Effectiveness and safety of mandatory antimicrobial indications and durations and a pharmacist-driven 48-hour time-out in a pediatric hospital.

PURPOSE: To evaluate the effectiveness and safety of mandatory antimicrobial indications and durations (MAID) and a pharmacist-driven 48-hour time-out in a pediatric hospital. METHODS: MAID and a 48-hour time-out were implemented on February 14, 2017. Antibiotic days of therapy (DOT) per 1,000 patient days were compared between the pre- and postperiod for select antibiotics using unadjusted Poisson models. A prepost comparison was used to compare antimicrobial stewardship program (ASP) intervention rates between time periods. A 2-step process, including distribution of a discontinuation (DC) report to pharmacists and ASP-prompted reorders, was instituted to reduce unintentional antimicrobial discontinuation with MAID. ASP-prompted reorders occurred only when a discrepancy persisted between the order and provider-desired duration. Missed antimicrobial doses were identified by ASP and the institutional event reporting system. Safety of MAID was assessed by reviewing the rate and details of ASP-prompted reorders and missed antimicrobial doses. RESULTS: A significant decrease in DOT per 1,000 patient days was observed for cefazolin (39.7 to 36.9; P < 0.001), ampicillin (39.9 to 35.7; P < 0.001), clindamycin (38.2 to 35.9; P < 0.001), ceftriaxone (46.5 to 43.4; P < 0.001), and meropenem (8.7 to 6.6; P < 0.001) following implementation. No change in ASP intervention rate occurred between the pre- and postperiod (16.9 vs 16.8%; P = 0.94). With MAID, ASP-prompted reorder occurred on 7.3% of orders. Unintentional discontinuations resulting in missed antimicrobial doses occurred in 3 orders (0.07%); no patient harm resulted. CONCLUSION: MAID and a 48-hour time-out significantly reduced DOT of select antibiotics. No patient harm occurred with the 2-step safety process.

Leveraging drug-utilization and external benchmarking data to drive change in prescribing behaviors.

PURPOSE: Improved outcomes and cost savings achieved at a large hospital through a drug utilization benchmarking and reporting initiative are described. SUMMARY: Using the University HealthSystem Consortium (UHC) Clinical Resource Manager (CRM) database, the University of Kansas Hospital identified nine target areas (based on Medicare Severity Diagnosis-Related Group) in which the hospital's drug-utilization practices were deemed suboptimal relative to those of other UHC member facilities with similar caseloads. The pharmacy department developed a CRM template for generating customized reports comparing the hospital's performance on various drug-utilization metrics with that of top-performing peers (i.e., institutions achieving the best patient care outcomes in terms of mortality and length of stay) in the nine target areas. A pre-post comparison of drug-utilization data collected before and after implementation of the reporting initiative indicated improved outcomes in all nine initially selected target areas, with estimated cumulative annualized cost savings of about $900,000. The CRM-generated reports are now distributed semiannually to attending physicians and other hospital leaders via electronic and hard-copy means, focusing on variances from UHC top-performer and overall UHC averages in the use of higher-cost drugs. The reporting initiative has generally fostered enhanced physician-pharmacist collaboration in the investigation of identified drug-utilization variances and implementation of practice changes. CONCLUSION: By evaluating service-specific trends of internal drug utilization against external benchmarks and emulating prescribing practices at top-performing institutions, an academic medical center has achieved improved patient care outcomes and cost savings.

Compliance with recommendations for prevention and detection of controlled-substance diversion in hospitals.

PURPOSE: The use of recommended practices for preventing and detecting diversion of prescription controlled substances at U.S. acute-care institutions, as reported by a sample of pharmacy service providers, were characterized. METHODS: A 41-item questionnaire was developed for an online survey of directors of pharmacy regarding strategies to combat controlled-substance diversion at their institutions. The survey questions were based on recommendations presented in a 2007 series of articles in the professional literature focusing on diversion control in three areas (the pharmacy, the operating room, and nursing units). Only institutions that had an accredited pharmacy residency program or were members of the University HealthSystem Consortium (UHC), an alliance of U.S. academic medical centers and affiliated hospitals, were targeted for the survey. Four hundred ninety-nine pharmacists were invited to participate in the survey, and 140 survey responses were received; all respondents did not answer all questions. RESULTS: The survey responses indicated considerable variation among the institutions in the use of 37 specific recommended practices, as reported by the pharmacy providers. Statistical analysis of comparative data suggested that larger institutions (400 or more licensed beds) were more likely to be using more of the recommended practices. CONCLUSION: The results of a survey of directors of pharmacy at a sample of U.S. institutions (hospitals that had pharmacy residency programs or were UHC members) suggest wide variation in facilities' use of recommended practices for the prevention and detection of controlled-substance diversion.

Telepharmacy and bar-code technology in an i.v. chemotherapy admixture area.

PURPOSE: A program using telepharmacy and bar-code technology to increase the presence of the pharmacist at a critical risk point during chemotherapy preparation is described. SUMMARY: Telepharmacy hardware and software were acquired, and an inspection camera was placed in a biological safety cabinet to allow the pharmacy technician to take digital photographs at various stages of the chemotherapy preparation process. Once the pharmacist checks the medication vials' agreement with the work label, the technician takes the product into the biological safety cabinet, where the appropriate patient is selected from the pending work list, a queue of patient orders sent from the pharmacy information system. The technician then scans the bar code on the vial. Assuming the bar code matches, the technician photographs the work label, vials, diluents and fluids to be used, and the syringe (before injecting the contents into the bag) along with the vial. The pharmacist views all images as a part of the final product-checking process. This process allows the pharmacist to verify that the correct quantity of medication was transferred from the primary source to a secondary container without being physically present at the time of transfer. CONCLUSION: Telepharmacy and bar coding provide a means to improve the accuracy of chemotherapy preparation by decreasing the likelihood of using the incorrect product or quantity of drug. The system facilitates the reading of small product labels and removes the need for a pharmacist to handle contaminated syringes and vials when checking the final product.

Nationwide antibiogram analysis using NCCLS M39-A guidelines.

Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported <100% vancomycin susceptibility for Staphylococcus aureus, 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus, 20% that reported <100% imipenem susceptibility for Escherichia coli, and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.

Compliance with safe practices for preparing parenteral nutrition formulations.

Compliance with the guidelines of the National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition (NAG) was studied. A questionnaire based on the NAG guidelines was developed to identify common practices used in the preparation of parenteral nutrition formulations in a variety of health care settings. The questionnaire was mailed in January 2000 to a national sample of 1445 pharmacists. There were a total of 633 usable responses, for a net response rate of 45.2% (based on 1400 deliverable surveys). Almost 80% of the respondents were employed in an urban setting, and 64.3% worked in hospitals. Relatively high compliance was reported for guidelines related to filtration (86.9% and 85.9%), verification of product stability and compatibility by a pharmacist or computer program (86.4%), evaluation of the aseptic technique of persons preparing sterile products (81.4%), and having a pharmacist assess formulations to determine whether the contents are within acceptable standard ranges (78.8%). Low compliance was reported for guidelines related to the inclusion of dosing weight on the label (15.4%), the use of amount per day as the unit of measure for labeling ingredients (26.1%), direct pharmacist-to-pharmacist communication about prescriptions when patients are transferred among health settings (33.4%), and daily in-process or end-product quality assurance testing of formulations. The NAG guidelines on parenteral nutrition formulations with which pharmacists' practice was most discrepant were the use of amount per day as the unit of measure for labeling ingredients, inclusion of the patient's dosing weight on the label, direct pharmacist-to-pharmacist communication when patients are transferred, and daily quality assurance testing.