Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital.

The influence of pharmacist participation on economic and morbidity outcomes at a tertiary care teaching hospital was studied. Patients admitted to internal medicine wards during a nine-month period were assigned to either a treatment team or a control team. Each team consisted of an attending physician, senior and junior medical residents, and medical students; the treatment team included a pharmacist who reviewed all patient charts, made rounds with the team, and recommended modifications of drug therapy. Pharmacy interaction with the control team was limited to contacting physicians about potentially dangerous orders, answering questions from the medical team, and handling orders for items not on the formulary or otherwise unavailable. After discharge, data from patient records were analyzed for pharmacy costs and total hospital costs and length of stay (as markers of the pharmacist's effect on economics and morbidity, respectively). Analysis of baseline characteristics showed that the two groups of patients were statistically comparable. Treatment team patients who were included in the data analysis (414) had significantly shorter stays (by a mean of 1.3 days) and lower pharmacy and total hospital costs (by a mean of $301 and $1654, respectively) than those included in the control team analysis (453). The direct participation of a pharmacist on a patient care team significantly decreased pharmacy and hospital costs, as well as length of stay, compared with minimal participation of a pharmacist.

Re-engineering for dramatic improvement in the medication-use process.

Planning for re-engineering the medication-use process at a university hospital is described. In summer 1992 the University of Cincinnati Hospital hired a consultant on quality to help with work-process improvement and re-engineering. By early 1993, re-engineering for patient-focused care was under way. Within a year of the implementation of patient-focused care in a pilot unit, it was realized that all departments that provided direct and indirect care would also have to undergo re-engineering. In August 1994 a retreat was held to begin the re-engineering effort in the pharmacy department. The retreat participants set as goals of the re-engineering (1) support of the hospital's strategic initiatives, (2) getting the right drug to the right patient at the right time, (3) improved patient outcomes, and (4) reducing the pharmacy labor and drug budget. Pharmacy activities for re-engineering were identified, and two planning teams were created, a pharmacy production team and a pharmacy knowledge-transfer team. The production team was made responsible for re-engineering dispensing, inspecting, producing, storing, and transporting, and the knowledge-transfer team was assigned teaching, recording, treating, and monitoring. A detailed plan was prepared for each team to follow using a framework provided by the consultant and consisting of strategy, technology, process, and personnel. Careful planning and a consultant helped a university hospital prepare for organizationwide re-engineering.

Harvey A. K. Whitney Lecture. Shifting pharmacy's paradigm.

Changes occurring in the pharmacy profession and their effects on the paradigm for pharmacy practice are discussed. The paradigm of pharmacy, the pattern or model of pharmacy's structure, services, daily activities, and organization, is shifting, and if pharmacists do not shift with it, they will be left behind. Advances in technological capabilities often result in automation and centralization of services. Improvements in drug therapy have caused shifts in the performance of clinical functions. Philosophical changes about the way health care should be delivered have produced the concepts of pharmaceutical care, patient-focused care, and continuous quality improvement of care. Teams of caregivers whose primary concern is the patient have replaced caregiving based on technology, discipline, or employee needs. Pharmacists have focused on the patient as their primary customer instead of the nurse or practitioner, and they anticipate the patient's needs in a structured and documented fashion. The principles of continuous quality improvement have been applied to every aspect of providing pharmaceutical care. If pharmacists are to adjust to the shift in the pharmacy paradigm, they must recognize their strength as a group, make proper recommendations about pharmaceutical use, move horizontally to grow as professionals, consider themselves clinicians, be active in the making of pharmaceutical care decisions, and believe in themselves.

Development of a pharmaceutical care system in a neonatal intensive care satellite pharmacy.

The development of a pharmaceutical care system for a neonatal intensive care unit satellite pharmacy from existing integrated clinical, distributive, and quality assurance activities is described. Components of practice already in place included pharmacotherapeutic monitoring, evaluations for childhood immunizations, monthly medication summaries, and daily follow-up on scheduled doses returned in the unit dose exchange carts. Pharmacists documented patient drug therapy consultations on a standard form. New elements of practice emphasized organization of patients' clinical data by problem, development of specific outcome-oriented standards of care for common neonatal conditions and disease states, and quality improvement activities that evaluated the appropriateness of patient monitoring and patient outcomes. Written standards of care for specific disease states improved clinical decision-making, documentation of pharmacists' performance, and communication about patient care with other health care professionals. Elements of pharmacy practice already in place may provide a good foundation for a structured pharmaceutical care system.

