Comparison of hospital course and outcome in hospital-acquired vs pre-existing delirium.

BACKGROUND: Delirium is a major source of morbidity in the inpatient hospital setting. This study examined differences between patients with delirium present prior to hospital admission and those with hospitalacquired delirium in several health outcomes. METHODS: A total of 12,529 patients on 2 inpatient units were included in this retrospective cohort study. Outcomes were assessed using chart review. Other variables were compared across groups and included in multivariate models predicting discharge location within the hospitalacquired delirium group. RESULTS: Of 709 patients with delirium, 83% had pre-admission prevalent and 17% had post-admission incident delirium. Compared with patients with preexisting delirium, patients with hospital-acquired delirium had greater hospital durations and mortality and were more likely to receive ICU care, more likely to receive multiple classes of medications, and less likely to be discharged home without home health services. Multivariate analysis in the hospital-acquired delirium group found that several variables independently predicted discharge location. CONCLUSIONS: Patients with hospital-acquired delirium had worse hospital outcomes and a more complicated hospital course than those with preexisting delirium. Administration of various medications, several demographic variables, and some hospital-related variables were independently associated with worse outcomes within the hospital-acquired delirium group. These results demonstrate that patients with hospitalacquired delirium are a vulnerable subgroup deserving special attention.

Prevalence and risk factors of burnout in community pharmacists.

OBJECTIVES: This study aimed to identify the prevalence and risk factors for occupational burnout in community pharmacists. METHODS: Community pharmacists were solicited through a professional network e-mail Listserv to complete an anonymous, electronic survey on burnout. The survey included the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and a work-factors-based questionnaire. The MBI-HSS assessed burnout on the basis of feelings of emotional exhaustion, depersonalization, and reduced personal accomplishment. The additional questionnaire was used to evaluate risk factors for burnout by collecting information on pharmacist demographics, position characteristics, and pharmacy store characteristics. Logistic regression was performed to identify the risk factors associated with burnout. RESULTS: A total of 412 community pharmacists responded to the survey (7.4% response rate), of whom 411 were included in the final analysis. Overall, 308 (74.9%) of responding community pharmacists experienced burnout in at least 1 of the 3 subscales of the MBI-HSS. Most of the pharmacists experienced burnout owing to emotional exhaustion (68.9%), followed by depersonalization (50.4%) and reduced personal accomplishment (30.7%). The significant risk factors for burnout included shorter years of experience, practicing primarily in a chain pharmacy, and a lack of resources for burnout or resiliency. CONCLUSION: There is a high degree of burnout in community pharmacists (74.9%). Future research is warranted to examine optimal strategies to prevent burnout and promote resiliency in the profession.

Evidence of burnout in critical care pharmacists.

PURPOSE: Studies of critical care physicians and nursing personnel indicate a potentially high rate of burnout. To date there is a paucity of data in critical care pharmacists assessing burnout in this group. The purpose of this study was to assess the incidence of risk of burnout in critical care pharmacists. METHODS: Critical care pharmacists were solicited via email to complete an anonymous, electronic questionnaire regarding burnout. Subject demographic and employment characteristics were collected along with the validated, 22-item Maslach Burnout Inventory Health Services Survey in the study cohort. Burnout was assessed from 3 aspects, emotional exhaustion, depersonalization, and lack of personal accomplishment. High degree of burnout was defined as a score >27 in emotional exhaustion, or score >10 in depersonalization, or score <33 in personal achievement. Risk factors of burnout were evaluated using descriptive statistics and logistic regression. RESULTS: Out of 3,140 critical care pharmacists, 193 (6.1%) completed surveys. The mean scores were 25.3, 7.5, and 36.7 for emotional exhaustion, depersonalization, and reduced personal achievement, respectively. Overall, 123 pharmacists (64%) reported at least one syndrome of burnout, and 28 pharmacists (14.5%) reported burnout in all 3 scales. No single risk factor was identified to be associated with the risk of burnout. CONCLUSION: Risk of burnout is high in critical care pharmacists, at 64%, and is comparable to the risk in other critical care practitioner groups. This emphasizes the importance of continuing to evaluate risk factors for burnout and providing resources for burnout prevention to high-risk practitioners.

Digital content delivery in a pharmacy technician training program in a health system.

