Transformation of Hospital Pharmacist Opioid Stewardship.

Purpose: The heightened involvement of government organizations to improve pain management and mitigate opioid adverse events brings to light the need for an opioid stewardship model. Summary: The US opioid epidemic has resulted in new hospital requirements for pain management by regulatory agencies. Opioid stewardship is a concept in the early development stage of pharmacy practice. There exists a need for a cohesive vision of opioid stewardship and the role of the pharmacist. Over the course of 17 years, the tracks for opioid stewardship in Fairview Health Services were laid through numerous initiatives to mitigate adverse events and improve the quality of pain management. This article will describe a transformation process for establishing the framework for opioid stewardship within Fairview Health Services and role of the pharmacist. Conclusions: The vision for opioid stewardship will ultimately be defined through the actions taken to improve quality care and patient safety. Opioid safety should be expanded to include stewardship of approaches that reduce the risk of diversion, overdose, and medication abuse. Pharmacists currently have a major role monitoring opioid medication in hospitals and this component will increase with new regulatory requirements.

Relationship between a Weighted Multi-Gene Algorithm and Blood Pressure Control in Hypertension.

Hypertension (HTN) is a complex disease with interactions among multiple organ systems, including the heart, vasculature, and kidney with a strong heritable component. Despite the multifactorial nature of HTN, no clinical guidelines utilize a multi-gene approach to guide blood pressure (BP) therapy. Non-smokers with a family history of HTN were included in the analysis (n = 384; age = 61.0 ± 0.9, 11% non-white). A total of 17 functional genotypes were weighted according to the previous effect size in the literature and entered into an algorithm. Pharmacotherapy was ranked from 1⁻4 as most to least likely to respond based on the algorithmic assessment of individual patient's genotypes. Three-years of data were assessed at six-month intervals for BP and medication history. There was no difference in BP at diagnosis between groups matching the top drug recommendation using the multi-gene weighted algorithm (n = 92) vs. those who did not match (n = 292). However, from diagnosis to nadir, patients who matched the primary recommendation had a significantly greater drop in BP when compared to patients who did not. Further, the difference between diagnosis to current 1-year average BP was lower in the group that matched the top recommendation. These data suggest an association between a weighted multi-gene algorithm on the BP response to pharmacotherapy.

A Survey of Opioid Medication Stewardship Practices at Academic Medical Centers.

Purpose: The results of a survey of academic medical centers assessing the presence and description of opioid stewardship activities. Methods: Academic medical centers within the Vizient University Health System Consortium Pharmacy Network were asked to complete a survey related to opioid stewardship activities. The survey consisted of 30 questions aimed at identifying current opioid stewardship practices among hospitals and health systems. Results: There were 27 respondents to the survey. Only 42.3% of respondents have opioid stewardship activities in place. Opioid stewardship practices are primarily linked to either formal consult services or the role of a clinical pharmacy specialist. Very few institutions have opioid stewardship embedded into the daily practice of clinical pharmacists. Just over half of respondents have pharmacists as part of a pain consult team. Principle roles of pharmacists on consult teams include provider education, patient education, and optimization of therapy outside of a collaborative practice or prescribing role. Over half of the respondents participating in stewardship maintain a pharmacist's role in monitoring surgery and postoperative opioid prescribing. The majority of respondents have opioid medication policies in place to address range orders, smart pump programming of opioids, limits on meperidine use, and cumulative limits on acetaminophen dosing. Conclusion: There are limited examples of pharmacy services related to opioid stewardship. The authors believe this is a pharmacy practice model that will evolve with the national attention to the opioid epidemic and new Joint Commission Standards.

Value of pharmacy residency training: a survey of the academic medical center perspective.