Expanding staff pharmacists' responsibilities to maintain pharmacy services in a neonatal intensive-care unit.

The conversion of pharmacist responsibilities in a neonatal intensive-care unit (NICU) pharmacy satellite from drug distribution to both clinical services and drug distribution is described. When the pharmacy department could not recruit a specialty-trained clinical practitioner to fill an open NICU position, the position was converted to a fourth satellite pharmacist position, and each of the four NICU satellite pharmacists assumed clinical responsibilities for the NICU. Clinical and distributive functions had previously been separate. Staff development programs and a contract with the previous NICU clinical practitioner for consultative services helped to ease the transition. NICU pharmacists currently provide inservice education to medical residents and the nursing staff, provide drug information, monitor drug therapy, perform pharmacokinetic monitoring, are involved in research, and work to streamline satellite operations. For one of every four months, the NICU pharmacists primarily provide clinical services; the remainder of the time clinical activities are combined with drug distribution responsibilities. The staffing schedule has enabled the department to extend the hours that clinical services are available. The NICU pharmacists maintain secondary areas of staffing, and other pharmacists periodically staff the NICU satellite. Staff pharmacists in the NICU pharmacy satellite developed clinical skills that permitted integration of clinical and distributive pharmacy services.

A multicenter model for examining in vitro susceptibilities of bacteria to antibiotics.

In vitro bacterial susceptibility data are often considered in both hospital formulary and antibiotic prescribing decisions. In this multicenter study, susceptibility data from 105 United States hospitals resulted in a database containing 211,142 isolates for 31 different bacteria and 38 antibiotics. To identify susceptibility patterns of bacteria to antibiotic alternatives, this computerized database was subjected to confidence interval analysis, while controlling for potential sources of random error. This paper describes the multicenter study design and provides several examples of the type of information the analysis can provide to P & Committee members and to practitioners who ultimately must make decisions regarding antibiotic use, sometimes without the benefit of complete hospital-specific historical antibiogram data. Limitations on the interpretation of aggregate in vitro susceptibility data gained from multiple institutions are also discussed.

Cost analysis of using premixed frozen versus hospital-reconstituted cefazolin sodium injection.

The costs of preparing cefazolin sodium 1-g small-volume injections (SVIs) by each of two reconstitution methods were compared with the costs of using premixed frozen cefazolin SVIs at two hospitals. Both hospitals routinely used premixed cefazolin 1-g SVIs. Each converted to its previous reconstitution system for approximately two weeks. One hospital used a once-weekly "batch" system, and the other hospital used the twice-daily "extemporaneous" system. Pharmacist and technician time involved in both systems was determined using time-and-motion methods. A total of 40 preparation cycles of 10 SVIs each were monitored to determine labor costs. Hospital purchase-contract prices were used for determining material costs per SVI, and waste was calculated based on the number of SVIs that could not be recycled. The total time required for preparation of 10 cefazolin 1-g SVIs by each method was comparable (6.2 minutes for the batch method, 5.8 minutes for the extemporaneous method); labor costs contributed minimally to overall costs of each reconstituted SVI. Approximately 5% of reconstituted SVIs were wasted in each system. The conversion to premixed cefazolin SVIs resulted in an annual cost increase of more than $5000 at each hospital, compared with the reconstitution methods. However, subjective evaluations indicated that use of the premixed admixtures resulted in increased efficiency of i.v. preparation by allowing pharmacy personnel to devote more time to other labor-intensive duties. The results of this study allowed the pharmacies to negotiate more equitable prices for premixed cefazolin sodium injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial and fungal growth after freezing or refrigerating parenteral nutrient solutions.

Parenteral nutrient (PN) solutions were evaluated for growth of pathogenic organisms after refrigeration or freezing and then thawing. Sixteen bags of hypertonic dextrose and amino acid solutions were divided into two series (refrigerated and frozen), inoculated with Escherichia coli. Candida albicans, Staphylococcus aureus, or Streptococcus faecalis, and exposed to freezing or refrigeration. The inoculum concentration was greater than would likely occur with patient contamination of the solution. Microbial growth in the solutions was determined after warming to room temperature and at 17 or 18 hours after reaching room temperature. There was no increased growth of C. albicans in PN solutions that were frozen versus the refrigerated samples. Counts for all of the organisms in the frozen series, immediately after freezing and then thawing, decreased or stayed the same compared with baseline counts. Growth of E. coli, Staph. aureus, and Strep. faecalis increased in the frozen samples compared with the refrigerated samples after room-temperature storage, suggesting a possible increased risk of infectious complications if contaminated solutions are left at room temperature for extended periods. Since no increased risk of microbial growth is likely in frozen versus refrigerated PN solutions that are thawed and promptly infused, batch freezing may be an effective and convenient means of preparing PN solutions for home patients.