PURPOSE: Development and implementation of a pharmacy technician training program are described. SUMMARY: As key members of the healthcare team, pharmacy technicians are integral to a pharmacy's operation. Training programs allow technicians to assume roles that support pharmacists practicing "at the top of their license," assist in providing optimal patient care, and serve as an important tool for retaining trained pharmacy technicians. Duke University Health System (DUHS) launched its Pharmacy Technology Training Program (DUHS-PTTP) within the department of pharmacy at Duke University Hospital in April 2018 to assist in meeting current and future pharmacy technician demand. Candidates are provided with the tools to become certified pharmacy technicians through the completion of an affordable accredited program incorporating didactic, simulation-based, and experiential education. The program's partnership with a digital content provider enables accelerated start-up, minimizes investment in content creation and maintenance, enables automated record keeping, and provides flexibility for program participants to complete didactic content outside of the traditional classroom setting. Implementation of this program aims to support students both internal and external to the institution. Students are trained to begin a career as a pharmacy technician with the intent of producing graduates well equipped and eligible for certification by the Pharmacy Technician Certification Board. CONCLUSION: Implementation of a pharmacy technician training program is a logical extension of the demonstrated core training competency of health-system pharmacy departments.

Evaluation of the Role and Impact of Ambulatory Clinical Pharmacists in an Academic Comprehensive Cancer Center.

INTRODUCTION: In recent years, there has been significant growth of ambulatory oncology pharmacy, yet there is a paucity of published studies on the clinical activities and impact of ambulatory oncology clinical pharmacists. At Duke Cancer Center, dedicated pharmacist services are embedded in specialized outpatient oncology areas. Pharmacists document their clinical and administrative activities in the electronic health record. The primary objective of this study is to quantify and assess ambulatory oncology pharmacist interventions in clinics in a large academic comprehensive cancer center. METHODS: For the purposes of this single-center, retrospective, descriptive study, pharmacist interventions were collected, quantified, and described over a 6-month period from July 1 to December 31, 2015. The study evaluated the perceived contribution and impact of a pharmacist on patient care in ambulatory oncology clinics via a survey that was distributed to providers and nurses. RESULTS: In the 6-month time period, there were 5,091 interventions spanning 3,967 patient encounters between nine ambulatory oncology clinic pharmacists. The average time per encounter in the 6-month time frame was 22.4 minutes. There were 92 respondents to the survey (61.7% response rate). Overall, responses showed that the clinical pharmacists add value to patient care and are integral members of the team. CONCLUSIONS: Although previous studies have described pharmacist activities in outpatient oncology clinics, this study showed a larger number and variety of clinical pharmacist activities in outpatient cancer clinics to improve patient care. Future directions include conducting prospective, controlled studies to link pharmacist activities to tangible outcomes.

Evidence of burnout in health-system pharmacists.

PURPOSE: Results of a study to determine levels of and risk factors for professional burnout among health-system pharmacists are reported. METHODS: The Maslach Burnout Inventory Human Services Survey (MBI-HSS) was distributed to a target population of health-system pharmacists to assess study participants for burnout, which is characterized by feelings of emotional exhaustion, depersonalization, and reduced personal accomplishment. Health-system pharmacists were solicited via email through a professional network listserver to complete an anonymous, electronic questionnaire regarding burnout. Demographic information, employment characteristics, and responses to the MBI-HSS were collected using a cross-sectional cohort survey methodology. Descriptive statistics were used to assess MBI-HSS scores and risk factors associated with burnout. RESULTS: Of the 371 survey responses received, 329 were complete and included in the final analysis. Overall, 175 study participants (53.2%) reported scores indicating a high degree of burnout on at least 1 subscale of the MBI-HSS. Twenty-eight respondents (8.5%) had scores indicating burnout on all 3 subscales. Average scores were 22.9, 6.2, and 36.3 for feelings of emotional exhaustion, depersonalization, and reduced personal accomplishment, respectively. Modifiable and nonmodifiable risk factors for burnout were identified. The findings warrant further research on burnout prevention and action to promote resilience in the profession. CONCLUSION: Half of health-system pharmacists assessed using the MBI-HSS in this study identified themselves as being at risk for burnout.

Evaluation of the value of team-based psychiatric consultation in a general hospital setting.

Background With the increase use of pay for performance in healthcare, 30-day readmissions after discharges are critically important. Objective A team-based psychiatric consultation approach was tested in an inpatient hospital setting. This is the first study that examines 30-day readmission rate with this approach. Methods In this quality improvement study, 164 patients received a team-based psychiatric consultation that included daily meetings during the weekdays between psychiatrists and hospitalists and 436 received care of treatment-as-usual or traditional consultation-liaison services. Results Overall 30-day readmission rate was not significantly different between intervention and nonintervention groups. However, in subgroups with high risk of mortality or severe illness, the intervention group had a 0% 30-day readmission rate for both high risk of mortality and severe illness subgroups, while the nonintervention group's readmission rate was 5% for high risk of mortality group and 3% for severely ill patients. Annual hospital cost saving is estimated between a quarter million and 1.5 million dollars for these subgroups. Conclusion The team-based psychiatric consultation approach demonstrated the potential for substantial cost savings in providing care for patients with high risk of mortality and severe illness. Thus, this intervention may be very useful in caring for patients with complex chronic conditions.