PURPOSE: The results of a survey assessing the views of pharmacy directors, medical center executives, and pharmacists on the value of residency programs to their institutions are reported. METHODS: In a two-phase survey entailing face-to-face interviews and the use of an electronic questionnaire, representatives of the pharmacy departments and executive staffs of eight academic medical centers were asked to rate the impact of pharmacy residency programs in areas such as educational and research innovation, quality-of-care and cost outcomes, and opportunities for revenue generation. RESULTS: Seven hospital administrators, eight directors of pharmacy, 122 pharmacists serving as residency preceptors, and 91 nonpreceptor pharmacists participated in the survey. The survey responses indicated that hospital administrators view pharmacy residency programs as important contributors to their institutions' prestige, academic success, and capacity for delivering educational programs. All directors of pharmacy surveyed were in agreement that the costs associated with conducting a pharmacy residency program are outweighed by the cost savings achieved through resident contributions to patient care and medication error prevention. A large majority (90%) of preceptor pharmacists agreed or strongly agreed that residents help reduce medication errors by educating prescribers and other activities that promote rational medication use; only about half of nonpreceptor pharmacists shared that view, although 65% of nonpreceptors acknowledged the contributions of residents to overall pharmacy department success. CONCLUSION: All groups of survey respondents viewed residency programs as important assets to their institutions, especially in the areas of institutional prestige, staff recruitment, and professional development and education.

Lessons learned from a pharmacy practice model change at an academic medical center.

PURPOSE: The development and implementation of a new pharmacy practice model at an academic medical center are described. SUMMARY: Before the model change, decentralized pharmacists responsible for order entry and verification and clinical specialists were both present on the care units. Staff pharmacists were responsible for medication distribution and sterile product preparation. The decentralized pharmacists handling orders were not able to use their clinical training, the practice model was inefficient, and few clinical services were available during evenings and weekends. A task force representing all pharmacy department roles developed a process and guiding principles for the model change, collected data, and decided on a model. Teams consisting of decentralized pharmacists, decentralized pharmacy technicians, and team leaders now work together to meet patients' pharmacy needs and further departmental safety, quality, and cost-saving goals. Decentralized service hours have been expanded through operational efficiencies, including use of automation (e.g., computerized provider order entry, wireless computers on wheels used during rounds with physician teams). Nine clinical specialist positions were replaced by five team leader positions and four pharmacists functioning in decentralized roles. Additional staff pharmacist positions were shifted into decentralized roles, and the hospital was divided into areas served by teams including five to eight pharmacists. Technicians are directly responsible for medication distribution. No individual's job was eliminated. CONCLUSION: The new practice model allowed better alignment of staff with departmental goals, expanded pharmacy hours and services, more efficient medication distribution, improved employee engagement, and a staff succession plan.

Relationships between colleges of pharmacy and academic medical centers.

PURPOSE: The nature of the relationships between academic medical centers and colleges of pharmacy, particularly in respect to experiential education, was studied. METHODS: A 22-item questionnaire was developed to assess the extent and type of student experiences academic medical centers offered, the presence of a contractual agreement, satisfaction level, role of pharmacy staff and residents, and perceived value of the relationship. The questionnaire was distributed electronically to pharmacy directors at 90 University HealthSystem Consortium (UHC) academic medical centers, with subsequent responses analyzed with descriptive statistics. RESULTS: The response rate was 52% (n = 47), representing a broad geographic distribution of UHC members. All academic medical centers reported having a relationship with at least one college of pharmacy. The mean number of academic affiliations for each respondent was 2.4. The majority of medical centers were satisfied with these relationships. All academic medical centers provided fourth-year pharmacy student clerkship training, with 20% and 27% offering experiential activities for second- and third-year students, respectively. Compensation from colleges of pharmacy for practice-based education was typically directed to the pharmacy department, with a mean of $500 per rotation. The majority of medical centers also trained pharmacy residents, with 62% of these engaging the residents in student experiential education. The most common motivations for offering student experiential education were fulfilling professional responsibility, developing future employees, and financial compensation. CONCLUSION: While relationships between academic medical centers and colleges of pharmacy were generally positive, the growing need for early experiential education sites, increased class sizes, and shortage of qualified preceptors necessitate a reexamination of the relationships to ensure that they continue to benefit both parties.

Implementation of standard order sets for patient-controlled analgesia.

