Implementation and evaluation of a team-based pharmacy practice model in a community health system.

PURPOSE: The development and implementation of a team-based pharmacy practice model is described. METHODS: In January 2016 a transition from a staff-specialist to a team-based pharmacy practice model was implemented. The overall goal of the model change was to enhance the pharmacist's clinical roles and further integrate pharmacists into the healthcare team. Before implementation of the new staffing model, a formalized metric evaluation process was created. The aim of this metric evaluation was to gauge model success, determine areas of model revision, and objectively communicate pharmacist impact. Objective metrics were evaluated before implementation and 1 year after implementation. In addition, surveys were distributed to pharmacists, physicians, nursing and hospital administration before and after model implementation. RESULTS: At 1-year postimplementation, the pharmacist:patient bed ratio decreased from 1:87 to 1:47, the number of rounds/huddles with pharmacist attendance increased by 63% to 80 per week, and the number of clinical interventions and new clinical consultations increased from 57 to 62 and from 12 to 16 per day, respectively. Nonformulary medication use also decreased from 1.77 to 0.623 per 1000 patient days, and compliance with therapeutic initiatives increased from 77%to 91%. Overall, 72% of pharmacist survey responses indicated satisfaction with the model change. CONCLUSION: A team-based pharmacy practice model was designed and successfully implemented over a 3-year period. Data analysis revealed improvements in clinical and operational endpoints and enhanced pharmacist, physician, and nursing satisfaction.

Impact of telepharmacy in a multihospital health system.

PURPOSE: The impact of telepharmacy in a multihospital health system was evaluated. SUMMARY: Telepharmacy services were implemented at five hospitals within a Catholic, nonprofit, integrated delivery network health system. Telepharmacy services were provided by seven pharmacists employed by the health system. Using a virtual private network or terminal server, pharmacists directly accessed hospital servers and information systems to conduct their work. Telephone calls were automatically routed to the telepharmacist so that handling of nursing and other calls would be transparent to staff. Hours of telepharmacy service were 5 p.m. to 2 a.m. Monday through Friday evenings at four of the hospitals and 8 p.m. to 10 p.m. at the rural hospital. Order-processing time for routine orders was reduced from 26.8 to 14 minutes (p < 0.0001), while stat order processing was shortened from 11.6 to 8.8 minutes (p = 0.007). For routine orders, turnaround times greater than 60 minutes became almost nonexistent after telepharmacy services were implemented. The number of clinical interventions documented increased by 42%, from 619 to 881, equivalent to a net annualized saving of $1,132,144. A significant improvement in nurses' global satisfaction with pharmacist availability for unit consultations was reported (3.0 versus 4.0 on a 5.0 Likert scale; p = 0.028). CONCLUSION: The implementation of telepharmacy services in a multihospital health system expanded hours of service, improved the speed of processing of physician medication orders, and increased clinical pharmacy services and cost avoidance. Surveys of health care staff found that telepharmacy services were well received.

Effect of preprinted order form on epoetin alfa prescribing.

PURPOSE: The effect of a required preprinted order form on the prescribing of epoetin alfa was evaluated. SUMMARY: An initial drug-use evaluation (DUE) was conducted in January 2004 to determine how closely prescribing guidelines for epoetin alfa were being followed. A preprinted order form was then developed and approved by the medical staff, with use required for all adult epoetin alfa orders. A follow-up DUE was conducted in January 2006 to assess the effects of the preprinted order form on prescribing patterns. Expenditures for epoetin alfa for 12 months before and after implementation of the preprinted order form were also calculated. Data for 45 and 44 patients were reviewed for the initial and follow-up DUEs, respectively. Smaller doses were ordered at more frequent intervals and epoetin alfa was prescribed more often by nephrologists and less frequently by surgeons and critical care intensivists after implementation of the preprinted order form. Use of epoetin alfa according to hospital guidelines improved from 44% to 73% (p = 0.0089). Significantly more patients' ferritin and transferrin saturation values were measured postimplementation of the order form (p = 0.0176). In addition, the annual expense for epoetin alfa was reduced by $151,042, a 36% reduction from baseline. CONCLUSION: Implementation of a required preprinted order form increased the frequency of appropriate prescribing of epoetin alfa in a community teaching hospital.

Implementation of an electronic system for medication reconciliation.

PURPOSE: The feasibility of implementing an electronic system for targeted pharmacist- and nurse-conducted admission and discharge medication reconciliation and its effects on patient safety, cost, and satisfaction among providers and nurses were studied. METHODS: This study was conducted in two phases: a preimplementation phase and a postimplementation phase. In the preimplementation phase, admission medication histories and discharge medication counseling followed standard care processes. During postimplementation, pharmacists and nurses collaborated to electronically complete admission and discharge medication reconciliation documentation. Four reports were developed for medication reconciliation documentation: (1) home medication profile report, (2) home medication reconciliation report, (3) discharge medication reconciliation report, and (4) patient discharge medication report. Patients were contacted after discharge to measure their satisfaction with the medication counseling and medication instructions received. Health care providers completed a survey indicating their satisfaction with the electronic medication reconciliation processes. RESULTS: A total of 283 patients were included in the study. Patients in the postimplementation group took significantly more prescription and nonprescription medications, and their total number of medications significantly exceeded the number taken by the preimplementation group. Pharmacists completed significantly more dosage changes in the postimplementation phase than in the preimplementation phase. In the preimplementation phase, nurses identified more incomplete medication orders, dosage changes, and allergies than they did in the postimplementation phase. Patients in the postimplementation group reported a higher level of agreement on all survey items regarding adequate discharge medication instructions. CONCLUSION: Patients who had their medications electronically reconciled reported a greater understanding of the medications they were to take after discharge from the hospital, including medication administration instructions and potential adverse effects.

