Investigating inpatient medication administration using the theory of planned behavior.

PURPOSE: Results of a study to determine behavioral factors that help explain why nurses often do not obtain and administer medications from automated dispensing cabinets (ADCs) "one patient at a time" are reported. METHODS: To investigate nurses' frequent failure to adhere to best-practice standards for ADC use, a 12-item questionnaire developed using information obtained from an elicitation study and a focus group session was e-mailed to 755 nurses at an academic medical center. A model based on constructs of the theory of planned behavior (attitude, subjective norm, and perceived behavioral control) was used to evaluate nurses' intent to follow ADC best practices through univariate and multivariate analyses. RESULTS: Of the 755 nurses targeted in the survey, 271 (34%) submitted usable responses. A favorable attitude toward safe ADC dispensing practices and a supportive subjective norm were strongly associated with intent to use ADCs properly; those factors remained highly correlated with intent (p < 0.001 for both) after controlling for demographic and work-related variables such as years in practice and patient workload. Eighty percent of observed variability of intent was explained by the evaluated constructs and variables (p < 0.001), suggesting that direct interventions at the patient care unit level and peer influence would likely be effective in promoting safe ADC use. CONCLUSION: A survey based on the theory of planned behavior demonstrated that attitude and subjective norm were important independent predictors of nurse intent to use ADCs properly.

Development of a metrics dashboard for monitoring involvement in the 340B Drug Pricing Program.

PURPOSE: An electronic tool to support hospital organizations in monitoring and addressing financial and compliance challenges related to participation in the 340B Drug Pricing Program is described. SUMMARY: In recent years there has been heightened congressional and regulatory scrutiny of the federal 340B program, which provides discounted drug prices on Medicaid-covered drugs to safety net hospitals and other 340B-eligible healthcare organizations, or "covered entities." Historically, the 340B program has lacked a metrics-driven reporting framework to help covered entities capture the value of 340B program involvement, community benefits provided to underserved populations, and costs associated with compliance with 340B eligibility requirements. As part of an initiative by a large health system to optimize its 340B program utilization and regulatory compliance efforts, a team of pharmacists led the development of an electronic dashboard tool to help monitor 340B program activities at the system's 340B-eligible facilities. After soliciting input from an array of internal and external 340B program stakeholders, the team designed the dashboard and associated data-entry tools to facilitate the capture and analysis of 340B program-related data in four domains: cost savings and revenue, program maintenance costs, community benefits, and compliance. CONCLUSION: A large health system enhanced its ability to evaluate and monitor 340B program-related activities through the use of a dashboard tool capturing key metrics on cost savings achieved, maintenance costs, and other aspects of program involvement.

Improving patient care through implementation of an antimicrobial stewardship program.

PURPOSE: The implementation of an antimicrobial stewardship program at a health system is described. SUMMARY: In 2008, the Center for Antimicrobial Stewardship and Epidemiology (CASE) was formed at St. Luke's Episcopal Hospital (SLEH) to improve the quality of care for patients as it related to antimicrobial therapy. The charter of CASE contained specific aims for improving patient care, furthering clinical research, and training the next generation of clinical infectious diseases pharmacists. The CASE team consists of at least two infectious diseases pharmacists and one physician (the medical director) who provide direct oversight for antimicrobial utilization within the hospital. The CASE medical director, an infectious diseases physician, is responsible for overseeing the activities of the center. With the oversight of the CASE advisory board, the medical director develops and implements the antimicrobial stewardship and management policies for SLEH. Another key innovative feature of CASE is its extensive involvement in training new infectious diseases pharmacists and conducting research. CASE uses a model in which a clinical scenario or problem is identified, a research project is undertaken to further elucidate the problem, and policy changes are made to improve patient outcomes. The CASE team is supported by a CASE advisory board, a CASE research collaborative including university faculty, and a dedicated training program for pharmacy fellows, residents, and students. CONCLUSION: Implementation of an antimicrobial stewardship program at a health system helped decrease the inappropriate use of antibiotics, improve patient care and outcomes, further clinical research, and increase training opportunities for future clinical infectious diseases pharmacists.

Effect of bar-code-assisted medication administration on nurses' activities in an intensive care unit: a time-motion study.

PURPOSE: The effect of bar-code-assisted medication administration (BCMA) on nurses' activities in an intensive care unit was evaluated. METHODS: A prospective, observational, time-motion study was conducted by considering two approaches to medication administration in an intensive care unit: paper-based medication administration (PBMA) and BCMA. The time spent on nursing activities was measured using a prevalidated time-motion observation instrument and categorized based on workflow factors such as direct patient care, indirect patient care, administration, and miscellaneous or other. A descriptive analysis was conducted with the amount of time spent on each of the nursing activities. A multivariate analysis of covariance was conducted to assess the difference between the two approaches for the amount of time spent on various categorized nursing activities. Covariates included in the analysis were patient characteristics, medication administration characteristics, and number of nurses involved in medication administration. RESULTS: A total of 101 PBMAs and 151 BCMAs were reviewed. The mean duration of total medication administration time was higher in the BCMA phase compared with the PBMA phase, as was the mean time spent on direct patient care activity. However, nurses spent less time on administration activity during BCMA. Statistical analysis revealed that the medication administration approach (BCMA versus PBMA) had a significant effect on time spent on direct patient care and medication administration activities. CONCLUSION: The implementation of BCMA led to a reduction in the time spent by nurses on medication administration activities and increased the time spent on direct patient care activities.

Descriptive analysis of workflow variables associated with barcode-based approach to medication administration.

Bedside barcode technology is used during medication administration to ensure patient safety. This study evaluated the workflow variables related to a bedside barcode technology-based medication administration process. A time-and-motion technique was used to assess the observational episodes related to medication administration conducted by registered nurses. In an observational episode, nurses spent adequate time in "documenting medications" and "giving medications." Nurses were primarily engaged in tasks at the patient's bedside.

Symposium on roles of and cooperation between academic- and practice-based pharmacy clinicians.

PURPOSE: The findings of an academic symposium as they relate to the history and role of the academic pharmacy clinician, the strengths and limitations of the academic pharmacy clinician model, and the framework for future synergistic work relations among clinical pharmacy practitioners are summarized. SUMMARY: On April 23, 2008, a symposium was convened to bring key thought leaders together to discuss the relationship of the academic-based pharmacy clinician and the practice-based pharmacy clinician. Participants included clinical faculty and administrators from two colleges of pharmacy, practice-based clinical pharmacists and pharmacy managers from seven health care institutions, and representatives from the American Association of Colleges of Pharmacy, the American College of Clinical Pharmacy, and the American Society of Health-System Pharmacists. Symposium participants discussed the roles and expectations of clinical pharmacists based on primary affiliation within the contemporary practice model for academic- and practice-based pharmacy clinicians and identified sources of conflict for academic- and practice-based pharmacy clinicians. Symposium participants agreed that in order to succeed, the academic-based and the practice-based pharmacy clinicians must function in a true partnership as each individual has strengths, resources, and benefits to bring to the relationship. Furthermore, knowledge, consideration, and an understanding of the potentially different goals and objectives of each institution are critical. CONCLUSION: A symposium attended by clinical faculty members and administrators from two colleges of pharmacy, practice-based clinical pharmacists and pharmacy managers from seven health care institutions, and representatives from three national pharmacy organizations was conducted to discuss the roles of and cooperation between academic- and practice-based pharmacy clinicians.