PURPOSE: The implementation of standard order sets for patient-controlled analgesia (PCA) is described. SUMMARY: A review of naloxone usage at the University of Minnesota Medical Center (UMMC) from January to June 2004 found that 8% of patients receiving PCA had severe respiratory depression. A subanalysis of each event found that 85% of these patients had never before received opioid therapy. To reduce the risk of respiratory depression with PCA, separate standard order sets were developed for patients new to or tolerant of opioid therapy. A major component of both order sets was the standardization of a 10-minute lockout interval between each PCA dose. Implementation of the new PCA order sets raised concerns among health care professionals at UMMC that medication safety may be improved at the cost of increased pain. After implementation of the order sets, prescriber compliance, pharmacist interventions, the frequency of adverse effects, and patients' pain management were evaluated. After implementation of standard order sets for patients receiving PCA, 57% of patients' pain was documented as being controlled, and the orders for 93% of patients were in compliance with the recommended dosage interval of > or =10 minutes. There were no reports of oversedation or respiratory depression requiring reversal with naloxone. CONCLUSION: The implementation of standard order sets for PCA resulted in a dramatic decrease in the number of cases of severe respiratory depression and increased use of the order set for patients new to opioid therapy. Changing the order sets to improve medication safety did not appear to negatively affect patients' satisfaction with pain management.

Intrathecal drug therapy for long-term pain management.

PURPOSE: The use, safety, and efficacy of intrathecal medication administration with implantable pumps for cancer and chronic pain management are reviewed. SUMMARY: Implanted intrathecal drug-delivery systems (IDDSs) are used for long-term management of persistent, severe pain despite a multimodal approach with conventional pain treatment options. Currently, consensus papers published in the literature are used as guidelines for determining patient selection and medication administration, because there is a lack of supporting evidence from randomized, controlled, clinical trials. Pharmacists have a critical role in the safe use of intrathecal medication. Most of the medication concentrations and combinations administered through IDDSs are not commercially available and therefore must be compounded in a pharmacy. Medications commonly administered through IDDSs include opioids, local anesthetics, clonidine, baclofen, and ziconotide. It is important for pharmacists who prepare products for IDDSs to understand the pharmacology, adverse effects, and concentration limitations of each medication in order to prevent adverse events related to postoperative subarachnoid hemorrhage, infection, catheter-tip inflammatory masses, withdrawal, and overdose. Pharmacists play an important role in maintaining quality assurance of intrathecal drug use, including the use of standard procedures for ordering and compounding medications, documentation of patient education, and monitoring of patient outcomes. CONCLUSION: The use of long-term intrathecal drug delivery for the treatment of intractable pain or intolerable medication adverse effects has expanded to include the treatment of patients with chronic or cancer-related pain. Important considerations for the use of intrathecal drug therapy include the appropriate selection of patients, delivery systems, and medications, as well as potential complications of therapy and quality-assurance measures necessary to ensure patient safety.

Prostaglandins, not lipoxygenase products, mediate insect microaggregation reactions to bacterial challenge in isolated hemocyte preparations.

Nodulation is the predominant cellular defense reaction to bacterial challenge in insects. Eicosanoids mediate several steps in the nodulation process, including formation of hemocyte microaggregations. Isolated hemocyte preparations synthesize and secrete eicosanoids, which mediate hemocytic immune reactions. Two major groups of eicosanoids are prostaglandins (products of cyclooxygenase pathways) and various products of lipoxygenase pathways. In this study, we test the hypothesis that prostaglandins, but not lipoxygenase products, mediate hemocyte microaggregation reactions in response to bacterial challenge. Our results indicate that isolated hemocyte preparations pretreated with the cyclooxygenase inhibitors indomethacin and naproxen yielded fewer microaggregates than untreated control groups (3.7 x 10(5) microaggregates/ml hemolymph vs. 11.0 x 10(5) microaggregates/ml hemolymph). These inhibitors influence hemocyte microaggregate formation in a dose-dependent manner in treatments ranging from 0 to 200 microM. The lipoxygenase inhibitors esculetin and caffeic acid did not impact the formation of microaggregates in this system. The influence of the phospholipase A(2) inhibitor dexamethasone was reversed by amending experimental (dexamethasone-treated) preparations with prostaglandin H(2), but not prostaglandin D(2), prostaglandin E(2), nor 5(S)-hydroperoxy-6E,8Z,11Z,14Z-eicosatetraenoic acid, a product of the lipoxygenase pathway. We infer that prostaglandins are the primary mediators of microaggregation reactions to bacterial challenge in insect hemocyte preparations.