Effectiveness of half-dose versus full-dose influenza vaccine in health care workers.

PURPOSE: A prospective, randomized, double-blind study comparing the effectiveness of half-dose versus full-dose trivalent inactivated influenza vaccine (TIV) in health care workers was conducted. METHODS: The study was conducted at a 760-bed tertiary care community hospital. Study participants (n = 444) were hospital staff or employees over 18 years of age who were enrolled during a two-week period in October and November 2004. Participants were assigned to either full-dose (n = 222) or half-dose (n = 222) TIV. The participants completed a standardized questionnaire monthly from November 2004 through March 2005. The primary outcome was the incidence of influenza between the two groups; the secondary outcomes were self-reported days of work missed as a result of influenza and the proportion of participants in each group self-reporting signs and symptoms of influenza. Laboratory confirmation of influenza diagnosis was sought in participants reporting a clinical diagnosis by their physicians. Differences in the groups were analyzed with Fisher's exact test, with a < 0.05 considered significant. RESULTS: There was no difference between the full-dose and half-dose groups in the diagnosis of influenza (4% versus 7%, p = 0.198). Laboratory confirmation of an influenza diagnosis occurred in one participant who received full-dose TIV. CONCLUSION: Half-dose TIV demonstrated a similar effectiveness to full-dose TIV, measured by the number of diagnoses of influenza and symptom survey of participating health care workers. Administration of half-dose TIV is an acceptable strategy for maximizing the number of vaccinations in health care workers, but additional studies are needed to confirm the comparable immunogenicity and effectiveness between the two doses.

Venous thromboembolism prevention in acutely ill nonsurgical patients.

OBJECTIVE: To review recent advances in the prevention of venous thromboembolism (VTE) in acutely ill nonsurgical inpatients. DATA SOURCES: A MEDLINE search (1966-March 2005) was done to identify relevant articles relating to prevention of VTE in acutely ill nonsurgical inpatients. STUDY SELECTION AND DATA EXTRACTION: Four major prophylaxis trials, one registry, one guideline, and supporting articles representative of the subject matter from the last few years were included. DATA SYNTHESIS: Enoxaparin, dalteparin, fondaparinux, and unfractionated heparin 5000 units every 8 hours are effective in reducing the risk of VTE in acutely ill medical patients, but such prophylaxis is currently underused. Barriers to be overcome include recognition of the importance of VTE in this population, definition of the optimal strategy to assess risks, optimal timing of the risk assessment, optimal prophylactic regimen for a given level of risk or disease state, and optimal duration of prophylaxis. We recommend that acutely ill medical inpatients should be risk-stratified early in their hospitalization. At this time, the specific risk-assessment protocol should be derived from the trial(s) of the available formulary agent(s). Decisions about providing prophylaxis must also be made considering anticoagulant contraindications and renal function. Mechanical methods of prophylaxis should be considered as monotherapy only if an anticoagulant contraindication exists. The optimal duration of prophylaxis is not known, but 14 days was used in recent studies. CONCLUSIONS: Prophylaxis of VTE in acutely ill medical inpatients is underused. Data provide some guidance for increasing awareness and optimizing patient care.

Impact of fluconazole administration on outcomes in critically ill patients.

BACKGROUND: Serious infections caused by Candida spp. are an increasingly important cause of morbidity and mortality in critically ill patients. It is unclear which patients will benefit from therapy and at what point to institute treatment. OBJECTIVE: To evaluate the impact of administration of fluconazole therapy in critically ill trauma patients on mortality, length of hospital stay, incidence of deep-seated fungal infection, and positive fungal cultures from any site. METHODS: We conducted a retrospective, matched case-control study of 116 critically ill surgical trauma patients who did or did not receive fluconazole. Patients were followed until hospital discharge or death. A consecutive sample of 58 patients who received fluconazole was selected. A parallel group of patients was evaluated, from which 58 were matched with fluconazole-treated patients based on age (+/- 5 y), gender, and APACHE II score (+/- 3). RESULTS: The groups of patients were well matched, with the exception of central venous catheter placement and broad-spectrum antibiotic use. We found no difference between groups in hospital mortality (21% vs 26%; p = 0.661) or incidence of deep-seated fungal infection (0% vs 2%; p = NS). However, patients receiving fluconazole had a significantly longer stay in both the intensive care unit (ICU) (18 +/- 13 vs 7 +/- 11 days; p < 0.001) and hospital (25 +/- 15 vs 9 +/- 11 days; p < 0.001). Fluconazole patients were significantly more likely to have Candida cultured from sites associated with colonization (43% vs 2%; p < 0.001), possibly explaining why they received fluconazole. CONCLUSIONS: We were unable to detect a benefit from use of fluconazole in our surgical trauma patient population. Isolation of Candida from the mouth or throat alone, in the absence of correlating clinical signs of infection, should not lead to initiation of fluconazole therapy. Fluconazole use should be reserved for carefully selected patients in the trauma ICU setting.