grain ASA capsules and placebo group subjects received lactose placebo for seven days. Blood salicylate level (BSL) and audiological evaluations were performed on Days 0, 3 and 7. BSLs never exceeded 21 mg/100 ml. BSLs during the seven days varied only slightly among aspirin group subjects but dropped consistently in the placebo group. Intra-subject comparison of scores on low versus high BSL days indicated significant differences between mean speech reception thresholds (SRT) scores and pure-tone air-conduction thresholds at all test frequencies for both groups, except at 2000 Hz for the aspirin group. Inter-group differences occurred on SRT and high-frequency pure-tone thresholds. The results indicate that moderate BSLs adversely affect hearing ability. These adverse effects appear to be temporary.
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