Health Care Systems and Transitions of Care: Implication on Interdisciplinary Pharmacy Services.

Effective medication management is critical to successful patient outcomes. Pharmacists and pharmacy technicians working within North Carolina Health Systems provide a variety of services that aid in those successful outcomes. By leveraging the North Carolina Clinical Pharmacist Practitioner designation along with integrated health records, health system pharmacists are uniquely positioned to provide expert clinical support to patients. Services such as medication history collection, discharge medication dispensing and counseling, post discharge clinic engagement, and drug therapy management are all components of an even larger number of strategic health system pharmacy assets that aid in the care of patients whether they are admitted to hospitals, seen in clinics, or cared for in the community.

Columnar architecture improves noise robustness in a model cortical network.

Cortical columnar architecture was discovered decades ago yet there is no agreed upon explanation for its function. Indeed, some have suggested that it has no function, it is simply an epiphenomenon of developmental processes. To investigate this problem we have constructed a computer model of one square millimeter of layer 2/3 of the primary visual cortex (V1) of the cat. Model cells are connected according to data from recent paired cell studies, in particular the connection probability between pyramidal cells is inversely proportional both to the distance separating the cells and to the distance between the preferred parameters (features) of the cells. We find that these constraints, together with a columnar architecture, produce more tightly clustered populations of cells when compared to the random architecture seen in, for example, rodents. This causes the columnar network to converge more quickly and accurately on the pattern representing a particular stimulus in the presence of noise, suggesting that columnar connectivity functions to improve pattern recognition in cortical circuits. The model also suggests that synaptic failure, a phenomenon exhibited by weak synapses, may conserve metabolic resources by reducing transmitter release at these connections that do not contribute to network function.

Comparison of a Pharmacist-Performed and Physician or Advanced Practice Provider-Performed Medication History in Pediatric Patients.

Background: In the adult population, a high rate of discrepancies exists between provider-performed and pharmacist-performed medication histories. Limited data exist regarding pharmacist-performed medication histories in hospitalized pediatric patients. Objective: Identify the incidence and severity of discrepancies in medication histories performed by practitioners compared with pharmacists in the pediatric population. Methods: After institutional review board approval, a retrospective analysis of pediatric patients admitted to inpatient pediatric units in a tertiary hospital was performed. The primary endpoint of the study was the percentage of provider-performed medication histories with any discrepancies compared with the pharmacist-performed medication history. Secondary endpoints included the number and type of discrepancies and the discrepancy's potential risk of patient harm. Results: A total of 101 subjects were included. Nineteen patients (18.8%) had at least one medication discrepancy. Missing medications accounted for the majority of the discrepancies. Advance practice providers performed a small number of the initial medication histories (5%) and had at least one discrepancy for each history performed. The percentages of Grades 1, 2, and 3 discrepancies were 57.2%, 17.1%, and 25.7%, respectively. Medications with the most frequent discrepancies included anticonvulsants, antihistamines, and histamine receptor antagonists. Limitations include the retrospective nature of the study and lower than expected discrepancy rate. Conclusion: In this study, 18.8% of pediatric patients had a discrepancy between medication histories. Missing medications accounted for the largest amount of discrepancies. A large percentage of discrepancies had the potential to cause patient harm.

Coping with critical drug shortages: an ethical approach for allocating scarce resources in hospitals.

The number of critical medication shortages in the United States has reached an unprecedented level, requiring decisions about allocating limited drug supplies. Ad hoc decisions are susceptible to arbitrary judgments, revealing preformed biases for or against groups of people. Health care institutions lack standardized protocols for rationing scarce drugs. We describe the principles on which an ethically justifiable policy of medication allocation during critical shortages was created at our hospital. Based on supportable scientific evidence and with all clinically similar patients treated as similarly deserving of consideration, drugs were distributed according to a hierarchy of clinical need and predicted efficacy. We explain the ethical rationale for the procedures we adopted, how the policy was implemented at a large academic medical center, and more than 1 year of experience with a number of different medications. Our experience has demonstrated the feasibility and utility of formulating a rational and ethically sound policy for scarce resource allocation in an academic teaching hospital that could be used in a variety of health care settings. The method has proven to be reliable, workable, and acceptable to clinicians, staff, and patients.