Monitoring a primary wholesaler depot program.

Techniques for monitoring a primary wholesaler depot program used by a university hospital pharmacy department are described. One year after the program began, data from the past four months, obtained from monthly management reports provided by the wholesaler, were reviewed. Attention was focused on the drugs and drug categories that represented the bulk of purchases (in dollar value). Summary purchase orders showed that approximately half the drugs were purchased at the most favorable prices (usually contract bid prices). Most drugs not purchased at the most favorable bid prices were accounted for by sole-source items, inadequate computer documentation by the wholesaler, and atypical orders. A study of ordering patterns revealed that 16 of the top 40 drugs ordered (by volume and dollar expenditures) were ordered less than once per month; the inventory management goal was to order a two-week supply. The wholesaler could not completely fill orders for 18% of the contract drugs, often because of back orders from manufacturers. Although the computerized management reports used in this study did not allow evaluation of all aspects of the primary wholesaler depot program, they provided a convenient mechanism for concurrent assessment of the program's effectiveness. The program appeared to be advantageous to the pharmacy department, and most problems encountered were easily remedied. Several performance measures for institutions considering depot programs are recommended.

Subjective assessment of patient outcomes of home parenteral nutrition.

The medical, financial and psychosocial impact of home parenteral nutrition (HPN) therapy on patients' lives was assessed. A questionnaire that solicited patient characteristics and therapeutic outcomes of HPN therapy, such as number of hospital admissions, physiological complaints, and psychosocial interferences, was sent to 49 patients currently participating in a HPN program based at a university hospital. Questionnaires were returned by 42 patients. HPN-related complications were responsible for 39% of all reported hospital admissions during the previous year; of these, 27% were related to HPN catheters. Patients reported few physiological complaints, except for cramping in the hands and feet. Patients who complained of diarrhea had significantly more physiological complaints and psychosocial interferences than those who did not. The majority of patients had medical insurance coverage, but 26% had to pay at least part of the costs of HPN therapy. Only 25% of patients who were able to work did so. Most patients believed that HPN therapy had a very positive effect on their lives. The majority of patients in this HPN program appear to have a reasonable quality of life.

Supplementation of total parenteral nutrition solutions with ferrous citrate.

Daily infusion of a total parenteral nutrition (TPN) formulation containing 1 liter of 5.5% Travasol provides less than 0.1 milligrams of iron. By comparison, a formulation which includes a liter of 10% Travamin provides 2 milligrams of iron per day. To meet iron requirements in patients infusing formulations containing Travasol, iron was added as ferrous citrate. In in virto experiments, 74% of this iron was available to transferrin. In seven patients in whom in vivo availability was tested by red cell incorporation, the mean availability was 81%. Ferrous citrate is recommended as a safe, effective additive to TPN solutions for adult patients requiring iron supplements.

Influence of propranolol on supraventricular tachycardia early after coronary artery revascularization. A randomized trial.

A total of 116 patients undergoing coronary revascularization were randomized preoperatively in a double-blind manner to receive 80 mg daily of propranolol or placebo in the postoperative period. Preoperatively, all patients had been receiving at least 80 mg of propranolol a day to the time of the operation. In addition, all patients had a left ventricular ejection fraction of 0.4 or more, no history of supraventricular tachyarrhythmia (SVT), and no need of digitalis preparations or other antiarrhythmic drugs. All patients were monitored for 5 days and propranolol or placebo was started 24 hours postoperatively. SVT was documented with biatrial electrograms in all cases. Study groups were similar in postoperative creatine kinase MB levels and postoperative weight gain, but the placebo group tended to be older and have more grafts per patient. Seven patients randomized were dropped from the study, two with perioperative infarction, four with persistent ventricular arrhythmias necessitating quinidine or procainamide, and one with persistent postoperative hypotension (placebo). There were no significant differences in the incidence of postoperative SVT in these two groups: 13.2% in the propranolol group and 16.1% in the placebo group. We conclude that 80 mg daily of propranolol given postoperatively to patients undergoing coronary revascularization does not effectively reduce the incidence of SVT.